Lower Back Problems: Identifying, Managing and Healing

Dance has become a highly participated activity with its own unique set of injuries. Consequently, we are seeing more and more dancers seek physical therapy, chiropractic care, or other therapeutics to treat what can become debilitating back pain (particularly, lower back pain). From a physiotherapy perspective, it is quite interesting treating a dancer as they usually have a high degree of flexibility and hopefully good strength. However, since dancers have to be able to contort themselves into infinite positions, often at speed there is always a risk of injury. Muscle strain is caused by a tear in the muscles of the back or in the tendons that connect the muscles to the spine. This kind of injury usually occurs after any sudden impact, such as twisting or overstretching. It often can happen when exercising, particularly if you are new to an activity or by making sudden moves after sitting for long periods of time. Lifting heavy objects also can place excess pressure on the spine and create a risk of injury. Let’s not forget that sitting for long hours can also take its toll on the lower back – pain and discomfort in the back are very common amongst office workers too. Sitting, particularly in a stressful environment, can place an incredible amount of pressure on a lower back area. Some additional risk factors for back strain include being overweight or obese and having poor posture.

Lower Back Pain in Dancers: Stress Fracture

This is arguably the most serious lower back issue for dancers. Stress fractures occur in the lumbar spine with repetitive extension (leaning back) movements. This can include jumping or hopping with poor core control and as a result, landing with a “swayback” posture. A stress fracture in the lumbar spine occurs in the part of the vertebra known as the pars interarticularis which is put under load during these movements. Often these are referred to as a pars defect (which is a progression of a stress fracture) or spondylolysis. The risk factors for a lumbar spine stress fracture are:

  • Repetitive extension (arching backward) activities – as mentioned above arching backward places a big load on the region of the spine that can develop the stress fracture.
  • Age – stress fractures in the lumbar spine can occur at any age but are more prevalent in adolescents.
  • Sex – boys are roughly 3 times more likely to develop a stress fracture than girls. It is uncertain as to whether this is due to differences in the body through adolescence or differences in activity levels.

Unfortunately, a stress fracture can mimic regular muscular low back pain which makes it difficult to diagnose. The tendency is for you to have pain with arching backward exercises but can also occur with running, hopping, and jumping. Compared with muscular pain you may notice that it lingers on after finishing the activity and sometimes hurts at night. Generally, the pain is localized to the lumbar spine and can be one-sided or both sides. However, these symptoms are highly varied. As noted above there are a few symptoms that we may look for if we believe you have a stress fracture. If there is any concern of one then you will likely need a scan to check for it. X-rays show stress fracture but only very late in the natural course of the injury. Consequently, your physiotherapist or GP or Sports Dr may refer you for a CT scan which shows bones in far greater detail, or an MRI which can show bony bruising. Often this bony bruising is a response to increased load on a bone. Bone scans are used less frequently these days since MRI’s have become so detailed

Caught early a stress fracture has a good chance of healing with simply rest. If you leave it too long and continue activity it can progress to a full pars defect (ie fracture all the way through). If this occurs on both sides of the spine it can create an instability called a spondylolisthesis. This sounds very scary but even most spondylolisthesis cases are manageable with core strengthening and activity or technique modification. On very rare occasions, they may need to be stabilized surgically. However, in an ideal world, we would catch the fracture early and let it adequately heal. If you do have a stress fracture it is likely you’ll need some time away from dance (or whatever other activity that may be causing it). We usually decide how long in consultation with a Sports Dr or Sports Physician to achieve the best outcome. In the meantime, you can work on any flexibility issues and strength deficits. The problems that we tend to see frequently are tight hip flexors and weak core and gluteal muscles.

Lower Back Pain in Dancers: Lordosis

Unfortunately, lordodis calls for more aggressive physiotherapy. As stated earlier, dancers are quite flexible but we often find that they aren’t evenly flexible.  There are 2 patterns that we commonly see in the clinic. One is where the dancer stands in an exaggerated sway back position, or lordosis. If you tend to do this you will often be quite tight through the hip flexors. Stretching the hip flexors in the short term will allow you to adopt a better standing and moving posture. In the long term, you need to work on core control. This means using your core muscles to stabilize your back rather than your hip flexors which will stop them from getting tight in the long run. In turn, this keeps your low back in a better position. The last thing you need to do is break the habit of standing with a sway back. Even with the strongest core and nice loose hip flexors if you don’t actively retrain your standing posture the back pain may return.

Lower Back Pain in Dancers: Equal Splits?

One of the most common problems in uneven flexibility is split positions. Often dancers will favor their good splits side for performances. Consequently, the good leg forward gets looser and looser whilst the more difficult leg forward stays the same. When in a straight splits position you rely on loose hamstrings in the front leg and loose hip flexors in the back leg. As a result, practicing the splits on one side repeatedly can cause the hamstring and hip flexors on the opposite sides to be relatively less flexible. This muscular tightness imbalance around the pelvis can lead to low back issues. The solution for this one is fairly simple.  Keep practicing your bad splits to make sure each side stays fairly even.

Most low back pain is very treatable for dancers. However, to get the best result it is worthwhile having a thorough assessment with a physiotherapist. This should give you a specific plan to work on the flexibility of certain muscle groups and the strength of other muscle groups. Don’t forget to look at technique and posture. A strong, flexible person can still get their body into painful positions if they have poor postural awareness or potentially dangerous movement patterns.