Marc Darrow MD,JD

In the patients we see and the people who contact our office for low back pain, the ones who happen to be surfers, tell us about their concerns that a suggested back surgery recommendation will keep them from surfing.  The reason to have the back surgery these surfers are told is because “everything else” has not worked. Everything else being rest, ice, anti-inflammatories, back braces, exercises, physical therapy, yoga, perhaps cortisone injections. They are in our office because “everything else” may not have included other injections including stem cells or platelets. Which I will explain these injections below.

The surfer’s back pain

When you explained to your doctor that you are a surfer and then you described the motion required of surfing beyond balancing on the board, the paddling, swimming, pop-up, etc,  your doctor may have focused on the aspect of paddling or the prone pop up as being particularly stressful on your lower spine. Paddling would be suspected as a back stressor if you also had shoulder pain or  surfer’s shoulder. A doctor more experienced in dealing with surfers may also question you about your technique, specifically the pop up. Very few surfers want tips from their doctors on a pop up although medical papers have recommended the knee pop-up to help alleviate back pain problems. One such paper in the North American journal of sports physical therapy (1) offered this recommendation:

“Clinicians with patients who are surfers with intermittent low back pain can recommend the knee pop-up to prevent re-injury or exacerbation of symptoms. When patients with existing symptoms insist on surfing in spite of their back pain, the knee pop-up is an alternative to consider that might make surfing more tolerable.”

The back is compensating for other areas of the body and other areas of the body are compensating for the back

If it were as easy as a knee pop up, a lot of surfers would be healing. The problem is, as some of you well know, your back pain and weakness is usually not the only issue you are having. You may be having a lot of issues.

What hurts the New Zealand surfers?

A 2020 study in the Journal of science and medicine in sport (1) examined gradual-onset injuries associated with surfing including duration, mechanisms, body locations and types of gradual-onset injuries. This study included 1473 New Zealand surfers.

The surfers reported a total of 550 gradual-onset major injuries:

  • 44% acute duration (less than 3 months) and 56% chronic ( more than 3 months).
  • Shoulder (146 injuries, 64% chronic)
  • Low back (115 injuries, 58% chronic) and
  • Neck (105 injuries, 46% chronic) were the most commonly reported injury locations.
  • Prolonged paddling was the most commonly reported mechanism of injury (40% of all injuries).
  • Better surfers had a slightly more probability of developing chronic pains than surfers with lower ability and
  • 13% higher for long boarders compared to short boarders.

As you can see the percentages show that surfers had more than one ailment to deal with. When a surfer or patient has multiple areas of concern, there is usually a compensatory factor involved. If it is your back that hurts and causing spasm, your hips, pelvic, groin, knee , ankle and foot may be involved as they are trying to take some of the load from the low back and help with pain and function. If you have a neck issue, your spine may compensating for this neck pain all the way down to your pelvis. If your back pain has gone on long enough, your gait may be off and now you have a back pain that caused a knee problem and a knee problem that is returning the favor and making your back pain worse.

Physical therapy did not help back pain

I am not sure if I know more discouraged patients than an athletes who have not progressed with their physical therapy. Surfers are very fit athletes. They are not used to failure when it comes to “building the core.” Yet here they are in our office in constant spasm in their lower and mid back and a radiating dull pain that wraps around them to their abs. In a confused voice some may say, “I do not know why the physical therapy did not work, my other doctor is telling me that that is a sign that surgery is the only way for me now.”

It has probably been a long way for some of these surfers from the early onset of chronic, nagging low back pain to surgical recommendation. Along the way they have probably tried many different exercises to strengthen the muscles needed for paddling and while these exercises may have helped initially with pain and spasm, they are not helping now. But is it the muscles?

One of the means to help prevent surfer injuries from worsening is to focus on the break down of ligaments and tendons. Ligaments and tendons are subjects that may have not been discussed with you at length in your back pain treatments. Ligaments are the strong connective “rubber band-like” tissue that stabilizes the spine and hold the lumbar vertebrae in their proper position. The tendons are the muscle attachment to the bones. Often a surfer will complain about a loss of their core strength. They believe this to be a problem with the muscle. In many cases this may not be a muscle problem but a ligament problem stressing the muscle tendon.

