The Truth about Lower Back Pain

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In the last 3 months, the CDC reported that 25% of Americans are dealing with lower back pain (LBP). Furthermore, research tells us that 80% of people will deal with lower back pain at some point in their life. (LBP) is one of the leading causes of missed work in the United States, and one half of working Americans will report having back pain at some point each year. So, the question to ask is what can we do about this? If (LBP) is such a monumental issue, why doesn’t society work harder to solve the problem? Perhaps the fix is already known.

Some people associate exercise with a high risk for injury. Specifically, there are many who believe that exercise poses a moderate threat to spine health. While exercise is not hazard free and accidents do happen, research shows us that exercise, and specifically resistance training, can be an effective method for actively improving lower back health and preventing future (LBP). Let’s take a look at some of the anatomy behind what can cause harm within exercise and how we can train our body to be more resilient and better prepared to handle the demands of life on our back.

Our lumbar spine has a natural curve to it. Every person has a different degree to which we curve in the spine, and those anatomical differences between everyone will mean that there is no one-size-fits-all approach to approaching (LBP). When we move, whether that be walking, jumping, running, squatting, or lifting something from the floor, we produce a variety of forces on the spine. The good news is that our spine is designed to absorb some of these forces. The bad news is that the spine is not well prepared to deal with other forces. Before I go any further, allow me to give you framework for what these forces are:

Compression – Forces that push from opposite directions towards each other (think hammering a nail) – Our back is good at dealing with this type of force

Torsion – Forces that twist or corkscrew – We are somewhat well prepared for these forces.

Tensile – Forces that pull apart – fortunately, we do not usually experience these forces often in exercise – We are decent at dealing with these unless there is also shear or torsion paired with it.

Shear – Forces that displace such as a horizontal force while undergoing compression (what most commonly breaks bones in the body) – We are very poorly equipped for these forces.

Now that we have those forces defined, we can look at how they can keep us safe while exercising or resistance training. Most back injuries occur when a combination of compression and shear, or tensile and shear act on the spine in an amount greater than we are able to stabilize. This is where things like endplate fractures on the vertebrae or herniated discs can occur. So, how can we prevent shear force from occurring? Unfortunately, we do not have much choice over when shear force occurs or not. The forces act on our body based on how our body is designed. What we can do, however, is improve our body’s strength to combat shear force so that we avoid injury. This is done through improving our core strength. Now, I do not just mean training our abdominal muscles, while they do play a role. By training all the muscles that help stabilize our skeleton (deep extensors and flexors, as well as transverse abdominus, internal obliques, etc.) you can help lock the spine in place, so it does not become overwhelmed by the forces at play. This is why you have probably heard coaches say to “brace your core”, or “squeeze your abs and glutes”. They are trying to queue you to protect your spine.

Let’s take a brief pause from bracing and proper engagement to prevent injury and chat a little bit about pain. It is estimated that, of all cases related to (LBP), only between 2-5% are associated with a disc herniation. It is rare to have a major back injury from lifting weights or exercising. You are far more likely to get a muscle spasm, which can be treated with relative ease, than have a major issue. One area that plays a large role is our belief or fear of pain in the low back. Those who have low back pain and fear going into motions that may cause those symptoms to flare up were reported to have more restrictions in range of motion. This is an issue because a lack of range of motion can be a primary cause of lower back pain.

Research shows that our lumbar spine (lower back) has the potential for injury in both flexion and a neutral spine position. So, regardless of how we position our body from a spinal organization stand point, we do run the risk of a back injury. However, in these studies the spine is always manipulated with the exclusion of activated muscles to help manage the forces. While the research generally suggests that a neutral spine will be less likely to result in injury, the most important factor in preventing injury is proper bracing of the core prior to each movement. If we organize our body to be stable, it is capable of incredible things.

We put our backs through a lot each day. Sitting down for drives, picking something up from the floor, carrying a bag, going up stairs, etc. The reason we train our bodies in the gym is so that we don’t slip into injury outside of the gym. If you would like to know more about how to brace your core properly, or how to move in a safe efficient way throughout each day, be sure to ask us! It is what we are here for!

Sources:

  • https://www.acatoday.org/Patients/What-is-Chiropractic/Back-Pain-Facts-and-Statistics
  • Callaghan JP, McGill SM. Intervertebral disc herniation: studies on a porcine model exposed to highly repetitive flexion/extension motion with compressive force. Clin Biomech (Bristol, Avon). 2001 Jan;16(1):28-37. doi: 10.1016/s0268-0033(00)00063-2. PMID: 11114441.
  • http://www.greglehman.ca/blog/2016/01/31/revisiting-the-spinal-flexion-debate-prepare-for-doubt
  • Gunning JL, Callaghan JP, McGill SM. Spinal posture and prior loading history modulate compressive strength and type of failure in the spine: a biomechanical study using a porcine cervical spine model. Clin Biomech (Bristol, Avon). 2001 Jul;16(6):471-80. doi: 10.1016/s0268-0033(01)00032-8. PMID: 11427289.
  • https://www.strongerbyscience.com/lumbar-flexion/
  • Thomas, J. S., & France, C. R. (2008). The relationship between pain-related fear and lumbar flexion during natural recovery from low back pain. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 17(1), 97–103. https://doi.org/10.1007/s00586-007-0532-6
  • Steffens D, Maher CG, Pereira LSM, et al. Prevention of Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med.2016;176(2):199–208. doi:10.1001/jamainternmed.2015.7431
  • Veres SP, Robertson PA, Broom ND. ISSLS prize winner: how loading rate influences disc failure mechanics: a microstructural assessment of internal disruption. Spine (Phila Pa 1976). 2010 Oct 1;35(21):1897-908. doi: 10.1097/BRS.0b013e3181d9b69e. PMID: 20838275.
  • Wade KR, Robertson PA, Thambyah A, Broom ND. How healthy discs herniate: a biomechanical and microstructural study investigating the combined effects of compression rate and flexion. Spine (Phila Pa 1976). 2014 Jun 1;39(13):1018-28. doi: 10.1097/BRS.0000000000000262. PMID: 24503692.

