Running has many great physical and mental health benefits. However this can drastically change if you develop a running related injury like low back pain (LBP). It has been reported that up to 10% of runners will experience LBP, with lumbar facet joint syndrome accounting for up to 40% of these LBP cases.
Lumbar facet joint syndrome is characterised by a localised ache with stiffness in the lower back close to the spine. Essentially, it is an irritation, inflammation, or dysfunction of the facet joints. Facet joints are located on the back part of the spine and consist of two adjacent joint surfaces, the surrounding ligamentous capsule, and the fluid within the capsule. These components allow the spine to move smoothly and provide stability by limiting excessive ranges while bending and twisting at the lower back.
Why is there pain in my lower back when I run?
Normally, the lumbar spine forms a natural curve and the compressive forces from gravity on our bodies are distributed optimally through the spine. the pelvis and down through the legs. The pelvis (located at the bottom end of the spine) acts as an important pivot point in the body. It attaches to your spine by strong ligaments and by your core muscles. An imbalance due to weak muscles at the front of your core and hamstrings or overactive muscles at the lower back and quads, tilts the pelvis forward and forces the lumbar spine into an exaggerated curve.
In runners with good control of their core muscles, they can keep the pelvis level and counteract the exaggeration of the curve. However, runners who have poor or weak muscle control allow this forced exaggeration of the curve and an increased pressure is redirected through to the facet joints. When this is done repeatedly, the joint surfaces become aggravated, the joint capsules begin to swell, the surrounding muscles begin to stiffen and guard, and nearby nerves become irritated, leading to pain and stiffness. Other symptoms can include tenderness at the affected joint level and referred pain around the lower back, buttocks, thighs, or down the back of the leg (sciatica-like pain).
How do I fix this?
If you have some of these symptoms, clinical practice guidelines recommend a 3-month trial of conservative treatments before considering more invasive interventions like nerve block injections. At Breathe, we provide you with a clear and individualised Roadmap to Recovery to improve and limit future episodes of your low back pain. We have provided a rough guide of the Roadmap, but it will be tailored to each individual as required.
Breathe’s Roadmap to Recovery consists of 4 stages:
Stage 1: Pain reduction
The Roadmap always starts with reducing your pain. Here are 3 ways that we can reduce your pain:
manual therapy
passive positions of ease
gentle mobility exercises.
The 2021 'Consensus practice guidelines' highly recommend spinal manipulation therapy (both thrusting and gentler mobilisation techniques) for people with any type of acute or chronic low back pain. It is also recommended to apply soft tissue massage and mobilisations for short-term pain relief. Hot and cold packs can also be beneficial as part of these treatments as they are easy and readily available.
However, a simpler and an effective way that you can do at home to immediately reduce your pain is by bringing your lower back into a position of ease. These positions reduce the amount of pressure that is directed to the facet joints by bringing the lumbar spine into flexion. These can be achieved with some yoga poses like the 'Child's pose' or with some gentle movements like 'pelvic tilts'.
Child's pose:
To achieve this position, start on your hands and knees, with your hands directly in line with your shoulders, and your knees directly in line with your hips (4-point kneeling position).
While keeping your hands in place, slowly sit back on your heels.
Reach out as far as you can with your hands on the floor and hold this position until the pain eases.
Pelvic tilt:
To perform this movement, begin by laying face up on the floor with your knees bent, and with the soles of your feet flat on the floor.
Place one hand underneath your lower back and squish it using your lower back (think: tucking your tailbone between your legs, bracing your abs for a punch, or flatten your spine). Do this multiple times or hold this position until your pain eases.
Stage 2: Activation
After reducing your pain, you can now focus on activation. "McGill's Big 3" are three exercises that were developed by Dr. Stuart McGill to train core muscle activation and ease low back pain. These exercises will help you know how to activate your core muscles to keep your pelvis level and to keep your lumbar spine in its natural curve while running. (This set of exercises has been covered by us before in one of our previous blogs too!)
Ab Curls: For the front of the core.
Begin by laying on your back, with one hip and knee bent, and hands behind your lower back.
Activate your core as if you're bracing for a punch.
Lift your head and the top of your shoulders just off the ground and hold for up to 6 seconds.
