Can A Flat Back Cause Low Back Pain?  5 Ways To Support Your Lordosis

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For reasons that we’ll get into here, the flattening of the low back to eliminate the normal natural lordosis we all have is a factor that seems to be associated with back pain that is persistent. When we take a look at modern life and the numerous ways this pathological derangement from normal structure is baked into our daily lives, it is easy to see why back pain is such a drain on society. From practitioners and specialists who seem to poorly understand this phenomenon, to the lives many of us have to lead on a daily basis, this week we’ll explore the lower back, the cause of this flattening, how it affects your lower back health as well as how we can go about restoring a degree of normal lordosis. Towards the end we’ll also touch on 5 exercises and stretches you could consider adding into your daily practice to make sure you avoid this issue of a reduced lumbar lordosis, or “flat low back” reducing your lower back health for the long term.

What is a normal lower back and why is this important?

The lumbar spine develops in all of us from a smooth forward bending curve when we’re a fetus. For obvious reasons our spine develops this single curve, however, it is quickly worked out through our infant years, as we begin to crawl in the first year of life, move to walking, go through our growth spurts and then settle out as a fully formed adult the curve has changed dramatically. Certain points along this timeframe the curve goes through temporary reductions, or flattening out, and then restores as we finish growing. 

We won’t go into all the details of precisely the steps here, suffice to say, as a fully grown adult our lumbar curve, the technical name “lordosis”, should be fully formed and is a vital strut supporting the human body, the “back bone” if you will. The natural backward bending curve is supported on the front from the psoas and anterior longitudinal ligament primarily. On the back of the spine however, we have the erector spinae muscles, including the quadratus lumborum, we have the many spinal ligaments, interspinous, posterior longitudinal ligaments, ligamentum flavum, we could also include the posterior aspects of the annulus fibrosis of the disc. Then there is the dense thoracolumbar fascia as well as the huge latissimus dorsi muscle.

We labor to name so many of the supporting structures on the back because it helps you understand the sheer design of this structure and how it is so heavily reinforced to support this natural curve in the low back. Imagine a Bow, with the string being reinforced in a huge way, and the wooden part being the spine. For a moment, imagine what would happen if instead of the curved bow, the bow was a straight bar instead, considering the string can only contract or lengthen, not draw back like a bow and arrow, how would contractions of these muscles work? Difficult to visualise this being done in a good way. Something to mull over, especially for those with more significant loss of lumbar lordosis. 

This low back curve allows for the right balance of strength and flexibility, it relies on the stiffness of the many ligaments to allow the unit to work effectively, and be worked effectively by the musculature that surrounds the low back. It also offers a degree of shock absorption. Crudely if the vertebra were stacked on top of one another the absorption of shock would not be nearly as effective as it is with the smooth curve.

More importantly, when everything is in its rightful place and the lordosis present and to a normal degree, all the muscles are as they should be, in neutral, neither stretched out or contracted short. The ligaments, discs and bones all have the right amount of strain through them and the system is efficient.

This fundamentally allows the human body to engage in great displays of flexibility and strength. When looked after, it can allow us to lead fulfilled lives, but so many of us fall into the trap so common when it comes to our health. We do not value it until it fails us, many of us do not even think about it until it fails us. By which point the many bad habits developed over the years leave us in a predicament having to unlearn and relearn even the basics.

The Biggest Issue With A Flat Low Back

We discussed the development of this normal lordosis in the lower back and its importance, but why is the flattened lower back such an issue? One of the reasons is simple, for the low back to flatten, some vertebral segments, i.e. L4, L5 and L5, S1 have to move significantly more away from their “normal ” neutral position than others, for example, L1, L2. There Are other issues that occur in the upper lumbar spine and the presence of actual forward bending but that is for another day.

The L4 to S1 region, the lowest two mobile parts of our spine, are the most common to become injured. This is the common sight of: slipped discs or herniated discs, degeneration of the spine, spondylolisthesis, the list goes on. We’ll talk about possible causes of these vulnerabilities later, however for the time being, we see these segments in the flattened lumbar spine often are those which have the most change from the normal. For example, the L4,L5 joint can be measured with tangent angles. A line along the back of the one vertebra, bisecting a line along the back of the second. If they were straight, the angle would be 0 or 180 degrees. However, in the normal spine, measured in an upright position these should be around 19 degrees, give or take. In our experience seeing thousands of images of those with long-standing or stubborn lower back issues, with the sorts of diagnoses previously mentioned, it is not uncommon to see this measurement below 5. When the individual is standing upright! This is often in the context of a spine where many of the other joints have reductions in their amount of lordosis too, which indicates the slow degradation of this lordosis in most of these cases. 

The result of this example above is that the ligaments we mentioned earlier, the many that we reeled off that should be between the L4 and L5 on the back of the spine, have given an awful lot more than they should, to the point where their at-rest position is stretched out, This represents a significant change in tension in this specific region, a change in tension which is likely in stark contrast to the tension through the rest of the ligaments on the rest of the spine. It is unsurprising that this is often the sight of an injury to these very ligaments, the disc’s annular fibers in particular. This results in yet further asymmetry in the stability and healthy tension at this level. 

