Low Back Pain
At least 80% of people in the U.S. will
experience an episode of low back pain at least once in their lives.
Approximately 15% of these episodes will progress to chronic back pain.
and volumes have been written about low back pain, and a complete
discussion is beyond the scope of this site. But we would like to
present you with some facts and ideas that you may not hear anywhere
Low Back Stability, Structures & Pain
low back gets its stability from several structures—the bones and
joints, the intervertebral discs, the ligaments, and the muscles.
The Bone & Joints
bones and joints form the building blocks of the spine. The joints of
the low back are called the facet joints. They are the small joints
located on the back of the spinal column. Compression fractures of the
vertebral bodies, arthritis of the facet joints, surgery that removes
facet joints (such as a laminectomy), and fractures or congenital
abnormalities of the portion of bone between the facet joints (called
the “pars interarticularis”), causing a “spondylolysis,” all can
disrupt the stability of the bony spine.
conditions in the healthy spine, the facet joints bear about 25% of the
axial load the spine, and the discs bear the remaining 75%. When the
discs start to wear out, more of the load is shifted to the facet
joints, which causes premature wear, arthritis, and subsequent
instability and pain. Arthritic change in the facet joints is known as
degenerative joint disease.
discs act as shock absorbers between the vertebrae. The disc is a
fluid-filled structure, with a thick fibrous outer ring, called the
annulus, surrounding a gelatin-like center, called the nucleus
pulposis. The discs are firmly attached to the vertebrae above and
below. There is therefore no such thing as a “slipped disc.”
a water balloon when you squeeze it, discs bulge under pressure or
load. They’re supposed to do this! This is how they help cushion the
bones. In other words, disc bulging is normal. Problems occur when they
bulge too much, thereby stretching the outer fibrous ring and
irritating the attached nerves.
Over time, the fluid inside
the discs begins to diminish, and the disc undergoes “degeneration,” a
type of wear and tear. Again this is normal. However, sometimes
excessive physical or sports activities, injuries to the disc, and
genetic factors can cause a disc to wear out prematurely. This is known
as degenerative disc disease.
It is used to be thought that
degenerative discs did not cause pain. But recent research is
questioning this, and some researchers believe that as the disc breaks
down, occasionally it leaks out inflammatory chemicals that irritate
surrounding nerves and ligaments.
A herniated disc occurs
when a tear develops in the outer ring (the annulus), allowing some of
the gelatin-like nucleus to squirt out. This puts pressure on the nerve
exiting the spine and causes symptoms of sciatica.
MRI Evaluation of Disc Problems
often ask that an MRI be performed to look for disc problems. The
problem is that not all disc cause pain. A study published in 1994 in
the new England Journal of Medicine, performed MRIs on almost 100
people with no history of back pain (Jensen et al. N Engl J Med.
1994;331:115-116). 64% of these “normal” people had at least one
abnormal disc—52% had bulging discs, 27% had disc protrusion, and 1%
had a frankly herniated disc. 38% of the subjects had more than one
abnormal disc. But none of them had any pain! MRIs and CT scans can
show disc abnormalities, but they cannot tell whether a disc is causing
Low Back Ligaments
bone to bone. They hold the joints together. They are the “guy wires”
that limit and control motion. They also have a strong nerve supply,
which is why it hurts so much when you sprain something. Damage to a
ligament is called a sprain.
ligaments of the low back help stabilize the low back joints. The
ligaments are damaged in several ways. Lifting an item improperly,
bending and twisting (such as shoveling snow or reaching into the trunk
of your car), childbirth, or repetitive strain over time all can injure
them. When a ligament is damaged, spine stability can become
compromised, occasionally leading to slightly increased motion in the
Sprains can range from mild overstretching to
complete tearing of the whole ligament. In the low back, complete
tearing almost never occurs. More commonly, overstretching or small
tears cause the pain. Ligament injuries in the low back can cause pain
in many ways. The ligament itself can cause pain over the injured area
or it can refer pain to another location. They can cause the muscles of
the low back to tighten up, both because of the pain and because the
muscle is trying to stabilize the spine in the face of a loosened
ligament. Ligament injuries also can cause pain due to the increased
motion in the joints, as noted above, resulting in additional wear on
the joints and discs.
The pictures below show the referred pain patterns (the stippled areas) from the key low back ligaments.
muscles of the low back are critical for support, stability, and
movement. In fact, a human spine with all of the muscles stripped away
(leaving only the ligaments) will collapse under only 5 pounds of
force! Strong muscles help take stress off the discs, joints and
ligaments. In addition, strong muscles provide the endurance to perform
physically demanding tasks throughout the day. Think of the muscles as
the “shock absorbers” of the spine.
muscles of the low back work in close conjunction with the muscles of
the buttocks and legs to provide stability for the low back. This
coordinated muscle activation is so closely intertwined that, when one
muscle is not working properly, other muscles will begin to work harder
to compensate for it, leading to pain.