The Effect of Hip Strength on Ankle and Knee Health

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Ankles and knees account for two of the most common locations for injury to occur in the human body. While there may be a variety of reasons for each of these injuries, let’s look at how we can recover from injury as well as prevent injury altogether.

Ankle sprains account for the most common injury amongst athletes. On top of that, the likelihood of additional sprains goes up significantly for those with a history of ankle injuries. Many people develop what is referred to as a chronic ankle sprain. This refers to severe instability in the ankle, and chronic pain throughout the joint. Research has evaluated groups with chronic and acute ankle sprains to determine common characteristics within the body. The hope is to determine potential causes and effective treatment and prevention protocol. In these studies, one common thread shows that people with acute or chronic ankle sprains have either significant weakness, or motor control dysfunction in their hip abductors, external rotators and/or extensors.(2,3,4) The two primary muscles that achieve these motions are the gluteus maximus and the gluteus medius. These hip muscles help us stabilize the joints up and down the chain of the body and allow us to move with good mechanics. (7) Physical therapists use various exercises to train these muscles along with the gluteus minimus to treat ankle sprains. This begs the question, do ankles get injured due to weak hips, or do weak hips develop as a result of sprained ankles. One thing can be sure, having strong hips will only help protect the ankle joint, so it only makes sense to train the hip muscles.

Knee injuries are next in line with many people developing some sort of knee issue throughout their life. One common reason that pain or injury occurs is due to biomechanical issues where one or more of the moving pieces in knee flexion or extension isn’t functioning properly. Studies have shown strong links between knee pain and weak hip abductors and external rotators. (1,5,8) The hip plays a major role in the movement of the knee as it helps keep the knee into proper alignment. One tendency that someone with weak hips may experience is knee valgus. (the knee falls in towards the mid-line of the body). The Q angle, (angle from the outside of the hip, to the inside of the knee) allows for a good predictive tool for the occurrence of knee injury or pain. The larger the Q angle, the more shear force is applied to the knee joint. Women tend to have larger Q angles than men due to generally wider hips explaining their higher rate of knee injuries than men. This makes it especially important for women to have strong hip abductors and external rotators to pull the knee into a good movement pattern. Across a large body of research, findings consistently point to an improvement in the condition of the knee following hip strengthening protocol. (6)

How we move plays a large role in the wear and tear on our bodies. For athletes who train daily and push themselves to their limit, it is important that those hard trainings are done with excellent movement mechanics because without those, the wear and tear is amplified! The incidence of injury for athletes with poor mechanics is significantly greater than those with good mechanics.

So, what are some signs that you may have weak hips? When you do lower body exercises, do your knee(s) fall in towards the middle of your body? When standing on one leg, do you tend to twist your knee across when bending your knee in order to help with balance? These are just a few signs that it may be time for you to add hip work to your training plan!
 

About the author: 

 

Trevor Wiltz MS, PES, Pn1

Trevor is a Strength and Conditioning coach at RTG Performance Academy and Adjunct Professor of Kinesiology at Dallas Baptist University.
 
References

  1. Barton C. J., Lack S., Malliaras P. (2013). Gluteal muscle activity and patellofemoral pain syndrome: a systematic review. British Journal of Sports Medicine: 47:207-214.
  2. DeJong, A. F., Koldenhoven, R. M., Hart, J. M., & Hertel, J. (2020). Gluteus medius dysfunction in females with chronic ankle instability is consistent at different walking speeds. Clinical biomechanics (Bristol, Avon), 73, 140–148.
  3. De Ridder, R., Witvrouw, E., Dolphens, M., Roosen, P., & Van Ginckel, A. (2017). Hip Strength as an Intrinsic Risk Factor for Lateral Ankle Sprains in Youth Soccer Players: A 3-Season Prospective Study. The American journal of sports medicine, 45(2), 410–416. https://doi.org/10.1177/0363546516672650
  4. Friel, K., McLean, N., Myers, C., & Caceres, M. (2006). Ipsilateral hip abductor weakness after an inversion ankle sprain. Journal of athletic training, 41(1), 74–78.
  5. Ireland, M. J., Wilson, J. D., Ballantyne, B. T., Davis, I. M (2003). Hip Strength in Females With and Without Patellofemoral Pain. Journal of Orthopaedic & Sports Physical Therapy: Vol 33:11 671-676. https://www.jospt.org/doi/10.2519/jospt.2003.33.11.671
  6. Kim E. K. (2016). The effect of gluteus medius strengthening on the knee joint function score and pain in meniscal surgery patients. Journal of physical therapy science, 28(10), 2751–2753. https://doi.org/10.1589/jpts.28.2751
  7. MacKinnon, C. D., & Winter, D. A. (1993). Control of whole-body balance in the frontal plane during human walking. Journal of biomechanics, 26(6), 633–644. https://doi.org/10.1016/0021-9290(93)90027-c
  8. Rowe, J., Shafer, L., Kelley, K., West, N., Dunning, T., Smith, R., & Mattson, D. J. (2007). Hip strength and knee pain in females. North American Journal of sports physical therapy: NAJSPT, 2(3), 164–169.