Physical therapy works by strengthening muscle and retraining muscles to be more effective. To do this physical therapy requires the muscle to get stronger through resistance training. If the tendon attachment to the bone is weak and stretched out, the necessary resistance will be very difficult to achieve. Our treatments are help to strengthen this attachment and are explained below.

Is it the discs or the ligaments causing the surfer’s back pain?

The person with low back pain, whether a surfer or a day laborer, will have an MRI and a recent medical history that will talk about discs and the millimeters that these discs are bulging or herniated. When we discuss realistic options to avoiding a disc surgery, this person may get puzzled because I am not focusing, in many cases, on the amount of bulge. Some people will need a surgery if they have a significant and severe herniation. Some people who think they have a significant and severe herniation may not.

In my many books and for years on my radio show I have told readers and listeners that some people will have an MRI that will show a “massive” herniated disc and yet the person has no back pain.

So when is it a disc problem that needs surgery and when is it a spinal ligament weakness problem that does not need surgery?

Doctors at the Mayo Clinic (2have published a paper entitled: Comparative role of disc degeneration and ligament failure on functional mechanics of the lumbar spine. In this paper the Mayo Clinic researchers wanted to make a clear definition between two problems affecting low back pain patients.

  • First, that pain could be coming from the discs.
  • Second that pain could be coming from the spinal ligaments.

The Mayo researchers suggest that recognizing how the spine moves is essential for distinguishing between the many different types of spinal disorders, and a diagnosis which may ultimately, and erroneously lead to back surgery.

  • If a patient has instability, excessive movement, and decreased stiffness, doctors should examine for ligament damage.
  • If the opposite, less movement, more stiffness, the doctor should look for disc disease.

Stem cell injections for low back pain

In our practice, Stem Cell Therapy is a treatment for musculoskeletal disorders. We treat degenerative joint disease, degenerative disc disease of the spine, and tendon and ligament injury. We offer stem cells drawn from patient’s own bone marrow. Stem cells are “de-differentiated pluripotent” cells, which means that they continue to divide to create more stem cells; these eventually “morph” into the tissue needing repair — for our purposes, collagen to help make ligaments and tendons, bone, and cartilage.

Because these surgical procedures and MRIs deal with the problems of the spine as being disc related, there is an assumption that our regenerative non-surgical injections of Platelet Rich Plasma and stem cells are injected directly into the disc. This is not how our treatment works. Our treatment works by regenerating and repairing the damaged supportive tissue of the spine; the ligaments and the tendons at the enthesis (bone attachment). The enthesis is the special connective tissue that attaches the ligaments and tendons to the bones. When these supportive tissues are rebuilt, the spine can heal the pain and help restore by slowly pulling that vertebrae back into alignment and with it, the herniated bulging disc.

Research in the medical journal Stem cells translational medicine (3) suggests that stem cells, without direct injection to the site of disc lesions in the spine, can repair disc lesions by changing the healing environment of the spine.

Highlights of this research:

  • Stem cells are effective in inhibiting disc degeneration and disc herniation by way of the complex interplay between themselves and immune system cells in achieving successful disc tissue regeneration. The stem cells regenerated the outer tissue of the disc and contained and lessened the bulge.
  • Remarkably, stem cells were able to bring more oxygen to the damaged disc and accelerate healing by reversing the low-oxygen (degenerative or dying) environment in the spine. Everything heals with more oxygen.
  • Stem cells were able to reduce or prevent herniation by suppressing the non-healing inflammation.

PRP for Back Pain

PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration. PRP puts specific components in the blood to work. Blood is made up of four main components; plasma, red blood cells, white blood cells, and platelets. Each part plays a role in keeping your body functioning properly. Platelets act as wound and injury healers. They are first on the scene at an injury, clotting to stop any bleeding and immediately helping to regenerate new tissue in the wounded area.

