When a patient comes into a physical therapy clinic with a doctor’s prescription for physical therapy, it includes a diagnosis. It might say “Right Knee Torn Medial Meniscus” or “Left Shoulder Supraspinatus Tendinitis.” But more often than not, when someone came into the physical therapy clinic where I worked for their back, the diagnosis was “Back Pain.”
But that’s not a diagnosis. It’s a symptom. Here’s another medical terminology tidbit:
Symptom - something that someone complains of.
Symptoms include:
Nausea
Pain
Tingling
Numbness
Sharp pain
Dull ache
Throbbing
Sign - Something that someone else can detect.
Signs include:
Redness
Swelling
Loss of range of motion
Bleeding
Vomiting
Temperature increases
Deformity
Pain isn’t a diagnosis. It’s a symptom that forces someone to see the the doctor, hoping that the doctor would provide a diagnosis and tell them what’s causing the pain.
This “pain” diagnosis is unique to back problems. We never got a “knee pain” diagnosis. It would say “Torn Meniscus”. A person presenting with foot pain would have a diagnosis that said “Plantar Fasciitis,” not “Foot Pain”.
But not with back pain, and here’s why:
ANATOMY:
Imagine you have a cadaver in your college athletic training room supply closet. (We did.) You work on this human cadaver, making incisions in the skin to reveal all the tendons of the hand, all the muscles of the arms and legs, the tendons and muscles of the neck and shoulder, and the incomprehensible complexity of the low back. If you peel back the skin on the cadaver’s low back, then take your pinky and put it into the back musculature, your pinky won’t be as deep as the muscles along the spine. No other muscle group is as deep.
These muscles form an incredible support network for the trunk. The muscles in the front of the spine help the spine bend (flex), the muscles behind the spinal column help your spine straighten (extend). There are even tiny little muscles between the bony prominences of each vertebra. Beyond just helping you bend and straighten, they keep you upright, instead of flopping around like one of those inflatable tube men.
No core stabilization.
But that’s just the muscles! Wait until you see all the ligaments that connect the vertebrae together!
Now let’s imagine that you lunge for a backhand shot on the pickleball court and you feel a twinge in your low back. After a few minutes your back gets really stiff and it hurts every time you move. No matter which ligament or tendon you’ve injured, the signs and symptoms will be the same. It’s impossible to determine exactly which tissue is injured, but fortunately, if your disc isn’t involved (that’s a whole different ball of wax), our approach to your low back injury will be the same no matter which tissue you’ve just jacked up.
By now, if you’ve read the previous articles, you know what’s coming. The approach to virtually any muscle strain or ligament sprain is R.I.C.E.: Rest, Ice, Compression, Elevation. But there are some real complications to that approach when it comes to the low back.
REST: If someone comes to me with an ankle sprain I can provide crutches, tell them to stop using the injured side to walk, and the rest of their function will be just fine. They can go to work or school, sit in a chair with their foot on another chair, go to the store, hang out with friends, and even drive if the injury is to the left ankle. But a back strain gets worse if you just stand, because keeping you upright is the job of your spinal muscles. Sitting is even worse, because strain on the low back muscles is doubled when you go from standing to sitting. To really rest a low back injury, you’ll have to lay on your back with your knees elevated so that there’s a 90° angle at the hips and knees.
This position is excellent for resting a low back injury, but it’s incredibly limiting! You can’t use the restroom without aggravating the injury, let alone pick up a child or grandchild. You can’t sneeze without increasing back pain, and you can’t stand at the stove and cook dinner. You can’t go up or down stairs without significant strain to the low back. The low back muscles are involved in EVERY MOTION. You can’t put a cast on it or immobilize it, so you have to just lie still and stop doing EVERYTHING (except using the restroom) for several days after a “back pain” diagnosis.
ICE: Going back to that sprained ankle, I can use ice packs or even a cold ice bucket to cool an ankle and reduce the swelling to the area. But ice packs penetrate only about ½” below your skin, …if you’re pretty lean. If you have a bit of a spare tire around your middle, the cold might not cool the muscles beneath the skin at all. With a group of muscles that are deeper than your pinky, how effective will an ice pack really be? Moist cold is more effective than dry cold, so let’s use an ice towel instead. You put crushed ice inside of a towel, then lay on it. But even with a moist towel we’re talking about ¾” in a lean person. It’s still recommended to apply ice, because even if it doesn’t penetrate to the injured muscles, it will draw heat out, reducing the surrounding temperature at least a bit.
