Ten Rules for Treating Low-Back Pain in Runners

Ten rules for treating low-back pain in runners.

By on February 11, 2020 | Comments

Stay the CourseThis month, the North American institute of Orthopedic Manual Therapy (NAIOMT), a leader in physiotherapy and manual-therapy-based treatment and research, published their Ten Rules for Treating Low-Back Pain. They developed this list based on their extensive hands-on clinical experience, teaching, and research to help guide the current best practices for treating back pain, which is among the most difficult and costly medical issues in the world.

While their list is intended to guide physical therapists, I also found it compelling for us patients and potential patients. I have expanded upon the list with specific insights for how low-back pain–and NAIOMT’s best practices for treating it–can be applied to ailing runners.

Please note that this list does not constitute actual medical advice, diagnosis, or treatment of low-back pain or any other pathology, nor is it a substitute for actual medical care. If you have low-back pain, seek care through a highly skilled medical professional with experience in low-back pain and treatment.

  1. Low-back pain is often not a serious, life-threatening medical condition.
  2. Most acute episodes of low-back pain improve on their own.

Most of the time, back pain doesn’t implicate any serious damage in the spine, even if severe in intensity, range-of-motion loss, and referred pain. A great deal of weight and force as well as a number of sensitive structures run through and around the spine. For these reasons, spinal pain can be severe and debilitating, even with a simple ‘sprain,’ where a joint gets out of alignment or loses range of motion. Rest and progressive range-of-motion recovery resolves most back pain. A skilled medical professional can help runners identify the source of back pain and the best possible treatment.

When to worry? When your symptoms include significant loss of strength, changes to bowel/bladder function, or significant impairments to sensation and balance. This could mean one or more nerves are being compressed or that more sinister pathologies are present. In these cases, getting prompt medical attention is important.

  1. Treating only the painful region of the lumbar spine is strongly associated with persistent pain.

This is an interesting and counterintuitive notion. In a ‘Western’ medical paradigm that overemphasizes specialization, both clinical- and research-based outcomes indicate a strong association between symptom-based treatment and chronic pain.

However, the direction of the correlation/causation arrow may be in question. Treating only the low back, for example, doesn’t necessarily cause chronic low-back pain. Rather, more challenging cases of persistent back pain often require more holistic, multi-body-areas treatment for sustained relief.

This is especially true for runners. In a sport consisting of ‘transporting’ the spine by propelling with our legs and arms, hip and pelvic dysfunction play a major role in the onset and persistence of back pain. Stiff or weak hips transfer strain to the low back, and in some cases, runners can compensate for gluteal weakness by lumbar hyperextension. Thus, a treatment plan that, say, only mobilizes or strengthens the back will fall short of full relief.

  1. Imaging does not correlate to low-back pain or dysfunction, and often induces fear from the frightening descriptors.

The scientific literature on pain and diagnostic imaging is pretty clear: there is poor (if any) correlation between what is shown on a diagnostic image (such as an x-ray or MRI) and pain. In other words, you can have a lot of pain and a picture-perfect MRI or you can have a scan showing significant pathology (including ‘bulging discs,’ arthritis, or other bony- and connective-tissue degeneration) and no pain at all! Related data include:

  • Fifty percent of all people over the age of 30 with no neck pain have a bulging disc in their neck.
  • Fifty percent of all people over the age of 40 with no back pain have a bulging disc in their back.
  • Fifty percent of all people over the age of 50 with no shoulder pain have a rotator-cuff tear in their shoulder.
  • Fifty percent of all people over the age of 60 with no knee pain have a meniscus tear in their knee.

This may seem uncanny, but this is the reality of diagnostic imaging. This means two things:

  • Imperfect anatomy doesn’t necessarily cause pain; and
  • Even the most severe pain can occur with otherwise perfect anatomy due to either mechanical, neurological, or ‘central’ (spinal cord or brain) causes.

This can complicate the lives of both the patient and medical professional (and lead us back to most of the other rules), but this knowledge is key for expedient and complete recovery because of the psychological effects of bad scans on chronic pain. Chronic-pain research, much of it coming from the Neuro Orthopaedic Institute, shows a strong relationship between ‘anatomical bad news’ and poor outcomes in chronic pain. Indeed, even well-intentioned anatomical education using pictures and models can have a worse effect on pain relief than using none at all!

Where diagnostic imaging is most useful is to rule out sinister pathology (fractures, tumors, or another abnormality) or to correlate severe pain to particular structures (say, severe back pain with radicular symptoms that create weakness and using MRI to identify the offending tissues) that might guide treatment. Note that in both these cases, pain is either acute or dynamic.

For persistent pain, runners need not read too much into diagnostic images or get too down when they hear the words ‘degeneration,’ ‘torn,’ ‘bulging,’ or the like. Just like our running isn’t determined by VO2max, know that there is more to your pain than what your tissues look like. Or as one research doctor says, “If I tell you that you have a degenerated disk, basically I’m telling you you’re ugly.”

