How to Master Your Assessment of Athletic Low Back Pain

Low back pain is a top musculoskeletal complaint worldwide, but athletic low back pain requires specialized assessment due to its unique features. First, athletes have the pressure to quickly return to high levels of physical performance. While most episodes of low back pain resolve in 6-12 weeks, many athletes attempt to return to play much more quickly. Another unique feature is that athletes likely fall on the far side of the “U-shaped” curve of exercise and low back pain. While too little physical activity is a risk factor for low back pain in the sedentary population, athletic low back may arise from too much physical activity or spikes in activity.

Lastly, when an athlete has low back pain, they usually cannot afford to be sedentary during their rehab process. They need to maintain their fitness as best possible in order to safely return to training and sport. Keeping these features in mind, our initial assessment should give us a working diagnosis, initial decision on referral, and timeframe for recovery (including how to train in the meantime).

If you’d like to see how a world-leading expert assesses athletic low back pain, be sure to check out Kellie Wilkie’s Practical, which I’ve based this blog on. With Practicals you can see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster. Learn more HERE.

Subjective Examination

Description of Symptoms

The description of symptoms provides a wealth of information to nudge us towards a working diagnosis. Most physiotherapists routinely ask about types of pain and neurological symptoms (e.g. numbness and tingling in the extremities). Another feature Kellie focuses on is the “shape” of the pain. Typically a finger line distribution of pain is representative of radicular pain whereas a hand span width broader distribution is more likely to be somatic referred pain. Often patients with radiculopathy present with both. In addition, pointing to the pain in the sacrum can indicate either SIJ pain or L5/S1 radicular pain. Patients with SIJ pain will describe aggravators as activities involving single leg stance.

Training/Sport History

The athlete’s sport and its movement patterns help us determine the likely drivers of pain. For example, sports involving repetitive flexion such as cycling and rowing often correlate with disc related pathologies. On the other hand, repetitive extension motions, like those seen in gymnastics or baseball usually involve the pars interarticularis and/or facet joints. Understanding the likely involved structures helps us unload the affected area, guides treatment, and enables training with non-provocative movements.

Also, we need to examine the athlete’s training history to understand what training factors may have led to this episode of low back pain. We know that a spike in training load is related to the onset of pain, while maintaining high training loads is actually protective.

Red and Yellow Flag Assessment

Another crucial part of the subjective is the assessment of red and yellow flags. Red flags such as unrelenting night pain or changes in bowel/bladder likely will necessitate referral to a physician for further evaluation. During the subjective, we can also catch yellow flags such as pain sensitization and psychosocial factors that may affect recovery. For example, if an athlete has had repeated bouts of low back pain, we may need to further assess this in the objective portion of the exam.

For a full walk through on red and yellow flag assessment, check out Kellie Wilkie’s Practical.

Objective Examination

A crucial consideration for the objective assessment is to keep it concise. We don’t want to unnecessarily aggravate an athlete already in pain. There will be time in future sessions to assess further. Also, in cases of intense low back pain, certain measurements may not even give us accurate information since pain may alter an athlete’s movement capacities (e.g. due to upregulation of certain muscle groups).

Lumbar Range of Motion

Standing lumbar range of motion tells us how motor control has changed and informs our working diagnosis. First, we look at movement quality. For example, in forward flexion does the athlete posteriorly weight shift and get full segmental flexion? Or do they hip hinge and try to avoid flexion through the low back? As we observe these motions, the athlete’s pain response can suggest possible involved structures. Lumbar flexion tends to aggravate the disc, whereas extension tends to aggravate pars interarticularis and facet joint pathologies.

However, as Kellie explains in the video below from her Practical, pain with extension can also be related to a large disc bulge or even an annular tear.

Neurological Examination

Beyond lumbar motion assessment, we also need to assess neurological function. We start with basic dermatome, myotome, and reflex testing. Kellie points out that to improve efficiency of myotome testing, we can use assessments like the heel and toe walk, which eliminate the need for manual muscle testing of those myotomes.

Next, we perform the passive straight leg raise, where we examine symptom provocation and when resistance to movement occurs, as Kellie explains here in this video from her Practical.

If the straight leg raise test is negative, the slump test can be performed. We assess both symptom provocation and range of motion, where normal is achieving -20 degrees of knee extension (20 degrees short of full knee extension).

Since the straight leg raise focuses on segments L4-S1, we may need to include the knee bend test (sometimes referred to as the femoral nerve tension test) to target nerve roots L2-L4.

Lastly, Kemp’s Sign can be used to assess contribution of the facet joints and spinal stenosis to an athlete’s pain.

Thoracic Spine and Hip Range of Motion

Assessing range of motion of the hips and thoracic spine will help us target any mobility deficits that may be decreasing movement efficiency. The hips and thoracic spine are better suited for mobility, whereas the lumbar spine is better suited for stability and transferring force. When we lack mobility in these areas, we are likely to have less efficient movement in sports that requiring operating near end range. For example, rowers typically need 130 degrees of hip flexion and cyclists need 115 degrees, so having a reserve of hip flexion will be helpful for these athletes.

In this video from Kellie’s Practical you can see how she assesses hip flexion.

Similarly, hip extension is crucial for throwing athletes, gymnasts, or any athlete that needs to express large degrees of extension. Thoracic rotation is also important, especially for swimmers or throwers, who perform repetitive extension-rotation movements.

Somatosensory “Smudging”

If an athlete is presenting with persistent pain, we should assess for somatosensory “smudging”. This refers to cortex level changes in representation of a painful area and may affect motor control. One assessment of such neural changes is testing 2-point discrimination on the low back. We also can assess the ability of the athlete to identify letters/numbers traced onto the painful area, if we suspect somatosensory “smudging”. These objective tests can then be repeated to show progress to the athlete.

Wrapping Up

The assessment of athletic low back pain should give us a working diagnosis, initial decision on referral, and timeline for recovery. Following the initial assessment we can refer out for further evaluation, begin conversations about return to sport, and modify training.

To learn a lot more about assessing athletic low back pain and see exactly how an expert goes about their assessment, be sure to check out Kellie’s fantastic Practical.