Low back pain anatomy and biomechanics explained

This is session number 65 of the Performance Place Sports Care Podcast. The 4th of July! Welcome to the Performance Place Sports Care Podcast, where you can learn about sports injury theory, rehab, diagnosis, and how to understand the doctor lingo you didn't understand at your appointment. And now, your host, Dr. Sebastian Gonzales. Hey everybody, it's Dr. Sebastian, also again with the Performance Place Sports Care Podcast. And this is the beginning of my personal, probably, extremely annoying phrases. And I think there's about five here that, apparently, when I get around friends, they already know this is their imitation of me, basically.

And I can definitely tell this first one, when we're talking about the month of July, or more importantly, the holiday of the 4th of July, I personally think it is the most exciting holiday there is, and mainly because there's no real traditional stuff around it. There's not like you have obligation to go a bunch of different places like you do with Christmas, so you can't really relax and so on. This is like an ultimate barbecue, have a couple beers, go to the beach holiday. So, that's what I dig the most, and it really gets me excited. So, pretty much all year, especially when we get into the new year, around January, I start getting excited.

And I tell people how many months we are away from the 4th of July! And it becomes infectious, I believe. I mean, I think everybody I probably know that I see multiple times in a month know that when this topic comes up, they have to auto-correct themselves already. So, they're talking about like, oh, you know, I'm going to do something in July. I'm like, what? What did you say? I can't hear you. And they're like, sorry. July! So, they automatically correct themselves. So, we have this whole collection of people that just get excited about that holiday, the 4th of July! So, this is why I'm the most annoying person that you've probably ever met in your life.

So, anyways, this is the first of a few things I thought I'd bring up, my personal annoying phrases. So, this month, by the way, this is the first month that I've actually scheduled out non-randomness in the podcast topics. And I'm not going to say in the past that I've done a really bad job or like have neglected to, like there wasn't any thought in it, because there was thought. But it's funny, like in the beginning, like I was just wanting to make sure that I was ahead of the game. So, a lot of people that I interviewed, they're asking, when is it going to come out? I'm like, well, yours is scheduled to come out in like 10 weeks.

And they're like, well, why so long? I'm like, well, because I'm ahead. You know, I want to make sure that we have time to edit. We have time to make sure that everything is streamlined and good and my leveler or my audio person had a chance to do all the work. So, yeah, I was never really, I kind of looked out in the future. I'm like, when am I going to actually be able to schedule some topics that I can combine around each other and ones that I can correlate the YouTube channel with or the Instagram with? I need to blend these things together, which is my thought, because you've heard me in the past podcast where I'm going to say, I'll drop this video or this reference into the show notes, which I do, but I'd rather just have it all released in the same week.

The YouTube goes out on Friday. The podcast comes out on Wednesday. I feel like I can correlate this together. There's no reason why I can't. So, this first month is going to be on low back pain, okay? So, this month we're going into, as you heard, it's going to be my personal experience was last time. This one I'm going to go into some anatomy, which is going to be a little bit more boring, but I'll try to make it interesting for you guys. Next week we are going into, we're going to have an expert on. It's Dr. Seth Meyers. And then after that, we're going to have another expert on, and we're going to talk about some high reward, low risk return to lifting and return to play.

So, that's my plan for this month. Next month we're going to do some hamstring stuff. So, hopefully if you guys have a general interest in sports injuries, then you're going to stay on these couple months. And I guess if you have a shoulder or an ankle or a knee, I guess you might want to tune out for a month or so, or go back and listen to the old podcast, since we do have a lot dropped in there. Okay, so recap. If you guys have not gone to the P2 Sports Care site, you need to do so. It is slash podcast is where you can find all the show notes. And any of the references of the products or posters or bands or kettlebells that I recommend on videos or the show is also under the shop area.

Okay, there are a couple affiliate links in there. I do get a small percentage of money for things like that. But for the most part, just think of it, I'm just categorizing it for you guys because I have people email me here and there. Hey, where do I get this? Where do I get that? And I'm trying to make it easy for everybody here. Okay. So, let's just go right into the anatomy of the low back. So, I guess the first thing we have to realize is that the anatomy of the low back, it's kind of, everyone kind of thinks of the bones or the spine. They think of like, you know, the thing you'd see on Halloween.

And the spine is only a small part of it. So, I will go over the bony as well as the structural components of the spine. But we're then going to go into a lot of the musculature, the intra-abdominal pressure, and all the technically, I guess, quote-unquote core area and why that's important for supporting the low back. Because, like I said, it's kind of funny how this goes, but like, when people come in with a complaint of back pain, oftentimes they'll blame the spine when they should be blaming other parts of the body for not doing their work. So, the first thing we have to realize is the spine is made up of bones, which are called vertebra or vertebral bodies.

