Why is low back pain so common?

You don’t have to look far to find individuals with low back pain. It is the leading musculoskeletal cause of disability in the world. This does not come as a surprise to anyone who has had to deal with this condition. When your back hurts, it’s tough to do any of your normal tasks. Not to mention a decrease in the enjoyment or the quality of your life as well. What makes this condition so prevalent?

The Lumbar Spine

Before we get too far in the weeds, lets define what is meant by the “low back”. For purposes of this article, I am referring to region of the body between the ribcage and the pelvis. Primarily the 5 lumbar vertebrae and the associated spinal column structures (joints, nerve roots, muscles, fascia). It is worth noting that because of it’s location, the low back also has the most weight and load through it because it supports the rest of the spine. Part of the issue in the treatment of low back pain is obtaining a proper diagnosis, as there are so many different structures and pathologies that can be involved. Too often, we, as a healthcare community, are satisfied with the diagnosis of “low back pain” when we should dive deeper and see what is at the root of the back pain. Back pain is truly more of a symptom of something else than a condition.

So now that we have a clear definition of the low back, we can return to the question at hand. Why does the low back hurt so often? For one, the lumbar spine region is inherently less stable than the regions directly above or below: the pelvis/hips and the ribcage/thoracic (middle) spine. Both the pelvis and the ribcage are naturally stable due to the increased presence of bony structures. Both segments essentially act as a “bony ring” and what is in between them? 5 lumbar vertebrae. The rest is soft tissue (tendons, muscles, fascia), including the “core”.

Why does stability matter? It is important to realize that every joint in the body requires a certain amount of stability (ability to control movement) and a certain amount of mobility (available range of motion). Typically, when a joint is inherently very stable based on anatomy, it is less mobile. On the other hand, when a joint has a large range of motion (mobility), it typically struggles with stability. A good example is the shoulder joint versus the hip joint. The shoulder joint and the hip joint are both “ball and socket”, or diarthrotic, joints. However, the shoulder joint has a much more shallow “socket” compared to the hip. Therefore, the shoulder typically has a greater range of motion (mobility) than the hip and the hip is typically more stable (able to resist extremes in ranges of motion) and less likely to dislocate than the shoulder.

Okay, so back to the low back (see what I did there?). The low back in this example would be more like the shoulder than the hip in that it more commonly lacks stability versus mobility. A big reason for this relates again to the segments above and below the lumbar spine: the ribcage/thoracic (middle) spine and the pelvis/hips. Due to multiple factors (including activity level, static postures, and our daily tasks), the thoracic spine/ribcage and the pelvis/hips are typically more “tight” and “stiff”. Use whatever word you want to describe a less than ideal range of motion. This means that whenever you need to perform a task, lets say bend over to pick something up off the floor, you need to use more motion at your low back (lumbar spine) because you are not getting it from the pelvis/hips or the thoracic spine/ribcage.

The body is amazing at compensating. The body will do this with all of your joints to accomplish the given task in the short term. The problem, especially in back pain, is in the long term. You may be able to get away with moving inefficiently for weeks, months, and even years. However, eventually, you will likely begin to notice the consequences. This may come in the form of pain, deformities, decreased performance, or simply continued restrictions in range of motion. An analogy I like to use is the bending of a paper clip. If you bend a paper clip back and forth in the same location, eventually it will break right at this spot. If you bent the paper clip uniformly from end to end, the stress is evenly distributed throughout the entire structure (similar to the spinal column) and is less likely to get overused at one location and break down.

The Core

“Core” and “core training” have become huge buzz words within the fitness community. Rightfully so, as this area of the body is responsible for the stability of the lumbar spine. What does the core consist of? A 3-D cylinder of musculature including the rectus abdominis (6-pack muscle), internal and external obliques, erector spinae, multifidi, and transversus abdominis. These structures achieve stability via co-contraction (contraction of muscles on both sides of the joint) and by utilizing pressure differentials and fluid dynamics.

