Low Back Pain

In the general population two-thirds of adults will experience low back pain at some point in their life and athletes are no exception. Few things are as annoying or distracting to runners and triathletes as low back pain. Depending upon severity it can really put a dent in your training plans and disrupt competition. The exact source of back pain may be due to mechanical factors, which account for 97% of cases, or potentially more serious conditions such as infections, tumors, inflammatory arthritis, or internal organ disease. These latter etiologies are beyond the scope of this article.
By far the most common diagnosis in patients with low back pain is the lumbar sprain/strain, which accounts for about 75% of all cases of low back pain. Other mechanical causes of low back pain are age-related degenerative changes in the discs and facets, spinal stenosis, and disc herniation. Because lumbar sprains are so common further discussion is warranted.

What exactly is a lumbar sprain? The answer is that no one really knows for certain (yes, you read that correctly). There is no test to accurately diagnose a lumbar sprain, because there is no anatomical or pathological abnormality that can be reliably found in patients with “lumbar sprains”. What about MRI scans, don’t these high-resolution images show exactly what’s going on? Surprisingly, MRI scans are not only unnecessary for most patients with low back pain, but may also be misleading and confusing. Of note is that two-thirds of healthy volunteers without back pain have abnormalities on MRI. Thus, finding an abnormality with MRI is very common and often has nothing to do with the back pain. For most patients with low back pain, X-ray, MRI, and other imaging studies are just not needed. However, it is important to note that there are certain warning signs and symptoms, and other circumstances, that may indicate more significant disease necessitating further evaluation. These include bladder or bowel dysfunction, muscle weakness or numbness in the legs, sciatica (pain down the back of one or both legs), persistent or prolonged pain (e.g., weeks), weight loss, and fever. The bottom line is, consult your doctor.

During the acute phase of a lumbar sprain there are a few useful things to keep in mind. With respect to activity, do what you feel you are capable of. Neither absolute bed rest nor aggressive back exercise regimens are helpful. The patients that do the best are the ones who listen to their body and strive for a rapid return to usual activities. Non-steroidal antiinflammatory drugs (NSAIDs), such as ibuprofen, can help with pain and mobility in the short-term. Physical therapy and spinal manipulation are of limited benefit in most patients. Finally, keep in mind that although the first few days are the worst, recovery is usually rapid (approx. 90% of patients are well within two weeks).

For runners certain situations may predispose to acute or recurrent lumbar sprain/strain. These include,
  • weak abdominal muscles,
  • tight muscles/poor flexibility (e.g., hamstring, calf, back)
  • poor posture (standing, sitting, or running).

Some examples of poor running posture are, hunched or stooped-over position, too much curvature in the low back (butt sticks out with excess arching of the lumbar spine), and pelvic tilt (anterior or lateral). Triathletes have the added complication of the bicycle. Improper fit of the bike, such as handlebars too low or too far forward (or saddle too far back) contribute to back problems. The “aero” position is well known for its ability to apply extra stress to the low back and neck. For all types of athletes training errors may compound the problem. Too much volume or intensity too soon in the training cycle, or hill climbing in the “aero” position may lead to low back pain. Not to be overlooked is the contribution of the work place environment (e.g., ergonomics of computer workstation).

Completely addressing lumbar sprain/strain in an athlete involves the identification of factors that lead to the problem, and proper rehabilitation. Consider having a friend videotape you -- especially at the end of a workout when fatigue is more likely to reveal problems with posture, etc. This feedback can be very useful. An experienced coach can greatly aid in this process. Rehabilitation following lumbar sprain/strain should highlight and correct muscle weakness, imbalance, and inflexibility. Proper muscle function can help prevent the problem from returning. Back strengthening and stability exercises should be a routine part of the training schedule for anyone who has had recurrent low back problems. Some useful ones are, sit-ups, back extensions, hamstring curls, and quadriceps and gluteal strengthening routines, such as lunges, squats, knee extensions, and leg press. NOTE: check with your doctor first, and then get qualified instruction for proper resistance training technique. Poor technique is the most frequent cause of injury during resistance (weight) training.

In summary, seek qualified medical care for back pain. If you are one of the many that fall into the category of “lumbar strain”, look at all of your day-to-day activities, workout schedule, and equipment. Evaluate for contributing factors and fix them. Finally, keep your back in good shape through proper posture and strengthening exercises -- even if you have never had back pain!

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