#287 ‒ Lower back pain: causes, treatment, and prevention of lower back injuries and pain | Stuart McGill, Ph.D.
Stuart McGill, Professor Emeritus and CSO at Backfitpro Inc., delves into lower back pain, covering anatomy, pathophysiology, and challenging the concept of non-specific pain. He emphasizes finding causal relationships, empowering patients, and shares protocols for strength, stability, and maintaining a healthy spine.
Deep Dive Analysis
16 Topic Outline
Peter Attia's Personal Journey with Lower Back Pain
Anatomy of the Lower Back: Spine, Discs, Facet Joints
Mechanisms of Disc Injury: Delamination, Bulges, and Innervation
Why Lower Lumbar Joints (L4-S1) are Prone to Injury
Pathophysiology of Acute Disc Herniation and Immune Response
The Concept of Stability and its Role in Performance and Injury Prevention
Introduction to the McGill Big Three Exercises for Core Stability
The Importance of Movement Patterns: Squats, Deadlifts, and Longevity
Addressing Psychological Trauma and Empowerment in Back Pain Patients
The Myth of Nonspecific Low Back Pain and Mechanistic Assessment
When Surgical Intervention for Back Pain is Appropriate
Understanding Nerve Pain, Stenosis, and Tarlov Cysts
Limitations of MRI and Dynamic Assessment for Back Pain Diagnosis
Impact of Muscle Bulk and Arthritis on Joint Stability and Pain
Advice for Maintaining a Healthy Spine and Avoiding Pain
Resources for Back Pain Education and Qualified Clinicians
7 Key Concepts
Disc as Biological Fabric
The intervertebral disc is a flexible structure made of concentric rings of collagen fibers (a biological fabric) holding a pressurized gel. This design allows for spinal flexibility and efficient dimensions, but its fabric-like nature makes it susceptible to delamination from repetitive stress-strain reversals.
Proximal Stiffness
Proximal stiffness refers to creating rigidity in the core (torso) to stabilize the body's linkage. This allows for efficient force transmission from the hips and shoulders, preventing 'energy leaks' and enabling powerful distal movements in athletes, while also protecting the spine from injury.
Open Fissured Disc Bulge
This is a type of disc injury where the outer collagen fibers delaminate, allowing the inner nuclear gel to seep out through an opening. It often causes acute, debilitating pain, but can sometimes be 'vacuumed back in' with specific movements or rest, leading to temporary resolution.
Nonspecific Back Pain
Stuart McGill asserts that 'nonspecific back pain' is a myth. He believes that every instance of back pain has a specific mechanical cause or 'pain mechanism' that can be identified through a thorough assessment, even if it's not immediately obvious from imaging alone.
Virtual Surgery
A non-surgical approach for patients told they need surgery, involving strict adherence to a behavioral protocol that mimics the forced rest and careful progression of post-surgical recovery. It aims to strategically desensitize the pain mechanism and retune the body with appropriate mobility, stability, and movement skills.
Russian Descending Pyramid
A training method used for building endurance and stiffness, particularly for core exercises like the side plank. It involves performing repeated short bursts (e.g., 10 seconds) of an exercise without reaching full fatigue or breaking form, which helps build endurance and neural stiffness.
Strain as Injury Metric
Tissue damage is primarily caused by strain (deformation) on the tissue, not simply the applied force or pressure. Different biological structures (e.g., thin cervical vertebrae vs. thick lumbar vertebrae) tolerate different types and amounts of strain, explaining why certain regions are more prone to specific injuries.
10 Questions Answered
The lower back consists of vertebrae, which are stacked bones forming a flexible rod, intervertebral discs that act as biological fabrics providing flexibility and stiffness, and facet joints at the back of the vertebrae that guide motion.
These lower lumbar joints are the thickest part of the spine, making them less tolerant to bending stresses compared to compression. Their shape (often limacon in larger individuals) also creates stress risers when twisting, and facet joint orientation can predispose to conditions like spondylolisthesis.
A healthy, virgin disc typically has no vascular tissues or nerves within its nucleus because high intradiscal pressure kills them. However, when a disc is damaged and loses its ability to contain pressure, vascular sprouts and nerves grow into the damaged area, making the disc capable of feeling pain.
Repeated heavy lifting, especially with poor form, can cause delamination of the disc's collagen fibers from the inside out. Eventually, the outermost layer is breached, and the nuclear gel extrudes, triggering a strong inflammatory immune response because the immune system encounters this material for the first time.
