Rethinking Muscle Spasm: How Misdiagnosis Can Lead to Chronic Lower Back Pain

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Muscle spasm is one of the most common causes of lower back pain, or so you might have thought, but is this really true? Why is this such a common diagnosis when you first visit your practitioner, be they a GP or another practitioner such as physiotherapist, osteopath or chiropractor? Does it really make sense that you pulled your lower back muscle when you put your socks on? That’s hardly a load worthy of a muscle strain.

Even a moment’s consideration about the prospect of your back pain being caused by a “muscle spasm”  will lead you to the realization that this is a hopelessly simplistic and superficial diagnosis that fails to demonstrate adequate understanding of what’s going on. 

Today we’ll be taking a deep dive into this and putting the topic to rest. No, muscle spasm is not causing your lower back pain, but it certainly is unhelpful. In order to understand how to proceed however, we must improve our understanding. 

What better place to start than at the beginning.

The muscle spasm myth: understanding the symptom of low back pain

Muscles are great parts of our body and they allow us to do all manner of things, from the great feats of strength to intricate movements of crafts like painting, or sculpting. Our muscles allow us to do all this and more. They regenerate very well when strained and providing the strain is not beyond a certain level as to cause significant damage, they will actually regenerate stronger too! They are however, at their root, reactionary. They respond to the designs of our will, and the control of our nerves via the spinal cord. 

There are some more local reactions such as reflexes which do not travel up to the brain but relay a cause and effect via a more local route, for example the patellar reflex. When sat with the knee at 90 degrees hanging freely, a tap on the tendon just below the kneecap will elicit a spasm in the muscle. Conversely you could sit there from now until next week and would not get any such spasm. You did not consciously kick your leg, it was reactionary, to an insult, a sudden change somewhere else, this is an important truth. 

Imagine if our muscles had a mind of their own and would randomly go into spasm for no apparent reason. Of their own free will. That would be rather peculiar. Of course we do have instances of cramping for example, when electrolyte levels in the local area change and the muscles fire inappropriately, but again, we have a cause. Local, extreme levels of work on a target muscle with perhaps dehydration as well as lactate accumulation. 

Chances are, that hardly sounds like the onset of your low back pain.

So muscle spasm really is not a primary driver of the lower back pain, it is clearly still there, so what is it, and what’s causing the muscle spasm?

The reality: muscle spasm as a reaction not the cause of low back pain

Take any injury you like, for argument’s sake, we’ll take an ankle sprain. When you injure the ankle, there will nearly always be a degree of local muscle spasm around the joint. The muscles are triggered by the injury to go and brace the area. Something has failed and the body does NOT want any more of that happening. So it signals to these muscles that they need to contract – go into spasm. This can happen in a short term way immediately, at the time of injury, but it can also happen in a more chronic way over the long term in two ways. 

Firstly, the local musculature around the ankles will tighten up to try to restrict the possibility of any, particularly end of range movements, occurring through the ankle so as to maximally challenge an injured ligament. This is to prevent further damage. Secondarily, we see further afield, the hamstrings tighten up to bend the knee, the hip flexors to lift the leg and the lumbar erector spinae including muscles like QL on the one side all go into a degree of “spasm”. This is obviously to elevate the leg and naturally avoid putting pressure on the injured limb. Fairly logical. You see again, the cause that triggers the muscle spasm was the injury and the subsequent direction of the muscles to be less relaxed. 

The same is true for the lower back. This same defense mechanism will occur however there are two main ways this will happen and the second is more of an irritation, especially during flare ups. When you injure your lower back, there will be the same process going on. Signals will be sent to the surrounding low back muscles to tell them to tighten up, hence the tightness in the lower back. In the case of the low back this muscle tightness is often not helpful because the contracture of the muscles creates a degree of compression and when the majority of injuries to the lower back are caused by compression this additional force is unwanted. Secondarily however, because of the nature and location of lower back injuries, it is common for signals to be sent along the nerves associated with that spinal segment, for example, the glutes or the hamstrings. These muscles then tighten too, not directly in response to the injury in the spine itself, but the pressure from the disc, or build up of inflammation on the nerve fibers that control these muscles. 

We’ve all hit our funny bone at one time or another, this is a perfect example. That nerve on the inside of the elbow carries information from the skin on our forearm and hand to the brain. By interfering significantly in the middle of the cable, it creates an impulse that’s received by the brain. The brain only knows that the signal should have come from the hand, so this is mapped in your brain as the tingling feeling in the area that nerve is responsible for. 

