Spondylolisthesis

Spondylolisthesis occurs when one vertebra slips forward over the one below it. If you've received this diagnosis, rest assured: it's a common condition that generally responds very well to treatment. This slippage typically affects the L5-S1 or L4-L5 levels, where your back works the hardest. Approximately 5 to 7% of people have the isthmic type, and 2.7% of men compared to 8.4% of women have the degenerative type.¹ Three out of four cases are Grade I or II, and conservative treatment is successful in 80 to 98% of cases.² At Physioactif, our physiotherapists specializing in spinal rehabilitation use stabilization programs that target the mechanical problem to help you regain normal function.

What is lumbar spondylolisthesis?

Spondylolisthesis refers to the forward slippage of one vertebra over the one below it. This displacement can compress your nerves, alter how your spine functions, and cause pain in your back and legs.

The L5-S1 level is the most common site for isthmic spondylolisthesis because the junction between your lumbar vertebrae and your sacrum experiences the highest shear forces.³ For degenerative forms, it's more often L4-L5 because the orientation of the facet joints at this level offers less resistance to shear forces.¹

The Meyerding classification is used to assess the severity of the slippage. This system measures the percentage of vertebral body displacement and remains highly reliable.⁴

Flexion-extension X-rays are also used to check if your spinal segment is stable. Dynamic instability occurs when the slippage changes with your position.⁵ This assessment influences your treatment plan: stable, low-grade slips respond very well to active exercises.

What Causes Vertebral Slippage?

Six major types exist: isthmic, degenerative, dysplastic, traumatic, pathological, and post-surgical. Isthmic and degenerative forms are the most common in clinical practice.

Isthmic spondylolisthesis begins with a defect in the pars interarticularis, the bony bridge connecting the upper and lower parts of your vertebra.⁶ This defect results from repetitive stress fractures caused by hyperextension. This form is common in athletes who repeatedly extend and rotate their spine: gymnasts, football linemen, wrestlers, divers, and cricket bowlers.⁷

Degenerative spondylolisthesis results from arthritic changes in your facet joints and disc degeneration, causing instability without a fracture of the pars interarticularis.⁶ This form is much more common in women and typically develops after age 50.⁸ This type shares underlying mechanisms withlumbar osteoarthritis, in which normal age-related degenerative changes in the joints compromise stability.

What are the symptoms of spondylolisthesis?

Symptoms include mechanical lower back pain that worsens with extension, hamstring stiffness, postural changes with increased lordosis, and sometimes nerve symptoms in the legs.

Lower back pain worsens with extension and improves when you bend forward.⁹ Activities that require hyperextension of the spine increase shear forces: raising your arms above your head, walking downhill, or standing for long periods. This pattern of mechanical pain differs from inflammatory conditions, which worsen with rest. Pain from spondylolisthesis often tends to increase with exercise and activity and then decrease with rest. If you live with low back pain, understanding the specific nature of your pain helps guide treatment.

Hamstring stiffness is a characteristic finding, particularly in adolescent patients with isthmic types.⁹ You may exhibit a shortened stride length that results in a "waddling" gait because tight hamstrings limit hip flexion. This stiffness represents a protective muscle spasm: your muscles are trying to reduce shear forces.

Neurological symptoms develop when the slippage compresses neural structures.¹⁰ Neurogenic claudication is pain in the legs that begins with walking and improves with lumbar flexion (i.e., walking with the trunk bent forward). This compression can occur when spondylolisthesis coexists with spinal stenosis. Lumbar radiculopathy may also occur, resembling classic sciatica.

Many people with spondylolisthesis visible on imaging remain completely asymptomatic. Up to 18% of adults undergoing lumbar MRI have incidental spondylolisthesis, and this rate reaches 23% in asymptomatic individuals over 60.¹¹ If you have an MRI and a slippage is discovered, don't be discouraged: it's not automatically the cause of your pain.

How Is Spondylolisthesis Diagnosed?

Diagnosis combines clinical evaluation with imaging. Standing lateral X-rays show the vertebral displacement and measure the percentage of slippage. MRI provides a detailed assessment of nerve compression and disc condition.

Which Imaging Best Shows the Slippage?

Standing lateral radiographs are the primary diagnostic method.¹² The oblique view shows the classic “Scotty dog” sign—with a collar around the neck—when a pars interarticularis fracture is present. Flexion-extension views reveal dynamic instability: more than 3–4 mm of translation or 10–15 degrees of angular movement between positions indicates problems with the stabilizing structures.⁵

MRI assesses the severity of nerve compression, the state of disc degeneration, and soft tissue problems.¹² The results correlate with nerve symptoms and help differentiate mechanical back pain from nerve pain.

