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My MRI shows I have a damaged disc at L5/S1. I am disappointed that I can never play basketball, golf and go for a run ever again. A neurosurgeon says he can perform a fusion. Is there anything else I can do?

24-year-old athlete with disabling low back pain

Low back pain (LBP) is the leading cause of disability in the world affecting both the general population and athletes alike. In this chapter we outline a contemporary, multidimensional understanding of LBP and detail a clinical perspective of assessing and managing the disorder.

The anatomy of the low back is shown in Figure 29.1.

Figure 29.1

Anatomy of the low back (a) Surface anatomy (b) Muscles of the lower back from behind (c) The intervertebral segment (d) The three-joint complex consisting of the intervertebral disc and the two zygapophyseal (facet) joints (e) Segmental motion: (i) flexion/extension (sagittal plane motion); (ii) torsion (transverse plane motion); (iii) side bending (frontal plane motion) showing compressive and torsional forces


Back pain affects up to 85% of the population at some time in their lives. LBP is rarely reported before the age of 10; however, during adolescence there is a rapid increase in the reporting of LBP reaching near-adult rates (lifetime prevalence of 70%) at the age of 17 years. While the majority (70–80%) improve from an acute episode over a 3-month period irrespective of treatment, between 50–80% will have at least one recurrent episode. However, for up to 20–30%, LBP can become persistent and disabling, limiting sporting activity, physical functioning and impacting on a person’s quality of life.1

LBP is the most common cause of disability in those under the age of 45, and the most expensive healthcare problem in those between the ages of 20 and 50. Back problems account for a significant percentage (25% in the United States) of workers’ compensation claims. LBP is also a common cause of lost time from sport. Of great concern is that in spite of enormous financial resources being spent on radiological imaging, treatments and medicating for LBP, the chronicity and disability rates are increasing.2 The estimated annual cost of LBP in the United States, for example, is over US$40 billion.

The multidimensional nature of low back pain

Once serious and specific pathology has been excluded, LBP in an athlete is frequently considered to be caused by an injury to the spine’s structures. This is in spite of the fact that a clear mechanism of injury or even biomechanical strain often cannot be identified. Consequently, clinicians often reinforce the belief to the athlete that LBP is due to tissue damage, with treatments being directed at treating spinal structures.

In contrast, contemporary evidence supports the ...

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