Uncommon Causes of Low Back Pain
Low back pain is one of the most common complaints I see as an exercise physiologist. While pain is a very complex issue (check out this interview with pain expert Dr. David Butler - interview), the aim of this article is to explore non-specific, mechanical low back pain. Meaning spinal structures have become sensitised in the absence of pathology or injury, the pain has a clear and consistent anatomical focus, has a response that is proportionate to the stimulus and is clearly provoked by specific activities and postures.
There are a number of common and not so common reasons why people end up with sore backs. More often than not the issue is a result of trying to perform an activity you aren’t prepared for, functionally or anatomically. I like to refer to this as "Trying to jam a square peg in a round hole."
Injury = Load > Capacity
Below are 3 less common ways the low back can take excessive load and become painful during exercise and movement.
1. Poor Ankle Range of Motion (bilaterally or unilaterally) – do you find your chest pitching forward during your squats? This can be caused by numerous reasons, a jacked-up ankle that doesn’t have sufficient dorsiflexion (getting your knee over your toes) being one of them. Once that ankle hits a road block the torso starts to lean forward increasing the moment arm of the spine and subsequent the load on the back. Perform the knee to wall assessment in the video below to see if you have the required ankle range. Range of greater than 10cm and symmetry between right and left is what you are aiming for.
2. Poor Over Head Shoulder Range – can you effectively get your arms above your head? If not, you haven’t earned the right to do overhead strength work such as shoulder pressing and all its variations i.e military press, push press and jerks, thrusters, snatch. If you continue to perform the movement without the requisite mobility the low back among other areas will take a beating.
Perform the wall shoulder flexion assessment in the video below to see if you have the required overhead range. You should aim to reach the wall with your hands, keeping your elbows straight and without your back leaving the wall.
3. Weak Upper Back Retraction – I have come across this dysfunction numerous times in rowing and Crossfit athletes. They present with higher low back pain around the Thoracolumbar junction. When they are assessed on the ergo and during rowing strength exercises their overuse of the lats and inability to effectively retract their shoulder blades causes them to hinge excessively through their back to achieve the same end point. Another factor impacting upper back strength is an imbalanced exercise program that doesn't have enough horizontal pulling variations or upper back accessories.
Helpful fixes for this include:
Modifying their rowing technique to allow more scapula retraction, this is achieved by focusing on keeping the elbow away from the body, something Eric Cressey talks about
Cueing and training proper anterior core activation so the ribs don’t flare during the movement. A cue I like is, "Imagine your abs are lego blocks, don't let them break apart"
Ensuring adequate horizontal pulling strength work and upper back accessories are programmed
A Real World Example:
I recently saw a 40 year old male who has a history of lower back pain that would “go” on him during exercise and keep him out of doing what he loves 3 times a year. He is a high achieving individual who likes to push the envelope in work and fitness. On this particular occasion he presented after WOD consisting of AMRAP thrusters. After running through a comprehensive functional movement assessment we identified some significant handbrakes on his performance, these included a 3cm knee to wall right side and he was unable to get his arms above his head without hinging through his low back - a recipe for disaster when thrusters are added to the mix. We worked through my pain to performance framework and he is now back training at maximum intensity, running ultra endurance events and has been armed with a long term strategy to keep his body feeling good and performing at a high level.
Thanks for making it through the article, I would love to get your thoughts or questions below!