(Article from Runner's World 2005 - May 2005)

BACK CHAT

It’s at the root of every movement you make – and many of the injuries you suffer – read on for all you need to know about your back.

BY ALISON HAMLETT AND ANDY RICHARDSON

If there’s one irreplaceable cog in your running machine, it’s your back. It is the crankshaft in your Ferrari or, if you like, the garlic butter in your kiev. Running with an injured back is as painful as sticking hot pins under your fingernails and as nausea-inducing as a spoonful of salt.

Back pain is the UK’s number one illness. It is the primary reason for people taking time off work and the charity BackCare believes 180m working days are lost in the UK each year as a result of back problems. The annual cost to business, the NHS and the economy is an estimated £5bn – that equals the annual takings at every cinema in every town in the USA. Four out of five adults experience back pain and on any given day there are a staggering 2.5 million people suffering. Runners are at increased risk because of the repetitive nature of the sport. So, to make sure you don’t become one of the statistics, arm yourself with this advice from some of the UK’s leading back experts. It will help you race and train without suffering.

Your back is a jigsaw puzzle of bones, ligaments, muscles, nerves and tendons. Its complex structure gives it great strength and flexibility. Comprising 33 small bones, called vertebrae, the back has built-in shock absorbers, called discs. The discs sit between the vertebrae and are made of a soft jelly-like substance held inside a tough, elastic and fibrous outer casing. The lowest part of the back, the lumbar region, is the most vulnerable area. It supports the entire weight of your upper body. Back pain often occurs here because the lumbar region has the most work to do and is also flexed, twisted and bent more than any other part of the spine.

“The human body moves around using a complicated series of interconnected structures,” says Clifton Bradeley, a leading authority on back care among runners and the Clinical Biomechanics Specialist to Sub-4 Ltd. “These structures are all required to play a role at specific times during the gait cycle.” Problems in one area can create injury elsewhere. Bradeley adds: “Biomechanical dysfunction and asymmetry in the locomotor unit can cause a variety of running injuries in both systems.”

Around 70 per cent of all lower back pain is idiopathic in nature, which means it originates elsewhere in the body’s multi-segmented system. The lower part of this system is called the locomotor unit and includes the pelvis. It carries the upper part of the body, which is called the passenger unit and includes the spine, upper body, arms and head. These two units meet in the lower lumbar spine.

The spine is central to all the body’s movements so minor damage can cause major pain. Most injuries that are referred to as “simple back pain” are caused by sprains and strains. Pay attention to any stiffness or irritation in your back and you could avoid a more serious injury. In our working lives, as well as our running lives, we can expose our backs to minor damage from poor posture, poor abdominal strength, too much bending forward or backward, repeated quick or strenuous muscle contractions, tightness in the gluteus and hamstring muscles, and tight connective tissue in the lower back, all of which easily lead to over-use injuries.

Understanding your back and how it affects your running is key to avoiding these over-use injuries, and something that Jim and Phil Wharton, a father and son team of musculoskeletal therapists, have spent years studying: “Because runners hold a specific form, the body ends up getting very little variety. Weakness and imbalance can set in,” they say in The Whartons’ Back Book. This can lead to injury: “Runners hold the record for overuse injuries among athletes in all fields – a massive 70 per cent. Of all runners, 37 to 56 per cent get hurt every year, although the injuries might only be minor,” the Whartons add.

The failure to treat simple back pain can lead to more chronic problems – in medical terms this means ignoring simple back pain for a month or more. By addressing the causes of simple back pain as soon as possible after you feel any symptoms, further injury can be avoided. “It has been clearly demonstrated that appropriate early management of back pain can help prevent the condition becoming a long term problem,” says BUPA’s head of care management, Dr Chris Dickson.

One of the key reasons for back injuries among runners is excessive training on hard surfaces, so try to avoid always running on roads or pavements. On these hard surfaces, any misalignment in your musculoskeletal system will be absorbed higher up in the body, creating instability in the pelvis and spine.

Wearing the right running shoes will help you to avoid injury, especially if you have low foot arches. Overpronation (rolling in) of the feet leads to excessive internal rotation of the shin, which causes excessive internal rotation of the thigh. The result is pressure on the hip joint, which tilts the pelvis forward. “This increases the angle where the spine joins the pelvis and is a very common cause of lower back pain,” says Bradeley. This scenario is commonly coupled with any number of other excessive pronation injuries such as Achilles tendonitis; plantar fasciitis; runner’s knee; shin splints and iliotibial band syndrome.

