• On Your Mark

Low Back Pain: 4 Not-So-Obvious Factors in Assessment, Treatment and Recovery

Updated: Jul 12, 2019


There are many reasons why back pain is so common and pervasive in the United States. You've probably heard of many of the most common ones, such as a weak core, inactive and weak glute muscles, too much sitting, sports injuries, age, lack of hamstring flexibility, etc.


But there are also four other specific biomechanical factors that often go under the radar for healthcare and rehab providers as well as patients.

When someone comes to me with low back issues, I always examine and assess for these four factors and in the vast majority of cases, one or more of these issues plays a role, whether it is the cause, outcome or some combination.


In short, it is so important with any injury to consider the joints and muscles above and below the injury. It's usually not enough to "zoom in" on the low back, or any injury for that matter, itself in order to achieve significant and sustainable results. A broader, zoomed out analysis is vital.

When doing an assessment, I don't assume that any of these factors are present. To the contrary, the assessment is what gives me the information to determine which ones are, if any.

1. Thoracic Spine

The Thoracic spine spans the mid and upper back and in so many people who suffer from low back pain, the T-spine lacks proper extension and rotational mobility. When this happens, the neck and low back become susceptible to overuses and increased wear and tear in order to compensate.


To be more specific, it is important to understand that the lumbar spine is built for stability more than mobility whereas the thoracic spine is built for mobility over stability. So let's say the thoracic spine loses its mobility due to inactivity, poor posture, injury or weakness. As a result, thoracic extension may become limited.

But the body still has to be able to extend in order to perform routine, professional and recreational activities. In order to do so, often times the lumbar spine is where the body then gets its extension from.


Regaining mobility in the T-spine through specific stretches, strength exercises and manual therapy can have a dramatic impact on the rehabilitation of low back injuries.

2. Hip Internal Rotation

When the hip joint does not internally rotate sufficiently, the low back can often be negatively impacted. This is due to the body's need to compensate for this lack of mobility by becoming more mobile in other joints, including the knee and lumbar spine. When one part of the body does not function correctly, other parts of the body are often the victims.


In these situations it is all about increasing mobility with very specific exercises that target the joint itself, not the muscles. Active Release treatments can definitely help, but doing consistent mobility exercises is the key.

3. Ankle Mobility

As with hip mobility limitations, a lack of Dorsiflexion in the ankle, due to calf tightness and/or ankle joint immobility, is directly correlated with low back pain. When I have clients perform a squat assessment with their feet slightly elevated, in many cases their low back discomfort significantly lessons as compared to squatting without their heels elevated. This is due to the fact that by elevating the heels, the ankle and calves are taken out of the equation,


In a lot of these situations people are unaware that their calves and ankles were a problem at all. But when I treat their calf muscles with ART and have them regularly stretch their caves AND perform an ankle mobility exercises daily, their low back problems begin to diminish, especially in combination with other treatments and exercises.

4. Tight / Short Hip Flexors

When the hip flexors, particularly the Illiacus and Psoas, are shortened, they can tip the pelvis forward and pull the lumbar spine into hyperextension and compression as well as contribute to the weakening of the Glute muscles.


Increased compression and hyperextension of the lumbar spine can cause an overactivity in the lumbar erector muscles leading to muscle spasms and strains. It also increases wear and tear on the facet joints and intervertebral discs. This can contribute to joint arthritis and inflammation.

Stretching and treating the hip flexor muscles is often an integral part of low back treatments with my clients.

In summary...

One take home message is that the pain is not often where the problem is. Another is that it's important to think outside the box when considering the causes and thus treatment for any injury, especially ones that occur in the low back.

Check out our Blog for several articles on low back health and many other topics.


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