Addressing Low Back Pain From The Ground Up

Almost every triathlete has experienced back pain at one time or another. Whether it is a chronic ache in the neck following a long ride, tightness between the shoulder blades with swimming or sharp pain in the low back during a run, pain inhibits our training, limits our performance and frustrates us—and probably any family member or friend friend who is within close range.

Written by: Matt Kraemer PT, ATC, CSCS and Nate Koch PT, ATC

When a breaking point finally occurs, you search the blogosphere for a diagnosis and cure. You see your doctor, have X-rays, rest and do more crunches than you can count, but still, pain relief seems temporary. Before you list your bike on eBay and donate your running shoes, take a step back and ask yourself a couple of basic questions: Have I exhausted all possible causes? Could the pain in my back be a symptom of a breakdown in the kinetic chain below my waist?

While it is generally understood that back pain can come from your back, it is also important to understand that your spine does not work independently of your lower extremities. Foot and ankle mechanics can have a direct effect on the mechanics of your pelvis and lower spine. When the foot strikes the ground, a domino effect of abnormal stress can affect the rest of the body. A combination of 26 bones, more than 30 joints and dozens of muscles and ligaments play a role in a complex sequence of motions that can result in Usain Bolt-like sprint form or a faltering gait with chronic pain.

There is a variety of different ways foot mechanics can alter the motions of the rest of the leg and affect the back. One example is pronation of the subtalar joint. The subtalar joint is the main joint in the foot and ankle, and it determines when and how much pronation will occur when the foot strikes the ground. Pronation at the foot and ankle is a normal and natural loading response that provides shock absorption and efficient propulsion during walking and running. Excessive pronation or lack of normal pronation at the subtalar joint can create abnormal stress and strain up the leg and into the spine.

If the subtalar joint is stiff, the foot may not get enough pronation and will cause you to stay on the outside of the foot, leading to outward rotation of the leg and backwards rotation of the hip. This means relative forward tilt of the sacrum and forward bending of the low back. The resulting strain on the low back muscles, discs and ligaments can lead to as low back pain.

On the other hand, if the subtalar joint is too loose, it may cause too much pronation, which in turn causes collapse of the medial arch, inward rotation of the leg and forward rotation of the hip. This leads to a backward tilt of the sacrum and backward bending of the low back. This extension of the spine creates compression of the lumbar spine and SI joints, resulting in possible low back pain.

If abnormal foot and ankle mechanics are a plausible cause of low back pain, how do you control or adapt to it? Foot mechanics can respond to both internal and external forces. Not everyone presents or responds to treatments the same;; therefore, there are many different options to help you change your mechanics and relieve your symptoms.

One method is to maximize your physical capabilities. All of the structures that are leading to your issues can also be the source of your relief. Sometimes it’s just a matter of teaching or reminding your body how to move. In a foot that is stiff and limiting your pronation, stretches can be used to reduce muscle and fascial tightness to allow for better motion. Self-mobilization exercises, or mobilizations performed by a licensed physical therapist or osteopathic physician, can also improve the amount and integrity of motion. Utilizing foot and ankle strengthening exercises to stabilize a loose foot with too much motion is another way to optimize your physical structure. Increasing the strength of the intrinsic muscles in the foot and extrinsic muscles in the lower leg that extend into the foot, as well as the muscles in the hips, can add stability and control to a foot that otherwise lacks it. These internal changes may be enough to normalize your lower extremity biomechanics and relieve your low back pain.

Another method used to help the body accommodate abnormal foot mechanics is to use external devices. This may be accomplished through footwear, orthotics or even taping. Having the right type of shoe can make a world of difference. Choosing the proper style of training or racing shoe is imperative.. Brand loyalty and aesthetic appeal should be secondary to a specialty fit. Each brand and style of shoe will have differences in lasts, widths, patented cushioning and stability or control systems, in addition to the latest color trend. A loose foot may benefit from having some increased subtalar joint control like that provided by a stability or motion control shoe. This contrasts with a rigid foot that would be more comfortable in a neutral shoe.

Sometimes more control or support is required than a shoe is able to provide, and an over-the-counter, semi-custom or custom orthotic is necessary. It can be used to bridge the gap between the ground and a stiff foot, or to help control the extra motion of the foot inside the shoe. Proper forefoot analysis and posting are crucial in the design of custom running orthotics. We spend more time on or forefeet than we do on our heels when running, so a shoe or an orthotic that only addresses the rearfoot will typically not address the mechanics of running. Taping techniques have also been commonly used to provide a focused control, especially during injury. There is a variety of foot and ankle taping techniques that are typically applied by a physical therapist, podiatrist, chiropractor or athletic trainer. These procedures and orthotics can also function as diagnostic “field tests” to help determine the cause of low back pain.

The most important step toward of eliminating your back pain is to find the underlying source and address it effectively. There are many causes of low back pain.; I hope you now recognize that one potential source could be the first body part that hits the ground when you run. Utilize triathlon-specific clinicians who are well trained in the evaluation and treatment of endurance athletes to help you determine possible causes and solutions to your injuries. Whether it is with manual treatments, stretching, strengthening, changing your shoes or getting orthotics, modifying your foot mechanics can assist in the alignment of your lower extremities and spine and thereby reduce low back pain. During exercise the human body performs a linked chain of movements involving many different structures, so don’t limit the assessment of your pain to a localized area.

Matt Kraemer and Nathan Koch are physical therapists at Endurance Rehabilitation in Arizona. Visit Endurancerehab.com.