In the case of the lower back, the muscle on the end of that nerve only knows that signals that come from this “cable” should have come from the brain, and they tell it to contract. It doesn’t know that half way down the nerve, there is a bit of disc or congestion from excess inflammation irritating the nerve and sending “phony signals”. So the muscle contracts. 

The problem with this, is that all this stiffness creates dysfunctional movements, and creates the propensity for more strain to be placed on the lower back, and so more aggravation of the “cause” and therefore more muscle spasm and a terrible cycle takes hold.

The misdiagnosis problem: limited resources and non-specialist care

Ultimately this is all rather basic and easy to understand for the average person, however the truth that the muscle spasm is making this worse is also one which we cannot escape. Let us be clear, in the case of lower back pain or injuries to the lower back including sciatica, muscle spasm is not helpful. Muscle spasm is also pretty easy to spot and diagnose. This is likely why it is so frequently misdiagnosed. 

We know that nowadays, public health services like GP’s are under strain, and simply put they do not have the time to do an examination of any length, get an understanding of the problem, treat you and then provide the necessary education to help fix this problem properly. The hope is that if you’re prescribed some muscle relaxants or have some massage, the back will heal itself and you’ll be back at it in no time. 

The problem is that it just doesn’t work like that. If you have had back pain for any length of time and followed our podcast or Youtube videos you’ll know back pain is caused by much more than a spastic muscle. 

Additionally your GP is a general practitioner, or your family doctor just that. They are not specialists in these areas, they need to function more like a quarterback or strategist, with an arsenal of resources and specialists at their disposal to filter and direct you to those who can help with more expert knowledge. 

However, often there is an initial referral or perhaps self referral to physio or another professional such as an osteopath or chiropractor. Oftentimes they will have a good understanding especially if they specialize in low back pain. However if your first prescription is exercises such as knee hugs or child’s pose then go somewhere else!

The mistake of treating lower back as muscle spasm

Misdiagnosis leads to mistreatment, and when you have a simple muscle spasm causing your pain, the answer is to ease the spasm or tightness by stretching it. The problem is that this is making things worse. The failure to appreciate the lower back and how structures in the lumbar spine become injured, and how they fail to recover is the reason why so many of our members join the program. 

They’ve tried the endless stretches, the flattening of the lower back and it does not provide long term results. At best it feels nice at the time, but it would have done even if you didn’t have a back injury! That doesn’t mean it is helping you now.

If you understand that an injury to the lower back has occurred in compression, with likely an element of rounding or flattening of the lower back you can make smarter choices. Of course, the muscles will be in spasm. But you alleviate that spasm, and allow those muscles to relax by doing two things.

Firstly, you stop aggravating the injury. Remember that in the ankle the muscle spasm was to protect and take pressure off the injury. Unfortunately in the case of lower back injuries it makes things worse and puts more pressure through the injured tissues. On top of this, if you think you can get away with sitting with a rounded lower back for hours on end you’re wrong. You must become wiser to the things you are doing EVERY DAY that are making your lower back injury worse. Things that have caused the gradual weakening and injury of your lower back. This is why education is so important as you just do not know, what you do not know.

Ignorance is not bliss either, it is dangerous so you need to spend the time on this, it’s your body at the end of the day.

Secondly you need to start taking steps to practically unload the lower back and take pressure off this area as well as alleviate any build up of inflammation in the region. Remember there were those two sources of the spasm. The first which is the injury itself, we want a scab to form and the healing process to get underway in a more stable manner. The second was the excess inflammation which we want to calm down, so there isn’t the pressure irritating the nerves. So those of you using heat need to stop. Icing or contrast bathing is the way to go here and we have specific guidance on this in the program.

The most irritating part of a muscle spasm diagnosis for low back pain

Before we get into moving forwards from this point, it’s only right to cover the most frustrating part of all this misdiagnosis. Ultimately we know these diagnoses carry weight with the patient. When you’re diagnosed with “it’s only muscle spasm” you’re relieved and you carry on doing what you did before knowing that this is just a muscle and it will go away. Then 6 months later you finally get the MRI or X-ray and you see the real cause…

What an anticlimax. 

Sure, if you do the right things, did you really need to see that it was a disc bulge or some other “real diagnosis”?

