Movement hacks: 4 easy ways to decrease back pain

1. Aim 

To give readers some easy to follow tests to help guide self administered interventions to manage and/or relieve lower back pain (LBP)

2. Intended Audience

The general public, recreational athletes and professional athletes.

3. Key Points

• You have a 50-80% chance of experiencing back pain in your life.
• Always look for red flags first. If you have any of these or you are unsure get to a qualified health professional.
• Clear the 4 keys test to investigate the origins of your back pain.
• Don't rest a bad back. Movement is the key to relieving back pain.
• Be consistent with the interventions everyday for at least 2 weeks. If there is no improvement in your symptoms or your re-tests, then get some professional help.

4. Introduction

Back pain, especially lower back pain, is a major global problem. The Global Burden of Disease study 2017 (1) shows that lower back pain is the leading cause of disability globally. In fact it has been in the number 1 spot since 1990, showing not only its prevalence but how badly we are addressing the issue.  It is a pain for the individual and a drain on society at large. In Western countries it is thought to cost governments 1-2% of gross national product (2). To put it another way €4,315 (approximately $4,840 or £3,923) per patient (2). Bearing in mind that 50% - 80% of adults will experience LBP at some point in their lives (3), often with recurring symptoms, it adds up to a lot of cash. This said it is only around 28% of cases that fall into the severe categories (2) with most back pain simply being due to a lack of activity or muscle imbalances. 

So what if I told you there were a few simple ways to clear some key culprits for causing back pain and therefore give you a guide as to whether or not you need to spend some of your hard earned cash seeing a professional? Read on to find out.

5. Red Flags 

These are things that should always be investigated by a professional just to make sure there is nothing more sinister occurring. 

• Tingling, numbness, coldness and/or loss of strength through the hips down to the feet. These can be indicators that there is neural or vascular involvement and should be investigated immediately.

• Saddle sign, problems with bowl movements and/or urination. The saddle sign is a worry as it may indicate an issue with nerves at the base of the spine called the cauda equina and you need to see a medical professional immediately to clear it.

Source: https://upload.wikimedia.org/wikipedia/commons/3/32/Saddle_anesthesia.png - Lesion / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)

• Unexplained weight loss or weight gain out of keeping with your current lifestyle.

• Abdominal pains associated with your back pain, especially if they coincide with blood in your stool or urine.

• Sudden onset especially when brought about with trauma.

These are some of the easier to identify red flags that should lead you to seek professional care ASAP. None of these symptoms mean there is anything wrong for certain, so don't panic if you have them. But they are indicators of potential more serious issues, which mean further investigations are needed. Bottom line though, if you unsure or you are worried, always get yourself down to a health care professional.

6. Quick check #1 - Leg Length

There is some data to suggest that a difference in leg length plays little to no role in back pain - unless it is extreme (approximately 1.5 cm and above). It is true that the majority of us have asymmetrical lower limbs and yes, it is true that lots of people with asymmetrical limbs don't have back pain. But there is other data to suggest that a Leg Length Discrepancy (LLD) does have a direct effect on lower back pain. One such study looked at meat packers (standing for long hours) and office workers (seated) finding that only a 6mm difference can have an effect on LBP symptoms for those standing all day. In fact an increased LLD meant more discomfort and more sick days off work (4).

Personally, I feel there is a direct association between LLD and clients who come to see me for back pain. It is quiet common that the only variable I have changed for a client, is their leg length, when low and behold their symptoms abate, often ceasing completely. This is why I think checking leg length is always a great place to start when experiencing back pain and most importantly it is really easy to do at home.

What you will need:

• A friend.

• A cloth measuring tape (tailors soft style tape).

• About 2 minutes of your time.

What you need to do (5):

• Lay flat on your back. Then have your mate locate the ASIS (Anterior Superior Iliac Spine) on your pelvis and the bottom of the heel on the same side. The ASIS is the most prominent bony point on the front of your pelvis roughly around your belt line.

Source: https://upload.wikimedia.org/wikipedia/commons/c/cc/ASIS_03_anterior_view.png - BodyParts3D is made by DBCLS / CC BY-SA 2.1 JP (https://creativecommons.org/licenses/by-sa/2.1/jp/deed.en)   

Surface anatomy for ASIS

• You then measure from the ASIS, to the bottom most point of the heel. Record the number and repeat on the other side. Exactly where you start measuring the ASIS from (above or below) doesn't actually matter. As long as you do the same for both sides. Remember it is not about getting an accurate figure for the actual length of the leg. You are only trying to find out how much difference there is between the two sides. So consistency is the key. 

