• Luke Nelson

SMA's Athletic Low back symposium: Put your back into it!

Updated: Mar 6, 2020

Sports Medicine Australia’s Athletic low back pain symposium held at Melbourne University on Sunday 9th February, was an action packed day featuring a multidisciplinary lineup of speakers which aimed to help attendees better manage low back pain in the athletic population. In this blog I will cover some of my key takeaways!

The day kicked off with a bang with Associate Professor Tasha Stanton who leads the Pain and Perception Group in Adelaide at the University of South Australia, on the topic “Just get more active? Psychosocial considerations (and their biological implications) for the athlete with low back pain”

Some of the misconceptions those suffering from low back pain include:

  • “I have back pain because I’ve injured my back”

  • “I have back pain because my back is weak and it hasn’t healed properly”

The INCORRECT assumption in the above statement is that pain reflects tissue damage.

The reliance on imaging for the diagnosis of low back pain:

“Abnormal” findings are commonly seen on MRI in pain-free individuals: As we age, we get the equivalent of “wrinkles” on our scans.

‪Asymptomatic athletes do have increased MRI findings compared to asymptomatic sedentary controls.‬ ‪AKA MRI changes are associated with sport/activity, NOT pain. Brancho et al 2010, 2015

Your knowledge influences pain: Things hurt more when you aren’t sure they are safe. Wiech et al J Neurosci 2010

  • Anything that suggests you need protecting (danger cues) increases pain.

  • Anything that suggests you don’t (safety cues) reduces pain

How to present imaging findings to patients:

“We are all bioplastic- this means our systems can always adapt and change...right until the very end.

“These scan changes look as I would expect for someone who is an elite athlete. Many of these changes are a bit like wrinkles- what we expect to see”

Message: our systems are designed to adapt and change. Some changes on scans are normal- they don’t tell us what you are capable of. Adapted from O’Sullivan & Lin 2014

Giving good information to people with back pain matters!

  • Enhanced reporting (altering the terminology of the report summary and including epidemiological information) improved back related perceptions & was found to be more reassuring. Karran et al 2017

‪Assessment items to consider in athletes with pain‬:

  • Ask your athletes about why they think they are hurting‬: what is their understanding of their condition?

  • ‪Ask about more than just the pain‬: think of all the things that can influence pain (sleep, stress, anxiety, fear etc..)

  • ‪Measure the functional state of the pain system: assessing temporal summation via exercise reps (ie movement evoked pain)‬

Psychological factors: athletes with pain/injury.

“When players knew the length of time they were out of the game, and were informed about the extensive nature of the rehabilitation process, they recalled how this was the most depressing time of all”

“Players described how sometimes it seemed that no one cared about their injury or how they were progressing through their rehab... focus on on-field performance”

“Feel isolated from the group”

Ensure that the athlete feels a part of the team when they are injured!

Ruddock-Hudson 2012

Do athletes with pain have increased fear avoidance and pain catastrophising?? YES

Increase fear avoidance is associated with decreased physical functioning

Increased pain catastrophising is associated with increased pain intensity.

Tasha used Butler & Moseley’s analogy from “Explain Pain” of climbing a mountain. Our bodies are designed to protect and warn us of danger. Pain protects us from exceeding our capacity, this is our “safety buffer”. However for some people post injury, their “safety buffer” increases to where their system becomes “overprotective”. We can educate these patients that they can be “sore but safe”: they can experience pain, whilst not exceeding their tissue capacity.

Treatments informed by pain science with psychological & movement ramifications that can be utilized for those with athletic low back pain include:

  • Increasing pain knowledge

  • Talking about scan results

  • Pain science based movement prescription

Should athletes with back pain just get more active??

Expanding on the previously written article by O’Sullivan et al 2019, the advice we should be giving our athletes with back pain include:

  1. Keep active

  2. But respect the influence of training load on pain

  3. Be aware of movement avoidance- they may need to become more active in terms of specific movements.

Athletes with low back pain: keep physically active but avoiding specific movements

  • A thorough objective assessment of their back

  • Assessing for movement changes or alterations that result in protecting the back from movement

  • Aim to rescue protective movements/postures by: increasing safety cues, decreasing danger cues

Unhelpful words

  • “stop immediately if it hurts”

  • “Don’t want to blow out a disc”

  • “Be very careful when you do that movement”

Message from all of the above is that movement is bad and could injure you further.

Adapted from O’Sullivan & Lin 2014

Instead (and evidence based)

  • “movement will be painful at first- like a sprained ankle- but will get better as you get more active”

  • “Our tissues heal best through loading - gradually increasing your activity is the very best thing you can do”

  • “Movement decreases the size of our protective safety buffer.”

  • “Your back is strong & robust”

Message: movement is the best thing for you to help you heal, and you are safe to move.