You’re also at risk from back pain if you have one leg shorter than the other. Leg length discrepancies come in two forms – anatomical and functional – and are extremely common. Research has shown that when there is a leg length difference it is normally the left leg that is longer. Sports injuries usually occur on the long side but in some cases, if the difference is great enough, the body’s centre of gravity is pushed over on to the short leg and injuries will occur on that side instead. The difference is usually anatomical (bony) in origin because a bone in one leg is longer than the equivalent in the other. This can be easily rectified with a heel raise placed on an orthotic insole, which fits inside the shoes.

When the discrepancy is functional in origin, it is usually due to muscular tightness around the pelvis, or one foot overpronating more than the other. This cannot be corrected with a heel raise but by addressing the peripheral factors with stretching and strengthening exercises.

Leg length discrepancies can be responsible for a range of sports injuries including sacroiliitis, sciatica, greater trochanteric bursitis, achilles tendonitis, plantar fasciitis, knee pain, shin splints and piriformis syndrome. A podiatrist, physiotherapist, chiropractor or osteopath will be able to tell you if you have a leg length discrepancy by assessing you for both anatomical and functional differences.

Running places great demands on your body but by listening to any aches or stiffness in your back, which may in turn be weakening other parts of your body, you’ll be able to identify problem areas. Address back pain with targeted stretching and strengthening, and follow the advice to injury-proof your back (see panel), and you’ll be able to return to your training stronger and more flexible than before.  

Injury-Proof Your Back

Follow these tips to put back pain behind you:

Food

Eat the right foods, such as fruit, vegetables and slow-release carbohydrates, all of which help to maintain muscle tissue. Don’t forget to drink. By staying hydrated you’ll keep your blood volume high, which means your heart will pump oxygen to your muscles more efficiently. This fires them up but also removes metabolic waste to keep the muscles healthy.

Rest

Since, on average, you spend a third of your life in bed, a decent mattress is a must. Your bed needs to give you cushioning and support, though you should be wary of the use of the word orthopaedic as it is often merely a marketing tool. Support is not necessarily related to price, but luxury and durability are. If you have trouble sleeping, try lying on your back with a pillow under your knees, or sleeping on your side with your knees bent. If you are in pain at night, try this: bend your knees, bring your heels towards your buttocks, let your knees fall to one side and as the weight of your legs takes you over, bring through your hip and shoulder. Do not twist.

Form

A desk-bound life can lead to poor posture so be sure to install work surfaces at a comfortable height. Stand up and walk around or stretch every hour. Make sure you don’t stretch too far when you’re performing manual tasks and don’t bend over to reach things from the floor: squat or kneel instead. Avoid sudden jerking movements and lifting heavy objects while twisting your back at the same time. Stretch well once you have warmed up, especially around the back and pelvis to cope better with the abnormal forces running places on your body.

Impact

Avoid hard-soled shoes and concrete as these will throw upwards any difference in leg length, tilting your pelvis. Instead, try to run on grass or a treadmill. Cross-train with low-impact exercises, such as swimming, cycling, or the elliptical trainer. If you’re relatively new to running, build up your mileage gradually and seek advice if you develop any problems.

Last resorts

If you do suffer a back spasm, you may need to administer DIY first aid. Make yourself comfortable, keep as mobile as possible but, if the pain is bad, rest in the most comfortable position. Apply an ice pack to the affected area. If anything is inflamed because of a torn muscle or torn ligament, use ice and not heat. Avoid bed rest. Movement, even crawling on hands and knees, is better than inactivity.

Back Issues

Ruby Mills started running a few months ago but despite increasing her mileage slowly, she started to feel a twinge in her left hip. “The pain would subside after a few rest days, but every time I started running again it would return,” she says. A fellow runner suggested that since the pain was only present in her left hip, that she might have an imbalance in her pelvis. Mills visited London-based chiropractor Dr Christina Leach [of Gonstead Clinics UK] to find out more.

Leach x-rayed Mills’s spine and pelvis. She explains what this revealed: “A spondylolithesis [a slipped disc] was putting pressure on the nerves in the base of the spine. She may have had this condition from a very young age and not known about it until running started to irritate the area. A vertebra had slipped forward slightly, causing some irritation to the part of the sciatic nerve that was supplying the hip, which caused the pain.”

Mills was surprised to learn that a slipped disc in her back was affecting her hip. “If you have any problems in your back, they often come to the surface when you start running because it is quite a compressive sport,” says Leach. “You need to make sure the biomechanics of your lower back are working at 100 per cent.”

