Back Injuries and the Fire Fighter
Incidence of Low Back Pain
Back problems are among the most expensive of musculoskeletal
disorders in industrialized nations, and one of the most common work related
ailments affecting adults in the United States. In any given year, 50% of
the working population will experience back pain, with 80% reporting low back
pain (LBP) at some time during their lifetime. Although the vast majority
of individuals suffering from back pain will fully recover within 1 month (90%),
low back pain may also be a cause of chronic pain and long term disability.
As might be expected, fire fighters are at increased risk of back injury
compared to other professions secondary to rigorous physical requirements of the
occupation. The International Association of Fire Fighters' annual
Death and Injury Survey reveals that sprains and strains routinely account
for approximately 50% of all line-of-duty injuries and back injuries account for
approximately 50% of all line-of-duty injury retirements each year. These
injuries may result in significant lost time and medical expense.
This article will discuss the anatomy of the lower back, common causes of LBP,
measures for preventing LBP, and treatment of minor LBP. Given the fact,
however, that back pain has a number of causes with more severe implications, it
is recommended that LBP always be treated in consultation with a health care
Anatomy of the Lower Back
"lower back" is most commonly described as the area from the thorax to the
pelvis on the dorsal (back) aspect of the body, containing a number of anatomic
structures which should be understood if a thorough understanding of back pain
is to be gained. These anatomic structures include the lower back
musculature, lower back ligaments, lumbar vertebrae, vertebral discs, the spinal
cord, spinal nerves, and several joints as shown below.
Lumbar vertebrae – The spine itself is made up of 33
vertebrae (bony segments stacked on top of each other connecting the upper
spine to the pelvis) arranged in 5 sections (cervical, thoracic, lumbar,
sacral, and coccygeal). The lumbar segment contains 5 vertebrae and is
the origin of most back pain. A complex system of ligaments,
cartilage, and muscle maintains these vertebrae in proper position.
Working together, this system's components provide enormous strength and
flexibility, helping to support your weight and maintain your upright
position while resisting the jarring physical rigors of daily life.
Small joints - Each vertebrae consists of a thick
cylindrical hollow-core bone from which three bony pieces jut out, one to
each side and one toward the rear. The bony prominences join with those of
the adjacent vertebrae at a joint called a facet. When thrown out of
alignment, the facet presses on nerve tissue and causes pain. When the
vertebrae are aligned, their centers form a canal through which the spinal
cord passes; spinal nerves, connecting the cord to the body's network of
nerves, pass through openings between each vertebra. Vertebral fractures or
pressure from protruding disks at the point where nerves pass through spinal
openings can impinge or "pinch" the nerves, causing damage and pain.
Lower back muscles and ligaments – Muscles and
ligaments connect vertebrae and provide strength and stability while at the
same time allowing flexibility. Strains (muscle) or sprains
(ligaments) of these structures are a common source of low back pain.
Vertebral discs - Acting as cushioning shock
absorbers/stabilizers, the lower back contains 6 vertebral discs which
protect the lumbar vertebrae. The vertebral disk is composed of the nucleus
pulposis, a soft jelly-like center or nucleus, and the fibrous annularis, a
tough outer portion surrounding the nucleus. Discs may degenerate
under stress or as a result of the normal aging process.
Spinal cord and nerves - The spinal cord runs through a
central canal in the lumbar vertebrae, allowing transmission of electrical
signals from the brain to the muscles of the legs. Spinal nerves leave
the spinal cord between each set of vertebral bodies with
compression/impingement potentially resulting in pain, numbness, or loss of
Common Causes of Low Back Pain
The following paragraphs will describe several common causes of
LBP. Although most sources of LBP resolve spontaneously and may be
self-treated, a number of causes are more serious medical conditions with
serious consequences. It is therefore recommended that back pain be
treated in consultation with a physician.
Lumbosacral sprain and
strain - As shown above, the
lower back contains numerous muscles and ligaments allowing strength and
stability for walking, lifting, standing, bending, etc. A strain is an
injury to the lower back musculature, usually caused when a muscle is
overworked, overstretched, or used in a poorly conditioned state.
Pain most commonly occurs during or immediately following activity, and is
usually worsened with back flexion/standing and relieved with rest.
