Low back pain is one of the most common causes of disability in the US.
8 in 10 people are likely to have an episode of low back pain in their lifetime.
The good news is that the majority of these cases resolve completely.
Unfortunately, however, the recurrence rate is rather high, and a few individuals do go on to have persistent pain.
So what can we do to prevent this?
Low back pain is complex and there are different types of low back pain that may need to be managed differently. By no means do I intend for this post to give you all the answers on this topic.
What I do want to do is share some simple do’s and don’ts of how to manage the most common types of low back pain that do not involve serious injury or pathology.
I’ve done my best to base these recommendations on current evidence and our evolving understanding of pain and treatment strategies.
So, let’s start with some things you absolutely should NOT do if you experience low back pain...
...DON'T fear the worst
Again, low back pain is fairly common and most episodes end up resolving completely. So don’t fear the worst. Rather, know that you have good reason to be optimistic, and there are several things you can do to help yourself get better...more on that in a little bit.
….DON’T get on the internet to find answers
That might seem contradictory since you’re reading this post about low back pain on the internet. But the fact is there is a lot of bad and outdated information on the internet. Plus, you're likely to stumble across scary terms like "degeneration" and "disc bulging" which can create unnecessary fear. These terms actually just describe normal findings in most people, even those that don't have any pain.
….DON’T ignore the pain
The opposite of being overly worried about your back would be ignoring the pain and pushing through activities that make it worse. And that's not a good approach either. Pain is your body’s alarm system meant to protect you, and if you ignore these signals and continue to provoke the pain, it may be harder to turn the pain off.
….DON’T rely solely on passive strategies
What do I mean by passive strategies? Massage, electrical stimulation, needling, manipulation, adjustments, etc. None of these things are bad in and of themselves, and they certainly might useful tools to help you improve. But they are most effective when combined with active exercises that help you build self-efficacy rather than creating dependency.
So, here’s what you should DO instead…
….DO stay active
Find some low-intensity exercise that doesn’t increase your pain, and use that to keep moving. That might mean walking, biking, swimming, or something else that doesn’t hurt… the key here is to break a sweat and get the endorphin release from exercise to help reduce the pain.
….DO work on improving your lumbar spine mobility
Often when you have low back pain, your movement becomes stiff and guarded. Working on improving your range of motion gradually can help reduce the pain and protective guarding.
Here's a simple exercise that can help you target your lumbar spine mobility...
Many people with low back pain tend to be sensitized to spine flexion. This can be challenging because we tend to spend a lot of our time in spinal flexion (i.e. sitting) or performing flexion activities (i.e. bending over to pick something up or tie your shoelaces).
For this reason, many people respond well to extension exercises. Moving the spine opposite of the painful direction can give your body a break and serve to “reset” the nervous system, decreasing sensitivity and pain.
Below is an example of an extension exercise called a "press up." You can use this as a test to see if you have full mobility (able to lock out your arms without your hips leaving the table) without any pain. If you are limited or do have pain with this movement, perform a few reps to see if the pain decreases with gradual improvement in the range of motion. If it does, this is something you can repeat multiple times a day until it's all clear with full range of motion and no pain.
....DO work on getting stronger
It's a common belief that core weakness or instability causes low back pain. However, you might be surprised to know that research isn't clear on this. So while we might not be able to say that core weakness causes low back pain, there is still good reason to work on strength. Getting stronger can improve your confidence and decrease the nervous systems protective pain response. So rather than focusing on just the core, developing trunk (abs, obliques, back extensors) and hip strength in general can aid in building strength and improving your tolerance to activities.
Here's an example of a great exercise that can help build trunk and hip strength simulatneously...
Barbell good mornings are another great option for posterior chain strengthening, including the back extensors. Focus on hinging at the hips while maintaining spinal position. When done correctly, you should feel tension in your hamstrings. I recommend starting with a light weight and slowly building up.
Lastly, I"m a big fan of deadlifts as a way of reducing low back pain and improving strength. But don't just take my word for it. Zach Long (The Barbell Physio) has a great write-up about the research behind this (read here).
….DO work on improving your mechanics for high load activities
Getting your mechanics dialed in for high load activities, such as weightlifting, can help ensure that you aren't placing additional stress on your low back. Enlist the help of a coach or clinician who is well-versed in these movements. Don't progress the loads until you demonstrate mastery over the movement and with consistency over time.
Hope this information helps some of you. Thanks for reading!
If the pain persists or there are more serious symptoms like numbness/tingling, pain shooting into your legs, difficulty going to the bathroom, pain at night that isn't relieved by changing position, etc., go see a medical professional.
If you struggle with shoulder pain or proper positioning during overhead lifts, then THORACIC SPINE MOBILITY something you should take a look at.
T-spine mobility is often overlooked in its importance to obtain proper overhead positioning. Not enough of it and your scapula (shoulder blades) will not be able to tip back enough to get your arms overhead. Often, that results in excessive strain on the glenohumeral (shoulder) joint and can be a factor with pain during overhead activities and missed lifts due to not being able to get into a good overhead position.
