Welcome back to Spine IQ’s Back Blog! The past week brought us “Super Gold Sunday”, a chance to watch both the Super Bowl and the Olympics, where we saw the Los Angeles Rams prevailing in spite of injuries to key players. This week we build on our blog last week by discussing the most recent evidence for treating low back pain in athletes and how that translates into routine clinical practice.

As discussed in our blog last week, there are a lot of similarities between athletes and the general population when it comes to low back pain. These include prevalence and risk factors such as stress level, socioeconomic status, and cumulative exposure to hard labor tasks.1 However, the general population has a few additional risk factors that do not commonly effect athletes such as low physical activity level, obesity, and smoking.2,3  These are characteristics that clinicians can reinforce and cultivate in all patients in order to maximize the benefits of conservative care. It is also just as important to avoid overuse of imaging, spinal injections, surgical interventions, and pharmacological interventions in both populations.4 In fact, recommendations for the treatment of low back pain in athletes and others are similar, with an emphasis on providing care that has a maximum benefit and minimal harm.5

Exercise for low back pain in athletes

Similar to the general population, exercise is high-value as a treatment for athletes with low back pain, all exercise seems to be equivalent, and individual factors should be taken into account.6 Exercise in athletes appears to have small to moderate effect on low back pain compared to usual care. Since no exercise has been shown to be better than another type of exercise for low back pain, clinicians should consider the athletes sport, goals, and preferences through shared-decision making when choosing the exercise type and intensity. The athlete is, for the most part, conditioned and therefore exercise is not one of the major deficiencies in care, but a majority of the general population treated by clinicians are de-conditioned and exercise can and will play a disproportionate role in rehabilitation and recovery.

Manual therapy for low back pain in athletes

Similar to the general population, manual therapy appears to be an effective intervention for low back pain. Both, massage and spinal manipulation appear to have short-term small to moderate effects on low back pain.6 As quickly as one session of spinal manipulation combined with stretching has been shown to reduce low back pain intensity.7 Considering athletes goal is to return to their sport, manual therapy should be used in combination with exercise to make sure the athlete is prepared to return to sport and maintains in good physical conditioning while managing their pain.  It is important for clinicians to remember that the goal of the athlete is very different than the goal of the general patient population. Finding the motivation for what is important to the patient will enhance the effectiveness of the care plan suggested.


There is an increasing opportunity for conservative spine care clinicians to play a significant role in the management of low back pain in athletes. Two of the most high-value interventions for low back pain, exercise and manual therapy, are commonly delivered by chiropractors and physical therapists. Additionally, the importance of chiropractors and physical therapists is being recognized as almost every professional team in the NFL, NBA, MLB, NHL, and college sports are currently employing chiropractors and physical therapists. This growing recognition of the value of conservative spine care in sport will boost the general public’s awareness of appropriate care for low back pain.


  1. Wilson F, Ardern CL, Hartvigsen J, et al. Prevalence and risk factors for back pain in sports: a systematic review with meta-analysis. Br J Sports Med. Published online October 19, 2020:bjsports-2020-102537. doi:10.1136/bjsports-2020-102537
  2. Alhowimel A, AlOtaibi M, Radford K, Coulson N. Psychosocial factors associated with change in pain and disability outcomes in chronic low back pain patients treated by physiotherapist: A systematic review. SAGE Open Med. 2018;6:2050312118757387. doi:10.1177/2050312118757387
  3. Alzahrani H, Mackey M, Stamatakis E, Zadro JR, Shirley D. The association between physical activity and low back pain: a systematic review and meta-analysis of observational studies. Sci Rep. 2019;9(1):8244. doi:10.1038/s41598-019-44664-8
  4. Darlow B, O’Sullivan PB. Why are back pain guidelines left on the sidelines? Three myths appear to be guiding management of back pain in sport. Br J Sports Med. 2016;50(21):1294-1295. doi:10.1136/bjsports-2016-096312
  5. Hainline B, Derman W, Vernec A, et al. International Olympic Committee consensus statement on pain management in elite athletes. Br J Sports Med. 2017;51(17):1245-1258. doi:10.1136/bjsports-2017-097884
  6. Thornton JS, Caneiro JP, Hartvigsen J, et al. Treating low back pain in athletes: a systematic review with meta-analysis. Br J Sports Med. 2021;55(12):656-662. doi:10.1136/bjsports-2020-102723
  7. Hanrahan S, Van Lunen BL, Tamburello M, Walker ML. The Short-Term Effects of Joint Mobilizations on Acute Mechanical Low Back Dysfunction in Collegiate Athletes. J Athl Train. 2005;40(2):88-93.