Sometimes people call the section of them that. And there's also the disc. So, the disc are the part of the body that, or part of the spine that a lot of people blame back pain for. Honestly, discs are like, they're like jelly donuts. That's the most common analogy we use. And when the jelly is contained within the inside of the donut, we're all good. But when the jelly starts escaping or the sides of the donut start breaking down for one reason or another, we start blaming the disc as a possible reason for injury. When it's not always is. So, there's different types of disc injuries, herniations, prolapse, sequestrations, and so on.

And there's a lot more things that could be unique to each person. But for the most part, the disc is a cartilage-based structure, and it tends to get a lot of blame for back pain. Now, since the discs are between the bones, they kind of call them bone spacers is a slang term for them. And that jelly donut is, it's made up of hoops of collagen, and the inside is called the nucleus. And this whole section here, this whole nucleus, is actually pressurized. So, you want to actually think of it kind of more of like the internal pressure of like a car. Now, some of the common injuries you'll hear surrounding disc are degenerative disc disease.

Again, we have those disc injuries, the ones where they actually start pushing the jelly out of the side. And it's funny, these things kind of come along with different age groups. Usually, younger people get disc injuries. And when you have a disc injury that is the actual cause of your pain, later on in life, sometimes that disc starts to dry up because it is kind of a, it's kind of like a water-loving structure. It starts to dry up, and a lot of times, the disc pain will just self-resolve over the course of years. But then when you get older, you start hearing about degenerative disc disease, which is a whole different story.

That is, they call a normal aging process. It's definitely not the cause of a lot of people's pain, although a lot of people have it. I'm sure I have it right here, and I'm 35. But a lot of people that have that actually don't have pain. And we're going to go a little bit into that in the next coming podcast as well. Now, when you look at the spine, and you see that you have these bones, you have these bone spacers over the disc, and then you have these little holes that are kind of like in and around the spine. You see these yellow things come out typically on models. So that yellow thing is the spinal nerve root, and that hole is called the foramen.

Okay, so it's called the vertebral foramen. You will hear this reference on MRIs when they talk about occlusion or narrowing or stenosis of the foramen. So a foramen is technically a hole that something goes through. Now, on the backside of the spine, and I guess it's kind of relative since we're thinking of the back, we're just behind the foramen or the nerve roots is a series of joints. And when you actually hear your back popping and cracking, a lot of times it is these joints just kind of releasing some air within there, they say, or they're kind of gapping the joint. And these are called the facet joints.

And basically what their function is is to kind of guide the spine into bending and rotation and turning and so on. And it actually guards against shear forces which will damage the spine. Now, without going too complex into the facets or those little joints in the back of the spine, just know that in different sections of the spine they have different purposes and they allow for different movement. And that's why the mid-back moves differently than the neck or the cervical spine. And that's why the cervical spine moves a little bit differently than the lumbar spine or the low back. So it's all dependent upon what the functionality or the reason for that section of the spine's really existence.

Now, there are ligaments around the spine, and I'm not going to go too much into this. Just know there are ligaments there because they can get really extreme with their names. But just know there's also tendons and muscles as well. So all around the backside of the back, probably the muscles you've heard the most about are the multifidus, have gotten a lot of popularity over the years. Those are ones which are little stabilizer muscles in the back of the spine, and they're almost like sausage-like. I remember we dissected a body in grad school, and I mean, these things were thick. I mean, it was like a big kielbasa almost, like it was encased in fascia or like this kind of like white, like silvery covering.

And it goes just along the gully of the spine. And if you felt up and down your spine, you'd feel first the ridges right in the middle. And just on the side there is kind of like where we have that gully where there's still bone. It's just deeper. And there's that gully, and that's filled up with the multifidus muscles as well as some of the rotators rotating, or they call the rotatory group in the area. Now, some of the larger muscles you've probably heard about are the quadratus laborum, which are to the sides, kind of sitting in and around kind of where the kidneys are. You'll feel them just at the bottom part of your last rib in the back.

And it goes all the way down and attaches to the pelvis. Now, around the front side of the spine, or around the sides, we have the obliques, the internal and external oblique. We have the transverse abdominus, or sometimes in studies you'll see them called the TA. We also have the rectus abdominis, and we have on the inside part, which you really can't see, which I know you've heard about this before, though. One is called the diaphragm, okay? And the diaphragm is the top of the abdominal area, or also the lower part of kind of the lung field or the chest cavity. Okay, it kind of differentiates between the upper part where the ribcages are, is, and the down part where all your guts are.

Now, on the very bottom of that, we have the pelvic floor, which I'm not going to name all those muscles, because I don't even know if they mention them in studies now that I'm thinking about it. They usually call it the pelvic floor or levator anii or something like that. But when they talk about the pelvic floor, they're basically talking about kind of the bottom part there, and I guess the slang term would be your kegel muscles. Now, I'm going to come right back to the core section and kind of the function of it in a few minutes here. But one thing I like to think of, at least when I differentiate these sections of the spine to people, when I show them, at least on these models, is I like to think about front side elements of the spine and backside elements of the spine.

