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Back Pain: Why are back pain guidelines being ignored for our athletes?

If you've been involved in any high level of sport you know that athletes have excellent access to medical attention. Usually there is a sports medicine team staffed with athletic therapists, doctors, physical therapists, and sometimes even massage therapists. These professionals often travel with the team and are focused solely on their care.

When it comes to back pain it affects almost everyone. It has been documented time and again that most people will experience back pain in their lifetime. More surprisingly, it has been documented that people who do not seek out medical attention don't differ substantially in terms of the intensity or frequency of the pain they feel. Lets think about that - people who seek out care don't feel better than those who don't. What does that tell us? Perhaps the medical community is missing something on how we treat back pain?

Peter O'Sullivan, a prolific researcher on the back, recently published an editorial in the British Journal of Sports Medicine examining this idea. He noted 3 major myths that are widely held beliefs among both patients and medical professionals:

Myth 1. The back is vulnerable to injury and needs protection, especially when symptomatic
Myth 2. Back pain is caused by tissue damage
Myth 3. Directing treatment at specific tissues and structures will result in symptom resolution

These myths fall in line with a biomedical model of back pain. Meaning that back pain is caused by specific anatomical structures, like a disc or a ligament for example. And once that structure is damaged it needs to be repaired and protected. But when it comes to non-traumatic low back pain, it's just not true. Current research and back management guidelines tell us it's far more complex than that. Studies have shown that when healthy, pain-free backs are imaged most of them show 'damage' of various back structures. In fact 25% of healthy adults who were imaged showed a bulging disc, 90% of those between 50-55 showed degenerative disc disease. The point is – if your scan shows a bulging disc for example, it's not necessarily responsible for the pain that you feel. This certainly applies to athletes too.

That means that when sports medicine programs have the resources to quickly get MRI and CT scans for their athletes, they are creating the illusion that these 'damaged' and 'faulty' structures in the back are directly responsible for the pain. They may also have the resources to perform surgery quickly to fix these 'broken' structures. Afterwards they should avoid certain movements to protect their back, which is now vulnerable to injury. This creates a cycle of fear and a propensity to stiffen muscles to 'protect' the back. Overall, this does not have good outcomes.

That's not to say that imaging doesn't have an important role. About 1-5% of the time scans identify serious lesions that must be treated. However there are published guidelines that your doctor and physical therapist can use (it's called identifying red flags) to determine the appropriate time to send you in for a scan. The problem is that scanning has become overused to the point where patient outcomes are being compromised.

I'd propose these 3 realities to challenge the myths above

Reality 1. The back is a robust structure and should be trusted to move freely
Reality 2. Non-traumatic back pain is complex. It is cause by a complex interplay of factors such as poor movement patterns, rigidity in movement, poor lumbar control and psychosocial factors like anxiety, depression and high levels of stress.
Reality 3. Directing treatment at specific tissues is misleading. Early use of scanning for non-traumatic back pain has been shown to lead to high disability and surgery rates.

The solution to low back pain is multi-faceted and will be different for each person. It's about identifying the sources of stress in your life and improving the way you move. It's time to stop fearing the vulnerability of the back and focus on how to break the pain cycle and improve its function.

Back pain is more complex than identifying a particular structure that is damaged. Current research tells us that non-traumatic low back pain involves not just anatomical structures but a number of psychosocial components as well. So if you have back pain, unless you show specific red flags as they're called, you're most likely to benefit from skipping the scan. It is much more beneficial to focus on how to enhance the inherent capabilities of the dynamic and complex structure that is the back.


Balagué, F., Mannion, A. F., Pellisé, F. & Cedraschi, C. Non-specific low back pain. The Lancet 379, 482–491, 10.1016/s0140-6736(11)60610-7 (2012)

Darlow, B. & O'Sullivan, P. B. Why are back pain guidelines left on the sidelines? Three myths appear to be guiding management of back pain in sport. British Journal of Sports Medicine 50, 1294–1295, 10.1136/bjsports-2016-096312 (2016)

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