287 ‒ Lower back pain: causes, treatment, and prevention of lower back injuries and pain

KEYPOINTS

• 01

  McGill says Attia's history fits a classic disc pattern.

  Attia had disabling episodes every three years (at 21, 24 and 27), each triggered by bending (rowing, a steep climb, bending to lock a bike) and lasting about two weeks. The last became burning foot pain and required surgery for a roughly 5 cm free fragment from L5–S1. McGill, a professor emeritus at Waterloo, identified a posterior, left-biased open-fissure disc bulge that could be 'vacuumed' back in between episodes. He predicts Attia's facet joints at that level have since thickened, causing the occasional grumbling ache of the 'unstable phase' that Kirkaldy-Willis described.

• 02

  The spine is a flexible rod that must stiffen to carry load.

  Discs allow motion and act as a mechanical stop at end range, which keeps the torso slender. Discs are layered collagen around a pressurized gel. Repeated load plus motion delaminates the layers from the inside out until the last layer gives way. The gel has never been exposed to the immune system, which sets off a fierce inflammatory reaction. Healthy discs have no nerves or blood vessels because high pressure prevents ingrowth; damage lets both grow in, so 'the body grows more hardware to feel pain.'

• 03

  L4–L5 and L5–S1 fail most because thicker structures tolerate bending poorly.

  Strain, not force, drives damage. Like a thick stick versus a willow branch, the thick lower discs bear compression well but bending badly. Bigger skeletons have more lobed discs that concentrate stress when twisted, which is why world-record sit-up holders aren't powerlifters. Gymnasts' open facet joints allow twisting but make them prone to pars stress fractures (spondylolysis).

• 04

  Don't combine powerlifting and yoga adaptations.

  Deadlifters stiffen their discs and tend to bulge posteriorly when flexing under load. Very flexible yoga spines bulge anteriorly when bending backward. Each should train hip and shoulder mobility for its own goal, and yogis should avoid very heavy loads. According to McGill, surgeons mostly replace the hips of 50-year-old women with 30 years of yoga and men around 50 who've deadlifted all their lives, not moderates.

• 05

  'Chronic' back pain is usually repeated acute irritation, and 'non-specific' pain doesn't exist.

  Most of his 'chronic' patients are re-triggering a specific mechanism throughout the day. Stop the trigger and the pain stops. He reserves 'chronic' for pain with changed central sensitivity and no clear mechanical trigger. He spends three hours per assessment provoking the pain to find its mechanism. No insurance billing code covers this, which he sees as the system's core failure.

• 06

  The McGill Big Three build stiffness in the core so the hips and shoulders can deliver power.

  They are the modified curl-up (hands under the low back, head and shoulders hovering), the side plank and the bird dog. All spare the spine; the side plank loads only half the musculature. They're done as 10-second holds in a 'Russian descending pyramid.' One session increases torso stiffness for about 20 minutes or longer, so pain patients do short sessions mid-morning and mid-afternoon. Isometric training increased punch force in MMA athletes. But they aren't for everyone: already stiff people need mobility instead.

• 07

  Most people told they need surgery can avoid it with 'virtual surgery.'

  At his university clinic every patient was followed for two years. Of those told they needed surgery, 95% reported avoiding it and being glad. The plan copies post-surgical rest and gradual return (day one: up only to use the bathroom), then desensitizes the pain mechanism and retrains mobility, stability and movement. He even manages sciatica this way if he can move the pain during assessment, including in NHL, pro tennis and UFC athletes.

• 08

  Surgery is warranted in specific cases.

  These include red flags, which he says referrals have still let through: aortic aneurysm, pulmonary embolism, metastatic cancer. Also pain patterns that don't fit a spinal mechanism, severe multilevel stenosis needing laminectomy, cervical myelopathy, post-trauma instability, unstable spondylolisthesis compressing nerves that can't be controlled, and some Tarlov cysts. Even with spondylolisthesis he tries intensive stabilization first, and says slippage distance isn't the deciding factor.

• 09

  Aim for 'sufficient' strength rather than maximal deadlifts.

  Ed Coan took months off after a true personal best. Max lifts cause microfractures under the end plates that take about a week to scaffold, so deadlifting heavy three times a week lets them accumulate. McGill steers older lifters toward goals like getting off the floor with grandchildren at 80. He uses backward uphill walking, sled work and log lifting. He values grip strength over deadlift numbers.