And obviously, each case is very different. So, the symptom patterns are a little bit different, too, but I'm going to generalize it and say that usually when we see someone who can't bend forward or it hurts to tie their shoes or sitting for prolonged periods of time or they have shooting pain down into the leg with correlation with these movements, a lot of times we're looking at some type of disc injury. And that's more of a front side element. And the front side there, it could also be a fracture as well. So, there's other things that could be on the front side there. But kind of the differentiating line there is that foramen or that hole that we spoke about.

And I know that people have probably heard about sciatica or radiculopathy or basically these are conditions which correlate to some type of leg pain, numbness, paresthesia, ants crawling, burning, stabbing, hot, cold sensation. These are all kind of correlated to some type of nerve irritation, whether it be at the spine or even a little bit out of it. But the disc injury could affect that, okay? But on the flip side, the backside elements such as the facet joints in this area can also affect it as well. And usually people of older age will have something like this. They have facet arthrosis which creates foraminal stenosis.

There's also central stenosis as well. But basically what this stenosis means is kind of a narrowing of the hole or the foramen. And we have another strangulation of the nerve. So, it kind of presents as like the same thing in the leg but kind of for a totally different reason. And a lot of times it increases when the person is leaning back or arching their back. So, this is one reason why, and probably a lot of you have heard your friends or family before who have said, well, my back hurt. I tried this. It was great. You should do it. You probably shouldn't, okay? Because how do we know that's the exact same injury?

Because every case is unique, okay? That's the most important thing to realize. There is a way to figure out how to deal with your pain. And if we assess it down and check out the movements which bother it, and then we talk and have a conversation and so on. And that's the reason why to have an exam with someone like me or hopefully someone who's better than me. I want you to find someone better than me. But not every case of back pain is the same a lot of times. There are exercises which will help a strong majority or a subset of back pain patients, but it doesn't help everybody. So, a lot of times, so, say we had a front side element injury, let's say a disc injury, and you were talking to someone who was, let's say, in a walker.

Bending forward feels good to them, okay? So, they might tell you bending forward feels good. You bend forward, it's going to shoot down your leg. It's going to hurt. So, this is the reason why you can't just take everyone's remedy as gold. Now, for a lot of the remainder of the podcast, I'm actually going to go into core function, okay? And I was looking up, trying to figure out the best way to explain core to everybody. I always think it's best with pictures, which I probably should attach a video to this podcast. So, if I do, it will be in the show notes, don't worry. So, p2sportscat.com slash podcast, because I explain it to everybody in the office with a picture.

And what I typically do is, and I will divert away from this in a couple minutes and give you probably a better example, but usually what I start to do is I grab a can of Coke. Actually, sorry, I don't take Coke. I take, I actually take, we have this, it's called, they're called cavi wipes, actually, in the office. They're basically in a small cylinder, they're a sanitary wipe that we use to clean tables and so on. But just imagine Coke can, but I tell them, imagine a Coke can. Imagine we have a can here, right? Here's one can, here's the other. I'm going to open one. Everything else remains equal.

I'm going to stand on one. Which one has the better possibility of holding my weight? And most of the time, they answer the one that's not open. And I say, why? They're the same can. They're like, well, it's open. So what happens here is basically the pressure on the inside changes. So the inside pressure is what we reference to as intra-abdominal pressure, which is one of the parts of the core, which is extremely important, but a lot of times unknown to people. So if you've ever had anyone tell you that you breathe poorly, and that's the reason for your back pain, this is kind of what they're referencing.

And it's not necessarily about do you get enough oxygen in or anything like that. It's about are you using your chest to breathe rather than your abdominal area. And I did have someone ask this question. They're like, well, how am I not supposed to use my chest and lungs when I breathe? How can I use my abdominal area? I'm like, that's a good point. So here's what happens in the lung field. So just to make sure everyone's on the same page with this, I'm not blowing smoke. So if everyone's had a needle put in them, so they typically stick the needle inside the medication, they pull the stuff out, it's now sitting in the reservoir, and then they push it in to you.

Okay? So that is an example of negative pressure. So by expanding the cavity that the medication goes into, it inherently sucks the medication into the cavity. Same thing happens with the lung field. So as we expand the lung field, or the rib cage, or that chest cavity rather, air comes into it. Now you have a couple different options. You can expand it by moving side, kind of like going up and down, and I guess I'm going to breathe. Kind of breathing with your chest, like almost like when you see someone who's stressed out and they're breathing with their chest, like they just got that angry look on their face, you know?

That is chest breathing, okay? And it does get air in, but at the same time also it changes the pressure in the abdominal area or around the surrounding low back or the core region. So what we typically want is we want them to lower the diaphragm and keep the diaphragm in a horizontal position, and I'll explain that in a second. So let's go back to that vial, okay? If we can pull that vial or pull the plunger back, then we still get air and liquid into it. We want to do the same thing with that diaphragm or the can section of the abdominal area. Now, it's going to seem, I think it's best to think about from now on, think of your abdominal region, everything below the ribcage, as that can of Coke, or I guess the back end of that needle or the syringe.

