Low Back Pain When Running? A Guide for Runners & How a Physical Therapist Can Help
If you’ve ever experienced discomfort or pain in your low back while running, you're not alone. Low back pain is relatively uncommon amongst runners (read about the prevalence in this article) but it does occur and can even stop us from running. While most causes are relatively benign and treatable, others may signal more serious underlying issues. Understanding the potential causes, seeking the right care with a sports orthopedic physical therapist, and addressing the problem early can ensure you get back on track ASAP.
Common Causes of Low Back Pain while Running
It’s essential to understand some of the most common causes of low back pain in runners. Here are some of the most common we see at our practice:
1. Poor Running Form
Limited Hip Extension
A client with limited hip extension while running
If you don’t have enough hip extension (10-20 degrees depending on speed) during the terminal stance phase of running, then you may compensate with unnecessary motion from your lower back.
Limited hip extension during the terminal stance phase of running can cause you to overextend your back and strain the paraspinal muscles (muscles along the spine) or irritate the lumbar facet joints (joints of the low back), leading to low back pain.
Excessive Lateral Trunk Lean
An excessive lateral trunk lean while running often results from decreased lateral stability at the trunk and pelvis. This occurs due to decreased hip abductor (gluteus medius) and obliques recruitment during the midstance phase of running.
Decreased hip abductor (gluteus medius) and obliques recruitment during the midstance phase of running can cause you to overuse your quadratus lumborum (QL) muscle for stability or irritate the lumbar facet joints, leading to low back pain.
To read more about running form/mechanics, see our running analysis blog.
Lumbar facet pain or lumbar facet syndrome is low back pain resulting from irritated lumbar facet joints.
Photo from HealthCentral
Lumbar Facet Joint
2. Weak Core Muscles
A weak core can lead to poor spinal support and posture breakdown during runs.
3. Overtraining or Sudden Increase in Mileage
Rapid increases in distance or intensity can stress muscles and joints, including the lower back.
4. Muscle Imbalances or Tightness
Tight hip flexors can cause an anterior (forward) tilt of the pelvis and pull on the lower back.
Tight hip flexors can also limit hip extension, which can lead to poor running form and low back pain (see above).
Weak glutes and abdominals can also lead to overuse of lower back muscles (see above).
5. Sciatica or Lumbar Radiculopathy
Sciatic Nerve
Pre-existing conditions like herniated discs, sciatica, or spinal stenosis can be aggravated by running.
Sciatica or lumbar radiculopathy can cause pain, tightness, numbness, or tingling in the low back, hip, thigh, lower leg, and foot.
To read more about sciatica or lumbar radiculopathy, see our sciatica blog.
6. Stress Fractures
A more serious cause of low back pain, stress fractures, occur when the bone is subjected to repetitive stress that leads to microtrauma of the bone. When the rate of bone cell breakdown exceeds the rate of new bone cells forming, that is when a stress fracture can occur. Stress fractures in the lower back can occur in the sacrum and can cause a sharp pain or dull ache in the lower back, buttock, or hip that worsens with activity / weight bearing. Your physical therapist will help you rule this in by asking you a series of questions about your training and by performing tests that have a high rate of bone loading (hopping). If a sacral stress fracture is suspected, your physical therapist will refer you to an orthopedist who can request MRI imaging. These types of injuries often require a period of non-weight bearing / rest from running. Depending on the location and extent of the fracture, surgery may be required to avoid long term complications.
According to this article, sacral stress fractures are correlated with low body mass index, vitamin D insufficiency, disordered eating, and malabsorption disorders.
How a Physical Therapist Helps with Diagnosis of Low Back Pain while Running
A physical therapist who specializes in treating runners is key in addressing low back pain. They use a combination of patient history, physical tests, and their clinical expertise to perform a differential diagnosis. This process helps determine the exact cause of your low back pain and rule out other conditions.
Our physical therapists will start with a subjective history to gather information about your injury to help determine whether the pain is due to a mechanical issue, muscle imbalance, overuse, or something more serious, like a bone stress injury (BSI).
Tests a Physical Therapist Might Perform
After gathering the initial history, our physical therapists will perform various physical tests to confirm their diagnosis. These could include:
Range of Motion Tests: to assess flexibility and movement in the low back and hip joints.
Strength Tests: to check for weakness in the hip and core muscles, particularly the glutes, abdominals, and obliques, which play a critical role in running.
Palpation: your PT will press on different areas around the low back and hip to locate where the pain is coming from.
Special Tests: your physical therapist will perform tests that help target specific tissues in the low back and hip (i.e. Straight Leg Raise, Slump, FADIR, and FABER Tests)
Hop Testing: this is necessary for helping to rule out bone stress injuries (BSI’s) if your PT suspects one. We do not recommend doing this on your own, as you can potentially aggravate a BSI.
Gait Analysis: watching you run to assess your form, stride, and any mechanical abnormalities that may be contributing to your low back pain.
How a Physical Therapist Helps with Treatment of Low Back Pain while Running
A physical therapist will provide a tailored treatment plan based on your specific condition, goals, and running habits. This typically includes:
1. Manual Therapy: soft tissue massage to the low back muscles, stretching of the hip flexors, quads and QL, and joint mobilizations to the low back and hip (and other joints such as the ankle that may be impacting how force is being absorbed at your low back).
2. Education / Exercise / Running Mechanics: your PT will teach you about proper running mechanics, stretches, and exercises to help prevent future injuries. You’ll learn how to strengthen your glute and core muscles and improve flexibility of your hip flexors and quads to address any imbalances contributing to your low back pain.
3. Return to Run Protocol: your PT will help you create a running routine that will allow you to get back to running safely. We will discuss parameters such as frequency, intensity, duration, and how different grades can influence your low back pain when running.
If your PT suspects a more serious injury, such as a stress fracture, they will refer you to an orthopedist for further imaging and evaluation.
Best Stretches for Runners with Lower Back Pain
Half Kneeling Quad / Hip Flexor Stretch
Doorway QL Stretch
Best Strength Exercises for Runners with Lower Back Pain
Side-lying Clamshell
Side-lying Hip Abduction
Side Plank Variations
Forearm Plank with Hip Abduction
Glute Bridge Variations
Single Leg Hip Thrust
Lateral Step Down
How to Prevent Low Back Pain while Running
The best way to prevent lower back pain while running is to incorporate strengthening of the hip abductors, hip extensors, and core muscles, maintain adequate flexibility of the hip flexors, and run with proper mechanics. This will allow proper muscle recruitment, muscle firing timing, movement coordination to stabilize the lower back and hip while running. Some of the recommended exercises videos can be referenced above.
Conclusion
Low back pain while running can be stressful, and it can be difficult to establish an effective plan to address it. A physical therapist specializing in treating runners can help you navigate the differential diagnosis process, pinpoint the root cause of your pain, and create a personalized treatment plan. Whether you're dealing with common issues like lumbar facet pain, sciatica, or suspect something more serious like a stress fracture, a PT can guide you on the road to recovery. Don’t let low back pain sideline your running journey – get the help you need to heal and come back stronger than ever before!
If you are experiencing low back pain when running and you would like to work with us, click the button below to speak with one of our Doctors of Physical Therapy.
Disclaimer: This is not intended to be formal medical advice. Your individual needs should be met by the appropriate health care practitioners. Please consult with a trusted provider.
Dr. Vincent Liu, PT, DPT
Doctor of Physical Therapy
The Game Plan Physical Therapy