Low back pain in runners

Low back pain refers to pain located between the lower margin of the ribs and the lower gluteal fold. In runners, it can be acute, subacute or chronic and can have very different origins: it is therefore more accurate to speak of low back pain in runners than of “muscular back pain”.

Most low back pain in athletes is described as non-specific: despite a thorough clinical examination, no single structure can be identified as responsible for the pain. Other situations, however, require a specific approach: low back pain with radicular pain, symptomatic disc herniation, sacroiliac pain, spondylolysis, spondylolisthesis, stress fracture, muscle injury, hip pathology, inflammatory disease or, much more rarely, infection or tumour.

In young athletes, spondylolysis should in particular be looked for in cases of persistent low back pain linked to sporting activity, especially when it is aggravated by lumbar extension.

The lumbar spine is made up of five vertebrae (L1 to L5), linked together by an intervertebral disc, posterior joints, ligaments and stabilising muscles. It must simultaneously support the weight of the trunk, allow mobility, protect the neurological structures, transmit forces between the trunk and the pelvis, and absorb and redistribute stresses. In runners, it constantly works in interaction with the pelvis, hips, knees, ankles and trunk muscles: low back pain should therefore not be analysed solely as a local problem of the spine.

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The intervertebral disc

Between two vertebrae lies an intervertebral disc, made up of a central nucleus pulposus and a peripheral annulus fibrosus, which contributes to shock absorption, mobility and load distribution. With age, it is common to see reduced hydration, tears in the annulus, loss of disc height, or protrusions and herniations — abnormalities that are also common in people without pain. An MRI showing “disc disease” therefore does not necessarily mean that the disc is responsible for the low back pain.

The posterior joints

The zygapophyseal joints, or facet joints, are located at the back of the vertebrae and contribute to stability, movement control and the limitation of certain ranges of motion. They can be involved in some low back pain, particularly when the pain is aggravated by extension and rotation — but a radiological abnormality of the posterior joints is not enough to establish a causal diagnosis.

The trunk muscles

Lumbopelvic stability depends on many muscles: multifidus, erector spinae, transversus abdominis, obliques, rectus abdominis, quadratus lumborum, diaphragm, pelvic floor muscles and gluteal muscles. Their role is not simply to “keep the back straight”: they make it possible to control trunk movements and to transmit forces efficiently between the lower limbs and the pelvis.

Does running damage the back?

No. There is no general reason to consider running a dangerous activity for the lumbar spine. A systematic review published in 2024 found transient disc changes after running, probably linked to compression and a temporary redistribution of water, but longitudinal data did not show any clear harmful effect of running training on disc health. A meta-analysis published in 2026 even suggests that exposure to physical exercise may have favourable or neutral effects on disc health. The question is therefore less “is running damaging my back?” than “what load can my back currently tolerate?”.

Low back pain is a common reason for runners to seek medical advice. The vast majority of low back pain in athletes is non-specific and progresses favourably with active management. Situations requiring a specific approach (radicular pain, symptomatic disc herniation, spondylolysis, spondylolisthesis, stress fracture, inflammatory disease) are rarer but must be identified, particularly spondylolysis in young athletes with persistent training-related low back pain.

Low back pain can appear when the load imposed temporarily exceeds the adaptive capacity of the lumbopelvic system: a sudden increase in mileage, a return after a long break, marathon preparation, a large increase in elevation gain, more frequent sessions, interval training, general fatigue, insufficient recovery, an abrupt change of terrain, or a major change in shoes or technique. But low back pain can also appear without any obvious increase in load: the pain is therefore not always linked to an identifiable structural injury.

Contributing factors

Training factors: rapid increase in volume, simultaneous increase in volume and intensity, repeated long sessions, lack of recovery, too rapid a return, more frequent hill sessions, abrupt change in practice.

Muscular factors: gluteal strength deficit, quadriceps deficit, weakness of the trunk muscles, poor endurance of the lumbar extensors, single-leg strength deficit.

