THE SPINE AND SPORTS 0278–5919/02 $15.00
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00

MANAGEMENT OF THE
ATHLETE WITH LOW BACK PAIN
Steven Z. George, MS, PT, and Anthony Delitto, PhD, PT, FAPTA

Low back pain (LBP) is a common experience for the general popu-
lation, and, unfortunately, athletes are not immune to the effects of LBP.9
The elite athlete losing significant playing time because of a back injury
is a familiar but anecdotal story. A brief review of the literature indicates
that LBP is a common cause of limited play and practice time for a
variety of sports, including rowing,42 swimming,24, 48 gymnastics,24, 38, 44
football,26, 45 weightlifting,1, 43 racquet sports,8 and triathlon.32 In addition
to affecting many different types of sports, LBP is found at all levels of
athletics.10, 28, 39, 46 For these reasons, clinicians working with athletes
should be familiar with the evaluation and treatment of LBP.
The clinician evaluating an athlete with low back pain must consider
a management dichotomy. The majority of athletes with low back injur-
ies are likely to have pain from a benign source.46 These athletes will be
expected to respond well to nonoperative treatment and return to their
sport in a timely manner. A minority of athletes, however, may experi-
ence pain from a different source (e.g., spinal stress fracture or nerve
root compression).5, 17, 23, 29, 30 In these cases, different management may
be indicated. The clinician evaluating athletes with LBP must be able to
effectively distinguish between these two scenarios.46
After making the determination that an athlete is appropriate for
nonoperative treatment, additional decisions are to be made. For exam-
ple, the clinician must consider the severity of the disease process. The
clinician cannot be expected to manage the athlete with acute LBP in
the same manner as the athlete with chronic low back pain. After the

From the School of Health and Rehabilitation Sciences (SZG, AD); and the Department of
Physical Therapy (AD), University of Pittsburgh, Pittsburgh, Pennsylvania

CLINICS IN SPORTS MEDICINE

VOLUME 21 • NUMBER 1 • JANUARY 2002 105

106 GEORGE & DELITTO

severity of the disease is considered, a treatment that is specific to the

athlete must be employed. In making these decisions, the clinician must
consider factors that are unique to the athlete’s clinical presentation.
Delitto et al12 have proposed a treatment-based classification system
(TBC) for the management of LBP. This system provides a framework for
clinicians to determine whether a patient is appropriate for nonoperative
management, to determine the severity of the disease, and to apply a
specific, matched treatment. The clinician makes these decisions using
historical information, self-report questionnaires, and clinical examina-
tion findings. The purpose of this article is to discuss the evaluation and
treatment of the athlete using TBC as proposed by Delitto et al.12

FIRST-ORDER CLASSIFICATION: DOES THE ATHLETE

NEED ADDITIONAL DIAGNOSTIC TESTING?

The question to be answered during first-order classification is: ‘‘Is

this athlete appropriate for physical therapy?’’ With athletes, the primary
concern at this level of classification is the identification of situations
that require the clinician to consult with surgical or medical specialists.
This is accomplished by recognizing signs of serious pathology that are
not musculoskeletal in nature or by identifying lumbar pathology that
is commonly misdiagnosed in athletes. Examples of such pathology
include Scheuermann’s disease, lumbar stress fractures, spondylolytic
defects, nerve-compression disorders, infection, and metastatic diseases.5,
23, 30, 46, 48
For athletes, a lesser concern at this level of classification is the
identification of signs and symptoms that are associated with magnified-
illness behavior. Because of its relative importance to the athletic popula-
tion, this discussion will focus on the identification of suspected lumbar
pathology.
Athletes are screened for the presence of serious pathology by using
a medical questionnaire, a disability questionnaire, and a pain-intensity
scale.12, 19 The clinician then reviews these forms so any issues can be
further reviewed with the athlete during the examination. The medical
questionnaire includes questions that are intended to identify serious
pathology that is not musculoskeletal in origin. These questions focus
on unexplained weight loss, history of cancer, night pain, history of
immunosuppression, vascular insufficiency, and alterations of bowel and
bladder function.4, 49 Any positive response on this questionnaire should
be reviewed with the athlete, and, if appropriate, a full screen of the
body system in question should be performed.12
The Oswestry Disability Questionnaire (ODQ)15, 16 and the pain-
intensity scale are used to screen athletes for the presence of serious
pathology. For the ODQ, athletes rate their function in 10 different areas
by using a 0–5 scoring system. The total score is then expressed as a
percentage, with 100% indicating total disability and 0% indicating no
disability.15, 16 In the absence of magnified illness behavior, ODQ scores
greater than 75% raise the suspicion that serious pathology may be
 MANAGEMENT OF THE ATHLETE WITH LOW BACK PAIN 107

