Low Back Pain in Runners

Last updated: 05-Nov-18

By Karina Teahan, Chartered Physiotherapist

Low Back Pain (LBP) is one of the most common conditions presenting to a GP or physiotherapist. 84% of people worldwide get one or more episodes of LBP at some stage in their lives.

Being a runner does not exempt you from it but nor does it make you more predisposed. In fact, as runners we are usually well conditioned & strong which is protective. However in reality most of us are not just runners, we have a job, family, friends and various other commitments.

Sometimes trying to squeeze all these things into our day, as well as training can be just too much.

The most important thing to remember is that LBP is usually not serious. This doesn’t mean it isn’t painful or distressing, but it’s not harmful. Less than 1% of people with LBP have a serious underlying pathology.

As a physiotherapist we look out for a collection of signs and symptoms known as Red Flags to help identify the more serious cases. You need to go to your GP or A&E urgently if you present with any of these signs as well as severe LBP+/- leg pain which is not improving.

I have put together a table of these Red Flags at the end of the article.

Now that we know about the serious stuff, it is important to focus on the rest of cases of LBP. 95% of LBP is referred to as non-specific LBP as most of the time the pain cannot be attributed to a recognisable pathology or source.

It may come from muscle spasm, myofascial trigger points, ligaments, the intervertebral discs, sacroiliac joint, facet joint or a combination of them. 80-90% of people with LBP recover in 12 weeks, 50% will have a recurrent episode.

It is the most expensive healthcare problem between ages 20-50 years so we do not yet have all the answers.

For the normal population with LBP we encourage them to avoid prolonged bed rest and keep moving. We rarely need to tell a runner to keep moving but there are certain common themes that do affect us all.

Psychosocial Factors

Psychosocial factors influence our pain, our pain beliefs and hence our behaviours. LBP can lead to us catastrophising the situation and fearing the worst. We may feel depressed that we cannot train and anxious as to what the future with LBP may hold.

Our sleep and mood may become affected making the situation feel even worse. It is often difficult to manage these stresses on our own and so discussing them with your physiotherapist or GP may help alleviate some of these worries and realise many LBP myths can be dispelled.

Sleep is vital. We need 7-9 hours per night and ideally to wake up feeling refreshed. At times it is difficult to fit proper sleep time into a busy schedule but it is vital both to prevent injury and aid healing.

When I assess athletes with LBP I look at a number of things:

  • Range of movement in the lumbar spine (lower back), thoracic (mid back) spine and hips. All these areas need to move properly so as not to put increase strain on an area higher up or lower down to compensate.

For example reduced hip extension due to tight hip flexors will cause compensatory excessive extension in the lower back during the push off phase of the running cycle. Tight hip flexors may also put our glut muscles in a disadvantageous position so they cannot fire quite so well.  We need to be able to extend through our thoracic spines to maintain a nice upright running position.

  • Our quads and calf muscles work as both powerful movement generators but also take a significant load as we run (as much as 7-8 times body weight when we run fast). A quick test for calf strength is to see how many single leg calf raises you can do.

The aim is 25 (I can only do 15!). A simple way to check quad strength is a single leg chair raise test: how many times can you get up from your dining chair using one leg and no arms to assist before you fatigue. Again the aim is to build to 25 reps right & left.


  • Quality of movement: fear can often cause us to move differently. We want to protect the injured area or may have been told in the past to avoid a certain movement such as “bending our backs”.

Remember our spines are strong, resilient structures and are made to move. Habitual guarding will cause them to stiffen up and we adopt compensatory movements which are not as efficient or comfortable. You may find you hold your breath and move more slowly than prior to your injury.

It is vital you regain confidence in moving your back again and learning to dissociate this lumbar movement from your hip or thoracic area. We will go through a set of exercises later in the article to help achieve this. This is why it is so important to allay fears and dispel myths about our backs.

Some very unhelpful terminology may have been used such as slipped discs needing to be put back in place, crumbling discs, degenerative spine…..

We all show changes in our spines as we age. It might be nicer to think of them as similar to grey hairs and wrinkles like on the outside rather than crumbling or degenerative. An MRI is rarely indicated for LBP as it will show normal aging changes that may cause us to worry more, yet probably have very little to do with our LBP and rarely change management.

Research has shown that people that don’t have back pain have disc bulges (30% of 20 year olds, increasing to 84% of 80 year olds), disc degeneration (37% of 20 year olds increasing to 43% of 80 year olds), disc protrusions (20% of 20 year olds increasing to 43% of 80 years) and facet joint degeneration or arthritis. Only when a serious condition is suspected should a scan be indicated.

So, if you have had a scan and have read some of the scary terms, remember they are normal findings and a normal part of aging.

It is difficult to write a short article on such an enormous topic as LBP which has so many physical as well as psychological factors associated with it. However I have put together some useful tips on how to manage your LBP better.

1. Rule out red flags (below) and discuss with your GP any concerns you may have.

2. Take medication as advised by your pharmacist/GP that allows you to move better

3. Use ice/heat

4. Reflect on what may have caused it: change of training (intensity, volume, frequency, increased hill training), lack of recovery, poor sleep, life stress, travel.

5. Relearn to move your back normally again. Work on dissociating your lumbar (lower back) movement from your thoracic spine (mid back) and hips.

You can do this lying on your back, sitting, on all 4’s, or standing:



6. Restore movement in any stiff joints around your back & hips.

Exercise suggestions: Thread the needle, Prayer Stretch, Arm openings, hip flexor stretch, glut 4 point stretch, knee hugs, spine twists:




7. Running form: without getting excessively technical, a spine that is in neutral will tolerate load better than one that is flattened or overly arched. In running there are forces 2.7-5.7 times body weight through our spines.

Our spines are strong & robust structures but tolerate load better when we maintain a good posture.

8. Get in the habit of doing activation exercises and running drills prior to your run session. It wakes the appropriate muscles and gets them ready for the session ahead and helps us adopt better running form.

9. Keep your gluteal, quads and calf muscles strong: single leg squats & calf raises. I have discussed lots of gluteal exercises in previous articles.

So to summarize LBP is rarely serious but is distressing. Address your fears as they can be as disabling as your physical injury.


  • History of cancer
  • Unexplained weight loss
  • Constant non-mechanical pain behaviour (as in no movement/position can give relief)
  • Night pain
  • Night sweats/fever
  • Bowel or bladder changes – difficulty passing or controlling urine
  • Feeling systemically unwell
  • Recent infection
  • Numbness around your back passage or genitals
  • Unsteadiness as you walk
  • Having had a recent significant trauma
  • Prolonged use of steroids
  • Persisting limitation of spinal movements in all directions
  • Marked morning stiffness
  • Osteoporosis

*It should be noted that Red Flags have a low sensitivity in that they don’t necessarily rule out something more sinister such as a fracture, malignancy, infection or inflammatory disorder. However they may help rule something in.

The overall recommendation is that if you have one or more of the above, and your LBP is not getting better even with treatment – go to your doctor!

All images Karina Teahan.



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