In addition, muscles
can also react to damage to the discs, joints and ligaments by
tightening up. Think of it as the body’s attempt to protect and
stabilize itself. This can cause chronic muscle tightness. It also can
cause trigger points to form in the muscles.
are small focal areas of muscle irritability. The pain from trigger
points can be either local or it can refer to other areas. It can be
steady or intermittent, dull and aching, often deep. It may occur at
rest, or only with movement. It varies from being a low-grade
discomfort to severe and incapacitating. Also, the pain from trigger
points can mimic other causes of pain, occasionally leading to wrong
diagnoses and unnecessary treatment.
brain is actually the most important “pain” structure. It is our brain
that interprets the various nerve signals as “pain” and then tells us
how to react or respond to them. Dr. Tortland recalls one patient who
had chronic back pain that failed to respond to all treatments—physical
therapy, manipulation, injections, medication—and she was discharged.
Several months later Dr. Tortland met her in the grocery store, and she
told him her back pain completely disappeared one week after she quit
While not all back pain is due to stress, stress and psychological factors certainly can play a role in back pain.
addition, as noted above the brain and central nervous system can
become sensitized in the face of chronic pain, resulting in persistent
pain processing, even long after the original injury heals.
Diagnosing Low Back Pain
no matter what someone tells you, there is no test available to
diagnose “pain” per se. X-rays, MRI’s, CT scans, bone scans, etc. look
at structures, but they cannot tell whether those structures are
causing pain, even if the structures are abnormal. As noted above, over
half of normal people with no back pain will have abnormal discs on an
Does that mean it’s worthless to perform these
studies? Absolutely not. At the very least, these studies can help tell
us what is NOT causing the pain, and they can help pinpoint possible
causes of pain. But it is an inexact science at best, the test results
need to be considered in the context of the clinical picture (symptoms,
physical exam, etc.).
Also, not every study needs to be done
to make a diagnosis. Not every case of low back pain requires an MRI or
even an x-ray. The experience and clinical judgment of the physician
should dictate whether a study will aid in the diagnosis and treatment.
History and Physical Exam
single greatest tool in diagnosing LBP is the History and Physical
Exam. How/when the pain started, where the pain is located and refers
to, what makes it better/worse, what treatments have been attempted—all
these are important to help understand potential causes of LBP. In many
cases, a thorough history alone can point to a probable cause.
Physical Exam of course gives the doctor an opportunity to look for
signs that may help indicate the source of the pain. An exam should be
more than simply having you bend forward and checking your reflexes! If
a doctor does not physically examine you—feel for tenderness, muscle
spasm, trigger points, restricted range of motion, muscle firing
patterns, etc.—it simply is an incomplete exam.
tests can be performed to help determine the cause of pain. These can
be as simple as certain tests of movement done in the office, to a
novocaine injection to numb a suspected cause of pain, to tests that
have to be done in a special facility.
For example, to help
determine whether a disc is causing pain, sometimes a discogram is
done. Under x-ray guidance, fluid is injected directly into the
suspected disc in an effort to reproduce the patient’s symptoms. If the
identical symptoms develop, then the disc is likely the source of the
Your doctor will advise you as to what additional tests he/she thinks are appropriate.
Treating Low Back Pain
texts have been written about treating LBP, but the following is an
overview, including the approaches we use here at Valley Sports
There is no medication
that exists that will completely eliminate pain. Period. The goal of
medication is reduce pain to a level that enables you to perform the
tasks of work and daily activities with the least amount of intrusion.
that are commonly used to treat pain include anti-inflammatory
medications, such as ibuprofen (Advil®, Motrin®), naproxen (Aleve®),
and Celebrex; Tylenol; various narcotic preparations, including
hydrocodone, oxycodone, morphine, methadone; and narcotic-like
medications, such as tramadol (Ultram®, Ultracet®).
that are not specifically pain medications but that are very useful in
treating chronic pain include various anti-depressants, including
Cymbalta® and Lexapro®; anti-seizure medications such as gabapentin
(Neurontin®) and pregabalin (Lyrica®); and central nervous system
medications such as Gabitril®.
Muscle relaxers also are commonly used, typically in combination with other medications.
often a combination of two or more different types of medications is
used in order to take advantage of the different mechanisms of action.
In addition, occasionally several different medications may be tried in
order to find the one(s) that best help treat the pain.
medication by itself is rarely the sole answer to treating pain.
Medication most often is used to help reduce the pain so you can pursue
the other treatments, such as exercise and physical therapy.
chronic low back pain, the goal of physical therapy more appropriately
is to improve function. In chronic pain, whether as a result of the
original injury or as a result of muscular compensation, most people
develop altered movement and muscle firing patterns. Some muscles
become weak or inhibited, while other muscles become tight or
over-activated. These altered muscle firing patterns lead to changes in
motor control, which then helps perpetuate the chronic pain.
therapy procedures such as hot packs, cold packs, ultrasound, and
electrical stimulation may help you feel better in the very short term,
but they do nothing to address the altered motor control problems.