So how do you know if you have enough thoracic spine mobility?
Run yourself through this simple test...
So, were you able to get at least 50 degrees of rotation on that test? Not sure what 50 degrees even looks like? Well just imagine in the second picture above that 90 degrees would be If my right shoulder was pointing straight up at the ceiling. Half of that would be 45 degrees. So you want to be just a little past that. You can have a buddy help you with this test and see if with their help, you can rotate any further. If you still can't get 50 degrees, then you my friend have a thoracic mobility limitation.
Here is my favorite way to work on passively improving thoracic extension....
Key points: Exhale before each rep to pull your ribs down and prevent arching your lower back. Move to different segments across your upper back and spend more time on areas that feel more stiff or restricted.
If you don't currently have any shoulder pain, then you can try the advanced version of the last exercise, with a kettlebell or dumbbell to help add some overpressure to the stretch. Be careful not to overdo it with this one, especially if you're new to these drills.
It's important to follow up any passive technique or mobility exercise with some active drills to improve strength in the newly gained range of motion so that you can maintain it and use it!
This next one is a great drill to work on active thoracic extension.
Key points: Keep your abs and glutes tight to prevent substituting with motion from your lumbar spine. You can see that I struggle with getting my arms into a good overhead position and end up having to lift my chest off the bench. Don't be like me. Try to keep your chest down get your arm to be in line with your ear. If that's too difficult, then move your hands a bit wider apart on the PVC pipe. If it's too easy, then move them closer together. You should feel this in your upper back, between your shoulder blades. If you don't feel it there, you're likely not doing it right.
Hope this helps some of you. Go ahead and give these a shot before your next overhead lifting day, and report back to let me know you felt!
This week we look at how to improve your ankle mobility in order to obtain better deep squat positioning.
In Part 1 you learned that olympic lifts and front squats require more ankle mobility than a back squat or deadlift. That's because the torso needs to be more vertical in these lifts to keep from dumping the weight forward. And in order to keep the torso vertical, the knees have to travel forward which requires adequate motion at the ankles. We call this motion ankle dorsiflexion and below is the test we learned for it, so hopefully now you know if it's a problem for you or not.
If you were limited here and couldn't reach the wall, there are two common reasons:
If you are in the first camp and feel a block or pinch in the front of the ankle, here are a couple mobilizations to try:
In addition to helping to improve ankle dorsiflexion, this next exercise can also help you to keep your knees out when you squat.
If you are in the second camp and feel more resistance in the calf, here is a great exercise for that:
If you've been stretching your calves for years and feel like you go right back to being tight again minutes after you stretch, this may be just the exercise for you.
A 2012 systematic review by O'Sullivan et. al. looked at the effects of eccentric training on lower limb flexibility and found "consistent,strong evidence" for increased range of motion and muscle flexibility in all the muscle groups they studied following an eccentric training protocol. The most likely mechanism for this increase in range of motion is that the mild muscle damage caused by eccentric training actually causes muscle adaptations where new structural units of muscle (called sarcomeres) are created in series, thereby increasing the length and flexibility of the muscle.
HOW COOL IS THAT!
But that's not all...eccentric training also improves length-tension and peak torque which can actually help to prevent many common muscle/tendon injuries!
Last point here...it's important to follow these exercises up with loaded movements to help you maintain the range of motion that you gained. Goblet squats are a great option here (Part 2). Really focus on keep your torso upright, pulling your knees forward a bit, and driving your knees out.
That's all for now folks!
Part 1 of this series covered squat mobility assessment - simple tests you can use to determine what might be limiting your squat.
In Part 2 will look at some ways to improve your hip mobility if you found a limitation or experienced pain/pinching in your hip during your assessment.
Below are four of my go-to exercises to improve hip mobility and comfort in the bottom position. You can view this as a progression from more passive techniques to active/loaded techniques to help maintain gains in mobility long-term.
Banded Lateral Distraction
This is a great one to use if you do experience pinching in the front of your hip. I've found with many athletes that the distraction force from the band helps to reduce or eliminate the pinch.
Bench Hip IR mobilization
This one is a bit of an advanced version of the first exercise. DO NOT work through any pain/pinching in this one. Either limit the range of motion or stick to the first drill until you can better tolerate this one.
90/90 Hip Pails & Rails
This next drill comes from Dr. Andreo Spina of Functional Range Conditioning. It is a great way to actively work on improving strength/control at the end ranges of your hip mobility. I rushed through the demonstration a bit but feel free to take your time in each position to stretch and gradually ramp up and ramp down the intensity of the contraction. After 1 cycle, move further into the stretch and repeat as many times as needed.
Paused Goblet squats
Goblet squats allow for a more upright torso and therefore greater depth in the squat. Loading the squat and spending time in the bottom the most effective way to improve squat mobility long term, in my opinion.
