Getting a diagnosis for your lower back pain or sciatica pain is on the mind of many who injure their lower back. Wanting to find out what exactly is going wrong, having the specific thing highlighted that explains their symptoms. This can be really insightful, and when accompanied with imaging and a specialist that really cares to spend the time educating you about your own body it can be tremendously fruitful. We know this from our experience going through imaging with thousands of patients over the years. When you sit down with someone, explain their lower back to them, and help them put two and two together to understand why they feel what they feel, it can be a therapeutic experience in itself!
When we carry out these appointments, either in the past in our clinic, or more recently virtually, the benefits remain self-evident. However, one important fact about those discussions is that they are holistic. We are using the imaging to educate the person on the specific local area that is injured, yes, but we spend much more time talking about the wider structure of the spine, signs of wear, and the way in which their spine works within their body. Then we talk about the way their body works within their life and the demands of daily living.
Your lower back does not exist in a vacuum, it exists within you and in your day to day life. Shifting the focus more holistically we can see the myriad of factors that have led to this specific area becoming injured. In a vast number of cases, perhaps just like your low back pain, we also see the major areas that are focused on diagnostically, have been “damaged” or “worn” for many months, years or longer, before you had the symptoms.
This realization may sound strange, but today we’ll dig into this much more with specific examples of a more severe diagnosis one might have and help you appreciate the fact that if you didn’t have pain before, there is very little reason why you can “not have pain” again.
Unveiling the difficulty in diagnosis of low back pain
Now, diagnosis is important of course, however as we’ll see here, the pain is not a particularly good indicator for the diagnosis, and certainly not the severity of pain. For starters, there will be people who have extremely debilitating pain. When we come to objective tissue damage, the soft tissues are injured yes, but the severity of such injuries could be considered to be mild. Conversely, we can recount a specific case of an individual seen clinically with some minor back ache, who was in his 40’s, only visiting the clinic because there was a promotional offer. Meaning, that the pain was not bad enough to prompt him to have investigated it other than the fact that there was an offer on. In this particular case the patient was walking around with a Grade 3, almost grade 4 spondylolisthesis at the L5/S1 level. That is to say the spinal bones should stack vertically on top of one another, this case was so bad, that the vertebra was almost falling off the front of the one below. Thankfully these cases are rare, but as shocking as it was to see clinically, the man was completely unaware and had never had any imaging in the past. Suffice to say that it will have been there for some time judging by the condition of the spine at that level.
This stark example shows that severity of an injury is not always accurately reflected in the pain experienced.
The huge difference in experienced symptoms for the same issues
Bear in mind you could do exactly the same for “disc bulge or herniation”, “minor strain”, “facet joint degeneration” etc. Spondylolisthesis is a nice example because of its objective seriousness, compared perhaps to other diagnoses.
Many people with this specific condition will have had the condition for a very long time prior to their original “back pain”. This means that the back has been structurally less sound than it should be for many years prior to that bout of low back pain or sciatica. Unlike the case above, some with this condition would hobble into the clinic with crutches, in tremendous pain unable to freely walk because the symptoms were so bad. This is normal.
Another example in clinical practice of this condition, a severe spondylolisthesis approximately Grade 3 was found in a young girl in her early 20’s, let’s call her Sarah (not real name). Similar to the earlier example, she was in for a consultation and had little to no symptoms. This was much earlier on in my career, very shortly after university however its significance stuck with me. She had no pain, and was having a check up. Yet this young lady, a former gymnast, was walking around, active with this very bad structural issue in her spine.
Although we do not have the benefit of seeing things in the fullness of time, this young lady’s case is a perfect example of how these “pains” often come about. At the time of consultation, she was an extremely well conditioned athlete, spending a significant amount of time working out and honing her craft, in spite of what was hiding beneath the surface. How is this possible you might be thinking, simple. The conditioning of the musculoskeletal system was such that it will have enabled her to compensate for this weakness. Extremely mobile hip joints, coupled with good strength levels are something that gymnasts in particular benefit from. To be both very strong, and flexible, especially in the hips, is such a powerful support system for the lower back.
