Back Pain in Sports: Understanding the Overhead Athlete's Burden

If you’ve played sports growing up, you probably remember a time when you had back pain, and the norm was just to “keep going.” But now we have a deeper understanding of just how prevalent back pain is in in our youth athletes as well as the importance of addressing it head on. Studies show up to 15% of youth overhead athletes are sidelined or unable to compete at their highest level due to back pain. Even more concerning, one study showed that up to 84% of athletes in rotational sports (think baseball, tennis, hockey, lacrosse, among others) experience back pain as a result of their training (Gillies et al., 2003). The spine endures significant torque when an athlete generates high force output for throwing and hitting motions, transferring energy from the ground all the way up to the arm and hand. Now, add in overuse stress from daily practices and strength training, as well as substandard mechanics from fatigue, and we are placing our youth athletes at risk for injury. In this post, I will delve further into common causes, treatment strategies, and preventive measures for low back pain in our overhead athletes.

In Focus: Origins of Back Dysfunction

There is a delicate balance of stability and mobility in our body. When we try to achieve mobility in a certain range of motion, but don’t have stability in that area, our nervous system is very good at telling our body that this movement is “not safe.” Our body goes into protective mode resulting in what we all know as stiffness. This is also how we create variations in our movement patterns to accommodate to a “safer” path of movement. With increased load and repetition, this new movement pattern may then lead to other injuries. What does this have to do with back pain? Well, a lot, and the good news is that we can train our stability and our mobility! The first step is to assess an athlete’s posture and how they move off and on the field.

What are we looking for in an overhead athlete with low back pain?

1. Insufficient mobility in key areas such as the hips, thoracic spine (middle/upper back), and shoulders.

2. Muscle imbalances, weakness, and funky activation patterns (which muscles fire first during a movement). Do your abdominal and spinal muscles work at the same time?

3. Improper lifting or movement techniques

4. Signs of overuse and wearing down of the muscles that work to stabilize the low back. What are the demands of a particular athlete’s sport?

5. Excessive mobility leading to instability. This is very common in the low back, since when there is not enough rotational or extension motion coming from the hips or upper back, we get extra movement from our low back, which is not equipped to handle the brunt of the motions we are demanding i.e.during a baseball swing or when throwing a pitch.

6. Postural cues such as in the arches of the feet or in-toeing/out-toeing, that lead to changes in alignment up the chain

In most cases, low back pain indicates injury and/or inflammation of bone, muscle, tendons/ligaments, a disk or nerve, that either results from a specific event or over time from wear and tear, at segments where the body experiences lapses in stability and inability to absorb the force applied. Pinpointing which of these body tissues are affected is essential in determining a distinct approach to treatment. The rehab protocol for a muscular issue, for instance, differs significantly from that of a nerve-related problem. When recovering from low back pain, we need to TREAT THE ROOT CAUSE OF THE PAIN, NOT JUST THE SYMPTOMS! We need to address the imbalances in stability and mobility that increased the athlete’s likelihood of injury in the first place so it does not occur again (and likely on a greater scale the next time around). Once an area is injured once, there is an even greater risk of it sidelining an athlete again.

Therefore, a thorough assessment by a qualified professional is often the first and most critical step in your journey towards recovery and pain-free movement.

Expert Insights: The Idea of Intentional Asymmetry in Rotational Athletes

When working with rotational athletes, I emphasize the importance of asymmetry—to a certain extent. Consider a golfer or a baseball player who consistently swings and throws from the same side. These athletes have been performing repetitive unilateral rotations since their youth. Is their body perfectly symmetrical? In almost every case, the answer is a clear no. This asymmetry manifests in various ways:

• Differences in shoulder internal and external rotation

• Variations in hip and spine rotational capacity

• Significant strength discrepancies between sides

• Better balance and stability on one leg

A degree of asymmetry is not just common but necessary for these athletes to generate the explosive power their sports demand. However, excessive asymmetry can lead to chronic injuries, particularly in the spine. The key lies in finding the right balance—enough asymmetry to optimize performance, but not so much as to compromise long-term health and functionality. For an athlete’s longevity, we also want to consider the ability of an athlete to move through adequate ranges of motion and movement patterns and show a good baseline strength on both sides despite their apparent asymmetries.

Technique Spotlight: Assessment of Overhead Shoulder Range of Motion

Check out this simple assessment of lumbar spinal stability, thoracic extension, and shoulder flexion range of motion. Have your athlete sit on a therapy ball and raise his or her arm overhead. I like to do one arm at a time and then both together. What we want to see:

• Stabilization of the lower body with feet planted

• A relatively neutral and controlled lumbar spine that does not significantly change shape

• Extended posture through the mid-upper back

• Full shoulder range of motion overhead without arching the back or bringing the shoulder up to the ear

This simple yet revealing assessment can be a key factor in identifying poor core control with overhead movement, as well as finding areas of stiffness and compensation, for example, excess movement at the low back to compensate for lack of end-range shoulder motion overhead.

Here you can see an exaggeration of the compensations we often see through the spine with overhead motion.

Ask the Expert: How Should I Structure my Training to Reduce the Risk of Low Back Pain?

In rotational sports, the repetitive nature of your movements can lead to an imbalance in tissue stress. Some areas become overloaded, while others remain underutilized due to the consistent unilateral motions.

To address this, your training regimen should evolve throughout the year:

1. During the immediate off-season:

   • Focus on a more balanced, symmetrical training approach

   • Aim to relieve stress on overloaded tissues

   • Target and strengthen areas that were underused during the season

2. As you progress towards preseason:

   • Gradually shift back towards sport-specific training

   • Maintain awareness of potential imbalances

This cyclical approach helps manage the asymmetrical demands of your sport while reducing injury risk and optimizing overall performance.