Core stability creates proximal stiffness in the torso, which prevents 'energy leaks' during movement, allowing muscles to efficiently transfer force to the limbs for faster and more powerful actions (e.g., punching, cutting). This controlled stiffness also protects the spine from excessive shearing motions and deformation, reducing injury risk.
The 'McGill Big Three' are a modified curl-up, side plank, and bird dog. They are designed to create proximal stiffness and stability in the core while sparing the spine, helping to build endurance and neural stiffness that improves performance and reduces pain by controlling unwanted spinal motion.
Surgery is best indicated for clear red flags (e.g., aortic aneurysm, tumors), when the pain pattern doesn't fit a mechanical explanation, or in cases of severe stenosis (narrowing of the neural canal), significant spondylolisthesis causing nerve compression, or certain spondylomyelopathies in the neck. It's often a last resort after conservative methods fail to arrest shearing movements or nerve trapping.
Psychological trauma can be addressed by empowering patients through a clear understanding of the mechanical mechanism of their pain. By demonstrating how specific movements or postures trigger and relieve pain, and providing strategies to mitigate these triggers, patients gain control and realize the pain is not 'in their head,' which can significantly reduce distress and improve outcomes.
Young people should focus on developing 'sufficient strength, sufficient mobility, and sufficient endurance' rather than constantly chasing maximum effort personal bests in lifts like deadlifts. They should learn proper movement mechanics, avoid excessive spinal flexion/extension under heavy load, and prioritize a well-rounded, sustainable athleticism that spares their joints.
Individuals should start by reading 'Back Mechanic' for self-assessment and understanding their pain mechanism. For professional help, the backfitpro.com website lists certified clinicians (who completed a 50-hour course and exams) and master clinicians (personally trained by Stuart McGill) who specialize in mechanistic back pain assessment and treatment.
34 Actionable Insights
1. Understand Pain Mechanism for Empowerment
Seek a healthcare provider who focuses on understanding the specific mechanical mechanism of your back pain, as this knowledge can empower you, alleviate psychological distress, and guide effective mitigation strategies.
2. Demand Dynamic Pain Mechanism Assessment
When seeking help for back pain, ensure your assessment includes dynamic observation of your movement, palpation of muscles, and testing specific postures to identify the precise mechanical triggers of your pain, rather than relying solely on static imaging.
3. Perform McGill Big Three for Core Stability
Incorporate the McGill Big Three exercises (modified curl-up, side plank, bird dog) into your routine to build core stiffness and stability, which can enhance athletic performance, prevent injury by reducing energy leaks, and provide temporary pain relief.
4. Prioritize Core Stability to Prevent Injury
Prioritize developing core stability to prevent ’energy leakage’ during movement, as this not only enhances performance but critically reduces the predisposition to injury, especially as you age.
5. Read “Back Mechanic” for Self-Assessment
Read ‘Back Mechanic’ by Stuart McGill to conduct a self-assessment, understand the specific mechanism of your back pain, and learn strategies to mitigate it, as it guides you through identifying pain triggers and appropriate exercises.
6. Avoid Simultaneous Load and Motion
Avoid excessive simultaneous load and motion, especially at end ranges, to prevent delamination of disc fibers, which can lead to disc damage and pain.
7. Don’t Mix Spinal Adaptation Schedules
Do not mix adaptation schedules for spinal training; if you train for powerlifting, focus on torso stiffness, and for yoga, focus on flexibility, to prevent specific injury patterns.
8. Prioritize Sustainable Athleticism Over Max Lifts
For middle-aged individuals, re-evaluate deadlift goals; prioritize sustainable athleticism for long-term joint health and the ability to perform daily tasks over setting personal bests, which can cause micro-fractures and lead to joint issues.
9. Aim for Sufficient Fitness, Not Max
Shift your fitness mindset from maximizing every strength, mobility, or endurance metric to achieving ‘sufficient’ levels in each, which promotes sustainable joint health and overall well-being, avoiding both rust-out and wear-out.
10. Allow Natural Inflammatory Response
If experiencing a disc herniation, consider allowing the natural inflammatory response to occur for about two weeks, as recent data suggests it helps the immune system clean up extruded disc material, potentially making anti-inflammatory drugs counterproductive in the long term.
11. Address Low-Grade Aches with Posture
For low-grade back aches, explore postural adjustments and targeted relaxation techniques (e.g., lying on tummy, deep breathing, specific hand placement under hips) to address micro-movements and muscular tension, potentially avoiding the need for muscle relaxants.