Unfortunately, as Sarah stops her regular practice of gymnastics, like so many, the demands of adult life begin to take priority, a full time job and social commitments that go alongside this give her less and less time to commit to keeping her body in good order. She does however do some work in the gym to keep up her conditioning, but it’s nowhere near the level it used to be. It is however sufficient to maintain an above average level of strength and mobility.
Next, however, she settles down to have a family, pregnancy, then the demands of life have made it more and more difficult to make the time to keep her body in good condition and now she’s out of practice and out of the routine. As her body begins to become more akin to the condition of the average person, discomfort starts to creep in. Back ache, maybe a little sciatica. She then tries some rudimentary exercises, see’s a few practitioners who say it’s just muscular, she’s looking after two young children now so of course she’s got some aches and pains. The problem is they’re not going away, they’re getting worse and now she’s worried and frustrated.
The issue here is that Sarah now has the conditioning of the “average person” but her low back needs more than this, remember, that the spondylolisthesis there is not “average”.
Finally she gets some imaging done (probably after much back and forth and protestations that imaging isn’t necessary or helpful – sense the sarcasm).
My goodness! There’s a grade 3 spondylolisthesis in the lower back!
The practitioners don’t bother to consider or explain that it has likely been there for a long period of time and Sarah now is petrified that this has “just happened recently”.
How will she ever get out of pain!?
Sarah’s back was vulnerable, but she did a fantastic job in her former years of keeping her body in great condition. As her condition deteriorated and approximated more the average person, the sub-par condition of her lower back became an “achilles heel” ; it was exposed, its armor had been taken off. Yes, avoiding this deterioration over time would be the optimal solution, but the important takeaway is that by committing to rebuild just a fraction of her former conditioning as her back heals, she will be able to protect this vulnerability again.
Yes, healing of the offending soft tissues at present will take some time, restoration of stability will take longer still, many months, perhaps longer. However, the degradation of Sarah’s lower back health has been occurring for years by this point. Comparatively speaking the journey to get her back in shape again will be much shorter. But the belief that this has been a problem since she first became aware of symptoms is false.
“But it only started hurting 6 weeks/months ago”
The actions that lead to this area being overwhelmed began many years ago, don’t be dogmatic about this, evaluate honestly if you have been a good steward of your own body, or have other priorities got in the way over the recent years and decades.
Chances are you had a problem before you felt the problem too!
Take a moment to consider, unless your back pain started after falling down the stairs, or a car crash, it probably came on slowly with the “last straw” being a somewhat insignificant movement or event. An everyday activity that should not cause such a strong structure, the human spine, to fail and become injured.
It is this situation that is seen much more commonly in the bulk of patients with lower back pain. This is also why we talk so much about lifestyle changes and commitment to long term results.
Many conditions or injuries have long tails, meaning that they build up without symptoms over a long period of time, this is why there are communities all over the world utilizing modern science to get ahead of their health. Whether it is blood tests, or other testing, heart rate monitors, body composition scanning, the list goes on. These tools enable you to find the problems and act on them before the problem starts to affect your life.
Seeing the condition of your spine before you injured it might have given you the prompt to start taking your health more seriously, engaging in resistance training, starting to work on your flexibility more regularly, change the way you do things every day, sitting less. You see, it is so much easier to make changes like the above when you do not have pain, than when you do.
The best way for you to think about moving forward from here, is to come to the realization, that it is incredibly likely, the diagnosis that you’ve got for your back pain, especially where imaging has been done, could have been made long before you had pain.
This means there is a great chance that if you do the right things and start to act now, you can not have pain; again. Just like Sarah, who had a significant issue in her lower back, more significant than most, long before she had any significant pain to speak of!
