Preventing Lower Back Pain: Assuming is Okay
Written on June 21, 2010 at 7:43 am, by Eric Cressey
It's widely known that approximately 80% of the population will suffer from lower back pain at some point during their lives. What isn't widely known, however, is that even those who are asymptomatic are usually walking around with a host of nasty stuff going on with their spines. Don't believe me?
A 1994 study in the New England Journal of Medicine found that in a study of MRIs of 98 asymptomatic individuals, 82% of those MRIs came back as positive for a disc bulge, protrusion, or extrusion at one level. And, 38% actually had these issues at more than one level. You can read the free full text HERE.
As the others discovered, it doesn't stop with disc issues, either - and that's where a great study from Soler and Calderon comes in. They looked at the incidence of spondylolysis (vertebral fractures) in elite Spanish athletes, and found that 8% of those they examined had them. Only about half of those diagnosed via imaging actually had back pain, though. The incidence was highest in track and field throwers, rowers, gymnasts, and weightlifters - and I'd expect that this figure is actually higher in the U.S., where we have more sports (hockey, baseball, lacrosse) involving violent extension and rotation, more contact sports, and more participation in weight training.
What does this mean for us? Well, as Chou et al. reported in The Lancet, "Lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes. Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition." That's not the point of my article today, though; I'll leave that stuff to the physicians to decide and rehabilitation specialists to interpret and treat.
As fitness professionals, strength coaches, and even just fitness enthusiasts and athletes, we need to assume that there is are probably a lot of structural abnormalities going on in the spines we encounter - including our own. The programs we write and follow need to be sound and take these issues into account, considering differences in age, gender, sport participation, and injury history. The technique we use needs to position us so that we can avoid causing them to reach threshold. And, we need to appreciate that there is a risk-reward balance to be "struck" with everything we do in training because nobody will ever be "perfectly prepared" for the demands to be placed on their bodies.
Rather than lay all my thoughts out here, I'm going to direct you to some previous writing of mine:
To Squat or Not to Squat?
Lower Back Savers: Part 1
Lower Back Savers: Part 2
Lower Back Savers: Part 3
I'd also highly recommend Ultimate Back Fitness and Performance by Dr. Stuart McGill.
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June 21st, 2010 at 9:45 am
There are many studies like the New England Journal study showing that pain free individuals are likely to have structural issues visible on an MRI such as bulging discs or torn rotator cuffs. For example, close to half of pain free hockey player show labral tears on an MRI, and one third of pain free people over the age of 40 with full shoulder function show damage on an MRI such as partial or full thickness rotator cuff tears. The stats for active pro baseball pitchers are far higher, close to 70%. I agree that one possible interpretation of this evidence is that we need to be mindful of potential structural damage in persons without pain. But there also is a more hopeful interpretation, namely that structural abnormalities such as these are simply not as predictive of pain as we previously assumed, and therefore we should focus on these issues less, not more. Pain science has made great progress in the last twenty years and it all points way from the condition of the mesoderm to the function of the ectoderm as the source of pain. Eyal Lederman has some excellent articles on this subject, some of the evidence from which is summarized in a blog post I wrote here, in case anyone is interested. http://toddhargrove.wordpress.com/2010/06/08/back-pain-myths-posture-core-strength-bulging-discs/
June 21st, 2010 at 9:55 am
Thanks for providing this in the link To Squat or not to Squat it says:
Roughly 3/4 of all athletes have disc bulges/herniations that go completely undiagnosed.
It’s estimated that 4.4% of six-year olds have spondylolysis (lumbar fracture[s] (3)).
4.4% of 6 year olds vs. 8% of elite Spanish athletes had spondylolsis…. What are the base rates? It seems that the athletes might be no different than the regular population.
June 21st, 2010 at 11:18 am
Nice Post Eric, Looks like you were correct in your thought that day in the gym when you wondered what kind of dirt an MRI would pick up on people with no pain who have a history of strenuous weight lifting, mainly yourself! I don’t think I even want to see what weight lifting and years of catching both ends of double headers has done to me…I’ll just stay mostly pain free and ignorant for now!
June 22nd, 2010 at 6:28 am
Todd – that’s part 2! 🙂
Richard – “Most” athletes aren’t much different from the general population. If we are talking about sports with violent extension and rotation, those numbers are markedly higher (look at the track and field throwing example).
Greg – Ignorance is bliss!
