All About Back Pain Part 1

What’s the #1 reason people visit the family doc? The common cold.

What’s the #2 reason? Lower back pain.

80% of adults report lower back pain at some point in their lives and 10-15% of all sports-related injuries involve the spine. Low back pain accounts for more lost person hours than any other type of occupational injury and is the most frequent cause of activity limitation in those under age 45.

Thus, it’s important to understand what the spine is, what it does, and — most importantly — how we can keep it healthy.

What is the spine?

Along with opposable thumbs that we can use to work the TV remotes we invented, one of the things that distinguishes us from many other animals is our spine. The spine provides structural support for our bodies, protection for our central nerves, and facilitates locomotion (aka movement).

The spine is made up of 24 semi-rigid presacral vertebrae (seven cervical, twelve thoracic, five lumbar) separated by discs. Five sacral vertebrae fuse to make up the sacrum, which helps transfer upper body weight to the pelvis through the sacroiliac joint. The coccyx (tailbone) makes up the bottom of the vertebral column.

Intervertebral discs hold vertebrae together, act as shock absorbers, and allow dynamic spinal movement. These discs measure around one centimetre in height and consist of a gooey center (nucleus pulposus) surrounded by connective tissue (annulus fibrosis). (Think of an Oreo with the disc as the filling and the vertebrae as the hard cookies.)

Bony projections come together along your mid-back to form the spinous process, which you can feel and see.

Ligaments run along the spine and provide stability, helping the spine protect nerves extending from brain to body.

Spinal muscles and their roles

Several muscle groups attach to the spine or play a critical role in spinal health. Problems with these muscles can cause back pain. (For more on how this works, see the next section.)

1. Iliopsoas (psoas + iliacus) complex

These lie deep within the abdomen and hip, connecting the lumbar vertebrae and the iliac crest to the top of the femur. They’re major movers during bent knee leg raises and sit ups.

Aggravated with: Lots of sitting/driving, lots of kicking (martial arts or soccer), long bike rides in bent position, and sleeping in the fetal position.

2. Paraspinals

These are like the spine’s “suspenders” and help to control rotation, extension and bending. This group includes the erector spinae and multifidus along the spine.

Aggravated with: Sudden spinal overload, repetitive movement with poor technique, hunched posture, tight abdominal muscles, and lots of sitting.

3. Rectus abdominis

This sheet of muscle is your “washboard abs”. It runs between the lowest ribs and top of the pubic bone, and helps stabilize the torso. Excessive training of the rectus abdominis (at the expense of posterior chain muscles) can diminish the ability to carry weight overhead (think jerks, snatches, overhead presses) and lead to lower back injury. So: fewer crunches, more swings.

Aggravated with: Too many crunches (especially without posterior chain training), over-exercising, excess abdominal fat, reliance on weight training belts.

4. Gluteus group: maximus/medius/minimus

Aka the booty, these are the muscles that help bring your thigh behind you (think: donkey kicks), rotate it, and bring it to the side.

Aggravated with: Prolonged sitting, sleeping in fetal position with knees pulled up, sitting on your wallet, standing for long periods on one leg, sleeping on your back with feet splayed under the weight of a heavy blanket.

5. Piriformis

This small muscle lies deep within the glutes and connects the thigh to the pelvis near the sacrum. It rotates the thigh outward and swings the leg to the side when the thigh is flexed.

Aggravated with: Distance running (repetitive overuse in general), prolonged contraction (such as driving a car), sitting with one foot underneath you, walking with duck feet (toes out), sitting too much.

6. Quadratus lumborum

The “QL” lies deep in the side of the torso around the kidneys. It helps to bend, rotate, and straighten the torso from bent position. It also helps with exhalation (coughing, etc.), which many folks discover when they strain the QL and then live in fear of sneezing.

Aggravated with: Structural imbalances (one leg longer, uneven pelvis, etc.), habitual leaning to one side, slouching, always sleeping on one side.

7. Hamstrings

These big leg muscles run along the back of the thighs, attaching at the hip and the knee. They bend and stabilize the knee.

Aggravated with: Pressure from chairs, prolonged sitting, bed rest, overload (e.g. lots of sprints when a trainee isn’t used to sprinting).

8. Soleus

This deep calf muscle assists with walking, jumping, and pointing the toes. When irritated, pain can radiate to the sacrum.

Aggravated with: High heeled shoes, rigid/tight shoes, bedding that weighs down toes, standing still for extended periods, prolonged driving, sitting on chair that is too high (so the feet don’t touch the floor).

What can lead to spinal problems?

