Athletic Low Back Pain Management 101
Athletic low back pain is quite common, however there is a paucity of literature specific to this population. Evidence based guidelines for acute low back pain center around exercise as a mainstay treatment, with heat, manual therapy, and pharmacological interventions as adjunct treatments (1). Based on our assessment, we should be working on a diagnosis of what tissue is affected and what movements are provocative. Knowing this we will initially reduce tissue load, maintain training load, and then gradually reload the affected tissue with a return to normal training and competition.
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.
Acute Phase: Pain Management and Movement Restoration
In the initial phases of acute low back pain, the primary goals are to offload affected tissues, control pain and restore normal movement patterns.
Offloading affected tissues
Based on our assessment we should know what movements and postures to temporarily avoid/limit. For example, for a rower with disc-related pathology, we would reduce exercises with repetitive loaded flexion and advise them to limit sitting time. Of course, the athlete needs to return to tolerating flexion, however, we initially want to decrease pain so we should avoid/limit provocative movements and postures.
Along with offloading affecting tissues, pharmacological agents can be a helpful adjunct in managing pain. While evidence is equivocal about the efficacy of pharmacological agents for long term outcomes (1), many athletes want to return to some level of training quickly, so these agents can be helpful in the interim. Note that your scope of practice in discussing pharmacological agents as a physiotherapist depends on your country and/or territory.
Another tool for pain control is taping of the low back, which can help limit provocative motions. In the video below from Kellie’s Practical, she shows her preferred taping technique for the lumbar spine.
With acute low back pain, normal movement patterns are initially limited by pain and abnormal muscle activation patterns (e.g. over activation of the erector spinae). To restore normal movement patterns, we want to select positions that minimize lumbar spine load while encouraging movement, such as quadruped rocking, pelvic tilts in quadruped, or even reverse lunges. There is no single exercise that will work for every athlete, so use your assessment and gradually try different movements to find what exercises the athlete can work on.
Sub-Acute: Returning to Training
After we control pain and restore regular movement, we can begin working on an athlete’s fitness, while not excessively loading the lumbar spine. Initial strength and conditioning in this phase will be modified variations of their usual training modalities. Then as tissue irritability decreases we can introduce familiar exercises. Also, throughout this process, manual therapy can be an adjunct treatment to help manage pain.
Initially, the athlete might be so irritable that manual therapy can be quite uncomfortable. Once the athlete can tolerate manual therapy, we can use it to help decrease muscle tone. As Kellie recommends in the below video from her Practical, manual therapy should be done with a test-retest approach, whereby a technique is applied to achieve a specific outcome.
Returning to training
Exercises performed in this phase of rehab should minimally load the lumbar spine, but they should start to resemble familiar training exercises and provide a robust training stimulus. In the below video from Kellie’s Practical, she explains how she implements a step up during this phase.
There are many other exercise options here, but some common examples are front squats, hip thrusts, and lunge variations.
Return to Sport
Return to sport planning should start on day 1, with the athlete, coach and other pertinent staff. After the assessment is performed, we should have a rough recovery timeline to inform training and return to sport. Initially, much of their training will be modified and less specific to the sport. Gradually over time, the volume of regular training (i.e. strength and conditioning exercises that were performed pre-injury) and sport specific work should increase, while modified training volume decreases.
Ideally, the modified training schedule mimics their regular training schedule. For example, if a rower is accustomed to rowing in the morning Monday through Wednesday, Friday, and Sunday, they could perform swimming, biking, and incline walking following the same schedule. Then, rowing sessions could be gradually reintroduced depending on the athlete’s response.
Another aspect to consider during this phase is to boost key movement capacities to prevent a recurrence of low back pain. For example, a tennis player may need to shore up deficits in anterior trunk strength and thoracic mobility by including specific exercises in their regular strength and conditioning program.
Lastly, nutrition may need to be altered depending on the training program. For example, as the athlete is performing cross training and reintroducing sport specific training, this high training load likely will demand an increased energy intake. To ensure athletes meet energy and nutrient requirements, working with a nutritionist may be warranted, especially for youth athletes.
In her Practical, Kellie discusses how to properly progress an athlete back to normal training and competition.
Athletic low back pain management is all about a solid assessment, individualizing exercises based on the athlete’s response, and planning return to sport as a team effort. Initially we want to offload the affected tissue and modify training to maintain fitness. Then we ramp up regular training load as we ramp down modified training. Lastly, as the athlete returns to full training and competition, their strength and conditioning program can have components that target deficits (such as decreased hip mobility or anterior trunk strength) to reduce the risk of re-injury.
To learn a lot more about managing athletic low back pain, be sure to check out Kellie’s fantastic Practical.
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