Managing Low Back Pain for Lifters

As a lifter, sifting through the sea of information surrounding how to manage low back pain can be overwhelming.

Low back pain can limit your performance and make training unenjoyable or seemingly impossible. At the very least, athletes lifting with pain often feel frustrated that they aren’t performing to their fullest potential. It's important to have a more complete understanding of low back pain to take the necessary steps to maximize recovery while still training.

First, pain is complex and there are an abundance of factors to how each person experiences pain. Pain can be influenced by our biology, psychology, environment, and society. Modifiable factors that can negatively impact low back pain include poor general health, physical stress, physiological stress, severe sleep problems, and prolonged walking (Parreira, 2018). So to blame something as simple as a single lift as the cause of one’s back pain is reductionist to say the least.

In this article, we'll discuss managing low back pain for lifters with a more pragmatic approach on what low back pain really is, how to respond to pain, common training adjustments, and how to maximize the rehab journey so you can improve your performance in the gym and continue safe participation.

I hope this guide will help you gain a better understanding of low back pain, and remind you how resilient your body is!

What Does Low Back Pain Mean for Me?

The first thing you should do is assess the situation. If you can stand, walk, and you aren’t shitting your pants (literally), you are in pretty good shape and can take a sigh of relief. Complete loss of sensation, motor function, or bowel/bladder control are all red flags that something is seriously wrong. If these symptoms are NOT present, this article IS for you.

When pain comes on, stay calm. 70% of adults in industrialized countries will experience back pain in their lifetime. However, back pain is not a life sentence, and 90% of all low back pain resolves within 6 weeks of initial onset (van Tulder, 2006). Even injuries that are considered more traumatic, like disk herniations can heal spontaneously. Up to ⅔ of lumbar disk herniations can reabsorb and heal without surgery (Zhong, 2017). Additionally, most lifting-related injuries aren’t that serious. Even if there is a disk herniation present, these injuries can also resolve and aren’t always painful.

It's important to understand that your experience with low back pain doesn't always correspond directly with the level of injury. Pain is an experience of abnormal sensation and while it can be an indication of serious injury, this is not always the case. Think about stubbing your toe on a coffee table; it hurts a ton, you let out a few expletives, and then it typically resolves independently within minutes. Your back is not unlike the toe in this example. The primary difference is that most people who stub their toe have done it before, and know it will get better whereas a low back pain experience is often associated with high fear of disability and can magnify the perceived severity of the pain experience.

Ultimately, pain is a normal sensation, outside of one’s familiar stimulus level. We have nerves that sense light touch, pressure, hot/cold, movement, and tension, but not pain. Pain is experienced when the AMOUNT of stimuli we get for any of these sensations exceed that which we are accustomed to experiencing. Warm bath’s are nice; boiling water can severely damage the skin.That abnormal intensity is perceived as dangerous and we experience that sensation as pain, as a protective mechanism (Cohen, 2018). This is largely helpful, but when we no longer need that protection, and just want to move again, it can become limiting.

When one can acknowledge that everything is okay, and remember the above to be true, it can drastically improve outcomes and perceived levels of injury/disability.

What happens when the pain persists and interferes with our training though?

What Do I Do Next?

Injuries happen when lifting; you are not alone. While it sucks, this is part of the process and presents a challenge to overcome that creates a more well-rounded athlete. Don’t focus on pushing through the pain, work with what you have session-to-session.

So your back hurts and is limiting your training? Take the burden away, and accept that you are going to be briefly limited. Acceptance and managing expectations will go a long way in mitigating frustration and pain during the recovery process (Peerdeman, 2016). This means it’s time to adjust what is most important RIGHT NOW.

The main thing you want to avoid following the onset of low back pain is inactivity. Don’t be shy getting back to training, the longer you wait, the more you ruminate about what could go wrong and anxiety builds. Inactivity will create a larger gap in your typical lifestyle, schedule, and will negatively impact your routines outside of just training.

Further, your goal should not be to avoid pain. If you focus on NOT experiencing pain, you are subconsciously searching for pain. The likelihood of finding something (pain) is much higher if you are searching for it, than if you are not. For example, if instructed to not think about a pink elephant… I bet the first thought that came to your mind was a pink elephant. Pain avoidance works very similarly to this example.

