Low Back Pain in Adolescents
By Jake Moore
Every one of us has worked with a young athlete with low back pain. In fact, we have all likely have worked with and missed the signs of serious low back pain in our athletes. Looking back at my career so far, I’m sure I have. Of those young athletes with lower back pain, up to 47% have spondylolysis or spondylolisthesis (1). Spondylolysis and spondylolisthesis are injuries to the posterior vertebrae and result from excessive spinal extension loading. Unfortunately too many young athletes are over-trained and exposed to poor training, leaving them at risk for these injuries. On the positive side, these injuries are preventable with good movement training and knowledgeable coaches. As IYCA professionals we expect to be held to a higher standard than other exercise professionals when working with young athletes. If we can recognize the signs of serious back, and how to train to prevent such injuries, it will go a long ways in diminishing low back pain amongst your athletes, help those with low back pain get timely treatment and decrease the impact of low back pain into adulthood.
Young athletes are at a vulnerable time to develop low back pain from excessive trunk extension. In late middle school and early high school they may be participating in multiple sports throughout the year. It is not uncommon to be in-season for one sport and still participate in off-season training for their club teams. (It would be worth another article to discuss how these athletes would benefit more from developing fundamental movement skills instead of being in-season all year.) In addition these athletes will be asked to begin a strength and conditioning program in their school as part of their athletic participation. Meanwhile this athlete is at a time in their development where:
1. The rate of bone growth is often outpacing the lengthening of muscle and fascia, leading to tight hips and poor posture.
2. Growth plates are still open and bone density is not yet fully developed.
3. Core strength is not developed as the body adapts to having longer limbs.
4. Motor control and posture are continuing to be shaped.
If these athletes are asked to perform fully loaded strength movements with poor form with an immature and ill-prepared body, the body has but one choice to accomplish this task. That is to hang onto ligaments and bony restraints instead of utilizing muscular control.
Pelvic influence on spinal curves
The spine has three curves. A lordosis, or slight backward bend at the cervical and lumbar spine, and a slight kyphosis or forward bend at the thoracic spine. This helps the spine absorb shock and increases stability versus a completely vertically stacked spine. The lumbar spine position is controlled largely by the pelvis. The pelvis is able to anteriorly and posteriorly rotate based on the muscle pull on the front and back side of the body. The images below demonstrate the muscles involved in creating rotation of the pelvis. The line of action of the hip flexors and spinal erectors pull on the pelvis to create anterior rotation. This anterior rotation results in increased lumbar lordosis. On the other hand, the glutes, hamstrings and abdominals create posterior rotation and a decrease in lumbar lordosis. It’s common to see individuals with inhibited glute and abdominal musculature and tight hip flexors and spinal erectors. The result is a tendency to position the pelvis in anterior tilt and increase compression of the lumbar vertebrae. When this occurs repeatedly over time, the posterior structures of the lumbar vertebrae are at risk for injury.
Spondylolysis and Spondylolisthesis
Some of the most significant injuries affecting adolescents are spondylolysis and spondylolisthesis. We all have likely trained athletes with this injury, whether we knew it or not. Spondylolysis refers to a stress reaction of overload to part of the vertebrae. In the lumbar spine this is often the pedicle or pars interarticularis. Spondylolisthesis is an advancement of spondylolysis with an identifiable fracture to the vertebrae and possible forward slippage.
The pedicles and pars interarticularis are located on the back side of the vertebrae and are placed under compressive and shear load when the spine moves into extension. Injuries to these structures often occur gradually over time. As an athlete is asked to do exercises that are beyond their ability for the core musculature to control, the lower back will drift towards extension to find stability. Think about trying to bend a copper wire. As you initially bend the wire a hinge point develops. As you do this over and over again the wire will bend more easily and eventually break. This is exactly what is happening to young athletes with spondylolysis. It’s critical that these individuals get treatment before it is too late (spondylolisthesis).
Recognizing serious low back injury
To recognize the signs of spondylolysis or athletes at risk, look at posture, core strength, hip mobility and activities. Posture is often excessively lordotic when doing squats, overhead presses, deadlifts, back extensions, push-ups and planks. These athletes may be some of your more capable squatters and deadlifters because they understand how to keep the spine from rounding forward. The problem is they can’t control spine extension. Athletes with poor core strength are more apt to use this type of strategy to make-up for inadequate active lumbar stabilization.
An athlete with limited hip mobility is also at risk. Without flexibility in the hamstrings, glutes and hip flexors, the athlete will have to bend more through the spine on order to perform sport specific or weight room movements. Tight hip flexors will pull the spine into excess extension and poor glute and hamstring mobility will force the athlete to contract more through spinal erectors. The end result either way is increased posterior spinal loading. Any athlete who has made recent large increases in loading in the weight room should be monitored closely for low back pain. Football players and gymnasts seem to be most at risk as well as athletes participating in multiple sports at the same time.
