Back and Pelvic Pain in Older Athletes
Ross Hauser, M.D., Marion Hauser, M.S.,R.D.

Injuries to the lower back are quite common, especially in athletes. By midlife more than 50 percent of the population has had significant episodes of low back pain. Some people suffer from chronic daily pain in their backs and pelvis and have often even required lower back surgery. Unfortunately, back surgery usually causes the muscles and ligaments to become even weaker. A surgery that was supposed to strengthen the area actually ends up weakening it to the point that the non-surgerized back is stronger than the back that was surgically repaired.

Golf is a popular sport, especially for middle-aged athletes. Golf, however, is a sport that puts significant stress on the lower back. (See Figure 25-16.)


The back is held in a position that frequently causes strain in the lower sacrum. Back muscles are held in contracted positions in order to obtain the proper form.

Many other sports put a strain on the back as well. For example, hikers and backpackers may suffer significant back pain due to the posture required for hiking and the weight of carrying packs. Although bicycling is quite good for cardiovascular health, the proper position on the bike or the exaggerated forward streamlined posture on the bike can result in significant increases in pressure on the back. Basketball and bowling are also sports that put the back at moderate risk for injury. Frequent falls that occur with basketball can result in injury to the sacrum and significant exacerbation of lower back pain. Bowling can result in muscle imbalance and strain to lower back muscles and ligaments. Another factor that puts the back at risk for injury includes poor posture that has occurred year after year and puts undue stress on certain segments of the back. (See Figure 25-17.)




When talking about the aging athlete and back pain, it is important to talk about the intervertebral disc. It is not commonly known that the intervertebral disc undergoes the most dramatic age-related changes of all connective tissues. (Adams, P. Qualitative changes with age of proteoglycans of human lumbar discs. Annals of Rheumatic Diseases. 1976; 35:289-296.)

By the third decade of life, much of the distinction between the annulus fibrosis (outside of the disc) and the nucleus pulposus (jelly middle) is lost, as the latter is progressively replaced with fibrocartilaginous tissue. (Adams, P. Biochemical aspects of development and aging of human lumbar intervertebral discs. Rheumatol. Rehabil. 1977; 16:22-29. / Ballard, W. Biochemical aspects of aging and degeneration in the intervertebral disc. Contemporary Orthopaedics. 1992; 24:453-458.)

In an elaborate study by Gresham and Miller in 1969, the fourth and fifth lumbar discs were dissected out during autopsies on people with no history of back pain. (Cyriax, J. Textbook of Orthopedic Medicine. Volume 1. Eighth edition. Balliere Tindale, 1991, p. 228-229.)

Between the ages of 14 and 34 years, 90 percent of the discs were found to be normal. At ages 35 to 45, degeneration was evident in 75 percent. After the age of 46, every single fifth lumbar disc was degenerated, and only 25 percent of the fourth lumbar discs were normal. This study showed that it is not the degenerated discs that cause low back pain. Many patients and athletes are distressed at being told that they are suffering from one or more degenerated discs. This suggests an irreversible and crippling phenomenon. The term "degenerated" should be discarded because disc degeneration is universal as age advances, and often causes no symptoms. There must be other structures in the back that are causing the athletes' symptoms. The structures causing athletes' back pain are most often the ligaments.

The low back is composed of muscles and ligaments. The posture is held erect by four particular sets of muscles. These muscles include the abdominal muscles, the back extensor muscles, and a set of paraspinal muscles that lie to the side of the vertebra. There are also important muscles that control hip, leg, and pelvic motion. The most important of these is the iliopsoas muscle. These muscles have a significant influence on the function of the back. The supraspinatus and interspinatus ligaments go from vertebra to vertebra. There are also strong ligaments that go from the vertebrae to the ilium (iliolumbar ligaments), along with the ilium to sacrum (the sacroiliac ligaments). Cumulative trauma through years of sports can result in small tears of these ligaments. One major trauma or injury can also be of such severity that healing never occurred. Since the ligaments do not heal, the intervertebral discs do not have the support that they need. This is why there is such a high degree of Degenerative Disc Disease in the lower back, which is essentially 100 percent by age 46. Degenerative discs are the result of ligament laxity or instability in the lumbar vertebral segments. The instability and ligament laxity cause the chronic low back pain and send athletes by the droves to chiropractors. Manipulation is helpful to realign the vertebrae, but does nothing to regenerate the damaged ligament. Prolotherapy must be given to repair the ligament tissue to allow the vertebrae to stay in place permanently.

In our opinion, Prolotherapy is the treatment of choice for treating low back pain in older athletes. Injections are typically given into the ligaments connecting the vertebra, along with injections into the ligaments between the ilium and sacrum. This helps to tighten the connections between the pelvis and lumbar spine and assists the muscles in providing stability to the back. It is amazing how many athletes end up avoiding surgery once they have Prolotherapy because Prolotherapy gets rid of the pain and stabilizes the back.