present.12 For the pain-intensity scale, athletes rate their pain from 0 to
10 under three different conditions. The first condition is the athlete’s
present pain, the second condition is the athlete’s best pain rating in the
past 24 hours, and the third condition is the athlete’s worst pain rating
in the past 24 hours. Because mechanical LBP is often associated with a
posture that reduces pain intensity, very high levels of pain (8–10) on all
three conditions also increase the suspicion of serious pathology.12
In addition to considering the presence of more serious pathology,
the clinician evaluating athletes with LBP must be aware of situations
that are unique to athletes. A high level of suspicion for pars interarticu-
laris pathology is needed for athletes involved in sports involving fre-
quent collisions, loading of the lumbar spine in hyperextension, or
repetitive, combined extension and rotation movements of the lumbar
spine (e.g., gymnastics, ballet, football, diving, lacrosse, soccer, or
hockey).3, 18, 47 Because stress reaction is often not detected during radio-
graphic examination, additional diagnostic testing is often indicated to
resolve the suspicion of pars interarticularis pathology.3, 47 In addition to
lumbar spine defects, Featherstone17 recommends the evaluation of sa-
cral stress fracture through magnetic resonance imaging in athletes with
persistent LBP.
Special attention must also be given to the adolescent and younger
athlete. Micheli recommends that a high level of suspicion should be
maintained to diagnose stress fractures and spondolytic defects in these
athletes.38 To ensure proper evaluation of these defects, Libson30 suggests
the use of oblique lumbar spine views. To detect rare conditions that
may mimic LBP, Watkins and Dillen46 recommend bone scans in adoles-
cent athletes having significant LBP for more than 3 weeks.
Signs of serious pathology and indications of lumbar pathology that
are sometimes misdiagnosed need to be thoroughly investigated by the
evaluating clinician. If appropriate, additional diagnostic testing should
be requested before a decision regarding rehabilitation is made. Clini-
cians taking this approach are ensured that the athletes under their care
are receiving the most appropriate treatment.

SECOND-ORDER CLASSIFICATION: STAGING THE

ATHLETE WITH REGARD TO ACUITY

The question to be answered during second-order classification is:

‘‘What stage in the disease process is this athlete?’’ This is similar to
determining whether the patient has symptoms that are consistent with
acute, subacute, or chronic LBP. In TBC, there are three possible stages:
Stage I, Stage II, and Stage III. This staging decision is not solely based
on the amount of time that has elapsed since the initial injury. Instead,
the athlete’s ability to perform basic activities and the athlete’s amount
of disability (via ODQ score) are also considered when determining the
severity of the disease process.
Athletes who are unable to stand for 15 minutes, sit for 30 minutes,
108 GEORGE & DELITTO

or walk 1⁄4 of a mile because of LBP would be considered appropriate

for Stage I treatment.12 In our clinical experience, these athletes are
expected to have an ODQ score that ranges between 40% and 60%. The
treatment goal of Stage I is pain modulation, and specific treatment for
patients in this stage will be discussed in detail in the section on third-
order classfication.
Athletes are considered appropriate for Stage II treatment when
they exceed the requirements of Stage I but still have limitations in
performing daily activities that are more advanced than standing, sitting,
and walking (e.g., jogging).12 In our clinical experience, these athletes
are expected to have an ODQ score that ranges between 20% and 40%.
Athletes may progress from Stage I to Stage II with treatment, or athletes
may have symptoms that are consistent with Stage II during the initial
examination session. Pain modulation continues to be a treatment goal,
and the additional goal of addressing signs of physical impairment is
added in this stage. Treatment in this stage will be geared toward the
athlete’s specific physical impairments and may include strength train-
ing, flexibility training, aerobic training, and postural/body mechanics
training.
Athletes are considered appropriate for Stage III treatment when
they can perform all daily activities but cannot resume full participation
in sport.12 Stage III treatment is also appropriate for athletes with mini-
mal disability who continue to have recurrent episodes of LBP. In our
clinical experience, these athletes are relatively asymptomatic and are
expected to have an ODQ that is below 20%. The ODQ is most helpful
in documenting disability in Stage I and Stage II. Athletes in stage III
will often have very low ODQ scores and will still not be able to return
to their sport. This is because the ODQ is not as sensitive in rating
disability among individuals who return to activities with a high physi-
cal demand. The treatment goal for patients in this stage is to return to
full athletic participation and to prevent recurrence of LBP. This is
accomplished through trunk-strengthening exercises, functional training,
and sport-specific training. Stage III treatment represents the most im-
portant component of managing the athlete because it results in the
athlete returning to sport and instructs the athlete in an exercise program
that may prevent future episodes of LBP.

