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What is causing my back pain?

By Benjamin Hasan | Feb. 25, 2020, 1:57 p.m. (ET)

back pain in triathletes

“I am strong! I am fit. I am healthier than before I began my journey into multi-sport training. Why do I have this frustrating and difficult back problem?”

Back pain, most often low back pain, is one of the most common conditions that lead adults to see their physician in the US each year (1). Back issues can affect up to 84% of adults at some time during their lives. Triathletes can be fit and can also have back issues.

The great majority of patients seen for back pain have non-specific causes. This lack of specificity does not mean that the medical field is confused. It means that the medical evaluation did not identify any of the many serious problems that could result in back pain. After ruling out the potentially bad causes, the remaining tissues of the back and spine (muscles, ligaments, joints, bones, nerves, soft tissues) are left as the most likely causes of back pain. Eliminating bad problems is the main reason to have ongoing back problems evaluated a physician.

Many experts refer to soft tissue causes of ongoing back problems as “chronic muscle strains or ligaments sprains” of the back. Our medical terminology is crucial for selecting and communicating appropriate treatments for specific conditions. These medical terms fit many of the athletes we see in our offices and clinics. These common conditions can be treated. The prognosis is good.

What can we be missing? Can the cause be dangerous?

Absolutely, there are dangerous problems that can be missed if care is not sought. Luckily, these problems are quite rare. A list of concerning but uncommon medical conditions that can cause back pain includes (2):

  1. Infection of the spinal canal
  2. Infection of the bone, called “osteomyelitis”
  3. Tumors of the spine
    a. Bone tumors
    b. Spinal cord tumors
    c. Muscle tumors
    d. Tumors spread from other sites
  4. Cauda equine syndrome (severe symptoms into both lower legs caused by physical pressure around the entire lower spinal cord-often caused by tumors)
  5. Kidney problems, including kidney infections
  6. Ankylosing spondylitis (an inflammatory condition that can cause fusion of segments of the spine, mainly affects men under 40, but also rare)
  7. Intestinal or abdominal causes (less common since these would be expected to cause abdominal pain)

More common causes for back pain can include:

  1. Degenerative arthritis of the spine (in many cases causing “spinal stenosis” or pressure on exiting nerves)
  2. Vertebral compression fractures (post-menopausal softening of the bone called “osteoporosis” can lead to this)
  3. Pressure and sensitivity of a nerve root (often with pain or numbness radiating down the leg, more significant if travelling down lower on the leg to the foot)
    a. Common
    b. Most often not from an intervertebral disc but rather other causes of pressure
    c. The cause of “radicular pain” (medical term) or “sciatica” (non-medical term)

Infection of the spine is more often found in diabetic patients, patients with an open wound near their spine, after surgery, or if they are immunocompromised by prescriptions medications such as immuniosupressants for an organ transplant, long-term steroid use, or various treatments for rheumatoid arthritis and related conditions.

Does all back pain become chronic?

No. For the majority of the back cases we treat, the end of the patients’ story will be that the back problem will improve, pain will resolve, training and conditioning will return, and the athlete will be able to return to regular activities and daily routines. Following-up with the doctor is important to make sure resolution is complete. However, Chronic persistent back problems can occur (3).

Physicians who treat patients with low back pain and patients alike are all to aware of the potential chronicity of back pain. Chronic back problems can be addressed. Cortisone injections, microwave procedures for persistently frustrating cases, and implantable spinal stimulators are used for the most severe cases. Surgery is also an option for some patients, but only about 5% or so of back pain patients will need to consider surgery. There are many studies evaluated the incidence of back surgery and while they differ slightly in their results; they all are low. The majority of successful strategies for treating back pain are non-surgical strategies.

Who should see the doctor for back pain?

If any medical symptom continues or is behaving in a manner that is making a person ill or getting worse, as visit with a physician is important. Severe pain also requires help. Suffering without a clear reason is not necessary. Pain treatments are available. Although the American medical system is using strong opioid pain medication less often in treating common back pain due to significant side-effects and the risks of dependence, we do not let patients suffer. Outpatient or inpatient (admitted to the hospital) pain treatments are available.

How do physicians evaluate back pain?

Physicians are detectives looking for clues, some commonly seen and obvious, and some hidden and requiring more digging to find.  Physicians initially talk with you and take your “medical history.”

The description and types of symptoms you have had and how these relate to the physician’s physical exam are essential parts of a medical evaluation for back pain. Once an athlete decides they need some help for this problem, these steps are essential.

Imaging can also be helpful. If a sports medicine physician is asked if every injury requires an x-ray, the answer is “no.” But a patient with persisting back pain despite initial attempts to treat it with common-sense steps does indeed require an x-ray to make sure abnormal bones (breaks, stress fractures, bone disease, arthritis findings, infection, and inflammatory changes) are either discovered or ruled-out.  On the flip side, imaging results can be confusing.  There is a high incidence of abnormalities found on imaging of the back especially as people age. The doctor will interpret the radiographic findings with the clinical presentation to help arrive at a solid diagnosis.

