Why wait? Immediate physical therapy for adolescent lumbar spondylolysis

Posted on by bjsm

Key words: Lumbar Spondylolysis; Adolescent Athlete; Physical Therapy

This blog summarises a study recently published in BJSM (1).

Why is this study important?
Lumbar spondylolysis is one of the most common causes of low back pain in adolescent athletes (2-4). Although standard care varies, many clinicians prescribe prolonged rest (1–3 months) prior to starting physical therapy (PT), an approach that has never been tested in a prospective trial (5). 

Rest has traditionally been prescribed to promote healing and improve outcomes, but the data raise concerns; only 68–82% of active lesions heal on imaging, and radiographic healing does not clearly correlate with clinical improvement (6-8). Further, injured athletes are commonly out of sport for 4–7 months and up to 40% report recurrent or chronic low back pain years after their spondylolysis diagnosis (9).

Prolonged rest, therefore, may have unintended consequences. It can lead to atrophy of lumbar paraspinal muscles, deconditioning, weight gain, and fear of movement — all factors associated with persistent low back pain (10, 11). But will starting PT too soon interfere with bony healing?

We are left with a simple but important question:  Do adolescent athletes with active spondylolysis really need to rest before starting PT?

How did the study go about this?

We conducted a multicentre randomised controlled trial including 64 adolescent athletes (ages 10–19) with MRI-confirmed active lumbar spondylolysis. At diagnosis, all athletes were removed from sport and randomly assigned to either Immediate PT or Rest Before PT.

The Immediate PT group began a structured progressive PT program within one week (Immediate Functional Progression Program). The Rest Before PT group rested from all activity beyond basic activities of daily living until their pain resolved and then began PT within that week. The exercises and progression were standardized across groups and individualized to the athlete — the only difference was when PT started.

Participants were followed for 12 months. We assessed pain-related function using the Micheli Functional Scale, time to meet return-to-sport criteria, recurrence of low back pain, bony healing on MRI, and changes in lumbar multifidus muscle morphology.

What did the study find?

Our study revealed several important findings:

  1. Adolescents who began PT immediately improved faster. At one month, the Immediate PT group demonstrated more than a 20-point greater improvement on the Micheli Functional Scale and met return to sport criteria an average of 38 days sooner.
  2.  Immediate PT did not compromise bony healing. MRI healing rates were similar between groups, challenging the long-held concern that early PT may interfere with bony healing.
  3. Recurrence rates differed substantially. At 12 months, only 3% of athletes in the Immediate PT group experienced recurrent low back pain compared to 29% in the Rest Before PT group.

We also observed meaningful differences in lumbar multifidus muscle morphology. Athletes who began PT immediately increased multifidus muscle size over time, whereas the Rest Before PT group overall showed slight decreases, with approximately half demonstrating atrophy. Given the association between multifidus morphology and recurrent low back pain, this may partially explain the lower recurrence rates.

By 3 and 12 months, both groups reported similar levels of pain and function. However, athletes who started PT immediately reached those outcomes sooner — and experienced fewer setbacks.

What are the key take-home points?

This study is the first randomised trial to directly test the long-standing “rest first” paradigm for adolescent lumbar spondylolysis. Our findings suggest prolonged rest before starting PT may not be necessary. Adolescents who began structured PT immediately recovered faster, returned to sport sooner, and had fewer recurrences of low back pain, while bony healing rates were similar between groups. For clinicians, these findings suggest that starting rehabilitation earlier may help adolescent athletes recover sooner—without compromising healing.

Authors: Mitchell Selhorst, Emily Sweeney, Anastasia Fischer

References: 

  1. Selhorst M, Sweeney E, Martin LC, et al. Immediate Physical Therapy Is Beneficial for Adolescent Athletes with Active Lumbar Spondylolysis: A Multicentre Randomised Trial. British journal of sports medicine. 2026; 60(2):125-132. doi:10.1136/bjsports-2025-110606
  2. Schroeder GD, LaBella CR, Mendoza M, et al. The Role of Intense Athletic Activity on Structural Lumbar Abnormalities in Adolescent Patients with Symptomatic Low Back Pain. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. Sep 2016; 25(9):2842-2848. doi:10.1007/s00586-016-4647-5
  3. Selhorst M, Fischer A, MacDonald J. Prevalence of Spondylolysis in Symptomatic Adolescent Athletes: An Assessment of Sport Risk in Nonelite Athletes. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. Nov 14 2017; doi:10.1097/jsm.0000000000000546
  4. Sweeney EA, Rodenberg RE, Howell DR, et al. The Prevalence of Spondylolysis and the Diagnostic Sensitivity of Radiography in Adolescent Low Back Pain. Exercise, Sport, and Movement. 2024; 2(4):e00025. doi:10.1249/esm.0000000000000025
  5. Hollabaugh WL, Foley Davelaar CM, McHorse KJ, et al. Clinical Practice Patterns of Isthmic Spondylolysis in Young Athletes: A Survey of Pediatric Research in Sports Medicine Members. Current sports medicine reports. Nov 1 2022; 21(11):405-412. doi:10.1249/jsr.0000000000001008
  6. Klein G, Mehlman CT, McCarty M. Nonoperative Treatment of Spondylolysis and Grade I Spondylolisthesis in Children and Young Adults: A Meta-Analysis of Observational Studies. Journal of pediatric orthopedics. Mar 2009; 29(2):146-156. doi:10.1097/BPO.0b013e3181977fc5
  7. Kuroshima K, Miyazaki S, Hiranaka Y, et al. Rate and Duration of Bone Union for Conservative Treatment in Pediatric Lumbar Spondylolysis. Spine. Oct 9 2023; doi:10.1097/brs.0000000000004849
  8. Miller SF, Congeni J, Swanson K. Long-Term Functional and Anatomical Follow-up of Early Detected Spondylolysis in Young Athletes. Am J Sports Med. Jun 2004; 32(4):928-933. 
  9. Selhorst M, Fischer A, Graft K, et al. Long-Term Clinical Outcomes and Factors That Predict Poor Prognosis in Athletes after a Diagnosis of Acute Spondylolysis: A Retrospective Review with Telephone Follow-Up. The Journal of orthopaedic and sports physical therapy. Dec 2016; 46(12):1029-1036. doi:10.2519/jospt.2016.7028
  10. Goubert D, Oosterwijck JV, Meeus M, et al. Structural Changes of Lumbar Muscles in Non-Specific Low Back Pain: A Systematic Review. Pain Physician. Sep-Oct 2016; 19(7):E985-e1000. 
  11. Stevans JM, Delitto A, Khoja SS, et al. Risk Factors Associated with Transition from Acute to Chronic Low Back Pain in Us Patients Seeking Primary Care. JAMA Netw Open. Feb 1 2021; 4(2):e2037371. doi:10.1001/jamanetworkopen.2020.37371

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