Evaluation and Treatment of Low Back Pain in Weight Lifting Athletes

By Mike Reinold
Updated on August 14, 2025
Ask Mike Reinold Podcast

Low back pain injuries are common in athletes, and often present differently than the typical orthopedic disc-related neurogenic pain.

In this episode, we discuss a recent review article on the diagnosis and management of low back pain in athletes.

It was nice to see this topic applied to a specific athletic population and include recommendations on treatment as well as evidence-based lifting modifications.

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#AskMikeReinold Episode 368: Evaluation and Treatment of Low Back Pain in Weight Lifting Athletes

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Show Notes

Transcript

Mike Reinold:
Welcome back, everybody, to the latest episode of the Ask Mike Reinold Show. We are here at Champion PT and Performance, answering your questions. Anything you want to talk about, sports, PT, performance, career advice, we’re here for you. Go to mikereinold.com, click on that podcast link, and ask away. On this episode, we’re going to do another journal article review. I still want to hear your feedback. Send us messages on social media through the website. I still want to hear how you like this format and these journal article reviews because it’s something we’ve been dabbling with a little bit.

After answering questions for 10 years, we’re starting to ask some of our own questions. I got Lenny Macrina, Lisa Lowe. We’re here for you today. Dave Tilley is going to take the lead to discuss a recent article. It was a review article that was from JBJS Reviews a couple of years ago on chronic low back pain in weightlifters, and a little bit about the path mechanics and how to manage it, and some of our evaluation strategies. I know Dave and I have been talking about this article. It was kind of a good article to talk about some of those athletic low back pain injuries that we have. So, Dave, take it away. What’d you think of this article?

Dave Tilley:
Yeah, so a 2023 article, relatively recent. And essentially, this was a narrative review on these researchers who were trying to look at, across the literature, what are the rates and the impact of chronic lower back pain in people who are active? So they defined athletes as people who lift weights, regularly more than their body weight. So, strength training athletes. If you look at the methods of the papers inside the review, it kind of covers a large spectrum of what we would consider those athletes. So there’s the traditional sports performance, just like everyday lifters who are doing weight room training. There was a lot of bodybuilding, powerlifting, Olympic lifting, kind of sports performance wrapped into it.

I liked that aspect because it essentially was looking at a large range of different types of strength training athletes. And essentially, what they were doing is reviewing all these articles, and they were looking at, one, what is the incidence and prevalence of chronic back pain, and then what are the MRI findings, if they’re available, correlating to what these injuries show on imaging? And then essentially the third section of this article was, what are some evidence-based treatment strategies that help these people recover and get back to the things that they want to do? I like that it looked at three separate sections of who gets back pain, what type of back pain injuries, what are some imaging findings, and then what are some treatment strategies that work?

And the findings were, I think, important because it shows us that back pain is pretty common to people who do any sort of strength training. It’s the second most common thing reported, I think, in the sub-niches of the populations. There were a lot of powerlifters inside these studies, so they typically have a lot of knee pain, and that’s the first reported thing, and then back pain is second. So, powerlifting and Olympic lifting tend to be more in that second category, but up to 59% of people are reporting some sort of a chronic injury. And I think that the chronic nomer is something, I think, we highlighted this article specifically because I don’t know if this defines, in my mind, what chronic back pain is versus acute re-injury. So, keep that with a grain of salt.

But the reason this article stuck out to me is because, in doing a lit review for a course we’re working on, I found that there’s a lot of different types of injuries within one categorization of sports. So, either baseball, gymnastics, strength training, whatever… you find that in this study, they were showing that the average person was getting strains and sprains. They were getting spondys, they were getting facet syndrome, SI joint syndrome, and they didn’t say it specifically, but they referenced a lot of sciatica-type issues, which you would say is kind of more discogenic or herniation-related. So that was interesting.

They didn’t have a separate category for herniations, but they’re saying that in squatting and in deadlifting in particular, most of these injuries are coming up in some way, shape, or form. So squatting and deadlifting, and then you look at clean and jerks and snatches, those are also just a variation of squatting and deadlifting. It was interesting to me because within one category of strength training, you have, what, seven very widely different diagnoses of spondys versus disc, which, in my head as a clinician, those are very different types of categories of back pain. One is flexion-intolerant and compression-intolerant. One is extension intolerant or compressive axial loading.

