"But the MRI Says…" — Low Back Pain in Athletes, and Why the Scan Isn't the Story

Are you an athlete being treated like you're 80 years old? Has a doctor told you the only solution is surgery? Nervous you'll never get back to the same level?

The MRI problem

In my career as a physical therapist, the number of times I've heard "but my MRI indicates X, therefore surgery is a must" is too many to count.

MRI can be a useful tool. But it does not tell the story. The story is the 28-year-old professional soccer player. The story is the 41-year-old mother of two who loves her HIIT workouts. The scan is one data point about tissue; it is not a description of a person, and it is a poor predictor of pain.

Too often that image becomes a negative cloud sitting permanently in the back of someone's mind. Don't let it hold you back. There are things you can do.

Why we get back pain — the three I's

• Incomplete mechanics — faulty repeated motion over days, weeks, or months. Decreased mobility, poor motor control, one-sided weakness.

• Incidents — minor nags and small pains, usually overlooked and pushed through. "I tweaked my back deadlifting but it feels okay today."

• Injuries — when it all comes apart. Threw your back out, can't move, next stop is the doctor or the ER.

How long it actually takes

Like any injury, this takes time, and this is where I see clients get discouraged. It takes at minimum 2 to 4 weeks to see neural adaptations to a new movement — meaning about four weeks before a noticeable change in strength. Hypertrophy takes 6 to 8 weeks. If you're 10 weeks in with the same pain and no change, that's when it's time to get professional help.

The two most common types

I use the ICF classification model rather than chasing an imaging diagnosis, for two reasons: it lets us look past the scan, and it's better to treat the impairment than the label.

Low back pain with mobility deficits — limitation in back movement. Stiffness and unrelenting tightness, usually one spinal segment not moving as well as the others, causing global discomfort. Often with guarding in the low back, glutes and hip flexors. Pain and restriction with bending and extending.

Low back pain with movement coordination impairments — uncoordinated movement patterns or underlying weakness, usually with hypermobility. Episodic, with flare-ups across weeks, months, years. Foam rolling, massage and cupping reduce the flare-up but never fix the root. Pain without restriction in range of motion.

The squat test: squat and note the pain. Then brace your core, or hold a 5 lb weight straight out in front of you, and squat again. If it feels even slightly better, that points toward a coordination problem.

Mobility deficits — where to start

4 sets of 10 reps each, twice a day, for a month. Then retest. Always retest.

• Cat-camel — works the low back through difficult range without gravity compressing it. Build tolerance to the painful range slowly.

• Thread the needle — rotation for the mid and low back without gravity. Emphasize the restricted side; you'll feel which one it is.

• Kettlebell weight shift — happy hips, happy back. Clients with tight low backs almost always have limited hip rotation. Shift your weight over the outstretched leg until you feel the stretch.

Movement coordination — where to start

3 sets of 10 each. As long as there's no pain running down the leg.

• Pallof press — the single most-used exercise for back pain, and that doesn't make it a bad one. Keep the core tight and don't let the band rotate you.

• Side plank clamshells — core and glute isometrics together. Very fatiguing.

• Bridge with banded abduction — hip extension without stressing the lumbar spine, with lateral glute activation.

Important: if there's pain running down your leg, or things are getting worse rather than better, stop and get assessed.

Want this handled properly?

If your back has been episodic for years and nothing has stuck, the problem usually isn't the exercises — it's that nobody worked out which type you have. That's a one-hour conversation.

Dr. Mike Blanco, PT, DPT, Cert. DN — USAT Level 1 Certified Coach. Rival Physical Therapy, 681 Lawlins Road, Unit 110, Wyckoff, NJ. Call or text 201-220-9049.

This article is general education, not a diagnosis or individual medical advice. If pain is severe, worsening, or present at rest, get assessed in person.