Low Back Pain During Running: Tips For Ultramarathon Runners

Stay the CourseLow back pain is the most common physical ailment in the world. The majority of people will experience a low back pain episode at some point in their lives, often repetitively.

It is equally common among runners, though many runners tend to brush off low back stiffness and pain as part of the game, until it becomes debilitating. I, myself, have struggled with back pain for the better part of three years, until just recently. In retrospect, all of my low back pain was due to mechanical inefficiencies, as well as the unique demands of mountain trail running. But since reforming my stride, my back pain is almost completely gone.

Below are some critical strategies to limit low back stress and pain during running.

Background

Discussing the causes of low back pain in runners requires a review of my Four Concepts of Efficient Running Mechanics:

  1. Forward Trunk Engagement Through a Hip Hinge;
  2. The Short and Long Hip Pattern;
  3. Strong Arm Swing; and
  4. The Pawback.

Within this construct of efficient running is this fundamental mechanical theory:

  • Flexion-dominant trunk stability
  • Extension-dominant hip mobility

What that means is: to efficiently move forward, our trunk must be forward-oriented. This comes from hip flexion, but core stability is required to keep us trending forward without falling backwards. This could be why the vast majority of ‘core stability’ exercises deal with the anterior abdominal muscles.

At the same time, the way we propel is through hip mobility. The hips drive upward and downward, but the bulk of our propulsion in a gravity-dependent world comes from hip extension. Pushing off powerfully from the gluteal muscles is the central motor to fast, powerful, and efficient running.

That said, strong, efficient running requires this balance: flexion-dominant stability of the trunk, which provides a solid platform for powerful hip extension beneath and behind us.

Low Back Pain - Correct running posture

The author demonstrating a trunk-forward stability with hip-extension push off equal to the trunk. All photos: Joe Uhan

It is when we lose this balance that problems arise, often in the low back and pelvis.

Low Back Pain: A Misfire in the System

When either hip mobility or trunk stability is lost, so is efficiency. With the former, if the hip cannot extend–either due to tightness or poor positioning–’the buck is passed’ onto the low back. For the latter, if the trunk does not stay stable, the hips lose the ability to powerfully push, and excessive mobility occurs at the trunk.

The Culprits
Hip-Flexor Tightness
Efficient running requires the hip extend to the level of the trunk. That is all. Yet, few of us–including runners–have that flexibility. Excessive sitting–the cornerstone of Western civilization–is likely the culprit, where our hips are stuck in a flexed position for hours at a time each day.

The hip-flexor muscles–the psoas, ilacus, and rectus femoris–all originate on the lumbar spine or pelvis, and insert onto the upper portion of the femur. They act to active flex the hip upward during running, but they also must passively relax to allow the thigh to extend. If the hip flexors become tight, any attempt to extend fully during the running gait will result in low back stress. Tight psoas muscles, especially, will pull on the lumbar spine–on which they’re connected–causing lumbar stiffness and possible low back pain.

Trunk-Stability Deficit
On the other end, the core-stability system must keep the trunk stable so that the hips have a strong base for push off. When the trunk–namely the lumbar spine and pelvis–fails to stay stable during the push off, excessive motion tends to occur. With each stride–180 per minute–the lumbar and pelvic joints are being stressed. This is a prime generator of low back pain and degenerative stress.

Too Upright
If one has flexible hips and a strong core, it is still possible to have back pain. Since hip extension equal to the trunk is the prime job of the gluteal muscles, what happens if the trunk is completely upright?

Besides providing forward momentum, the vial importance of a hip-hinged forward trunk is that it gives the gluteals somewhere to go. A forward trunk creates a rearward, propulsive glute push off. But running too upright robs the hip extensors of a place to go. As a result, the body often compensates by extending through the lumbar spine.

Low Back Pain - Incorrect Running Posture

The author, a year ago, running too upright, with excessive active lumbar extension in push off. This compensatory motion caused significant back pain for years. But once corrected (previous photo), back pain was abolished.

This is extremely stressful to the low back, as the body is actively recruiting lumbar muscles to propel, which creates significant joint stress and overuse of a muscle group intended to stabilize and lightly rotate–not propel.

Excessive Trunk Rotation: ‘The Swivel’
A central component of a strong arm swing is the transfer of power from arms to the legs–and/or a counter-balance to the legs–using the trunk as a conduit. Inefficiency in the arm swing can cause a hyper-rotation, a ‘swivel-effect,’ where the arms twist from side to side, rather than pumping forward and back. This can cause the trunk to excessively rotate, often concentrating the motion in the lumbar spine.