If there are mechanical weaknesses where a vertebra that is out of position is causing nerve irritation, the brain (via the nervous system) will not be able to successfully send vital messages to the joints and muscles, in Mills’s case her hip. The result is reduced strength and reflexes, which ultimately leads to poor performance. Problems further down the legs can also occur since lots of muscles are attached to the pelvis, including the hamstrings and quadriceps, so any rotation or misalignment in this area will affect the tension and tightness of the muscles, and irritate the nerves in the area that supply the muscles.

Once Leach had identified Mills’s slipped disc, she set out to gently adjust the vertebrae to take the pressure off the nerve supplying the hip. Mills is delighted with the results: “I’m training to run a marathon and have been increasing my weekly mileage to about 40 miles with no leg pain,” she says.

Back To The Floor

Running uphill can cause lower-back pain because, as your hips rotate forward (leaning into the hill), the lower back arches, putting more stress on the area. Downhill running can also be problematic because most of the impact shifts to the quads and knees when running down an incline, which puts pressure on the lower back and glutes to add stability.

Strengthening your lower back and abdominal muscles should help ease any pain you experience while running on hills. To minimise stress on the lower back, use an upright posture (i.e. no slouching) while sitting, standing, walking, and running. You can also protect your back by doing most of your runs on forgiving surfaces, such as grass, dirt, or cinder trails, and by replacing your running shoes regularly to maintain adequate cushioning (most last 300 to 500 miles). These strengthening exercises will also help:

Trunk Curl-Up

This provides full support for the back while isolating and strengthening the abdominal muscles. Lie on your back and place your feet up on a chair, with your hips and knees bent at 90-degree angles. Curl up slowly, six to 12 inches, then hold the “up” position for five to eight seconds before lowering. Do three to five sets of 10 repetitions.

Superhero

Balance strong abs with strong lower back muscles. Lie on your stomach, with legs and arms straight out, so your body forms a line from fingers to toes. Simultaneously lift your left leg and right arm six to 12 inches while contracting your buttocks’ muscles. Lower them and do the same with the other two limbs. Repeat 10 times on each side.

Back Issues

Rob Watts had been running for more than 12 years before an old back injury he’d sustained playing cricket as a teenager resurfaced. Like many runners with back problems, the first symptoms he noticed were in his legs. “Initially I didn’t think it was my back because I was having problems down my hamstrings, even down into my knee,” he says. “The initial tightness I felt in my legs turned to pain and I was forced to visit an osteopath. He told me that the pain in my legs was caused by two joints in my lower back locking up.”

Andrew Harwich, Watts’s osteopath, explains his condition: “It’s not quite a dislocation, but the joints do get knocked out of place,” he says. “This leads to the muscles around the joints becoming strained and tense and this tension moves down into Watts’s buttocks and hamstrings, and even down into the calf and ankle.”

This leg pain caused by tension in his back has sometimes prevented Watts from training: “It’s the pain from my thighs to my ankle that stops me running. If I keep running, the soft tissue becomes bruised and in some cases torn, which normally means six weeks out,” he says.

After several years of six-monthly treatments, Watts knows when he is susceptible to aggravating his back, and how to avoid it. “It tends to happen more in the winter when I’m running on uneven ground. If my foot lands awkwardly, it can be enough to click the joints out of place, especially if the muscles and ligaments are cold and not particularly pliable. I know that if I’m stretching properly I’m less likely to have problems.”

Watts is managing to average 40 miles a week as he trains for an autumn marathon, hoping to beat his PB of 2:42, but he’s still looking after his back by stretching it regularly with a routine Harwich has given him that aims to reduce the tension in his hamstrings, calves, shins and ankles. “The stretches do help, but I still need a clunk on the osteo’s table every now and then to sort it out,” he says.

Useful contacts:

Gonstead Clinics UK- www.gonstead.co.uk - Tel: 020 7637 2920

Clifton Bradeley, Consultant Podiatrist -Tel: 07793 581 402

BackCare – a national charity aiming to reduce back pain www.backcare.org.uk - Tel 020 8977 5474

The Pain Society – Information on pain management clinics - Tel: 020 7631 8870

Pain Relief Foundation – Information on chronic pain - Tel: 0151 523 1486.

Chartered Society of Physiotherapy - Tel: 020 7306 6620

British Chiropractic Association www.chiropractic-uk.co.uk - Tel: 0118 950 5950.