Anatomy of the Low Back

Several key structures make up the low back: lumbar vertebrae L1-5; intervertebral discs that separate the lumbar vertebrae; the sacrum; and myofascial structures such as the psoas, diaphragm, and the abdominal viscera. Tension or imbalance in any of those structures can predispose someone to low back pain and/or injury, or cause pain in itself.

Lumbar Vertebrae, Discs, and the Spinal Cord

As you can see, the spinal cord runs through the spinal canal of each vertebra, sending out nerve roots at each level. Intervertebral discs act as spacers between the vertebra and allow for fluid movement of the spine. Damage to the discs--as a result of injury or long-term imbalance--sometimes causes part of the disc to bulge out and impinge on a spinal nerve root.

This unfortunate circumstance is, in my opinion, often the end result of a long-term imbalance, sometimes compounded by a triggering event (a fall, a lifting-and-twisting motion), but sometimes not. The source(s) of imbalance can often be found in the myofascial structures. If addressed early, the spine can restore balance and become more resilient, more resistant to injuries of this kind.

Myofascia of the Low Back

A few myofascial structures attach directly to the lumbar vertebrae: the respiratory diaphragm (via the crura, or “legs”, which connect the diaphragm to the lumbars,) the psoas, and the posterior portion of the peritoneum (visceral bag), which supports the large and small intestines.

Tension in the crura of the diaphragm, as well as shortness in the psoas may lead to uneven compression, imbalanced curvature, or rotation of the lumbars. Often, individuals with this kind of tension have a stooped posture and find it difficult to “stand up straight.”

Inflammation in the intestines, which leads to restriction in the peritoneum, may also influence movement (or its lack) in the lumbars.

The Sacrum

The sacrum, as the bottom of the spine, plays a crucial role in the balance of the spine as a whole. It acts as a counterbalance to the head, it is the touchstone of the pelvis, and it is through it that the motion of the legs translates up into the spine.

Some individuals have natural torsions in their spines and sacra and experience no ill effects from them. Others have less functional torsions that cause all manner of back and hip pain.

Any sacrum that finds itself in a position that is greatly abnormal relative to its usual will cause some kind of pain, very often in the low back. The triggering event may be major or minor (landing on one’s rear end, moving a heavy object, etc.) but the end result is a rotated and tilted sacrum.

In the interest of brevity, I have not made this an exhaustive anatomical list. There are many other ligamentous and myofascial structures that, when damaged or strained, can cause significant pain and dysfunction in the low back. I have merely attempted to highlight a few of the more interesting ones from a bodywork perspective, and attempted to shed some light on a common source of discomfort.

A Pain in the Back

If you struggle with low back pain and are contemplating what options exist for treatment, you’re not alone. According to the NIH (National Institutes of Health), 8 out of 10 people will suffer from low back pain at some point in their lives. I have worked with clients as young as 14 and clients well into their 70’s who sought treatment for low back pain.

So what causes low back pain? In my observation, there is the context and then there is the cause. Either one can result in low back pain, but commonly they occur together.

The context is the environment in which your low back functions. How well-supported it is by the legs, pelvis, ribcage, and other areas of the spine; how well it has developed in terms of movement, flexibility, and strength; its state of nourishment and hydration; and the mechanical forces of strain, pull, compression and rotation coming from above and below all add up to the context.

A well-nourished, hydrated, supported, strong and adaptable spine has a much smaller potential for injury in the low back than a spine that is starved, dehydrated, subject to strains or imbalances from above or below, and weakened from inactivity and disuse.

In a back that is poorly supported, routine and everyday tasks—such as prolonged sitting or lifting relatively light objects—can seemingly cause low back pain. In reality, it is the context that is at fault, not the task itself. The back is simply poorly equipped to handle normal tasks.

However, even the healthiest back can be subjected to a mechanism forceful enough to cause an injury. Therefore, the “cause” that we often look for emerges as a singular moment: the fall, the lifting event, or the accident.

Although we have little control over falls and accidents, we can favorably affect our odds by improving the context in which our backs function. A Rolf practitioner can attend to the structural context, while a nutritional consultant or yoga instructor can attend to other aspects. We can do much for ourselves by staying fit, staying active, watching our weight, nourishing our bodies well nutritionally, drinking enough water, and activating our deep, core abdominal muscles through pilates or other similar activities.

Next post, look for an anatomy geek’s view of the low back.

A Rolfing Perspective on Runner's Knee

A recent client came to my office with a diagnosis of Runner's Knee. I must admit, I had never heard of this term, despite 6 years of working with runners and triathletes. A quick internet search revealed that Runner's Knee is characterized by pain around the patella, often caused by patellar misalignment, and most often treated with physical therapy to strengthen the medial quads.

Any pain or crepitis around the patella is cause for concern, because damage to the patellar cartilage is by and large irreversible and a painful, frustrating condition for any athlete. Preventing the loss of cartilage is a key focus of my treatment plan in such cases.

Many clients do not undergo physical therapy due to lack of insurance or lack of funds, or both. Also, having undergone physical therapy for my own patellar issues and finding it impossible to even do the exercises without increasing my pain level (and, I suspect, further damaging the patellar cartilage), I am skeptical of the long-term viability of strengthening those quads in order to treat the issue. Once the patient stops doing the exercises, it would seem logical that the original condition would return as the muscle weakens to its normal state.

So what to do with Runner's Knee? With this particular client, I began with the foot. Incredibly tight calves has led to a rotation in her calcaneous, or heel bone, essentially causing her to over-pronate with every step. This pronation led to a counter-rotation at the knee, putting undue strain on her patella, caught as it were between an unstable ankle/lower leg complex and overcompensating quads.

Further investigation revealed a gait pattern that overemphasizes the quads as the primary hip flexor. An efficient gait uses the psoas, and by extension, the spinal engine, as the primary hip flexor. This imbalance exacerbated her symptoms, as tight quads are the main cause of her patellar pain.

Balancing this client's foot and knee and normalizing the tension in her quads led to a dramatic decrease in her pain level and a resumption of activities that previously were too painful to perform. After two sessions, she does those activities pain-free. The next step is to activate and prioritize her psoas in walking.

I am confident these structural changes are long-term. They are not dependent on continued strengthening exercises, and were achieved after only two hour-long sessions. Better yet, this young client is that much more unlikely to suffer debilitating arthritis or cartilage loss due to a structural imbalance. This is a testament to the benefit of addressing structural issues in athletic injuries, and is the kind of outcome I see on a regular basis. Rolfing rocks!

Potential for Health

Rolfing and bodywork are about hope. Ida Rolf had great faith in human potential, and in the human body's desire and capacity to restore balance. Everyday I witness the shortcomings of allopathic medicine to address pain and discomfort. Not that it doesn't have its strengths, but despite what doctors may say, there is ...always good reason to hope for better balance and better health.