Written By: Claire Kopko, PT, DPT, OCS, NASM-PES
Low back pain is an almost expected malady of any strength athlete. It is the rare lifter who has not complained of this and had his performance negatively affected by this problem. Some opt to ignore the problem and work through it, while others choose to avoid aggravating movements. Both of these options are subpar, as neither will lead to relief from back pain or protection from it in the future.
As a physical therapist, I have treated hundreds of patients with low back pain. They include high level and youth athletes, weekend warriors, laborers, and desk jockeys. Often, the patient can pinpoint a moment when he lifted an object or moved a certain way, and had sudden onset of pain. Other times, the patient details a more gradual onset of pain during specific activities, such as bending, lifting, running, or walking. The pain can progress to the point that the patient is uncomfortable even at rest.
The common theme is that patients can attribute the onset of pain to a specific movement, regardless of activity level or involvement in sports. The typical response is to avoid that movement, thus preventing further discomfort. This is completely expected and there are times when this is an appropriate response (not addressed in this article), but in the case of mechanical low back pain, research shows just the opposite to be true. Because avoiding the movement affords relief, this becomes a habit, further altering the biomechanics of the spine and trunk muscles. Here is where the problem worsens; atypical movement patterns are reinforced, creating further weakness and inflexibility, and a vicious cycle is born.
The brain is re-trained to associate movement with pain, and non-movement with relief. When vertebral motion becomes dysfunctional due to an abnormal pull or inadequate stabilization from the surrounding musculature, it creates an atypical movement pattern, which is perceived as pain. Each joint consists of nerve endings that relay proprioceptive information to the brain, so when abnormal movement occurs, the brain receives information that something is “wrong” and works to protect the body.
How does this pertain to strength sports and strength training? Let’s take a look at the deadlift, an exercise that is frequently avoided due to low back pain. The lumbar paraspinal muscles are highly active throughout the deadlift motion; they work to keep the low back extended, which in turn allows the lifter to keep his chest up and pull the bar back. If the lumbar paraspinals are overworked, typically due to incoordination of the abdominal, gluteal, and low back muscles, discomfort is felt as spinal motion becomes abnormal. The lifter automatically assumes that this pain is dangerous and stops deadlifting. For a while, back pain may decrease, but let’s say that he returns to squatting after a week of total rest. The squat also places high demands on the lumbar paraspinal muscles, with back extension being necessary for successful completion of the lift. The lifter may not think to avoid extension in this case, but the lumbar spine has “learned” that extension is dangerous and to be avoided, so the squat becomes pain-provoking as well. Pretty soon, the lifter ceases to participate in squatting as well. What’s left for lower body training that won’t anger the lumbar spine
“Working through” the pain is preferable to avoiding aggravating movements, but this approach also has its downfalls. Again, let’s look at the deadlift. The lifter has decided to power through his back pain, and finishes the lift, but it looks ugly. The brain has learned that extension is dangerous, so it works to inhibit this motion. The lifter finds a way to lift the bar from the ground, but does so with a rounded low back. In this position, the abdominal muscles cannot work to stabilize the lumbar spine, so movement becomes even more dysfunctional than it was before the painful lift. The brain is attempting to protect the body from further injury by inhibiting the muscles that will allow it to occur. The lifter may not develop fear-avoidance behaviors, but the stage is set for more threatening injuries and disappointing performances. He is incapable of performing the lift correctly until movement is normalized.
So what do we do in this seemingly “damned if you do and damned if you don’t” situation? The first step is to identify what is causing the low back pain in the first place. Most commonly, the problem arises from too much activity from the hip flexors and paraspinal muscles, and not enough support from the abdominal and gluteal muscles. An overworked muscle becomes tight, which itself causes pain, but also alters the movement of the joints to which it is attached. So the lifter has the overt muscle pain to overcome as well as incoordination. Treating the tight muscle is a good start – myofascial release, whether from a foam roller, tennis ball, or massage, will work, but this is symptom control. The problem will keep coming back until the root cause is addressed.
In the deadlift, a rounded back is often a sign of weakness and incoordination of the gluteal and hamstring muscles. These muscles work together to extend the hips and stabilize the pelvis; when this doesn’t happen, the lumbar paraspinals do not have a solid base to operate from and cannot properly extend the low back. They will continue to try to do this but simply cannot produce enough force to get the job done. At a certain point, the muscle will protect itself through inhibition – when too much tension is produced, muscle relaxation is forced, which causes strains and trigger points.
To treat this problem, it is necessary to strengthen the hamstring and gluteal muscles. Ensuring that it is done correctly is the trick; the exercises must be felt by the lifter in the correct muscles; if low back pain is reproduced or the lifter feels most of the work being done in the lumbar paraspinals, form and perhaps exercise type have to be altered. Learning a basic “glute set” is a good start so the lifter knows what he is trying to accomplish. This is basically squeezing the butt cheeks together. So when that can be performed, this can be integrated into movements involving hip extension, starting with “movement prep” exercises such as supermans, birddogs, bodyweight good mornings, and unweighted reverse hypers. Once correct coordination is established, a load can be added to the movements, starting slowly with bands and light weights. When the lifter is comfortable with moderately heavy loads focusing on hip extension, he can resume deadlifting, adding weight as he is comfortable, focusing on form for at least a month before really pushing the weight. It is vital to include ab training through all of this – the lumbar paraspinal muscles, hip flexors, and abdominal muscles all work to stabilize the trunk throughout extension of the hips and lumbar spine. If abdominal strength is neglected, back pain will return.
Once proper motor coordination is established, back pain is often cured, or it is at least reduced to a manageable level. The best way to do this is to work on correct movement rather than avoiding it or attempting to force the body to adapt with improper patterning. Correct movement will provide long lasting musculoskeletal health and ensure the longevity of a strength athlete’s career.