If there is a difference of more than 5mm. It maybe worth making adjustments. This is particularly true if you are in a job that involves you being on your feet all day or you spend a lot of time on endurance  activities like hiking and running (ultra athletes especially).

 

How to fix it:

Differences up to 10mm are pretty easy to fix. To make up the deficit, take from one side and add to the other. For eample, if the right leg is short by 8mm, then we can take the insole out of the left shoe and add a standard insole (no shaping or contouring to adjust how the foot moves) on the right. Insoles are normally around 2mm, so this will adjust the total deficit to around 4mm, which the body is more than capable of adjusting for. If we are above 10mm it can become a little more tricky.  There is only so much we can raise the insole in one shoe before your toes begin to get crushed and cause other issues. This often requires purchasing shoes that are a half size bigger to allow thicker (or double) insoles or actually trimming the sole of one shoe at a cobblers. Bear in mind most people with an LLD will sit between 5-10mm.

Do not be tempted to only raise the heel, as suggested by many. Yes, it does address the LLD but changes the mechanics at the foot, ankle and calf, which in the long run can harm you.

Although this is not the most accurate method for measuring leg length, it does give you a ball park figure to point you in the right direction.

Structural "true" LLD and functional "apparent" LLD:

Structural LLD is what we have dealt with above. However, there is also functional LLD. This is where muscle imbalances around the back and pelvis cause the LLD. It is very common and often directly linked to LBP. This is a whole article on its own so won't address it here but worth knowing.

7. Quick check #2 - The Lateral System (LS) 

To give a "thumb suck" statistc, I would say that at least 90% of all chronic lower limb issues with concurrent lower back dysfunction, are related in some way to a dysfunctional LS. I would go on to estimate that at least 80% of chronic lower limb injuries - with out lower back involvement - can be attributed directly to a dysfunctional LS. So what is it and why is it so important? 

Throughout our body we use force couples to create co-ordinated and often powerful movements.  This is whereby two or more sets of muscles work in concert to bring about the same action around a joint or joints. The LS is simply a term which was coined to describe a specific force couple to stabilise the pelvis in the frontal plane (i.e. looking at the body from the front or the back). 

Schematic showing a basic force couple

There are 3 other key slings (force couples) in the body; Anterior Oblique Sling, Posterior Oblique Sling and the Deep Longitudinal Sling. They are all important in their own rights but I find the one that should always be investigated first is the LS, as correcting it nearly always helps to decrease lower limb issues and LBP. If you are keen to read up on the slings look up "The Outer Unit" as proposed by Paul Check(6), whereby he gives a great introduction to the research contributing to the topic.

The LS comprises the quadratus lumborum (QL), the opposite (or contralateral) gluteus medius/minimus and the adductors (6). In the picture below, the left QL pulls the L side of the pelvis up, whilst the R glute med/min pulls the R side of the pelvis down. The adductors then play a supporting role to stabilise the hip. In doing so the pelvis remains level and stable during motion.

Source: Adapted from - https://www.healthwisecarecenter.com/single-post/2019/01/10/The-Lateral-Subsystem

What you will need:

• A mirror or phone to record a video

What you need to do:

• Stand on one leg, with your unloaded leg to the rear.

Single leg stance

• If your hips aren't level, your knee rotates towards your midline, your body rotates around the loaded leg, your trunk bends to one side or one of your shoulders elevates (and any combination thereof), you likely have an issue with your LS.

How to fix it: 

This can vary from individual to individual. But despite the variability in any one persons needs, there are some good "go to" drills that will give results for the majority of people.

The first is performing clams. In the video below you will see the preferred clams techniques. These techniques differ to many of the sources you will find because often clams are done with out linking the hip (glute med/min) to the opposite low back (contralateral QL). Although these help to increase the strength in the glute med/mins, it does nothing to retrain the force couple between the QLs and the glute med/mins. We have to have an integrated force couple focusing on how the brain organises the movement, in order to have a functional LS. You need to build to 20 of each variation, back to back on one leg, so 60 total. This is the baseline that you should be able to achieve.

The Clams Matrix

The next is hip hitching. Often done in standing with both legs locked, however, I much prefer to do this drill in a bulgarian squat position. The main reason being it places you in a position more akin to the running or walking stance.  As a result you train the portions of the muscles that work the hardest when we locomote. The video below explains the technique. Perform the drill as often as you can, for 2mins at a time over the course of the day, 4-7 days a week, until it becomes easy.

Hip hitching - bulgarian squat variation

These are the basic drills that you should be able to perform if your LS is working well.

