I have a client who had been suffering with back pain for 30 years. It had affected his quality of life considerably. He spent his weekends lying on the couch just trying to escape the pain, and dreading the return to work on Monday. When he came to me I asked him to put his finger on the point of pain. Unsurprisingly he pointed to the attachment point of the glute medius, which is just below the crest of your hip, about half way between the spine and the outer part of your hip. This is incredibly common, but it is not actually your back – this is one of your glute (butt) muscles – however it is typically confused with lower back pain.
I released the muscle and it relieved his pain in about 10 minutes. That weekend was the first he had spent in a very long time at the beach, and not on the couch. However, the relief came with a caveat – the pain would return as long as the cause remained.
His back pain was for the same reason most people experience back pain (and I’ll throw sciatica in here as well), so it is a relatively easy fix, as most back pain is. Which begs the question, why are so many people experiencing chronic back pain when it is so unnecessary? Well, here’s your answer.
The pattern that back pain sufferers follow is fairly common. They have suffered an event (not an emergency – that is a different ball game) or their pain has accumulated to the point they want to do something about it. So:
- They may go to their doctor who, due to time pressures, will have to make assumptions about what the problem is and a) prescribe an anti-inflammatory or even pain killers, with advice to sit it out. Or b) refer the patient for x-rays or (less likely) an MRI, which will draw no meaningful conclusions, or even misleading conclusions (surprisingly common). This becomes the non specific diagnosis we know as ‘idiopathic’ – an outcome that can consign a sufferer to years of non-resolution.
- So they go to a physiotherapist, but with mixed results, and possibly after many expensive visits, they decide to try something else.
- They may go to a chiropractor. They may get some relief after each visit, but it doesn’t ‘stick’ and so they don’t see the value in continuing, unsurprisingly.
- Maybe they will try the osteopath, and maybe get relief, or maybe not, with the pain returning sooner or later.
- Then there is the massage therapist. Well that felt better all the way home, but then back to the start again.
- By now they are looking for ‘the guy’, the dispenser of miracles, but after trying one or two of them they are no better off, poorer, or in hospital.
- They suffer for an extended period of time, believing that it is either a miracle that will save them, or possibly back surgery – which truly frightens them (and is almost always unnecessary).
This pattern is so very typical, unfortunately. People are lost and confused in an environment of resources that can actually help them reasonably quickly and permanently. So why isn’t it working for them? The pattern describes both the problem and the solution. But first we need to understand the principle causes of back pain.
I don’t want to seem reductionist or to be over simplifying things, but at the same time I want to address the chronic over thinking that can cloud this subject too. Having resolved chronic back pain for many long-term sufferers I dare say I’ve got a handle on this. So please allow me to humour you with my ideas.
Pain in your back can stem from the spine itself. This will most likely be due to a damaged disc pressing on the spinal nerves. However, the most common back pain, by far, is in the musculature of the back. And the two are closely related, with a common cause.
It comes down to this: our sedentary lifestyle conflicts with the design and function of the human body. The human body evolved on its feet, not on its backside, so a whole lot of things go wrong when we sit for extended periods of time. (And this does include people who do physical work because when they’re not doing that, they are sitting.) So I’ll list them:
- When we sit the body is aligned very differently to when we are upright and moving. Sitting causes muscles to change their natural length. Some muscles are relaxed and shortened when we sit, for example our hip flexors, and over time they get bound into the shortened position by collagen fibres (fascia). This means that when we return to the upright position those shortened muscles will be pulled tight as we try to achieve our correct posture.
Using the example of hip flexors, these are muscles that are attached directly to the lumbar vertebrae (the vertebrae of your lower back), and when these muscles are shortened and tightened in the process I just described, they will pull down on the lower spine and compress the associated discs. This will lead to tension and possibly pain in that area when we stand, and set us up for disc damage. This is just a simple example, but the reality is that when we sit this process is affecting multiple muscles, so when you consider the collective effect of this process you can see the origins of a problem.
Muscles becoming short and tight conspire to form what is called a ‘muscle imbalance’. The net effect of this is that when standing and moving our bodies are pulled out of alignment. This is generally invisible to an untrained eye, and is not something that can be detected by any form of imaging technology. This last point is crucial – the most used resources for diagnosis in modern medicine cannot detect the most likely contributor of back pain – muscle imbalance.
