Q: Hey Tony – I suffered a pretty severe L5 spondylolisthesis a couple years ago, and it took me nearly a year to recover.  I’m now back training again and feeling pretty good.  From what I’ve read, I realize I need to make sure I’m not in an anterior pelvic tilt position, so should I try to focus hard on developing glute, hamstring, and hip strength? 

I also realize that maintaining core strength is important.  Besides planks, side planks, anti-rotation exercises, and roll-outs, is there anything in particular you would do to make sure the lumbar spine is strong and healthy so I can prevent any possible re-injury?  Thanks for you input!  Really enjoy your educational videos and blog posts.

A: First off, I’m really sorry to hear about your injury. Speaking bluntly, back pain is about as fun as a bag of dicks – there’s really no way to sugar coat it. As someone who recently went through a spell of back issues (albeit not the same injury) I can commiserate.

Spondylolisthesis (along with it’s fraternal twin, spondylolysis) is definitely an injury that we’ve seen sporadically here at Cressey Performance, so we know how much work it takes to get back into groove of things – especially with regards to training.

For those reading, scratching their heads and thinking to themselves, “spondy- say what?,” lets take a moment to clear the air.

Spondylolysis refers to a fracture of the pars interarticularis portion of a vertebra (95% of the time, it’s L5). The pars essentially connects the vertebral body in front with the vertebral joints behind.

Presence of spondylolysis runs the gauntlet in terms of who it effects, but its highest prevalence is among weightlifters. That said we’ve seen a huge influx amongst young athletes as well, especially those who participate (and specialize too early) in sports that require excessive extension and rotation (ie:  baseball).

More pertinent to this conversation, spondylolisthesis is a lower back injury involving a forward slipping of one vertebra over another (far right picture above). It’s a very common diagnosis in athletes that participate in sports that have extreme axial strain on the low back (think powerlifters and strength athletes), but it’s also common in the general population as well.

With the geeky, spinal shenanigans out of the way, lets get to the fun stuff.

Off hand it sounds like you’ve got a fairly firm grasp on what to do moving forward, but I do have a few candid thoughts to add:

1.  Yes, correcting any EXCESSIVE anterior pelvic tilt would be wise.  You have to remember, though, that there is an “acceptable” range of APT (natural lordotic curve of the spine), but it definitely bodes in your favor to address any excessive tilt that may be playing into your symptoms.

2.  Expounding on the above point a bit more, most will say that you need to stretch the hip flexors, which, if you delve into the normal parameters of Janda’s lower cross syndrome (“tight” hip flexors, weak core/glutes) isn’t a bad place to start.  But as with anything, it’s not always quite THAT simple.

For instance, you can stretch your hip flexors until the cows come home (or George Clooney gets married, whichever comes first)…….but if your anterior core is weak – which is generally the case 100% of the time  – it’s a waste of time and effort.

Almost always, I place a premium on improving anterior core strength.  Things like Pallof press, various chops and lifts (done with spot on precision: abs braced, trailing leg glute firing, minimal compensation in the torso), as well as planks are a great place to start.

NOTE:  Most people will just haphazardly throw in planks because that’s what they’ve always been told to do.  Cool.  But most people absolutely BUTCHER technique.  To that end, you have to make absolutely certain that you’re doing these correctly!  Which is to say, they shouldn’t look like these epic balls of fail:

Or this:

In both scenarios each person is literally hanging on their spine and not doing their passive, ligamentous restraints any favors.

If you’re going to perform planks, at least do them correctly!

Another exercise to consider (for those who are a little further along in recovery such as yourself) is the reverse crunch.  As my colleague and business partner, Eric Cressey, has noted on several occasions: flexion from an already extended position to neutral is different than flexion from “neutral” to end-range lumbar flexion.

The external obliques help to posteriorly tilt the pelvis, but because they have no attachment points on the sternum (unlike the rectus abdominus) we don’t get all the nasty compressive forces on the spine.

Maybe serving as the rule of thumb above ALL of this is the notion that improving spinal stability is kind of a big deal.  Unless this addressed, all of the above won’t matter since all you’ll be doing is placing dysfunction on top of fitness.  Which, as we all know, would make Gray Cook punch a baby seal in the mouth!

On that point, my boy Dean Somerset wrote a fantastic post HERE which discusses in waaaaay more detail than I could ever cover.

3. Taking things a step further, anything that “encourages” more of a posterior pelvic tilt is most likely step in the right direction.

In addition to anterior core work, a healthy dose of glute work would be in order as well.  I’d start simple and perform supine bridges several times throughout the day.

While not shown above, I actually prefer glute holds, holding each rep for a 5-10 second count at the top.

You can then progress these to 1-legged variations and then proceed to perform 1-legged hip thrust, starting with your back on a bench and feet on the floor.  From there, if you’re feeling confident, you can add in a bit ROM and place your feet on a bench.

For my own edification – it’s important to note that there should be absolutely no lumbar compensation when performing these movements. Everything should be glute, glute, and more glute.  If you do tend to “feel” it more in your back, I’d regress the movement and make sure you’re firing the glute.

In case you missed it, you should feel these in your glutes.

Key Word: Glute.

4.  Above all, and this probably should have been point #1, you just need to make absolutely certain that you’re maintaining as much of a “neutral” spinal position as possible.

At. All. Times

We’ve had people with “spondy” deadlift with the trap bar with a lot of success, but we’re on top of them in terms of performing them correctly.  These may be a little too aggressive for you, so I’d be inclined to recommend exercises that won’t place a lof of direct loading on the spine to start:

Pull-Throughs.

1-Legged Hip Thrusts (see above).

Various single leg work.

And even Goblet squats may be acceptable here.

Nevertheless, getting lifting weights and attaining a training effect will undoubtedly help in that you’ll be making your active restraints (muscle) stronger and take the burden off your passive restraints (ligamentous tissue).

Anyways, that is in no way a thorough overview of the issue at hand, but my hope is that it sheds some light on the topic and points you in the right direction.