Back pain is the most prevalent musculoskeletal condition that effects the general population effecting approximately 15-20% per year. There appears to be a belief that low back pain is saved for the elderly, inactive, overweight or indeed those who are involved in heavy manual jobs. Unfortunately, sports people are not exempt from this problem. Up to 85% of athletes that participated in sports that involved high spinal load reported low back pain at some point in their career. (Baranto et al., 2009)
A study on Dutch soccer players found that 64% of players had low back pain at some point over a 12-month period and that it reoccurred in 59% of these.(van Hilst et al., 2015) Back related injuries in Gaelic football have been recorded as being between 2.5% and 15% of all injuries between 2011 and 2014. Similar figures have been reported for trunk injuries in Hurling over the same period. (Blake et al., 2015) Interestingly, research suggests that people who are involved in rotational based sports and who are less active during the day are more likely to experience low back pain. (Chimenti et al., 2013) This is particularly relevant to the footballer or hurler who sits at their desk all day and then can often have a long drive before rushing into dressing room and out into a warm-up.
Back pain has been shown to detrimentally effect physical performance in both men and women. As with most injuries recurrence rates are high. (Novy et al., 1999) Although lumbar spine injuries only make up 1-2% of new injuries during the AFL season, back injuries have been responsible for 5% of games missed over the past 10 seasons. (Orchard et al., 2014)
Although sports people receive more medical attention their short term recovery is thought to be poorer than the general population. This can be more problematic in amateur athletes who may incur loss of earnings as a result of their injury. Back pain can also take its toll on family and social life particularly when it becomes a chronic or recurrent problem.
What Structures are involved?
There are a number of misconceptions that appear to be commonplace in society and particularly in the sporting population with regard to the cause or contributors to back pain. Athletes often suspect a bone, joint or their pelvis being ‘out of place’ as being the source of their back pain. This was never more debated in the sports medicine world then in 2014 when Tiger Woods missed a major tournament citing his ‘sacrum being out of place’ as the primary factor.
The reality is that these phenomena are unlikely to occur and there is certainly no medical research to back up such opinions. A difference in leg length is also regularly offered as misconceived contributor to low back pain in athletes. Although there are a small number of hurlers/footballers who may have a leg length difference due to a fracture or birth defect there appears to be an over diagnosis of this problem in athletes who get recurrent low back pain.
|The importance of an accurate diagnosis cannot be overstated. Understandably I see a lot of athletes that are very concerned because they think there ‘disc bulge’ won’t get better or that they have ‘wear and tear’ in their back.|
Research on people without back pain shows evidence of disc degeneration (91%), disc protrusions (32%) and disc bulges (56%). (McCullough et al., 2012) These changes are more common at the lowest 2 levels of the spine in the athletic population. (Ozturk et al., 2008) There is little sports specific data on the sources of low back pain. Low back injuries that result in significant nerve related problems make up 5-10% of presentations. Nerve injury or compression that may causes pain, weakness and/or numbness in the leg in an athlete is most likely to be as a result of a disc prolapsed.
The majority of the remaining back problems (up to 90%) are difficult to attribute to one specific structure in the lumbar spine and are referenced as non-specific low back pain. These are most likely to be as a result of soft tissue strains, sprains or overload of the superficial/deep muscles of the lumbar spine or of the small facets joints the allow for movement of the lower back. Imaging in the form of MRI is generally not warranted in these presentation.
My work in the Sports Surgery Clinic allows direct access to a multi-disciplinary team including Sports Medicine Consultants, Radiologists, Strength and Conditioning Coaches and Consultant Neurosurgeons. Being able to call on these services ensures that we can make an accurate diagnosis and identification of the factors driving the issue relevant to the athlete and ease people’s fears with regard to their prognosis as many radio-logical findings are present in healthy pain free populations.
Why does back pain occur?
As with the majority of musculoskeletal injuries, causation is generally considered to be multi-factorial. Contributors can be divided into extrinsic (external to the athlete) or intrinsic factors. The primary extrinsic factor that may be key to a hurler or footballer experiencing low back pain is their training history. Training load and intensity need to be evaluated to ascertain whether players have had a sharp spike in load or indeed the opposite could be a contributor where players are not adequately prepared for the required demands of competition. Overall training load and spikes in training load have been shown to result in increased reporting of low back pain in a number of individual and team based sports. (van Hilst et al., 2015, Bahr and Krosshaug, 2005).
Lack of rest or recovery strategies employed by teams may also be a contributing factor. Liaising with the team physio, S&C coach or manager can be very effective in this incidence particularly when there is a trend of injuries within a team. Environmental factors such as weather and the type/quality of surface players are training on (i.e. Astroturf vs grass) may influence training load or increase the risk of contact type back injuries.
The type of training undertaken may be of importance. In my own experience there seems to be a group of athletes who report back pain after longer running distances while having little difficulty tolerating speed and acceleration work.
These athletes tend to over-stride which can result in a more pronounced anterior pelvic tilt (black arrow figure 1) and curve in the lower back. Fatigue can often result in an accentuation of these movement patterns leading to increase loads in the lower lumbar spine and the lumbosacral junction.
This type of movement pattern is commonly encountered in juvenile stress fractures. Lateral pelvic drop is also a common finding when assessing running style. This is often associated with trunk side flexion to the side of the pelvic drop. Poor lateral hip strength in the presence of low back pain should be addressed.
The gym based environment is a key part to most club and inter-county players training schedule. The exercises chosen/equipment used and the expertise of coaching are key factors in the possible prevention/reduction to low back pain in our athletes.
|Unfortunately, I would consider poor lifting technique as commonplace in GAA players.|
As it is relatively new to our game players may not have been coached in the basics of movement patterns from a young age. These patterns are essential when developing safe and effective lifting form. Gym based environments can foster a competitive culture leading to a focus on weight lifted rather than control of movement. Although athletes may not have any adverse effects in the short-term, use of poor technique while lifting large loads is likely to have unwanted consequences at some stage in their sporting career