Thanks for reading and watching. Now go crush your next squat day!
In the last post, we talked about mobility and tried to shed some light on what we mean by it and why it's so important. In this post, we'll talk about mobility requirements for one of the most basic functional movements and one we see a lot of in CrossFit, the squat.
So first, let's talk about the biomechanics of the squat. The hip, knee, and ankle simultaneously flex allowing the athlete to descend, while keeping the center of mass over the midfoot. The degree to which your joints will be required to flex depends on where the load is placed. Generally speaking, the more anterior (in front of the body) the load, the less hip motion required, while there is a greater demand for knee and ankle motion. Take a look at these photos and see if you can spot the differences.
Now that you understand the mobility demands of the squat, let's show you ways to actually assess your mobility. This is important because you don't want to guess and then waste time working on the wrong thing. Here are my favorite assessments:
Hip mobility Assessment
Quadruped Rockback (from elbows) for hip and knee flexion
This test virtually takes the squat and flips it 90 degrees. Without having to work against gravity in this position, we can get a good sense of where we bottom out. The key here is to maintain a neutral spine as you sit your hips toward your heels, and to stop at the point at which you begin to feel or see motion at your lower back (this may take some practice and having someone to watch you and give you feedback is helpful). If the spine flexes/rounds, we are no longer getting a true test of hip mobility. The goal is to see the hip crease go past the knees.
This is also a great position to determine the best stance width for your squat. Play around with bringing your knees closer together and further apart to see where you are able to sit back the furthest and most comfortably. Then adopt that stance the next time you get under a barbell.
Ankle Mobility Assessment
Half Kneeling Ankle Dorsiflexion Test
Start with your foot about a hand-width away from the wall (including your thumb). Push your knee forward reaching for the wall without letting your heel come up. You should be able to touch the wall. If you can't, this may limit you in the squat, especially the front squat and olympic lifts where the barbell is more anterior.
Go Try 'em out
Give these simple assessments a shot and then come back here soon for some exercises I'll be showing to help you improve your mobility in these areas.
Appreciate any feedback, comments, or questions!
A lot of people are talking about mobility these days. Here's a post to help you make sense of it all...
What is mobility?
The available range of motion at one or more joints that allows a specific movement to be performed.
Why does mobility matter?
It allows us to move. Depending on the movement, there are different mobility demands on particular joints. Take for example, a squat. In order to perform a full depth squat, you must have a prerequisite amount of ankle, knee, and hip mobility. Lack of mobility in any one of these areas will be a constraint. This means that the body will have to “borrow” motion from somewhere else. In the squat example, a lack of hip mobility could result in borrowed motion from the lumbar spine (one potential cause of the dreaded “butt wink”). So in order to move smoothly and efficiently, you must have the mobility required to perform a given movement.
It is imperative to evaluate mobility in the context of a specific movement pattern. This is the biggest error that I see in athletes looking to improve their mobility. They come across a new stretch or mobility routine and begin to hammer away in search of better mobility. But when does someone have enough of it? Well, it depends. The movements that an athlete has to perform for their sport will determine the amount of mobility that is required. A dancer is going to require significantly more mobility than a basketball player. An olympic lifter is going to have certain mobility demands that a powerlifter would not have. Breaking down a movement pattern and assessing mobility of each involved joint is the best way to identify and then systematically address limitations to improve performance and reduce injury risk. This also helps us to avoid wasting time doing arbitrary mobility work that could be better spent in ways that actually transfer over to performance in your sport.
Lastly, mobility is only as useful as the control you have over it. If you cannot control mobility at a joint, you will not be able to use it. If you take a very flexible individual who has never lifted weights, and put them under significant load, I guarantee they will not be able to access all of that mobility that they have. This is because they lack the strength and control required to move under load. So when working to improve mobility, we also need to keep in mind that stretching and passive mobility techniques in themselves are not sufficient. They need to be followed up by active or loaded exercises to gain strength and control over the newly acquired range of motion.
What limits mobility?
There are 3 primary limiters of mobility:
Knowing your limiter will determine the appropriate type and dosing of an intervention to use. It will also give you a realistic expectation of the improvements you can expect. For example, if bony approximation is the limiter, you are not likely to change that. Your bone structure is determined in large part by genetics and development, especially in adolescence. Knowing this can save you lots of time and frustration. On the other hand, neurologic tone usually improves rapidly after a stimulus is applied. This explains most of the short-term improvements we see after foam rolling, banded mobilizations, stretching, etc. If true muscular shortness is to blame, this takes more of a long-term approach, but does improve when a stimulus (i.e. stretching) is consistently applied over period of time.
At this point you might be thinking...this all sounds good, but I still don't know what to do to improve my squat or overhead mobility, and that's really what I'm looking for. Well if that's you, STAY TUNED for upcoming posts where I'll be sharing videos of actual assessments and mobility drills you can perform to start unlocking some mobility that may be holding you back in your training!
Joby Philip, PT, DPT