Back pain in sport: athletes neglected or athletes different?

Given the discrepancy between the management of back pain in athletes and the guidelines, either athletes are not being offered best practice care or guidelines do not apply to back pain in sport. Although performance expectations are very high for elite athletes, there is no evidence that athletes require (or benefit from) different back pain care. Management of back pain in sport seems to reflect a schizophrenic mixture of risk minimisation (eg, rest and scanning), intensive therapies (eg, passive treatments and stabilisation exercises) and early use of aggressive treatments (eg, spinal injections and surgery). This shotgun approach is enabled by the substantial financial resources available.

The approach to back pain in sporting populations appears to be founded on three myths.

• Myth 1. Back pain is caused by tissue damage.

• Myth 2. The back is vulnerable to injury and needs protection, especially when symptomatic.

• Myth 3. Directing treatment at specific tissues or structures will result in symptom resolution.

These myths are commonly believed by the general public as well as by clinicians.5 Yet this narrow biomedical perspective of back pain has little supporting evidence.4 There is a high prevalence of ‘pathoanatomical abnormalities’ in young pain-free populations, and little evidence that these findings predict pain and disability.4 ,6 Early use of scanning for non-traumatic back pain results in higher disability and surgery rates, and poorer rates of return to work,7 with knowledge of scan findings worsening patients' recovery expectations and contributing to beliefs that activity should be avoided or limited.5 Scanning can also lead clinicians to apportion blame for back pain on structural findings, provide advice to avoid pain provoking activity and focus on mechanical or surgical solutions.5 ,6 Avoiding activity for fear of pain or injury is associated with worse outcomes for people with back pain, while time away from training also reduces sporting performance and chances of success.8 Interventions such as lumbar discectomy have not been found to improve athletes' return to sport compared with conservative management.9

Athletes are potentially vulnerable. They are singularly focused on sporting performance, and are willing to make any sacrifice to achieve this. They can feel disempowered to make reasoned decisions about their healthcare. This places a responsibility on clinicians to advocate for the well-being of the athlete, ensuring that treatment provided is governed by strong evidence and rationale rather than availability.

What care should athletes receive? If you are a player, read this!

Scanning for back pain is only recommended when there is suspicion of pathology such as fracture, infection, cauda equina compromise or severe/progressive neurological deficit.4 Thorough examination includes careful history taking, screening for psychosocial, lifestyle and training factors, and assessing physical signs and functional limitations.

Once pathology has been excluded, back pain guidelines recommend providing reassurance along with advice to continue or return to normal activity and work as soon as possible, and explaining that it is safe to experience some pain with physical activity.4 This management approach delivers improved outcomes (relative to comparators) and reduces costs.10

Time for athletes to benefit from 21st century care—based on the biopsychosocial model

Guidelines for back pain management recognise that structural, physical, lifestyle, training load, psychological and social factors may be part of an athlete's presentation, and that limiting focus to structural factors is likely to result in poorer outcomes. Psychological factors appear to better predict pain and disability levels than do anatomical or biomechanical factors.4 ,11

The current practice of managing back pain in athletes appears driven by a combination of negative beliefs, expectation, and easy access to early scanning and treatments. We argue this does not serve athletes and teams well. Current restrictions on participation while experiencing pain or discomfort, and subsequent aggressive approaches to investigation and intervention are unhelpful for athletic performance, and may ultimately harm the athlete. Aligning athlete management with best practice guidelines may help everyone achieve their goals.