Lower back pain: causes, treatment, and prevention of lower back injuries and pain | Stuart McGill, Ph.D. (#287 rebroadcast)
This episode features spine biomechanist Stuart McGill discussing lower back pain, challenging the concept of non-specific pain, and emphasizing individualized assessment. He shares insights on spinal anatomy, injury mechanisms, the "McGill Big Three" core exercises, and the importance of stability for longevity and performance.
Deep Dive Analysis
15 Topic Outline
Peter Attia's Personal Journey with Lower Back Pain
Anatomy of the Spine: Vertebrae, Discs, and Facet Joints
Mechanisms of Disc Injury and Pain Pathophysiology
Why Lower Lumbar Spine is Prone to Injury
The Role of Inflammation and Muscle Relaxants in Back Pain
Understanding Core Stability for Resilience and Performance
Stuart McGill's Big Three Core Stability Exercises
Stuart's Perspective on Squats and Deadlifts for Longevity
Addressing the Psychological Trauma of Back Pain
The Importance of Mechanistic Assessment for Back Pain
When Surgical Intervention for Back Pain is Appropriate
Treating Nerve Pain, Weakness, and Stenosis
Limitations of MRI in Diagnosing Dynamic Pain Triggers
Advice for Maintaining a Healthy Spine Throughout Life
Resources for Individuals Dealing with Lower Back Pain
8 Key Concepts
Flexible Rod (Spine)
The spine is a series of vertebrae forming a flexible rod, allowing for diverse movements. However, to bear load effectively, this flexible rod must be stiffened, similar to how a rope cannot be pushed but a stiff object can.
Disc as Biological Fabric
Spinal discs are not ball-and-socket joints but rather a fabric of concentric collagen fibers. This design provides stiffness at the end ranges of motion, offering tremendous evolutionary efficiency for a slender and mobile torso.
Stress Strain Reversals
Repeated bending and loading can cause the collagen fibers within a disc to delaminate from the inside out. This process eventually allows the pressurized nuclear gel to seep through, leading to disc injury and pain.
Innervation of Damaged Discs
A healthy, virgin disc typically lacks blood vessels and nerves due to high intradiscal pressure. However, when a disc is damaged and loses its ability to contain pressure, vascular and neural sprouts grow into the injured area, making the damaged disc capable of feeling pain.
Proximal Stiffness
Creating stiffness in the core (torso) is crucial for efficient force transmission from the hips and shoulders. This proximal stiffness prevents energy leaks, enhances distal athleticism and power, and reduces the risk of injury by stabilizing the spinal linkage.
Non-Specific Low Back Pain (Myth)
Stuart McGill contends that 'non-specific low back pain' is a misnomer. He believes that almost all back pain has a specific mechanical cause or trigger that can be identified through a thorough, individualized assessment, leading to targeted treatment.
Virtual Surgery
This is a strategic, non-surgical protocol designed to mimic the forced rest and structured rehabilitation of post-surgical recovery. It involves desensitizing pain mechanisms and retraining the body with specific mobility, stability, and movement skills to avoid the original stress concentrations, often allowing patients to avoid actual surgery.
Sufficient Strength
This concept advocates for training to achieve adequate strength, mobility, and endurance to meet life's demands and ensure longevity, rather than continuously pursuing maximal strength (e.g., lifetime personal records in heavy lifts). The latter can lead to excessive joint wear and injury.
10 Questions Answered
These segments are the thickest part of the spine, which makes them excellent for tolerating compression but less tolerant of bending compared to thinner segments. Additionally, the shape of the discs in larger individuals (limacon) can create stress risers when twisted, contributing to injury vulnerability.
Disc pain, often associated with open fissured disc bulges, is typically acute, debilitating, and can resolve within a couple of weeks. Facet joint pain, which often develops years after a major disc injury due to increased load on the facets, is more of a slower-onset ache that can take two to three months to wind down.
When the nuclear gel from a damaged disc extrudes and encounters the blood immune environment for the first time, it triggers a strong inflammatory response. While painful, this response is crucial for bringing in immune cells like macrophages to help reabsorb the extruded disc material, aiding long-term recovery.
The 'Big Three' are the modified curl-up, the side plank, and the bird dog. They are crucial for building proximal stiffness in the core, which spares the spine from excessive load while performing movements, enhances athletic performance by improving force transmission, and helps prevent injuries.
Proximal stiffness in the core acts like stabilizer bars on a backhoe, allowing for efficient force transmission from the hips and shoulders without collapsing the body's linkage. This prevents energy leaks, boosts power (e.g., punching harder, faster cuts), and reduces the risk of injury by creating a stable foundation for movement.
Surgery is recommended for clear red flags (e.g., tumors, aortic aneurysm, lung embolism, metastasized cancer), when the pain pattern doesn't fit a mechanical explanation, or for severe conditions like heavy stenosis (narrowing of the neural canal), significant spondylolisthesis that chokes nerves, or certain post-trauma cases requiring stabilization.