Again, this left-and-right twist that propagates 180 times per minute creates a potentially enormous stress to the low back, often resulting joint wear and tear, and low back pain.

*****

In summary, low back pain can arise from:

  • Tight hip flexors that fail to allow full hip extension, causing lumbar stress;
  • Poor core stability, where the lumbar spine and pelvis fail to stay stable as the hip pushes off;
  • Being too upright in the stride, resulting in compensatory extension from the low back; and/or
  • Excessive trunk rotation due to an inefficient arm swing.

Low Back Pain Prevention: Exercises and Form Cues

Stretch The Hips!
The hip flexors must be flexible enough to allow hip extension equal to the trunk. A simple test of this involves lying on the edge of a table or bed and hugging one thigh tightly to the chest. The opposite upper leg should be able to remain fully level with the table, with the lower leg hanging close to 90 degrees.

This test, itself, is a stretch: passively hanging, or actively ‘pulling’ the leg toward the table and floor. This can be done for 30 to 60 seconds, for several reps, to improve hip-flexor mobility.

A great ‘on-the-go’ stretch, pre- and post-run, is what I call the ‘Split Hip Stretch.’ It involves putting a foot up on a step, bench, or any object two to three feet high.

The flexed leg should rest against the chest (with the knee behind to toes). The trailing leg is getting stretched by being slightly wide and fully extended. The stretch is created by actively squeezing the trailing leg’s glutes and quad muscles.

This exercise creates a combined flexion, extension, and abduction stretch for both hips, all the while protecting the low back from extension stress.

Hold for 20 to 30 seconds, for several reps, each side.

Low Back Pain - Split Hip Stretch

Split Hip Stretch

Trunk-Stability and Hip-Mobility Exercises
Practice trunk stability while extending the hips using these exercises:

All Fours Bent Knee Leg Extension
This exercise practices the ability to extend the hip on a stable trunk. Extend the bent-knee leg upward, careful to keep the low back and pelvis stable. The goal is to extend the thigh to the level of the trunk. However, only go as high as you can go without over-arching through the low back.

Hold three seconds or a single exhale. Alternate, 10 repetitions per side.

Low Back Pain - All Fours Bent Knee Leg Extension

All Fours Bent Knee Leg Extension

Straight Leg Extension Plus Opposite Elbow
This exercises adds an opposite-elbow extension, working on arm coordination along with hip extension and trunk stability.

Extend the leg and opposite arm simultaneously. Hold three seconds or a single exhale. Do 10 repetitions in a row, per side.

Low Back Pain - Straight Leg Extension Plus Opposite Elbow

Straight Leg Extension Plus Opposite Elbow

Plank Plus Leg Extension
This is an advanced strength exercise, combining an elbow plank with a straight-leg-extension lift.

Emphasis is on keeping the low back and pelvis stable, while the hip moves to a level equal to or just slightly higher than the level of the trunk.

Hold each extension three seconds or a single exhale. Alternate, 10 to 20 total repetitions.

Low Back Pain - Plank Plus Leg Extension

Plank Plus Leg Extension

The Deadlift
As covered in the August 2014 column, the Runner Deadlift exercise works hip-extension strength and mobility with a stable trunk. Practice this exercise as indicated.

Form Cues for Low Back Pain Prevention
The Hip Hinge
Maintaining neutral-forward-trunk momentum is the most important element of low back pain prevention. Besides preventing over-striding, a trunk-forward position allows the hips to extend without over-arching the low back. Keeping the trunk forward and neutral is vitally important during mountain trail running. Avoid backward leaning–and significant low back stress–by maintaining the hinged-hip position, even on steep downs!

Strong, Efficient Arm Swing
While a small amount of trunk rotation is ideal in an efficient stride, excessive ‘swivel’ of the trunk on the pelvis is stressful to the low back. Work on a strong forward and back arm swing where the elbows drive powerfully rearward. Efficient arm swing should create approximately an inch or so of trunk rotation in each direction, but no more. The exercises outlined in this column are useful in developing arm-swing efficiency.

Lumbar Stability in Extension
While lumbar extension and rotation can be stressful and pain producing, a lumbar-extended position is not only okay, but desirable. Neutral spine mechanics involve a moderate amount of extension curvature. This helps orient the pelvis and hips for optimal rearward hip push off.

However, it is excessive lumbar-extension motion that is stressful. Be careful that you are not allowing the low back to repetitively extend during the stride. While actively ‘tensing’ the abdominals during running is neither desirable or sustainable, some degree of stability in the low back is required to prevent this excess motion.