Applying these principles during rehab

Unpairing movements that hurt with that EXACT movement

  • If back movement during a kick is painful, find new ways of achieving back & leg movement that do not mirror the exact kicking motion: Pilates reformer, dance, tai chi

  • Use a different movement pattern to create a new representation and to promote increased diversity in representation

  • We are NOT correcting vulnerability, we are helping the system to relearn that certain movements are safe


  1. Pain is there to protect, it doesn’t necessarily tell us about damage: just because you feel pain doesn't mean you are injured. Our systems can become over-protective

  2. Consider psychological factors (anxiety, fear avoidance and pain catastrophizing) in athletes with low back pain

  3. Use education to increase athlete’s pain knowledge to target fears about movement and re-injury.

  4. Our words matter!!

  5. We can help athletes to interpret scans to promote reassurance & safety, not fear & danger

  6. We can use movement to help our system “unlearn” associations between pain & activity.

  7. Stay as active as possible, focus “increased activity” on movements being avoided, promoting robustness not vulnerability.

Paul Marks: MRI lumbar spine- advanced techniques

Radiologist Paul Marks then delved into a discussion on imaging and athletic low back pain in his talk “MRI lumbar spine- advanced techniques”

Indications for CT

  • useful if MRI not available/safe

  • Pacemaker/spinal stimulator

  • Spinal intervention

  • Metalware

Indications for MRI

  • One stop shop

  • Efficient use of time

  • Normal MRI reassuring

  • Specialist Centre and radiologist for scan and interpretation to minimize errors

  • 3T better than 1.5T

  • Fat sat: important for Inflammation, bone oedema. Some imaging centers don’t perform this.

  • THRIVE or VIBE: allows to get thinner image slices

High intensity zone (HIZ) lesions

86% positive predictive value for symptomatic disc. April & Bogduk 1992

Despite the frequency of other pathological imaging findings in asymptomatic individuals, Disc extrusions are NOT a common finding in asymptomatic people.

Alex Kountouris - “Managing lumbar bone stress in athletes”

Alex Kountouris, Cricket Australia’s Sports Science and Sports Medicine Manager, then led a discussion of the management of lumbar spine stress injuries.

Very rare to see spondylolisthesis in elite cricket: they may be career ending?

Where do they occur? they can occur all around the posterior neural arch but just more common at pars interarticularis

Mechanism: repetitive axial loading

Risk factor: age is the most important.

  • <22 years old has 4x risk of bone stress injury

  • <25 years of age: 3.1x more likely to suffer bone injury in the next month

  • <25 and played in a first class match: 4.9 x more likely bone injury in the next month

  • <25 and you bowled >40overs in a game: 9.5 x more likely bone injury in the next month

Grading bone stress

There are 3 stages of the bone stress continuum

Bone strain=pre-symptomatic bone stress (micro-fractures)

Stress reaction= early stage (macro fractures)

Stress fracture=cortical/trabecular breach

Chronic defects=non united fractures


  • Easy to detect later in the process, more challenging to pick up early

  • Can usually diagnose from the history: in those at risk (young active, fast bowlers) and with some recent history of loading, usually localized pain & specific movement that will aggravate it. With palpation can often identify the level of the lesion.

  • Clinical test: extend, rotate and lateral flex/ ensure you get to end range and not letting them cheat (bending knee)

4 tips:

1. Get them early!

  • Difference of 100 days in return to play between managing a stress reaction versus a stress fracture

  • MRI: fat sat is a MUST, with THRIVE/VIBE images

  • Bone marrow oedema: if you had in the preseason you were 5x more likely to develop stress reaction in season

  • Lag of 100 days between seeing oedema and then appearance of symptoms

Cricket Australia is now screening all at risk players at the END of the season. They were finding that most stress fractures occur in early season and by then they probably haven’t done enough to create a new stress reaction, it was likely already occurring at the end of the previous season.

2. Bone marrow oedema is Real: use MRI not CT

Yet to be published study of 31 stress fractures: the size of fracture and BMO was proportionate to healing time.

Mean healing time 200 days for stress fracture.

3. They heal

Non union will result if there are management errors

Early: continue to load and they become asymptomatic

Avoid reloading too quickly

Recurrence rate

Those who suffered a recurrence commenced bowling mean 12.1weeks post injury (range 9-18wks) versus those did not suffer a recurrence commenced bowling at 21.8 (range 16-25 weeks)

Management stages

Week 0-8

  • Fracture protection stage

  • Protect fracture

Week 9-20

Protected reloading

Commence running/strength

Week >20

  • Transition to RTP

  • Commence bowling

  • RTP>30weeks

4. Do the time

  • Pre-symptomatic bone stress: no bowling 4-8weeks

  • Stress reaction: no bowling 8-10 weeks

  • Stress fracture: 20-30 weeks of no bowling

Management- previous non union

  • fibrous tissue at the non-union site is enthesis like histologically