How to prevent injuries to your lower back

I recently touched on the topic of low back pain in fast bowlers but this was really just the tip of the iceberg. Pain in the lower back is one of the most common conditions experienced by most people, so every cricketer is at the very least equally as susceptible to low back pain. The fast bowler is even more at risk because of the loads he encounters, and statistically he has a higher tendency to break down than the other cricketers. The breakdown can be the result of not only stress fractures, but intervertebral disc degeneration, hamstring strains, side strains, groin pain; the list goes on just in this region of the body alone.

Fortunately, research and advances in pain sciences are continually helping medical practitioners understand and manage these injuries more appropriately.

But high-profile cases continue to occur in every international team. Though bowling loads are monitored and bowlers are rotated, these don't always prevent injuries. In fact, bowling load guidelines are still hotly debated.

Cricket Australia holds a conference on medicine and science in cricket every two years, and researchers, medicos, coaches and ex-cricketers meet to discuss/debate these topics. One of the frustrating aspects of being a sports medicine professional is the paradox of injury prevention - that all the hard work does not necessarily guarantee the prevention of lower back pain and injury. Similarly, a season without key injuries also does not necessarily mean that the injury prevention programme cannot be improved upon. There are so many variables at play, including luck, which is why injury prevention is all about controlling the controllable.

Proactive national cricket bodies are all developing evidence-based systems in the hope of predicting injuries and being able to implement risk-reduction strategies.

If you are a fast bowler or coach looking for some injury-prevention ideas to introduce into your training, the following concepts are a suitable place to start without getting too scientific and technical. There is no panacea as such, rather a multi-modal approach. You should have already introduced the balance and low load core stability exercises that were discussed earlier. Physical conditioning is obviously another area. Now consider two more - myofascial (i.e. muscles and other soft tissue) and joint flexibility, and bowling specific prehabilitation drills.

In order to move more efficiently and to distribute load appropriately especially around the spine, each body segment needs to have a minimum gross mobility/flexibility. Sports medical practitioners use a variety of functional movement screening tests to localise specific problem areas. We see in the general public as well as in sportsmen that certain movements/structures are susceptible to tightening or shortening as a result of poor postural habits and repetitive movement. A simple example is bending to touch the toes; flexion movements occur at the hips, the pelvis, and the spine with muscles, nerves and other connective tissues undergoing various amounts of tension. Stiffness and tightness at any of these levels force compensatory motion elsewhere in order to achieve the same total range. So in this example, if the hips don't have good flexion mobility then the range necessarily comes from compensatory movements at the spine and/or the pelvis.

Similar compensations apply to restrictions in any direction or combination of movements. In fast bowlers a restriction of rotation in the hips and thoracic spine are particular issues since the lower back is the region caught "in between". Thus injuries could occur anywhere along the kinetic chain when movements are repetitive or acutely overloaded.

Even without a proper screening assessment there is benefit for fast bowlers to perform the following exercises. Try them after a core or other practice session when the body is warm and more receptive to mobilisation. Combining the mobilisation/stretch with breathing techniques can enhance the outcomes. Use deep inhalation when coming out of a stretched position and exhale when moving back into the stretch - this can facilitate neuromuscular relaxation, resulting in a more effective stretch. Try adding the following into the programme:

Hip extension Kneel with the right knee on a pillow and place the left leg forward. Tuck the tailbone under (posterior pelvic tilt) and tighten the right glute. Drive this right hip forward to feel the stretch in the front of the right hip. Avoid arching the lower back. Increase the intensity by leaning the trunk towards the opposite side. The knee should be able to extend behind the frontal plane of the hip.

Hip rotation (internal) Studies have shown that the hips with approximately 30 degree of internal rotation range are less likely to be associated with low back stress. This reflects both musculature and capsular tightness. Kneeling on the right knee again, block the inside of the right ankle against a door frame or heavy table leg. Instead of the left foot being in front, place it more toward the right-hand side of the midline and follow by twisting the pelvis to the right. Increase the tension in the right hip by moving further into range. Avoid flexing the hip to keep pure rotation.

Hip flexion Stand with both feet facing forwards and place the right foot up onto a bench or chair. Bend forward and place the left hand on the bench. Keeping the lower back in neutral (i.e. don't let it flex or extend), take the right elbow down toward the right inside ankle. Keep the leg touching the upper arm. This stretches the inner hamstrings, adductors and glutes in one hit, but the tightest structure will be felt.

Ankle dorsiflexion Commonly known as a calf stretch; a flexible calf allows the ankle to bend forward or dorsiflex. Perform the stretch with both the knees extended and slightly flexed.

Thoracic spine extension Tightness in thoracic extension will be compensated for by extension in the lower back. The upper back also cannot rotate properly. All fast bowlers should ensure that their thoracic spines are capable of reasonable active extension range of motion. Lying supine over a foam roller is one of the best techniques but if this is not available then extend over a Swiss ball or even use a rolled up beach towel at various levels of the upper back. Extend gently and keep the knees bent to protect the lower back. The stiffer foam roller gives a mobilisation as well as a stretch.

Thoracic spine rotation Standing side-on next to a wall, raise the inside leg to block hip movement then twist the upper body to this side in an attempt to get the chest flat to the wall. Use the arms to increase or overpressure the intensity of the stretch. Avoid slumping during this movement.

Shoulder flexion (combined elevation) Kneel on both knees with arms extended out in front and forehead resting on the floor between them. Begin by trying to drop the armpits down to the floor. Alternate a slight left and right bias to this in order to target the lats and side trunk. Improving shoulder flexion range of motion also offloads the lower back by allowing the bowler to get into a better position.

With persistence over time, these exercises should improve the overall range of movement in the body necessary to off-load the lumbar spine when bowling fast. Unfortunately, the body is a complex piece of machinery and normal flexibility alone doesn't always reflect optimal neuromuscular tone and function. There can be areas of increased tone within a muscle, which on its own is not enough to cause a loss of flexibility, but can disrupt normal muscle function at the local level. Often described as myofascial tension or trigger points, one of the best ways to self-manage and restore normal muscle tone is to use the foam roller again. Most of the main muscle groups can be targeted for deep kneading and myofascial release. Without a roller, deep sports massage is equally effective.

In part two (two weeks from now), I will discuss a more dynamic approach to add to the injury prevention process for the fast bowler that is used by all elite players today.