Rowing Low Back Pain: What Rowers and Coaches Need to Know

Low back pain is the most common rowing injury, causing around 60% of rowers to miss at least one session per year. The vast majority of low back pain is non-specific, meaning not medically serious and not diagnosed to a specific tissue pathology causing pain or dysfunction. Non-specific low back pain in rowing is mostly due to training factors that are under the control of coaches and rowers, with secondary causes under individual athlete control. This article is a practical guide to what rowers and coaches need to know about rowing low back pain, focusing on preventing, managing, and returning from injury to full performance.

Key Points: Check out this summary graphic for a one-page flowchart of key points to rowing low back pain symptoms, management, and returning from injury. Also, read a partner guide here for the more detailed medical side of diagnosing and treating rowing low back pain, written by my friend and rowing physical therapist Dr. Lisa Lowe. I also have a reference section at the end of this article where you can read a lot more about rowing low back pain from the resources I have found most helpful. Finally, read my article, “Rowing Injuries: Understanding, Preventing, and Managing,” that sets up the basics of general injury understanding and prevention before the injury-specifics of this article and “Rowing Rib Stress Injuries.”

Table of Contents:

• Defining Rowing Low Back Pain
• Low Back Pain Risk Factors: Rowing and Individual
• Reducing Risk of Rowing Low Back Pain
• Low Back Pain Initial Care and Reducing Pain
• Low Back Pain Longer-Term Workarounds
• Returning to Training After Low Back Pain

Defining Rowing Low Back Pain

Here is the obligatory disclaimer that I am just a strength coach with a library card, not a medical professional. I am relaying information from academic research on rowing injuries and rib stress injury in this article, plus my own opinions and experiences as a strength coach of rowers. I cannot diagnose injuries or prescribe rehabilitation programs, and do not attempt to do so here. Like everything, there are varying opinions about low back pain and many different individual athlete, coach, and professional experiences. I have done my best to synthesize what I have found to be the most useful information for this guide, with thanks to everyone who has published on this so the rest of us can learn and work to apply that knowledge! Read my references at the end of this article for more information, and check all of this with a medical professional if you are personally working through low back pain.

Most low back pain is non-specific and not medically serious. This form of back pain is referred to as “LBP” from here. It’s important to know that LBP can be painful, frustrating, and disruptive to training, and yet not cause for medical alarm. However, athletes should seek attention from a medical professional if LBP is accompanied by the following red flags for medically serious low back pain:

• Non-mechanical pain (wholly unrelated to time or activity)
• Mid-back pain in addition to low back pain
• Presence of other unexplained symptoms (e.g. rash, multiple joint pains, burning with urination, vomiting, etc.)
• Unexplained weight loss or night sweats
• Pain radiating to legs or feet, numbness, or tingling
• Bowel or bladder dysfunction (e.g. incontinence, inability to void)
• Fever or chills in addition to pain at rest or at night
• Leg weakness or gait disturbance
• Pain so severe it interferes with sleep or walking

Without these red flags, non-specific LBP means that there wasn’t necessarily a singular moment of injury or one clearly damaged specific structure within the low back. This can be challenging to assess due to clinical opinions, disagreements on causality, and sometimes inconsistent pain. One professional might say one thing, while another professional says something else. Either or both could be right (or wrong!), and this is commonly frustrating for the athlete. If the LBP came on more gradually rather than a singular moment of acute pain and isn’t accompanied by one of the red flags above, an exact diagnosis may not necessarily change the overall treatment, care, or rehabilitation program.

Modern researchers and clinicians recommend against routine imaging (eg. x-ray, MRI, CT scan, etc.) for LBP, to avoid cost, misdirection, and adverse outcomes for the athlete. This is especially applicable in rowing when we already know so much about the risk factors for injury. There is often not a connection between the individual’s LBP symptoms and their imaging results. Imaging may not find problems in individuals with LBP, and may find problems in individuals who don’t experience LBP. This is frustrating in the short-term. It also has potential long-term consequences for athletes who may now second-guess future symptoms, fail to make appropriate training adjustments, and develop negative perceptions about the back.

When no red flags are present, initial LBP care and treatment is called “conservative therapy.” This generally consists of 1-6 weeks of activity modifications, trying to avoid positions or motions that clearly worsen symptoms, and a spine rehabilitation program with a focus on hip and trunk strengthening. Consider implementing the training strategies and modifications in this article to see if pain improves or resolves. Seek more enhanced diagnosis if pain does not resolve in 1-6 weeks, worsens during that time even with conservative management, or recurs during a progressive return-to-train phase. Details on how to manage this all ahead.