So what we're looking to do is we're looking to depress the top of the can, okay? So think about this from just now we have that can of Coke and we put it into a vice or, you know, I always imagine back into Star Wars, and I forget which one this was, but they were in this trash compactor thing and they were just kind of on the sides. And imagine you had that can of Coke that was the only thing that was going to hold the two sides so you didn't get squashed. Now, when that can of Coke hits a certain point, it's going to explode, but it's going to explode from the sides. And the reason for that is because the pressure inside increases because we're changing that top and bottom volume, okay?

So what we're looking for with the core region is we do want, and don't get me wrong, we do want the muscles of the sides to activate. We do want the obliques and the transverse abdominis and all the multifidus and the quadris, the borum and the glutes and all this stuff. And by the way, a lot of the core muscles do expand well beyond the ones that I mentioned, even the lats and muscles which cross the ball and socket joints are included on this. So the hips and shoulders are really included on this as well. So what we want is that pressure on the inside to remain fairly constant or higher. And when we think about, let's just say we had, what is a good analogy here?

Sorry, I'm not, I usually have good analogies, I think, but this one, I can draw a picture of this, but it's going to be a little tough to, okay, so let's just go with that can of Coke analogy. Imagine it's a cylinder and you have that whole thing. Now it's as big as a bucket, okay, like a bucket from Home Depot. It's full of, actually, no, I go back. I'm going to go back because I do have these now. So I have water bottles at the office, these big five-gallon ones. Imagine we insert that thing into your spine. Is it going to move at all from the lumbar spine region? No, it's not, right? That thing is super rigid.

It's full of fluid. Its sides are good. Its top and bottoms are contained. It's designed not to break or bend, and that would be an extremely rigid torso. So if we find that someone has an injury with the back and it hurts to bend forward or backwards, perhaps we want to create some rigidity for a period of time to make it so they don't keep ripping that scab off there. So the reason why I brought that whole part in was because breathing or being able to breathe well and create high intra-abdominal pressure is extremely important when we're lifting objects especially and protecting the spine when it's looking for that compression or we're protecting against compression.

So I've noticed a lot of patients that come in, it's a completely new idea to them, and that is one of our fundamental building blocks. We have to make sure that we can create stability within that spine area before we actually get them to do core work, I believe. So people might differ on the thought process to me, but for the most part, there's a lot of research which indicates that intra-abdominal pressure is an extremely important part of the core and spinal health. So now back on to the drawing that I'm going to do for you guys. I think about people using that can of Coke analogy and then thinking about putting it onto, like we're going to roast that can of Coke, you know, like over a fire.

We're going to stick it on just like a marshmallow or maybe like a rotisserie chicken and just spin it, right? So the can of Coke really doesn't move, but it does spin or rolls. And what we want is kind of on the ends of like say that rotisserie, we want to make sure the ball, there's a frictionless point. There's something that really doesn't rub that much and those are the kind of the ball bearings on the side of the rotisserie, okay? So that thing can move really smoothly in the middle and it doesn't bend and break and so on. So what I have drawn is a can of Coke with ball bearings on the side.

And if we flip that thing over, we can kind of see that that is the spine and then we have the ball and socket joints. We have the hip and the shoulder, which are extremely important for health of the spine. Now, granted, yes, the spine is supposed to be flexible in some instances, but also you have to be able to provide stabilization when it's under load to protect it. So that's the beauty of the spine. And to kind of explain this further, I actually was looking around for some examples of how I should better explain the core. And I couldn't get past one of the articles that Dr. Stuart McGill wrote, which you can find on his website, which I will put in the show notes as well.

And this is a free download. So I'm just going to read through this thing for you guys, because I think it was extremely, extremely well written. And a lot of my patients who listened to the podcast that I suggested to them on the same topic, they came back and they're like, wow, that is amazing. I didn't know that the core did that. I didn't know it was that important. Like they knew the core was important, but they didn't know the reasons why. And that's what I'm going to go through now. So you can find this article on backfitpro.com, by the way, and it's labeled why everyone needs core training.

And I strongly suggest you read it on your own. But I know for the sake of a lot of people not wanting to read anymore, I'm just going to read it to you. So I'm going to jump around here a little bit. But this is basically verbatim by Dr. Stuart McGill, which, by the way, I'm very excited to say that within two podcasts here, he's actually going to be on the show. So I'm excited to have some questions directly to him. I think it's going to help you guys out a ton. So here we go. So core stiffness is essential for injury prevention. Core stiffness is essential for performance enhancement. Core stiffness is not optimized in bodybuilding exercise.

