On this episode of the #AskMikeReinold show we talk about how to work with athletes that may have anterior pelvic tilt and low back pain. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 233: Low Back Pain and Pelvic Tilt in Athletes
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Transcript
Student:
All right. So we’ve got a question from Dylan from Montana. He says, “Hey, 17-year-old gymnast/dancer is coming in with low back pain, usually elicited from hyperextension of her spine. She presents with an anterior pelvic tilt. When she posterior pelvic tilts her pelvis to a more neutral position, she has pain with walkovers effectively when doing so. How do you train such excessive motions with control in the clinic while trying to avoid issues in the future?”
Mike Reinold:
I got to say Ray, you did a really good job reading that, like that was one of the better student readings of a question, but like, even your zoom has a Southern drawl, right? I’ll paraphrase that a little briefly because you broke up a little bit, but essentially we have a 17 year old gymnast with low back pain that she gets from hyperextension of her spine. So she’s in a typical lordosis anterior pelvic tilt, and she has pain in that position. So this Dylan from Montana has been doing a bunch of stuff for pelvic kind of stability, I guess. Like low back stability type things, trying to get a more a neutral pelvis and it’s worked really well. But he doesn’t know how to help her get back to gymnastics and still use that because she needs some hyperextension, right?
Mike Reinold:
So I think, let’s just let Dave, let’s just … I don’t know, Dave why don’t you just answer there. And to be clear though, I mean, this is like tons of athletes. I actually think doing it with the gymnastics model is awesome because they’re like one end of the spectrum. They’re so extreme with this mobility into hyperextension of the back but we deal with this in almost all of our sports. So Dave, what do you do, pain with hyperextension? Is there anything you recommend doing for treatments that would be a little bit different than what Dylan said to get out of that anterior pelvic tilt a little bit? But more importantly, how do you get them back to their sport activities?
Dave Tilley:
Yeah, on the first point, I would say 90% of the people that come to us at Champion or I treat for this kind of issue baseball, fitness, whatever. They’re getting a ton of core strengths. They’re just doing tons of bracing and core strength and like non-stop ab work. And most gymnasts especially are doing plenty of that already in the gym. So that’s one thing, if they have an issue it’s with core control. I just don’t know how to like brace in the proper position. So ease back on the crazy amount of core strength. But I find that everybody is missing things above and below. So, yes.
Mike Reinold:
So based on that Dave, do you find because you said the gymnast are doing a good job with that on their own and in the gym. Do you find that they’re developing core control as appropriate as possible? Are they ever, like unidirectional? Like for example, they’re just working on anterior dominant or something like that.
Dave Tilley:
Yeah. I think they’re often very strong. Sometimes to your point, they’re not strong in 360 degrees. They’re very good in one plane, they don’t think about anti-rotation or anti-side bending. So I would say you can maybe sprinkle in balance there. But most of them are extremely strong. They just don’t know how to actually activate and do it properly under load, that’s the problem most of them have. And so with the secondary thing is that most people typically have some sort of hip extension soft tissue limitation or overhead flexibility issue. And what they lack above and below gets made up by one or two segments. And usually it’s L5-S1 and [inaudible 00:06:13] issue, right?
Dave Tilley:
So like, if it’s a hip issue, they usually have L5 shearing. If it’s a top-down issue, they have the thoracolumbar junction shearing. So look at those things first. I can’t tell you how many people we are politely telling them that maybe we need to work on other things outside the spine. But with the actual return to sports, there’s just like, you start with unloaded movements first, like you would with most people. I think like cat camels, and like trying to restore just the basic half press up is usually where you want to start.
Dave Tilley:
If they can’t do pain-free cat camels and press-ups, then you’re not going to have a great experience when you try to do some like explosive work or stuff down the road. So like check that box first. I think you’ve taught me this in baseball players, have a pain-free exam first before you talk about throwing. It’s the same thing with any other athlete like this. So we do that first and then usually, we try to go back for like a single leg hip lifts. That’s like a relative extension force on their spine. Like, even though they’re not extending to get some sort of loading to that area. And also overhead like tall kneeling work is really good. So tall kneeling on a pad, try to just do like shoulder overhead mobility to get back. And that also is a little bit of that.
Dave Tilley:
So we do that for awhile and then, I like med ball work. I think med ball work is usually the best place to go here. I really like seated overhead med ball throws. We do a lot of those. And then we start to do a standing overhead med ball throws. So it trains like that kind of triple extension and overhead motion positions. And that kind of sets the stage for someone to do a graded interval sport. So with throwing, it would be distance in number of throws. In gymnastics, we do it with a lesser force skills like basics and then on softer surfaces. And then we just slowly progress them up over four weeks.