What does all that fancy talk mean? The core muscles all work together to achieve stability of the lumbar spine, not just the abdominal musculature. Many people falsely equate core training with abdominal work (things like crunches, etc.). In addition, the core works as a soda can, utilizing intra-abdominal pressure to maintain stability in addition to muscle contraction. If you have a closed can, and squeeze the sides of the can (similar to muscle contraction in the core), you increase the pressure within the can (or abdomen). Both of these systems together increase the stability of the lumbar spine. An easy way to feel this sensation is to forcefully blow through a coffee stirrer or small straw. You will instantly feel your core engage and the small opening for air will cause a back flow pressure and increase your intra-abdominal pressure. This can be a useful tool for me as a physical therapist in patients with low back pain, as it can be difficult to explain how to activate these muscles if you have not done so in a long time.

A Note On Posture

Posture concerns can have an entire article written about it (and likely will at some point in this blog). For the topic at hand, it is important to consider the impact of certain prolonged postures with the lumbar spine, or low back, in an end range position. This could be any of the possible motions of the spine (flexion, extension, side bending, and rotation). For example, when you are seated and you slouch forward (rounding), you place your low back into lumbar spine flexion. This places increased strain on the ligaments on the back of the vertebrae/spine as well as the intervertebral discs. As discussed before, you may be able to get away with this for a long time before it ever becomes an issue. If you do the opposite and over-arch your spine into lumbar spine extension (bending backwards), then you place the most strain of the joints of lumbar vertebrae where they come together, called the facet joints. If you bend backwards like this far enough, often enough, you can begin to wear down the cartilage between these joints.

Why do people adopt either of these postures? Their bodies are searching for stability. Both of these postures achieve stability by relying on the passive structures of the spine, that is the ligaments, discs, and bones. This does achieve stability, but may not be the most efficient and may begin to cause issues later. You are asking these body structures to do things they are not necessarily designed to do under load or repetitively. Doing this over time can inhibit and weaken the core because it no longer needs to do it’s job. As we discussed previously, it is the job of the core to stabilize the lumbar spine. Due to this, it also takes more physical effort and energy expenditure to “hold you up” when compared to using the passive structures. It is more energy efficient in the short term to rely on these passive structures, whether due to core muscle fatigue from a long day at work, an under active or weak core, or just plain laziness.

Having said this, it is important to note that posture is not correlated with pain in the research. Just because someone is determined to have non-optimal posture (which, lets be honest, is most of us), does not mean they are more or less likely to have spinal issues or pain at some point. There are many factors that influence this including activity level, work tasks, genetics, and more. The primary application of this posture component with regard to low back pain is while performing tasks with load (lifting things) or if you have to perform tasks repetitively and in some cases, both.

Summary

  • The lumbar spine, or low back, is at the bottom of the spinal column. Therefore, these segments have the greatest amount of weight, or load, through them. This magnifies the impact of any non-optimal position or movement.

  • The lumbar vertebrae are the lone bony supports between the inherently stable (and often restricted) ribcage/thoracic spine and pelvis/hips

  • The lumbar spine often has to make up for the lack of mobility (range of motion) in the thoracic spine and the hips

  • Common postures of the spine combined with under active or weak core musculature can promote poor movement patterns and increase reliance on the passive structures (including the intervertebral discs, facet joints, ligaments, and vertebrae themselves) of the spine and increase the likelihood that they will break down

About the Author

Dr. Ryan Queen is a doctor of physical therapy, certified strength and conditioning specialist, and level 1 certified precision nutrition coach, in addition to holding certifications in other adjunct treatment modalities and paradigms.

He created Revolution Performance as a gym-based physical therapy practice and wellness coaching service after becoming frustrated by the conflict of interest that health insurance company restrictions bring. His vision with the company has always been to provide high quality, holistic care while forming life-long relationships.

His mission is to help busy, hard-working adults get out of pain and dysfunction, whether from a current injury, a past one, or just daily aches and pains. In addition, Ryan has a passion for creating a proactive environment where issues are addressed before they become debilitating, or even before they exist.

After working 40 hours a week at a full time job while going to physical therapy school, Ryan knows how it feels to think you do not have enough time in the day to take care of yourself in all facets of health. It has been a goal of his to share the information and strategies he has learned to help others improve their overall health and become more productive.

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Medical Disclaimer: All information on this website is intended for informational and educational purposes only. The authors and partners are not responsible for any harm or injury incurred. It is important to seek professional guidance about your condition or injury. No guarantees have been made or implied regarding specific results of the services described.

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