Core stiffness requires dedicated training. So here's the next paragraph. And by the way, I might stop a couple times just to reiterate or explain some parts. Just because I want to make sure everyone realizes the terminology we're using here. So a discussion of the core requires a three-dimensional perspective. The spine is a stack of vertebrae that is asked to bear a load, yet it's flexible. A design engineer will tell you that you can't design a structure to be both good at both. A steel beam that's straight and sit on end is stiff and can bear loads that try to compress, shear, and twist it.

So that's an important point right there because when we stiffen up, then we protect against compressive shear and twisting forces, which when you look at, and you can probably go on WebMD and other websites that will talk about how disc injuries and back injuries happen. It's a lot of these compressive shear and twisting forces, especially under load. So the beam can bear load, or it can bear load, but it can't move. A flexible rod, which allows movement, will bend and buckle under load, but it absorbs shock. Our spines do it all. They bend and allow the lungs to fill with air. They even allow us to dance.

The spine is a beautiful structure that's flexible and allows flowing movement, but requires a three-dimensional guide wire system to stiffen and stabilize it when it requires load bearing. Now, let's break that part down a little bit here. And I don't know if you guys have heard my podcast with the Full Body Fix. We were talking with Dr. Mills on there, and he asked me about my testing for leg or knee conditions, rather. And I said, we start with three-dimensional testing. I mean, that is actually, it's not our actual first start, but every person with a knee injury comes in, and we have to test all three planes of motion for the trunk and the pelvis to see if the person has the ability to control them.

So, it does all start with the core and the pelvis, and back pain is no different. So, we have a three-dimensional thing going on here. So, forward-backwards, by the way, is what we call the sagittal plane. Okay, that's when you bend forward to tie your shoes. It's when you extend back to, I guess, stretch your back. The frontal plane is side-to-side. I guess I think about that song, elbows up, side-to-side, elbows up, side-to-side. Okay, so it's a dance where you're just kind of going back and forth. Now, the transverse plane is rotational, and think about a dancer spinning on axis. So, we have to be able to protect the spine against some of these forces, because if excessive and repeated, they will damage the spine and create pain.

Now, before we go on any further, I want to make sure that we're not missing part of the original points I made in this podcast is, can you have pain without actually having damage to the spine? Yes, you can. Can you have damage to the spine visible on imaging, yet no pain? Yes, you can. Okay, so we're protecting against damage to the spine. I mean, sure, a lot of damage, there's a ton of damage to the spine. Yes, that is more than likely the pain generator. But a lot of times, just like my back pain that I had years and years ago, I still have that 3mm herniation. It didn't go away. It's still there.

It's probably not dynamic or moving anymore. But I haven't had pain in 20 years. So, just remember, so my training here that I do for myself, in case you're wondering, is I protect my back against some of these three-dimensional forces. So, I'll continue. Analysis of the muscular system, together with its associated fascia sheets, reveal a clever guy wire system and creates balance stiffness, eliminating the possibility of buckling and injury. The concern is that modern living does not tune and train the guy wire system. In many people, it lapses into complacency. So, I think that's an excellent point there.

And actually, I was speaking to a patient a little earlier before this podcast, and we were talking about, he said that he's now active. He's about 55 years old, I think. So, now he's starting to, you know, weight train and, like, get in better shape and so on. And he's telling about some of his friends who they are now having hip replacements and back surgeries and so on. And he's like, it's probably good that, you know, in my high school days, I kind of didn't do athletic stuff because then I saved my body for later on. And he said, do you think you can wear things out? And I'm like, I don't, I mean, I think sure you can wear things out, but I don't think if you're responsible in how your body moves, I think it doesn't wear out.

And he's like, well, what do you mean, you know, like, I'm like, well, I think, let's just say we're talking about a pulley system, you know, let's just say a single pulley and a single rope. And say it's a nylon rope or something that's really, you know, resistant to aging, not some, like, old one made of, like, twine or cotton or anything like that because that would just wear away too. So think about that pulley system, it's kind of a frictionless system, so there's not really much that's going to wear away on it. Sure, you might have a little bit of aging, but for the most part, it'll last a long time.

Now, say we're pulling that rope up and down, up and down, up and down, right? And if it moves well and works well, I think we're all good, you know? But let's just say that we dropped that pulley and it had a little bit of damage, which created like a metal kind of burr that came out of the side. Now, we're rubbing the rope past that. Is that going to damage? Yes, it will. So, I think that analogy, at least when I gave it to him, I think it really comes down to when we were younger and athletic, like I was, I think we did more of the necessary things to make it so that pulley worked better, so we didn't damage the areas.

Granted, there are exceptions, especially when, I know there's a big thing right now with hip injuries growth plate expansions or what we call cam deformities in young athletic kids. That's a whole different story. But for the most part, I think what happens later in life and the reason why these things wear down and backs included is that we no longer take care of what's needed to train this guy wire system. So, he was saying, well, like my friends played softball or they played baseball and then they played like adult league, then they played softball, and now they're all having replacements.

