The Lower Back and Common Dysfunctions

Lower back pain is one of the most common complaints that massage therapists encounter. In fact, in the United States 70 million people visit a doctor each year in search of relief for their lower back pain (Muscolino, 2022). Still the causes of lower back pain are poorly understood, treatment is often inadequate, and misconceptions are widely spread (Lowe, 2006). Many practitioners are often intimidated by the idea of assessment, but it is arguably the most important step when working with a client (Buford & Coverly, 2022). Assessment is an investigative tool that allows you to provide treatment that is unique and tailored to your client. It is also critical when determining if massage is indicated or contraindicated. With the right assessment and evaluation, practitioners can help to determine back pain causes and craft a treatment plan.

Bone Structure

The spine consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae. The lumbar vertebrae are larger and stockier, built to support the weight of the upper body. In between the vertebrae there are intervertebral discs that act as small cushions between the bones. The fifth lumbar vertebra articulates with the sacrum, which serves as the base or pedestal of the spine followed by the small coccyx bone. The sacrum sits as a wedge in between both hip bones at the sacroiliac joint. The sacroiliac joint has minimal movement, only 1-2 millimeters of translation and by the age of 80, 10% of the population have a completely fused sacroiliac joint (Lowe, 2022). The spine as a whole has 4 natural curves, cervical lordosis, thoracic kyphosis, lumbar lordosis, and sacral kyphosis. Sitting in the center of our body, the spine and pelvis together play a very important role. The smallest dysfunction can have rippling effects that can be felt far beyond our trunk.

Musculature

There are also many muscles that surround and stabilize our lower back region. Crossing the hip joint we have the anterior hip flexor group containing the Iliacus, psoas, pectineus, rectus femoris, and sartorius. Often acting as the antagonist to hip flexion, opposite to the flexor group, are the hip extensors. The hip extensors include the gluteus maximus, biceps femoris, semitendinosus, and the semimembranosus. Also posteriorly we have the trunk extensors which include the erector spinae muscle group with fibers running vertically and the transversospinalis group with fibers running short and diagonal. Acting as an antagonist to those groups and wrapping our internal organs are the anterior abdominal muscles, the rectus abdominis, external oblique, internal oblique, and the transverse abdominis. There are many other muscles that also surround and support this area. The deepest abdominal muscle, the quadratus lumborum has attachment sites at the posterior iliac crest, the last rib, and the transverse processes of L1-L4 and is often called the “hip hiker”. Other important muscles in the area include the lower extremity muscles gluteus minimus, gluteus medius, piriformis, and tensor fascia latae, as well as the pelvic floor muscles.

Understanding the complexities of the lower back is critical to providing the best treatment for your client. Below I will discuss some dysfunctions that you may encounter when treating the lower back region. Starting with minor ligament sprains, moving to an anterior pelvic tilt or lower crossed syndrome, and finally discussing herniated discs, we will look at how these affect our body and what treatment should be used. This is certainly not an exhaustive list but rather focuses on common dysfunctions seen by massage therapists. For many years disc herniation was thought to be the leading cause of lower back pain which led to a large uptick in back surgery (Lowe, 2006). Although disc herniations are serious and can cause severe pain and dysfunction, most back pain can be attributed to less serious musculoskeletal injuries including hypertonic muscles or muscle tightness, muscle strains and tears, and ligament sprains. In fact disc herniation has been discovered in many asymptomatic individuals (Lowe, 2006). Another factor that makes lower back pain difficult to treat is referred pain. If a client is experiencing pain in the front of their thigh it doesn’t necessarily mean that is the root of the problem. Lower back dysfunctions often refer pain to different areas in the body, causing confusion for both the individual and the massage therapist (Buford & Coverly, 2021). 