Mobility factors: limited hip mobility, limited ankle mobility, reduced thoracic mobility. These factors are not, however, necessary causes: a runner can have excellent mobility and still develop low back pain.

Psychosocial factors

Stress, poor sleep, anxiety, fear of movement, catastrophising, worry about a presumed injury or a feeling of loss of control also play an important role in the persistence of some low back pain. This absolutely does not mean that the pain is “psychological” — the pain is real, but it results from the interaction between tissues, the nervous system, context, load, recovery and psychological factors.

The pain of common low back pain can be central, one-sided, two-sided, low lumbar or sometimes slightly gluteal; it can be triggered by running, sitting, bending forward, bending backward, rotation or carrying loads, and can vary from one day to the next. Mechanical low back pain can sometimes be very intense while remaining benign.

Acute low back pain comes on suddenly, sometimes during a movement, a training session, an effort, bending forward or a rotation; the patient may feel “locked”, which often corresponds to an acute pain reaction with reflex limitation of movement rather than a “displaced” vertebra. Most episodes progress favourably. Low back pain is described as chronic beyond three months of symptoms; the pain may then become less directly linked to a specific tissue injury, with possible deconditioning, loss of strength, reduced activity, fear of movement, hypersensitivity, sleep disturbance and a gradual drop in sporting level.

Low back pain associated with pain radiating into the buttock, thigh, leg or foot may correspond to radicular pain, sometimes with pins and needles, numbness, muscle weakness or a reduced reflex. Sciatica, radicular pain in the distribution of the sciatic nerve, is often linked to the L5 or S1 nerve roots — but pain in the buttock or the back of the thigh is not necessarily sciatica and must be distinguished from piriformis syndrome, proximal hamstring tendinopathy, sacroiliac pain or hip pathology.

In young runners, spondylolysis (a stress injury of the pars interarticularis) should be considered in cases of persistent low back pain made worse by extension, localised pain during training and no improvement despite simple management. Spondylolisthesis, the forward slippage of a vertebra relative to the one below, may be isthmic, degenerative, traumatic or dysplastic; its presence on imaging is not necessarily responsible for the pain.

Clinical examination

The examination must be comprehensive: posture, lumbar and hip mobility, strength, sensation, reflexes, neurological testing, gait, pelvic control and single-leg control. A neurological examination is essential when radiating symptoms are present: strength (dorsiflexion, big toe extension, plantar flexion, knee extension and flexion), sensation in the nerve root distributions, patellar and Achilles reflexes, and neural tension tests (Lasègue). A clear or progressive motor deficit is particularly important to identify.

In runners, functional analysis (squat, single-leg squat, step-down, lunge, jump, single-leg balance, running) looks at pelvic control, trunk movement, hip stability, knee control and landing strategy — the runner must be considered as a functional chain.

Most common low back pain does not require surgery. It may be discussed in certain situations: significant neurological deficit, cauda equina syndrome, persistent radicular pain with matching compression, certain instabilities or particular structural lesions — imaging must then show an abnormality consistent with the symptoms. A herniated disc visible on MRI in a patient without neurological symptoms is not in itself an indication for surgery.

When a herniated disc causes radicular pain, initial treatment often remains conservative in the absence of a severe neurological deficit, and most patients progress favourably. An MRI becomes particularly relevant when symptoms persist or when a procedure (surgery or epidural injection) is being considered.

There is no universal duration. Most episodes of acute low back pain progress favourably; for common low back pain, the aim is often to maintain or quickly reintroduce suitable activity rather than to wait for a fixed period. Low back pain is described as chronic beyond three months of symptoms. For a specific injury such as spondylolysis, the timeline for returning depends on the diagnosis and how it progresses, and must be adapted to the stage of healing.

Preventing recurrence depends less on a perfect “good posture” than on a good capacity to adapt to load: avoid sudden increases in volume and intensity, keep up regular strengthening (quadriceps, glutes, hamstrings, calves, trunk muscles), plan recovery days, make sure you get enough sleep — as lack of sleep can increase pain sensitivity and reduce recovery capacity — and vary your activities (running, cycling, strengthening, walking, swimming).