Take a moment to be critical of yourself
Too often we see individuals getting drawn into a focus on flare ups and the back pain specifically, wanting to know the specifics of their diagnosis, or if it has changed because their symptoms changed, thinking it will hold the key to overnight results.
This matters little, you could get 10 people with a herniated L5/S1 disc, and they’d all have slightly different symptoms, by the way, some would have no symptoms at all. But all will have issues with the structure of their spine and all will have areas where they can improve their health by acting proactively.
Take a moment to think for yourself, are you in good physical condition, are your hips and knees healthy, can you carry out movements like the squat or lunge to full range without falling over or things hurting. Do you have good control and an ability to move correctly through what we refer to as the “fundamental movements” the squat, hip hinge and lunge? If not, there are issues that you can fix right away.
Do you need to fix those issues if you are diagnosed with a disc herniation on the left side at L4,L5 – YES.
Do you need to fix those issues if you have a L5,S1 spondlylolisthesis grade 1, 2 or 3 – YES
What about if you have a minor strain to the L4, L5 facet joints – YES
But what about if you’ve had surgical fusion to the lower lumbar spine – Definitely, YES!
You see, it doesn’t matter what the case is, weakness and vulnerability in your lower back, and the slow degradation of your back health to the point where your socks or the shopping bag caused debilitating back pain is not acceptable.
In the possession of such a vulnerable body, it is then just a matter of chance as to which specific condition is going to get you.
There’s good news for your back pain!
Chances are that you’re not contending with the same issues in your back as Sarah was. It’s also likely that you have had periods in the past without pain whilst perhaps harboring the very diagnosis that currently makes you fearful of moving forwards and getting results.
Don’t get drawn into specific quick fix exercises or stretches, or the delusion that some skilled chiropractor or osteopath will just “click it back into place”. Healing takes time, just like that cut on the surface of your skin, you’d laugh if someone said they could fix it with a quick stretch, or “stick it back together” in an instant. Healing takes time, and you need to support your back better!
Focus on a program of exercise that teaches you foundational spinal stability, this is the ability to support your spine in a neutral position, as opposed to being weak and unable to do so. Absent this control, your spine will be pulled in all manner of directions, at the whim of external forces, a frequent source of “silly” relapse.
Your program should then build resilience to this mechanism of spinal stability by challenging the spine in various upright positions to maintain control. No pelvic tucking, just core control of the spine. Using movements that replicate real world activities that you are doing EVERY DAY is vital to early successes and quickly mitigates risk of relapse. You must apply these skills to activities of daily living, not just when you’re doing the “exercises”.
Once this is being established, the exercises should have resistance and load added. Stimulating your spine and surrounding support systems to develop resilience again to load. Life has loads and you’re not going to avoid it, so rehab it instead. Steadily build resistances and loads, first in smaller increments, it’s safer.
Focus on working through the fullest possible range of motion when doing these movements and with time the incorporation of dedicated flexibility work, particularly to the hips, will help further your progress, rebuilding resilience and fortifying your lower back, regardless of the diagnosis.
Do this and you will be part way to being pain free again. The final part of the puzzle comes from applying this newfound competence to daily life, evaluating the way you haphazardly move your body in ways which are not efficient or helpful for your lower back.
The reason you cannot put your shoes and socks on is because your hips are awfully inflexible, dispense with the belief that you “have to round your back”. Granted some unfavorable movements will be present long term, but they will be hugely reduced in both severity and frequency when you are conditioned properly.
If you need help with your lower back pain or sciatica and aren’t sure what you should be doing, hopefully now you have a little more of an idea, at least of the principles. Use the link below to learn more about joining the Back In Shape Program and we can help take you from where you are now, to having your Back In Shape.
It’s not overnight, it’s not got any secret stretches, but it does work. Solutions to real problems rarely are gimmicky and instant. When it comes to your health, hard work and consistency is what’s required, cutting corners for short term results always leads to disappointment.
Do the basics,
Do them well,
Do them consistently,
You’ll get there 🙂