Not only does it affect the segment as above, shifting load more onto the discs, with stretched out ligaments on the back, it also has knock on effects elsewhere, meaning the muscles are also stretched out, the whole system now, working a little more inefficiently, with a focal point of injury to throw instability into the mix. 

Adding a secondary issue to this, when you have low back pain or sciatica, one of the major drivers of your symptoms is the build up of inflammation in the confined spaces of the spine and its bony holes, called foramina. These are the holes the nerve’s go through as they leave the spine. Build up of inflammation creates pressure, which creates irritation and symptoms. Instinctively you are driven to flatten your spine even more, making these overall situation even more pronounced. Similarly if you have a reaction to stinging nettles or an irritant, you vigorously scratch your skin to ease the irritation, this only serves to open your skin, perhaps penetrating too deep with the scratching to reveal more vulnerable layers of our skin, thus the irritation gets worse as the substance is exposed to the more sensitive tissues. It’s common sense “not to scratch it” yet when it comes to our back, we have medical professionals giving you “prescribed scratching” in the form of knee hugs and child’s pose stretches.

One Major Driver Of A Flat Low Back

The average adult spends 9.5 hours a day sitting. The mechanics of sitting dictate that even the most diligent among us will have some level of increased flexion at the level of the lower back, particularly L4, L5 and L5, S1 segments. With such a significant amount of time spent in this position, is it any wonder so many have this lower back issue. Over the years clinically, seeing thousands upon thousands of patients with lower back pain, we would see the overwhelming majority, if there was a case of misalignment to a significant degree, too much or too little low back curve, it was that the low back was too flat when standing upright. Granted, many of these patients unfortunately had seen many other specialists before visiting us in most cases, so it could well have been a result of the wrong exercises making the situation worse, but this is highly unlikely given the way that our bodies work. Granted, it probably made the situation worse, stretching a damaged structure more, forcefully, repeatedly, because you’ve been prescribed to do so, but it was likely just making the issue that was already there, worse.

Flexion itself is not bad, and flattening the lower back is normal.

Wait, what was that? You did hear it right. Flexion of the lower back is a normal movement that we should all be able to do. However life should have a degree of balance and we should be proportional and intelligent about how we use our body at certain times. A perfectly healthy person can round their back when tying shoelaces, or curl up on the sofa every so often. But when you have an injury in the back things change, just like you would not go hopping around on your sprained ankle, you would not want to force flexion through segments that are trying to recover and restore balance. Unfortunately flexion has no role in the rehabilitation and healing process of the individual with a flattened lumbar spine. Your spine is in permanent flexion, even when standing upright, FLEXION! 

In some cases even, when the individual actually tries to bend backwards during an extension X-ray, they cannot even get back to neutral, let that sink in. Even when they bend backwards, their lower back is still bending “forwards”.

The simple fact of the matter with flexion is that if one understands the lower back fully and the way in which it is injured, within the context of an individual living in modern life, the sort of “average” working adult that spends 9.5 hours a day sitting. Flexion is a problem, and it certainly is when it is so omnipresent. 

We can make arguments for the fear of flexion being a problem in the healthy individual with no back injury and we can also make specific arguments for the role of flexion, however, those arguments would be extremely case specific, and should be arguments of last resort. For example, areas that should be investigated and optimized before you start worrying about adding spinal flexion to your exercise routine are:

  • Do you still spend tremendous amounts of time sitting every day?
  • Do you have insufficient levels of strength & stability on movements like squat & hip hinge for your age – measured objectively performed at FULL range and good form?
  • Do you have inadequate levels of hip flexibility? 
  • Is your low back injured?

If you answered No to all four of the above then congratulations! You can consider the appropriateness of flexion as a daily practice if you do NOT have a flat low back.

The Reason Why Your Low Back Is Flat

The human body is remarkable, it adapts, however there are certain simple facts around tissues of the body that can get the better of us. The flat lower back is a casualty of this process. As we mentioned above the spine is meant to move in all ranges and flexion is one of those NORMAL movements. The ligaments will happily allow the back to round over and then spring back with youthful vigor and your back will be fine. However, the one thing that ligaments specifically do not like, is the process of sustained stretch. This is where the ligament is stretched, and then the stretch is held for minutes on end. The ligament starts to deform under this constant stretching force, this process is called creep. It is what is happening in your lower back when you camp out at your desk without moving for the last 2 hours of the day trying to get that work finished. When you’re sat slumped in that dining chair for 40 minutes at dinner time watching the TV. Every morning and evening you spend in rush hour traffic, in your car seat still, flexed, stretching. Those 9.5 hours aren’t really that hard to imagine are they!?