COMPRESSION: When someone has a sprained ankle I can compress it with an ace wrap to prevent the increase in swelling to the area. With a back injury we can apply a supportive belt, but that just provides stability and won’t decrease the swelling to the area. There is no compressing a low back injury.
ELEVATION: With an ankle sprain I can tell the injured athlete to lay on a couch with the foot higher than the heart. This slows circulation to the area and reduces the amount of swelling that will go to the ankle. It’s not possible to elevate a low back above the heart when there’s a low back injury. The best we can do is lie flat.
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TREATMENT
As mentioned above, the best approach to the first few days of a low back strain or sprain include calling in to work, lay on your back with your lower legs elevated, tuck a cold pack under your low back for 20 minutes every hour or two, and have someone else bring you your favorite books, the remote control, and your meals.
WHATEVER YOU DO, DON’T ADD HEAT!
Not for at least 3 days.
Heat packs and warm baths will penetrate twice as deep into the tissues as cold packs for some reason, and if you read the first installment of “Oh, My Aching Body,” you’ll know why you should absolutely avoid adding heat. But you know what else adds heat? Motion. Exercise. Massage. Theragun. Even just laying still without adding cold will be adding heat.
PREVENTION
The best ways to avoid a back injury is to use your legs and stabilize your core.
Use Your Legs: If you’re picking something up off the floor, bend your knees instead of your back. If you’re on the pickleball court, the same rules apply. Try to lower your hips, keep your back straight, and move to the ball with your feet, not by reaching for the ball by bending and twisting your back.
Stabilize Your Core: The muscles of the back and abdomen work to support your torso on your pelvis. Pilates is the ultimate approach to core stabilization, but that can’t be attempted until your back injury has healed. The exercises we used in the physical therapy clinic included very simple things like pelvic tilts, where you lay on a table or bed on your back with your knees bent and feet on the table, then tighten your abdominal muscles so that the spine of your low back touches the matt, and your tailbone lifts off the table. Repeat for three sets of ten, holding each for 5 seconds. That’s it. You can’t push your heels into the table to push your tailbone upward. It all has to be done with your abdominal muscles. You’d be amazed at how many people found this very difficult. Once you can do this, you can graduate to lifting one foot a few inches off the table for five seconds. If your pelvis starts to drop when you pick up your foot, you’re not ready. Reset your pelvis and pick up the foot again. Then alternate. Eventually you’ll graduate to the “dead bug” exercise. (I didn’t name it, but I wish I did.)
Pelvic Tilt exercise. The foundation of all pelvic stabilization to protect the low back.
This is the dead bug exercise.
Next are the exercises where you’re on your hands and knees, you set your spine so that there’s no movement side to side when you lift one hand forward off the table, and hold it for 5 seconds. Then the other hand. Once that’s mastered, send one knee backward and hold the leg straight for 5 seconds, then slowly lower it. Once you can do that, you can lift one arm and the alternate leg, keeping the core stable and your body balanced on the table.
In addition to these exercises there are important muscle balance issues often involved in back problems. If the front of the hips and the back of the thighs are tight, this throws the pelvis into an arched position. Stretching the hip flexors and hamstrings is the opposite of what happens when you’re sitting, so a good thing to do is get your hips and hamstrings into the opposite position of sitting.
Here’s more exercises to protect your low back, for those who are feeling really motivated.
If you have a back injury that nags at you regularly, it’s best to get a physical therapist to guide you through how to correct your posture, your movement, your alignment, and your muscle balance (stabilization and flexibility). It’ll make it less likely that you’ll hurt yourself again, and it will improve your pickleball, too!
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Do you have another aching-body topic you’d like to know more about? The last two articles were my response to requests from your fellow PIKL members, but now I’ve run out of requests. Please feel free to let me know what you’d like to know more about!