The stability exercises above will help train the brain to maintain this stability when running.

When in Doubt, Film It!
If you’re unsure if you’re adequately hip hinging, or stabilizing, have someone watch you run and give you feedback, or hold your camera phone to take a quick side-view video. This ubiquitous tool may be the most powerful way for runners to monitor their stride. Be sure the trunk is forward-oriented, and the low back stable. In the front or rear view, be sure there is only an inch or so of trunk rotation, with a strong forward and back arm swing.

We Walk How We Run
Be mindful of your walking form. The same inefficient habits–too stiff in the hips, too upright (or backward leaning), and too much arching or rotation can just as often occur when walking. Be sure to maintain a light, forward trunk and extend powerfully with your hips behind you, even when walking. Efficient walking begets efficient running!

*****

Low back pain can put a damper on a lot of things, and, over time, it can jeopardize your running career. Take these steps to ensure you limit back stress, and maximize hip mobility and strength over the course of your run.

Call for Comments (from Meghan)

  • Do you suffer from low back pain when you run? How long have you suffered and do you know what might be the mechanical cause of your pain?
  • Have you addressed any of the running-form issues discussed in this article in your own running gait? If so, what issues did you previously have and how did you correct them?
Joe Uhan

is a physical therapist, coach, and ultrarunner in Eugene, Oregon. He is a Minnesota native and has been a competitive runner for over 20 years. He has a Master's Degree in Kinesiology, a Doctorate in Physical Therapy, and is a USATF Level II Certified Coach. Joe ran his first ultra at Autumn Leaves 50 Mile in October 2010, was 4th place at the 2015 USATF 100K Trail Championships (and 3rd in 2012), second at the 2014 Waldo 100K, and finished M9 at the 2012 Western States 100. Joe owns and operates Uhan Performance Physiotherapy in Eugene, Oregon, and offers online coaching and running analysis at uhanperformance.com.

There are 21 comments

  1. evanr28

    Thanks for the great writeup! I acutely injured my back going on 2 years ago while doing yard work, and I think the root cause was tight hip flexors and hamstrings stemming from a heavy training load and a new desk job (sitting all the time). I thought I had it figured out, but I was sidelined again recently after The Rut 50k, and I've struggled with self-analysis to figure out what about my biomechanics and movement patterns was affecting the back. From your insights, I think that compensatory extension in the low back may be part of it, Another suspect is the tight hamstrings placing additional strain on the low back and weakening it prematurely in a run. Any thoughts on this, or would the hamstring tightness be less of a factor with a proper neutral forward trunk?

    1. 00joeuhan

      Thanks for the comment, evanr28.

      Per the hamstrings: in slow ultra running, it's tough to say whether hamstring tightness is a CAUSE of back pain, or an EFFECT. If you're running too upright, not only will you engage in "compensatory extension" through the back, but the hamstring will also get over-worked trying to extend the hip. Also, if the hip isn't working well, the hamstring also gets overworked, with a relative over-stride. In general: less hip hinge = more hamstring lengthening when you contact the ground.

      Try the hinge and deadlift exercises, and "stretch everything" and see how you feel, good luck!

  2. Steve Pero

    Great post, Joe.
    I know when my back starts getting tight and sore, I've been sitting too much. I started standing at work a couple of years ago and 90% of my back problems went away.
    I recently moved back east and after driving for 2 days (sitting all day!), I started unloading the moving truck and "crick"…I couldn't stand straight for days. All I needed to do was get back to my standing workstation and some stretching, many of which you point out above, and I slowly got better. Now running (and working) totally pain free again!

    1. ripvanracer

      I ran 3 cross country races in college and then wasn't able to run for 18 years because of tight psoas muscles. In the early 80s nobody I went to had a clue what my problem was. After being able to start back running 12 years ago, I again had the psoas go into spasms to the point I could hardly walk. I was referred to this site that has a very simple psoas stretch you can do. http://www.julstro.com/joint-pain-lower-back-pain
      I also think the psoas can go into spasms or tighten up more if you transition from sitting and start runs too fast. A slower first mile or two gives the psoas more time to loosen up from the contracted position.

      1. 00joeuhan

        Thanks for the comment!

        I have a saying: "The best exercise is Living Well". What that means is, if we move efficiently, we seldom need to stretch and strength a great deal.

        The psoas tends to get excessively tight with running too upright: the muscle gets over-stretched during running when the leg tries to push off, then is over-worked trying to flex the knee upward. This effect is multiplied if foot recovery is low (e.g. "long lever") in swing.

