SSD Health & Wellness Q&A – Low Back Pain

Q: What can I do to alleviate lower back pain?

 A: There are a few ways to make our lives more comfortable. This job is inherently hard on our backs and posture. The lower back takes a beating from seated positions where the normal curvature is pushed too far forward in the wrong places, the thoracic spine gets pulled out of position from our vests and tired shoulders and the cervical section can get beat up if we wear helmets of any type in our course of duties. All in all, this job is less than favorable for the back.

However, when we usually complain about our backs hurting, it’s the lower back that is the big problem. This stems from not only the aforementioned reasons, but also from a lack of strength in the area as well as inflexibility in muscles that tie into the spine and pelvic region. I am going to start with talking about improving flexibility first and then about strengthening the low back. People who tend to avoid the flexibility aspect and go right to strength work will overuse the back and put more tension in the musculature and basically go nowhere, or even take steps backwards. So, improve your flexibility first, then work in the strength.

If we were looking to improve strength and posture in the back as a whole, deadlifts, squats and barbell rows would help to that end. Neck strengthening exercises would help the deep muscles of the neck grow stronger and withstand the loading and constant torque placed on it, while shoulder based pulling and pressing movements would help strengthen the upper T-spine / lower C-spine and the muscles like the trapezius and rhomboids.

There are obviously a boat load of lower trunk muscles, but the ones that cause major grief for people are a set of antagonists (opposites) on the front and the back (anterior & posterior) of the body. The hip flexors are a prime problem on the anterior side of things. The hip flexors allow you to pull the hip closed (flexion). This is best thought of as being able to draw the thigh straight up as if you were marching in place. There a few muscles in the flexor group, but one of note in it’s relation to low back pain is the psoas, sometimes called the iliopsoas.

The psoas originates on the inside of the Lumbar spine (L1-L5) and runs through the pelvic cavity attaching to the top of the inner femur. This is a large, thick muscle that has a lot of power and function in the hip joint. It can move the leg and even is strong enough to lever the body upwards if the legs are anchored. As such, it gets overworked all the time and is rarely taken care of. As with the other hip flexors, and any muscle for that fact, when they are used and then “put away” and allowed to cool off on their own, they shorten. Add to the mix that most of the time, especially in our jobs, we move around and then sit for long periods of time, and the psoas and it’s counterparts get tighter and shorter all the time.

Because the psoas is under so much tension and it attaches to the front of the lower spine, it will begin to pull the lumbar arch of the spine forward ever so slightly. Any slight deviation from the norm in the spine is felt right away due to the vast network of nerves exiting the column over it’s entire length. Discs that become slightly distorted and have pressure placed on their anterior side in this case, start to press on nerves and that hurts. Then once you start lifting or moving heavy loads with any variance in good form, those discs that are under pressure due to the forward pulling tension on the spine, have a higher likelihood of becoming injured in a more substantial manner.

To add to the mix is the antagonist musculature on the backside in the form of the hamstrings. The hamstrings originate at the bottom of the pelvis on the ischial tuberosity, aka, the sit bones. They run the posterior length of the femur and insert in various places on the top of the tibia (lower leg / shin bone).  This is another very strong collection of muscles that flexes the knee and, through action with the glutes, open the hip.

Again, they get used a lot and when we don’t stretch them regularly, the hamstrings begin to shorten. As the hammies shorten, they begin to pull on the bottom of the pelvis. The pelvis, being connected to the lower spine via the lumbosacral area, starts to add deviation to the normal position of the pelvis by “tilting the bowl” backwards. This posterior tilt of the pelvis changes the normal curvature of the lower back and adds pressure to the discs on the anterior side of the lumbar spine – the same place the tight psoas muscle is pulling out of whack. So you can see the lower back gets a double whammy from the hip flexors and the hamstrings. This is where stretching the muscles can make a huge difference in alleviating back pain.

For the hip flexor, lunge stretches with the knee in various positions can pull the psoas pretty good. If doing lunge stretches, it is important to keep the upper torso as vertical as possible to keep tension in the hip. These lunge stretches can also incorporate some PNF type stretching (pull/push) as well as rotational (twist the upper body at the waist in the direction of the knee that’s up).

