Archive for the ‘Lower back’ Category


Today’s blog post comes at the request of a few of my back pain patients. Over the past few weeks I have been talking with my patients about their back pain. I have come to realize that some of  these patients genuinely believe they injured their back from bending over to tie up their shoe, picking up a pen off the floor, or reaching for that jar at the bottom of the fridge (all real storey’s about “why” they hurt their backs)…and every time I hear a story like this I have to shake my head….

I think patients think their back is like this...

Patients must believe their backs are about as sturdy as a Jenga tower if they think those simple actions caused their backs to go out. I have to always tell my patients that 9 times out of 10, the pain they’re experiencing is due to many weeks, months, or years of misuse. It is only when the body is tired of trying to compensate for faulty movement (or lack of moevemnt) do they experience pain.  When asked about their gym routines (for the ones that actually go!), almost always do they proudly mention that they do sit ups and crunches as part if their core routine. This is a sure fire way to slowly but surely hurt the back.

Without getting into it too much detail, Dr. Stuart McGill out of the University of Waterloo has done the research and we now know that flexion based exercises (like sit ups and curls) are BAD for the back…and in reality, it doesn’t even train the core in a functional manner at all. Here is a quote from Dr. McGill’s book “Low Back Disorders”

“Too many exercises are prescribed for back pain sufferers that exceed the tolerance of their compromised tissue. In fact, I believe that many commonly prescribed flexion exercises result in so much spine compression that it will ensure that the person remains a patient. The traditional sit-up imposes about 730 lbs of compression on the spine at each repetition. The National Institute of Occupational Safety and Health (NIOSH) has set the action limit for low back compression at 730 lbs; repetitive loading at or above this level is linked to higher injury rates in workers, yet this is imposed on the spine with each repetition of a sit up!”

I said earlier that a sit up is functionally a rather stupid exercise. It trains the rectus abdominus to act as a thorax flexor. While the muscle does have the properties to act as a flexor, its real job lies in its ability to be an anti-extensor. The abs functional job in the human body is to control the rate of spinal extension as apposed to producing spinal flexion. For example, try leaning back while sitting on a workout bench. While leaning back, put a hand on your abs…they are firing like crazy! Why? Because they are contracting eccentrically to make sure you don’t fall off the back of the bench. This is their job in life and sport… the obliques, rectus, and transverse abdominus are ANTI-MOVEMENT muscles. They stabilize the spine and prevent spinal buckling or shearing from occurring. With this in mind, training them as flexor muscles is about as useful as training your biceps by only doing curls…sure you’ll make them look nice (nothing wrong with that!) but you’ll be missing out on all that they can do!

My patients always ask me then “Ok Mr.wiseguy physio, if I can’t do sit ups or crunches, how else am I going to work the core?” Here are my favourite (and safe!) core exercises listed in no particular order:

Chops and Lifts: LONG video demo by Gray Cook but I think it’s worth the time. He explains this far better than I ever could


McGill big 3 (plus stir the pot): Another great video with Prof. McGill explaining WHY these exercises are good…plus they are backed my tons of high quality research


Deadbug: Great exercise because it uses the core to stabilize the extremities while not putting any load through the back


In summery,

  • Your back doesn’t “go out” from picking up a pencil, it was already dysfunctional but you just didn’t know it yet
  • Functionally, the core acts as an anti-extensor and anti-rotation unit–not as a upper body flexor
  • A good core exercise is one in which the extremities move against resistance while the core is stationary working to stabilize the back
  • Sit-ups and crunches suck…they do more harm than good
  • The exercises I listed above will not only make your core stronger, but they will in most cases help your back pain

As always, questions are always welcome

Jesse Awenus, PT

Remind you of someone?

Oh, another HUGE reason for back pain is sitting too much at one time (hmm, I should probably get up). Here is a GREAT and simple exercise sheet you or your clients can use to help stay back pain free at work (courtesyof Dr. Craig Liebenson)

Love this picture!

A few months ago I wrote an article on how muscle tightness might be a result of a skeletal imbalance as apposed to simply a shortened muscle. I discussed how an anterior pelvic posture might actually lengthen the hamstrings due to their origin and insertion being forced further away from one another leading to a series of events that causes the hamstrings to group to seem tight. In this case, the hamstrings aren’t tight, thy’re in tone via the sympathetic nervous system telling the muscle group to stay tense as not to allow tearing to occur. Read my previous post HERE to get caught up.

