One of the most common complaints I’ve seen in my many years as a massage therapist is stiffness and pain in a client’s low back.
Thankfully, massage therapy is one of the most effective treatments for low back pain.
Identifying the Source of Low Back Pain
There are many anatomical structures in the body that can be the cause of your low back pain. Disorders such as arthritis or ankylosing spondylitis can often be the culprit.
Let’s break these structures down into a few easy-to-understand categories for a closer look:
Skeletal Structures of the Low Back
For simplicity, let’s consider the lumbar spine and sacrum the “low back.”
Made up of five individual vertebrae, the lumbar spine begins below the last rib, approximately 6-8 inches below your shoulder blades.
These vertebrae are larger than any others in the rest of your spine. They are designed to bear more weight and have very strong muscles attached to them.
Natural Curvature of the Lumbar Spine
A characteristic of the lumbar spine is the natural inward curve towards the front of the abdomen.
If you think of the strength of an arched shape in bridges and buildings you can easily understand how this curve increases the load-bearing strength of the low back.
There are some genetic and medical conditions that can change the shape of this curve, weakening the back. Scoliosis (a lateral, ‘S” shaped curve of the upper spine) can affect the lumbar curve.
Polio, osteoarthritis, spinal degeneration, and Ehler’s Danlos Syndrome are just a few of the other conditions that can physically change the shape of the lumbar curve.
"Swayback" or Lordosis
A common issue related to this natural curvature of the lumbar spine is “lordosis” or what some refer to as “swayback.”
In this case, the curve is more pronounced. A loss of abdominal muscle tone, weak hamstrings in the back of the thigh, or excessively tight muscles in the front of the hip can cause this condition. Obesity can be a cause, as well as multiple pregnancies.
There are flexible discs between each of the vertebrae in your spine.
These discs cushion the spaces between the bones, keeping them from rubbing together, protects the spinal cord, and reduces vertical impact force, such as when you jump or lift a heavy box.
Occasionally, one or more of these discs can develop weak spots where a portion begins to squeeze out of place. This is commonly known as a “bulging” or “slipped” disc. Without treatment, these bulges can actually rupture and become a “herniated” disc.
In either case, the disc can put pressure on the spinal cord causing severe low back pain.
Sometimes one or more individual vertebra can become dislodged or shift its location away from its correct place.
Chiropractic adjustments and massage therapy are the best treatments of subluxations.
The sacrum is actually four individual vertebrae that have naturally fused together into a single shield-shaped bone that attaches the spine to the pelvis. At the bottom end of the sacrum are two-to-four (it varies from person to person) partially fused small bones collectively called the “coccyx” or “tailbone.”
Because these vertebrae are fused together, there are no vertebral discs in the sacrum. The sacrum as a whole can become subluxated, or shifted, but unless there has been a fracture of the sacrum, which can happen due to a car accident or devastating fall from a great height, the sacrum itself is rarely the cause of low back pain.
The spot where the sacrum meets the pelvis, however, is a very common cause of low back pain for which massage therapy can be an amazing treatment.
Sacroiliac (SI) Joint
A problem with your SI joint can be extremely painful.
It can cause difficulty walking, pain while lying down, standing, sitting, or basically living your life.
The SI joints are the spots where the sacrum meets the wing-shaped bone of the pelvis called the “ilium.”
You have two SI joints on either side of your body. There are several very strong ligaments that hold these two bones together. These ligaments can be strained by any number of the surrounding muscles of the low back and pelvis.
Other conditions, such as arthritis or infections, can attack this joint causing terrible discomfort and pain.
Muscular Causes of Low Back Pain
There are dozens of muscles that can cause low back pain. I won’t bore you by talking about all of them, but I will point out a few of the most common culprits.
Erector Spinae and Paraspinals
The Erector Spinae is a group of muscles that run the entire top-to-bottom length of the spine. Picture it as three rubber bands on each side of your back that keeps the entire spine held together and erect.
The Paraspinal muscles are smaller individual muscles that attach between two or more vertebrae, as well as to other bones along the spine, such as the ribs.
Any one of these muscles can develop an adhesion, or “knot,” at any spot along the way. These adhesions can cause pain and spasms. When one develops in the lumbar region, the resulting spasms can irritate other muscles in the area, causing a cascading effect. One of the primary purposes of massage therapy is treatment of these adhesions to alleviate spasms and pain.
Quadratus Lumborum (QL)
These very strong muscles attach the lumbar spine to the back side each ilium (hip bone). This muscle raises your hip toward your shoulder, making it known as the “hip hiker.” It also allows you to bend to one side (lateral flexion). The QLs are common causes of low back pain that an experienced massage therapist can treat.
The Psoas (pronounced SO-AZ) muscles are very deep in the abdomen and connect the front of the lumbar spine to the top of your femur (long thigh bone). This pair of muscles is one of the few that actually crosses the pelvis, attaching the top half of your body to the bottom half.
They are the muscles that make it possible for you to bend forward at the waist or bring your knees up toward your chest (hip flexion).
