Low Back Pain

Low back pain (LBP) is a common symptom amongst athletes, workers and the general public. Many structures in the low back (lumbar spine) may produce pain when injured or inflammed. It follows that every back problem and pain is usually different and therefore requires different management and treatment.

Diagnosis is established through history of injury/pain, physical assessment and clinical tests. Generally, further investigations are not required, however certain clinical indications may require diagnostic tests such as X-Ray, CT scan, bone scan or MRI.

Common conditions that cause LBP pain are :

1. Facet joint hypomobility/locking/sprains
The small facet joints either side of each vertebrae require movement and translational gliding to move efficiently. If these become stiff or locked, then LBP may follow. These joints usually require mobilisation or manipulation to correct the problem.

2. Disc inflammation/ protrusion
Repetitive bending and heavy lifting may result in gradual damage/bulging to the lumbar discs (most commonly the lowest L4/5 or L5/S1). This may result in severe LBP requiring significant activity modification, analgesics and anti-inflammatories to settle the disc. Treatment and rehabilitation should be progressed to ensure your deep core muscles and function is optimal.

3. Sacroiliac joint (SIJ) inflammation/ injury

These pelvic joints are often inflammed when abdominals and gluteals are weak and increased strain occurs through the joint and ligaments. This pain is often seen during and following pregnancy when the joints show laxity and the muscles do not have normal function and strength.

4. Muscle tightness/ trigger points
The deep 'quadratus lumborum' muscles on the side of the back often become overactive when the abdominals are weakened/inhibited due to pain or imbalance. This often occurs in sports that require lumbar rotation (eg: tennis, golf and ski paddling). These muscles require treatment with firm “trigger point release” to assist in releasing the muscle guarding.

5. Osteoarthritis/ lumbar stenosis

Certain degenerative conditions of the lumbar spine may develop over the years following injury, neglect, overuse or imbalance. These findings may be seen on X-Ray and the joints often benefit from mobilisation to reduce hypomobility/ stiffness and ease pain.

6. Lumbar functional instability/ poor core stability
This very common cause of LBP results from poor muscular stability and control of the lumbar spine. This may result in micro-inflammation of the joints, ligaments or nerves which triggers a pain response. Core stability exercises such as 'swiss ball' or 'Pilates' are benefical at improving muscle control and managing this problem.

Other less common causes of low back pain are:

1. Stress fracture of the pars interarticularis (spondylolysis)
This overuse injury may occur in athletes that place excessive stress on the lumbar spine in extension/ rotation combined movements. It therefore often presents in fast bowlers, gymnasts and dancers. Treatment is usually rest, abdominal rehabilitation and gradual return to pain free movements over 2 to 3 months.

2. Spondylolisthesis (vertebral slippage forward)
This gradual degenerative condition may progress in backs that exhibit spondylolysis and occurs more commonly in females at the L4/5 level. Treatment consists of pain relief, rest and abdominal rehabilitation.

3. Varied medical conditions
Consideration must always be given to medical conditions that may refer pain to the lumbar spine eg: kidney infections, bowel problems, other sinister pathologies. Your GP requires you to see them for assessment if these conditions are suspected.

Treatment for LBP depends on the condition and your Sports Physio may:

1. Recommend activity modification/ avoidance/ rest.
2. Provide you with manual therapy/mobilization techniques to relieve pain and restore movement.
3. Treat you with soft tissue massage/ “trigger point release” to relieve muscle tightness/ guarding.
4. Advise you in specific exercise to reduce the pain.
5. Apply tape to unload / support the back.
6. Identify and correct factors that caused the pain eg: poor posture / muscle imbalance / pelvic asymmetry / dysfunction in deep core muscles.
7. Advise you in maintaining fitness with other types of exercise eg: swimming / hydrotherapy.
8. Assist you in gradual return to your desired sport / activity as full range / pain free movement is re-established and any flexibility and control issues are addressed and resolved.

The functional activation of the deep core muscles of transversus abdominus and multifidus is paramount in prevention and recovery from low back pain.