A better alternative focus is to search for what you CAN do!

The goal of returning to training after back pain onset is not to be pain-free; the goal is to return to training. Collect that win by starting quickly! Once you return to training, even if it’s modified, you can work through the process that leads to training without limitation.

Modifying the immediate priority of training is often challenging for lifters with their sights set on bigger goals than reducing pain. Quickly collecting a win can be a huge step in building confidence and reducing fear when returning to training. The best way to collect a win is to set the bar lower than what you already believe is attainable, this CERTAINTY to meet your expectations for your first session back makes the next steps even easier. Conservative goal setting early is an effective way to prevent digging a hole of despair, and helps prepare for more wins.

This entry point is intended to be a stimulus that is tolerable within the parameters of discomfort. When experiencing intolerable, painful stimuli, this can create MORE fear and a bigger barrier to overcome.

Modifiable Variables & Progression Methods

To find your entry point, it’s key to modify some aspect of ones’ training. In this section we will review some of the simplest variables to modify with training.

Load

Changing the load or resistance for an exercise is the most intuitive option to create an entry point with a given movement. Typically, this is my first adjustment when working with athletes experiencing low back pain.

Adjusting load allows an athlete to continue performing their desired movement with the maximum amount of specificity. If reducing load makes an exercise tolerable, and does not worsen symptoms, it means that your goal is to gradually progress load tolerance of your back. Small, incremental increases in load over the following weeks is the most clear-cut path to returning to normal participation.

Further, when utilizing lighter loads, additional repetitions may be performed to increase the intensity of each set. So instead of 315lbs for 5 reps, it may be 135 lbs for 15 reps.

While lighter loads for additional reps may allow an entry point, what happens if the increased repetitions are not challenging enough for a set?

Tempo

Adjusting tempo is a great means of increasing intensity to challenge oneself without using typical heavy loads. When eccentric tempo is slowed, time under tension (TUT) is increased per rep. This can generate more fatigue and lead to increased motor unit recruitment compared to lifting the same load at a typical tempo.

So when load adjustment allows for movement tolerance, but not sufficient challenge, slow tempo can intensify the challenge of a given set.

Additionally, slowed tempo can help build confidence with the movement again, especially at the bottom of a lift where athletes often feel the most nervous.

What happens if a movement hurts regardless of load or tempo? 315 hurts as much as 225, 135, and the empty bar?

Range of motion (ROM)

Adjusting ROM is a great modification if a movement is painful in only a portion of the lift, but not the full activity. This scenario is nothing to worry about, it’s less about the position itself, and more about the increased force demands of muscles at these more lengthened positions.

For squats, if the bottom position of the exercise is painful, but an athlete can tolerate the rest of the movement, pin squats or box squats may be a helpful alternative to reduce ROM. From session-to-session, gradually lowering the pins, or box height is a great way to gradually expose oneself to increasingly more specific movements to the full ROM squat the lifter desires.

For deadlifts, if the pain hurts from the initial pull, working from an increased bar start height can be helpful. Options like the block pull or rack pull can reduce the positional force demands when starting a movement and reduce the barrier of entry into the specific deadlift one actually wants to do. Similarly to squats, gradually decreasing the height from week-to-week will allow an athlete to progressively increase the ROM of their deadlift.

Sometimes reducing weight or ROM can allow for tolerable movement and be a good entry point, but what do you do if ROM modifications still don’t allow a movement to be tolerable? In my experience, this is a very small portion of athletes experiencing pain, and it can largely stem from fear of the movement itself. We adjust by collecting a win with a movement that is even less specific!

Exercise selection

When reducing load, tempo, or ROM does not permit an athlete to find an entry point, with a movement, changing the exercise entirely can be a helpful alternative to collect the win of practicing a general movement pattern again.

This can be as simple as switching bar placement on a squat from high bar to low bar, or using the opposite deadlift stance than your preferred lift. If an athlete is still unable to tolerate the new movement with these slight adjustments, alternative free weight or machine-based exercises may be an appropriate entry point.