When one or both of these muscles are extremely tight, they can actually cause your pelvis to tip backwards, straining your lumbar spine and shortening your hamstrings. If these muscles are too weak, your pelvis can tilt forward causing lordosis or “swayback” discussed above.
Gluteal and Other Hip Muscles
I know you’re thinking, “What do the muscles in my butt have to do with my low back pain?”
Remember, everything is connected. When one of these extremely strong muscles goes into spasm, it can twist the pelvis in multiple directions.
If your pelvis is shifted out of a neutral position, stress is applied to the sacroiliac (SI) joint, irritating Psoas, your QLs, or the Erectors.
Other Causes of Low Back Pain that Massage Therapy (Probably) Can't Help
Often, a client seeks massage therapy to treat their low back pain and after a few sessions it becomes clear that the cause is not muscular.
At this point, the massage therapist would refer you to a medical doctor for further evaluation.
There are certainly other possible causes for your low back pain that massage therapy won’t be able to help.
Constipation, kidney or bladder infections, menstrual cramps, prostatitis and other reproductive conditions can also cause low back symptoms.
Your primary care physician should evaluate and diagnose all of these conditions.
Everything is Connected
Clients are often surprised to learn that the cause of their low back pain is a problem with another body part quite far away from the lumbar spine. Let’s look at two quite common examples:
Paul's Ankle: Case Study
Paul recently sprained his left ankle during a volleyball game.
After a trip to the emergency room, he was put on crutches for six weeks, told to elevate and ice the area, and prescribed an anti-inflammatory medication.
After a few days, he developed excruciating spasms and pain in his low back, making it nearly impossible to sleep, stand, or sit for any length of time. Why?
Here are some reasonable expected causes:
- Initial injury – Paul jumped into the air and rolled his left ankle inward. This initial impact was on one side of the body, the force of the impact traveling from his foot up the left leg, into the left hip. This one-sided force could have triggered a spasm in his left hamstrings, left gluteal muscles, and the left Erectors.
- Resulting fall – Naturally, the pain and structural collapse of the ankle joint caused Paul to fall and land hard on his left side. This fall caused bruising along his left thigh, hip, and shoulder.
- Use of crutches – shifting the normal function of weight-bearing from the legs and low back to the shoulders via crutches changed the natural state of these lower muscles that were used to a certain constant level of tension.
- Inactivity – staying in bed or in a recliner for extended lengths of time while recuperating made muscles used to walking and frequent use weak.
- Prolonged hip flexion – keeping the legs elevated meant long periods of time with the hips flexed. This causes increased strain on the Psoas and a decrease in the function of the flexors on the front of the hip. This caused his pelvis to tilt backwards.
- Limping – Keeping the weight off one side of the body causes the other side to work harder. Limping can cause the non-injured side of the body to become tense and overworked. In Paul’s case, his right leg became tired and sore from overuse. This could have caused the pelvis to tilt to the right due to increased effort by the right quadriceps.
- Splinting – Whenever an injury occurs to a joint, the surrounding tissues become inflamed and swollen to limit the motion of that joint. The muscles in the area tense up to splint the joint, further reducing the range of motion.
Any one of these seven scenarios could be the cause of Paul’s problem. When I visited Paul for a mobile massage therapy appointment, I addressed his low back pain by evaluating his SI joint and discovered a forward pelvic tilt due to an extremely tight Psoas. Paul felt immediate relief after just one session. I used additional appointments addressing the splinting muscles in his left calf and inactive hamstrings.
Tech Neck Causes Greg's Low Back Pain
Like a majority of us, Greg spends a lot of time on his phone.
He uses it for work emails, texting his insurance clients, playing games, and keeping in touch with his friends and family on Facebook. And, like a majority of us, he has terrible posture when using his smartphone.
He hunches his shoulders forward and flexes his neck down for many hours every day. His neck and shoulders are tense, he often has pain when turning his head. He has frequent headaches.
In other words, he had “tech neck.” Now, he has started to experience pain in his low back. Why?
- Posture – When Greg’s shoulders rolled forward, he increased the strain on the muscles of his upper back. His Rhomboids and Trapezius were constantly tense. Keeping his neck flexed while looking down lengthens and weakens the Erector Spinae muscles at the top of his spine. These muscles run all the way down to his sacrum.
- Splinting – Greg’s Sternocleidomastoid and scalene muscles were shortened and tight, making it difficult and painful to turn his head from side to side. Other muscles in the back of his neck were weakened throwing his entire upper body out of whack.
When I visited Greg for his first massage appointment, his chief complaint was his neck.
During my assessment, he experienced pain when I pressed into the muscles of his lower back. He cried out in pain when I touched one particular point in his lumbar spine.
Because his neck was so painful, he wasn’t even aware that his low back was as bad as it was.
I spent a majority of our session addressing the muscles of his neck. I performed several range of motion stretches in his neck and shoulders and used a few Thai stretches for his low back.
When I left his home, he was able to turn his head without pain. He noted a “miraculous” reduction in his low back pain, all from bodywork done to his neck and shoulders.