What is the extent of back problems in rowing?

An episode of back pain in rowers is very common and some good research over recent years has shown that 30-50 per cent of rowers will have an episode of low back pain in a 12-month period. Low back pain is also highly prevalent in the general population although the 12-month incidence is reported as 3-18 per cent worldwide, so rowing is clearly higher.

Also, it is known that common risk factors for low back pain such as smoking, obesity and inactivity are largely absent in the rowing community indicating that involvement in rowing is the direct cause of the most rower’s back pain rather than just the human experience. It is difficult to know if the problem is getting worse or better, as although rowers seem to be training hard year on year, diagnostic and rehabilitation techniques have been improving. There are, however, some recent studies that suggest that pushing juniors early (particularly in weight training) is causing changes in hip joints, that is having a knock on effect on back health.

What are the causes of back pain?

Injury studies have shown that there are some key factors that increase risk of having an episode of rowing back pain. Having one episode increases your chance of having another. The indoor rowing machine is frequently found to be strongly related to risk; specifically sessions which are longer than 30 minutes. Risk increases with the volume of training hours per week and also increases with years of rowing. There are peak times of the year for the injury; specifically a few months into winter training and just before regatta season. Of interest, core stability work was not found to protect from injury and has conversely been found to increase risk in some cases (a possible explanation given below).

Biomechanical analysis in both the lab and on the water has shown that the position of the pelvis has a crucial role to play in risk of injury. This clarifies the idea that rowers should flex through the hips, rocking the trunk forward over the ‘sit bones’, particularly in the transition from the drive to recovery, keeping the lower back in a fairly neutral position. As fatigue sets in there is a tendency to move through the lower back, rather than maintain good hip movement. This appears to load the lower back unfavorably.

It is interesting to note that fatigue has a different response in the boat compared to the rowing machine and the increasing lower back flexion with fatigue is not so pronounced in the boat. This is likely to be why the rowing machine increases the risk of back pain. Fatigue is, of course, normal in rowing training and rowers are experts at pushing through it. However we know that the ‘spinal creep’ we observe with increased time on the rowing machine (and less so in the boat) has an effect of damping down the spinal tissues own protective reflex activity and is associated with inflammation. This means it may make the lower back more vulnerable to injury through either poor technique or inadequate recovery.

What is the best management approach?

The best approach to any sports injury is prevention using the knowledge we have to date. Indoor rowing machine training is really important, particularly as it is often used for selection but it should be treated with respect. Rowing machine session length should be reasonable, particularly for juniors and it should not be used as a warm up, particularly before a weights session. This is because of evidence that the ‘spinal creep’ seen in the tissues of the back following a long rowing machine session may dampen down their protective reflex activity which may make it difficult to maintain the good technique which is necessary to perform weight sessions safely.

Technique should be analysed by a good coach ensuring emphasis on moving from the hips and not the lower back. The spine should not be rigidly straight; rather a relaxed ‘C’ shape or a smooth arch, which allows force to be evenly distributed. This is explained well in the figure below. In 1a and 1b it is clear that the spine is one gentle curve which is distributing the flexion throughout its length. In 2a and 2b the spine is flatter in some areas and very flexed or ‘kinked’ in others indicating that its not smoothly distributing the forces.

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Having really good range of motion in the hips is now recognised as crucial to protecting the lower back and rowers should be able to comfortably do a full squat, keeping heels down without having to tilt their pelvis backwards.

Some core stability approaches (such as those that concentrate on isometric holds such as ‘the plank’) appear to have failed rowing and good coaches and clinicians are moving away from this approach. The old approach to trunk strengthening, which is now recognised as optimal, is where the endurance of trunk muscles are improved through dynamic exercise. This is much more reflective of rowing demands and is likely to protect the back more effectively.

Most episodes of low back pain in rowing will resolve on their own within a few weeks. There is limited need for scans, injections or complex treatments with the exception of cases where there is considerable leg pain or other complexities.

What is the focus of future research?

Advance in wearable technologies is improving understanding of spinal biomechanics, particularly with potential to examine on the water where research is limited. There are ongoing studies examining the psychological impact of back pain in rowers. Cognitive approaches such as mindfulness training has been identified as very important in the general population and its likely it will apply to athletes also. The importance of good sleep (as well as recovery) has recently been noted to play an important role in injuries and work is ongoing in this area.

Wilson’s full presentation