For the hamstrings the old standby of “bend forward and touch your toes” has some merit, but it works better if you don’t let your upper back round over to get to your toes. Instead, keep the chest up high and the lower back locked in it’s natural arch. You will most likely only be able to get about half way down in this manner and you should feel way more stretch deep in the belly of the muscle.

Another good one is to lie on your back with a rolled up towel under the low back to maintain the arch. Keep your head, shoulder blades and both butt cheeks in contact with the ground. Put a strap around the bottom of one foot and gently pull the leg upwards until you find your end range with the strap. “End range” is the point where any more pull towards you will tilt the pelvis and lift your butt off the ground. The knee should be fairly locked out and the other leg should be laying flat on the ground. Apply a slight bit of backpressure into the band as you pull it toward you. Hold this for about 20s., release for about 5s and repeat a couple more times and switch legs. You will find that each time you release and get back into it, the leg comes up a bit more and the stretch gets a little deeper. This is a PNF stretch (pull/push) which helps override the nervous system to allow for a deeper, more powerful stretch.

There are a lot of very good psoas and hamstring stretches out there you can find on the internet, YouTube or you can corner me and I can pass some down that would take way too long to explain in text. Another good resource is Kelly Starett’s “Mobility WOD”. Regardless of what you are stretching, each stretch should be 1-2 minutes or longer in length to really make a difference. The old “hold for 20 seconds” rule is junk – it doesn’t effect any change. Do this a couple times a day when you have the time, especially after working out, and there will be noticeable changes to your low back, your movement and less chance of injury.

On that note, don’t do a ton of static stretching as described above before your workouts. This changes reflexive properties in the muscle and will actually lead to a loss of performance and higher likelihood of injury during the workout. Instead, use dynamic range of motion (DROM) stretching before the work out. Leg kicks, trunk twists, arm circles, light runs, and/or any kind of multi joint/multi muscle movements will do way more to loosen the muscle in it’s natural work pattern as well as warm up and loosen the joints and the connective tissue. This is something that static stretching beforehand does not do adequately.  Save the static stuff for post workout.

Now if you have been paying attention to the pattern of what is affected by tight hip flexors and hamstrings, you can see the low back is getting beat to hell and any strength work without adequate flexibility will either injure or tighten things up more. Hence the reason you need to break things up a bit first for a few days. It’s like warming up car before you try to hit 0-60 right out of the gate.

Most strength work needs to start out light and basic for folks and then progress up. This can mean starting with simple exercises that don’t involve rolling around on overblown balloons, or using lighter weight and impeccable form on more technical externally weighted movements.

Much can be gained through back extensions, but people overuse them, then don’t balance out the movement with full ROM based ab movements. Note I said “full range of motion” – this means crunches are not part of the equation. Sit ups and other ab work should be done to the full extent of the movement patterns, no ifs, ands or buts about it. Good solid ab work will help balance out overworked muscles of the lower back.

Both of those types of movements are pretty linear (moving forward/backward) and one that gets overlooked is rotational work. Twisting based movements are huge for building lower back and midline strength and they are not used nearly enough. Things like Russian twist lunges or sit ups, Med ball partner or wall twists, half moons, barbell twists are awesome. Start doing them. Look them up on the web or ask me what the heck something is.

To top off rotational movement, isometric contraction work is a good choice as well. This can be done in the form of planks. You can do them on your elbows, in a Superman, side planks, flag planks, etc. They basically force you to contract the musculature of the midline to maintain a nice neutral spine through the low back and abs. This is why it’s isometric – basically meaning “locked in place with no movement”. This stuff goes a long way and is overlooked all the time.  Gymnasts have incredible strength in these positions.

Lastly, once you start getting some flexibility and strength built up, you can start to incorporate external loading. This is where deadlifts, barbell rows, kettlebell work, Olympic lifts, presses and squats come into play. The lower back will be placed under stress in all the movements, some more than others, in various stages of muscular contraction and effort. These motions also involve the hip flexors, hamstrings and their supporting musculature as well to help develop those areas now that they are getting more pliable. Good form and attention to not overload the weight too soon is the best bet, so find a good coach and go slowly.

In the end the ingredients come down to developing flexibility in the hips and hammies, developing strength in the low back, hips and hammies, and then maintaining the flexibility while working the strength stuff in. Go easy at first, but be diligent in working this formula and back pain will be greatly alleviated!