Loose Ligaments:
The Key to Solving Sports Back Pain
Ross Hauser, M.D.

When back pain is due to loose ligaments, a very characteristic behavior of pain is observed. An athlete with loose ligaments of the lumbar spine or pelvis will experience recurring dysfunctions at the intervertebral joint (degenerative disc and possible nerve compression), at the facet joints (locking in flexion or extension), and at the sacroiliac joints. In other words, the low back pain can be due to an unstable disc problem, facet joint locking, or sacroiliac dysfunction.

However, the low back pain can originate in the ligaments themselves. The ligaments in the lower back contain an abundant supply of small nerve endings. Good and strong ligaments will stretch very little when a load is applied to them. When the ligaments are weak, an excessive stretching will occur with the same load. The greater the ligament laxity, the faster the ligament will elongate or stretch. This exaggerated elongation of the weak and overstretched ligaments allows excessive pull on the non-stretchable nerve endings. As a result, pain and/or numbness is felt locally over the ligaments or referred distally in the buttock or in the legs, following a specific pattern for each ligament.

Ligament injury is very painful. This is, in part, because of the nerves in the ligaments, but also because ligament injury typically occurs where the ligament attaches to the bone, an area called the fibro-osseous junction. The outside of the bone, where the ligament attaches (the periosteum), is also full of nerve endings. The most sensitive structures that produce pain according to Daniel Kayfetz, M.D., are the periosteum and the ligaments. It is important to note that in the scale of pain sensitivity (which part of the body hurts more when injured), Dr. Kayfetz explains that the periosteum ranks first, followed by ligaments, tendons, fascia, and finally muscle, respectively. (Kayfetz, D. Occipital-cervical (whiplash) injuries treated by Prolotherapy. Medical Trial Technique Quarterly. 1963; June: 9-29.) When a ligament is injured, pain will be elicited from both the periosteum and the ligament. This is why ligament injury can and does cause severe pain. This also explains why ligament pain can come and go. The ligament will not be overstretched in certain positions, therefore no pain is felt at that time.

An athlete with loose ligaments of the lumbar spine and pelvis will often complain of not only nagging low back pain, but also of an inability to maintain the same position for a long period of time. If the same position is held for a long time period, this will stretch the already injured ligaments with sensitive nerve endings. The athlete will find relief by changing posture or position because the nerve endings are no longer being stretched. This relief is only temporary. As the new posture is maintained, the weak ligaments gradually start to give and the small nerve endings are again stretched, and the pain recurs. This is why an athlete may be able to play with only moderate discomfort or feel better while playing. This should not, however, fool the athlete into thinking the injury is not serious. The injury is serious in the fact that if it is not healed, the degenerative disc cycle will not stop.

Here are some typical pain patterns experienced with ligament injury to the lower back:

Lying Down
When lying in bed, position must be changed repeatedly to get comfortable.

Sleep is poor, and often disrupted because of the recurring back pain.

Arising out of bed and walking around often gives some relief of the pain.

Morning
The pain is more intense in the morning.
   
After lying down for 5 or 6 hours, the athlete gets out of bed early (5 or 6 a.m.) because of the pain.
   
Stiffness and pain in the lower back upon rising in the morning.

Standing and Sitting
Standing too long aggravates the pain (like standing and watching a sporting event, standing too long at a cocktail party, or in line at the grocery store or bank).
   
Sitting too long aggravates the pain (observing a sporting event, sitting at the theater, taking a long drive, or watching a movie).
   
Walking around after standing and sitting too long helps decrease the pain.

Any athlete who has pain characterized by the above, needs to consult a physician with special training in the diagnosis and treatment of ligament problems.