Ligament Sprains

Sprained sacroiliac ligaments and other ligaments stabilizing the low back and posterior pelvis are the most frequent cause of chronic low back pain (Buford & Coverly, 2021). Microtears to these ligaments are common and often go untreated, resulting in a buildup of adhesive scar tissue (Benjamin, 2008). Furthermore, muscles in the surrounding area become affected. To understand how to best treat ligament tears we must first understand the structures. There are about 13 ligaments in the low back and pelvic region that are commonly sprained (Buford & Coverly, 2021). Ligaments connect adjacent bones to provide stability. They are made of dense connective tissue that contain both elastin fibers, which provides pliability, and collagen fibers, which provides tensile strength. Certain ligaments contain different amounts of elastin and collagen based on whether they need to be more elastic or more strong and tight (Lowe, 2006). When ligaments bear overwhelming tensile load they can tear, causing a sprain. There are also other factors that can increase your risk of ligament tears including dysfunctions involving connective tissue weakness like Ehlers-Danlos Syndrome or Marfan Syndrome, and pregnancy, which increases production of the hormone relaxin, increases ligament laxity (Lowe, 2006). Some of the most common sacroiliac ligaments to sprain include the sacrotuberous ligament, the sacrospinous ligament, and the suprasacral ligaments (Benjamin, 2008). The sacrotuberous ligament connects the sacrum to the ischial tuberosity and can often become strained through hamstring fascial connections (Lowe, 2022). The Sacrospinous ligaments connect the sacrum to the ischial spine. The suprasacral ligaments are small ligaments on the sacrum that are a continuation of the supraspinous ligaments. 

Treating microtears in these ligaments can be easy if you know what to look for. Ligament sprains can produce swelling, pain, stiffness, warmth on the skin, and redness (Walton, 2011). Often ligaments have distinct referral pain patterns which can give you clues to which ligaments are causing the pain (Buford & Coverly, 2021). There are also many assessment tests that can provide you with information to tailor your treatment. Asking your client to perform flexion (bending forward), extension (bending backwards), and side flexion (bending to each side), can help you assess lower back pain. Ligament tears will cause pain at the sacrum, lower part of the back, buttock, thigh, and lower leg with any of these movements (Benjamin 2008). Clients may even experience pain during passive movement and this would be an indication of a more serious tear/sprain. It is also important to note that injured ligaments can cause pain for decades due to inadequate and improper healing and repetitive tearing (Buford & Coverly, 2021). Furthermore, we live in a society which promotes “no pain, no gain”, which oftentimes means clients are not allowing injuries to properly heal and they are constantly reinjuring ligaments. Ligament tears persist due to many indirect causes working together. These can include emotional stress, depression, poor diet, nutritional deficits, excessive chronic muscle tension, bone misalignment, and poor movement habits (Benjamin, 2008). Fortunately, ligament tears can normally be treated non-invasively. 

For more immediate relief, sacroiliac ligament tears can be treated with nonsteroidal anti inflammatory drugs. The combination of rest, ice, compression, and elevation (R.I.C.E.) is always a good treatment for many injuries and can provide relief (Walton, 2011). For more long term relief, it is important to take a holistic approach which includes looking at what has perpetuated the chronic lower back pain. Diet, exercise, posture, strengthening, and stretching are all factors in maintaining back health and ultimately assist in healing torn ligaments. Daily exercises and stretches are very important because they promote scar tissue fibers to grow in correct alignment (Buford & Coverly, 2021). Exercises that will benefit clients should be done on hands and knees and include, cat and cow, side flexion, weight shifting, leg extension, arm extension, combined leg and arm extension, and pelvic tilts (Benjamin, 2008). Your diet also plays an important role in strengthening your immune system which determines your healing capacity (Buford & Coverly, 2021). When it comes to massage treatment, deep massage of the low back and sacral region is needed. This should include targeting the erectors, quadratus lumborum, gluteus muscles, piriformis, hamstrings, and tensor fascia latae. Friction therapy should also be applied to the superficial sacroiliac ligaments to break up scar tissue and promote circulation (Benjamin, 2008). It can also be beneficial to balance the psoas muscles. Other effective treatment strategies include craniosacral therapy, manipulation for postural alignment, and active assisted stretching. In some cases, the ligaments injured cannot be accessed with the hands. In these cases, proliferate injections can be used to help break up scar tissue (Benjamin, 2008). It is important to remember that the longer the back pain has persisted, the longer the healing process. If lower back pain has been chronic for 10-20 years it may take 6 months or so to really break up scar tissue and build up lower back health. 