- Sitting also causes some muscles to ‘turn off’ as part of the natural process of muscle atrophication (the old use it or lose it routine). These deactivated muscles receive a reduced signal from your nervous system, much the same way as when a light is dimmed in your house. This will diminish the connectivity between your brain and the underused muscles as nerve cells atrophy. The inactive, deactivated and now atrophying muscles are further weakened as cells and mitochondria are shed, and the blood supply for the delivery of oxygen and nutrients is reduced.
So when you add the muscle imbalance with the deactivation of muscles you get a picture of a body that is pulled out of shape and unstable, which collectively adds up to compromised physical function. This is a set up for injury and painful muscle spasms.
- The most important muscles that turn off (deactivate) are our core muscles. These muscles are critical to good posture, and significantly, our dynamic posture. In turn, good dynamic posture is the very basis of good function. So, if your core muscles are inactive (along with other muscles in the system) it is going to throw out the ability of your body to function properly.
This means that any load you are attempting to shift (shopping, baby, football, toolbox etc.) will put force into a dysfunctional system and sooner or later something has to give. Maybe a disc, but more commonly a muscle will spasm – and this is the proverbial mother of pain.
The human skeleton has evolved to give structure to the body. It gives structure to our musculature so that we can do the things we need to do in order to survive – and historically that meant a life of hunting and gathering. Importantly, the work the body was designed for was meant to be accomplished by the muscles of the body, not the skeleton. The bottom line is that the human skeleton is not meant to take up load – this is the job of the muscles. But – and this is a big but – because our core is inactive the load is shifted into the skeleton, and most notably into our spine.
This will overload the discs and the stress of this can damage them to varying degrees. Notably, when a disc is damaged the muscles around it will spasm as a natural response in order to protect the affected disc. Generally, this spasm can be a greater source of pain than the disc damage itself.
As a note: damaged discs generally take less than six months to heal, even with significant damage. Was does not ‘heal’ is the muscle spasm that occurred at the time of the damage. That spasm – and associated pain – can last for decades.
So when you add all this up you get this picture: an unbalanced muscle system involving muscles that are short and tight with opposing muscles that are pulled long and tight. A set of muscles that are inactive or under active and atrophied. A posture and dynamic posture that is pulled out of alignment. Core muscles that are inactive and allowing load to press into the spine. Musculature that is allowing load into the skeleton, notably into the hips and knees, overloading those joints too. A general state of instability throughout the body due to inactive and under active muscles, which is prone to triggering spasms. Okay, with this kind of picture how can you not expect a problem sooner or later?
And this is the condition of the general population – the only variable is whether it has become severe enough to cause pain.
There is another significant component that needs to be factored in. Without addressing this, back pain cannot be resolved. Imagine for a moment the human skeleton. Then imagine that you could move the pelvis in any direction – rotate it, lift it on one side – or both – you can see how the whole skeleton is affected by this shift in the pelvis, and notably the spine. The reality is that almost everyone – and I’m suggesting 99% of the Western population – has a pelvis that is misaligned. This is due to process I have described – muscle imbalance, instability, and physical dysfunction especially when the body is loaded in some way – and notably poor sitting habits.
To some extent it is something of the chicken or the egg story. Did the pelvis go out first, or did the muscle imbalance pull the pelvis out? Likely it is a combination of the two, with incremental steps shifting the cause from one to the other and back again.
So what is the complete picture we have now? A misaligned pelvis that is creating a misalignment through the whole skeleton. A musculature that is unbalanced and by degrees tight, weak and unstable. A misaligned dysfunctional system that is just waiting for an opportunity to freak out and cause considerable pain.
Getting back to my original point about the close relationship between the causes of disc damage and muscle spasms, you can now see the close relationship in cause – misalignment, unbalanced musculature and weakness in the system will manifest as disc damage or muscle spasm, and usually both, as the muscles around the damaged disc go into spasm to protect it.
Okay, in my next posts I will discuss:
how to resolve back pain efficiently
explain why so many people are suffering unnecessarily and what we can do about it
how to sit so that back pain is mitigated, and corrective exercise for people who have to sit a lot