Adolescent gymnast with L5 spondylolysis and a 10-week meet
A 15-year-old competitive gymnast presents with 4 months of insidious low back pain, worse with back walkovers and tumbling. Pain is 3/10 at rest and 7/10 with extension. She has no leg symptoms. Examination: positive single-leg hyperextension test on the right, lumbar extension 20° with pain, and no neurologic deficit. MRI shows a right-sided L5 pars interarticularis stress injury without slip. The physician has cleared her for non-operative rehabilitation but restricted extension and impact activities. She wants to compete at the state meet in 10 weeks. Her parents are concerned about losing her scholarship prospects. She trains 20 hours/week and has not had a graded return plan. She is otherwise healthy and has no eating disorder screening flags.
1. Design the first 4 weeks of rehabilitation and specify what must be true before she advances to impact work.
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First 4 weeks: stop extension and impact-no back walkovers, tumbling, or repeated lumbar extension. Use relative rest, not complete bed rest. Rehabilitation focuses on pain control, hip hinge, glute strength, trunk anti-extension and anti-rotation, and cardiovascular fitness via swimming or cycling if pain-free. Address the parents' concerns with realistic timelines: pars stress injuries need gradual loading, and 10 weeks is tight. Bracing may help symptom control but does not replace loading control. Advance to impact only when she has pain-free extension, a negative single-leg hyperextension test, symmetrical hip strength, and pain-free activities of daily living for at least 2 weeks. Then start low-impact running and controlled extension in small doses. Document that return to tumbling is conditional and that the state meet may not be realistic. This balances adolescent bone healing with her competitive goal.
2. At week 6 she is pain-free at rest but still has 5/10 pain with back walkovers. Her coach wants to reintroduce tumbling. What is your decision and rationale?
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Do not clear tumbling. Pain-free rest does not equal tissue readiness; 5/10 pain with back walkovers shows the pars is still being loaded beyond tolerance. Reintroducing tumbling now risks nonunion and a longer absence. Instead, continue anti-extension strengthening and add low-impact conditioning. Discuss with the coach and parents that the state meet is not worth a setback. Reassess in 2 weeks with extension and provocation testing. If pain-free, begin a staged gym-based progression-no tumbling until she can perform controlled extension, landing, and low-impact jumps without pain. Consider physician review if pain persists. The judgement is to protect long-term participation over a single competition, and to make that reasoning explicit to a family under pressure.