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Physiotherapist And Doctors Services - Low Back Pain

Sam Simpson, Tuesday, 1 February 2011

Lower Back Pain















(spine instabilities)

- Low back pain. Usually one side, but can be across both side.
- Pain worse with extension (particularly single leg extension)/rotation loading and skills.
- Worsens with activity, improves with rest
- Common presentation
- Occurs over time, but athlete may report sudden onset of pain 
- Consider as highly possible diagnosis if athlete is an adolescent with functionally limiting low back pain.
- Overload of region is a continuum, and the athlete may be at any stage of that continuum (i.e. early or late stage).

Stress reaction to stress fracture

Early in continuum can be soft tissue concern, or low level stress reaction of bone

Early spondylolysis

Hairline fracture

Progressive spondylolysis

Wide pars defect

Terminal spondylolysis

Non union pars defect with little chance of healing



The anterior displacement of a vertebra or the vertebral column in relation to the vertebrae below

- Spondylolysis – fatigue fracture of the ‘pars inter-articularis’ (section of arch of bone at back of vertebrae that comes under compression from vertebra above when back extended).
- Spondylolisthesis – bilateral (both sides) fracture – may lead to forward slip of one vertebra relative to lower level

Contributing factors

Can be family history
- Female and male athletes
- Often other spine abnormalities present on investigations which may contribute to overload
- Occurs more frequently around periods of increased athlete growth
- Increased numbers of skills requiring extension of back (e.g. flicks, walkovers etc)
- Flexibility deficits (particularly limiting contributing to extension) anywhere in upper limb or trunk chain (e.g. wrist, shoulder, thoracic spine, hips) – elbow may compensate
- Muscular/neuromuscular stability at forearm, shoulder, trunk and pelvic (in either hang or lower limb/supper limb support) may cause overload of elbow

Key management points

- Reduce all aggravating activity until follow up with health professional (Sports Physiotherapist, Sports Physician)
- Work closely with health professionals experienced with gymnastics and low back concerns
- Seek review of Sports Physician for confirmation of diagnosis – developing lesion (positive SPECT, -negative CT), active lesion (positive SPECT, positive CT, silent/established lesion (positive CT, negative SPECT). MRI – now different weighting improving sensitivity and specificity and can be very helpful in determining stage of lesion.
- Seek sports physio advice for confirmation of diagnosis, identification of possible contributing factors, rehabilitation outline and timelines

Management strategy

- Identify periods of increased growth (spurts) and reduce overall training loads until spurt over
- Pain worse on extension
- Seek advice and investigations a.s.a.p (Sports Physiotherapist, Sports Physician)
- Plain X-Rays of little benefit
- MRI improving sensitivity and specificity of findings – can also use with CT to define fractures. Historically SPECT and CT scans used as investigations of choice.
- Early and mid-stage lesions have better chance of healing, so length of time unloading will generally be longer to establish healing at lesion site (3- 5 months avoiding aggravating activity and rest).
- Terminal lesions still require up to 2 months modified loading to settle symptoms. Unfortunately later stage lesions are less likely to heal, and can lead to further low back changes and wear issues overall.
- Modified training should avoid running, landings and impact loading. Strict avoidance of extension essential.
- Keep diary of activity levels _ if symptoms increasing, remove aggravating activity until pain begins to subside
- Back support (neoprene) can assist in management to improve low back position sense and thermal effect
- To target areas of flexibility (above and below) contributing to low back overload - thoracic spine/hip extension/shoulder capsule etc (athlete may compensate for deficits above and below by increasing lumbar extension range)
- Address trunk endurance all planes, hip and shoulder stability in position of support (run/landing/overhead support) – limitations in support base can cause trunk to compensate
- Deep abdominals/pelvic floor program.
- Trunk/abdominal program with emphasis on maintenance of neutral lumbar spine
- Improve lower limb (and upper limb – overhead support) general conditioning to assist dampening loads/impact.
- Return to activity on advice from health professional (Sports Physiotherapist, Sports Physician) only.
- Return to activity should be monitored closely, and should build up slowly.
- Coaches to emphasise correct technique (avoid hyperextension or lack of mid-body control)
- Ice baths post training if symptomatic
- Continue mid body and lower body programs


- Thoracic wedge, hip extensors (hip flexors/rectus femoris)
- Lat dorsi stretches
- Hip internal rotation, hip anterior capsule
- Pectoral minor stretches (open book) over roller, sleeper/cross body stretches,
- Triceps, wrist stretches
- Trigger releases of soft tissue
- Ankle incline board stretches (knee straight/bent)
- General lower limb flexibility


- Lower limb conditioning – lunges/single leg squats/standing hip exercises
- Calf raises with emphasis on correct alignment ankle to foot – straight knee and bent knee
- Hip exercises to target glut med and min in side lying
- Trunk endurance exercise all planes of support all performed with emphasis on neutral spine
- Deep abdominal + pelvic floor program
- Trunk exercises around neutral lumbar spine in support or hang
- Scapula stability exercises all planes of support (with variation of hand position in each plane of support) and hang
- Hip/pelvic control exercises in position of support

CV fitness

- Modified to low impact only during rehabilitation – water running (with belt to unload completely), bike, cross trainer etc.


- Thoracic, wrist, elbow and shoulder mobilisation,
- Pectoralis minor releases, regional soft tissue mobilisation
- Lumbar and hip mobilisations, fascial/sacrotuberous releases etc.
- Prescription of rehab targeting conditioning deficits
- Monitoring of training loads, progression of rehabilitation program and suitable training loads.

Return to sport

- When given all-clear by doctor/physiotherapist - progression and increased loading depending on pain-free activity. If pain returns athlete to unload and seek advice before re-commencing.

Key management points

- Follow up with Sports Physician for investigation
- Seek physio advice for confirmation of diagnosis, identification of possible contributing factors, management outline
- Early identification, single level lesion, no family history = better prognosis
- Late identification, multiple level lesion, family history, co-existing spinal abnormalities = poor prognosis
- Unload back as per management advice doctor/physio
- Use soft brace for improved position sense of trunk
- Rehab to identify contributing factors to overload (see ‘Management Strategy’)
- Coaches to monitor ‘growth spurts’, training loads, improve condition of surrounding muscles groups in support to assist sharing loads. Report any concerns to Sports Medicine support.



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