Injury & Rehab: Overlooked causes of lower back pain

Lower back pain may be an incredibly common complaint, but its causes are not always obvious ones, writes corrective exercise expert Justin Price.

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KEY POINTS

• Lower back pains is experienced by 80% of the population at some time in their lives, but it’s causes are not always obvious
• Two less obvious causes of back pain are overpronation of the feet, and having a forward head position
• Your corrective exercise program for addressing either imbalance should  begin with a program of self- myofascial release
• As the health of the myofascial structures improves, a series of stretching and then strengthening exercises can help correct the foot and neck imbalances.

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Many health and fitness professionals take a symptomatic approach to helping their clients alleviate lower back pain. While this strategy may prove helpful in the short term, a more complete and long term solution lies in understanding and addressing the underlying causes of this problem. In this article you will learn about two of the most overlooked causes of lower back pain and what you can do within your scope of practice as a fitness professional to help your clients so they can get back to exercising without pain or movement limitations.

A forward head

The average weight of a human head is between 4.5 to 5 kilograms, and its position directly affects the alignment of the entire body. When the head is forward of the body, all the structures below it, including the lower back, must adapt to maintain balance and keep the body upright. For every inch forward of its optimal alignment that it sits, the weight of the head effectively doubles, placing additional stress on the lower back (Eriksen 2004; Louw 2007). The lower back is particularly susceptible to issues caused by a forward head position because it has a natural lordotic curve that is perfectly designed to arch backwards and help pull the torso and head upright. However, when the head is forward of its optimal alignment, the lower back arches more than normal to help support the weight of the head (see Figure 1). Over time, this can lead to excessive wear, tear, stress and strain to the lower back, causing pain and dysfunction.

Evaluating the position of the head

The following assessment can help you evaluate whether a client’s head position may be contributing to their lower back soreness.

Ask the client to sit on a gym ball or on the edge of a chair with the feet and head facing forward. Stand to one side of the client and locate the part of their cheekbone that protrudes outward the most, just below the eye. Place one of your index fingers on this part of the client’s cheekbone and your other index finger directly below it on the client’s collarbone. With your index fingers positioned in this way, stand directly over your fingers and look down to assess the position of your index fingers in relation to each other (see Figure 2). Ideally, they should be vertically aligned, that is, with the tip of one finger directly below the tip of the other (Chek 2001; Price and Bratcher 2010). If the end of the index finger on the client’s cheekbone is forward of the one on their collarbone, the head is too far forward for optimal alignment and may be contributing to their lower back problems (Chek 2001; Price 2018).

Overpronation

Overpronation, or collapsing of the feet and ankles, can cause musculoskeletal imbalances and myofascial restrictions to the structures of the lower back (Price 2018). Overpronation causes the feet and ankles to roll toward the midline of the body which, in turn, rotates the lower legs, knees and upper legs inward. This change in the position of the legs causes the hip sockets to shift backward, the pelvis to drop down and forward, and the lower back to overarch (see Figure 3) (Price and Bratcher 2010). Over time, this can cause excessive stress and strain to structures of the lower back and be a major underlying cause of pain and dysfunction in this area of the body.

Evaluating for overpronation

The following assessment can help you evaluate whether overpronation may be contributing to a client’s lower back pain.
Ask the client to stand in bare feet facing you in their normal standing position. Now take a look at their feet, ankles and toes for visual indications of habitual overpronation. Since overpronation results in excessive pressure being transferred over the inside of the foot and ankle, the following issues may be present (see Figure 4):

• inflammation and/or swelling at the ankle
• inflammation of the first joint of the big toe (i.e. bunions)
• calluses on the skin of the big toe
• a big toe that has shifted toward the lesser toes (i.e. hallux valgus)
• lesser toes that are scrunched up and/or appear bent and crooked.

Overpronation also rotates the knee toward the midline of the body. To compensate for this position of the knee, a person will unconsciously turn their foot/feet noticeably outward to help externally rotate the lower leg and align the kneecap forward again. Therefore, a person who overpronates will typically have an abducted foot position (see Figure 4).

The presence of any (or all) of these visual irregularities suggest that a person habitually overpronates, and this may be an underlying cause of their lower back problems.

Corrective exercise strategies

Musculoskeletal imbalances such as a forward head position and overpronation can be corrected with exercises to help alleviate discomfort in the lower back. Your corrective exercise program for addressing either imbalance should begin with a program of self-myofascial release (i.e. self-massage). These types of exercises will help improve the health and flexibility of those soft tissue structures that have become irritated and restricted, and prepare the client’s body for the stretching and strengthening exercises that follow.

Sample self-myofascial release exercises

Use a Theracane massage stick or tennis ball to massage the muscles on the back of the neck and upper back to help rejuvenate and recondition those structures that have been adversely affected by a forward head position (see Figure 5).
A golf ball, tennis ball or cricket ball/baseball can be used for self-myofascial release techniques of the feet and calves to address tissues that are negatively impacted by overpronation (see Figure 6).

Sample stretching exercises

As the health of the myofascial structures improves, stretching techniques should be introduced to the client’s program to increase range of motion of those areas surrounding the head and feet. For example, stretching exercises for the back of the neck, underside of the foot and back of the calf should be implemented (see Figure 7).

Sample strengthening exercises

Finally, strengthening exercises should be integrated into your client’s program to retrain the appropriate muscles to help pull the head back (see Figure 8) and support the foot to prevent it from collapsing (i.e. overpronating) (see Figure 9).

Assessing your client’s musculoskeletal system, identifying problematic imbalances, and resolving these problems with the regular application of corrective exercise can prevent the underlying causes of lower back pain and dysfunction, helping your clients feel better both in the short and long term.

REFERENCES
Chek, P. 2001. Primal movement patterns. Presentation at the IDEA Health and Fitness Association Conference, San Francisco, CA.
Eriksen, K. 2004. Upper cervical subluxation complex: A review of the chiropractic and medical literature. Philadelphia: Lippincott Williams & Wilkins.
Louw, D.A. 2007. Human development. 3rd ed. Cape Town, South Africa: ABC Press.
Price, J. 2018. The BioMechanics Method for corrective exercise. Champaign, IL: Human Kinetics.
Price, J., and M. Bratcher 2010. The BioMechanics Method corrective exercise specialist certification program. 1st ed. San Diego, CA: The BioMechanics Press.

LISTEN UP!

Click here to listen to Justin Price’s chat with The Fitness Industry Podcast, in which he discusses preventing clients from falling off the fitness wagon, incorporating advanced exercise skills into your PT services, increasing your professionalism and revenue, and the importance of simplicity.

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Want to help clients with pain – and earn CECs online?

Justin Price, author of this article, is the creator of The BioMechanics Method Corrective Exercise Specialist Certification powered by Australian Fitness Network (Fitness Australia-approved). The BioMechanics Method is the fitness industry’s highest rated specialty certification with trained specialists in over 70 countries. To find out more about how to become a corrective exercise specialist in The BioMechanics Method so you can help people alleviate their pain, move better and exercise without limitations, click here.