Back pain
By far one of the most common ailments I see, and that folks on the trail ask me about, is back pain. I apologize for the long-and-winding nature of this post, but hear me out.
Back pain can be a tough one to treat, primarily because it’s so very many things; there is no single cause of back pain. And all of you who talk about bulging or herniated discs, a pinched nerve, or your back being “out of alignment,” or any other anatomical things that someone once told you you had – well, I hate to tell you, but those things are generally irrelevant.
The fact is that far more than half of the PAIN FREE population has massive herniated and bulging discs, pinched nerves, even spinal fractures! When MRI first came on the scene it was a game-changer: we could now actually see soft tissue in the body. Before we only could infer what MIGHT be there based on how far apart bones were in X-rays, but now – now we can actually see those discs! So everyone with back pain (and neck pain, and shoulder pain, and knee pain…) had an MRI. And guess what? We saw all kinds of bulging discs, herniated discs, pinched nerves, meniscal tears in the knee, rotator cuff tears in the shoulder, and on and on. And orthopedic surgeons made a fortune taking all these things out or sewing them back together.
But now guess what? Many of those patients found they hurt just as bad before the surgery as before. I’m sure many of you know people who had back surgery only to still be in pain afterwards – and that is because MRIs cannot show pain. [Heck, there is even a brand new study of meniscal tears in the knee: a group of people had a real meniscectomy (removal of the torn piece of meniscus) and the other group just had a sham surgery. Do you know which group had the most relief?? Yep, they were IDENTICAL: no differences between those who actually had the torn meniscus removed and those who just thought they did.] We always assume that any anatomical deviation we see on an MRI must actually hurt, but a wave of new studies is finally starting to take MRIs of people who do NOT hurt. Their MRIs look exactly like the MRIs of people who do hurt.
I like to use the analogy of your car: imagine that one morning you go to your car to go to work and oh no! it won’t start! So you call your mechanic in a panic – help, my car won’t start! Well, he says, go out and take a picture of it and send it to me. Heck, even lift the hood up and take a photo there, too. So you do. And what does the mechanic say? Well look at that! you have a huge dent in your driver’s side door…we’d better fix that!
Just as you would never expect your mechanic to figure out why your car won’t start by looking at a photograph – you should not at all expect someone to figure out what hurts based on an MRI. [Now, I’m not saying there aren’t uses for MRI and X-ray, of course there are, and I refer people for them all the time. But all an MRI or X-ray is going to show me is if you have a tumor, or a new unhealed fracture, or possibly an infection. If you have no other symptoms besides pain, don’t bother. If you have PROGRESSIVE neurological weakness, bowel or bladder problems, fevers, that sort of thing, well then YES, that is when imaging is important.]
Now, what does this have to do with your back? A lot.
I would say I spend more time actually teaching people about back pain than anything else. If you understand that your herniated disc from 21 years ago, or that old fracture you have, likely has NOTHING to do with your back pain today, then already you are on the road to recovery. Even if you had an MRI for your first instance of back pain and it showed a bulging or herniated disc, it STILL doesn’t matter, because you don’t know how long that has been there – it might be 10 years old.
So much of pain is mental – well, actually, ALL pain is mental, really – and we have great studies showing that once you learn that you are not actually squishing out disc material, or you aren’t moving that old fracture, then your pain scores go down significantly. So my first bit of advice to you is to STOP thinking about that old injury which may or may not have ever actually hurt in the first place. Backs usually hurt without anything actually being “wrong” with them, and that’s a very difficult concept to understand. But realize that more than 90% of low back pain has NO identifiable cause.
That does not mean we can’t treat it, it just means we can’t identify what it is based on a photograph (which is really the only technological tool we have). So what IS back pain?
Back pain is usually a combination of muscle pain, joint pain, possibly disc pain, and some nerve irritation. Nerves don’t have to be pinched to be irritated and inflamed, and sometimes that can be more troublesome than an actual mechanical compression. The key is to understand that most back pain is a constellation of all these things and that it WILL get better: with time, and with movement.
Stay tuned for what to do if you have brand new back pain, or have been suffering through it for decades……
backpackerPT
backpackerPT 
Hi Jennifer,
Interesting article about pain and the sources (or lack thereof). While my pain(s) is (are) minimal, my father complains of back pain all the time for decades. And while I do my stretching/strengthening homework, he has never followed any regimen that may help him. It makes me wonder (believe) that what I do to help myself has had thepositive outcome of less (perceivable) pain.
I have read with interest your article on pain in the knees by strengthening other areas. While I have now put them into my routine, I have not hiked any substantial elevations to see the effects. I will keep at it and hopefully a trip west this spring will provide the opportunity for that.
Thank you for the blog. After having a number of shoulder problems along with knee and back issues, I am convinced that a good physical therapist is well worth the money spent and your site is proving to be a good supplement.
Happy Trails,
Rod