Yes, often. If the nerve pain can be moved or altered during a thorough assessment (made worse or better with specific movements), it indicates a mechanical trigger that can frequently be managed through strategic movement patterns, targeted stability exercises, and avoiding aggravating postures, even in elite athletes.
MRI is a static image and doesn't always reveal dynamic pain triggers like micro-movements or instability. Individuals with strong, bulky musculature can maintain joint stability despite disc degeneration, leading to less pain. Conversely, those with insufficient muscle bulk and excessive joint mobility can experience significant pain even with healthy-looking discs due to instability.
The key is to avoid repeated insults to the spine, such as prolonged poor posture (e.g., sitting 'like a cashew') and excessive bending with heavy loads. Instead, cultivate sufficient, well-rounded physical activity that builds sustainable strength, mobility, and endurance, rather than waiting for pain to force behavioral change.
Stuart McGill recommends starting with his book 'Back Mechanic' for self-assessment and guidance. For professional help, individuals can consult the list of certified and master clinicians on his website, backfitpro.com, who are trained in his mechanistic assessment approach.
30 Actionable Insights
1. Seek Individualized Back Assessment
Reject the idea of ’non-specific low back pain’ and seek a truly individualized assessment before any therapy to understand your specific pain mechanism.
2. Understand Your Pain Mechanism
Actively seek a healthcare provider who focuses on understanding the specific physical mechanism of your pain, as this empowers you to address the underlying cause.
3. Identify & Avoid Pain Triggers
Be aware of common movement triggers for low back pain, such as prolonged sitting, excessive flexion, shearing motions, and heavy lifting, and avoid them to guide effective rehab.
4. Practice McGill Big Three Exercises
Incorporate the modified curl-up, side plank, and bird dog exercises to build core stability, transmit force efficiently, and prevent energy leaks that invite injury. Scale them using the Russian descending pyramid (10-second intervals) for pain relief and performance.
5. Build Proximal Core Stiffness
Develop proximal stiffness in your core to effectively transmit force distally, preventing energy leaks and enabling more powerful and efficient movements while sparing the spine.
6. Prioritize Sufficient Strength
For long-term spine health, prioritize achieving ’enough strength,’ mobility, and endurance rather than continually chasing lifetime personal records (PRs) in heavy lifting, as extreme efforts can lead to micro-fractures and joint wear.
7. Incorporate Daily Spine Habits
Practice simple daily habits like walking, posture tweaks (ears over shoulders, shoulders over hips, soften knees), and hip hinge practice to calm pain flares quickly and maintain spine resilience for decades.
8. Master Efficient Movement Patterns
Learn and practice efficient movement patterns, such as spreading feet apart, leaning forward, and pulling hips through (like a squat) to stand up from a seated position, to prevent injury and maintain independence.
9. Cautious Deadlifting Approach
While deadlifting can be valuable, be cautious of overzealous training, especially for middle-aged individuals, as continually pushing for PRs can compromise long-term joint health. Consider alternative, lower-axial-load exercises for muscle activation.
10. Rest After Max Effort Lifts
After setting a true personal best in heavy lifts, take a couple of months off or at least a week, as the body experiences micro-fracturing in trabecular bone that requires time for healing and callus formation.
11. Pursue Sustainable Athleticism
Shift focus from maximum effort squats and deadlifts to a well-rounded and sustainable athleticism (e.g., sled work, backwards walking up hills) that spares joints, maintains training capacity, and ensures fitness for daily life tasks into older age.
12. Cultivate Grip Strength
Recognize grip strength as a crucial proxy for longevity and overall fitness, indicating consistent physical work and stability. Engage in activities that build grip strength, such as carrying heavy objects or chopping wood.
13. Allow Post-Injury Inflammation
In the acute phase of a disc injury, consider dispensing with anti-inflammatories for two weeks, as the inflammatory response brings in the immune system to help reduce the long-term disc bulge.
14. Use Muscle Relaxants for Tension
For minor flare-ups, a light muscle relaxant (like baclofen) can help break the cycle of tension in paraspinous muscles, allowing for deep breathing and relaxation, rather than focusing on inflammation.
15. Postural Re-alignment for Aches
If experiencing low-grade aches, try lying on your tummy with hands under hips and melt into the table with each exhale to relax muscles and realign micro-shearing movements. Then, stand with ears over shoulders, shoulders over hips, and softened knees to shut down erector spinae activity.
16. Big Three for Performance Stiffness
Perform the Big Three exercises prior to physical activity to create residual neural stiffness in the core, which can lead to faster running and cutting, and greater punching impulse.
17. Don’t Mix Training Adaptations
Avoid mixing adaptation schedules; if you train for powerlifting, focus on hip/shoulder mobility and torso stiffness, avoiding excessive bending, while flexibility training should avoid very heavy loads.
18. Maintain Healthy Disc End Plates
To keep a healthy spine, focus on maintaining healthy end plates by avoiding damage to the joints, as this is crucial for long-term spine health and mobility.
19. Virtual Surgery for Disc Pain
If told surgery is needed for disc issues, consider ‘virtual surgery’ by mimicking post-surgical behavior, including forced rest and strategic desensitization, to potentially avoid the actual procedure.