And I just found that really interesting that they have all these different categories of subsets of back pain within one category of powerlifting, bodybuilding, or whatever. And then MRI findings, they were just looking at if those MRI findings were available, what did it show? And I like this study because they were looking at all these different imaging findings, but they pointed out that just because somebody has disc degeneration on MRI, it doesn’t mean that correlates to their symptoms. It doesn’t mean that correlates to their long-term outcomes. So you can have someone who has discogenic pathology on imaging, but they have a facet issue.

They have a spondy issue, which is obviously not the same type of correlated movement pattern. And then lastly, when they looked at some of the interventions that were evidence-based to support it, they essentially highlight how technique and exercise selection is really important. And I found this was one of the first articles that I’ve read that really pointed out what we do every day in the clinic, which is modifying technique. Do you have to front squat versus back squat? Why would you choose a trap bar deadlift versus a conventional deadlift? Maybe your mobility is not quite there to get a full hinge on a conventional deadlift, and that’s why your back is not tolerating so much shearing forces.

So, evidence-based wise, they said that doing a lot of exercise selection and technical work is really important. They also point out how weightlifting belts don’t really have a great correlation to reducing injury risk long-term. Sometimes, some studies show that it actually increases it a little bit. And then lastly, I also found this very interesting, is they show that McKenzie exercises or Williams flexion exercises, which are directional preference, didn’t really have an impact on someone’s short and long-term pain. And my two big takeaways are they didn’t really have any type of classification for movement preference in all of these studies.

So we’ve talked about, in another podcast, how if you take a huge group or cohort of people and give them nonspecific exercises for nonspecific back pain, you’re going to get extremely diluted results on what’s effective. And I think this study showed that really well. You have extension-based exercises, flexion-based exercises, and you’re trying to apply McKenzie to everybody who has back pain, that’s flexion, compression, axial loading, and you’re probably not going to get great results if you just blanket approach some of these type things. And the second piece is they kept referencing chronic pain. Chronic pain to me is you have one incident of back pain and you become centrally sensitized because of fear avoidance and true central nervous system changes.

That is not what I think was described in this study. I think a lot of these people with chronic back pain kept having the same type of injury over and over in acute bouts, something that Mike has pointed out a lot. I didn’t really see anybody defined as chronic back pain of, “I had one back pain incident and I’m out of work with chronic sensitivity that I can’t get away from,” from one single event. It seems like they were maybe not defining that well, and I think it gave chronic back pain a bad nomer. It sounds like these people kept getting the same injury over and over again over eight weeks or 12 weeks. So yeah, I kind of thought about that quite a bit as I went on. So yeah, that was the study. A lot of different types of back pain. There are things that work, technique and exercise selection is really important, and MRI findings don’t always equal what their pain levels were, but my takeaways…

Mike Reinold:
I always go back to, “I’ve had thumb pain for a year,” and then you’re like, “Well, what have you been doing?” It’s like, “Well, once a week I hit my thumb with a hammer.” You’re like, “Is that chronic thumb pain? Do we need to have a discussion about my ability to handle pain, or should I just stop that precipitating factor over and over again?”

Len, I want to hear your thoughts because you and I can go first, because I’m sure Lisa’s going to have more important things to say than us, because she works with this a lot, so I’d love to hear it from her perspective. I know for me, for somebody that doesn’t see a lot of low back pain in my day-to-day practice, but working within sports and athletic training stuff, this is something that happens all the time.

I think a lot of students and people early in their career, they find low back pain daunting because it could be so many things. You could have from discogenic to muscle to SI, to Pars, to a stress fracture of a bone. It’s so many different types of things you could have that I think sometimes students and early career people just get really taken aback by this. I thought this was a really good article to talk about “this isn’t disc pain, this isn’t a herniated disc, this is athletic low back pain.” And the strategies are funny, and this is what we teach our students. It’s mobility, it’s control, and load. And it’s getting them back into those things, how funny it was. But that was my take on it. Len, what was your take on, again, somebody that doesn’t treat low back pain all day like Dave and Lisa do?

