What To Do If You Get Back Pain When Running

Back pain affects many people, including runners. The good news is that most cases are not serious and respond well with the right management. Another piece of good news is that as physios, we don’t see a big link between running and back pain, so we are often able to get runners back out there without too much disruption to their running program. However, we do see some runners who get recurrent or persistent back pain that they link to running, and this can be really frustrating for them and needs to be managed properly.

In this post we’ll go through what could be causing your back pain, things you can try to manage it by yourself, and if that’s not working then when to see a running physio and how we can help. As always this is general advice and if you’re not confident with how to manage your problem then please see your physio or healthcare provider for a full assessment.

How Do We Diagnose & Classify Low Back Pain?

The way we initially diagnose and classify back pain in runners is the same as how we classify back pain in any other person. So before we discuss how running could be contributing to your pain, let’s look at the three types of back pain;

By far the most common type, accounting for about 90% of cases. Pain is felt around the low back area and it can range from mild/niggly to moderate/severe. Sometimes the pain may extend down into the legs but there is no numbness, pins-and-needles or muscle weakness. The painful structures may include joints, discs, muscles and ligaments. There may have been a specific mechanism to start the pain, e.g. a rapid increase in training volume, or it may begin without a particular trigger. It is called “non-specific” because the exact structure producing the pain cannot be identified, but this is not a problem for management because the principles we use to treat are the same regardless of exactly which structure is irritated.

Commonly called sciatica or a pinched nerve, this type makes up 5-10% of low back pain cases. It occurs when a nerve is compressed as it exits the spine, causing pain to be referred from the back down into the leg and also producing neurological symptoms including tingling, numbness or weakness. If you are feeling any of these neurological symptoms then you should get assessed by your healthcare provider to make sure this nerve compression is managed early.

3. Serious Pathology

This is very rare – less than 1% of low back pain cases. It includes things like spinal fractures (broken bones), tumors, and some types of infections and inflammatory conditions. People will usually have other significant symptoms apart from their back pain, e.g. fever, weight loss, constant pain not linked to activity, feeling systemically unwell, or have had a significant trauma. This type of pain is not related to running except in the case of bone stress injury or stress fracture, where a bone is overloaded (e.g. by a rapid increase in training volume) to the point of developing a stress fracture. There are specific and effective screening questions and tests that physiotherapists use to identify possible serious pathology and if they are concerned your physio will refer you for medical investigation. If your pain is of higher intensity, is waking you at night, lasting for long periods after your run or becoming constant, then you should get checked out by your health professional.

How Can Running Cause Low Back Pain?

Assessing the cause low back pain in runners is a very individual process. There are many things that can contribute to back pain, and something that is aggravating to one runner can be fine in another. For example one runner may report that stretching out tight hip flexors relieved their back pain when running, but another runner may not get any benefit, and other runners with tight hip flexors are running without any pain! So in this example we can’t really say that “tight hip flexors cause back pain with running” because some people run fine with tight hip flexors, and others who stretch them out still get back pain. What we can say is that for the first particular runner, tight hip flexors were a contributor to their back pain, but that doesn’t mean hip flexor tightness always causes back pain in runners.

How can this happen? Well, our bodies are complex. We’re all made a bit differently (even each person will have some left-right asymmetry!), we all have different lifestyles and injury histories, and back pain can be caused by a wide variety of things. This means that it’s hard to find things that are consistently proven to cause back pain in a wide large proportion of runners. Something that causes pain in one runner may be fine in another. This means we need to take a personalised approach to assessing and managing back pain in runners.

Which Running Factors Can Cause Back Pain?

While we don’t have clear research identifying specific factors about running that always cause back pain, there are some things that we see in the clinic as running physios that we commonly see in clients who come to see us for running-related back pain. These include;

1. Increasing Running Training Too Quickly

Increasing the volume or intensity of your running training too quickly is among the most common causes we see for many running-related injuries, including back pain. If we increase our running slowly our bodies have time to adapt by increasing the strength of our muscles, bones, tendons, cartilage and ligaments. If we increase too fast we load these tissues beyond their capacity, causing injury.