I'm like, well, what do they do during the week to make it so they responsibly play their sport? And I'm sure if you've heard, guys have heard my podcast before, you've heard me say this many a times. I think training, rehab, strength training, sprinting, all these things and change of direction drills, all these things are in an effort to make it so I don't get injured playing. They can be performance enhancing as well, but the body is very adaptable, okay? It will adapt to almost anything you throw at it, okay? We've seen this with osteoporosis, okay? And if any of you have or know someone with osteoporosis out there, if they're not weight training to some degree, they're missing the boat.

Sure, you can take supplements. Sure, you can take medications and so on. But realistically, the body abides by or the bones abide by a principle called the Wolf's Law, okay? And you guys can look that up if you like. Basically, the bone will grow in the orientation that it's stressed. And it happens over time, and you'll see that with six months of weight training, if you went back and did a DEXA scan again, you would see that, oh my God, it's getting better. It's becoming normal. This happened to my mom, okay? He was just using disbelief with it. Same thing happens with muscles and tendons, okay?

I know I haven't done a podcast on tendinopathies yet, but collagen remodeling happens because of mechanical loading. We have to load the area to some degree. Sure, you might load it too much, but at the same time, if you don't load it, it doesn't really repair. So going back to the article here is that, I'm going to say it again, the concern is that the modern living does not tune and train this guidewire system. Many people let it lapse, and they're just complacent with it. So it's not just sitting around, but it's also stuff that you're doing on the free time when you are not sitting around.

Are you being active? Are you going out drinking? Are you laying by the pool? You know, are you swimming? Are you weightlifting? You know, there's a lot of things that I think that could be done more responsibly to decrease the amount of back pain that we see, at least as Americans. Okay, here we go with the article again. So the greater the load that's placed upon the spine, the greater the need for muscular stiffening to the spine, or greater the need for the musculature to stiffen the spine. How can this be? The muscles contract. When muscles contract, they do two things. They create force, and they create stiffness.

Stiffness is always stabilizing to a joint. Okay? And this is not only in regards to the back. This is in regards to other joints, too. The stiffness prepares the joint to bear load without buckling. Failure to appropriately stiffen is the biggest cause of joint injury, although not the only cause. So let's digest that a little bit there. So stiffness comes from the musculature. It comes from that high intra-abdominal pressure. It comes from knowing when to turn it on. The back is stabilized. Like I said in the very beginning of this podcast, I said we do see, when you see a skeleton, you see the bony portion of the stabilizing.

And it does do some work, but it doesn't do all of it. Okay? That's important to realize. It's not about your back. It's about the stabilizing structures. Are the muscles doing the work? Okay? Are you putting the time in to teach the muscles to do the work? Are you breathing well? Is your Coke can losing its top? Are you popping the top off of it? So these are all things that can be trained. They can be learned. And when I start with patients in my office anyways, we start first with breathing. And then we first, then we start with, well, actually it depends on the case, but we teach them to do a few exercises specific to their back injury that they do at home.

Now, are they going to do it? That's a whole different story. Okay? That's an accountability thing. And just recently at the office, this actually today is the first day that we're going to implement it. And I'm so excited. Is that I've actually heard of gyms doing this. And I know it sounds ridiculous. And I feel a little silly doing it, but I think there's something to it. Because someone had me do this one time, and I took it seriously. So when we go through the testing to see where the person's at, I'm going to ask them what their goals are if their body didn't hurt. And this will go for any different type of injury.

So I want to know what their goals are. What do they want out of this? Okay? Because it's realistically what I train them for, how I rehab them is based upon their own goals. Now, what I'm going to have them do next is sign the bottom. Obviously, not legally binding or anything. But the bottom is basically saying that they're going to make a promise to themselves. That they're going to do everything that is asked of them in their time under my care. Okay? Next is they're supposed to tell a friend or family member to keep them accountable. I want them to tell them, because telling is learning. There's a reason why I partly want it.

I want them to tell them what their injury is and what is expected of them. And I've actually heard of couples doing something to the effect of even that they said, hey, look, I really want to get this rehab done. I'm having a hard time with it. Can you help me? And the other couple says, okay, great. Every day you don't do it. You owe me $20. So now there's some type of skin in the game there, you know. And I think, I thought I'd heard that Harvard, or maybe it was MIT, they did a study on, I think it was an app called GymPact or Pact, where the person really didn't pay anything for the app. They set their goals.

And when they hit their goals, they won or they got money. This is a small amount of money, like $5, $10, I think. But they put their credit card on file there, too, I think. So every time they didn't hit their goals during the week, they had to pay the app some money. Now, I think it's genius because now there's something that they're going to lose. There's some skin in the game there, which I think is a big issue with a lot of people. I think we all know how to eat. We all know how that exercise is important. We all know we know a lot of health things. We know we shouldn't be smoking, drinking excessively, all that kind of stuff.

