Treatment of Athletes with Low Back Pain
It’s not a secret that low back pain in athletes can be extremely frustrating to treat. Even though low back pain is a common condition ranking in the top three of most commonly injured regions of the body in sports with a recurrence rate of 50%, sports medicine professionals still encounter frequent challenges.
The causes of low back pain are varied and considering 80-90% of lumbar pain cannot be identified, it is difficult to establish a standardized treatment approach. Though, there have been many attempts to establish Clinical Prediction Rules and diagnostic classification systems, researchers have been unable to consistently reproduce the results of these original studies.
Add to all of this the endless barrage of overhyped treatment advertisements and social media success stories, our athletes have skewed recovery expectations
How do we as evidence informed medical professionals maintain athlete buy-in and optimize recovery?
First, we need to know what the research says.
Presentation / Differential Dx
Certain low back pain conditions are more common for athletes in particular sports. The age of the athlete also matters. Nearly 70% of lumbar spine injuries in adolescent athletes occur in the posterior elements of the spine, whereas the majority of low back injuries in adult athletes are related to muscle strain and discogenic etiologies.
The majority of low back pain has a benign source of pain, but we need to be sure we ruled out the red flags.
Though low back pain is difficult to diagnose, there are more common diagnoses that if we get wrong, can halt or worsen progress.
Common in sports that require repetitive extension and rotation, spondylolysis is the most common cause of low back pain in adolescent athletes. Spondylolysis refers to a defect in the pars interarticularis. It can be assumed that a stress reaction, a micro-fracture, an overt fracture, and spondylolisthesis can be the consecutive stages of the same overuse injury at the pars interarticularis.
Pain will present with an insidious onset with provocation during lumbar extension movements. Occasionally, there is radiating pain, numbness, or weakness present, usually with no radicular symptoms. Because a pars defect is present on plain radiographs in about 8-14% of elite adolescent athletes, a SPECT is recommended for persistent conditions as it is more sensitive than a CT or MRI.
Generally, an athlete will require about 2-4 months of rehab with a return to sports at around 5 to 7 months after diagnosis. Healing timelines have not shown to be different in athletes that were braced (soft or rigid) vs. no brace.
There are many diagnoses to describe soft tissue injuries (mechanical low back pain / muscular low back pain / hyperlordotic low back pain / posterior element overuse syndrome, etc.) In general, there is insult to a muscle-tendon unit, ligament, facet joint, and/or joint capsule. Muscle strain may be the most common cause of low back pain in college athletes.
Symptoms are usually localized without radiculopathy, but pain may radiate into the hips. No specific imaging is usually necessary. The majority of cases will resolve with modified activity with pain resolution in 90% of patients within 12 weeks.
This is less common in young athletes as the incidence is around 11% compared to 48% in the general adult population. Athletes may present with localized back pain with potentially little or no radicular component, although radiculopathy still is often present. Positive straight leg test or dermatomal/myotomal/reflexive testing may confirm your findings. It was shown that 79% of conservatively treated athletes with a disc herniation returned to sport an average of 4.7 months.
As many already know, a positive finding on an athlete’s imaging only tells part of the story and these findings may or may not be associated with pain symptoms. Several studies have shown that at least a third of asymptomatic people (non-athletes) in their 20’s have at least one degenerate lumbar disc. Another study looking at Olympic athletes showed that ONLY 38% of athletes demonstrated normal findings at the L5/S1 spinal level with 58% of athletes demonstrating some sort of disc bulge or protrusion.
Many times, our athletes just need proper education as they can develop serious anxieties about training hard because some other medical professional told them they were more or less ‘broken’. Please learn about the power of the nocebo effect before you start labeling an athlete’s condition.
Causes and Risk Factors
There are many baseless theories on how low back pain occurs and many medical providers can’t help themselves and make leaps in logic connecting irrelevant findings to explain their patient’s symptoms.
But what do we know?
Many studies have found in general that being an athlete does not increase your risk of low back pain. Lundin et al. revealed that despite significantly more radiologic abnormalities among athletes, the frequency of reported back pain was no greater than non-athletes.
With that being said, many studies have shown associations and potential risk factors for low back pain in athletes. Let’s break them down.