Lenny Macrina:
I thought it was a good overview of a lot of my thoughts. I think it helped reiterate in my head stuff I look for and look at, and things I’m trying to test for people. Maybe that’s going to bias me now because I agreed with a lot of it. A lot of the papers were retrospective in this review and not prospective. So take it with a grain of salt. You can cherry-pick that as you want. But I think overall, MRI findings don’t always correlate to symptoms. Good to know. I think we tell that to our patients. In this paper, and the studies that they pulled out, told us that most people have an irregular finding on MRIs. I think we can use that information to help educate our patients. And then I think, just keeping it simple, I think talking people through their pain and letting them know that over the next couple of weeks it’s probably going to improve.

And as long as it’s not any red flags that are presenting to us, which we typically don’t often, knock on wood, see. And then it’s just building people’s tissue tolerance back up and building up the, I guess, mental strength, so to speak, to feel comfortable going back into a gym and deadlifting. We had a kid, what was it, last year, who had a big trap bar injury and was down on the ground and writhing in pain, and weeks later, he was back in the gym. It was a full-blown to-do, and he’s back in, beast mode, getting back at it. And I was pretty impressed by him. And every time I saw him, I gave him a fist bump because I was so impressed by him. That’s what we like to see, is somebody who has a big old injury and is able to work through it, and we build tissue tolerance back up, and being able to do all that, I think that is key.

So that’s what I took from this paper, is there’s information out there that we can use for our patients on injury rates, which again, weight training has far fewer injuries than most other sports. CrossFit has fewer injury rates as well. If you look at soccer and stuff like that, the injury rates are 20 times more in soccer versus weight training. We don’t tell kids to not do soccer. So little things like that. So I think we have injury rates, we have educational components for our patients, and then we have basic guidelines on what we can do for evaluation and treatment for our patients. So that’s what I took out of this paper. So yeah, thank you for pointing this out to us, Dave. It was a good one for me to read.

Mike Reinold:
Yeah, great stuff. Lisa, as somebody that I feel this probably hit home, just like you and Dave, I think you see this a lot with your population. What’d you think of the article? Anything you’re going to do different based on it? Did it just more refine stuff? What were your thoughts?

Lisa Lowe:
So similar to what we’ve already said, I feel this article is a good resource for people who are trying to start to understand back pain beyond “people have disc herniations.” You know what I mean? I feel that’s most people’s go-to and often the missed PT… People will get that diagnosis from a PT just because it’s what people say. I honestly bookmarked table three, or whatever, because I was like, “Wow, this is a really beautiful summary of the reasons why certain parts of the back break down.” The structures that we need to explain to patients that are involved. The potential imaging findings. All of the pieces that I feel like being able to explain why someone’s back hurts to them and the mechanisms of what’s going on in the structures that are affected is really, really, really important when you’re trying to help someone not be fearful of moving when their back is still bothering them.

For one side of this, rowing back pain is 80-plus percent of rowers. So, even higher incidence than this study says for weight room-based stuff. So rowers, understanding the why behind their back pain and understanding the difference between soreness because you rowed for a really long time and your muscles got tired and, “Hi, we’ve actually injured something and your back is truly in pain and we need to make a change here,” is something that is really important to be able to understand and be able to help an athlete understand. And I think, similar to this study, there are back pains that you can train through, and you can just modify things in the weight room and work your way through. And having a PT understand, or strength coach understand, how to change stuff up so that you can keep up your activity level and not continue to piss your back off is super-duper helpful because then you don’t get that, “Wow, my back pain shut me down for a year.”

We get people that come in who said that, then I’m like, “Why weren’t you moving for a year? That’s a really long time. That probably wasn’t necessary.” So I feel helping people understand the why behind their back pain is one of the biggest pieces of something that we can be impactful for. And I think this article does a really good job of summarizing that without it being overwhelming. Towards the end of the article, there’s a really beautiful, simple image, figure one, now that I’m looking back at it, of just the different positions that you might see somebody put their self into for different lifts and why one is going to hurt their back and one isn’t going to. And I think being able to even explain those pieces of how someone’s moving and why that’s continuing to make their back pain persist is another role that we get to play.

