From The Eyes of a PT - Low Back

Low Back Pain and the Core

In the first of our three part series “From The Eyes of a PT” with Stephanie Romich we discussed some common issues that people pursuing an elite level of fitness can run in to from time to time, specifically with their knees.  Here, in the second installment, we will be discussing low back pain (with or without occasional radiating pain into the butt/down the leg). There is a complex system of support that the lumbar (lower) spine must rely upon to ensure we are protecting the longevity of our athletic careers and keeping our spines healthy.

Why do I have low back pain?

There are a multitude of issues which can lead to low back pain (LBP) and the can vary based on whether the pain is becoming chronic or is still fairly new and acute.  Acute LBP refers to something that has appeared within the last 1-3 days and in an active/athletic population might be most closely related to heavy lifting with movements such as a back squat or deadlift.  Usually acute LBP tends to be related to muscle injuries and can be a result of strained musculature or overstressing the muscles in a way with which they are unfamiliar.  Chronic back pain refers to a range of about 3+ weeks with ongoing and nagging lumbar pain, pain shooting down into the gluts or legs, or repeated occurrences of pain over the past few weeks/months/years.  While there is always a chance that the LBP could be a result of something structural like a herniated disc or degenerative disc disease, the cause doesn’t matter as much because we tend to treat the pain with a similar scope of practice.

One of the two biggest causes for LBP in an active/athletic/fitness driven population is poor lifting and exercise mechanics. Proper position and protection for the lumbar spine (L/S) is often an area that athletes have never truly thought about unless they have been coached.  As a physical therapist (PT), we tend to focus first on teaching the athlete how to find a neutral pelvic position and preventing anterior pelvic tilt (the “butt wink” in part 1) or a posterior pelvic tilt.  The most common compensation we see in the lifting athlete, and more so in the female demographic, is the anterior pelvic tilt.  The anterior pelvic tilt causes stress to the L/S in what is known as the “lower cross syndrome.”  This happens when the abdominals and gluts are weak and overstretched causing them to be inhibited or turned off and are overcompensated for by the iliopsoas (hip flexors), rectus femoris (quads), and thoracolumbar extensors (the muscles along the spine).  Which end up becoming very tight, shortened, and overactive.  All of these muscles must work properly in conjunction with each other to protect the back or else undue stress and strain is put on the spine and causes the normal curvature to be altered.  Acute LBP can be caused by stressing the L/S and the hip flexor, quad, and extensor musculature during heavy lifts or with high reps/sets with poor form.  Over time, continually repeating this stress and strain will cause a more permanent change in the spine and consistent or chronic pain. 

Neutral/Pelvic Tilt Standing

Neutral/Pelvic Tilt Squatting

 The second biggest issue we see with LBP is the inability to activate the core muscles properly in order to protect the L/S when lifting, even when the pelvis is in neutral alignment.  Most assume that the term “core” refers to one’s “six pack” but this is not accurate.  The core is comprised of a group of musculature that run from the base of the ribs to the top of the pelvis and around to the spine and sacrum (bottom of spine).  The core acts as the body’s natural girdle system in order to protect and safeguard the spine from undue stress.  There is some debate about all the musculature which is involved in the core but most PT’s would consider the layers of your abs (external obliques, internal obliques, rectus abdominis, and transverse abdominis), multifidus (the muscles which help hold the spine upright), hip flexors, gluts and spinal erectors to all be involved.  When any of these muscles is not properly activated, the muscles surrounding them will tend to overwork or shut down and cause an imbalance or weakness in the core.

The addition of radiating or shooting pain can usually be traced back to one of a few things – nerve impingement at the disc or lumbar vertebra level, or sciatic nerve entrapment below the spine level along the piriformis at the glut.  In the clinic, one of the most over self-diagnosed injuries we see is “sciatica” (pain radiating down the sciatic nerve of either leg) which most of the time is not truly the cause of the problem.  It is rarely only the sciatic nerve being trapped, but usually a nerve related irritation from the combo of the above listed issues involving poor posture, a weak core, and improper form causing stress on the L/S, discs, nerves and surrounding structures.

I have low back pain, now what?

Now let us address all the ways you can turn this pain around and become stronger in the process.  There are several exercises that help with LBP, and should be done together to have the greatest effect.  However, there is a process everyone should go through when evaluating how to deal with their low back pain.

• Your standing, sitting, sleeping, jumping, bending, twisting, and turning posture must all be considered for us to protect our backs properly.  Even finding a neutral spine and eliminating a pelvic tilt while working out means nothing if the athlete goes back to their desk and sits in a completely slumped and rounded posture all day.  These are lessons we must all be aware of throughout all the aspects of our lives, especially as we age. 

• If you strained your low back due to bad form or heavy loads the best first step is to REST.  Take time off, recover, and mobilize.  Continuing to strain the L/S with compound or other directly fatiguing movements will only continue to make the problem worse by compensating with the overactive musculature and further inhibiting the weak musculature. 

• The best place to begin is exercises that involve lying on your back and engaging the deep core musculature and pelvic floor while finding you pelvic neutral.  Learning to engage these together will be vital for protecting the spine. These exercises will mostly begin on your back with your knees bent to be able to feel the L/S flatten on the floor.  Then work on pulling the belly button to the spine (not sucking in) and engage the pelvic floor (the muscles you would use to hold in your pee).  You should be able to do this while still breathing normally and maintaining a neutral position with your rib cage.  If finding a neutral position is difficult on the floor it may be easier to utilize a wall (see standing video below).

 Laying Neutral Spine

Standing Neutral Spine

• Once the lying exercises are mastered, begin to move towards quadruped, standing, and finally to lifting progressions.  Performing crunches and sit-ups is not the solution.  It is very easy to perform them without properly engaging the core and keeping the L/S in neutral (rounding the spine). 

• Avoid using a weight belt.  Weight belts are primarily used and most effective for athletes who do not have the appropriate core strength to achieve a certain weight or lift.  When an athlete wears a belt, he/she is allowing an external force to perform the action the body should be performing and can cause the proper musculature to be inhibited and prevented from improving.  Weight belts are appropriate for protecting the spine when the core might fail at significant loads as a safety net for completing the movement properly. 

• Instead, back down the weight and start to rebuild the movement focusing on core engagement and proper mechanics.  The priority must be high reps with less weight and consistent core engagement with neutral spine before adding weight.  

• In the pain situations we have discussed above, mobility will always help with decreasing pain because it is decreasing the strain and pull on the spine.  As mentioned above, the paraspinals and hip flexors/quads tend to be a very common area of tightness, as well as hamstrings, piriformis, and calves. If muscle elasticity is maintained, it will be easier to achieve a neutral spine while engaging the core. 

• If you suspect sciatica, which is usually localized to the glut and not into the low back, then try performing trigger point release (see below) along the piriformis and incorporating a figure-4 stretch (see below) which should work miracles for relieving pain and irritation. If there is numbness and/or tingling in the butt, legs, or thighs that is not resolved with the trigger point release, it can also be caused by other issues that should be discussed directly with a medical professional.

Trigger Point Release

 

Figure 4 Stretch

Figure 4 Stretch w/ Knee Push