June 22nd, 2010 at 10:31 am
Hi Eric,
My low back seems to be mostly ok, so long as I don’t have bad form on the deadlifts, but I tend to have a lot of upper back pain, neck, traps, near spine and near shoulder blades. Have you done an article on the upper back and how to prevent back pain there? I know working on computers and bad form there is going to help me, but I’m wondering what I’m doing exercise wise that seems to cause problems. When I try to get back into lifting I do something to my upper back area and end up to a point where I have to go in for ART to correct it, gets to the point where looking up, down, left and right is painfull. Wish I lived closer so I could get some help in form and exercise selection. Worked with you before online and was great working with you back then.
Thanks,
Mike
June 24th, 2010 at 7:43 am
Anyone know anything about vertical herniations (Schmerl’s nodes) and squatting? Several years ago I had an MRI done and I had a number of vertical lesions. The doctor told me that they have no idea what causes them, nor do they normally cause problems. The MRI was for leg pain, but I have no back pain at all.
June 24th, 2010 at 11:30 am
I suspect the prevalence of non-painful bulges also explains the prevalence of terrible back pain resulting from one sneeze.
Mik – are you talking about a herniation that fractures the end plate of a vertebra? McGill in Low Back Disorders writes that these are caused by excessive compression forces, usually with the spine in neutral. A Schmorl’s node can exist without true vertical herniation. Even if there is vertical herniation, it won’t necessarily cause pain. The body has an amazing capability to adapt, you are probably not screwed, especially if you haven’t been having any problems, but I suggest you contact McGill himself about squatting. You should be able to find his email at the website of the University of Waterloo.
June 24th, 2010 at 1:50 pm
Good stuff EC.
You are absolutely correct that everything has a risk/reward to it and this must be accounted for indeed.
The hard part is that we really don’t know what a “normal” structure is and how far from “normal” we can go before we get pain.
Similar to Todd, I view the studies as a positive, that we can go away from normal without immediate pain. The good thing about pain is that it will tell us if something is wrong.
I am not for pushing athletes that far at all, but stopping sets before pain, and even before excess tension and altered breathing will keep the risk/reward balance more favorable.
Rock on
Mike T Nelson PhD(c)
October 14th, 2010 at 11:00 am
Great article! I dislocated some discs in my back many years ago. I lifted something beyond my limit (and I lifted it the wrong way – using my back)! I went to the chiropractor for a few months and started to feel a lot better. Recently I have been having some lower back pain again. I feel as thought he smallest things will bring about this back pain. I may have to pay the doctor another visit.
July 5th, 2011 at 10:56 am
This is a timely discussion for us to be having with all the diagnostics going on in injured athletes (and folks in general) when injury strikes. Every year it seems like I counsel more and more people on their MRI findings after they come to my office freaking out about how scary their scans look. I love the point of your article but was honestly hoping for the slightly different patient/client centric message that follows:
Just because you have an ugly MRI scan of your back, shoulder, or knee, doesn’t mean you have to limit your activity or worry about not being pain free in the future. The feeling of anxiety and hopelessness in clients following these surprisingly ugly scans can do more emotional damage and thus delay healing more than the injury itself. So, I think it behooves us as clinicians and trainers to make sure we are reacting to these scans in a positive and hopeful way to reassure clients that they have an opportunity to get and stay below “threshold” almost regardless of what their MRI says. Our ability to educate people on what you (Eric) are saying in your post is critical. And, a client’s success in getting well conservatively and avoiding surgery (which is commonly a client’s knee-jerk solution) hinges on our ability to teach them how to move well and take care of their [insert body part here]. I don’t think there is anything more satisfying than getting someone with an ugly scan pain free and strong without surgery. And, it happens more often than not if the person is willing to learn about their situation and put in the work. Orthopods are not positioning ugly scans to patients in such a positive way so it is our job to take on that role.
Thanks for a great post Eric.
Charlie Merrill, MSPT
July 7th, 2011 at 6:51 pm
I had not seen your 2008 “squat or not” article before. It was gold. I have incorporated most of your recommendations already. I live and die by magnificent mobility. The Olympic lifts really helped with my ankle mobility. I am going to try deloading once a month and see if that helps further. I get a little symptomatic when I go heavier on the back squat and deadlift on a program (without varying from it).
What is your take on Cat/Camel? I do it religiously pre-workout with scorpions, reverse scorpions, bridging and some lying knee across the body stretches then single leg bridges and light overhead squatting. That combo seems to allow me to squat and deadlift pain free heavy as I need to go. Is it increasing my lower back mobility to my detriment? Should I avoid it or focus more on thoracic mobility in the cat/camel with lower back stability?
Please keep up the great work. Your articles add tremendous value to my life!
July 12th, 2011 at 12:11 pm
Very interesting, Eric. It seems that pretty much everyone have some abnormalities somewhere in there body..