Rehab & Recovery Zone!

Getting a Leg up on Back Pain

Jason Soncrant

By: Jason Soncrant P.T., Gary Gray's Physical Therapy Clinic

Things often go in cycles and many times you find yourself back where you started. Such a cycle has been taking place in rehabilitative and performance enhancing circles. Attempts to analyze, dissect and understand how people move and how to correct movement errors caused confusion.

For instance, take a look at back rehabilitation. Patterns of both symptoms and behaviors were identified among the population.

We focused intensely on the spine. We determined which anatomical structures had pain receptors.

We calculated intradiscal pressures during various postures and it was determined which postures were bad. MRI's, EMG's and plain radiographs showed differences in healthy and injured subjects. Our minds are filled with all of these facts but clinically we are left scratching our heads.

Simple questions remained unanswered. What is wrong? Why is it wrong? How can I fix the problem? Written studies and two dimensional pictures and diagrams dominated our thoughts and covered our eyes. Often we failed to see the dynamic and three-dimensional person in front of us. Like forcing a square peg into a round hole we forced two-dimensional treatments on three-dimensional problems. We focused on pelvic tilts, back braces, flatlying strength assessments and exercises. Single joint, single plane stretches were emphasized. We told patients the only good body rotation was no rotation.

True, some got better but many people did not. They were labeled prematurely as medically futile and told to live with the pain. Certain activities were to be avoided and appropriate body mechanics used at all times. In other words live inside of the box and move like robots.

Fortunately the trends are moving towards the big picture. The Lumbar Spine is the ultimate Relay Station. It continually takes inertial energy from the environment through an extremity...gravity, ground reaction forces, walking, falling, throwing and catching a ball...and transforms it into elastic energy for another extremity to use, thereby allowing efficient transition from one posture to another. In other words, your back allows movement from one limb to influence movement in another. Also, remember, our extremities allow us to manipulate our environment and dampen inertial energy from the environment.

So, looking at gross movement patterns like walking provides meaningful insight into how the lumbar spine works and its symbiotic relationship with the extremities. Thinking three dimensionally and looking beyond where it hurts for answers is crucial.

Lets take a patient with lower back pain when walking with a shortened step length. We can make this assumption; the shortened stride length is a symptom or a cause of low back pain. Lets assume it is a cause. A biomechanical assessment must be done to find the source of restriction such as an equinas foot type, compensated forefoot valgus, soft tissue restriction of subtalor joint mobility or tight lower extremity musculature from too much sitting.

All of these causes create an environment of dysfunction for the lumbar spine. The lower extremities are now inept at dispersing ground reaction forces, insufficiently lengthening trunk musculature to initiate leg swing at the right time or speed and their hypomobility causes postural hypermobility of the lumbar spine. Think of tying shoes to understand the former point.

In closed chain posture if I cannot dorsiflex the ankle and flex the knee, the lumbar spine is forced into endrange flexion to get the hands closer to the floor.

If closed chain ankle dorsiflexion and knee flexion is improved via conservative methods like functional strengthening exercises, balance training, stretching, modalities and orthotics, lumbar spine function is also improved. The patient can reach the floor without going into endrange hip/trunk flexion. In gait, increased dorsiflexion allows longer step lengths. So, calf, hamstring and hip flexers are now functionally lengthened. Simultaneously, trunk musculature is also functionally lengthened. Ground reaction forces are efficiently converted into elastic potential energy and abnormal gait compensations are now reduced.

The take home message is that the lower extremities can play a large role in spinal dysfunction. Try not to focus on the site of pain. Look lower to find answers to clinical questions. Maybe if we treat patients with back pain like people with knee pain we would be pleasantly surprised.