Over time this has the effect of creating a change in your body, the lower back curve being gradually eroded. Once more, in the minutes immediately following particularly drawn out episodes of sitting the back ligaments have changed so much that the mental map your brain has of where everything is has changed – think of a teenager going through a growth spurt and the clumsiness some suffer as the brain simply cannot keep up with the updating map of where the limbs are in space. This moment, although it is brief, it is longer than a few minutes, is when the back is commonly vulnerable. It is the moment that has preceded that seemingly innocuous event that kicked off the most recent episode of back pain.

It is always flexion! 

You shouldn’t ever say “always” but let’s be real, nowadays it is so unlikely for the opposite to be true, 99.9% of the time may as well be “always”.

What Can You Do To Help The Flattened Lower Back

Fundamentally exercises are going to have little chance of helping you unless you fully understand the situation which is why we’ve gone to such lengths to spell it all out above. Unless you make changes to the way you do things on a daily basis you will not have success. You must also be honest with yourself and your expectations. You’ve likely been crafting a flat back for years in advance of ever having a back injury. So do not expect it to change overnight. That being said, if you start working on the right things with commitment, and you eliminate the “bad things”, you’ll be surprised how quickly you can improve your low back resilience. Flare ups will become less severe, you’ll build strength that will be protective while you continue to put in place practices and habits to reinforce a healthy low back curve as opposed to the pathological flatness your back has shown to this point.

With that said, here are 5 actionable exercises and stretches you can take to make improvements, supporting a normal low back curve and good low back health, they will help you both in the short term, but more importantly the long term too!

The Low Back Towel Stretch

By far the most accessible, we consider this to be the best single stretch for your lower back health regardless of whether you have a flat low back or not. This is whereby you roll up a towel to about 3-4 inches in diameter and lie over the towel with it supporting your lower lumbar spine. This short 60 second video will show you how to do the towel stretch at home. The bonus here is that you can use a slightly smaller towel when seated for long periods, this works much better than back supports as they are often not focussed enough, and you can easily end up slouching even worse if you’re not careful. The towel will noticeably slip down if you get sloppy with your posture, and so you can use this as a cue to adjust and reposition, a double benefit.

The Low Back Towel Mobilisation

Another simple strategy to support the mobilisation of the low back curve. With this exercise you can perform 5 to 15 pulses slowly moving through the full range of the exercise. The towel is used here rolled more tightly as a fulcrum around which the lower back can be articulated into lordosis.

It is important that we point out that these two towel stretches, unlike the next strategy, offer more focused lordosis support in a way that also helps elongate the spine and support normal extension by providing a fulcrum.

The Cobra

This one is often more appropriate for the individual without more active back pain, perhaps to be considered more for the individual looking for a practice to help offset the activities of the day. The reason being that unlike the previous two exercises, this does not include a fulcrum and does not elongate the spine. Instead it is considered to be a form of extension and compression. For this reason, some with stenosis, disc herniations or facet arthritis, not to mention spondylolisthesis, will want to avoid the movement. 

The Hamstring Stretch: Done Properly!

All too often people do a hamstring stretch with a rounded back doing little to stretch the hamstring and a lot to stretch the lower back. However, if you master good form and control of your hip movement, isolating this from lower back movement, the hamstring stretch is a great option. It offers the ability to alleviate the pull from below the lumbar spine. This pull of tight hamstrings results in a flattening of the low back. 

The downside of relying on hamstring stretching when you’re in the early days of a back injury, or rather the “active days” is that you’re fighting the signals from your low back telling them to tighten back up again, so this has a limited effect until you’re in a better, more stable position. These can really have great lasting effects later on in a rehabilitation program.

Strengthening Your Body.

We alluded to this earlier, ultimately strengthening the structures that support your back will be your biggest ally in the short, medium and long term as you make the necessary changes and incorporate some of the above practices. Proper strengthening work will help you maintain your own neutral, and prevent the flattening from worsening, so long as you make the changes mentioned in the earlier parts of this article. If you do this correctly, then you can transform your back pain and finally get relief that lasts and a spine that is resilient. 

If you are unsure about how precisely to go about this and want a little more support as well as a program that you can follow then you should check out membership to the Back In Shape Program where we help members from around the UK and all over the world get results where other treatments and programs have failed. You can learn more about the membership using the links below. 

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  1. Good afternoon Michael,
    As mentioned previously, I have Grade 1 anterolisthesis at L4/L5. This to me, indicates that it is not a flat lower back issue, but rather an inward curvature of the lower spine (a forward shifting of L4 on L5). Could this indicate a tightening of the associated tendons and muscles, rather than stretched out tendons/ligaments/muscles in this area?

    1. Hey James, this is a good question, unfortunately it’s not clear cut, you might have heard me mention the grade 4 we saw in clinic, the guys spine was more or less a straight line which on the surface doesn’t quite make sense. The big problem with spondys is they’re pretty much always secondary findings so it’s very likely that they’ve been there for years before any investigation is done. Clinically we would see many with increased curvature, but we also saw many with reduced curvature. Any muscular changes would certainly be secondary to the changes in the spine and considered separately. The best way to be sure what the case is for you specifically is to look & measure – but that’s generally the best way with all things.

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