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When high-grade isthmic spondylolisthesis (Grade III/IV) is present, especially in pediatric patients, the L5-S1 facet joints are often dysplastic (improperly formed) and subclinical signs of spina bifida may also be present at the L5 and sacrum level. There is usually a high slip angle and/or notable lumbosacral kyphosis (convex curvature). There may be scoliosis ('S' shaped curvature), secondary to the misalignment of the spine. The trunk of the body often sits in a forward position over the pelvis and the individual may adopt certain compensatory strategies to correct the imbalance (e.g., walking with flexed knees and hips).

Lower back pain is often present but may not be severe. Often patients present with radiculopathy stemming from the L5 nerve root and exhibiting pain or numbness in the thigh, calf, and/or foot. Unilateral pain is more common than bilateral.

Some clinical signs that are often recognizable in individuals with high-grade spondylolisthesis include:

• Shortening of the trunk
• Protruding abdomen
• Flattened buttocks
• Limited flexion
• Restricted spinal mobility
• Tight hamstrings
• Waddling gait
• Hip and knee flexion

As the upper vertebra translates over the lower, it also tilts producing a 'slip angle'. This leads to kyphosis (outward curvature) of the lumbar spine.