Usually, spinal problems are multifactorial. Predisposing factors include:

• Poor mobility in surrounding muscles
• Bad biomchanics
• Poor posture
• Weakness of supporting musculature
• Muscle imbalances
• Sedentary lifestyle, sitting, and immobility

Poor mobility in surrounding muscles

The pelvis is the foundation for the spine. Decreased mobility in the hips, hamstrings, ankles, and thoracic spine can lead to overcompensation at the lumbar spine and excessive pelvic tilt. This problem is particularly common in women — in part because of higher heels, but also because the connective tissues of an average woman’s spine are usually looser than the average man’s.

Bad biomechanics

Back pain only gets worse with poor biomechanics.

Most spine injuries that occur during training are muscle strains or ligament sprains, usually due to improper loading and technique. A common error is lumbar flexion during movements like good mornings, situps, deadlifts, and rows. Excessive lumbar extension is also dangerous and can lead to vertebral fracture (e.g., finishing a heavy deadlift).

The safest position for the lumbar spine is a neutral position — a natural but not exaggerated S-curve (double check the spine image at the top of this article for reference). You can find a neutral spine by flexing your lumbar spine, then extending it and trying to find the midpoint between the two, or by standing tall and taking a deep breath. Use a mirror to check.

It’s important to get good at the movements you regularly do. If you’re always lunging and twisting for martial arts or your plumbing job, get good at lunging and twisting. Don’t just go home at night and do situps hoping to preserve your back.

Poor posture

If your posture sucks, your back sucks.

Poor posture means higher levels of shear stress on the spine. When posture is appropriate (proud chest, natural lumbar curve, tight core, retracted shoulder blades, etc.) – then we’re able to handle higher amounts of compressive force. Oh, a big gut and high heeled shoes can negatively influence posture. Try to avoid one or both as much as possible.

Weakness

Many people assume that strong abs help them bend and twist. This is true, in part, but most often the core’s role is stability rather than movement — in other words, preventing motion rather than initiating it. Too much flexion or extension at the lumbar spine, usually caused by weak core muscles, can lead to injury. It’s also biomechanically weaker. You can throw a lot farther or punch a lot harder when your hips and shoulders are involved than when you’re just twisting at the waist.

Reliance on weight lifting belts can lead to torso stiffness and weakness.

Imbalances

Folks with chronic back pain often neglect the posterior chain (i.e. the muscles that run along the rear of the body from neck to ankles). This is especially true for gym rats who do too much bench pressing and not enough pulling or hip extension. This keeps back problems in full force (plus said gym rats end up looking like light bulbs).

Single leg exercises help develop the lower body and immediately challenge the lower back and hips, building stability and function. We tend to be weak and imbalanced on extension movements because we do them less.

Not moving

Doctors used to recommend bed rest for back pain. Now they usually recommend movement. And, as you can see from the list of muscle problems above, “too much sitting” factors into a host of back problems.

When we sit or lie around all day, intervertebral discs absorb fluid and become tighter, allowing less range of motion and promoting injury. Introduce yourself to regular movement (warm ups, yoga, and dynamic joint mobility, along with walking and swimming). These all help to preserve spinal health. See here:

Foam Rolling Warmup

Other common problems

“Spondylo”s

A collection of spinal dysfunctions known as the “spondys” can result from spinal fracture, overtraining, and/or over-extension/twisting of the spine. They’re common, for instance, in gymnasts and yogis who repeatedly bend backwards. They can also occur acutely in high-impact sports such as rugby.

• Spondylitis is an inflammation of the vertebrae.
• Spondylosis is osteoarthritic narrowing of the vertebral space.
• Spondylolysis is a fracture, usually a stress fracture, of the pars interarticularis. It can lead to a spondylolisthesis.
• Spondylolisthesis, which can occur after a spondylolysis, is the forward slippage of one vertebrae on another. Think of a stack of books in which one book is pushed forward.

Excessive flexion, extension and rotation are bad news for anyone with spondylo-situations. Work on building mobility of the hip flexors, hamstrings and ITB.

Prolapsed disc

This occurs when intervertebral disc material bulges from its normal confines. Minor tears to the outside of discs can lead to inner disc leakage.

The key is to never let the problem start. Translation: build core stability.

In part 2 of this series we'll cover how we approach treatment and why it's important to follow a certain protocol in order to achieve maximum results.  

 Dr. Bryan Dingsor is the owner of Watertown Chiropractic P.C. in Watertown, SD. He specializes in the treatment of many musculoskeletal conditions and weight loss. For an appointment, please call 605-882-2304 Today.