THIRD-ORDER CLASSIFICATION: MANAGING THE

ACUTE CONDITION

Third-order classification is reserved for athletes who are appro-

priate for Stage I treatment. The question to be answered at this level of
classification is: ‘‘What specific treatment is most appropriate for this
athlete?’’ This question is best answered by having the clinician form an
initial hypothesis as to what treatment would most likely benefit the
patient.13 Examination findings then influence the clinician to alter the
hypothesis if appropriate.13
 MANAGEMENT OF THE ATHLETE WITH LOW BACK PAIN 109

Table 1. SUMMARY OF TREATMENT-BASED CLASSIFICATION SYSTEM12

Classification Key Examination Findings Recommended Treatment

Extension Flexion activities increase pain Extension exercises
syndrome Status improves with extension Restriction of flexion activities
testing
Status worsens with flexion testing
Flexion Extension activities increase pain Flexion exercises
syndrome Status improves with flexion testing Restriction of extension activities
Status worsens with extension testing
Mobilization Local, unilateral LBP Mobilization techniques
syndrome Patterned, restricted range of motion Manipulation techniques
(lumbar)
Mobilization Local pain at PSIS Mobilization techniques
syndrome Positive sacroiliac tests Manipulation techniques
(sacroiliac)
Immobilization Frequent episodes of LBP Avoidance of sustained posture
syndrome Increased pain with static posture Trunk strengthening exercises
Lateral shift Visible deformity Pelvic translocation exercises
syndrome Unilateral sidebending restriction Extension exercises
Traction Radicular symptoms Mechanical traction
syndrome Status worsens with lumbar Autotraction
movements

Components of the clinical examination used to formulate and test

treatment hypotheses include the patient history, the observation of
posture, the assessment of pelvic landmarks, and the examination of
lumbar movements.12 The clinician identifies clusters of key examination
findings that are unique to the appropriate treatment classification. Refer
to Table 1 for a list of Stage I treatment syndromes and the corresponding
key examination findings.
Seven individual treatment classifications, broken down into four
classification categories, have been described by Delitto et al (Fig. 1).12, 22
The first treatment classification is specific exercise, containing the exten-
sion syndrome and flexion syndrome. The specific exercise classification
is based on examination and treatment principles first described by
Robin McKenzie.37 Athletes appropriate for this treatment category fre-
quently note a postural preference and often have symptoms radiating
into the lower extremity. Age is also an important consideration in this
treatment classification. Athletes who are younger than age 40 should
be considered more likely to be extension syndrome candidates, and
athletes who are older than age 50 should be considered more likely to
be flexion syndrome candidates.22
The key examination finding that confirms this treatment classifica-
tion is the ability of the athlete to improve (centralize37) or worsen
(peripheralize) the status of his symptoms by performing repeated lum-
bar movements.12, 37 This treatment classification also consists of patients
110 GEORGE & DELITTO

Figure 1. Original treatment classifications collapsed into classification categories. (From

Delitto A, Erhard RE, Bowling RW: A treatment-based classification approach to low back
syndrome: Identifying and staging patients for conservative treatment. Phys Ther 75:
470–485, 1995; and Fritz JM, George S: The use of a classification approach to identify
subgroups of patients with acute low back pain: Interrater reliability and short-term treatment
outcomes. Spine 25:106–114, 2000; with permission.)