Mike Reinold:
So based on the question that Dylan had there said that she has pain relief with a more neutral position but she can’t perform her gymnastics activities. He said backward bends and walkovers effectively when trying to maintain this posterior pelvic tilt. Is that something you try to que them and talk to them about, about having posterior tilt while they’re performing their sport activities? Or do you just hope there’s carry over?
Dave Tilley:
Yeah, I think this is where the exam is so important. If you check somebody out mobility wise and they have no mobility issues in their shoulder T-spine or hips, then it’s a queuing issue, it’s a strength issue. But I find oftentimes people don’t have a great assessment system for really good shoulder flexibility and hip flexibility. So they couldn’t get themselves in a proper core position if their life depended on it because of their mobility restriction above and below. So you have to figure out which bucket they fall into and write a program like that. I’ve had people who are just like, unfortunately really on the wrong side of the road in terms of like queuing this as much as I can. And they have like 20 degrees of missing elevation and soft tissue problems.
Mike Reinold:
And I like what you said about the hip too, by the way because say for like baseball or any of the rotary sports that we tend to do. We see a lot of people where they hyper extend their back. For example, maybe during like a baseball swing, just because they don’t have the hip range of motion to get into that end range position. So all that torque creates the extra stress on the back. So like to Dylan’s point, it’s not about like, well, how do we get them to, for this example, swing without going into excessive hyperextension? Well, it’s to give them more mobility in their hip.
Dave Tilley:
Right. And I treat a lot of baseball players all for the same stuff. And I would say, I typically go towards the rotational hip mobility assessments when it’s a baseball player, like IRER and their extensions, like standing position. Versus gymnasts are straight ahead. And nine times out of ten, they have a lot of anterior adductor issues that are missed and they have an anterior pelvic tilt [inaudible 00:09:14] at the longest and that gets overlooked. So I would say if you’re scratching your head, look for that kind of stuff.
Mike Reinold:
Right. And you know what, and I would just add to that, it’s not necessarily that we’re trying to do the sports-specific movement in a different pelvic position. I think what happens oftentimes with these athletes is that if they’re not training core control appropriately, then they just have like no control of it, right? What we’re trying to do is just get them to control a little bit, even if it’s just like a 1% difference in their range of motion. If they can actually like reflexively stabilize that spine a little bit better or a little bit like more 360, like we said earlier there that sometimes that helps with their injury just in and of itself.
Mike Reinold:
Sometimes they just rock back and sit there on their passive stabilizers. Right. So I thought that was pretty neat too. So awesome. Anybody you got anything to add to that? I mean, I think obviously I think Dave did a good job with that, but I’m sure there’s some other brilliant insight. Leonard?
Lenny Macrina:
I got a little just coming from my baseball experience that low backs and [inaudible 00:10:18] that I’ve treated in the past. It’s often a volume thing too. So I think Dave may have hit upon that but maybe not. When I see my baseball players and they’re taking a gazillion hacks in the cages because it’s November and they’re getting ready for April baseball, that’s when they begin to break down. So it’s probably the same thing in the 17-year-old, who’s a dancer/gymnast. She is just doing a ton of volume. Gymnasts don’t practice one to two hours a day. They practice four to six hours a day, oftentimes, probably too often. And five, six days a week and it’s just too much for these young people, females and males to handle. So it’s a volume thing as well. And that’s where, what Dave mentioned the strengthening and better core control and all that comes in, but it’s fatigue factor too. And we can’t necessarily objectify that. How fatigued is she? She’s going to say she’s not fatigued. Because she’s got to practice because her coach wants her practice.
Lenny Macrina:
So it’s a volume thing as well. And somehow we need to educate on that and get the kids and parents on board that maybe six hours a day is a little too much for a 17-year-old.
Dave Tilley:
Yeah. Harshest reality ever had is that the best PT program can’t outdo over-training, it’s impossible. And that’s what happens when they go to the gym, is they’re doing [inaudible 00:11:31] beam and floor and vault and bars. And they’re like, why does my back hurt? Like, well, I counted this once in the girls that I coach. It was like 2,500 back bends in two weeks.
Lenny Macrina:
Yeah.
Mike Reinold:
I’m going to try that. I’m going to work on that myself just around the house. But no, I mean, the part that I think that’s kind of amazing too, is that there’s nothing wrong with hyper extending your spine, but maybe doing it 2,500 times under load and with speed and at range. So awesome. All right. Great episode. We appreciate, I think we nailed that one. I don’t think we need to go much more into detail than that. I think that’s, to me that’s the key right there, Dylan. So hopefully that helps. If you have a question like that, head to mikereinold.com, click on that podcast link and you can fill out the form to ask us more questions. And please go to iTunes, Spotify rate and review so we keep doing this. And we will see you on the next episode, thank you.