Low Back Pain Risk Factors: Rowing and Individual

Low back pain is multifactorial and common in rowing, with an average of 61% of adult rowers experiencing LBP in a year of rowing training. There are usually many contributing causes to pain rather than one single, “smoking gun,” cause. These contributing causes include:

• High total training volume
• Rapid progression of training volume
• High per-stroke loading
• Change in equipment, such as from sweep to scull or on-water to erging
• Change in rigging, especially if this increases per-stroke load
• Challenging environmental conditions, such as cold water, against current, or up-wind
• Technique and change in technique, especially those that increase upper body force like very segmented drive phases and deep laybacks at the release
• Fatigue from non-rowing training, such as strength training and cross-training
• Low recovery from training, such as due to lack of sleep, insufficient calories, lack of micronutrients, or general stress

Does this sound familiar? Many of these factors also cause rib stress injuries (RSI), another common overuse injury in rowing. In fact, LBP and RSI are related: One is a risk factor for another. Rowers with LBP tend to shift force away from the heavier front-end (catch side) of the stroke, when the back is in a more challenging position. Rowers with RSI often row a more segmented stroke with greater emphasis on the mid-drive and late drive “swing” phases. Both of these changes increase torso and upper body force contribution in the rowing stroke, increasing stress and strain on the low back and ribcage.

Low back pain is common in the general, non-athletic population as well. It is important to not demonize (or glorify) rowing for its LBP rates. Making LBP seem endemic, inevitable, or a “badge of honor” among rowers has worse outcomes for individual rowers and our sport overall. There is also a strong biopsychosocial element to LBP, more so than other common injuries. This describes the “rest of life” factors outside of training factors that influence individual perception and experience of pain and injury. Both training and non-training emotional stress and anxiety is related to development and worsening of LBP. Read the biopsychosocial section of my “Rowing Injuries” general overview for more about this, including details of the graphic below.

Reducing Risk of Rowing Low Back Pain

The best thing we can do to reduce risk of LBP is pay attention to the overlap of risk factors. Low back pain most often occurs during major changes in training volume and equipment. For example, the beginning of winter erg training after the fall rowing season, or the beginning of spring on-water rowing after the winter erging season. The athletes may be perfectly cardiovascular fit, but the low back experiences different stress between these different modes of training that increases risk of injury. Coaches should reduce training load during transitional times. When possible, try to make the change in equipment progressively. For example, rather than a wholesale shift from 100% on-water rowing to 100% erging, start two weeks earlier with 50% rowing and 50% erging for one week, then 25% rowing and 75% erging for the next week, then 100% erging. We can do the reverse when transitioning from winter erging to spring on-water rowing. We might not like giving up the water time, but we like LBP even less!

World Rowing convened a panel of medical and rowing experts to produce a 2021 consensus statement about rowing low back pain, intended for high-performance adult rowers. In my experience, their recommendations are broadly applicable to junior and masters rowers as well. One of the biggest specific risk factors they cite is total time on static ergometers, especially doing sessions of 30+ minutes of continuous erging. Ergs are great, but they have some downsides. One is that the forces are higher on the rower than with a dynamic erg or on-water rowing. This is due to the rower reversing their entire bodyweight and momentum from the recovery phase into the drive phase on every stroke, rather than distributing this over both footplate and seat movement as on a dynamic erg or rowing on-water. The rower can also press harder with the lower body thanks to the stable footplate of a static erg. Ergs also allow for greatly increased training volume versus on-water rowing. There is also usually a more rapid progression of training volume due to the increased accessibility. Finally, researchers on rowers from novice to elite have found increased spinal movement beginning between 20-30 minutes of continuous static erging. These subtle, subconscious shifts occur even at low-intensity (“steady state”) training, and increase stress and strain on the low back. These factors all together–increased volume, increased load, potentially rapid progression, and subconscious shifts–add up to significantly increased risk of LBP.

Rowers cannot “out-recover” anything that coaches throw at them in training. Reducing LBP begins first and foremost with coach awareness and attention to minimizing risk factor overlap in training, especially during transitional phases. Rower recovery is a critical secondary factor after training management. Adequate sleep (7-10 hours per 24 hours, ideally mostly overnight but supplemented with daytime naps as needed), good nutrition (quantity as calories, and quality as macro and micronutrients), and stress management (inside and outside of training) are all crucial to recovering from training. Coaches and rowing programs still have responsibility here to help rowers achieve good recovery through education and ongoing coaching to make this a priority.