Muscle spasm (involuntary contraction) is a common response to injury as the
body attempts to immobilize the painful area and prevent further damage.
A sprain is an injury to the
ligaments of the lower back. These injuries commonly occur when a sudden or
forceful movement injures a ligament which has become stiff or weak due to lack
of conditioning or overuse. Lumbosacral sprains and strains are the most
common causes of low back pain, and are frequently caused by a number of factors
including poor conditioning, improper biomechanics/lifting, obesity, and
smoking. Although the aging process cannot be completely halted they
can be slowed by regular exercise, proper lifting techniques, proper nutrition,
and avoidance of smoking.
We will next discuss degenerative sources of LBP. Normal
"wear and tear" and several inherited factors may cause degenerative changes in
several areas in the lower back.
Degenerative Disc Disease/Disc Herniation - When
degenerative changes occur in the disks, the process is often referred to as
degenerative disk disease. Between vertebral bodies, vertebral disks
act as shock absorbers, cushioning the lower back from loads and stressors
of daily work. The vertebral disk is composed of the nucleus pulposis,
a soft jelly-like center or nucleus, and the fibrous annularis, a tough
outer portion surrounding the nucleus. With aging, the nucleus begins
to harden and occasionally cracks/weakens and material from the disk may
push out or rupture. Bulging of disks is
common and often painless. The herniation becomes painful when
excessive bulging or fragments of the disc herniate and place pressure on
nearby nerves, often
referred to as a herniated or slipped disk.
Osteoarthritis – Degenerative changes may also occur in
the small joints between vertebral bodies. These changes occur to some
degree in everyone, but are especially common in those over the age of 60.
Overload, injury, and aging may slowly cause deterioration of the cartilage
between vertebral joints. Disc narrowing, joint inflammation, and bone
spur formation may occur potentially resulting in low back stiffness, pain,
and nerve irritation/leg pain. These effects may be seen below.
- Disc herniation, osteoarthritis, and other causes of LBP may cause
inflammation or compression of nerves in the lower back with resulting pain in
the lower leg known as “sciatica”.
Compression or inflammation of the nerve roots in your spine that form the
sciatic nerve cause pain in the buttock or leg as seen below. As this
symptom may be caused by a number of processes including fracture, cancer,
infection, and vertebral body slippage, patients with sciatica should be seen by
Osteoporosis – Most commonly seen in patients older
than 50, especially women, osteoporosis is defined as a thinning of bone
mass. This condition results in porous and brittle vertebral bodies,
which are weaker than normal vertebrae predisposing the patient to vertebral
compression fractures. Management of osteoporosis with your doctor and
smoking cessation may reduce your risk of these fractures.
Stenosis – Spinal stenosis is defined as
soft tissue and/or bony encroachment on the spinal cord and/or nerve roots often
resulting in leg pain, numbness, or weakness. Spinal stenosis commonly
occurs in middle age to older adults and is worsened by walking and relieved by
sitting. Your provider may order imaging studies to confirm this
Personal Risk Factors
Studies have linked incidence of low back pain to
smoking and being overweight. Therefore stopping smoking and maintaining
an ideal body weight may decrease the incidence and duration of back pain.
Click here for the
US Fire Administration manual on Ergonomics
Prevention of Low Back Pain
The effects of aging that result in decreased bone
mass, decreased strength and elasticity of muscles and ligaments can’t be halted
completely, but may be slowed. With a little care and attention, you
may be able to avoid an aching back in the first place. Speak with
your health care provider to find out what you can do to reduce your likelihood
of developing LBP.
Exercise - Regular aerobic activities that don't strain
or jolt your back can increase strength and endurance in your lower back,
allowing your muscles to function more effectively, and allowing you to
maintain an appropriate body weight, eliminating unnecessary strain on your
back muscles. These aerobic exercises may include walking, swimming or
biking. Talk with your doctor about which activity is best for you.
Conditioned abdominal and back muscles work to protect and stabilize your
back. Flexibility in your hips and upper legs allows for proper pelvic
bone alignment, which improves how your back feels. Performing simple
exercises on a regular basis can help support and align your back.
– additionally, the following activities will reduce stress on the lower
back during everyday activities.