Furthermore, most physical therapy stretches and exercises likewise not
only most often do not address the motor control issues, but more often
just reinforce the underlying muscle firing dysfunction. This is one of
the reasons why many physical therapy programs either do not help—or
even sometimes aggravate—chronic back pain conditions.
are two other problems with most traditional physical approaches to
treating chronic pain. First, most therapy clinics do not allow enough
one-on-one time between the patient and therapist. Many therapy clinics
have the therapist treating more than one patient at a time in order to
maximize revenue. Treating chronic pain requires at least 30 minutes,
and preferably 45-50 minutes, of dedicated one-on-one time. Second,
physical therapy for treating chronic back pain is best performed once
every 1-3 weeks over a several month period, not 2-3 times a week for
just a few weeks.
Most physical therapists, while
well-meaning and sincere in their desire to help patients, are not
properly trained in the rehabilitation techniques to identify and
address the underlying neuromuscular firing abnormalities. At Valley
Sports Physicians, we regularly send our therapists to special training
courses, taught by internationally-recognized rehabilitation experts in
chronic pain and motor control. Please see our section on Physical Therapy.
Manual treatment, such as Osteopathic Manipulative Treatment
or chiropractic treatment, can be a useful treatment as well. Rarely
does this type of treatment cure chronic back pain. However, it can
help improve and maintain mobility and help the other treatment
approaches work more effectively. Be careful, though—manipulation
treatments that are too frequent can actually worsen your condition by
creating further instability. In our opinion, there really is no
indication for manipulation treatment multiple times a week, and
usually not more than one or a few times a month.
There are a number of injection therapies that may be tried for the treatment of chronic LBP.
Trigger Point Injections
As noted above, trigger points are small focal regions of muscle
irritability that can cause local and referred pain. In addition,
trigger points prevent the muscle from being stretched fully. When you
try to stretch a muscle that has a trigger point in it, the stretching
activates the trigger point, causing the muscle reflexively to tighten
up. Trigger points are treated by injecting them with novocaine, then
almost immediately, while the trigger point is still numb, stretching
the muscle. Numbing the trigger temporarily inactivates it so you can
then stretch the muscle more fully. If you do not stretch the muscle
after doing the injection, you have almost wasted the injection. Many
times trigger points need to be treated multiple times in order to
“break” the cycle or pattern. If the triggers continue to return,
however, then there is usually something else going on that is causing
the triggers to form.
Epidural Steroid Injections
epidural space is the space between the dura mater (a membrane covering
the brain and spinal cord) and the wall of the vertebral column. It is
filled with fat and small blood vessels. It is located just outside the
dural sac. The dural sac surrounds the nerve roots and cerebrospinal
fluid (the fluid that the nerve roots are bathed in).
“epidural” is an injection that delivers steroid medication directly
into the epidural space in the spine. Sometimes a flushing solution
(either lidocaine or normal saline) is also used to help "flush out"
inflammatory proteins from around the area that may be the source of
There are often inflammatory factors and other
substances that generate pain that are associated with a lumbar disc
herniation, and this inflammation can cause significant nerve root
irritation and swelling.
Steroids (corticosteroids) have
been shown to reduce inflammation by inhibiting the production of
substances that cause inflammation. The epidural steroid injection can
be highly effective because it delivers the medication directly to the
site of inflammation.
Epidural injections can be used
diagnostically as well as therapeutically. If the diagnosis or cause of
the pain is unclear, particularly if there is a question about whether
a disc is causing the pain, an epidural can be done. If there is
significant pain relief, then it is more likely that the disc or
disc-related structures are causing the pain, and further treatment can
be directed accordingly.
Epidural injections are performed under special x-ray guidance by physicians properly trained in the procedure.
Facet Nerve Blocks
facet joint is the small bony joint on either side of the vertebrae.
Like all joints in the body, there is a nerve that innervates the
joint. As noted above, the facet joint can be sprained or undergo
arthritic change and cause pain. The nerve that innervates the facet
joint can be numbed temporarily to see if there is pain relief. Like
epidural injections, this is done under x-ray guidance.
is a special injection procedure designed to repair damaged ligaments
and tendons. Many times, low back pain is due to ligament and tendon
injuries (sprains & strains). If physical therapy and other
conservative treatments don’t help, prolotherapy may be indicated. A
more thorough discussion on Prolotherapy is contained elsewhere on this
Surgery may be indicated
for certain herniated discs or disc-related problems. However, most
studies indicate that over 90% of herniated disc do not require
surgery. Fairly recent technological advances have made disc
replacement surgery a reality for many patients, and a spine surgeon
can advise you as to whether you may be a candidate for this. However,
except for a few rare circumstances, surgery is almost always a last
Many alternative therapies may be useful as part of a comprehensive treatment plan for chronic LBP. These can include:
- Massage therapy
- Yoga or TaiChi
- Therapeutic Touch
Ask your doctor about the appropriateness of these for your particular condition.