Notice that the back is in a forward leaning position, and the arms and head are positioned forward and downward.
With good form, the shin should be perpendicular to the floor, knees are bent at 90 degrees, and the buttocks are in a more seated position. The lower back should have a slight curve, the elbows are bent upward, and the head is positioned facing forward.
If the LBP has already occurred, then measures need to be taken to prevent a recurrence. This includes many of the primary measures already mentioned with the addition of a tailored exercise program, which will be discussed below. Studies have shown that patients who receive a therapy program in addition to medical management had less recurrence at 1 year than those who received medical management alone (5).
WHEN TO IMMEDIATELY REFER TO A PHYSICIAN
When first evaluating LBP, clinicians should be aware of rare but significant “red flags,” listed in Table 1, which are signs and symptoms that may suggest a serious condition that would require prompt attention from a physician.
Medical causes of red flags include:
- Cauda equina syndrome: Compression of the nerve roots supplying bowel, bladder, and perineum (skin in-between), which may require urgent operative management.
- Cancer: Cancer cells stretch the bone at night, causing intense night pain out of proportion to what would be anticipated for a more benign condition.
- Occult infection: Infection of the spine including osteomyelitis, abscess, and diskitis typically need to be treated with antibiotics and sometimes with surgical intervention. If left untreated, infection may progress, leading to sepsis and death.
In addition to screening for red flags, it also is important to be cognizant of other medical causes of LBP that are not necessarily emergent conditions, such as those included in Table 2. Screening questions may include the presence of recent fever, significant weight loss, pain with urination, pain in multiple joints, and so on. If these conditions are suspected, the athlete also should be referred for further evaluation from a physician.
DETERMINING COMMON PAIN GENERATORS
Once the clinician has screened appropriately for medical causes of LBP and red flags, the next step in the process of evaluating LBP is determining the primary pain generator. A useful way to diagnose the pain generator is to assess which types of back movements are most painful for the athlete and which specific movements relieve the pain, also known as the DP. We traditionally classify pain generators into three categories: pain with flexion, pain with extension, and pain with transitional movements. Classification is useful because each movement is associated with loading particular anatomic structures. Although patients may have pain with all planes of movement, it is worthwhile to make an extra effort to delineate which specific movement is most painful for the athlete because this can guide treatment plans.
Below are common pain generators for each category.
Nonspecific Directional Pain
Lumbar Strain and Sprain
The lumbar muscles are more prone to this injury because they are the main supporter of the spine and are involved in a variety of movements. Lumbar sprain occurs when ligaments are excessively stretched or torn, whereas strain occurs when there is an injury to the muscle or tendon. Pain may occur suddenly after the injury and typically worsen during the next 24 hours. Pain is typically in the middle to lower back region and may be tender to palpation. Symptoms usually resolve on their own in 7 days. If symptoms persist beyond that, other causes should be pursued.
Pain With Flexion
Flexion of the spine will tend to load anterior spinal structures, namely, the vertebral body and intervertebral disk. We usually ask about pain in flexion by asking them if it is painful to bend forward to put on their shoes and socks in the morning. Sometimes simple observation can help in recognizing the athlete who has pain with flexion. For example, athletes may wear slip-on shoes to avoid bending at the waist.
Intervertebral disks sit in-between each vertebra. Each disk is made up of an outer rim, the annulus fibrosis (AF), and an inner core, the nucleus pulposus (NP). The AF is composed of firm collagen fibers that encase the inner gelatinous NP. A disk herniation occurs when there is a disruption of the AF, allowing the NP to protrude through, which may push on or irritate spinal nerve roots and cause pain going down the buttocks and into the leg (often called sciatica or, more properly, radiculopathy). Pain is typically worse with sitting and forward bending. In addition to pain, there may be neurological deficits such as numbness or weakness if the nerves are significantly involved. Athletes that participate in sports involving lifting, bending, and twisting motions such as weightlifting are more prone to this injury.