Pelvic Tilt

As stated before the lower back is complex and understanding it is critical to treating your clients. Besides ligament tears around the sacrum we also have to be aware of pelvic tilt. We can experience lateral pelvic tilt where one iliac crest is lower than the other, or one iliac crest is depressed and the other is elevated (Buford & Coverly, 2022). We can also experience pelvic tilt across the transverse plane in the form of rotational distortion. This is the hardest tilt to see but can be assessed by having a client face you and observe where their belly button is facing and where their anterior superior iliac spines are facing. The third way our pelvis can tilt is either anteriorly or posteriorly. This tilt can be easily assessed by observing your client from the side (Buford & Coverly, 2022). An anterior pelvic tilt is when the pelvis tilts forward. Some people can have an anterior pelvic tilt with no pain while other times it can cause multiple other dysfunctions in the region. Anterior pelvic tilt can lead to an increase in lumbar lordosis (Lowe, 2014). A hyperlordotic lumbar spine can then lead to a narrowing in the intervertebral foramen. This narrowing can lead to nerve root compression. Muscles locked long and muscles locked short are both a symptom and a cause of pelvic tilts. Our bones are passive and our muscles are pulling machines that act on our bones. When a client experiences tight hip flexors, tight low back extensors, weak anterior abdominal wall muscles, and weak gluteus muscles, the pelvis will tilt forward from the pull of the stronger muscles and the lack of stability from the other muscles. Other factors that can contribute to an anterior pelvic tilt are hyperextension of the knees and wearing high heels frequently (Muscolino, 2022). Since back extensors and hip flexors are experiencing hypertonicity, soft tissue massage therapy and stretching are great treatment options for an anterior pelvic tilt. This treatment must be paired with postural re-education in order to improve back health long term. Alexander technique, yoga, and Feldenkrais can also help with postural changes (Lowe, 2014). In the age of working from home, it is also important to talk to your clients about ergonomics. As many say “sitting is the new smoking” because there is actually more pressure on your spine when you sit than when you stand. Encourage your clients to take short walk breaks and make time for stretching and strengthening throughout their day. This will have major benefits to their spine health as they age. 

Disc Herniation

Although most lower back pain is musculoskeletal, massage therapists need to be aware of signs of serious dysfunction. A client should be referred to a physician if they are experiencing severe, apparent muscle atrophy, bladder incontinence, bowel incontinence, extreme limitation of movement, severe pain, or severe numbness as these could be signs of more serious injuries or dysfunctions (Benjamin, 2008). We have two major bundles of nerves in our lower back, the lumbar plexus from L1-L4 and the sacral plexus from L4-S4 (Marieb & Hoehn 2019). The lower back is also home to our thickest and longest nerve of the body, the sciatic nerve. One dysfunction that can cause severe nerve pain is a herniated disc. Herniated discs are often called slipped discs but this gives the wrong imagery. 

Our discs are designed to handle shock absorption and they sit in between our vertebrae. They contain a gel-like center called the nucleus pulposus, and collagen layers on the outside called the annulus fibrosus. A herniated disc is when the nucleus pulposus bulges or ruptures the annulus fibrosus outer layer. In fact, the term herniation means “pushing through”. Disc herniation has varying levels of severity. A protrusion is when the disc bulges but does not tear or rupture the annulus. A prolapse is a partial rupture. An extrusion is when the nucleus pulposus breaks through the annulus fibrosus and protrudes into the spinal wall. The most severe is a sequestration, when there is complete rupture of the annulus and both the annulus and the nucleus pulposus are protruding. Disc herniations cannot be diagnosed without an MRI and are most common in the lumbar region between L4-L5 and L5-S1 (Lowe, 2006). There is usually some disc degeneration also present. You may be asking, how can I determine whether a client has musculoskeletal low back pain or if they are dealing with something more serious like a herniated disc? 

