Why runners with back pain is not getting better

All of us treat back pain in our practices.  It can easily be as much as 50% of our patient population, which has led to many schools of thought.  Do I manipulate?  Do I use the algorithms from McKenzie?  Should I strengthen the core?  All of these have their time and place and are each incredibly valuable for the right patient!

For years, I used these schools of thoughts, but still often struggled with a specific population – RUNNERS. Runners are supposed to come in with aching knees, IT Band Syndrome, Achilles Tendon pain, but back pain?  Yes, more often than you might think, they complain of back pain.  It’s not that manipulating a runner’s back is not helpful and plenty of us could benefit from a few extra planks, but there’s something more.  If you don’t address this, the likelihood of the back pain returning is high because you haven’t addressed the activity provoking the pain.

Many runners adopt a hyperlordotic position when they are running and even worse, they hinge in a specific segment of their lumbar spine.   They run very upright and may even show excessive vertical oscillation (bounce when they run).

Once you determine that this may be a contributing factor, you need to look at what may be the cause. Typically, it is one of 3 things:

1. Habit: The runner is just too upright and needs to work on a forward lean.  You can cue the the runner to fall through their ankles when they run.  Let them stand still with their feet together and begin to fall forward at their ankles.  They then naturally step forward to keep from actually falling. This is will promote the natural forward lean we are looking for.
2. Hip PROM: Inadequate extension PROM is present, resulting in a compensatory anterior pelvic tilt and hyperlordosis during late stance.
3. Lumbopelvic and Hip Motor Control: Instead of extending the hips through the gluteals, extension occurs through the lumbar spine and no hip extension PROM deficit is present.

You can quickly determine whether this is a problem with PROM or motor control by performing both active and passive hip extension in prone.  I often find a PROM restriction exists, but not always.  Once you treat the passive restriction you need to retrain the new motion with motor control drills.  A simple prone hip extension exercise or quadruped hip extension will often do the trick, but you must focus on promoting hip extension and not anterior pelvic tilting.  Finally, retraining running form to use the new ROM and motor control completes the cycle.  You can use your falling drill at this point.