In addition to overloading our tissues, another possible effect of increasing running too quickly is muscle fatigue leading to poor running form. If excessive muscle fatigue later in our runs causes changes in our running gait we potentially load tissues differently to what they’re used to, further increasing our injury risk.

2. Not Being Strong Enough

Having good base strength forms a foundation for reducing your risk of injury as well as running at your best. Strength training increases the capacity of many tissues in your body including muscles, bones, tendons and cartilage. This increased capacity means that we can absorb the stresses of running without overloading our tissues, which reduces the risk of back pain and many other injuries.

3. Running Gait And Biomechanics

The effect of running gait and biomechanics as a cause of back pain is unclear. The is no clear research showing that specific aspects of running gait or posture consistently cause back pain with running. However, this does not mean that running gait and biomechanics don’t play a role in back pain. As discussed above, something that is fine with one runner may cause pain in another, so a more individualised approach is required.

CASE STUDY: Let’s say we assess John, a marathon runner, on a treadmill. He reports left-sided back pain when he extends his left hip during running (i.e. when his left foot leaves the ground and goes back up behind him). When we then test John’s left hip flexor, we find it’s much tighter than his right, and his glute strength is weak (glutes are the main muscles that move the hip into extension).

Based on these findings we decide to test whether John’s lack of left hip extension is causing their pelvis to rotate forward during running, causing irritation of joints in his left lower back. So, we mobilise John’s hip flexor and do some activation exercises for his glutes to increase his hip extension, and re-test him running on the treadmill. We find that John’s back pain has improved significantly, so we start him on a home program to increase his left hip extension by strengthening his glutes and increasing the mobility of his hip flexors. Progression of these strength and mobility exercises over time fully resolves John’s back pain and allows him to run pain-free.

The above strategy worked great for John – fantastic! But unfortunately, that doesn’t mean that it will work for every runner. Some people with tight hip flexors or weaker glutes run pain-free – maybe because their body has adapted to run comfortably with less hip extension, perhaps by changing another aspect of their running gait. Or maybe other lifestyle factors play a role, e.g. a desk-worker may have a stiffer low back than someone who moves a lot in their job, and this stiffness may mean that they are less able to compensate for reduced hip extension by increasing their low back movement, so they may get back pain but the more active worker may not.

I know this sounds like a complex situation, but the main point is simple: running gait and biomechanics can play a role in causing running-related back pain, but it will be different for each runner. There is no “single correct way to run”, so what works great for one runner may cause pain in another. So a process of clinical reasoning is required, where we test different strategies to alter our biomechanics and running gait, and re-assess the effect on that particular runner’s pain.

4. Foot Posture (Flat Feet Or Pronation/Supination), Running Shoes And Orthotics

We are often asked if being flat footed (i.e. over-pronated) is a cause of back pain, and if so, should that client change running shoes or start wearing orthotics. Again, there is no simple answer! There are lots of runners with flat feet who don’t get any back pain, but there are also runners with running-related backpain who feel much better when they are in pronation-control shoes or wearing orthotics. So, the same principles we discussed for running gait/biomechanics also apply to foot posture, running shoes and orthotics: there is no single answer that applies to every runner. The solution lies in an individual assessment and on then clinical reasoning to determine if foot posture/pronation is contributing to your pain, and if it is, is it best managed by trialling different running shoes or would orthotics be a better option.

It’s worth noting that as a general rule we don’t see foot posture, choice of running shoe or orthic use as a significant contributor to running-related back pain. That’s not to say it doesn’t happen – I’m sure there are definite cases where it is a factor – but just a comment to say that if you’re starting to investigate possible causes of running-related back pain, we normally wouldn’t start with these things. Perhaps if you’ve had a change in your running shoe or started/stopped wearing orthotics around the time that your back pain began it’s worth checking these factors out earlier, but otherwise we don’t see them as likely primary causative factors for running-related low back pain.