Range of Motion (ROM)
Numerous studies have found an association between hip ROM deficits/asymmetries, hip flexor/hamstring tightness and low back pain (here, here, here). Reduced lumbar mobility has also been reported to associate with low back pain. However, the evidence is not conclusive as some research shows no association.
Of note, some researchers have identified the highest risk for adolescence for developing low back pain was during growth spurts. One study showed that a >5cm height increase in a six-month period increases the likelihood of low back pain by 3 times.
Finally, many people have varied bony anatomies in their hips and lumbar spine allowing some to have wonderful movement qualities while leaving others to make modifications in their training. For example, don’t think you failed as a professional if your athlete can only maintain a good posture while deadlifting using a RDL variant versus pulling from the floor. Forcing an athlete to train in positions they do not own is the fastest route to injury.
Multiple studies have found an association between trunk strength and low back pain (here, here). However, some studies have shown that it is not so much the strength of the trunk, but rather the endurance that is more associated with low back pain. This would make sense since trunk postural muscles are rich in Type 1 muscle fibers. Either way, individuals with low back pain have found improved symptoms and function with both a strength focused as well as endurance based programs, respectively. So, it would be wise to establish an endurance foundation first and then progress to train for strength and speed.
Studies also demonstrate an association between hip extensor and abductor strength and low back pain in athletes (here). Though, it should be noted that hip strength asymmetries are more common in asymmetric sports, so use your clinical judgement to determine the relevancy of these discrepancies in your patients.
The internet is full of headlines scaring people to maintain a perfect posture for every second of the day unless their spines will explode. However, to maintain an unsupported upright posture for extended periods of time can actually accumulate to high levels of stress on your spine.
On the flip side, because of the viscous properties of your spinal disc, prolonged slouching redistributes the nuclear material in your disc posteriorly which can set you up for a herniation.
Stuart McGill, a prominent spine Biomechanist and Researcher, calls the “ideal sitting posture” ERRONEOUS as the ideal sitting posture is one that involves variable postures. It has been shown that it takes over 2 minutes after sitting with a flexed spine for 20 minutes to regain only half of your spinal stiffness. McGill recommends changing your sitting posture every 10 minutes and getting out of the chair at least every 50 minutes. Which is very relevant for our athletes who sit in desks for the majority of their days.
So, before your athletes train, invest 10-20 minutes in a proper warm-up to ensure sufficient spinal stiffness. And please, keep your athletes moving between training sets and not let them sit slouched on a bench to rest.
What’s also interesting is that numerous studies have shown that athletes with a previous history of lower extremity injury have been found to have differences in hip strength and muscle firing compared to controls which, in theory, may lead to low back injury. But, these discrepancies are seen in athletes with a history of low back pain as well. There seems to be no consensus on this “chicken or the egg” question.
In regards to low back health, I believe our biggest training flaw is our preference to train harder in the sagittal plane relative to the other planes of movement. We train for strength and power with squats, deadlifts, Olympic lifts, and sprints, but arguably do not develop enough robustness and capacity in the other planes. Most sports place tremendous stress on our spine during ballistic tri-planar movements and we cannot hope to adequately prepare our athletes with only Bird Dog and plank exercises.
Training volume is always a consideration when discussing most injuries. Studies have shown that high-volume training can increase the risk of low back pain. One study in particular found that training for greater than 15 hours per week led to a higher incidence of low back injury.
However, it’s hard to argue that an absolute cut-off is relevant for every athlete. Rather, the concept of acute:chronic workload is likely more meaningful. Piggott et al. showed that 40% of injuries were associated with a rapid change (>10%) in weekly training load in the preceding week. Gabbett et al. had similar findings when training load was increased by 15% above the previous week’s load as the injury risk escalated to between 21% and 49%.
For more information on the acute:chronic training model, I recommend reading Gabbett’s 2016 review in BJSM.
Many are familiar with the early works of Hodges and the subsequent studies demonstrating subjects with low back pain have increased latencies in trunk muscle activation and de-activation compared to healthy controls (here, here, here).
However, there is no conclusion on whether these altered activation patterns are the cause of, or the result of low back pain.