A herniated disc almost always presents asymmetrically (Buford & Coverly, 2021). This is because we have a posterior longitudinal ligament which runs directly behind our discs (Lowe, 2006). The disc will normally protrude on one side of this longitudinal ligament, causing consistent pain on either the left or right side but not both. In rare cases there can be a straight posterior protrusion of a disc which causes bowel, bladder, and sexual dysfunction (Lowe, 2006). This is called cauda equina syndrome and, if not diagnosed and treated, can lead to paralysis (Walton, 2011). If a client is experiencing these symptoms they should seek medical attention immediately. 

A herniated disc does not always cause dysfunction and as stated before, has been found in many asymptomatic patients. This is why it is crucial to distinguish between bilateral pain and unilateral pain. If a client has an asymptomatic herniated disc and is experiencing bilateral pain across the sacrum, they may find relief with massage and deep friction because their pain may be from ligament tears and not their herniated disc. If a client is experiencing shooting pain down their left leg and can only walk 10-20 steps then the client likely has a symptomatic herniated disc. Still, a client should not seek out surgery unless pain has persisted for months and has not responded to rehabilitative exercises (Lowe, 2006). If nerve pain persists, causing muscle atrophy and major weakness, a client may want to consider surgery. Massage therapy is not completely contraindicated for herniated discs but therapists should use caution when applying pressure to the area because minor vertebral movements can aggravate the disc (Lowe, 2006). Massage can be used to decrease muscle tension in the surrounding areas but cannot lessen the disc herniation. Clients may find massage therapy useful after surgery to help with scar tissue release. Our bodies are incredibly complex. As massage therapists, we are not responsible for diagnosing but being able to assess clients and cater treatment is crucial. This is what separates a good therapist from an excellent therapist. With low back pain being so prevalent, having knowledge on common dysfunctions of the area will only benefit your practice. For some, lower back pain can be chronic and debilitating. With the proper treatment, you can provide relief that changes a client’s quality of life. 

References

Benjamin, B. (2008) The Ligaments of the sacrum: The primary cause of low-back pain. Massage & Bodywork, 98-105. Retrieved from: https://www.benjamininstitute.com/resources/all/low-back&group=articles

Biel, A. (2019). Trail Guide to the body (6th ed.). Boulder, CO: Books of Discovery.

Buford, D. & Coverly, K (Hosts). (2021, June 8). Low-back pain with Dr. Ben Benjamin (No. 116) [Audio podcast episode]. The ABMP Podcast: Speaking With The Massage & Bodywork Profession. https://www.abmp.com/podcasts/ep-116-low-back-pain-dr-ben-benjamin

Buford, D. & Coverly, K (Hosts). (2022, May 10). Pelvic tilt with Dr. Joe Muscolino (No. 229) [Audio podcast episode]. The ABMP Podcast: Speaking With The Massage & Bodywork Profession. https://www.abmp.com/podcasts/ep-229-pelvic-tilt-dr-joe-muscolino

Lowe, W. (2006). Orthopedic assessment in massage therapy. Sisters, OR: Daviau Scott Publishers.

Lowe, W. (2014) Exploring the anterior pelvic tilt. Massage Today. Retrieved from: https://www.massagetoday.com/articles/14942/Exploring-the-Anterior-Pelvic-Tilt

Lowe, W. (2022) Current concepts in sacroIliac joint dysfunction. Massage & Bodywork. 22-27 Retrieved from: http://www.massageandbodyworkdigital.com/i/1464088-may-june-2022/24?

Marieb, E. and Hoehn, K., 2019. Human Anatomy & Physiology. 11th ed. San Francisco: Pearson Education.

Muscolino, J. (2022). Pelvic tilt & spinal compensation. Massage & Bodywork, 36-41. Retrieved from http://www.massageandbodyworkdigital.com/i/1464088-may-june-2022/36

Walton, T. (2011). Medical conditions and massage therapy: A decision tree approach. Philadelphia, PA: Lippincott Williams & Wilkins.