Lower back pain and trail running: getting back to downhills safely

You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. Hey everybody, it's your co-host Sebastian with the Restoring Human Movement podcast. Thanks for joining the show. Today I wanted to do an email about lower back pain and trail running, somebody seeking some guidance. So what I decided to do, rather than affect anybody's privacy, is I actually asked AI to create an email about what they have found in the internet to be common questions and concerns associated with this problem.

So I'm going to answer AI today and let it know what I think it should possibly do. So I'm writing you because I'm struggling with persistent lower back pain that really puts a damper on my trail running. I've been dealing with lower back pain for a few months now, and while it's improving somewhat, I'm still hesitant to get back into my regular trail runs. The pain is mostly a dull ache in my lower back, sometimes radiating to my glutes. It tends to flare up after prolonged sitting and any activity that puts stress on my lower back. I've been doing some core strengthening and flexibility exercise, which have helped, but I'm still nervous about the impact of trail running, especially in uneven terrain.

My main question is, how do I safely return to trail running without aggravating my lower back, in particular concerned about the impact of downhill sections and twisting movements required on technical trails? Are there any specific exercises or stretches you'd recommend to strengthen my lower back and core for trail running? Should I focus on shorter runs or flatter surfaces initially, or are there specific training protocols to follow? Also, are there any specific trail running techniques that I should be aware of to minimize stress on my back? I'm eager to get back on the trails, and I want to do it safely and avoid setbacks.

Any advice you would be able to give is appreciated. Wow, Aya is actually pretty good at this. So let me be direct with some of these, since this is a fake person and I can be more particular. I would say, actually, the first question about how to return back into running safely, I think it comes down to being able to desensitize the tissue, which is symptomatic. To me, this sounds a little bit more like a low back disc injury. And the reason why is that it's more painful with sitting time. And although that's not specific to all types of sitting, but it seems like the more strain that you put on somebody's back with bending forward or sitting time or rounded postures for prolonged anyways, it seems to increase disc pressure, which can refer out into the glute region.

It can make the back muscles feel tight and strained, but it's not really their problem. They're just protecting against excessive flexion. Or it could be more of more facet referral. Facet referral is more common with people who have had longer standing back problems. This person, I can't really tell, or this AI person, I can't really tell. So if we knew how long they've been dealing with lower back pain, like say this is their first time, this is probably more discogenic. I don't know too many people who have created, we call it posterior element injuries, like facet injuries in their first time, unless it's going to be like a PARS injury, which is going to be a younger athlete.

I mean, that's a PARS, PARS injury is just kind of like a fracture. So it's a non-traumatic fracture, which probably wouldn't be in the scenario with this, although with someone who's running, often you have to worry about energy levels too. Are they taking in enough food as they're expending? If they're not taking in enough, then they could be depleting some of their bone density and be subject to something like a fracture. Now, if now, if someone had a longer standing injury, a lot of times what they'll do is that area of the original injury, typically the disc is L5S1 is the most common and that area stiffens.

And so as they stop using that one or change their activities and movement patterns to compensate for it, they end up bending and moving in different segments. And so I've spoken to some surgeons about this and they say that even like with possibly people with fusions, like they kind of know that like movement will be excessive in the surrounding region. So L4, L5 will be a little suspicious in the coming years and then it'll kind of work its way up a little bit. Not to say that this is a doomsday thing, but just being aware that that may actually be a factor. And the area of symptom generation in this case could be more of referred from the TL junction, which is L1, T12, which can refer into the upper glute area as the superior clonial nerve.

Now, it's debatable which one it is. I'm not saying I'm trying to be wishy-washy about it, but the fact is I don't have an exam and I can't answer follow-up questions or ask follow-up questions to this person to get a better idea. Now, what I usually would do is I'd figure out, next is what we call directional preference. Directional preference is typically established by finding a pattern of how the person responds to basic positions to figure out, again, which structure are we loading. If we have the person sit in sloppy posture and they start to feel pain in those areas and it immediately happens, but they sit up straight and it goes away, that could be more discogenic type of scenario, like an L5-S1, which refers out into that upper glute area oftentimes and sometimes down the leg.

Now, if we get them into like a tucked position, like face-up tucked position, knees to chest, and it feels better, that would kind of counteract or that would contradict like what we just thought. The difference between the two positions is one is vertically, it's gravity compressed, the other one's not. We can also do a deep squat position. A lot of people who have discogenic symptoms don't fare well with the deep squat position, whether it's loaded or passive or you're sitting too low on a certain chair, like they don't like it and it'll increase their symptoms. The other people who have more like posterior element issues or more like higher lumbar superior clonal nerve types of issues, which are very common amongst runners, they tend to like it.

Actually, rounding helps them a ton, but rounding with compression, such as sitting, doesn't. So it's hard to know unless you really test that. Also, too, people who have more posterior element injuries and the facets, they tend to not like laying on their belly. Oftentimes they'll wake up. If they lay in their stomach, they'll feel worse in the morning. If they lay in their back, sometimes they feel bad. When they twist in bed, they feel bad. If they put a pillow underneath their knees, they feel better. And in that case, it flattens the back. It makes the spine neutral or slightly rounded, depending upon the softness of your bed.