Squats can become smith machine squats, or hack squats, or goblet squats. Deadlifts can become RDLs or good mornings. The important piece is remembering that the primary goal is to return to one’s desired movement. So as tolerance improves with these less specific exercise alternatives, be sure to shift back towards a modified version of your desired lift, potentially using the modifications outlined above.

There may not be a time when you feel completely pain free before progressing the movement, and that’s okay. Being pain-free isn’t a prerequisite to participate in a given exercise. Remember to work with what’s available on a given day, and manage discomfort.

The Journey

Hopefully by now, getting back into training after a low back pain experience is less daunting. Even with these tools and guidelines your journey won’t be perfect. There will be days where you can do more, and days where you are more limited. Try not to view these as good and bad days, but rather as experiences that will improve your ability to set yourself up for improved performance and expectations down the road.

These moments are all data points that contribute to your never-ending goal of mastering your training and life. Regardless of performance in a given session, you are learning and growing as a lifter.

Whenever setbacks occur, don’t freak out. Everything is fine. Setbacks happen in normal training, even when injuries are not a variable. Why would we expect it to be any different when including the complexities of pain?

If pain flares up, remember this process can be iterative. Start at the beginning, assess the situation, accept reality, find an entry point, and continue progressing once more! It is typically easier the second time around than the first; especially if you take the necessary actions to minimize fear and anxiety.

Conclusion (TL;DR)

If you lift, you’ll likely experience back pain at some point. However, this pain does not mean you have any structural damage. Even if damage is present, this isn’t a lifelong pain sentence, and injuries often heal on their own within a few weeks to months.

Staying calm, recognizing what you CAN do, and initiating return to training with minimal delay will help mitigate catastrophizing pain experiences and allow for a less rocky path to recovery.

Find an entry point for exercise that is tolerable, without pushing through pain, to initiate training after an acute pain experience. Modifying load, tempo, ROM, or exercise selection are all means of adjusting training to work with what’s available to an athlete initially.

Setbacks are inevitable and training isn’t linear. Keeping this in mind helps manage expectations and facilitate appropriate action in response to changes in performance along the rehab journey.

References

Cohen, Miltona,*; Quintner, Johnb; van Rysewyk, Simonc. Reconsidering the International Association for the Study of Pain definition of pain. PAIN Reports 3(2):p e634, March/April 2018. | DOI: 10.1097/PR9.0000000000000634

Parreira P, Maher CG, Steffens D, Hancock MJ, Ferreira ML. Risk factors for low back pain and sciatica: an umbrella review. The spine journal : official journal of the North American Spine Society. 2018; 18(9):1715-1721.

Peerdeman, K. J., van Laarhoven, A. I. M., Keij, S. M., Vase, L., Rovers, M. M., Peters, M. L., & Evers, A. W. M. (2016). Relieving patients' pain with expectation interventions: a meta-analysis. Pain, 157(6), 1179–1191. DOI: 10.1097/j.pain.0000000000000540

van Tulder, M., Becker, A., Bekkering, T., Breen, A., del Real, M. T., Hutchinson, A., Koes, B., Laerum, E., Malmivaara, A., & COST B13 Working Group on Guidelines for the Management of Acute Low Back Pain in Primary Care (2006). Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 15 Suppl 2(Suppl 2), S169–S191. https://doi.org/10.1007/s00586-006-1071-2

Zhong, M., Liu, J. T., Jiang, H., Mo, W., Yu, P. F., Li, X. C., & Xue, R. R. (2017). Incidence of Spontaneous Resorption of Lumbar Disc Herniation: A Meta-Analysis. Pain physician, 20(1), E45–E52.

Thank you

Cameron Clowser, DC. Thank you for reviewing and contributing knowledge to this article.

@cam_barbellmedicine

About the Author

Dr. Mitchell Tanner is a practicing outpatient orthopedic physical therapist, strength coach, educator, and lifting enthusiast based out of Ft Lauderdale, Florida. Originally from Spartanburg, South Carolina, he completed his undergraduate degree in Exercise Science at the University of South Carolina, and his doctorate in physical therapy at the Medical University of South Carolina. From working with recreational lifters to professional athletes, Mitchell is committed to helping each person in his care become more autonomous and resilient in their training and life. In his free time, you can catch Mitchell connecting with the people he loves, lounging at the beach, or casting a fishing line.