How does the grade influence treatment?

Grade I-II slips are managed with physiotherapy and activity modification, with a favorable response in 80-90% of cases.² Grade III-IV slips often require surgical evaluation due to increased instability and nerve risk.

Stability is just as important as the grade. A stable Grade II slippage with minimal dynamic movement responds well to conservative treatment. In contrast, an unstable Grade I slippage showing excessive movement may require more aggressive management.¹² A brace is not routinely prescribed. It is used primarily when rest alone is not sufficient to relieve symptoms, and is then gradually discontinued as the pain subsides.

How does physiotherapy treat spondylolisthesis?

Physiotherapy uses stabilization exercises targeting the deep abdominal muscles and lumbar multifidus, flexibility training for hip flexors and hamstrings, postural education focused on a neutral spine, and progressive functional strengthening. Success rates reach 80-98% for Grade I-II.²

Trunk stabilization forms the foundation of treatment. The transverse abdominis and lumbar multifidus provide segmental control of the unstable vertebra through low-intensity, high-endurance contractions.¹³ These muscles increase intra-abdominal pressure and improve posterior ligament tension. In patients with spondylolisthesis, these muscles exhibit delayed or insufficient activation, which physical therapy helps to retrain. Physical therapy places a strong emphasis on strengthening the deep muscles that stabilize the spine—such as the deep abdominals, obliques, and glutes—along with pelvic floor exercises.

The Abdominal Draw-In Maneuver (ADIM) technique targets transversus abdominis activation.¹³ You draw your lower abdominal wall inward without moving your spine or rib cage. This sub-maximal contraction (about 30-40% of maximal effort) is held for 10 seconds and repeated for several sets throughout the day.

Flexibility training addresses the characteristic stiffness.⁹ Sustained hamstring stretching, with 30-second holds repeated 3-4 times daily, gradually improves flexibility and normalizes movement patterns. Stretching the hip flexors reduces anterior pelvic tilt and excessive lordosis.

Postural training emphasizes the neutral spine—the natural lordotic curve that optimizes weight distribution.¹³ Treatment progresses in stages. It begins with the activation of deep stabilizers and then moves on to more functional movements. The transition from one stage to the next depends on clinical criteria, not a fixed schedule.

What Exercises Stabilize Spondylolisthesis?

Glute activation exercises strengthen the hip extensors to facilitate trunk extension through hip movement rather than lumbar hyperextension.¹⁴ Plank variations build core endurance with isometric holds lasting 20–60 seconds. Movements that arch the lower back—especially under load—place greater stress on the weakened area of the vertebra. This is why rehabilitation initially avoids repeated back extensions.

Progression must be supervised to ensure appropriate advancement.¹³ Premature progression risks symptom aggravation, while insufficient challenge does not stimulate the necessary adaptations.

Can you play sports with spondylolisthesis?

Yes, many athletes are able to compete despite having spondylolisthesis by maintaining good core stability and making technical adjustments. Conservative treatment results in a return-to-sport rate of 80–98% among adolescent athletes, with an average recovery time of 4.6–5.5 months.^7,14

Participation decisions depend on the type, grade, stability, and severity of symptoms, not on absolute restrictions based solely on imaging.⁷ Stable low-grade slips in asymptomatic athletes allow full participation after rehabilitation.

• Pain-free range of motion
• Resolution of nerve symptoms
• Adequate core strength and endurance
• Maintaining a neutral spine during sport-specific movements
• Stability on imaging (no progression)

When is surgery necessary?

More than 80% of cases of low-grade spondylolisthesis resolve without surgery. Non-surgical treatment—including rest, activity modification, and physical therapy—yields good functional outcomes and usually allows patients to return to their normal activities and sports. Surgery is considered for symptomatic high-grade slippage, progressive slippage despite conservative treatment, persistent neurological deficits, or failure of 6 months of comprehensive conservative management.¹⁵

In people with degenerative spondylolisthesis, one study found no difference in outcomes between decompression surgery (laminectomy) and conservative treatment. When spondylolisthesis is accompanied by lumbar spinal stenosis, one study showed that a structured physical therapy program, including education and exercises, yields results similar to those of decompression surgery in the long term.