7. Quick fix #3 - Hip rotational mobility

The human body is pretty resourceful thing. If something isn't doing its job then something else will take up the slack to meet the demand much like in any team in sport or work place. Take rugby for example. If Steve isn't pulling his weight on the wing then, Dave has to work extra hard in the centre to cover. The results are inevitable a.) Dave doesn't have the fitness to cover 1.5 positions and the opposition gets through from the start or later in the game as he tires i.e. the team doesn't function very well b.) Dave works like 10 men and ends up getting injured because he is so fatigued from the higher the normal work rate. The human body is the same. HQ (the brain) makes the demand and the body will then make a plan to meet that demand. 

The relationship between the hips and the lower back is much the same as that between Steve and Dave. If the hips aren't doing their job then the lower back tends to take up the slack. The result is you manage to get by but in pain or you simply can't perform certain activities like touching your toes because you can't flex or performing a back hand in tennis because you can't rotate properly to one side.

The hip is an interesting joint because not only is it required to be very stable it is also required to be very mobile. Unless there are underpinning structural issues most people have pretty stable hip joints, however, what most people struggle with is the mobility bit. Of particular note is the range and balance between internal and external hip rotation. If we have restrictions in to these ranges of motion then the lower back takes up the slack. 

The problem is lumbar spine is designed more for stability then it is for mobility. Not only this but the mobility it prefers is flexion, extension and lateral flexion (side-to-side bending), not rotation. This is all to do with the alignment of the facet joints (a.k.a zygapophyseal joints). In the cervical spine these joints are almost horizontal permitting large amounts of rotation, approximately 65-75º but as we move down the spine the ability to rotate becomes less as the facet joints become more vertically aligned. The thoracic spine has around 35º and the lumbar only 5-7º (7).

Cervical Facet Joints

Lumbar Facet Joints

So we only need to lose a relatively small amount of rotation at our hips in order to place excessive burden on our lumbar spine. Thoracic spine also has a major part to play in burdening the lumbar spine but we will discuss this in a further post all about the "Mobility Sandwhich".

This structure of the spine is one of the main reasons that traditional rotation exercises such as the one below are completely ineffectual and potentially make matters worse as they are often mobilising the wrong part of the system. The team isn't achieving results because Dave (lumbar spine) is overloaded (too much or imbalanced rotation demanded) and so is performing poorly (pain or poor function). You then use the kind of drills below that basically hump more demand on Dave. But the issue all along is Steve not Dave. 

Traditional spine mobility drill for lumbar rotation

Source: https://www.pinterest.com/pin/318066792410290179/

What you will need:

• A friend and some space on the floor

What you need to do:

• Supine test - Lay on your back. Your friend will then raise your knee above your hip with your shin parallel to the floor. From here rotate the leg externally and internally. There should be no movement in the trunk when rotating. We are only looking for movement at the hip. We should be able to get around 45º internal and external rotation.
• Prone test. Same principle as the supine test except this time you are on your front with your knees bent to 90º. Your partner then rotates the legs for you. Often in this position we can get slightly higher ranges due to the position of the hip joint but, again we should be looking for around 45º in both internal and external rotation. 
• Palpation. If you lay on your side and dig into the glute medius and minimus it should be uncomfortable at most. If it feel like someone has reach in and plucked out your very soul through your hip, this is not normal. The glute med/min can't function when they are in that state so it needs addressing.

Prone and supine hip rotation tests - Source: 

http://www.fiveringsathletics.com/blog/fixing-the-split-jerk-a-case-study-of-femoral-retroversion.html

Palpation of glute med/min in side lying

Primarily we are looking for balance between the hips and balance around the hip. If you are lacking internal rotation on the right hip then we would like to see a lack of rotation on the left and the requisite decrease in external rotation for each hip also. Stiff but in balance, beats mobile but way out of balance every time. Of course if you are extremely stiff this is an issue in its own right. If you have lost 15º of mobility all round this will definitely be causing you problems in your global movement. But the biggest factor here for back pain is the asymmetry between internal/external hip rotation and between left and right hips. 

How to fix it:

There are various ways to address internal and external rotation but these some solid ones to begin with  that will give you good results, fast.

• Seated groin mobilisation.  This drill encourage you to actively engage into external rotation and abduction (moving away from your midline). See the video below. Spend approx 2 mins each side. As a sore spot starts to ease off move to a new tender spot. If the area becomes bruised or very tender leave it for a few days to settle. Its not good to massage over bruised tissue. Eventually you should be able to get into the area every day. 

Seated groin mobilisation

• Hockey ball mob for glutes. This drill encourages you to engage into internal rotation and adduction (moving towards the midline). See video below. Spend approx 2 mins on each side. Same per the groin stretch you may need to leave the area to settle for a few days especially if it is bruised, but eventually you should be able to get into the tissues every day.