Annular tears are disruptions of the AF without an NP herniation, which can cause discogenic back pain, or pain that originates directly from the intervertebral disk. The disk is a very common pain source in athletes, especially the 20- to 40-year age group. As people age, particularly after 30, the AF begins to thin, which makes it more susceptible to injury. Pain is typically localized mainly to the midline of the lower back. Like with disk herniations, pain is worse with bending, prolonged sitting, or coughing/sneezing. Athletes who participate in twisting and flexion movements such as golf and tennis are more prone to this injury. Annular tears are a very common cause of LBP in athletes but are often overlooked because the characteristic complaint is a vague pain (similar to a stomachache and often called “spasms” because the pain is hard to characterize). Therefore, health professionals should always keep this condition in mind when assessing back pain.
Pain With Extension
Extension of the spine will tend to load posterior spinal structures, namely, the pars interarticularis, facet joints, and sacroiliac joints. We usually elicit pain with extension by asking patients if they find it especially painful to stand for prolonged periods, walk for prolonged periods, or arch their back. Oftentimes, the athlete will let you know characteristic movements that bother him or her in his or her sport, such as the gymnast who complains of pain with backbends.
Spondylolysis is a defect in a part of the bone called pars interarticularis that may be related to repetitive extension movements (3). Pain may develop suddenly or over time. It is usually dull in nature, localized to the lower back, and worse with lumbar extension. It is one of the more common causes of LBP in adolescent athletes, particularly in gymnasts, soccer players, track and field athletes (11), and swimmers who perform breast/butterfly strokes (Table 3) (10).
In addition to being a pain generator in itself, spondylolysis may allow slippage of one vertebra over another and subsequently cause an annular tear. Therefore, when assessing an athlete with spondylolysis, it still is important to assess which motions primarily exacerbate their symptoms. For athletes who have worse pain with extension movements, spondylolysis is the more likely pain generator. On the other hand, for athletes who have worse pain with flexion, annular tear is likely the primary pain generator. Although most causes of LBP are best diagnosed by a good history and physical examination, this is one situation where magnetic resonance imaging may be particularly useful to distinguish between the two diagnoses.
Pain With Transitional Movements
Transitional movements tend to cause sheer forces along the axial plane of the spine. We elicit pain with transitions by asking the athlete if he or she has pain when squatting or standing up from a chair. Oftentimes again, the athlete will volunteer movements that exacerbate the pain; for example, a second baseman who complains of axial aching LBP when standing up after fielding a ground ball.
Spondylolisthesis is the anterior or posterior slippage of a vertebral body on another, often in the setting of a patient who also has spondylolysis. Pain is typically described as dull and aching in nature and rarely radiates, like in spondylolysis. Pain also is typically worse with activity, especially with extension and rotational movements. Sports such as gymnastics, diving, and track and field can predispose athletes to this condition.
MANAGEMENT OF COMMON LBP GENERATORS
Once diagnosis is made, the athlete’s treatment plan should focus on regaining function and return to participation. For acute LBP, initial treatment should include ice to the area: 20 minutes in the morning, at night, and after activity. The athlete should withhold from activities that exacerbate his or her symptoms but should continue to participate in nonpainful activities. If needed, pain medications may be helpful, such as nonsteroidal anti-inflammatory drugs, for short periods.
Active exercises are a crucial component of preventing recurrences. Exercise programs should be tailored to the patient’s DP, such that he or she is performing exercises primarily in the direction that is least painful. For example, a patient who has LBP that is worse with flexion, thus has a DP for lumbar extension, should primarily be doing extension-biased exercises. Two types of exercise programs include the McKenzie Method and core stabilization.
“Centralization” is defined as finding movements that will shift referred pain out of the lower limb and into the lower back, with the goal of improving and eventually eliminating the pain. The McKenzie Method, also known as mechanical diagnosis and therapy (MDT), focuses on this idea of centralization. A key concept of MDT is identifying a patient’s DP, as described earlier, and gearing exercises based on that DP. In the case of athletes with herniated disks and annular tears, extension-biased exercises would be most helpful; whereas in cases of spondylolysis, flexion-biased exercises would be recommended. As the pain in the lower limb dissipates, LBP may initially intensify; however, with repeated motion, LBP typically will resolve as well.