There are currently no research-supported LBP prevention strategies. The World Rowing consensus statement authors emphasize the need to reduce exposure to risk factors, which we know a lot about, rather than add unverified prevention strategies without reducing risk factors. This attempts to address two problems here: unproven prevention strategies often add cost (coach/athlete energy, time, money, etc.), and they often detract from focusing on more worthwhile interventions of risk reduction.

One low-cost risk reduction strategy comes from a 2015 World Rowing blog by rower and chiropractor Bob Cummins. He proposes a one-minute “standing rest” break for every ten minutes of continuous erging to facilitate micro-recovery of the muscular and skeletal structures supporting the spine. No researchers have evaluated this strategy to prove if it does reduce or prevent LBP, although it would be easy enough to do. This strategy is appealing when combined with other risk-reduction strategies, because the only cost is the small amount of added total session time from the one-minute breaks.

Many of the non-rowing methods commonly thought to reduce risk of LBP, such as stretching, core strengthening, and strength training lack rigorous research or have failed rigorous research protocols. In a 2010 rowing study on high-performance rowers, time spent on core training and strength training was actually positively correlated with LBP! This does not mean that these are inherently bad, just that they are not inherently good. The researchers also note a lack of exact methodological definition of “core training” or “strength training,” making this harder to discuss and evaluate. The key takeaway is that general core and strength training cannot on their own prevent LBP. We must also address sport-specific risk factors and biopsychosocial elements as well.

In my strength coaching, I am always trying to reduce load on the low back through the exercises we use, how we use them, and how we develop muscles to support the low back. We front squat instead of back squat to reduce shear stress on the spine. We use single-leg squats like rear-foot-elevated split squats to work the legs without much, if any, load on the low back. We control the lowering tempo and squat to thighs-parallel or just below to increase muscular stress and reduce spine stress. We do a lot of work for the hip hinge movement and muscles to coordinate this important element of stroke technique. We generally hex bar deadlift or Romanian deadlift instead of conventional barbell deadlift, to load the posterior chain with reduced shear force and minimal loaded spinal flexion. Lateral and rotational hip exercise is a missing element from rowing and erging, and can help improve the strength of other muscles so that the low back is not used so heavily. Upper body strength, especially for the pulling muscles, is important to distribute stroke force over many muscles, reducing stroke force from the low back. We do lots of shoulder coordination and strength training to improve connection in the early drive phase, when stroke force is key to avoid shifting the force profile to the mid-drive phase and loading the back. Finally, we focus core training on suspension trainer (TRX/gymnastics rings) exercises and seated rockbacks, rather than static plank and crunch exercises. All of these elements are important to improve physical and athletic coordination for good stroke technique and force from many muscles in the long kinetic chain.

Low Back Pain Initial Care and Reducing Pain

The first step to initial care is offloading from painful forms of training to avoid further aggravation. This may involve a significant restriction at first during the initial high inflammation phase, or the athlete may be able to identify and avoid specific aggravating factors. Avoid “testing” the pain during this phase. Intentionally provoking pain “to see if it’s still there,” or prematurely or aggressively returning to painful forms of training can delay healing and cause pain to return or worsen. Reflect and consider other potential contributing factors to injury from the biopsychosocial model. Use pain-free strength training and cross-training to preserve strength, muscle mass, and fitness, while not interfering with healing.

Conservative management–moving and training in ways that avoid or reduce pain–is the focus for the first 1-6 weeks of mild-to-moderate LBP with no red flags from the first section of this article. Minor interventions beyond this may help reduce LBP symptoms, but should not be relied upon. This includes medication, stretching, mobility, light bodyweight exercises, massage and other manual therapy, heat, and transcutaneous electrical nerve stimulation (TENS). While these may help alleviate LBP symptoms in the short-term, the mistake is to think that this has “fixed” the LBP and return to training prematurely without providing enough recovery time or addressing actual factors contributing to injury. There is little empirical evidence for any one form of treatment or exercise in resolving LBP. There are no “silver bullet” exercises or stretches to prevent or resolve LBP on their own. I have compiled a listing of exercises here that I have found to help via increasing hip and trunk strength and stability. I’m careful to present these in a way that avoids the athlete perception that, “if these don’t work, then I’m really messed up.” Sometimes we just need some rest and recovery time, rather than yet more “training,” even with easy exercises.