Stand smart - Maintain a
neutral pelvic position. If you must stand for long periods of time,
alternate placing your feet on a low footstool to take some of the load off
your lower back.
Sit smart - Choose
a seat with good lower back support or place a pillow or rolled towel in the
small of your back to maintain its normal curve. Keep your knees and hips
Lift smart - Let your
legs do the work. Move straight up and down. Keep your back
straight and bend only at the knees. Hold the load close to your body.
Avoid lifting and twisting simultaneously.
- Lie on a firm mattress. Use pillows for support, but don’t use a
pillow that forces your neck up at a severe angle.
Treatment of Low Back Pain
Self Care -
Because most back problems aren't life
threatening, many doctors recommend home treatment first. Regardless of
the type of treatment, most people find that their back pain gets better within
6 weeks. If you have strained ligaments or severe muscle strain, your
recovery could take as long as 12 weeks.
A sore back often settles down or improves within a
short period of time. Rest for only 1 or 2 days if your back pain is
severe, because prolonged bed rest can reduce your muscle strength and lead to
further disability. These steps can help you treat back pain at home:
Apply cold, then heat. Sources of heat and cold,
including a hot bath and hot or cold compresses, can soothe sore and
inflamed muscles. Use cold treatment first. Immediately after
injuring your back, apply ice several times a day, for up to 20 minutes at a
time. Put the ice in a bag, then wrap the bag in a cloth or towel to
keep a thin barrier between the ice and your skin. Use ice for as long
as spasms persist. After spasms and acute pain subside, you can apply
heat from a heating pad or heat lamp to help loosen tight muscles.
Limit each heat application to 20 minutes.
Use pain relievers. Over-the-counter pain relievers
such as acetaminophen (Tylenol, others) may help control pain.
Nonsteroidal anti-inflammatory drugs such as aspirin and ibuprofen (Advil,
Motrin, others) also can reduce inflammation.
When to Seek Medical Advice - Most back pain disappears
with home treatment and self-care. Although it may take several weeks for
complete resolution, if you don't feel some improvement within the first 72
hours of self-care, or notice any of the signs/symptoms listed below, see your
LBP with a fever of 100.4 F or higher for more than 48 hours
Constant or intense LBP, especially at night
LBP spreading down one or both legs
LBP with weakness, numbness or tingling in one or both legs
LBP which interfere with bladder and bowel control
LBP associated with abdominal pain or pulsation (throbbing)
LBP following trauma (e.g. a fall or car crash)
LBP with a history of back pain, previous back surgery, or
LBP lasting longer than 6 weeks
LBP when you are older than age 50
LBP if you have lost more than 10 pounds within 6 months
Diagnosis - Your doctor will examine
your back to determine where the pain is, what degree of motion you have without
pain, and whether you have muscle spasms. Your doctor may also order the
following tests to help with diagnosis.
Magnetic resonance imaging (MRI) or computerized tomography
(CT) scans - These scans can generate images that may reveal herniated
disks or problems with bones, muscles, cartilage, ligaments, tendons and
Treatments for back pain
Heat, cold and massage - When performed by a
licensed professional, applications of heat, cold and gentle massage may
relieve back pain due to muscle spasms. A word of caution — manipulation of
your spine may aggravate a disk problem or cause compression fractures if
you have osteoporosis. Ask your physician if spinal manipulation is
safe and helpful for you.
Electrical stimulation - Transcutaneous
electronic nerve stimulation (TENS) may help stop pain by blocking nerve
signals from reaching your brain. A physical therapist places
electrodes on your skin near the area of your pain. TENS may relieve
pain in your leg due to inflammation or compression of nerves in your back
(sciatica), but it may provide little relief for chronic back pain.
Back schools - These programs, available in many
communities, focus on managing back pain and preventing its recurrence.
Classroom study generally involves back anatomy and function, followed by
practice sessions on how to protect your back at home and work.
Exercise and physical therapy - Once your pain
subsides, your doctor or a physical therapist can design an exercise program
to improve your flexibility, strengthen your back and abdominal muscles and
improve your posture.
Lastly, before you decide on back
surgery, consider a second opinion. Surgery to remove a herniated disk is
among the most frequently performed procedures in the United States. This
surgery carries little risk, and the results usually are good. But
long-term outcomes also are often similar following less-invasive treatments for