When treating physical pain, there is one question that is rarely asked and even more rarely answered. Why? Why have I got back pain? Why have got neck pain? Why have I got knee pain? Even if a diagnosis is made and it is known to be the source of pain, no one ever asks Why is my disc painful? Why is my tendon painful? Why do I have arthritis?
Every day people tell me that they have been told that they have an injured tissue or structure and that they need to have medication, a cortisone injection, denervation, surgery or other passive technique in the hope that these interventions will solve your problem.
But unless you know why these tissues and structures have become painful, then your chances of getting permanent pain relief are at best remote. It is like putting a band-aid over a cut and then you keep cutting the area. You have simply masked the pain for a short time. Once the effects of the intervention have worn off, the structures will become painful again as you keep aggravating the damaged or irritated tissue.
This point was born out in a research article titled Effects of manual therapy and exercises targeting the hips in patients with low back pain that was published in the Journal of Evaluation in Clinical Practice, January 2017.
This article indicates that low back pain and hip pain are becoming increasingly associated and that together they cause greater pain at each site than if the back pain or hip pain existed in isolation. As yet, it hasn’t been determined which causes which. In other words, does low back pain cause hip pain or hip pain cause lower back pain?
But perhaps more importantly, what has been found is that treating and freeing up the hip has resulted in reduced lower back pain.
The bigger issue that this raises is the concept of regional interdependence. This means that even seemingly unrelated parts of your body can cause pain and injury in other parts of your body.
As physios, we know that stiffness of your ankles, knees, and hips, as well as tightness and weakness of your leg muscles, can cause back injuries such as disc bulges, arthritis, and stenosis. Why? Because stiffness in your leg joints will cause you to twist in your back every time you squat, get out into/out of the car or on/off a low chair.
Likewise, weakness in your leg muscles will mean that instead of squatting, you will bend at your back every time you need to reach low or pick something off the floor. This is not to say that you shouldn’t bend at you back. It is to say that you shouldn’t bend so much and that bending at your back hundreds if not thousands of times a day because you can’t squat will eventually lead to a back problem.
The more that these incorrect movement patterns become practiced, the more that they become habits leading to muscle imbalances, joint mal-alignment, joint irritation, stiffness and eventually more pain.
A quick scan test to see if your legs might be contributing to your back pain is a Squat Test. Stand with your feet pointing directly forwards, hip-width apart. You should be able to squat all the way down to your heels and not allow your feet to turn outwards. If you cant then this test is indicating that your leg joints are either stiff or your leg muscles are weak. This means that every time you get in/out of a car, or on/off a seat, you are likely to be compensating at your back.
Other commonly associated areas of your body that can cause pain include excessive turning in of your hips causing knee and foot pain, a stiff mid-back and weakness in your leg muscles can be causing elbow and shoulder pain or poor hearing and vision leading to neck pain.
This is because one area of your body will try and compensate for other areas of your body that may not be doing their job optimally and it is these areas of compensation which so often become painful as they are trying to perform functions that they are not designed to do.
Another way of beginning to understand what the cause of your pain is to identify what you are doing or what have you just done when your pain comes on.
Are you sitting, getting out of the car, gardening or putting on shoes and socks, in which case it may be bending and/or the way that you are performing these activities which are likely to be the cause of your pain. Or are you walking, in which case it may be arching your back or something to do with placing weight on your legs that may be the cause of your pain.
Then we get to be a detective. What is it about these activities and the interactions of your body which is causing your pain? Are your calves so tight that they pull you back as you stand, causing you to bend slightly forward to compensate and it is this constant slight bend forwards that then causes a disc bulge which leads to your lower back pain?
What’s even more frustrating is that these faulty ways of being have become such ingrained habits that you may have no idea what they are doing you harm until its too late and you are injured and in pain.
Many people will say that their parents had the same problem or that they were born this way. And it is true that you may have unique physical structural characteristics that may cause problems. One long leg, excessively arched or flat feet, twisted, bowed or knock-kneed knees, turned in or out legs, an excessively curved or flat back, tall pelvis, a wide pelvis and / or wide shoulders, pigeon chest and so on, all have particular physical effects that can lead to pain and loss of function. Some might need a structural solution such as orthotics, bracing or worst-case scenario, surgery.
The way that you then perform your daily activities will often make the effect of these variations worse. This is because it takes awareness, discipline, and perseverance to correct the detrimental effects of these physical forces on your body.
As your body follows the path of least resistance, it is so much easier to go with these forces than to oppose them. This means that not only will any negative effects be perpetuated, but they will also worsen over time making a chance of complete recovery more and more remote.
However many times, even these physical variations and incorrect movement patterns can be adequately addressed with hands-on treatment, movement correction, and physical training.
Hands-on treatment by itself, however, is not intense enough to create any sort of lasting improvement as it causes just a short term change in soft tissue tension levels and joint mobility.
In addition, exercise training by itself is also inadequate, because it is not specific enough to create change or increased mobility at the specific areas which have become stiff.
And finally, posture and movement retraining by itself is also inadequate because joints may be too stiff or unstable and muscles may lack the strength, endurance, coordination and control for ideal postures and movement patterns to be adopted in the first place.
To achieve permanent pain relief and sustained improvement in your ability to live pain-free and without limitation, requires a program of hands-on techniques, corrective rehabilitative exercise and optimal posture/movement pattern retraining.
And yet, this program will also be adequate, if it is not intense enough to change the excessive or abnormal mechanics and the postural movement habits that have created them, permanently.
Treatment/training once a week is simply not going to be intense enough. There are at least 167 other hours during the week when all the benefits from treatment can be undone.
It takes at least 4 weeks for your muscles to get stronger and at least 3 to 6 weeks for you to develop new, correct posture and movement habits. treatment/training must, therefore, be at least 2 to 3 times a week for at least 4 to 6 weeks to get a result. But the beauty of this approach is that once you have achieved an improvement, it is more likely to be permanent.
Not only does this mean that you will prevent further flare-ups and the possibility of re-injury, but you will also actually perform everyday movements better, with more freedom, strength, control, and confidence as well as with less fatigue.
Even better, you will have increased your capacity for living, giving you a reserve capacity that will enable you to perform unfamiliar activities or to keep going safely when physically challenged.
Whilst this approach does take more effort, time and work than passive approaches, the benefits of being set free to live without limitation and without the need for medications, injections or surgery are worth it.Until next time, Stay Bodywise, Michael Hall Physiotherapist Director of Bodywise Health Reference: Bade M, Cobo-Estevez M, Neeley D et al. Effects of Manual Therapy and Exercise Targeting the Hips in Patients with Low-Back Pain A Randomized Controlled Trial; Journal of Evaluation in Clinical Practice 2017; 23(4): 734-740. DOI: 10.1111/jep.12705. Epub 2017 Jan 27.