Slowly lower to the starting position.
Side plank: For the sides of the core.
Begin by going onto your side and prop yourself up on your forearm.
Bend at your hips and knees but keep your ankles in line with your shoulders and hips.
Activate your core as if you're bracing for a punch.
Push through your heels to bring your hips off the floor. At the same time, bring your hips forward so that they are in line with your knees and shoulders.
Get more height, by pushing your lower hip away from the floor. Hold for up to 6 seconds.
Slowly lower to the starting position
Bird-dog: For the back of the core and to bring them all together.
Begin by getting into the 4-point kneeling position. (It's best if you're near a mirror to see what you're doing!)
Activate your core as if you're bracing for a punch.
Reach out in front of you with one hand and straighten the opposite leg into the air.
Check the mirror and see if your hips and shoulders are level, and if you have a neutral spine.
Stage 3 and 4: Movement and strengthening
Now that you know how to activate your core, let's move on to adding some movement. In this stage, you will practise some key components of running, such as keeping your core active while you move your arms and legs. Here are three levels of difficulty:
Easy: Single leg march
Begin by standing up straight in a slight step stance.
Activate your core and bring one knee to waist height, with the opposite elbow at shoulder height (as if you are marching).
Check your lower back to see if it is neutral, and pelvis to see if it's level.
Practice doing this on both sides.
Moderate: Single leg march, onto a step
To make this moderately more difficult, place your front foot onto a step.
Activate your core, push through the glute as you step up.
Bring your other knee and arm up to the same height as before.
This harder movement focuses on keeping the spine neutral and the pelvis level as you put power through your leg and help you differentiate between hip and spine extension.
Hard: Bounding
The last movement before practising this in actual running is bounding.
This movement focuses on keeping the spine neutral and pelvis level as you put power through your leg as you push off AND as you land.
Begin in a slight step stance, ready to push off with your front leg.
Activate your core, shift your weight forward, and push off your front leg.
When you land, pause, and evaluate and correct your spine and pelvis positions.
If your spine is in the correct position when you land, the compressive forces from the top of your body will be distributed equally through the spine and pelvis and will not force your lower back into that overarched position.
Overall, despite runners having a small percentage of developing lumbar facet syndrome, it is important to continue to work on your core muscles to decrease the risk of pain and stiffness. Recent guidelines recommend manual therapy to help ease the pain and stiffness, but simple movements at home are also effective. A continual effort to maintain control of your core is essential to help prevent recurrence of pain and stiffness.
References
The Australian commission on safety and quality in health care (2022). Low back pain clinical care standard. https://www.safetyandquality.gov.au/publications-and-resources/resource-library/low-back-pain-clinical-care-standard-2022 (last accessed 19/07/2023)
Beresford, Z., Kendall, R., Willick, S., (2010). Lumbar facet syndromes. Current sports medicine reports 9(1). P50-56. https://doi.org/10.1249/JSR.0b013e3181caba05
Perolat, R., Kastler, A., Nicot, B., Pellat, J., Tahon, F., Attye, A., Heck, O., Boubagra, K., Grand, S., and Krainik, A., (2018). Facet joint syndrome: from diagnosis to interventional management. Insights into Imaging 9(5). p773-789. https://doi.org/10.1007/s13244-018-0638-x
Cohen, S. P., Bhaskar, A., Bhatia, A., Buvanendran, A., Deer, T., Garg, S., Hooten, W. M., Hurley, R. W., Kennedy, D. J., McLean, B. C., Moon, J. Y., Narouze, S., Pangarkar, S., Provenzano, D. A., Rauck, R., Sitzman, B. T., Smuck, M., van Zundert, J., Vorenkamp, K., Wallace, M. S., … Zhao, Z. (2020). Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group. Regional anesthesia and pain medicine, 45(6), 424–467. https://doi.org/10.1136/rapm-2019-101243
George, S., Fritz, J., Silfies, S., Schneider, M., Beneciuk, J., Lentz, T., Gilliam, J., Hendren, S., Norman, K., (2021) Interventions for the management of acute and chronic low back pain: revision 2021. Journal of orthopaedic and sports physical therapy 51(11). P1-60 https://doi.org/10.2519/jospt.2021.0304