What To Do For Running-Related Back Pain

From the above discussion we can see that there are no aspects of running that will consistently cause back pain in every runner: what causes pain in one runner could be fine in another. This makes it hard to give generic advice that will be helpful across all runners with back pain. However, there are some simple things you can try by yourself to help clarify the cause of your pain and manage it effectively.

1. Load Management

Since one of the main causes of running related injuries, including back pain, is increasing your running volume and/or intensity too quickly, a good place to begin management is to reduce your running training a bit to see if this lets things settle. This can be done by reducing your volume (length and frequency of runs) or intensity (reduce speed, less elevation/hills). The amount to reduce things by is variable, but if you have recently increased your training then dropping back to your last level of training that was consistently pain-free is a good starting point.

If this settles your pain you can then start to gradually increase your running again but do it more slowly. If your pain doesn’t settle, or if it returns when you try to increase your running again, look at some of the options below. It’s also a good idea to start working on strengthening and stretching your main running muscles while you have reduced your running load.

2. Strengthen And Stretch The Main Muscles Used In Running

As discussed above, some cases of back pain with running are related to muscles being too tight or too weak. This can cause overloading of some tissues which leads to pain, or it can alter your running gait which can lead to injury. Having the right balance of strength and length in your running muscles should be a goal for all runners, from recreational to elite, because this balance brings the dual benefits of significantly increasing your running performance as well as reducing your risk of injury.

At Central Performance we generally focus on increasing strength as a first priority. This is because strength training increases the capacity of your muscles, tendons, cartilage and ligaments to withstand the forces generated during running, so it is often very effective at relieving running-related back pain as well as protecting against other running injuries. Also muscle weakness can lead to muscle tightness due to a protective bracing response, so increasing the strength of a muscle can restore its length without the need for stretching or foam rolling. A final benefit of strength training is that it can significantly improve your running performance, allowing you to run faster for longer with less chance of injury.

Increasing the length of a muscle may also be necessary in some cases, for example in the case study above a combination of strength and mobility was used. Excessive muscle tightness may be more common if you have recently increased your running volume or intensity or have increased your participation in other sports or types of exercise, for example have added pre-season training sessions for winter sport on top of your regular running training.

Excessively tight muscles can change your running gait and cause abnormal loading of tendons, muscles and joints. You can increase the length of your muscles by using a combination of stretching, foam rolling or trigger-ball releases, theragun/massage gun, or massage. There is no right or wrong way to increase your muscle length, just experiment and find what works for you. However, it’s worth noting that if you always feel tight in certain muscles despite doing mobility work its worth looking for an underlying cause, e.g. muscle weakness. We regularly see clients who have previously spent way too much time stretching and foam rolling because they feel tight, however when we switch their focus to building strength their tightness improves significantly.

3. Trial Different Running Shoes

As mentioned above, we don’t generally see a significant link between running-related back pain and the type of running shoe used. However, if you have recently changed shoes and you feel that your back pain started at a similar time, it may be worth trialling different shoes, possibly going back to your old shoes for a few runs to see if things improve. The hard thing is that running shoes can be expensive, so buying another new pair just to see if it helps may not be possible.

If These Self-Management Tips Don’t Work, See A Running Physio

If your back pain doesn’t settle or keeps coming back despite trying these initial self-help tips, its time to get some professional advice and treatment. This is where a running physio can really help.

Firstly, your physio will diagnose/classify your back pain into one of the three categories described above: non-specific, radicular or serious pathology (this is very unlikely). This will allow targeted management to be provided to resolve your pain as quickly as possible.

As your pain improves, the underlying cause of your pain can be clarified. This will often include a running gait assessment to assess whether your running form is likely to be a causative factor for your pain. It will also include a thorough assessment of your muscle strength and length, which allows a targeted exercise program to be developed to address any imbalances. A combination of corrective exercise and running technique coaching is usually very effective in resolving your current pain and allowing you to run pain-free with increased performance into the future.