But do we still do that? Yes, we do, because there's nothing really on the other end keeping us accountable, okay? So we need to do that responsibly. And that's why I want to, or I am going to incorporate this with my patients. I want them to do their homework. I want them to get self-sufficient. And I tell them that when we find the exact exercise library for them, if they master it, they don't need to come see me, okay? Unless we're going to amp that up and give a little bit more progression to it, which a lot of times we do with exercises. But for the most part, you're in school. You have to just do it and do it well.

It's not about the time that you're under care. It's about the repetitions that you're doing in good form, which gets you good form so we can move well. Now, you might have lost me partly on that, but I'm going to go back and reiterate a section that I just read from that because I think it's important, okay? Stiffness is always stabilizing to a joint, okay? Thus, stiffness prepares the joint to bear load without buckling. Failure to appropriately stiffen is the biggest cause of joint injury, although not the only cause because obviously there's trauma and so on. So now I'll just go through in the performance side.

He wrote a paragraph on that. So on the performance side, of course, stiffness is mandatory. It's absolutely essential to carry heavy loads, run fast, change of direction quickly. It determines the rate of speed of movement of the arms and legs. There are those people who state that they don't need dedicated core training because they lift and squat, yet when I assess their strength and speed abilities, I often find they're unable to translate their strength to on-field performance. Pointing out their weak links brings them to the realization that core training is non-negotiable. Now I'm going to pause there for one second, and I'm not going to go too much into performance, but in regards to back pain, I asked a patient this the other week, and when he came in, we figured out what exercises and corrections needed to be done to make his back pain decrease significantly.

So before he left, he said, so do you want me to stretch my back? Or like, how should I get into those spots with a foam roller is what he said. And I said, well, so what's the function of the core, you know? And he's like, well, to stabilize the spine. I said, well, we worked on creating stiffness, so what happens if you stretch, what happens to a muscle when you stretch it? Well, it gets looser. I said, if it gets looser, does it provide as much support or less? And he says, less. And he said, oh, I don't know if I should stretch this. I'm like, exactly. I'm like, you can go to town on your hips.

You go to town on your, I'm okay with mid-back. Some people might not be. I'm okay with even the shoulder girdle and some parts of the extremities. But I don't really suggest people stretch their low back on their own. Now, that's not to say there's not a need for some tissue work. And I'm going to make sure I do say this in this podcast here because I think when I went through and did the one with full body fix with Dr. Scott Mills, I don't think I said it enough, but there is a time and place for tissue work. And even when it comes to knees, although knees, I've stayed a little bit further away from doing tissue work than I did in the past because it's a simple hinge joint.

I mean, it's affected by the above and below. It's affected by the ankle, the hip, and the core. And I think what happens a lot of time with people is that when we tell them that they need some tissue work, specifically on the spot of pain, that's what they want to hear the most so they gravitate towards it. So they start blasting the area with tissue work, massage, and other types of myofascial work. And, I mean, I think there's definitely a time and place for someone who's got some skills to really get in there and find those grisly portions. I mean, there is those adhesions or scar tissue that we find.

And the adhesions are basically when tissues don't slide amongst each other. We want that relative slide. So we can get that because there's multiple layers in the back area as well as other joints. So I think there is definitely a time and place for that, but I don't think it's not the end all, which I can't stress enough. And by the way, I do do tissue work in my office, but I tell people it's like a 25-75 rule on it. So 25% I'm doing tissue work on there, but by all means, like if you come in and you say like, look, can we just do tissue work today? No, you can't. I firmly believe that if we're going to loosen an area, at least for an effort to break up or enforce slide amongst those tissues in the spine, then we also have a strong responsibility to stabilize it as well.

And I do find a lot of times that with people with back pain or even pain in other joints, it hurts to move. So when we suggest certain types of rehab, if we can't get them to do what we need them to do, then they're not going to stabilize and strength that area anyways. So my suggestion a lot of times is why don't we do a little bit of tissue work or whatever protocol, or we don't do a lot of other machinery here, but let's just say we have a TENG unit or even like a hot, cold, all that type of stuff. Like these are all what I call our passive therapies. They have a time and place, and I think it's for getting us to move better.

And then we have to strengthen the area and make it stabilize itself locally and globally. So I just want to make sure to reiterate that, that I don't want people listening to this thing that I don't do that stuff. I do do that stuff, but the missing link in a lot of people is they are not taking the necessary time to make their body work better. They need a stronger core. They need their arms and legs to work well. So I'm going to jump much further in the article now because I think the other stuff is not going to be as interesting for you guys right here. But I'll start with the proximal stiffness or stiffening of the core between the hip and the shoulders produces higher limb speed and force.