Awesome Diagram

Professor Janda was a revolutionary in the field of muscle imbalances. Through both study and observation he derived what we now call the upper and lower crossed syndromes. In today’s society where we sit almost all the time, the lower crossed syndrome is almost epidemic! Think about it for a second…when you get up in the morning you sit to have your coffee, have breakfast or read the paper. You sit in your car to get to work, and most of us sit almost all day at work! Then we go home and sit down to eat dinner and relax in front of the T.V! That is a lot of sitting. If you don’t think sitting is detrimental to our health, click HERE to find out more.
From a biomechanical perspective, sitting puts the hip flexors in a shortened position for hours on end. This causes the gluteal muscles to “turn off”in what Professor Stu McGill calls Gluteal Amnesia (reciprocal inhibition). When the glutes turn off and the hip flexors become tight, we see the pelvis pulled anteriorly and then (to make matters worse) the lower back paraspinals get placed in a shortened position and the rectus abdominus gets places in a lengthened position. These changes only help to solidify the pelvis is an anterior position. Clinically, you can measure this by simply looking at the angle between the PSIS and ASIS. In her book Muscle Testing and Function, Florence Kendall states that the PSIS should be no more than 5-10 degrees higher than the ASIS.

See the belly on her? You might have a belly and it has NOTHING to do with your weight...


If it is higher, you might consider the patient has having an anterior tilt. Other things to look at are as follows:

Size of lumbar spine lordosis: An increased lordosis indicates the hip flexors and lumbar spine erectors are pulling the pelvis forward which creates an extension moment at the lumbar spine. As stated in the picture above, an increased lordosis might make it look like you have a spare tire around your waist…even if you’re skinny!

Positive Thomas Test: If the psoas, iliacus (NOT iliopsoas!) or rec fem are tight it will be evident in this test. Personally I like it because it’s fairly objective and a positive test is easy to identify. I don’t have the studies off hand, but I can only assume inter-rater reliability would be quite good. It’s hard to miss a leg popping off the table during the test!

 Hip bridge test: Have the patient do a bridge and palpate the glutes and hamstrings. Which are they using more? In the bridging position, the hamstrings are in a shortened position and because of this they should be using mainly their butt muscles to extend the hips off the table. If they are using too much hamstring, or they complain of muscle cramps in the hamstring, they have gluteal amnesia (a weak butt).

 So what do I do clinically for clients that have this issue (and MANY do!)?  There are a few different techniques I use depending on subjective complaints but on the whole, this is what I do (and it’s not rocket science).

1) Lengthen the hip flexors (rectus femoris, psoas, iliacus, and even tensor fascia latta if need be. I like to do this as a PNF (contract-relax) stretch in the Thomas test position because I can get all the above muscles at pretty much the same time. I also like this position because it prevents the lumbar spine from being pulled into extension as seen so much in people who try to stretch their hip flexors.

2) I do soft tissue work to the lumbar spine erectors to try and decerase their tone. I will often follow this by manually rotating the pelvis posteriorly to increase the stretch of the paraspinals and to simply help place the pelvis back where it should be. I like doing my posterior pelvic mobilizations in a side lying position.

3) Glute strengthening/activation. You can literally have a whole post dedicated to glute exercises but for simplicity sake I usually start off by having my clients’ squeeze their glutes while they feel the muscle contract while I palpate the hamstrings. I want to teach them how to fire up their butt while not using their hamstrings…often easier said than done! Mike Reinhold has a great modification to the bridge that I give my patients to strengthen their butt. Here is the video:

4) Core strengthening. Again, not getting too detailed here because there are 100’s of ways to do this. For my average sedentary clientele I give McGill curl ups, plank modifications (off a wall, on knees etc) or even crook posterior pelvic tilts to fire the rectus abdominus and push the pelvis posteriorly. For my athletic patients I like to give front/side planks with harder modifications, dead bug, stir the pot using a physioball, or shoulder touches in a pushup position

5) I do a lot of soft tissue release to the hip flexors, hamstrings, lower back thoracolumbar fascia and paraspinals. It makes the client feel better and hey, is that ever a bad thing?

 6) EDUCATION!! I always tell my clients they need to get up every 30-40 minutes to take a walk around the office. No one position for any extended period of time is good for the body…the lotion is in the motion! I have given my clients instructions to use a stop watch or there is even an app one can download on their home screen that will make a buzzing sound every 30 minutes reminding them to get up.

As always, different patients need different things and this is a general overview of what I do. By no means is it exclusive. A cookie cutter approach will yield cookie cutter results.

Thanks for reading,

Jesse Awenus B.A Hons (Kin), MSc.PT
Registered Physiotherapist