I’ve had a variety of age groups, rowers or non-rowers, come in who’ve said like, “Hey, I’ve been to five or six different PTs. I’ve been dealing with this for a while. I really just can’t get my back pain to stop. I want to be lifting, I want to be doing these things, but I’m afraid because I just can’t figure it out.” And one of the first things… I know Dave does this too, one of the first things I do is I’m like, “Okay, well, what have you been told about why your back hurts?” And oftentimes they have no clue. So I feel like, again, this article is a really nice resource so that you can start to become better at explaining why someone’s back hurts. And even if it is just directional preference and that’s all you’ve got because there’s no imaging, great. Like Dave said, people are often all treated in this bucket of flexion-based back pain.

It’s like, “Well, if they’re extension-based, oh my goodness, we’re just making things worse.” Again, I think this article is a phenomenal resource, and it was kind of exciting for me as I got to the end of it and saw the different technical pieces that they highlighted for what to look at in the weight room. In my brain, I’m like, “Oh, that is exactly what I try and teach my rowers to do as part of their rowing stroke and why I try and get them into the weight room so that on land and with fewer reps and more control, they can actually learn how to do these movement patterns well.” Because I feel in the rowing world, back pain exists because people just don’t know how to move properly in a lot of ways. The strength capacity and this and that, right, it’s multifactorial, but at a baseline, we teach a high schooler how to do a squat while in the weight room.

Like, hello, this changes their overall prevalence of back pain and ability to participate in their sport. I really was excited that Dave picked this article and that Mike picked to have us talk about it because, again, I think it’s a great resource for people to have in their back pocket if they get a funky back pain person that comes to you and they’re like, “Hi, I’m desperate. I’ve seen 12 other people, and nobody’s helped me.” And you’re like, “Well, crap. How am I supposed to be the one that helps you here?” I think this article does a good job of giving a basic tool so that you can go back and actually be helpful for that person.

Mike Reinold:
And I agree too. And the tables are very phenomenal and very helpful as a resource. Table three, which you can check out in the article, is really good because it goes over all the differential diagnoses and the etiology, the clinical presentation, the image findings, the physical examples, all in one table, which is really cool.

To Lisa’s point, too, they go over the evidence-based treatment, but also evidence-based lifting modifications and behavioral things that’s evidence-based. It’s not just like, “Don’t squat this way.” They try to provide some evidence as to what’s the best resource for that. What do you think, Dave, did we miss anything?

Dave Tilley:
No, I think that’s a pretty good overview and cover of stuff. It’s a good, like Lisa said, a bird’s-eye view of the literature and what it suggested. But I think what you actually do differently in the clinic when you have a gymnast with this pain or a strength training athlete with this pain, it’s so easy to say, “Gymnast equals spondy, rower equals disc issue, baseball equals rotational spondy,” whatever. And I think you just really leave that at the door. Listen to someone’s story and talk about where did it come on, what types of movements bother it? The example I use with a lot of people is, if you look at somebody do a clean and jerk, there’s literally every type of directional preference that could trigger someone’s back pain in a clean and jerk.

So, off the floor is flexion. When you actually hit the bottom of a front squad is flexion and possibly compression. When you stand up a front squat, it’s extension. And when you do a jerk, it’s all extension and compression axial load. That’s four different types of back pain that could be caused in one movement. And if you just say like, “Oh, this person has flexion intolerant back pain” without a system to evaluate them, you could, to Lisa’s point, give them literally something that’s going to make them worse. If you give somebody extension-based exercises with a spondy and acute spondy, that person’s going to never come back to you again because you just made it much worse. So yeah, don’t just assume somebody’s back pain is one type of pathology.

Mike Reinold:
Love it. Awesome. Great article. Check it out in the links in the show notes. I think it’s a really good article to help start that process for you, understanding these different types of injuries that we can have. And really athletes, it says weightlifters, but every athlete nowadays essentially lifts weights.

So we end up seeing these types of injuries in all of our athletes because they’re all working out so much in the gym and all that fun stuff. Awesome. So, great stuff. If you like this format, let us know. Comment, let us know on social media. We want to hear if you’re liking this shift to more of the journal articles. We’d love to hear it. And as always, please subscribe, Apple Podcasts, Spotify, wherever you listen to your podcasts so you can get notifications. Thank you so much. See you on the next episode.

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