Strike force in MMA or baseball or golf is governed by this universal principle. Limb speed for throwing, running, and directional change is a fundamental athleticism. While proximal stiffening, he quoted the core, governs all of these athletic objectives, it also reduces back pain and injury by reducing the spine's bending when loads are imposed. The spine loses its load-bearing strength as it bends more away from its neutral position. Okay, so stiffening the core will help out with athletic endeavors. Now, I hope all that makes sense so far. I know I've diverted a little bit, but I want the take-home so far to be that, yes, the spine does have structure.

Yes, it has bones, ligaments, tendons, corelages, discs, nerves. It has all that stuff. But I think where the real magic happens and something we can actually change, especially in the short-term, but long-term is, I mean, just dedication to it, is how we use our body, how much endurance we have in the spine. So really, it comes down to, are we using our body responsibly? Okay, we can do all of the stretching and tissue work and medication in the world, but if you don't use your back well throughout your entire life, then you're going to end up having some type of back pain. Now, what I typically recommend people after they've gotten to a point where they've mastered a bunch of exercises, is if they feel like they have the need to then, quote-unquote, get into shape or start lifting or kind of mastering their body's movements, then they need to take a course on it.

And, like, I've made some really comprehensive videos on squatting, deadlifting, pushing, pulling, that, and the reason why I did it was because they are a big topic. And I've not once seen someone come in and have a perfect deadlift into my office, and that's probably why they're coming in because they're in pain. I usually don't see all of the other people who are good, but I think we have to think of it like a crash course in college. We have to just spend the time, spend six months or more, probably more. I'm probably being very liberal with that. Learning how to move our body, okay? Asking questions, putting the reps in, and then applying load when needed.

So that's what I typically recommend to people because, realistically, if we get them out of pain and we let them go, they're going to do the exact same things they were doing. They're going to move poorly how they were, and they're not going to understand and respect their spine. Now, I think I'm going to stop there for the podcast because we do have two other experts coming on. We have Seth Meyers, who is going to be the next one. Then we have Dr. Stuart McGill coming on after that, which he'll probably tell you a lot of the stuff that we talked about today. But I am going to ask them a lot of questions that we get as healthcare providers because what I kind of wanted to do, at least with both of these is actually this whole series, is I wanted every new patient that came in to, I know it's going to take a long time, but they're going to have to listen to nearly four hours, probably over four hours of audio on back pain.

And they're going to wonder why the heck they have to listen to this. Well, I'm going to say, well, why do you have back pain? You know, you have to understand it. And rather than thinking that a healthcare provider, your PT or doctor doesn't spend the time with you, this is the same stuff that they're probably going to be telling you anyways. So it's best to listen to these a couple times, really understand it. You can listen to it whenever you want to. I like to listen to podcasts when I drive or when I run. And then ask your doc or PT or chiropractor or ATC secondary level questions and really become a master at your condition.

So you can find all the show notes on ptsportscar.com slash podcast. And don't forget to subscribe on iTunes, okay? I found that it's actually really hard to review on iTunes, at least for me. So I think what you got to do is you have to go through, what was it like, almost like the share button, but then there's a description. So you'll find where all the reviews are at some point. Or you just Google and say how to review a podcast, and that's how I found it. It was the easiest way there. I should put a video out on that, actually. But if you guys can review it, any five-star review would be amazing.

But even four stars or constructive criticism are appreciated. I'm going to make this podcast better and better. So if you are a doctor, PT, or your chiropractor, sports medicine physician, in case you don't know already, there are posters that I've created for patient education, okay? I have them on my website. You can go on to the shop or store portion. And what I'm trying to do is actually I'm trying to make it so we are making patient educational materials, such as posters, better for patients' comprehension of their goals. And the reason why I ran into the problem was because that I'm probably just like all you guys.

I still bring out my Netter's book. And it's the only book that I've really kept since grad school. And I show it to patients. But the problem is that it's so much going on in there that they get a little distracted. So, for example, shoulder cases, rather than flipping around, and again, if your book is like my book, the binding is ripped off. I mean, the pages are hanging out, and I just basically designed something I thought was better, inspired by Netter's, so anatomically correct, and putting some information on there, such as the three Ps of the shoulder, according to Dr. Jobe. We go through some pitching mechanics.

There's one on sports hernia. There's one on how to improve running performance based upon strength training, if you have any clients or patients who are trying to get faster, but they just don't want to weight train. There's a whole study on there. And then also we have a new one coming out, which is on deadlifting technique, which I think is going to be extremely popular because, I don't know about you guys, but I'm kind of tired of showing bad form examples or pulling pictures up because it kind of hurts us to do bad form. So that's why the poster is there. So if you guys like that or if you want even those free web versions, those are completely free.

Just go on there. All you have to do is drop your email on there. You get the web-based versions, which are not printable. I'll remind you on that because they're not high resolution enough. Those are the ones you're going to have to get from me. But I want to share the information, and that is the easiest way to do it. So share it on social media. Just give me credit is all I ask for. Linking would be amazing. So I will talk to you guys soon, and the next two podcasts are going to be great. See you.