Lumbar radiographs (anteroposterior, lateral and both oblique views)

If negative: MRI for initial screen

Localised CT scan for positive spondylolysis on MRI (staging the lesion) or for symptoms prevailing with normal MRI

If all negative: SPECT

The majority of athletes with spondylolysis or pars stress reactions respond well to non-operative treatment. Yet, the return to sport will be difficult, and, in most cases, the future performance will be affected by the underlying disease. Clinical decisions made with players presenting with spondylolysis and spondylolisthesis include apprehension for the future progression of the spondylolisthesis and issues concerning pain. In the acute setting, treatment includes rest from sport, stop repetitive extension/rotation activities and analgesic drugs. Achieve pain-free before initiating physical rehabilitation, and institute a return to play transition. Some authors advocate physical rehabilitation before pain-free.

The role and best type of external immobilisation continues to be debated. Controversy exists if the brace is to be used and the same applies to the type of brace. We still do not know unquestionably if the responsibility for the clinical improvement is the immobilisation or the forced compliance with activity restriction that works well in the pathology. Most authors defend bracing the acute lesions, but not the chronic ones. The objective is to limit hyperextension of the lumbar spine. There are many types of braces: thoraco-lumbar-sacral orthosis (TLSO) or Boston brace antilordotic, lumbar-sacral orthosis (LSO) antilordotic and corset/soft brace. The duration of immobilisation is another controversial subject. Authors defend 2–6 months brace 23 h a day. However the majority of authors have agreed that athletes can return to play when they are pain-free, regardless the time that has passed since the beginning of the symptoms or whether there is radiographic evidence of pars healing.

Bony stimulation is another option considered if the athlete has pain and no healing at 4 months treatment.

The authors defend return to sport after a short period of rest and brace, with transition when pain-free to physical rehabilitation for 1 month. Initial activities must be focused on core muscle strengthening and lower limb flexibility. Surgical excellent results mean that if pain persists after 1 month, the authors consider surgical treatment as a good option.

Several operative treatments have been performed for patients who do not respond quickly to conservative treatment or who have a developing progressive spondylolisthesis.

The best techniques for surgical treatment are controversial in their use and can be separated in three categories: direct repair of spondylolysis when there is no slippage or a grade 1 slippage without disc pathology, decompression alone when there is just radiculopathy in an older patient and decompression and in situ fusion or reduction and fusion.

There are many techniques for pars repair; the authors’ technique consists of iliac autograft and temporary fixation with transpedicular screws when there is a pars defect without spondylolisthesis or a pars defect with grade 1 spondylolisthesis with no disc disease. The screws are taken 1 year after the first procedure, and the results are excellent with full return to sport without physical limitations in most circumstances. When the disc is affected with spondylolysis or grade 1 spondylolisthesis, the authors use minimally invasive transforaminal interbody fusion (MIS TLIF). For grade 2 or more, the authors proceed to reduction and 360° fusion or in situ fusion without reduction (Fig. 23.2).

The aetiology of degenerative disc disease is multifactorial, including genetic predisposition, occupational/leisure physical loading, ageing, smoking and anthropomorphic factors [32, 33]. While current research places genetic factors with the principal role, it is known that elite athletes experience greater forces on the lumbar spine over prolonged, repetitive and consisting training periods.

Intervertebral discs have an important biomechanical role within the spine, as they permit motion between the spinal segments while diffusing compressive, sliding and torsional forces [34]. The deterioration of the disc can decrease its ability to resist to extrinsic forces, as they are no longer transmitted proportionally and are strongly associated with LBP. Disc degeneration involves structural disruption as well as cell-mediated changes in composition.

Discs have a tendency to degenerate earlier than other musculoskeletal structures, with adolescents presenting signs between the ages of 11 and 16 years [35]. It is particularly susceptible in exercises with repetitive flexion, or hyperflexion, combined with lateral bending or rotation [36]. When these movements are combined with axial compression, there is a distress of the internal structure of the disc.

The posterolateral annulus fibrosus is the weakest area of the intervertebral disc and is the most susceptible area to herniation of the nucleus pulposus (HNP). HNP results from repetitive torsional forces with lumbar flexion. Acute HNP accounts for approximately 10% of back pain in adolescent athletes.

Participation in sports appears to be a risk factor for the development of disc degeneration. Disc degeneration appears to be influenced by the type and intensity of the sport. Football players showed disc degeneration almost exclusively in L4 to S1 levels [37].