This is all too common of a story; a patient has severe back pain. The pain is so bad that the patient has to lay in bed for a day or two and take pain relievers. The patient goes to the ER or sees their physician and gets an image. Low and behold, there is a bulging disc at L4-5. Surgery is recommended and the patient is a good patient, and takes the physician's recommendation. After surgery, the patient feels good for a day or two, then the anesthesia wears off, and the pain comes back with a vengeance. Nothing was solved. 

The whole time it was just a muscle in severe spasm. Yes, a muscle can be that debilitating. 

The point of this is not to call out physicians. We live in a country where the bottom line matters above all else, and insurance reimbursements continue to dwindle. This causes a scenario where healthcare practitioners that work in the traditional insurance based model are forced to see way too many patients a day to keep the doors open. Some physicians see 50+ patients a day. So it makes sense that imaging is the main source of evaluation. Herein lies the problem. 

When you dig for dirt, you find dirt. This is how it is with imaging. Stenosis, spondylosis, degenerative disc disease, degenerative joint disease, schmorl’s nodes, foraminal narrowing, osteophyte formation; these are all scary words. Here’s the thing, they’re all normal. They are just words for aging. Of course any of these things when severe enough can lead to symptoms, but you can have all of these things and have no symptoms. 

In 2014, Brinjikji et al. performed a systematic review of 3110 subjects that were asymptomatic. Imaging on all of these subjects found a high prevalence of pathology that increased with age as follows:

Disc degeneration: 37% of 20 year olds that increased to 96% of 80 year olds

Disc bulges: 30% of 20 year olds that increased to 84% of 80 year olds

Disc protrusion: 29% of 20 year olds that increased to 43% of 80 year olds

They were all pain free. 

So if you pull in 100 people off of the street that are 80 years old and are pain free, then image them, 96 of them will show disc degeneration. Those are some good odds.

So what is actually going on? Well, in most cases it is just muscular. In some cases, the muscles “guard” protectively against an underlying issue. For example, if you have arthritis of the spine, or a vertebrae that has a bit too much “play” (we call it instability) the muscles are working double time to protect the area. So it is ready to get aggravated as it’s basically in a state of overuse. This is typical of a group of muscles that line the spine, called the paraspinals. 

Other times, it’s as simple as overloading a muscle. Probably the most common muscle to get irritated is the quadratus lumborum, or QL for short. This muscle is shaped like a fillet of fish and attaches the ribs to the pelvis, and has spinal attachments. It has a couple of functions; one is sidebending, so think of leaning to one side or bringing your hip towards your ear. If you turn on both QLs at the same time, it does extension, or standing. So it is on the whole time when you stand. Postural muscles such as this are prone to overuse because they are constantly working. Then introduce a heavy load, and then pick it up with improper mechanics, and the muscle gets fired up. Or maybe you are carrying something like this: 

This counterlean shortens the QL (remember, it does sidebending). You might be able to get away with a light load, but the heavier it gets, the more likely for that muscle to get irritated. 

One of the issues is that the body likes to take the path of least resistance. It wants to always conserve calories and energy in case we need to escape from a bear or defend ourselves in a fight. So it will do the easiest thing possible at the cost of potentially getting injured. 

How can physical therapy help? First we calm down the area with various techniques. Then we educate you in how to carry something with proper mechanics to avoid the injury. The most important part though, is strength. It always boils down to strength. We make you more resilient by strengthening the area. Think of it like this; your muscle is like a small cup of water. Once you use all the water in the cup, you are at risk for injury. We build a bigger cup. 

Do not get me wrong, there are certainly times that something serious is going on and it needs to be properly diagnosed. If you can’t move your foot or have severe, unrelenting numbness and tingling in the leg, make sure to get it properly diagnosed. A good physical therapist can usually tease out if it’s something serious or something that can be conservatively managed. 

Here is a great infographic that nicely summarize why you are not your MRI:

Here is a simple exercise you can do to improve strength of the muscle of the low back. As with anything, don’t do it if it causes pain (this one rarely does):

Reference:

Brinjikji, W., et al. “Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations.” American Journal of Neuroradiology, vol. 36, no. 4, 2014, pp. 811–816., doi:10.3174/ajnr.a4173.