This article was updated on 1/22/2020
We've all heard that lifting with a rounded lower back (flexed lumbar spine) can lead to low back pain. The theory here is that loading a flexed spine increases stress on the intervertebral discs and can eventually lead to overload and injury (herniation, end plate fractures etc.) (1,5).
What's also important to wrap your head around is that many people don't have trouble with lumbar flexion but with the opposite motion called extension.
The idea is that too much loading into lumbar extension can create injury to the posterior elements of the spine (6). Injured areas can include:
Folks with flexion based low back pain typically have more pain when their spine is in a flexed or rounded position. They'll often complain of pain during:
People with extension based low back pain may have pain during squats, deadlifts and olympic lifts but tend to have more pain with movements that place the spine into more extension like:
Now, we always need to be on the lookout for more serious issues like cancer, fractures and infections when the low back hurts. If you're experiencing any of the following issues then you need to speak to a physician immediately (22):
Keep in mind that I recommend seeing a therapist, physician or other qualified healthcare specialist to help you with any injury you may be facing especially if your symptoms are not improving over the course of 30 days. Everyone is an individual and a rehabilitation protocol should reflect that. The article you're reading provides general information and is not a rehab program for your own injury. If you're unsure whether or not your condition is more serious be sure go to the doctor. When in doubt, get it checked out.
With that being said, probably the most obvious cause of injury is overuse of low back extension in the gym. The more loaded extension that occurs, the more stress the low back takes. If the lower back takes too much stress coupled with a lack of preparation and or recovery from prior bouts of training, an injury may occur.
Pressing weight overhead will create extension in the lumbar spine. This is natural. However, due to mobility restriction, strength issues or technique errors, the low back may be forced to extend further, thereby increasing stress to the spine and increasing potential for injury.
Just as in in the overhead press, the bench press stresses the spine into extension in the lower back and can potentially result in pain.
The backswing during a kip creates quite a bit of lumbar extension. For some, this can be excessive and problematic.
This concept is a bit tougher to grasp than the previous two. Getting the arms overhead will naturally require some lumbar extension. Therefore overhead pressing will naturally extend the spine and increase stress. Squats and deadlifts will actually force the spine into more flexion, which typically isn't an issue for extension based pain. So that doesn't make much sense then does it? Well, let me explain further. People with extension based lower back pain typically end up getting into trouble for 1 of 2 reasons:
1: Substituting Hip Extension with Lumbar Extension - This can generally be seen in individuals at the top of a lift. These folks will finish their lifts but will finish the lifts with excessive lumbar extension and anterior pelvic tilt. They never truly reach full hip extension. These folks over-utilize the lumbar extensors to create power in the clean and snatch, which may lead to some overuse issues over time.
The other important variable to understand is that these folks are also compressing the structures on the posterior elements of the spine just as in overhead lifts. As you can see in the image above, these folks are also COMPRESSING the spine with the spine in an EXTENDED position. This is essentially the same issue that's occurring when the barbell is overhead and the spine is in an extended position.
Keep in mind that this can occur due to a lack of mobility of the hip flexors or simply because of poor technique.
2: Excessive Anterior Pelvic Tilt and Lumbar Extension Throughout the Lift - These folks generally start the lift with too much lumbar extension combined with anterior pelvic tilt and maintain that position throughout the lift.
and in the squat...
In general folks with extension based low back pain tend to have more issue with overhead lifts but this may be a potential reason why squats and olympic lifts are troublesome as well. Either way, addressing these variables can help your athletes get out of pain and keep pain at bay in the future.
As a side note, not only are we increasing compressive stress on the posterior elements of the spine in these folks, we're also placing the spine in a position of inefficiency with too much extension (1). (Except for the potential of reliance on passive structures as we'll discuss later).
The spinal musculature is strongest in a neutral position where the lumbar musculature is in an optimal length / tension relationship (Muscles are generally strongest in their mid-range of motion). In the overhead press and bench press examples we're potentially loading the spine toward end range extension which is implicated in disorders such as spondylolysis and spondylolisthesis (6, 7).
Using the example of someone who doesn't finish the lift with their hips we're potentially over utilizing lumbar extensor muscles and not optimally recruiting the powerful glute musculature, which could mean a lack of perform for these lifts as well. Either way these individuals sometimes end up with extension based low back pain with lifting technique being a main player.
So let's discuss a few reasons why someone's technique may create excessive lumbar extension shall we?
So one very common reason for overextension in the lumbar spine is a lack of adequate mobility in the shoulder joint. Check out the video below to see what I'm talking about including an assessment you can use with your athletes.
The inability to fully extend the hip will also force lumbar spine extension. This is often seen as increased anterior pelvic tilt at the finish position of a deadlift or squat as described above, but can also show up in the triple extension and catch position of split jerks.
Here's a video of the thomas test, which is an excellent test for hip extension mobility deficits.