What is your doctor looking for in the medical evaluation?

I have often suggested to my patients that we address back problems by looking for the rarer and serious problems first. When we quiz patients about their symptoms, we are looking for patterns of known causes. We have listed many common and rare causes of back pain in this review. I share with my patients that my exam and testing is done to try to make sure we know what they do not have. We quiz them, examine them, check their nerve status, look at the range-of-motion of joints including the then perform imaging to make sure we do not find patterns of spine infection, tumors, abnormal bones, severe degenerative arthritis, abnormally placed spine segments, discs far out of place, etc.

Do all age groups have the same type of back problems and with the same frequency?

Back and spine issues in younger patients can be the result of a more serious cause. Children and teens should be evaluated sooner when their back hurts to make sure important problems are not missed. Back pain is common in all adults, including triathletes. But the intensity in our training and willingness to push ourselves as triathletes can lead to back injuries. A common thread in caring for back pain patients is that severe medical problems are not often the actual cause, but as we age the frequency of degenerative arthritis increases. My older triathletes have more degenerative arthritis affecting their back and spine than my younger patients. The pain issues are treatable, as I have shared, but the degenerative arthritis as the cause is not yet curable. Science has not given us the cure for joint surfaces that get rougher as we age (degenerative arthritis). Motion and activity are the critical elements of helping arthritis pain. Stronger joints and ligaments allow more comfortable movement and training. 

What treatments do physicians prescribe for these issues?

The goal is movement. Relative rest is important for healing of any acute injury or painful part. Ice and heat are well known to triathletes. These can help our backs too. Safe over-the-counter medications can help with back and spine pain to facilitate motion but can have some side-effects such as stomach irritation from ibuprofen or naproxen, and some athletes prefer not to use medications. Acetaminophen (sold often as brand-name Tylenol or as generic acetaminophen) is a very good pain management option. It does not cause stomach irritation, can be taken with ibuprofen or naproxen, and is over-the-counter and available during travel. It should not be used by those with liver disease. Medications in the class of “muscle relaxants” can help relax muscles in spasm. Muscles that go into spasm as a reaction to the body’s back pain can relax again with rest, time, heat, ice bags, and muscle relaxants. These prescription medications can cause dry mouth and sleepiness. Consequently, muscle relaxants are ideally used before bed.

When we give advice for back pain, we are looking to help patients become more able to participate in rehabilitation (physical therapy). Physical therapy is important for active people only in that it leads to the patient being able to then carry on their ongoing core conditioning which is the ultimate goal of any back treatment program. Movement is the long-term solution. Athletes are interested in this type of approach, and I have found that active people, especially triathletes, do well with back treatment programs. Many endurance athletes need to add some muscle balancing activites, often abdominal strengthening or resistance training, to their programs. Evidence shows that physical therapy can decrease the likelihood of recurrent back problems. Rehabilitation from back pain is an excellent opportunity to broaden our training regimen and add more cross-training and muscle balancing routines. The sky is literally the limit with this topic. Back pain patients should be careful. It may be smart to avoid heavy squats, back extensions, and pounding routines following a significant back problem. Significant strengthening of the back is most often a long-term project.
For more severe cases opinions from spine surgeons, pain control procedures done by Pain Management specialists (spine injections and use of microwave procedures to eliminate painful nerves) may be needed. We do refer our active patients in our spine clinic for these services. Follow-up visits are essential to ensure safe and successful treatment and return to competition.

What is a good take home message for triathletes with back pain?

While back pain is quite common even with triathletes, it is usually benign in nature and resolves promptly. If you have back pain, ensure there is not a bad problem occurring by getting evaluated by your physician. He or she will initially exclude potentially bad problems and if this can be done successfully, treatment usually involves medication and physical therapy to facilitate return to exercise and training ASAP. 

Author: Benjamin Hasan, MD is in practice in Sports Medicine and Family Medicine and is the Medical Director of the NCH Back, Neck, and Spine Clinic in the northwest suburbs of Chicago. He is a Fellow of the American Medical Society for Sports Medicine, is one of the traveling team physicians for USA Triathlon and an amateur triathlete

Series Editor: Andrew Getzin, MD is the head team physician for USA triathlon.  He is a USAT level 1 coach, many year USAT age-group All-American and has qualified and competed in Kona.  He is a fellow of the American College of Sports Medicine.  Dr. Getzin is the medical director of Cayuga Medical Center Sports Medicine and Athletic Performance in Ithaca, NY, and the director of their shortness of breath in the athlete clinic,

The views expressed in this article are the opinion of the author and not necessarily the practices of USA Triathlon. Before starting any new diet or exercise program, you should check with your physician and/or coach.

1. Sauver, Why do patients visit their doctors? Mayo Clin Proc 2013
2. Deyo, Low Back Pain. New Engl J Med 2001
3. Carey, The North Carolina back pain project. New Engl J Med 1995