Spinal fusion procedures involve bone grafting to create a solid union between the slipped vertebra and the adjacent level, using instrumentation (pedicle screws and rods).¹⁵ The success rate of fusion with screws and rods varies across studies and depending on how success is measured. Selecting the right candidates is part of the decision-making process. However, fusion eliminates motion at the operated level and may accelerate degeneration in adjacent segments. Fusion can accelerate wear and tear in neighboring segments, a condition known as adjacent segment disease. This is yet another reason to carefully weigh the decision to operate.

Rehabilitation after surgery continues for several months. Patients gradually resume their normal activities. The extensive rehabilitation requirements and permanent loss of movement underscore the importance of exhausting conservative treatment options before undergoing surgery for low-grade spondylolisthesis.

How does spondylolisthesis progress over time?

Most adult spondylolisthesis cases remain stable with appropriate management. The risk of progression increases in children and adolescents during growth spurts. Grade I-II cases show long-term stability with stabilization programs.¹¹

Adult isthmic spondylolisthesis stabilizes after skeletal maturity, with 70-80% of Grade I-II patients remaining stable or improving with conservative management.¹¹ Degenerative spondylolisthesis shows variable progression but remains manageable with activity modification and periodic physiotherapy.

Pediatric patients face the highest risk of progression during growth spurts.¹¹ The recommended follow-up for asymptomatic adults with stable Grade I–II slippings is clinical monitoring without routine imaging. The guidelines discourage routine imaging unless severe involvement is suspected, the response to conservative treatment is unsatisfactory, or the imaging findings are likely to alter the management plan. For young patients, X-rays every 6–12 months until skeletal maturity help detect progression.

What daily modifications can help?

Daily modifications include avoiding repetitive hyperextension activities, using proper lifting techniques with a neutral spine, choosing low-impact exercises, and implementing ergonomic adjustments.

Overhead lifting activities that require prolonged extension concentrate stress on the unstable segment.¹⁴ Use step stools to reduce lifting height and alternate extension activities with flexion stretches.

Proper lifting mechanics protect your spine: the hip hinge pattern maintains a neutral lumbar spine while flexing at the hips and knees.¹⁴ Position loads close to your body and avoid twisting during lifts.

For sleep, lying on your side with a pillow between your knees maintains neutral alignment.¹⁴ Sleeping on your back with a pillow under your knees slightly flexes the hips. Avoid sleeping on your stomach, which accentuates lumbar extension.

Ready to stabilize your spondylolisthesis?

Our physiotherapists at Physioactif develop individualized stabilization programs that combine comprehensive assessment, targeted exercises, and progressive functional training. Whether you need treatment for acute lower back pain or a complete rehabilitation program, we tailor it to your slip grade, symptoms, and goals.

For low-grade spondylolisthesis, active rehabilitation is one of the recommended approaches. It aims to alleviate symptoms and help you stay active. Whether you’re an athlete, a worker, or simply looking to maintain an active lifestyle, we develop exercise programs tailored to your functional priorities.

References

1. Gagnet P, et al. Spondylolysis and spondylolisthesis: prevalence and association with low back pain. PMID: 24072198.
2. Kim B, Yim J. Core stabilization exercises in lumbar instability. J Exerc Rehabil. 2020;16(4):346-354.
3. Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative lumbar spondylolisthesis. Eur Spine J. 2008;17(3):327-335.
4. Baliga S, et al. The Meyerding Classification System of Spondylolisthesis. Clin Orthop Relat Res. 2020;478(5):1125-1130.
5. Jacobson RE. Radiographic assessment and imaging studies. In: Spondylolisthesis evaluation and treatment. Elsevier; 2019.
6. Tenny S, Gillis CC. Spondylolisthesis. StatPearls. 2024.
7. Sundell CG, et al. Return to play after treatment in athletes with spondylolysis. J Sci Med Sport. 2019;22(5):579-584.
8. Kalichman L, et al. CT-evaluated features of spinal degeneration. Spine J. 2010;10(3):200-208.
9. Standaert CJ. Spondylolysis in the adolescent athlete. Clin J Sport Med. 2002;12(2):119-122.
10. Vibert BT, et al. Treatment of instability and spondylolisthesis. Clin Orthop Relat Res. 2006;443:222-227.
11. Brinjikji W, et al. Imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816.
12. Tenny S, Gillis CC. Spondylolisthesis. StatPearls. 2024.
13. Kim B, Yim J. Core stabilization exercises in lumbar instability. J Exerc Rehabil. 2020;16(4):346-354.
14. Gagnet P, et al. Return to sports activity by athletes after treatment of spondylolysis. World J Orthop. 2010;1(1):26-30.
15. Försth P, et al. Fusion surgery for lumbar spinal stenosis. N Engl Med. 2016;374(15):1413-1423.