20. Identify Surgical Red Flags
Be aware of obvious red flags (e.g., aortic aneurysm, cancerous tumors, cauda equina syndrome symptoms) that indicate a need for immediate surgical referral, as these are not amenable to conservative management.
21. Conservative Nerve Pain Management
For nerve pain, sciatica, or brachial plexus nerve traps, try conservative management and voluntary skill-building (e.g., specific movement patterns, stabilization programs) before resorting to surgery, as these often resolve with patience and skill.
22. Stiffen Cervical Spine for Clunks
For cervical instability (e.g., whiplash patients with ‘clunking’ pain), practice light deep flexor activation (tongue to roof of mouth) and anti-shrugging to create controlling stiffness and arrest the clunking movement, which can reduce pain over time.
23. Pillow Count for Instability Clue
The number of pillows used at night can be a high correlate for joint instability; more pillows may indicate a need to address micro-movements in the spine.
24. Read Back Mechanic Book
For individuals seeking to understand and address their back pain, read ‘Back Mechanic’ by Stuart McGill to go through a series of self-tests and pattern recognition exercises.
25. Consult McGill Certified Clinicians
If self-assessment from ‘Back Mechanic’ is insufficient, seek out certified or master clinicians listed on backfitpro.com who are trained in McGill’s methods for a comprehensive assessment and personalized treatment plan.
26. Limit Prolonged Sitting
If your job involves a lot of sitting, ensure you are not sitting longer than an hour at your computer without a break, as prolonged sitting can be detrimental to spine health.
27. Daily Walking for Spine Health
Incorporate daily walks, even short ones (e.g., 30 minutes in the morning), into your routine to counteract the negative effects of a sedentary lifestyle and improve overall health and fitness.
28. Use Lumbar Support When Sitting
If sitting causes pain, use a lumbar support to maintain a neutral spine posture, which can help mitigate disc stress.
29. Avoid Pain-Triggering Movements
For athletes with specific pain triggers, identify and avoid movements that set off back pain, even seemingly minor ones like tying skates, by having someone else perform the action.
30. Manage Jiu-Jitsu Spine Stress
For athletes in sports like Jiu-Jitsu that involve positions stressing the spine, limit mat time and incorporate other training (e.g., stand-up) to minimize accumulative stress on disc bulges causing sciatica.
10 Key Quotes
You cannot push rope, but you can push stone, or in this case, an ivy to bear load.
Stuart McGill
You damage the disc and now the body grows a hardware, more nerves to feel pain even more.
Stuart McGill
Please never mix up deadlifts and yoga.
Stuart McGill
The best medicine for them in the long-term because it is helping to reduce the long-term disc bulge.
Stuart McGill
The stiffer, the core, when the hips explode into external rotation, you're now creating a faster directional change.
Stuart McGill
I don't have to leave my home, do I?
Patient
They stole my career from me, giving me that book, how to live with my back pain.
Patient
There is no billing code that exists for an assessment of back injury mechanism.
Stuart McGill
A little bit of arthritis is good for adding certain amount of joint stability and holding it all together.
Stuart McGill
I don't ever want to see another MRI of my spine until the pattern doesn't fit and I can't move the pain anymore.
Stuart McGill
3 Protocols
Stuart McGill's 'Big Three' Core Stability Exercises
Stuart McGill- Modified Curl-up: Lay on your back, place hands palms up under your low back, lift your elbows, then hover your head, neck, and shoulders off the ground. Propel the abdominal contraction while breathing through pursed lips, allowing the diaphragm to engage.
- Side Plank: Perform on the floor, holding the position for 10-second intervals. Utilize a Russian descending pyramid approach (e.g., start with 3 sets of 10 seconds, then reduce sets as needed, ensuring form is maintained without fatigue).
- Bird Dog: Extend one leg and the opposite arm simultaneously. Focus on activating one half of your low back and the opposite half of your upper back. This creates stiffness and stability in the core while teaching the brain to disassociate ball-and-socket joint motion of the shoulders and hips.
Movement Strategy for Getting Up from a Chair (Simulated Toilet)
Stuart McGill- To sit: Place hands with kneecaps between thumb and hands, slide hands down thighs. Lean forward like a 'leaning tower,' playing with the curve of your back to find a pain-free position. Anti-shrug your shoulders.
- To stand: Spread your knees apart and pull your heels underneath you. Sniff some air (engage core). Lean forward and pull your hips through (don't lift with your back).
Virtual Surgery Protocol
Stuart McGill- Behave like a post-surgical patient: For the initial period, engage in minimal activity (e.g., only getting out of bed for essential tasks like using the restroom three times on the first day).
- Gradually build back activity: Slowly increase your workload and movement over time, mimicking the progressive rehabilitation after surgery.
- Strategically desensitize the pain mechanism: Implement specific strategies to calm and reduce the sensitivity of the identified pain trigger.
- Retune the body: Engage in strategic mobility, stability, and movement skills training to correct movement patterns and avoid replicating the stress concentrations that caused the original problem.