Hockey ball mobilisation for glutes

Re-test your rotations every few days and you should find it steadily improving and with it, your back pain If not it may mean there are other drills you need to do in which get in touch and we'll have a look at you.

8. Quick check #4 - Modified Thomas Test

Technically this is another hip mobility check but because some of the muscles involved in this test directly attach to the lower back I have placed it in a separate section.

The Modified Thomas Test (MTT) is used primarily to check the length of your hip flexors at the front of the hip, however, it also gives extra information about other structures that are effecting the way you move in general.

Deep hip flexors - Psoas major and iliacus (they come together to form the iliopsoas)

Source: Adapted from - https://www.yogateket.com/blog/hip-flexor-psoas-and-yoga

Rectus Femoris - classed as a 2 joint hip flexor as it effects the hip and the knee

Source: https://www.pinterest.com/pin/563512972097893804/

If your hip flexors are tight then the likelihood is, that when you try and extend your hip, your lumbar spine will be forced in to excessive extension. The issue with this is that too much extension leads to alot of compressive force through the lower back, which can aggravate it. The stiffness in hip flexors can also lead to shearing forces, which again, can aggravate the lower back. Even if you don't experience any back pain, but still have tight hip flexors, you are hampering your performance. Especially in activities which involve running. With out good hip extension you are not utilising your butt properly. This is one of the most powerful muscles in the body and without the ability to access decent hip extension you're on a hiding to nothing.

What you will need: 

• A friend to look at you or a video camera set up so you can review your movement.
• A massage couch, kitchen table or anything else that is at least mid thigh height and firm. Do not do it on your bed for example. You will sink into it too much to be effective for the test.

What you need to do:

• See the videos below.
• Viewed from the side (sagittal plane), you are looking for the lumbar spine to be flat with the bed, thigh parallel to the bed, knee approximately 90º.
• Viewed from the leg end (transverse plane), you are looking for the foot, ankle, knee and hip to all line up. So no rotation and no Ab/Adduction (knee drifting in or out of line with the hip).

The main issues we are looking for here are all the faults when viewing from the side. Make sure you test both sides. As with the other tests we are looking for that symmetry left to right.

How to do the MTT

MTT faults in side view (sagittal)

MTT faults from the leg end (transverse plane)

How to fix it:

The first thing is to release the deep hip flexors. The psoas can be a bit tricky without some help but the iliacus is easy to get on to by your self. You will do this until the tenderness drops off and/or the function returns. If neither happens do it for no longer than 2 minutes.

Iliacus release

Next is to release the rec fem in a lengthened position. There are various ways to do this but I prefer doing it from the 90/90 hip stretch position to begin with. As with the other drills spend around 2 mins on each side. If one side feels a lot worse then the especially if it tested tighter during the MTT, the focus on that side first to regain some balance.

90/90 rec fem release

5. Summary

So there you have it. 4 quick checks that you can do at home, that will give you a road map to decreasing your back pain. If you get a positive test but the drills here don't help you let me know. You may need to try something else. But most of the time these drills, if done consistently every day for 2 weeks, should give you a marked improvement when you re-test and therefore an improvement in your back pain. I hope you have found this post informative and helpful, if so please subscribe to the blog, YouTube, Instagram and/or Facebook. Cheers!

References

1. Findings from the Global Burden of Disease Study 2017. Healthdata.org. 2018.http://www.healthdata.org/sites/default/files/files/policy_report/2019/GBD_2017_Booklet.pdf (accessed 27 Jun 2020).

2. Dutmer A, Schiphorst Preuper H, Soer R et al. Personal and Societal Impact of Low Back Pain. SPINE 2019;44:E1443-E1451. doi:10.1097/brs.0000000000003174

3. Fatoye F, Gebrye T, Odeyemi I. Real-world incidence and prevalence of low back pain using routinely collected data. Rheumatology International 2019;39:619-626. doi:10.1007/s00296-019-04273-0

4. Rannisto S, Okuloff A, Uitti J et al. Leg-length discrepancy is associated with low back pain among those who must stand while working. BMC Musculoskeletal Disorders 2015;16. doi:10.1186/s12891-015-0571-9

5. Sabharwal S, Kumar A. Methods for Assessing Leg Length Discrepancy. Clinical Orthopaedics and Related Research 2008;466:2910-2922. doi:10.1007/s11999-008-0524-9

6. Chek P. The Outer Unit | Article | PTontheNet. Ptonthenet.com. 2006.https://www.ptonthenet.com/articles/The-Outer-Unit-102 (accessed 15 Jul 2020).

7. Neumann D. Kinesiology of the musculoskeletal system: Foundations for rehabilitation. 2nd ed. St. Louis, Mo.: : Mosby/Elsevier 2010.