The low back pain problem
Your back pain has been hanging around for what seems like forever. You’ve been to multiple doctors, tried chiropractic, and have finally broken down and consulted an orthopedic surgeon. He ordered an MRI, but the MRI showed nothing more than mild stenosis (narrowing of the spinal canal) and “mild degeneration” (or wear and tear.) He informed you that these findings are essentially ones any of us can expect over the age of about 35. None of this explains your pain. The surgeon is at a loss. He can’t explain your pain, and says surgery will not fix it.
How is this possible? Is it all in your head?
No, the pain is not in your head, and this situation is more common than you might think.
The answer to recovering from low back pain
The answer to why you hurt may lie beyond the MRI’s view of bones and joints. It lies in the way your body functions– the way you move every day. The secret to function is in movement and in many cases, the muscle connections made by fascia.
What is fascia?
Fascia is the web of connective tissue that encases our organs and muscles, and is found throughout the body. The continuous web of fascia winds around the body, linking muscles on the left and right sides from head to toe, and toe to head. Fascia is full of nerves, and together with the muscles, have a large role in both facilitating and restricting movement. The fascial connections among muscles is important in understanding your pain, because pain may not be where the problem is. Many times, pain shows up where the body is compensating for a movement that is restricted somewhere else.
What is compensation?
By and large, we humans develop “perfect”, efficient movement as infants. Our growing bodies and brains learn how to roll-over, sit-up, crawl and eventually walk. These “programs” are practiced, perfected and stored in our nervous systems, muscles and fascia, giving us movement and postural tendencies that are unique to us. As children, we don’t have to stop and think about how to pick-up a toy off the floor without hurting our backs; we execute a perfect squat to retrieve the toy. (Watch any toddler at play, and you’ll see what I mean.)
But as we age, we narrow the scope of the movements performed in a typical day. Some movements are practiced less (perfect squats,) and some are done more (sitting and standing from chairs.) Attempts to keep us out of pain alter the pristine movement patterns we had from childhood. Sitting at desks, first in school, then at work, begins to replace sitting and standing from the floor, and over time, the muscles and fascia adapt. Some movements become restricted, others become overly loose, causing instability. In addition, we may accumulate some injuries along the way: a sprained ankle while playing basketball, a tweaked knee from skiing, and over time the body continues to adapt and change how it moves to avoid pain. It practices new strategies to achieve the same goal with less discomfort.
For example, instead of squatting to pick-up a toy off the floor, our stiff knees and weakened legs may tell us to bend over with straight knees to retrieve the toy. This is compensation. When a once-normal movement pattern causes pain or discomfort, the brain and body find another way to perform that movement to avoid the pain. If the movement is one you perform often, the body “practices” this new strategy over and over, until it replaces the older, painful strategy. As you can imagine, bending over with straight knees to retrieve an object from the floor will likely lead to back pain over time, driving more compensation down the road.
When compensation causes trouble
The notion of compensation doesn’t sound so bad at first—after all, the body is avoiding pain. But over time, most compensations create more trouble by causing the muscles on one side of a joint to chronically shorten, or over-work, while muscles on the other side of the joint become weakened or shut-down entirely. That imbalance can drive more pain and discomfort elsewhere, and even cause injury over time. A common example of this is the role of tight hip flexors (front hip muscles) and/ or quadriceps (front thigh muscles) in low back pain.
Consider the story of Emily Runner:
Emily was once an avid runner. She would get up early and run every morning before going into the office. After a shower and some coffee, she would drive to the office (about a 20-minute commute by car.) From there she would be in and out of meetings or at her desk most of the day. After work, she would drive the 20 minutes home, then collapse on the couch to watch a little TV before eating dinner, finally making her way toward bed so she could do it all again the next day.
Over time, as this routine set in, her quads and hip flexors began to shorten from all that sitting. (The daily runs were great for her cardiovascular health, but the 30-60 minutes a day of great exercise just wasn’t enough to counter the hours of sitting.)
The shortened muscles in the front of the hips and thighs caused the muscles of the buttocks (glutes) to become weakened or shut-down. Since the glutes are the muscles meant to hold us upright, as well as push us forward when walking or running, the body had to find another strategy.
With her glutes offline, Emily would notice fatigue and tightness in her lower back when walking or standing for long periods, as her back worked hard to keep her upright against the pull of the tight hip flexors.
She would also suffered from periodic hamstring strains and calf strains when running, as the hamstrings and calves were over-working to compensate for the weakened glutes.
None of these compensations showed-up on MRI, but Emily’s pain was very real.
There is hope for low back pain recovery!
If the Emily Runner scenario sounds familiar, please know that there is hope.
#1 – The first thing is to know that your lack of MRI results is a good thing: it means your problem is not a full-blown spinal injury—at least, not yet. That could change if you don’t take action soon.
#2 – The second thing to know is that you can learn to move well again (or your body can, to be exact.) The goal is to restore the balance of the muscles around the joints, lengthening and strengthening those that are short and dominant, activating and strengthening those that are weakened or inhibited. Over time, we can improve your body’s movement strategies or “programs,” and help you restore efficient, pain-free movement.
What if you do have significant findings on your MRI?
Do you already have a diagnosis by MRI? Spinal stenosis, bulging or herniated disc, or even spondylolisthesis (forward slip of a vertebra?) It’s not too late. As long as you no longer require medical attention (check with your doctor on this,) the right medical exercise intervention can help you continue to resolve the muscle imbalances that originally caused you pain. Even though you now have a structural injury, it was likely caused by a muscle imbalance like the one described above.
Not everyone with back pain is ready for exercise intervention. If you are unsure about whether an exercise solution is right for you, please consult a medical professional. You may need treatment by a physical therapist before beginning medical exercise.
Exercise to re-program the body
Back pain with no clear diagnosis can be a frustrating journey, but you don’t have to go it alone. Identifying which movement patterns cause pain will help us understand the compensations your body has been using to get by. Once we pinpoint the compensations, we can use exercise to re-train and re-program the body to move more efficiently and without pain. As you go through this journey, you will learn how to recognize movements and activities which could cause a re-lapse, as well as what to do when your pain flares-up.
With professional medical exercise, you can take back your body and enjoy an active lifestyle once again.
Please remember that this article does not take the place of medical advice, nor does it attempt to diagnose your condition. It does, however, mean to provide insight into a common cause of low back pain that is “difficult” to diagnose by imaging techniques such as MRI and X-ray. As always, please consult with your physician before starting any exercise program.