who were originally classified for lateral shift treatment and were able
to improve their symptoms with lumbar movements. The lumbar move-
ment associated with an improvment of symptoms is reinforced through
therapeutic exercise, and the lumbar movement associated with a wors-
ening of symptoms is discouraged through education or bracing.
The second treatment classification is mobilization, containing sacro-
iliac mobilization and lumbar mobilization. Athletes in this treatment
classification typically have symptoms that are unilateral and localized
to the low back or sacroiliac region. The key examination findings
for the sacroiliac mobilization treatment syndrome are based on pelvic
landmark testing and sacroiliac tests. If the clinician notes multiple
positive findings during these tests, sacroiliac mobilization is confirmed
as the appropriate treatment. Treatment consists of a sacroiliac manipula-
tion technique, which is typically followed by lumbar range of motion
exercises.
The key examination finding for lumbar mobilization treatment
classification is the presence of an opening or closing lumbar movement
pattern. An opening pattern is consistent with limited lumbar flexion
and limited lumbar sidebending opposite the side of pain. A closing
pattern is consistent with limited lumbar extension and limited lumbar
sidebending toward the side of pain. After the movement pattern is
detected, the clinician confirms the location of the limitation through
passive intervertebral joint testing. Treatment consists of the appropriate
lumbar mobilization/manipulation technique (i.e., closing mobilization
technique for a closing pattern), which is typically followed by lumbar
range of motion exercises.
When determining whether an athlete is appropriate for mobiliza-
tion/manipulation for LBP, the absolute and relative contraindications
of the manual techniques must be considered. In the athletic population,
 MANAGEMENT OF THE ATHLETE WITH LOW BACK PAIN 111

absolute contraindications for these techniques are signs/symptoms of

nerve root compression and the presence of spondylolisthesis.25 In addi-
tion, mobilization or manipulation treatment is contraindicated for any
athlete with a high level of suspicion (regardless of diagnostic findings)
of spinal stress fracture. Relative contraindications to consider in the
athletic population are the training of the clinician, and the apprehension
level of the athlete with the proposed technique. Mobilization/manipula-
tion of the athlete with suspected lumbar segmental instability is also
viewed as a relative contraindication.
The third treatment classification is immobilization. Athletes in this
treatment category will have a history of frequent episodes of LBP, often
from minimal spinal perturbations. In addition, a history of increased
pain with prolonged static postures is associated with this treatment
syndrome. The key examination finding that confirms the immobiliza-
tion classification is the worsening of symptoms with sustained lumbar
movement testing and the improvement of symptoms with repeated
movement testing. Treatment focuses on the avoidance of end-range
spinal postures through education and bracing. Trunk-strengthening
exercises and motor-control exercises are also prescribed for this treat-
ment classification.
The fourth treatment classification is traction. Athletes in this treat-
ment category will have symptoms radiating into the lower extremity.
The key examination finding that confirms the traction classification is
that the athlete is not able to improve his or her symptoms with any
lumbar movements. In fact, the athlete may experience a worsening of
his or her symptoms with most lumbar movements. This treatment
category also includes athletes who were originally classified for lateral
shift treatment but were unable to improve their symptoms with lumbar
movements. Treatment for the traction classificiation consists of mechani-
cal traction or autotraction. During treatment, the clinician must care-
fully monitor the athlete’s neurologic status through reflex, strength,
and sensory testing. Any deterioration in neurologic status should be
communicated to the referring physician so the appropriate medical
and/or surgical decisions can be promptly made.

CLINICAL SCENARIOS

The management of the athlete using TBC will be highlighted in

the three clinical scenarios presented below. For each example, assume
that the clinician has already determined that the athlete is appropriate
for physical therapy treatment. Because acute injuries are thought to be
of common occurrence in athletic populations,28, 32 the first two scenarios
demonstrate the determination of appropriate Stage I treatment. The last
scenario provides the rationale used to determine a Stage II and Stage
III exercise prescription for an athlete with recurring LBP and suspected
lumbar segmental instability.
112 GEORGE & DELITTO