Runners with ‘ugly’-looking spines can still run far, fast, and pain-free!

  1. Graduated exercise and movement in all directions is safe and healthy for the healthy spine, but not until the neuromuscular system is coordinated enough to control all movements.

What it means is that while full motion is important and useful, simply doing a wide range of spinal-mobility exercises may not only fail to relieve pain, but also exacerbate it.

Recall from previous articles that healthy function requires four dimensions of optimization: mobility, stability, efficiency, and pacing (tissue tolerance). Mobility without strength or neuromuscular control–the coordination of muscles plus the brain and nerves–is a common but less-often-thought-of cause of back pain. If parts of the low back move too much or too inefficiently, then pain can result. Ligaments and muscles can get sprained/strained, bone and joint tissues irritated, or nerves overstretched.

Thus, any running-specific low-back exercise program must include not only general mobility but also neuromuscular exercises (such as this abdominal exercise and this gluteal exercise) designed to help activate stability muscles and coordinate smooth, efficient movements.

  1. Spine posture during sitting, standing, and lifting does not predict low-back pain or its persistence; however, improper posture in these situations can increase shearing, torsion, and loading on structures not intended to resist such forces.

Posture matters, but we don’t yet know how or why. Numerous studies–including recent findings like this– have failed to show a compelling relationship between poor posture and pain or posture optimization and pain relief.

While disappointing, such findings simply underscore the complexity of spine pain. Through biomechanical research and modeling, it is well known that spinal tissues–bones, joints and muscles–are engineered to take load in certain ways more efficiently. In general, that way is to have a neutrally stacked and angled alignment.

Runner should keep in mind that just because research has yet to find a strong relationship between posture and pain, balanced posture is a safe bet for both pain prevention and efficient running.

  1. A weak core does not cause low-back pain, but a poorly coordinated lumbopelvic musculature does precipitate and perpetuate low-back pain.

This harkens back to #5. Efficient, pain-free spinal motion and function require not just flexibility and core strength; rather, coordinated muscle action is crucial for balanced function. For example, one might have very strong abdominal muscles, but if overpowered by hyper-active lumbar muscles, abdominal function may be impaired.

Neutral posture plays a big role in balanced, coordinated, and automatic core function.

  1. Spine movement and loading will be better tolerated when the neuromuscular system has been adequately trained to assist during the movement.

Simply put, smooth, coordinated movement occurs when the core-stability muscles keep the spine relatively stable as the mover muscles (primarily) move the limbs. In the efficient-running state, core-stability muscles hold the spine stable while the limbs powerfully create propulsion. Pain may result when this relationship is juxtaposed and there is not enough motion at the hips and too much in the spine.

  1. Back pain can increase acutely from chemical inflammation to sensitized tissues, or chronically from centrally sensitized segments.

Mechanical strain and overt tissue damage aren’t the only causes of pain. Chemical stress from inflammatory processes can cause and perpetuate pain. Such chemical stressors can have both physical and psychological origins. This is particularly true for nerve pain. When nerves in the low back and elsewhere become irritated, they are more sensitive to any other chemical stressors. Mitigating inflammatory and life stressors looms large in relieving and preventing low-back pain. For runners, this also means a mindful approach to cross training to avoid hyper-intensive cross-training loads that while seemingly ‘non-weightbearing still pack a heavy chemical strain.

  1. Effective care for low-back pain must address regions above and below.

Lastly, we return to the holistic approach. Regional interdependence refers to the interconnectedness of our system. All body systems are not only connected structurally, but also connected in efficient function. Cliché as it is, ‘it’s all connected’ is a hugely important concept in most pain, but nowhere is this truer than in the lumbar spine because it receives input from all directions–the spine above (including the head and neck), the pelvis and legs below, and even the abdomen (including viscera) in front.

For runners with persistent low-back pain, whole-person treatment is crucial for sustainable recovery and prevention. Pain-free, efficient, fast, and far running includes strong and mobile feet, balanced knees, mobile and efficient hips, a symmetrical pelvis, and segmentally efficient whole-spine mobility and stability… to name a few!


If you’re a runner with acute or chronic low-back pain, this list may help guide your approach to not freak out about acute sprains that are often as common as ankle sprains, but also to not ignore, dismiss, or give in to persistent and potentially debilitating low-back pain. Like with ultramarathoning, pay attention to the little things, understand that little setbacks are part of the journey, solve your persistent problems, think outside the box, don’t give up without a fight, and get a highly skilled medical professional in your corner when needed!

Call for Comments (from Meghan)

  • Have or do you suffer from low-back pain? Have you worked through it with the help of a medical practitioner? Can you share a little about the process?
  • If you have ‘solved’ low-back pain in the past, what do you think helped contribute to that resolution?
Joe Uhan

Joe Uhan is a physical therapist, coach, and ultrarunner in Auburn, California. 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.