No, most of the diagnostic process, for someone who is trained well in these things, comes from the case history, the symptoms etc. The imaging often confirms and adds nuance. And chances are it makes no difference what-so-ever to the strategies you need to employ going forwards. That is assuming you’re working with the right person beforehand. For example, in our clinical days, you would generally have a good idea of what was wrong before imaging, the imaging was a great tool for education of the patient about their body and helping them get the understanding necessary because it feels more real. But a similar educated outcome could have been gleaned many months before the imaging was done. 

What’s more, and we’ve seen this so many times in real life. The mental shift from when the person first gets the diagnosis of muscle spasm, to when they get the diagnosis of the disc bulge on MRI. Often this is so stark, it becomes real. But in reality it should have been taken seriously from day one. It sometimes feels as if the “muscle spasm” is a yellow card, that sets the expectation that it should resolve in a week or so. When in reality this is not the case. 

If you’ve had the diagnosis of muscle spasm for your lower back pain, please do not use it as an excuse to not resolve the issue and work properly on rehabilitating your lower back. Chances are there is much that needs to be done to improve the state of health in your lower back, why wait 6 months doing the wrong things assuming it is “only muscle spasm” to then find out it’s been a disc strain/bulge/herniation all this time. 

The best treatment for lower back pain: a comprehensive approach

We recently did a podcast on the best treatment for lower back pain so you can read more details there but conceptually it can be distilled here. Treatment for lower back pain should focus on unloading the lumbar spine and taking pressure off the injured area of the lower back. This can be done in a number of ways, from the towel exercise that we recommend to our members, an exercise featuring heavily in the program. This could be something like IDD therapy on the clinical treatment front, something we have a lot of experience with.

You then have the job to stabilize the lumbar spine in the first region to protect the area, that is to say you must provide stability to the lower back and spine, whilst providing mobility to the hips to take some of the movement burden away from the injured lower back. This however must be done in a way that does not compromise the lower back. For example, a classic mistake would be the stretching of the hamstring musculature by folding completely forwards. This is ineffective for the hamstrings and terrible for your lower back. 

Working to help reduce excess inflammation and optimize healing is another aspect of this approach. Often the most basic routes here are the essentials, using icing to control the excess inflammation, the contrast bathing in some circumstances as mentioned earlier. Also you should be making sure you’re fuelling your body appropriately. Are you eating well, good food and adequate protein?  Without resources your body cannot heal and regenerate. 

If you’re eating junk food your body will be junk too!

Making sure that you are rebuilding and guiding the healing process in the medium to long term is essential. Doing knee hugs or bending exercises for 6 months does not build resilience at all. Making progress with resistance training like we teach out members in the Back In Shape Program makes up an invaluable, essential part of the recovery process no matter what diagnosis you have for your lower back pain. The careful application of progressive resistance is what shapes your body and guides the remodeling process in tissues that have been injured,as well as the surrounding tissues that are being required to compensate for this weak link in the chain.

Finally you have to make the right sort of lifestyle changes. This is as simple as how you bend to pick something off the floor. For it is these small things that have added up over many years, in most cases, that are the real root cause of all of this. They’ve slowly been solidifying practices that focus strain on a specific part of your lower back, coupled with hours of repetitive tasks and sitting, the body eventually starts to become overwhelmed. These small tasks make up 95% of your day, yet they’re nearly always ignored. This is not “do nothing” this is, “modify what you’re doing, so you do it right”. Bending with your knees or taking a knee to go on the floor feels like more effort because you’ve not been doing it. Not because it is. If you condition yourself to do it, then your whole body will be better off for it, your knees, ankles, hips, low back etc. We talk about this at length in the episode on chronic lower back pain, which is often where these muscle spasms end when you approach them wrong.

The importance of understanding muscle spasms in lower back pain

Ultimately you need to appreciate that muscle spasm is just part of lower back pain, it is not the cause, at the same time, you do not need to wait and get a formalized diagnosis before you do anything. That’s another mistake. So long as you’re working with the understanding of a healthy lower back in mind, and with a principled approach, you will do well! We know this because the program is built this way. We have success with members with all manner of diagnosis, from the minor to the more severe and the post surgical, of all ages. Some will take longer, some will have an easier time, and others more challenges along the way. But with diligence and consistency, you can move towards being pain free. 

One thing is clear, the sooner you start to make positive changes and do the right things to address the causes of your low back muscle spasm, the sooner you’ll start getting better.

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