12. Practice Subtle Postural Cues
Practice subtle postural cues like softening your knees, pulling your chin back (ears over shoulders, shoulders over hips), and opening your hips to achieve muscular relaxation and reduce spinal load, which can alleviate chronic tension.
13. Train Core with Russian Pyramid
When performing core exercises like the McGill Big Three, use the Russian descending pyramid approach: repeated 10-second intervals to build endurance and stiffness without reaching fatigue or breaking form, allowing for higher training levels.
14. Time Big Three for Pain Relief
If the McGill Big Three provides temporary pain relief, schedule 12-minute sessions mid-morning and mid-afternoon to maintain core stiffness and manage pain throughout the day.
15. Utilize Alternative Leg Strength Training
Incorporate alternative leg strength training methods like sled work, backwards walking up hills, and monster walks to build sustainable athleticism and endurance, sparing joints from the high axial loads of traditional squats and deadlifts.
16. Develop Strong Grip Strength
Develop and maintain strong grip strength through activities like carrying heavy objects or chopping wood, as it serves as an excellent proxy for longevity and reflects overall body work and stability.
17. Consider “Virtual Surgery” for Back Pain
If advised surgery for back pain, consider ‘virtual surgery’ by strictly adhering to forced rest, strategically desensitizing your pain mechanism, and gradually re-tuning your body with specific mobility, stability, and movement skills to avoid replicating the initial problem.
18. Treat Movable Nerve Pain Conservatively
If experiencing nerve pain or sciatica, seek an assessment that can determine if the pain can be ‘moved’ (made worse or better) through specific movements or postures, as this indicates a mechanical component that can often be successfully treated conservatively without surgery.
19. Identify Best Surgical Indications
Understand that surgery is often most effective for severe spinal stenosis (encroachment from front and back), significant spondylolisthesis causing nerve compression, or post-traumatic instability, where mechanical decompression or stabilization is critical.
20. Recognize Red Flags for Urgent Care
Be aware of ‘red flag’ symptoms (e.g., unexplained weight loss, fever, bowel/bladder changes, severe progressive neurological deficits) that warrant immediate medical investigation, as these indicate serious conditions requiring surgical or urgent medical intervention, not conservative back pain management.
21. Value Dynamic Over Static MRI Assessment
Recognize that MRIs are static images and may not reveal dynamic pain triggers like spinal instability or ‘clunking’ movements; a dynamic assessment (e.g., with a skilled clinician) is crucial to understand the true mechanism of pain.
22. Control Spinal Clunking with Deep Flexors
To control spinal instability and ‘clunking’ that causes pain, activate deep flexor muscles by pushing your tongue hard to the roof of your mouth behind your front teeth and grimacing down, maintaining this controlling stiffness during movement.
23. Embrace Arthritis for Joint Stability
Understand that some degree of arthritis can actually contribute to joint stability, particularly in the spine, and may lead to a reduction in pain over time, even if it results in decreased mobility.
24. Minimize Lower Spine Bending Stress
Be aware that the lower lumbar spine (L4/L5/S1) is more susceptible to bending stresses due to its thickness and disc shape, making it crucial to minimize excessive bending, especially under load.
25. Rest Week Between Heavy Deadlifts
If engaging in heavy deadlifts, ensure at least a week of rest between sessions to allow for bone callus formation and prevent the accumulation of micro-fractures, which can lead to more severe injuries if training too frequently.
26. Understand Tissue Load Responses
Understand how different biological structures in the spine (e.g., bone, disc) respond to various loads (tension, compression, shear) to avoid specific types of damage, as tissues deform differently under these forces.
27. Prevent Disc Damage to Avoid Hypersensitivity
Understand that disc damage can lead to the growth of new nerves and blood vessels into the disc, making it more sensitive to pain, highlighting the importance of preventing initial injury.
28. Respect Spine’s Engineered Trade-offs
Recognize that the human spine is a perfectly engineered structure with inherent trade-offs between flexibility and load-bearing capacity, meaning certain movements or loads may lead to damage if not respected.
29. Learn from Elite Athlete Movement
Do not dismiss insights from elite athletes’ training, as their movement efficiency and strategies for managing load can be adapted to improve mobility, strength, and injury prevention for people of all ages and conditions.