And they start to feel a little bit better. So it's hard to tell exactly which one. And the reason I'm going into this is because if you establish that and you do a good exam, which, by the way, you don't need imaging for to identify these because it'll also show that old disc injury, which won't hold any weight other than just knowing that it was there. It wouldn't show you the L1 hinge point. It wouldn't show you the posterior element injury in the higher part of the lumbar spine. But the reason why this is important is because we have to pick something called a first aid. A first aid is something where the person does it consistently for about two weeks, multiple times today to take pressure off the symptomatic structure.

An example of this is, say, if you had a plantar fasciitis and you chose to use something like a heel pad or a heel cup, rather, you would wear it consistently until the tissue on the heel is no longer symptomatic. And then you take it and get rid of it, and then you start to do your normal stuff. So if you take pressure off the symptomatic tissue, it'll oftentimes feel a lot better very quickly. If you don't do that, you're swimming upstream the whole time. So in a long way of answering this, how to return back into running without aggravating your back, is find a first aid first. Take pressure off the structure that's involved.

Give it a chance. If you don't, then you're going to be having trouble. The next part we would probably do is, by the way, the downhills too, and twisting, that's usually associated to more posterior element injuries, like a facet. Now, stretches and exercises you should be doing is going to come down to what is weak or what is stiff. I think a lot of people just generally pick exercises they find on YouTube because someone else said that it worked for them, and it's not the right way to go. Although theory wouldn't be bad to add them either, I would say that a lot of runners would benefit from side planks or side bridges in this scenario.

But also, why stretch your hips if your hips aren't stiff? Why stretch your hamstrings if your hamstrings aren't stiff? Like, you're within general normal ranges because you've been tested and assessed, and both sides are equal. Why add that? There's actually a risk to having too much flexibility as well. And if you've talked to any dancers before who are super flexible, they also have pain too. So adding more range of motion doesn't always make things better. Also, on the same note, why would you strengthen things if there's no strength deficiency? Or you're within the normal parameters of strength for that athlete.

So I took a strength conditioning class years ago, and so one of the tests was, I forget all the details because I don't work with football players, but they said a bench press for, they gave four categories of things for that particular athlete. And they said, which one is deficient? And so it was, say, a quarterback. Quarterback can squat this, bench that, press that, sprint that, and so on. And so what you would expect is normal for that category. You would expect a linebacker to bench press more than a quarterback. So you'd have to know what's acceptable for that athlete. Now, someone like a runner, like, you would have to figure out, like, can they do something, like, reasonable?

They should be able to hop on their, like, pogo hop, single leg, like, 20, 30 times, easily. 40, probably. Like, it shouldn't be any question that they could do it, right? They should be able to do 20 calf raises super easy. They should be able to deadlift at least half their body weight once. Like, that would be fairly reasonable. We should be able to see a goblet squat with about 20, 35 pounds very easily. And these are very low parameters, like, super low. Like, meaning that anybody of any age should be able to do these, okay? And they should be able to go up and down on a lunge split squat.

We call it standing body weight, I'd say, about five times easily. They should be able to hang from rings or a bar for a minute, which is a little bit harder. Yes, gender doesn't matter on this. These are things that we would make sure that the person can do before we start recommending specific exercises and stretches that are just going to waste your time. Once we find the deficiency, though, we can start using those exercises to exploit it. Now, I haven't examined this person, but if I had to guess, there's going to be a mid-back component. Like, the mid-back is rounded and upper back, like a lot of runners are.

So, we've got to elongate extension and rotation in that mid-back. So, typically, that's a mobility concern. Also, the muscles on their upper back are usually pretty weak, so something like a pull-up would be pretty fair for that. Also, a lot of times, their hip is stiff. In that case, we may end up stretching the hip, but a lot of times, their hip is also weak in a hinge pattern. And so, I see a lot of runners who do terrible single-leg RDLs. And so, we would have to clean up probably an RDL, a single-leg Romanian deadlift, just to make sure that they're doing the right amount of weight, but also not loading their spine as well.

Plenty of people pick dumbbells, which are way too low. And if you can't touch your toes or put your palms on the ground, that dumbbell is going to be too low for you, and you're going to use your back in a lift. So, I would rather you do something that's a little bit bigger or higher, even if the weight is higher, too. Are there certain trail running techniques that I should use to be aware of for my lower rack? I can't really answer this. I mentioned in other podcasts that I'm not a runner myself. I've done half marathons and half Ironmans and stuff like that. I don't really enjoy it too much anymore.

So, I leave that stuff for our Dr. Mandy, who is our resident running expert, who is great with reintegrating people back into running after they've had the injury. So, as you can see, there's a strength component and an assessment component that a lot of people do need in the very beginning. But then adding mileage back in and being creative with your terrain and different running styles is something that she could probably help with. And you may end up using, like, actually a coach with as well. We're not running coaches, or actually she is, so she's a running coach. But we're not running coaches, so we don't try to do that part.

But it doesn't mean we can't co-manage you with somebody else. So, I hope this was helpful to everybody. And you should look at our webinar that we have about low back pain, about flexion and extension and tolerant low back pain, which is on the description for the podcast. Also, we do have consultations available. We're licensed in many states, and we can do telehealth, and we can help you right where you're at. So, if you're looking for some help, reach out to us, all of our contacts in the podcast. Subscribe. See you next time.