Initial symptoms of spondylolysis may be a dull ache in the back with no initial onset. These athletes often have the most pain with running and jumping due to large ground contact forces. Squats, cleans, deadlifts, overhead presses, planks and leg lifts are also exercises that can increase symptoms. These athletes may be able to do every exercise in your program but have pain doing it. These symptoms may go on for months before they bring it to your attention. It may even recur every year, increasing during track season for example, going away during the summer only to return during football season. Once diagnosed, these athletes may be held out of sports and put in a brace for up to 6 weeks with another 4-6 weeks of rehab before full sport participation. An athlete who develops spondylolisthesis may battle low back pain on and off for the rest of their lives.
Keys to prevention of Low Back Pain in Adolescents
1. Teach pelvic tilt. Understanding how to pelvic tilt is fundamental to developing awareness of the position of the spine and pelvis. An athlete who does not know how to posteriorly pelvic tilt will have difficulty controlling trunk extension and rest on boney structures during exercise. The athlete who cannot anterioly tilt the pelvis will have a hard time learning how to hip hinge and keep neutral spine with squats and deadlifts. Teaching pelvic tilt is easily done if doing and floor based core exercise. Have your athletes start with knees bent, feet flat. Have athletes practice arching the lower back up off the floor, keeping the glutes and shoulders down, then have them smash the lower back down into the floor. This can be progressed to quadruped, tall kneeling and athletic stance positions. Once your athletes understand pelvic tilt, many of your strength exercises will be easier to teach.
2. Train in neutral spine. Have your athlete’s pelvic tilt both ways and then find a happy medium. That’s roughly what we would call neutral lumbar spine. To find neutral spine a stick placed along the lower back works well. The athlete should be able to contact the stick at the sacrum, thoracic spine and back of the head.
Floor based core exercise should use neutral spine as well. Dead bug progressions work very well here. Have your athletes lift one leg or extend one leg and opposite arm, keeping neutral spine. Check under their back to be sure there isn’t an increase in the gap between the spine and the floor. Exercises such as double leg straight leg lifts will be too challenging for most athletes without a progression. This is why kids put their hands under their butt if asked to do excessive leg lifts with a weak core.
Look at how your athletes perform planks. Ideally the glutes should be tight and spine neutral. The pelvis position should not change when doing planks or push-ups. If it does, then the abdominals are fatigued or the athlete has poor core control and the lower back passive restraints will bear the load. Discontinue the set. This means push-ups may be limited more by core strength than by upper body strength.
Neutral spine applies for other strength exercises as well. Athletes should be able to use the force couples around the pelvis, engaging the glutes and abdominals to help control pelvic position. Exercises should maintain lumbar lordosis without forcing end range lumbar extension. Back extensions for example should be taken to full hip extension without hyper-extending the low back. For strength exercises, the cues to squeeze the glutes and tighten the abs will often help create balanced forces around the pelvis to control excessive pelvic tilt.
3. Improve hip mobility. As mentioned earlier, the hip flexors can create a force pulling the pelvis into anterior rotation, increasing lumbar lordosis. Keeping the hip flexors mobility is essential to allowing for neutral spine positioning when strength training and running. For younger athletes a specific static hip flexor stretch is not necessary. You can adequately train the hip flexors with lunges and split squats to develop mobility and neuromuscular control. Again use a dowel held along the spine and cue abs tight to improve pelvic control during the movement. On the other end of the spectrum, the athlete with tight hamstrings may not be able to utilize their glutes well when doing deadlifts, squats or getting into athletic stance. Getting the hamstrings more mobile will help young athletes access their glute strength and decrease demands on the lumbar extensors. Again, an isolated static hamstring stretch is not needed. Get your athletes to hip hinge with a stick and RDL with a neutral spine and you will develop functional hamstring mobility and trunk stability. These types of exercises along with many of the hip mobility exercises from your IYCA certification will help your athletes develop great hip mobility and allow for decreased demands on the lumbar spine during training and sport participation.
If you encounter Low Back Pain in Adolescents or an athlete who complains of LBP, take it seriously. Suggest that they see a therapist or physician for further evaluation. If their back pain is still there, suggest they see an orthopedic specialist. To help diminish the risk of spondylolysis, teach pelvic control through fundamental movement patterns and core exercise. Correct excessive spine extension just as much as you would the athlete who tends to round over. Teaching athletes how to move well and stay injury free is the essence of an IYCA professional and avoiding Low Back Pain in Adolescents. Being aware of the risk of spondylolysis in adolescent athletes will help direct those who need it to medical attention while improving the quality of training for all our athletes.
1. Motley G, Nyland J, Jacobs J, Caborn D. The pars interarticularis stress reaction, spondylolysis, and spondylolisthesis progression. Journal of Athletic Training 1998; 33 (4): 351-358