Welcome back to Squat University! Over the past few weeks we have been discussing the topic of low back pain. Last week we explained the differences between three common types of back injuries.
This week I want to jump into how we differentiate between each of these problems. My goal today is to help you understand if the injury you have is something you can work through on your own, or if you have signs of a more serious injury that requires help from a medical professional.
When an athlete strains a muscle in the low back, the area around the tear will usually become very inflamed. This rush of inflammation will usually lead to back spasms, pain, and difficulty moving.
These types of injuries usually occur suddenly. If the muscles of your low back are placed under excessive stress due to poor technique, they can eventually tear. This type of injury does NOT produce pain that radiates down the legs. It is almost always localized to the low back region.
What sets this injury apart from the more serious ones we’ll discuss next is how quickly the symptoms usually subside. Pain from this type of injury will usually clear up within a few days or weeks with rest, ice and proper therapeutic exercise (4,7).
Spondylolysis is one of the most serious injuries that can occur in the low backs of young athletes. Unfortunately, this injury is fairly difficult to diagnose without having a CT scan of the spine.
So how do we know if an athlete has this problem? You have take into account WHEN the athlete has pain. Athletes who have sustained a spondylolysis fracture often complain of a GRADUAL increase in low back pain after activity that includes spinal extension (1,6). For a strength athlete this would be during or after a workout that includes any barbell movements that places the low back in an over extended position repeatedly.
Trying to diagnose an injury as severe as spondylolysis based purely on when symptoms present is obviously difficult. However, it is currently one of the only ways to tell if an athlete requires a more in depth evaluation from a medical professional.
There is currently no physical screen to selectively test for this injury. In the past, some medical professionals proposed a test to diagnose this injury called the single leg hyperextension maneuver (1). To perform the screen, the athlete would stand on one leg and lean backwards. The test is considered to be positive for a spondylolysis fracture if it reproduces pain (2).
However, this test has NOT been shown in research to be very good at predicting this injury (3). This means a positive test can neither confirm nor deny the existence of a spondylolysis fracture. The extension performed during the movement can definitively aggravate a spondylolysis fracture. However, it can place force on other structures of the low back that could be injured as well, making this test not reliable.
If an athlete has pain with extension of their spine that is brought on over many months it is advised to seek the advice of a medical doctor. They will likely order bone scans of the back in order to rule in or out this injury.
One of the main signs of a possible disc injury is the presence of pain that radiates into one or both of the legs. This issue usually develops over a period of months and years. Symptoms can easily manifest all at once.
For example, if the back is placed in a flexed position (i.e. bending over to tie your shoes) when a disc herniation is present, forces placed on the spine can cause the disc to push against nerves in the spine. When this happens it is common to feel an instant shot of pain that will radiate from the back and down one leg or both.
The straight leg raise test can be useful in diagnosing this injury (5,8). You will need a partner to perform this screen. Start by lying on your back. With your legs completely relaxed, have your partner raise one leg at time as high as possible while keeping your opposite leg completely flat on the bed.
Here is a VERY OLD video from YouTube that describes this test.
The goal is to see if any symptoms of radiating pain are produced AND at what degree of movement the pain occurs. A positive test will reproduce pain (not hamstring tightness) on the raised leg between 30° and 70°.
The back can be a complicated area of the body to understand. There are obviously many different injuries that can be sustained at this area. Understanding the differences for WHY each injury occurs and HOW to tell them apart is the first step to taking control of your pain and getting back to the sports you love to perform.
Until next time,
- Syrmou E, Tsitsopoulos PP, Marinopoulos D, et al. Spondylolysis: a review and reappraisal. Hippokratia. 2010 Jan-Mar; 14(1):17-21
- Jackson DW, Wiltse LL, Dingeman RD, et al. Stress reactions involving the pars interarticularis in young athletes. Am J Sports Med. 1981 Sep-Oct;9(5):304-12
- Masci L, Pike J, Malara F, et al. Use of the one-legged hyperextension test and magnetic resonance imaging in the diagnosis of active spondylolysis. Br J Sports Med. 2006 Nov; 40(11): 940-946
- Koes BW, Van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ. 2006; 332:1430-4
- David J Magee. Orthopaedic Physical Assessment. Chapter 9: Lumbar Spine; 5th 558-564
- Letts M, Smallman T, Afanasiev R, et al. Fracture of the pars interarticularis in adolescent athletes: a clinical-biomechanical analysis. Journal of Pediatric Orthopedics. 1986;6:40-46
- Twomey LT & Farrell JP. Acute low back pain. Comparison of two conservative treatment approaches. Med J Aust. 1982 Feb 20;1(4):160-4
- Majlesi J, Togay H, Unalan H, & Toprak S. The sensitivity and specificity of the slump and the straight leg raise tests in patients with lumbar disc herniation. J Clin Rheumatol. 2008 Apr; 14(2):87-91