After pain is significantly reduced or resolved during the 1-6 weeks of conservative management, do a progressive return-to-train including the previously painful stimulus. Consider an approximately 1:1 return timeline. If the rower offloaded for five days, spend about five days progressively returning to normal training alongside pain-free cross-training to preserve total training load. Do not go immediately back to normal training or “make up for lost time” with increased training load or testing. A minor LBP incident often resolves without formal treatment in a week or two of offloading and self-care interventions, followed by an equal amount of progressive return-to-train time. More specific guidelines on this ahead.

All parts in this initial stage of care are essential:

1. Reduce the painful stimulus (offloading)
2. Use minor interventions as appropriate to ease pain/frustration (eg. exercises, self-care, massage, etc.)
3. Gradually reintroduce the previously painful stimulus (progressive return-to-train)

Low Back Pain Longer-Term Workarounds

We refer to a medical professional if LBP persists beyond six weeks, worsens or fails to resolve with conservative therapy, returns during a progressive return-to-train phase, or is so severe that even modified activity is not possible. A long-term injury requires greater and longer intervention. This may include physical therapy (see my list of go-to rowing PTs here), offloading for a longer duration to facilitate healing, and other training and lifestyle modifications.

A physical therapist can advise on clinical diagnosis (without imaging unless determined necessary), rehabilitation, and training modifications. What kind of training should the athlete do that facilitates healing? What should they NOT do that interferes with healing? This may include recommendations for cross-training, strength training, sport training, and off-training activities such as recovery interventions and modifications to activities of daily life. Finally, what kind of training is redundant with physical therapy? The athlete likely does not need to do hundreds of reps of the same exercises in both PT and strength or modified sport training.

The goal of training during this time is to preserve the athlete’s mental health, social connection to training and teammates, general fitness, and strength and muscle mass as much as possible, while not interfering with the rehab and healing process. We only use total rest when specifically recommended by a medical professional. The athlete, physical therapist, sport coach, and strength coach should all work together to find pain-free exercise options. Maintaining a training status and preserving general strength, fitness, and muscle mass usually results in better healing outcomes, better athlete mental and physical health, and a more effective return-to-train phase later.

Rowers with LBP typically experience pain from strength training and movement with one, some, or all of the following types of force: shear, compression, tension, and torsion. See the graphic below for illustrations of this. The athlete also may be more sensitive to spinal flexion (back rounding), spinal extension (back arching), or both. The goal while offloading is to avoid the movements that produce pain. We can focus our training on exercises from different movements and types of force that do not produce pain.

The following exercises are often not part of our typical strength training, but they can be effective to maintaining strength and muscle mass as injury workarounds. Single-leg strength training exercises such as the rear-foot-elevated split squat are often tolerable and effective for knee extension strengthening, even without added load. The belt squat is often tolerable for bilateral knee extension loading, while leg presses often are not. Posterior chain exercises without shear or compression force, such as the Nordic hamstring curl and glute-hamstring raise, may be tolerable and are effective for the hamstrings and hip muscles if so. Athletes can often do most upper body exercise, especially with torso support (avoiding shear). This may include: horizontal and kneeling or seated vertical pressing, chest-supported horizontal pulling (like a bench pull, but not), chin-ups or lat pulldowns, and isolation exercises for the arms and shoulders.

Core exercise involving repetitive spinal flexion, extension, and twisting can be a risk factor for and aggravating factor of LBP. This includes sit-ups, crunches, leg raises, Russian twists, and more. Athletes experiencing LBP or at risk of LBP should focus on core stability exercises with minimal spinal movement under load. For example, planks, side planks, and suspension trainer (TRX/gym ring) planks, as well as the bird dog hold and Pallof press. Consider a broader definition of “the core,” including the hip and shoulder where they join with the anterior and posterior trunk. Training for these muscles helps distribute load away from the low back.

Walking is one of the safest and most effective forms of aerobic cross-training with LBP. Athletes with significant LBP may need to begin with just ten minutes of walking on a flat, stable surface, such as paved roads or indoor track. Progress to longer durations, and then to faster paces or uphill walking. This is often best on a treadmill, since the incline, pace, and surface are controllable. Stationary cycling, sometimes with upper body support, may also be fine, as long as the athlete can achieve a comfortable position for long exercise without pain. Water-jogging is also an option. Swimming usually isn’t recommended due to the spinal extension position required.

