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Low back pain in the Athlete


by Mr Devitt Low back pain is a very common problem in general and in excess of 70% of all people in developed countries have experienced low back pain at some time in their lives. Any form of physical activity in excess of three hours a week will reduce the life time of muscular low back pain but despite this low back pain is still quite common among running athletes. Fitness is certainly an issue and the risk of injury in less fit individuals increases by an approximate factor of 10 compared to fit individuals. The good news is that 90% of acute episode of back pain will resolve within 6 weeks.

In approximately 80 – 90% of instances of low back pain a specific structural abnormality cannot be identified. The components of the spine can be divided into the skeletal support structures which include the bony vertebrae, intra-vertebral discs, small joints called facet joints and a variety of ligaments which hold the structures together and the neural components including the spinal cord and nerves which are protected by the bony and soft tissue skeleton. Surrounding the bony skeleton are several layers of muscles which have a very important role in spinal stability and strength and without which the spine would deform permanently.

It is usually possible to distinguish neurogenic pain or pain coming from the nerve structures in the spine from other causes of pain based on the characteristics of the pain itself. Nerve pain can be very severe and is typically felt in the buttock or leg rather than in the back. It may be associated with numbness or pins and needles or weakness in the legs. It may also be associated with bladder dysfunction. In the athlete it is usually a result of rupture of a piece of disc material causing pressure on a particular nerve root in the spinal canal itself.

Serious conditions such as tumours and infection can present with back pain but further consideration of these conditions is beyond the scope of this article.

For the most part the term mechanical pain is used to describe the type of low back pain experienced by athletes including runners. This pain is typically localised to the low back and is often described as a dull ache. It may be referred to the buttock but typically not below the knee. This may result from a number of conditions where there is a structural defect in the spine, eg. Spondylolysis or spondylolisthesis. These conditions which are not very common can usually be diagnosed on a plain X Ray.

In the majority of cases of mechanical back pain in athletes however a specific abnormality or cause for the pain is not identified. Contrary to popular belief MRI scanning is usually not helpful. Possible culprits for the pain source include the intra-vertebral discs, the small facet joints and spasm in the muscles surrounding the spine.


For an acute attack of low back pain it is worth while remembering that 90% will resolve within six weeks regardless of treatment. There is good evidence to suggest that maintaining normal activity and mobility without excessive exertion is better than bed rest. People are often concerned that walking or exercise may do further damage but this is unlikely to be the case. One should walk for exercise, ideally two to three miles at a time every day. For those who can swim, swimming is generally helpful. The breast stroke in particular can aggravate symptoms sometimes and if so should be avoided. Prolonged sitting or driving should be avoided if possible. Painkillers and anti-inflammatory tablets are helpful in the short term. Once the acute phase is over, an exercise based core strengthening exercise programme should be introduced. Initial rehabilitation should focus on isometric strengthening, progressing to controlled motion particularly extension. The concept of core stability is now well established and these programmes are available from a Physiotherapist or Pilates programme. Running should be re-introduced gradually as symptoms improve.
Treatment for prolonged or chronic low back pain is more difficult. If pain is strictly activity or running related and absent at rest then a critical appraisal of the particular activity is worth while. Shock absorption can be modified by use of good quality cushioned running shoes and running on softer surfaces such as grass or tract. More frequent shorter runs are less likely to generate low back pain than prolonged runs. If the problems persists then an assessment by a Sports coach or Physiotherapist is worth while.

Tight hamstrings or flat feet with over pronation of the forefoot can result in exercise induced back pain and these conditions are often treatable using stretching programmes and possible orthotic insoles.

Persistent problems despite all of the above probably warrants a visit to your doctor.

Mr. Aiden Devitt
Clinical Lecturer
Consultant Orthopaedic Surgeon