        Work the hinge, and strengthen the glutes and abs, and the improved efficiency will sustainably decrease psoas tightness.

        Good luck!

        1. PhilMaffetone

          Joe, your comment that, <<"The best exercise is Living Well". What that means is, if we move efficiently, we seldom need to stretch and strength a great deal.>> is great. Everyone should remember that the body takes care of itself when we live well. Thanks.
          Phil Maffetone

  3. marathoningmom

    so timely. I finished my first 100k this weekend. On the ride home we were all discussing our lower back pain and wondering why this happens. Thanks for the good info.

  4. NanoPT

    Good stuff. From my experience frontal and transverse views of the pelvis upon initial contact would be beneficial as well, right when the hip abductors are at their peak activation. It's seems that a) that deficit is a major issue with the running population and b) contralateral hip drop can potentially lead to ipsilateral compression of the lumbar spine. Also, maybe a couple functional/CKC strengthening exercises that reinforce proper motor patterns? There are a litany of things to potentially include but those stand out from my experience. Keep on writing!

  5. 00joeuhan

    Thanks for the comment and support, Nano-

    You're 100% correct on frontal plane pelvic/hip issues, and how that lack of stability –> stress.

    However, my experience is trying to actively (through cues and focused strategies) correct pelvic stability is very challenging. Focused strength exercises and drills (especially the 100-Up) can unconsciously improve this, but I've yet to develop a sustainable cue that's not, "Hey…don't let your pelvis collapse".

    Ultimately, what I've determined is that when there's inefficiency in *sagittal plane*, the body tries to "dump them" in the frontal and transverse planes. That said, maximizing efficiency sagitally (e.g. hinge, hips, arms, pawback) cuts down on frontal and transverse stress.

  6. marathonmanindia

    I have been running for several years. I have had lower back stiffness off and on. It usually happens post 15 Km. I have modified my posture and stride over the years, mainly to improve efficiency of running. I don't have any injuries any more. However recently due to the new body posture there is a dull pain that begins in the gluets and the lower back. I expect it is an error in the body posture. If I run a little faster by raising the knee it releases the tightness. This article points in the right direction on many fronts. Also on body posture. Now I need to be able to implement the same on the practice runs. Instinctively I need to open up a little when I run, it feels very controlled right now in an effort to complete the run.

  7. neeraj

    Great article!! Im over weight (BMI 27) runner, and after half marathon distance my back start hurting, and I usually end up with cramp like feeling on the right side glute muscle, pain slightly on the side. While researching I was suspecting piriformis syndrome, but my pain starts with back pain, and then ends up with spasm/ cramping feeling on right side of hip.

    While I had started to do flexibility exercises a couple of months back (hip opening exercise and stretches, even yoga), I really didnt understand the significance, and was doing those without interest. Now going through articles, I think I understand much better….

    Thanks a lot!!!

  8. Steven

    Smashing article, I have started to see the positive in the possiblity of running again after my discectomy (L5 S1) April 15th 2016
    There are a lot of negative posts concerning my condition, but there are a few out there that report good news.

    My biggest fear is starting to run again, my disc is damaged and they don’t repair again, but reading your article suggests I can do quite a bit to minimise the mpact force on said disc.

    I have been told by my doctor I can start to wak/run 3 months post op but I am choosing to wait at least 6.

    I have hired a PT and we are working on my entire body…from feet to neck, I feel like I have neglected my core, muscles and posture while still managing to run 3 Marathons 1 Half Ironman and countless halfs.

    I miss running with an absolute passion, it’s what kept me sane, and missing out on running Disney Dopey event this year almost broke me, but I still need to decide for myself how my back feels once I resume running as I cannot go through the mental and physical pain again.

    I consider myself one of the lucky ones as lots of people have perm or long term nerve damage, I myself see that I could be feeling mostly normal by the end of this year.
    I’m swimming 2-3 times a week, stability and strength training are also included in my daily life.

    Sorry for the waffle, needless to say I will focus on what you have written with great interest.

    Thanks again for your post, very very interesting.

    Kind regards

    Steven

  9. Jason

    Hi all, saw these illustrations, realized I have not been pushing off my back legs enough, tried focusing on that issue today, ran a longer distance at a faster pace. I’ll have to make sure I practice proper form on my long slow run days.

  10. Mike

    Hi Joe,
    I recently came across your article while surfing the web for a solution to a sore back. I have practicing your suggested exercises and would appreciate any additional guidance on how you changed your running form in a little more detail. Thanks.
    All the best,
    Mike

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