Obviously technique is a major influencer of both performance and injury risk. This is why we need solid coaches who can pick out these issues and correct them before problems arise. What you'll find are that some folks simply have no idea they are over extenders. Attaining a neutral spine is a skill and some people don't realize they are not in neutral until they've been shown. This can be an issue because a lack of coaching coupled with suboptimal technique can lead to injury over time (11, 14).
I often find that these folks also have lumbar flexion limitations and increased lumbar extension passive motion. Given they lack flexion and have excessive extension, a neutral position "for them" (or what they may perceive is neutral) is actually increased lumbar extension. What's important is that you teach these folks how to achieve a neutral position and maintain it during their lifts.
Also keep in mind that some people over extend due to a lack of strength in the core musculature and instead rely on the compression of the passive structures of the spine to create enough stability to press heavy loads overhead. However, I'm not sure that a lack of core strength is usually the main suspect when people overextend with overhead lifts. I think this usually comes from simply using too much weight...
Two things happen when athletes try to load excessively.
Applying the right stress in the right amounts while allowing adequate recovery between bouts of training is a huge player in progression and injury reduction. I've written about this extensively in the past and the literature is quite clear (2, 3, 4) in this regard. Proper programming and periodization is enormous.
Here's the conundrum. Preparing the body adequately for the future training and competing it will be exposed to is actually quite beneficial for preventing future injury (2, 3, 4). HOWEVER, the more often we expose our body to a given training stress, the more likely we are to get hurt (simply because you have more exposure to a stress that may cause injury). (2, 3, 4) This is also how injuries are generally recorded in research studies (Injuries per every 1,000 hours of participation).
Here's an example:
Athlete 1 has twice as many exposures to training and is therefore more likely to acquire an injury over the course of a year when compared to athlete 2. However, athlete 1 is also BETTER PREPARED to handle more training given that she has been training twice as often. For this reason athlete 1 is LESS likely to get injured PER HOUR of training then athlete 2. You can see how training becomes a double edged sword when attempting to reduce risk of injury...
The other variable we know relates closely to injury is having a spike in training volume. (2, 3, 4) Let's say athlete 2 decides to train 4x in a given week. This athlete is more likely to get hurt now because the amount of volume they're being exposed to in that week is twice as high as it normally is. Meanwhile, athlete 1 is already prepared for 4x per week training and has no increased risk.
So the main goal is to be on a training program that has a very CONSISTENT training stress. If we need to increase either volume or intensity in order to elicit a better training effect we must do it VERY SLOWLY and CONSISTENTLY. If we violate these rules we may end up injured.
Here are a few examples of programming and training issues that can increase risk of injury based on some relevant research articles:
Now, this next step goes hand in hand with #5. If I'm throwing too much at my lower back without proper rest and recovery between bouts of training, this may result in injury. Now, going in depth on these topics is not only beyond my pay grade (and certainly knowledge) but is also outside the scope of the major theme of this article. We won't be going too in depth here.
With that being said, what we're starting to discover is that variables such as sleep, nutrition, psychosocial factors and stress have profound effects not only on your risk of getting injured, but also recovery after an injury. We've got some interesting research to show that chronic lack of sleep has been linked to increased risk of injury in adolescent athletes (17). On top of this, sleep has been shown to be a predictor of who gets better and who doesn't after an injury and can predict daily fluctuations in pain.
Nutrition is also likely to be a contributor to risk of injury given that eating enough will help repair tissue after training (19, 20). Unfortunately this has not been explored thoroughly in our medical literature as of yet (20). However we do have research to show that low energy availability will increase bone resorption (your body breaking down bone for materials) and decrease bone formation (20). This does have some interesting implications in the development of stress fractures (pars interarticularis) which is a common injury associated with extension based low back pain.
We also have some interesting research to support that mood and stress scores such as anger, confusion, fatigue, tension, depression positively correlate with risk of injury in athletes (18). We also have some research showing that anxiety, negative-life-event stress, and athletes reporting excessive daily hassles were significant predictors of injury among professional soccer players (21). Markers of stress such as heart rate variability are now showing to also predict injuries in athletes too.
Again, the goal of this article is not to explore these factors fully but suffice to say that if we don't acknowledge these variables as potentially causative of injury (or atleast factors that influence risk) then we may be missing a major piece of the puzzle when it comes to figuring out why these injuries occur and how to rehabilitate current injuries and prevent future ones.
So that's it! Good old extension based back pain. Who knew it could be so much fun. If you liked this article and want a little more guidance on how to get out of low back pain I have a completely done for you training program to help you get out of pain and back to training. It's called "Ultimate Low Back" and it will be out soon!
I've taken the guesswork out of finding the right amount of sets and reps and which exercises to use and which to avoid. It's all 100% outlined. Consider it your roadmap to get out of pain and back to training.
Lower Back Pain Party,
Dan Pope DPT, OCS, CSCS, CF-L1
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