A Strength Coach’s Guide to Dealing with Pain, Part 3: Low Back
By
Andrew Paul
This article is part three of a three-part article series.
In parts one and two of this series, we discussed some strategies a strength
coach can use to reduce chronic shoulder and knee pain in athletes. In part
three, we’ll discuss some things we may be able to do in order to manage low
back pain.
When training athletes, an all-inclusive approach works best. This means that
not only do we pay attention to their strength levels, but we also pay attention
to their mobility, nutrition, and musculoskeletal alignment. This is apparent
the most when dealing with an athlete’s back. In parts one and two, I mentioned
the use of a massage therapist. They can be of great help. In this part, you may
need access to a massage therapist, a chiropractor, or a physical therapist.
Let’s get started and make this as simple as possible.
An athlete is complaining of chronic low back pain. At this point, we don’t
know what is causing the pain. For a strength coach, the first step is always
the same.
Refer out!
In the collegiate setting, we have athletic trainers. However, if you have
access to a chiropractor or physical therapists, use them immediately. It may be
nothing but spasms, and that’s fine but have a qualified professional look at
the athlete first. I regard my athletes’ spines as pretty important. Wait until
you get the go ahead from a doctor before proceeding with any other steps.
Check for anterior tilt of the pelvis.
In the athletes I work with, this is the single most prevalent cause of low
back pain. Anterior pelvic tilt is a result of tight hip flexors and weak
glutes, hamstrings, and abdominal musculature. Mainly, this is the result of our
modern sedentary lifestyle. I work with athletes who sit in class all day. Being
seated for a prolonged period of time causes their hip flexors to shorten and
hip extensors to lengthen. Anterior tilt is also seen in many sprinters. This
adaptation is a result of the body attempting to get more hip extension during
gait.
So what’s the problem? When the pelvis tilts forward, it causes the lower
back to be excessively lordotic, and it tends to tighten and ball up the
erectors of the low back. If this is the case (and it often is), we can manage
this very easily by hitting the body from all angles. Follow steps 3–5 and you
should be able to pull your athletes’ backs into a neutral position.
Lengthen the hip flexors.
Psoas, illiacus, and rectus femoris are our culprits. I will refer you to
part two of this series where we discussed lengthening these muscles using
exercises like the tempo lunge or EQI lunge. These can be very valuable tools
not only in dealing with knee pain but also in alleviating lower back pain.
Strengthen the glutes and hamstrings.
There are a million references out there that discuss posterior chain
strengthening. I’m not going to give you an exercise library or anything like
that. There has also been a ton of stuff written recently on glute activation
and strengthening techniques. Just remember to not only include straight leg hip
extension exercises but also bent knee hip extension exercises in your programs.
True single leg work also does a great job of recruiting your glutes as
stabilizers. The posterior chain is important in case you didn’t know.
Strengthen the core.
This is the most written about, controversial, and outright insulted muscle
group in the body. Strengthening the core doesn’t mean get out the Swiss ball or
do crunches until you die. We must learn to use the core for what it’s supposed
to be used for—stability. The abdominals are constructed in a way that holds the
low back and pelvis in a neutral position while the extremities move around it.
It’s hard to believe, but some athletes have a hard time with this concept.
In some cases, the deep abdominals go dormant and force prime movers to become
stabilizers. It’s most commonly seen in the piriformis. This muscle often kicks
in to become a pelvic stabilizer and ends up becoming overworked and inflamed,
cutting down hip internal rotation range of motion. And don’t forget that the
sciatic nerve lies deep in the piriformis. When this muscle tightens, it can
cause a lot of pain.
Dare I mention the word “Pilates?” This training style has become very
popular in commercial gyms in recent years. While this style may be misapplied
in some instances, in its true form, Pilates can be extremely useful. Shirley
Sahrmann’s core progression, presented in her book, Diagnosis and Treatment
of Movement Impairment Syndromes, has done some great things for my
athletes. Her progression is elementary and tedious, but you’ll be surprised at
how many people will struggle to do it properly. It starts as easy as a simple
supine abdominal bracing and progresses with various limb movements. Her goal is
to teach your core to stay stable as your limbs move around it.
Separate hip mobility from lumbar spine mobility.
We’ve all seen the traditional sit and reach test. Take a look and tell me
where a majority of the movement is coming from. If you said the low back,
you’re exactly right. If someone has tight hips, his movement comes from the
lumbar spine. Just watch one of your athletes do a high knee skip. If he has
weak or tight hips, he will collapse at his low back as if doing a crunch. This
is a perfect example of a common compensation pattern. Watch your athletes do
leg swings and try and see where a majority of the movement is coming from. If
it isn’t the hips, it’s wrong. This same pattern can be seen in many movements.
However, separating the hips and lumbar spine will allow us to begin to improve
hip mobility. This will take a huge load off your low back.
Leg swing with lumbar flexion (left) and without lumbar flexion
(right).
Mobilize the thoracic spine.
When looking at the structure of the spine, it becomes clear that the
thoracic spine has a much larger capacity for movement than does the lumbar
spine. When this area becomes immobile, we have a lot of problems in not only
the shoulder (discussed in part one) but also the low back. A great example of
this is during overhead pressing movements.
We’ve all seen an overhead press that looks something like this (see the
picture above). In this case, the lifter was purposely hyperextending. However,
you can go to the local commercial gym and see many people doing this
unconsciously. Because of an immobile thoracic spine, the body automatically
substitutes thoracic extension with lumbar extension. Mobilizing this region
will avoid unnecessary movement in the lumbar region. Tennis ball and foam
roller crunches were mentioned in part one of this series as well as overhead
squats. Another great way to work on this is to simply overhead press correctly.
Ankles, knees, hips, shoulders, elbows, and bar in a straight
line.
References
1. Sahrmann S (2002) Diagnosis and Treatment of Movement Impairment
Syndromes. St. Louis, MO: Mosby.
2. McGill S (2006) Ultimate Back Fitness and Performance.
Waterloo, Ontario: Wabuno Publishers.
3. Kendall F, McCreary E, Provance P, Rodgers M (2005) Muscles:
Testing and Function with Posture and Pain. Baltimore, MD: Lippincott
Williams & Williams.
Andrew Paul currently serves at the assistant director of strength and
conditioning at the University of Missouri. He works with the football,
softball, and volleyball teams. He can be reached via email at
andrewpaul@mizzou.edu.
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