Chronic Low Back Pain (CLBP) can be a major factor affecting sports performance. Affected athletes may experience substantial decrements in both training and performance in their sport. It is estimated that in a given year 6%-15% of athletes will experience low back pain generally resulting in 4-6 weeks recovery (**if the athlete reports the problem and seeks treatment). In certain sports this can represent a significant period of the preparatory or competitive season. CLBP not only affects athletic activities but can also have a negative impact on an individuals’ work/personal life.
In the athletic population CLBP is generally diagnosed as one of two things,
1 – Degenerative disc disease where the intervertebral discs are under excess load causing “bulging” of the disc and potential impingement on the spinal cord or nerve roots branching from that segment of the cord.
2- Spondylolysis – degeneration of the vertebrae which may lead to fractures or Spondylolysthesis where one vertebrae slips forwards on the one below it leading to spinal cord compression and nerve root impingement.
But what if neither of these conditions is diagnosed and the athlete still has CLBP?
In this case, where no structural cause of the pain is found we generally class this as “functional” or Mechanical low back pain….
Mechanical LBP is an abnormal stress or strain on the muscles and ligaments of the vertebral column generally resulting from inefficient movement and core control, poor posture, muscular imbalance or incorrect bending or loading patterns.
On postural assessment, athletes with MLBP generally present with what is commonly known as Lower Crossed Syndrome.
Lower Crossed Syndrome in is simplest form means that the lower back muscles and hip flexors become short and tight while the abdominals and glutes become overstretched and weak. So from this it would make sense that all we have to do is give the athlete a million sit ups and glut bridges and that’ll sort the problem right???
However if we look closer at what actually happens further out from the source of the pain we see muscles in the quads, groin, hamstrings and as far down as the calf can be implicated in the problem.
So to effectively treat our athletes we have to look not only at static posture but more importantly at the whole body and how it moves during simple and complex tasks.
At Doolin Performance we assess a range of different movements from simple superman or plank exercises to more complex tasks like squats, single leg squats, overhead press and more sports specific movements like running and cutting. This allows us to get a full picture of the athletes patterns so we can pinpoint where the breakdown in pattering and control is happening (i.e, a lot of athletes may be pain free and appear to be solid in basic static ‘core’ exercises and and some may be ok even under load in a compound lift but as soon as they move to a more complex task such as sprinting or change of direction/cutting they are unable to effectively engage the necessary muscles to support the movement and this is where pain and dysfunction presents itself).
Once we’ve taken a full injury and training history and put the athlete through the full range of movement assessment we can then start to piece together where the dysfunction is arising from and we develop an individualized treatment plan for that athlete.
The majority of the time we integrate this treatment plan into the athletes existing training programme using alterations and regressions of exercises already being used where possible. Under certain circumstances it may not be possible for the athlete to continue normal training but in this instance we develop a plan using the equipment available to the athlete in their team training facility. This allows them to remain within the team training environment.
WE NEVER STOP AN ATHLETE FROM TRAINING!!
Although every athlete will have different requirements there are 5 basic steps we follow when treating an athlete for mechanical low back pain-
Teaching athletes to breath is one of the most important steps in treating MLBP.
The diaphragm and transverse abdominis muscles are key stabilizing muscles within the core. Habitual, chronic, breathing pattern disorders can have a detrimental effect on the functions of these muscles, reducing their ability to act effectively. This effect is magnified when breathing is challenged and a load is placed on the low back (i.e During exercise) First we teach the athlete how to breath properly then we stress this under load.
If an athlete is suffering from MLBP for some time we generally see not only loss of mobility both within the lumbar and sometimes thoracic spine but also within the hip joint. As we’ve seen previously there are a number of muscles that can be implicated in low back pain so mobility needs to be varied and individualized to the athlete based on movement screening.
Although the cause of mobility issues generally stems from muscular imbalance a lot of the time muscle tightness will have caused a locking of the vertebrae or pelvic joints. Freedom of movement in these joints is essential for relieving low back pain and so if this loss of movement is present we apply some regular manual treatment to facilitate release in conjunction with mobility training.
As much as we need mobility for training, we also need to be able to use the body as a whole when training and performing. The best example of this is the back squat, if we don’t have sufficient scapular stability (link 1) to hold the barbell on the back we send the load directly onto link 2…. the low back or lumbar spine! If the glutes and hamstrings (link 3) are weak we send the load into the quads (quad dominant squat) As a result of this we overload the knees (link 4) and before we’ve even completed the exercise we have 4 links working in a dysfunctional pattern.
This is where we integrate rehab into the athletes pre-existing porgramme, most of the time we are able to simply de-load the exercise, alter the range of movement (i.e ¼ squat or raised deadlifts) and refine the athletes internal and external movement cues. Some extra accessory work is generally provided to compliment the compound movements and exercises are progressed to single leg variations as the athlete is capable.
Once the athlete is pain free on functional and compound movements we progress to more sport specific movements on the pitch (i.e running, sprinting, cutting, tackling or kicking). These are unstable movements performed in a constantly changing environment that cannot be controlled. This phase involves training the CNS to be able to adapted to the rapidly changing environment and perform tasks using safe and effective pre-determined movement patterns. During this phase we do a lot of dynamic movement analysis and speed/agility technique work.
At the end of phase 4 the athlete should be back to training and competing at their previous level prior to the onset of back pain. As the season progresses it is common for the athlete to be presented with new challenges that may not have arisen within the MLBP rehab period that may stress the low back. For this reason it is essential to equip the athlete with a progressive maintenance programme with scheduled reassessment to keep them on the right track!!