Research has shown Platelet-Rich Plasma Therapy (PRP) to be effective in treating degenerative disc disease by addressing the problems of spinal ligament instability and stimulating the regeneration of the discs indirectly (discs were not injected directly but showed an increase in disc height).

The same research cites that as in any medicine, the sooner the degeneration is addressed, the better the results in patient satisfaction. PRP is no exception. “The administration of PRP has a protective effect on damaged discs in the acute and delayed injection settings representing clinical treatment with PRP in the early versus late stages of the degenerative process. It appears that earlier intervention in the disease process would be more beneficial than PRP treatment of already severely degenerated discs.”(4)

In our research, Treatment of Chronic Low Back Pain with Platelet-Rich Plasma Injections, published in the journal Cogent Medicine (5) we wrote:

  • Platelet-Rich Plasma (PRP) is a non-invasive modality that has been used to treat musculoskeletal conditions for the past two decades. Based on our research, there were no publications that studied the effect of PRP on unresolved lower back pain. The aim of this study was to report the clinical outcomes of patients who received PRP injections to treat unresolved lower back pain.


  • 67 patients underwent a series one, two, or three PRP injections into the ligaments, muscle, and fascia surrounding the lumbar spine.
  • Patients who received two treatments received injections a mean 24 days apart and patients who received three treatments received injections a mean 20.50 days apart.
  • Baseline and posttreatment outcomes of resting pain, active pain, lower functionality scale, and overall improvement percentage were compared to baseline and between groups.


  • Patients who received one PRP injection reported 36.33% overall improvement and experienced significant improvements in active pain relief.
  • These same patients experienced improvements in resting pain and functionality score, yet these results were not statistically significant. Patients who received a series of two and three treatments experienced significant decreases in resting pain and active pain and reported 46.17% and 54.91% total overall improvement respectively. In addition, they were able to perform daily activities with less difficulty than prior to treatment.

You can read more about this paper and link to the study here: Darrow research study PRP back pain

Do you have questions? Ask Dr. Darrow


A leading provider of stem cell therapy, platelet rich plasma and prolotherapy

PHONE: (800) 300-9300 or 310-231-7000

Stem cell and PRP injections for musculoskeletal conditions are not FDA approved. We do not treat disease. We do not offer IV treatments. There are no guarantees that this treatment will help you. Prior to our treatment, seek advice from your medical physician. Neither Dr. Darrow, nor any associate, offer medical advice from this transmission. This information is offered for educational purposes only. The transmission of this information does not create a physician-patient relationship between you and Dr. Darrow or any associate. We do not guarantee the accuracy, completeness, usefulness or adequacy of any resource, information, product, or process available from this transmission. We cannot be responsible for the receipt of your email since spam filters and servers often block their receipt. If you have a medical issue, please call our office. If you have a medical emergency, please call 911.

Article citations:

1 Hammer RL, Loubert PV. Alternative pop-up for surfers with low back pain. N Am J Sports Phys Ther. 2010 Feb;5(1):15-8. PMID: 21509154; PMCID: PMC2953347.
2 Remnant D, Moran RW, Furness J, Climstein M, Hing WA, Bacon CJ. Gradual-onset surfing-related injuries in New Zealand: A cross-sectional study. Journal of science and medicine in sport. 2020 Nov 1;23(11):1049-54.
3 Cunha C, Almeida CR, Almeida MI, Silva AM, Molinos M, Lamas S, Pereira CL, Teixeira GQ, Monteiro AT, Santos SG, Gonçalves RM. Systemic delivery of bone marrow mesenchymal stem cells for in situ intervertebral disc regeneration. Stem cells translational medicine. 2017 Mar;6(3):1029-39.
4 Gullung GB, Woodall JW, Tucci MA, James J, Black DA, McGuire RA. Platelet-rich plasma effects on degenerative disc disease: analysis of histology and imaging in an animal model. Evidence-based spine-care journal. 2011 Nov;2(4):13.
5 Darrow M, Shaw B, Nicholas S, Li X, Boeger G. Treatment of unresolved lower back pain with platelet-rich plasma injections. Cogent Medicine. 2019 Jan 1;6(1):1581449.


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