Scenario 1

This athlete is a 20-year-old female tennis player without any previ-

ous episodes of LBP. She experienced a sudden onset of LBP 5 days ago
in practice while reaching for an opponent’s drop shot. Since then she
has treated her back pain with ice, but the pain has worsened during
the past 5 days. The team physician has referred her to physical therapy
for evaluation and treatment of LBP. Figure 2 is a pain diagram identi-
fying the location of this athlete’s symptoms.
The clinician’s initial hypothesis is that this patient is appropriate
for the mobilization classification. This decision was based on two fac-
tors: the symptoms are local to her low back, and this is the athlete’s
first episode of LBP. To test his hypothesis, the clinician decides to focus
the clinical examination on the athlete’s response to lumbar movements,
pelvic landmark tests, and sacroiliac tests. During the single lumbar
movement testing, the clinician detects a decrease in lumbar flexion but

Figure 2. Pain diagram depicting location of symptoms for scenario No. 1. The ‘‘X’’ used
by the athlete corresponds with a burning symptom descriptor.
 MANAGEMENT OF THE ATHLETE WITH LOW BACK PAIN 113

Figure 3. Demonstration of sacroiliac manipulation technique used to treat athlete No. 1.

does not detect an opening or closing pattern. In addition, the clinician

notes that the athlete cannot improve or worsen her symptoms with
repeated lumbar movements. The clinician does detect an elevated iliac
crest on the right side, a positive seated flexion test, and a positive prone
knee bend test for this athlete.
The clinician feels that he has confirmed his initial hypothesis and
that sacroiliac mobilization is the most appropriate treatment. This is
because of the lack of a lumbar movement pattern and the presence of
positive sacroiliac joint tests. The clinician decides to initiate treatment
by performing a sacroiliac joint manipulation (Fig. 3). After the manipu-
lation is performed, the athlete’s pain intensity and lumbar range of
motion are reassessed by the clinician. The athlete notes a slight decrease
in pain intensity, and the clinician observes an improvement in lumbar
flexion range of motion. At this point, the athlete is prescribed lumbar
range-of-motion exercise for her home program and instructed to return
to physical therapy in 2 days.

Scenario 2

The second clinical scenario involves an 18-year-old male high

school football player who experienced a sudden onset of symptoms
after a tackling drill in which he was forced into a flexed position. He
reports that the LBP radiates into his lower extremity and limits his
sitting time to 10 minutes. His leg pain improves with standing, but his
low back pain does not. His family physician has evaluated him and
performed radiographs, which were unremarkable. The athlete is being
referred to physical therapy for evaluation and treatment of lumbar
radiculopathy. Refer to Figure 4 for a pain diagram that represents the
location of this athlete’s symptoms.
The clinician’s initial hypothesis is that this athlete is appropriate
114 GEORGE & DELITTO

Figure 4. Pain diagram depicting location of symptoms for scenario No. 2. The ‘‘/’’ used by
the athlete corresponds with a stabbing symptom descriptor.

for the specific exercise classification. This decision was based on the
following factor: the presence of symptoms in the lower extremity.
The clinician further hypothesizes that the extension syndrome will be
appropriate because of the athlete’s postural preference and age. To test
his hypothesis, the clinician decides to focus the clinical examination on
pelvic landmark testing and lumbar movements. The clinician does not
detect any asymmetries during pelvic landmark testing. With single
lumbar movement testing, the clinician detects a significant limitation in
flexion and extension. With repeated lumbar movement testing, the
athlete is unable to improve his symptoms with flexion or extension.
During repeated flexion, the athlete notes that the symptoms go below
his knee after the fifth repetition. Attempts at repeated extension do not
alter this change in status.
At this point, the clinician decides to alter his hypothesis and feels
this athlete may be appropriate for the traction classification. This deci-
sion was made because the athlete failed to improve his symptoms with
 MANAGEMENT OF THE ATHLETE WITH LOW BACK PAIN 115

Figure 5. Autotraction machine used for treatment of athlete No. 2.

lumbar movements. Before initiating treatment, the clinician performs a

neurologic examination that reveals weakness in the great-toe extensors.
The clinician decides that treatment will consist of autotraction (Fig. 5)
in an attempt to have the athlete improve his symptoms. In addition,
the clinician initiates communication with the referring physician regard-
ing the athlete’s neurologic status. The clinician indicates that without
improvement in neurologic status within 1 week, the athlete will be
referred back to the physician for the consideration of additional diag-
nostic testing.