Typical McKenzie Extension-Biased Exercises
- Prone lying: Lie on your stomach with arms by your side. Maintain for 5 to 10 minutes.
- Prone lying on elbows: Raise up on elbows with forearm flat on the ground and hold for 5 to 10 minutes.
- Prone press-ups: Lie on stomach, place hands beneath your shoulders, as if to do a push-up, raise chest off the floor by pressing arms down into the ground. Keep hips on the floor.
- Progressive extension with pillows (for beginners): Lie on stomach with pillow under your chest for a few seconds. Add second pillow for a few seconds. If tolerable, add third pillow and hold in extended position for up to 10 minutes. Remove each pillow over several minutes.
- Standing back extension: Stand with feet hips-width apart, with back against a table (edge of table ideally should be just below the waistline), cross arms in front of your chest. Lift chest and lean backward. Hold for 3 to 5 seconds, relax, and repeat.
Core stabilization is a popular mechanism for preventing LBP because it was believed to provide a variety of benefits, including improving athletic performance, preventing injuries, and alleviating LBP (1). A study by Hides et al. (6) mentions the lumbar multifidus muscle to be significant because it is important for lumbar segmental stability. Recurrence of LBP has been linked to weakness of this particular muscle. Patients who underwent a course of specific stabilizing exercises in addition to medical management reported 30% recurrence at 1 year compared with 84% in subjects who only received medical management (5). However, if patients have radiating pain into the lower limb, centralization should be prioritized over core stabilization.
Typical Spine Stabilization Exercises
The McGill Big 3 (8)
- Start on all fours with hands placed shoulder-width apart and back slightly arched.
- Lift left arm off the floor and extend it forward. Hold for 5 seconds. Do the same for the right arm.
- Next, lift and extend right leg behind you, hold for 5 seconds, slowly lower. Do the same for the left leg.
- Combine left arm extension straight in front and right leg extension to the back. Hold for 10 seconds and slowly lower. Repeat with the right arm and the left leg. Do three sets of 10 repetitions.
- Be sure to keep abdominal muscles firm and keep hips/trunks still and level.
- Lie on your back with the left leg straight out on the floor. Bend the right knee and keep the right foot flat.
- Place hands palm down under the lumbar spine to support a neutral curve.
- Slowly raise head and shoulders off the floor without bending the spine. Hold for 5 seconds and slowly release. Do five repetitions.
- Switch leg positions so that the right leg is straight out in front and the left knee is bent with the left foot flat.
- Be sure to keep the neck in neutral position.
- Begin by lying on your right side, supported by your right elbow, hip, and knees.
- Slowly raise your hips off the floor while supporting your body with your right elbow and your knees. Be sure to tighten your core (by contracting your transverse abdominal muscles and pelvic floor muscles as if bracing for a punch) and keep your spine straight in alignment. Knees should be bent at 90 degrees.
- Hold for 10 seconds. Do five repetitions.
- Once these are tolerated, advance to straightening out the body with knees in extension. Raise hips off the floor, with body supported by just your elbow and feet.
- Do the same for the left side.
For many, maintaining an active lifestyle, including participation in sports and related activities, is an integral part of their well-being, whether it is the professional athlete or the everyday fitness enthusiast. LBP can be a debilitating factor that deters many from activity participation. It not only negatively impacts an athlete’s performance and lifestyle but also predisposes to chronic issues in the future if not treated properly. Therefore, fitness professionals need to be mindful of the various causes of LBP and when to refer to a physician for further evaluation. By discerning an athlete’s pain generator, the fitness professional may then better tailor a treatment plan and exercise regimen for the individual athlete to promote a quick return to participation.
CONDENSED VERSION AND BOTTOM LINE
Low back pain is a very common complaint in athletes and can encompass a broad range of etiologies. Therefore, in evaluating low back pain in athletes, it is worthwhile to ascertain the athlete’s directional preference, which can help determine the primary pain generator. This in turn can help guide the athlete’s individual treatment plan.
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Keywords:© 2014 American College of Sports Medicine.
Discogenic Pain; Annular Tear; Directional Preference; McKenzie Technique; Core Stabilization; Sports Medicine