Low Back Pain in Athletes Series: Part 2
The Young Adult Athlete
This is Part 2 in a series of posts on low back pain with athletes that will cover the lifespan. In my Physical Therapy practice, we regularly encounter patients with a high level of pain, fear, and misunderstanding with their symptoms. The purpose of this series is to provide a background on the causes, risk factors, and treatment strategies that will assist in the understanding the importance of early treatment and resolution.
I have personal experience with recurrent LBP throughout my 20s and into my 30s. Often, this is exercise-induced after long bouts of sedentary to low-level activity.
Low back pain (LBP) is poorly understood publicly and as a result, often mismanaged. Most young adults will experience back pain at some point in their lives and understand how debilitating it can be. LBP is the 2nd most common reason that young adults seek emergency medical treatment, and accounts for the 3rd highest medical expenses for adults, behind cancer and heart disease.
Rapid changes in lifestyle and activity are often the primary cause of LBP, with associated asymmetries and weaknesses. Reduced activity and transition to sitting at school or work often contribute significantly to the musculoskeletal impairments or asymmetries. Postural changes become exacerbated as the working population sits longer throughout the day.
- Disc pathology, primarily herniation (48%)
- Muscle strain (27%)
If an athlete complains of abnormal bowel or bladder function, or symptoms in both legs, he/she should seek medical care immediately.
Most back pain in young athletes is of a mechanical nature and thus, should be treated conservatively.
History and Activity
The #1 predictor of LBP is a history of back pain. Adults who experienced pain as adolescents or teenagers will often have back pain again if they do not address risk factors.
Rapid changes in activity level is often the cause of LBP in young adults. Changes to exercise regiment may include: frequency, duration, intensity, activity type, or technique. The student or desk-jockey who decides to play 2 hours of pick-up basketball with no warm-up should expect bad things will happen.
Abnormal posture and movement patterns are the primary cause of LBP. Read my post on checking your posture from the ground up here. It gives insight into the function of our core musculature and the impact of gravity on our bodies over time. Essentially, our bodies move in the path of least resistance and asymmetries develop over time. The result is changes in soft tissue, joint mobility, joint position, and neuromuscular response (our body's way of keeping us upright). If these are not corrected, we experience overuse injuries from long-term stresses - resulting in back pain.
The Mind Matters
Avoidance of movement due to fear of pain during bouts of LBP has been well documented as a risk factor for successful treatment. The worst thing to do when experiencing back pain is to stop moving. Bed rest has been shown to delay resolution of symptoms, but the fear is real.
The psychological component of LBP is poorly understood. What we know is that fear-avoidance plays a large role in outcomes and expectations. The good news is, most back pain is resolvable and the stress must also be managed.
Research supports physical therapy as the first course of action for mechanical LBP in young athletes when serious pathology has been ruled out. Returning normal pain-free movement is the focus of therapy, followed by gradual return to sports activity and addressing risk factors for recurrence.
Must-dos for reducing the recurrence of low back pain:
- Change positioning throughout the day - don't sit still
- Full dynamic warm-up before exercise, always
- Train the right muscles, the right way (see this post)
- Look elsewhere - thoracic spine, hips, and ankles
- Static stretch hamstrings and hip flexors 3-4x/day
Activity modification is key! I'm advocating that you keep moving, but be smart about the movement choices. Starting a Crossfit training program out of the gait with no experience weightlifting is obviously a bad idea. Trust me, people do it. The same goes for running a 10k.
Fix the mobility impairments before moving on to strength. Strengthening an already abnormal movement pattern will surely create greater asymmetry or dysfunction. Full tissue and joint range of motion without pain is the first step, then lock-in that range with stability and strength. Mobility is addressed through foam rolling, stretching, joint mobility strategies, and dynamic warm-up.
Commonly, people with chronic or recurrent back pain will seek treatment on their back (makes sense). However, the back is most likely the effect, not the cause. Looking at posture from the ground up (see here) and issues with the thoracic spine, hips, or ankles will fix the problem for good.
We will discuss this in another post and many people argue this point, but evidence supports static stretching "cold", preferable to warm. The goal of static stretching is to produce permanent change in the length of the muscle, also described as deformation of the tissue. If the tissue is warm, it lengthens easier without changes in the structure. The take home message is to stretch hamstrings, groin, and hip flexors multiple times/day. Get out of your chair and stretch those hammys!