Returning to Training After Low Back Pain

Rowers returning to training often experience reinjury or injury elsewhere due to a progression of training load that is too rapid for technical and physical remodeling to occur. History of LBP is a significant predictor of future LBP. In other words, an athlete who experiences one episode of LBP is always at higher risk of a future one. An athlete with LBP history may never be able to fully return to exactly the kind of training that they did before the injury. They certainly can return to equal or greater levels of performance by increasing attention to nutrition or recovery, excluding certain forms of high-risk sport or strength training, and including specific sport or strength training practices to decrease risk of injury or reinjury. This process of long-term maintenance and adjustment may take a year or more depending on injury severity.

Rowers should maintain some elements of their rehab training while returning to training, and even while pain-free following a successful return-to-train phase. I advise athletes to pick the 3-5 movements that they feel have the most beneficial effect in helping them feel good and ready to perform, and keeping those in the warmup or elsewhere in their training. See the “Reducing Risk” section for more specific strength training advice to reduce risk of LBP.

Any departure from normal training should be followed by a phase of gradual reloading approximately equal to the amount of time the athlete was away from normal training. For example, a rower who experienced minor LBP, offloaded quickly, and is free of pain within one week of conservative therapy could do a one-week gradual progression back to full training. A rower with more significant pain who did modified training for 4-6 weeks may need another 4-6 weeks to gradually progress to pre-injury levels of training and performance. This is valuable rebuilding time to address technical factors that may have contributed to injury, as well as attention to nutrition to improve bone mineral density and reduce risk of future injury. Remember this for future return-to-train phases as well. Rowers with LBP history often experience reinjury during phases of rapidly increased training volume or load, such as training camps or returning from vacation.

My go-to approach to any return-to-train phase following time away from normal sport training is the National Strength and Conditioning Association’s “50/30/20/10 progression.” This is a four-week low-intensity progression beginning with 50% of the pre-injury workload (on the specific mode of training), then 70% (or, a 30% reduction), then 80%, then 90%, then 100% on the fifth week with reintroducing intensity training. I use variations on this system as well for shorter time away and different scenarios. Read my “Rowing Injuries: Understanding, Preventing, and Managing” article for more details on this system and additional notes on returning to training following injury.

References

• Casey, M-B., Wilson, F., Ng, L., et al. (2022). “There’s definitely something wrong but we just don’t know what it is”: A qualitative study exploring rowers’ understanding of low back pain. Journal of Science and Medicine in Sport, 25, 557-563.
• Caterisano, A., Decker, D., Snyder, B., et al. (2019). CSCCa and NSCA joint consensus guidelines for transition periods: safe return to training following inactivity. Strength and Conditioning Journal, 41, 1-23.
• Koes, B., van Tulder, M., & Thomas, S. (2006). Diagnosis and treatment of low back pain. BMJ, 332, 1430-1434.
• Maher, C., Underwood, M., & Buchbinder, R. (2016). Non-specific low back pain. Lancet, 389, 736-747.
• Wilson, F., Ackerman, K., Smoljanovic, T., et al. (2020). Return to full rowing training and avoiding risk of injury. World Rowing. https://d2wmdlq830ho5j.cloudfront.net/worldrowing/wp-content/uploads/2020/12/04181810/ReturntofullrowingtrainingandavoidanceofinjuryFINAL100620_Neutral.pdf
• Wilson, F., Gissane, C., Gormley, J., & Simms, C. (2010). A 12-month prospective cohort study of injury in international rowers. British Journal of Sports Medicine, 44, 207-214.
• Wilson, F., Gissane, C., & McGregor, A. (2014). Ergometer training volume and previous injury predict back pain in rowing; strategies for injury prevention and rehabilitation. British Journal of Sports Medicine, 0, 1-5.
• Wilson, F., Ng, L., O’Sullivan, K., et al. (2021). ‘You’re the best liar in the world’: a grounded theory study of rowing athletes’ experience of low back pain. British Journal of Sports Medicine, 55, 327-335.
• Wilson, F., Thornton, J., Wilkie, K., et al. (2021). 2021 consensus statement for preventing and managing low back pain in elite and subelite adult rowers. British Journal of Sports Medicine, 55, 893-899.

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