Low Back Pain and the Athlete

 Low back pain is one of the most prevalent “dx” physical therapists see across the board.  So how does low back pain management change with athletes?  In some ways it’s exactly the same and others completely different.  The important thing is to pay attention to the big picture stuff so you don’t miss a major injury. 

Let’s talk about some of the major things we want to look out for and consider with the low back pain athlete.  First of all, low back pain is not a normal finding.  There is a reason the athlete is experiencing low back pain.  For example, when I have a football lineman or gymnast come to me with low back pain my PT senses are automatically heightened. Why? Because these particular sports and positions are more predisposed to having a potential spondylolysis or spondylolisthesis.  The reason being is the repetitive hyperextension and vertical loading required in these sports/positions.  Therefore, part of my screening process is determining if I need to get these athletes imaging.  From there, the management of these athletes with pars defects depend on the degree of slippage.  For example, if an athlete has a lower grade slippage than often there is some period of activity restriction until pain subsides and then most importantly a gradual reloading with activity.  
 
Another diagnosis often seen is disc issues.  These are more common than one would think and can be another injury that takes an athlete out for some time depending on the severity.  Athletes that undergo more axial loading, flexion and rotation in addition to collision sports are often in the higher rate of athletes with lumbar disc herniations.  One clinical pearl to offer is that sometimes when there is nerve involvement, the motor function is more affected than the sensory function.  Therefore, just because an athlete doesn’t complain of the “common” tingling or numbness in the leg, doesn’t mean you should skip a myotomal exam.  
 
Return to sport following a low back injury in the athlete can be another challenge.  While there is no “gold standard” return to sport testing for low back pain, plenty of data exists that athletes can return at a very high level following a low back injury (ex: Tiger Woods, Rob Gronkowski). Instead of the common algorithm like the knee has with hop tests (etc), the lower back is a little more multifactorial. However, similar principles apply. Return the athlete to his/her baseline function, clean up movement abnormalities, re-establish strength levels, and have a gradual return to sport with controlled to uncontrolled practices in the respective sport.  There is no one way and we should not make it one way.  Instead, understanding the needs analysis of the sport, position, and the athlete’s previous level of function should be our goal.  
 
Low back pain in athletes can be a challenging case to manage.  While it starts with a very solid assessment, understanding the biomechanics and positional demands of the respective sport will guide your interventions and eventual return to sport.  Make sure you understand each sport and position carefully.  For more information on return to sport considerations in the athlete and specific progressions and regressions, check out our Insider Access. 

Dr. Brian Schwabe, PT, DPT, SCS, COMT, CSCS
Board Certified Sports Physical Therapist
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