Understanding extension pattern back pain: an overuse injury


Low back pain is common in the general population, with rates as high as 84 percent reported. Low back pain is less common in athletes, accounting for only about 6-10% of injuries, trailing the more common ankle, knee, and shoulder injuries. Because low back pain in athletes involves only minor pain and dysfunction, the majority of athletes continue to train and compete. However, some severe pathologies result in more severe pain and dysfunction. When there is back pain, perform a thorough exam and differential diagnosis to rule out: 

•  Herniated lumbar discs, with or without radicular pain and radiculopathy. Spondylolysis, followed by pars interarticularis defects and spondylolisthesis. 

•  Pain in the zygapophyseal (facet) joint. 

•  Fracture of the facet joint 

•  Kissing Spine, also known as Baastrup’s disease. 

•  Pain in the sacroiliac joint. 

•  Stenosis of the spine. 

•  Ankylosing spondylitis is an example of a genetic group.

Patterns of pain in extension 

Extension pain patterns, first described by Shirley Sahrmann as part of her kinesiopathologic model of movement dysfunction, are a subset of the larger group of dysfunctions known as Movement System Impairment (MSI) classification and syndromes. The basic premise of the MSI classification is that repetitive direction-specific movements can cause microtrauma and tissue stress in passive and active elements such as ligaments and muscles, resulting in low back pain. 

It is difficult to pinpoint the exact source of pain in these extension pain patterns. Facet joints, ligamentous tissue creep or stretch, nociceptive fibres in the intervertebral disc, or ischemia in the paraspinal muscles can all cause pain.

Pattern of active extension 

Active extension movements cause pain by overloading the lumbar spine structures. These could be long-term extension forces or frequent moderate-load extension movements. Active paraspinal muscle contraction increases compressive forces on the lumbar facets. Athletes and sports with this type of back pain presentation include: 

1.  Runners who have hyperlordosis. The paraspinal extensors contract constantly in this posture to keep the pelvis anteriorly tilted. Prolonged extension and anterior pelvic tilt can cause muscle ischemia and pain on either side of the lumbar spine. 

2.  CrossFit athletes – Those who perform repetitive extension-based lifts, such as a deadlift ladder or Olympic weightlifting movements, generate high compressive forces on the facet joints when in extension. Because this type of activity is more intermittent, muscle-based pain is unlikely, and the clinician should look for pain in the facet joints. 

Rowers who sit with excessive lordosis and maintain a lordosis during the pull phase of the stroke may experience joint or disc pain. 

4.  Cricket, swimming, and tennis – The fast bowl, butterfly stroke, and tennis serve all require rapid active extension movements that can cause pain in the facet joints, ligaments, and discs. 

Low-level facet joint irritation is one source of pain in the active extension pain pattern. Three direct mechanisms(2) contribute to facet loading in the active extension pattern: 

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