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Bruce R. Wilk, P.T., O.C.S. Director
8720 N. Kendall Dr. Ste. 206
Miami, FL 33176
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Back injuries can do more than make training and competition painful. They can end an endurance athlete's participation in the sport unless properly treated. Eight out of 10 adults will seek medical attention for back problems at one time or another in their lives. At least seven million Americans are disabled by back pain at any given time. The challenge to Triathletes facing back problems is to maintain conditioning while receiving proper treatment for their injuries.

One of the most common causes of low-back dysfunction is stress caused by improper lifting of heavy objects during everyday life. Keep the load lifted to a manageable weight and bend the knees to avoid straining your back. Also, avoid any twisting motions that will stress the lower back.

Weight training, a central part of every serious athlete's training program, should incorporate good posture to strengthen the stabilizing musculature of the lower trunk. Strength-training exercises should be done sub-maximally to fatigue the primary muscles being exercised, while keeping the trunk in good postural alignment.

Muscular flexibility is an important factor for any athlete because it helps absorb shock and disperse the load placed on the lower back. Many Triathletes incorrectly place their entire training emphasis on strength and endurance. As a result, they suffer from leg stiffness after running or cycling. To promote flexibility, add stretching routines to your training program.

Cycling requires long periods of sitting in a crunched position, placing tremendous strain on various portions of the lower back. Many amateur triathletes who have desk jobs also tend to bend forward in their chair while working, which only compounds the amount of stress placed on the lumbar region. Proper sitting posture can alleviate back pressure during work
hours. Be sure to use a chair with proper lumbar support. The amount of daily tension placed on your lower back will decrease almost immediately.

After recovering from a lower-back injury and returning to a more normal training program, it's important to be aware of proper cycling form and training habits to avoid re-injury. Postural analysis of cycling form is important to reveal poor positioning that can strain the low back (see photo 1) . The handlebar and stem setup should allow for a comfortable flat-back positioning. We often see triathletes in an excessively flexed or crunched position that can strain the lower back. The position of the saddle and seat post must allow the pelvis to roll forward during cycling (see photo 2). On long training rides, it's a good
idea to change arm position frequently in order to avoid becoming over-fatigued and strained in anyone position.

The following three case studies illustrate the most common types of back injuries. Treated successfully, these triathletes resumed competition without further pain.

Poor-posture syndrome
Carl, a 20-year-old college student, experienced prolonged tenderness in the lower back, particularly when seated. A thorough examination revealed that his back pain resulted from sitting for long periods in a crunched, forward-bent position that strains the lower back. We placed Carl on a program of stretching and strengthening exercises to overcome the stress on his low-back musculature. We gave him a rolled pillow to support his lower back in good postural alignment while seated, so he would not bend forward.

When we analyzed Carl's cycling form on an indoor trainer, we found a bent-forward posture again his handlebar stem was too short, forcing him to overflex his back. His bike was also set up with a soft seat at a neutral pitch, thus rolling his pelvis and lower back backward, further rounding his back.

We lengthened his handlebar stem, gave him a firm saddle and adjusted it to tip slightly downward all to flatten out his back while riding. Carl was advised to continue cycling and maintain his training program, as long as he stopped before he developed pain. He was instructed to frequently stretch and change position to relieve stress on his lower back. Within three weeks of seeking treatment, Carl was back to his normal training program, free of pain. We advised him to maintain strengthening and flexibility exercises to prevent recurrence of his postural syndrome.

Stiff-back syndrome
Tanya is a 29-year-old office manager and amateur triathlete. Her job involves a great deal of desk work and she trains several times a week. She began to feel severe stiffness and pain in her legs and low back when bending, particularly during cycling and swimming flip turns. After several days of discomfort, she sought professional attention. Her examination revealed that her pain resulted from long-term inflexibility and repeated stress to the lower back and legs. We recommended that she take an over-the-counter oral anti-inflammatory drug and use ice on the tender areas to relieve pain. She was also told to halt her cycling and to swim without flip turns, but she could keep her running mileage constant during the recuperative period.

We placed Tanya on a vigorous program of flexibility training, emphasizing the leg and trunk areas. In-office physical therapy of stretching and anti-inflammatory medication helped relieve her symptoms during her self-management program.