30. Master Fundamental Movement Patterns
Learn and practice fundamental movement patterns, such as proper squat mechanics for sitting and standing, to restore function, prevent injury, and maintain independence, especially for daily activities like getting off a toilet.
31. Counter Sedentary Work with Activity
Be mindful that sedentary work, particularly prolonged sitting, can lead to a decline in health and fitness; proactively integrate physical activity and movement breaks throughout your day to counteract this.
32. Recognize Triggers for Behavior Change
Recognize that motivating significant behavioral change, especially for long-term health benefits like spinal longevity, often requires a personal realization stemming from sufficient discomfort or a compelling reason, as short-term sacrifices are difficult without immediate pressing needs.
33. Find McGill-Certified Clinicians
If self-assessment is insufficient, seek out certified or master clinicians trained in Stuart McGill’s methods via backfitpro.com, as they are equipped to conduct thorough mechanistic assessments of back pain.
34. Adopt Restrictive Lifestyle Trial
To potentially improve blood markers and overall health, consider adopting a more restrictive lifestyle, similar to Peter Attia’s, by reducing alcohol consumption and adhering to a disciplined diet for a trial period, as Stuart McGill did to test its impact on his genetics.
6 Key Quotes
You cannot push rope, but you can push stone.
Stuart McGill
The price that you pay though, is being a structure of many collagen fibers. Let's take my shirt, which is a fabric. If I wanted to delaminate the fibers, I would have to create stress strain reversals back and forth and slowly we would debond the fibers. This is what happens to people's discs.
Stuart McGill
Don't mix up the adaptation schedules. So if you want to be a power lifter, train your hip mobility, shoulder mobility, but torso stiffness. Try not to throughout the day do a lot of bending versus the yoga master. Please stay away from the very heavy loads.
Stuart McGill
I don't have to leave my home, do I?
Elderly patient
They stole my career from me, giving me that book, how to live with my back pain. Why didn't anyone show me what my pain was like you just did in 30 seconds?
Police officer patient
A little bit of arthritis and people are going to nail me for this one, but a little bit of arthritis is good for adding certain amount of joint stability and holding it all together.
Stuart McGill
4 Protocols
McGill Big Three Core Stability Exercises
Stuart McGill- Modified Curl-up: Lay on your back with hands under your low back, lift elbows, hover head, neck, and shoulders. Propel abdominal contraction, breathe through pursed lips, allowing the diaphragm to work.
- Side Plank: Perform on the floor, supporting body on one forearm and foot. Hold for 10-second intervals, using the Russian descending pyramid approach (repeated short exposures without fatigue).
- Bird Dog: Extend one leg and the opposite arm simultaneously. Focus on activating one half of the low back and one half of the upper back on the opposite side, creating stiffness and stability.
Virtual Surgery for Avoiding Spinal Surgery
Stuart McGill- Behave like a post-surgical person: Adopt a mindset of forced rest and careful movement.
- Strategically desensitize the pain mechanism: Identify and avoid specific movements or postures that trigger pain.
- Retune the body: Implement strategic mobility, stability, and movement skill exercises.
- Avoid replicating stress concentrations: Learn and practice new movement patterns to prevent re-injury.
- Gradually build back activity: Slowly increase workload and activity levels as pain subsides and function improves.
Movement Pattern for Getting Off a Toilet (Elderly Patient)
Stuart McGill- Place hands on thighs: Put kneecap between thumb and hands, sliding hands down the thighs.
- Lean forward: Become a 'leaning tower' by pitching the torso forward.
- Anti-shrug shoulders: Relax shoulders down, avoiding shrugging.
- Pull hips through: Use hip muscles to pull hands up the thighs, rather than lifting with the back.
- Spread feet apart: Position feet wider for a stable base.
- Pull heels underneath: Bring heels closer to the body for leverage.
- Sniff air: Take a quick breath to engage core.
- Lean forward and squat: Execute a controlled squat movement, maintaining proper form.
Relieving Low-Grade Aches and Muscle Tension
Stuart McGill- Lay on your tummy: Find a comfortable prone position.
- Hand placement: Place hands palms up under hips, or make a fist under hips, to find a relaxation point.
- Melt into the table: Every time you exhale, consciously relax and 'melt' into the supporting surface.
- Postural adjustments (if standing): Poke head forward (muscles on), then pull chin back (muscles off) to find neutral.
- Soften knees: Avoid ramming knees back into hyperextension, maintain 'jazz knees' (slightly bent).