A Quick Note
From the interpretations of the above studies, rehab providers have magnified the significance of the transverse abdominis and multifidus muscles. Now, it is common to see many providers spending considerable and excessive treatment time working on isolation and hollowing training to target these two muscle groups.
There are a handful of problems with this approach:
- Patients cannot just isolate the transverse abdominis or multifidus as demonstrated here and here.
- Studies have shown that virtually all trunk muscles demonstrate altered patterns of activation following back pain in athletic populations.
- These studies found the latency to be in milliseconds, which is impossible to detect in the clinic.
- There is no such thing as a muscle that is the ‘best’ stabilizer for the back as the most important stabilizers constantly change as the demands change.
- McGill’s work has concluded bracing is superior to hollowing stating “bracing appears to be a highly efficient strategy to enhance stability.”
To conclude, motor control training must certainly be addressed as the best athletes in the world demonstrate the ability activate and deactivate muscles quickly, but we must reconsider how we approach this and how we allocate our treatment time. For further readings on this and other rehab strategies for low back pain, I recommend McGill’s texts (here, here).
Therapist: “Engage your core”
The causes of low back pain are varied and no single treatment program is applicable to all athletes. Therefore, this section should be considered as a guideline only. However, because we are dealing with athletes, we must ensure we develop sufficient resiliency to sport demands while maintaining athleticism.
The progression principles are straightforward:
Re-establish appropriate motor patterns and postures
Reinforce those patterns by developing work capacity
Progressively improve power and force output
Goals: Restore ROM / Postural re-training / Anti-movement isometric holds
- Restore hip ROM, T-spine mobility, and pain-free lumbar ROM
- Re-train squat mechanics:
- Assisted squats
- TRX Squats
- Goblet squats
- Dowel overhead squats
- Assisted squats
- Hip hinge
Gluteal Activation / Strengthening:
- Clam Shells
- Bridge Progressions
- Plank Progressions
- Side-lying Plank Progressions
- Bird Dogs
- Pallof Press
Goals: Reinforce patterns / Develop work capacity / Eccentric focused
Gluteal Focused Strengthening
- Bench Bridges
- Single-leg Cable Column Abductions
- Front / Zercher Squats
- Split Squats / Bulgarian Split Squats
- Bent Over Barbell Rows
- Good Mornings
- Chops / Lifts
- Farmer’s Walks / Waiter’s Carries
- Sled Crawls
- Landmine Press variations
Goals: Force generation / Power and speed training
- Pulls / Shrugs
- Power / Hang lifts
Med Ball Throws
Multi-Planar Plyometric Training
Return to Sport Benchmarks
- Biering-Sorenson Test: >60 seconds
- You can use normative data as a reference, but because the standard deviations are so large, normative ratios are more relevant
- Right Side-Plank : Left Side-Plank = < 5% asymmetry
- Flexion : Extension = <1.0 (do not want flexion times to be longer than extension)
- Hip Strength
- <10% asymmetry; compare to age/gender norms
- Refer to our article on hand-held dynamometry testing and normative references
- Med Ball Rotational Throws for Distance
- Looking for symmetry
- Single-leg Hop Tests
- Single Hop for Distance / Cross-Over Hop / Triple-Hop Tests
- <10% asymmetry between limbs
- Single Hop for Distance / Cross-Over Hop / Triple-Hop Tests
Single-Leg Reactive Strength
- Compare the athlete’s single-leg vertical jump, ground contact time, and reactive strength index (RSI) to the uninvolved limb. Look for symmetry
- Repeated sprints
- Multi-directional drills (5-10-5, T-Test, etc.)
Low back pain can be a crippling experience, especially for our athletes who tie their identities to sport. Because it is so debilitating and the source of the pain is unknown, we have let fear dictate our practice. However, there are end-less variations of exercises to safely develop specific athletic qualities while rehabilitating from injury.
The principles of athlete rehabilitation and training still remain the same; progressively and appropriately load tissues to develop resiliency while maintaining high-performance training whenever possible.
Medical professionals have the potential to be incredibly influential in disarming athlete’s fears and instilling confidence through proper education and clarification of the available evidence. We just need to be sure we don’t allow ourselves to get caught up with the hype and bullshit that’s out there.