When we examined Tanya's bike, we found that it was set up with one-piece aero' bars that allowed only two cycling positions. On long training rides, she could not vary her position much to reduce the stiffness in her back. We installed drop-bars with clip-on aero' bars to give her more cycling positions. We also advised Tanya to purchase a second bike adjusted for an uncompromised aerodynamic position to be used only for racing. She should use the bike with the clip-ons for long training sessions and group rides because it allows for more position changes.

Tanya's pain was relieved within six weeks of her initial treatment, and she then resumed her cycling and flip turns without further discomfort. We added flexibility and strength exercises to her normal training routine to minimize back stress.
Herniated disc-syndrome
Thomas, a 35 year-old computer industry executive, takes his triathlon training seriously. After spending hours seated behind a desk and in front of a computer, he runs, cycles and swims several times a week to stay in shape for competition.

After a weekend of backyard gardening, he felt pain shooting down his leg, accompanied by discomfort in the low back. After the pain persisted for a day, Thomas visited his physician who ordered an MRl scan. The test results revealed a herniated intervertebral disc in the lumbar region of the back, which was contributing to his back and leg pain.

This severe condition most often occurs after a series of micro-traumas that create momentary strains on the lower back. These can include long periods of uninterrupted sitting or crouching, as well as repetitive twisting motions that can progressively damage the lumbar region.

The lower back consists of five lumbar vertebrae bones with intervertebral discs positioned between them along the spine. Each disc is a hard cartilage ring with a soft watery center known as the nucleus pulposus. Spinal nerves end in the middle of the back and the lumbar region, and a series of free nerves exits between the lumbar vertebrae and the discs (see illustration).

When the body is bent forward, the back walls of the discs stretch while the front walls compress. This causes the nucleus pulposus to be forced to the back wall, further stretching it. Twisting and sudden turning motions over prolonged periods can tear the area that is over-stretched. When the discs tear or herniate, the nucleus pulposes can escape, irritating or pinching the space between the vertebrae where nerves emerge. Unless diagnosed and properly treated, herniated discs can cause entrapment of nerves in the lumbar region, as well as other types of serious dysfunction that may require surgery.

After prescribing an anti-inflammatory drug and icing of tender areas to ease the pain, Thomas's doctor referred him for physical therapy. We reviewed his case history, and conducted an exam to identify his areas of inflexibility and weakness. He progressed through an individualized rehabilitation program that stresses increased trunk and leg strength and flexibility to speed recuperation and regain muscle function.

We also noticed that Thomas's lifestyle and training routine included some of the most common tendencies leading to lower-back dysfunction. Therefore, we recommended a number of modifications to help speed recovery: Thomas needed to avoid any exercise activity or position that increased his leg pain, which was a sign of worsening symptoms. He was put on an exercise program of water jogging, swimming drills and easy walking to help maintain his cardiovascular condition during the period he was experiencing acute symptoms.

Thomas's bike positioned him well in his clip-on aero' bars, but he was crunched in his drop-bars. We lengthened the stem to give him better drop-bar positioning, but that put him in an excessively stretched aerodynamic position. So we replaced the aero' bars with a set that had elbow pads behind the handlebars, giving him a flat back in his drop- and aero' bar positioning.

As the pain subsided, we recommended a moderate routine of running, cycling and swimming that maintained a comfortable level of activity. Proper healing continued and after six months Thomas was allowed to gradually increase his training program, eventually returning to his original level of activity.

Preventing and treating back pain
If you recognize any of these symptoms of low-back problems, consult your physician immediately to rule out all medical causes other than those related to mechanical dysfunction. Take aspirin or Ibuprofen, apply ice and avoid strain. A physical therapist specializing in the treatment of endurance athletes also can help your recuperation and Improve your overall physical conditioning. A cycling coach can work on cycling setup, proper posturing during riding and individualized training pro- grams to help prevent injuries while cycling.

A triathlete can minimize the chances of suffering low-back dysfunction by following these and other preventative suggestions. Yet any number of other circumstances beyond your control can also cause low-back injury.

Although you may have the urge to "tough out" a low-back dysfunction, it's better to take the cautious route and seek proper attention and individualized advice. –

by Bruce R. Wilk, P.T., D.C.S. and John Howard