Scenario 3

The third clinical scenario involves a 22-year-old gymnast with

recurrent episodes of LBP. During the initial examination, the clinician
detected several clinical signs thought to be associated with lumbar
segmental instability. These signs and the athlete’s history were used to
confirm the immobilization classification. The athlete responded well to
her Stage I treatment and has now progressed to Stage II treatment.
Because of the athlete’s history of recurrent episodes of LBP and pre-
sumed segmental lumbar instability, the clinician decided to focus Stage
II treatment on trunk-strengthening exercises. In selecting an exercise
prescription for trunk strengthening, the clinician must consider several
116 GEORGE & DELITTO

Figure 6. Exercise to strengthen the erector spinae muscle group. The athlete is instructed
to prevent excessive lumbar lordosis while performing this exercise.

factors, including the amount of lumbar compressive forces generated

by the exercise, the amount of lumbar shear forces generated by the
exercise, the appropriate muscle groups that are targeted, and the param-
eters of the exercise prescription that are appropriate.21, 36
Clinicians should prescribe trunk-strengthening exercises that gener-
ate minimal lumbar compressive and lumbar shear forces.36 For example,
McGill2, 34, 35 has suggested that bent- and straight-knee curl ups are to
be avoided because of the excessive compressive and shear forces gener-
ated. In addition, excessive compressive forces may be generated with
exercises that emphasize the lumbar erector spinae muscles.6, 7 The clini-
cian should also prescribe trunk-strengthening exercises that activate

Figure 7. Exercise to strengthen the transversus abdominis. The athlete is instructed to

pull the navel toward the spine and hold this contraction while moving the lower extremities.
 MANAGEMENT OF THE ATHLETE WITH LOW BACK PAIN 117

muscles that stabilize the spine. A consensus has not been reached, but
evidence in the literature exists to support the role of the transversus
abdominis,40, 41 the oblique abdominals,40 the multifidus,27, 40 the erector
spinae,6 and the quadratus lumborum33 as spinal stabilizers. Lastly, the
clinician must consider the manner in which the trunk muscles are
trained. A recent review indicates that more evidence exists for exercise
prescription that trains trunk muscles for endurance parameters, rather
than strength parameters.36
In this scenario, the clinician decided to initiate trunk strengthening
by training the athlete’s transversus abdominis, oblique abdominals, and
erector spinae muscle groups. A randomized trial reported that patients
with chronic LBP performing exercises similar to these had less pain and
disability at short-term (10 weeks) and long-term (30 months) follow-
up periods.40 In addition, the authors of this article hypothesize that
performance of trunk-strengthening exercises is an important component
in preventing recurrence of LBP.
The clinician selected exercises that have been documented in the
literature as generating acceptable amounts of lumbar compressive
forces. The clinician selected exercise parameters that had the athlete
perform high-repetition, low-load tasks on a daily basis. The exercises
performed by the athlete are pictured in Figures 6–8. As the athlete
with suspected segmental instability progresses through a rehabilitation
program (i.e., to Stage III), it has been proposed that the motor-control
system should also be trained.31, 41 One way to do this is to perform
the trunk-strengthening exercises during sport-specific activities or on
unstable surfaces (Fig. 9).

Figure 8. Exercise to strengthen oblique abdominal muscles. The athlete is instructed to

hold trunk in this position. To decrease difficulty, exercise can be performed with legs bent.
118 GEORGE & DELITTO

Figure 9. Exercise to promote motor control of trunk muscles. Athlete is instructed to

prevent excessive lumbar lordosis while performing this exercise.

SUMMARY

The evaluation of an athlete with LBP using the classification system

proposed by Delitto et al12 has been outlined. For outpatient orthopaedic
practice, evidence in the literature is available documenting the reliabil-
ity22 and the effectiveness of treatment guided by TBC.11, 14, 20 This classi-
fication system provides framework for the clinician to evaluate athletes
with LBP because it investigates the presence of serious pathology,
considers the severity of the disease process, and provides matched
treatment based on the athlete’s clinical presentation. When treating
athletes with episodes of acute LBP, pain modulation and return to daily
function are the primary treatment goals. When treating athletes with
episodes of chronic LBP, return to sport and prevention of recurrence
are the primary treatment goals.

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Address reprint requests to

Steven Z. George, MS, PT
6035 Forbes Tower
Physical Therapy Department
University of Pittsburgh
Pittsburgh, PA 15260

e-mail: georgesz@[Link]