Major Causes of
Low Back Pain
Whether it’s yoga, physical therapy, over-the-counter painkillers, environmental changes, injections of anesthetics and/or other substances, or undergoing a surgical procedure, there is a solution for most low back pain. I admit that for some people the right treatment isn’t so easy to find. That’s because so much of lower back pain is undiagnosed. Many patients who come to me have previously seen a number of other doctors and therapists without finding relief. Some of these patients are depressed, and some have almost lost hope.
I say to these discouraged individuals and to anyone else suffering from chronic low back pain that the cure is often a piece of cake—if and only if you know your diagnosis. Without knowing the source of your problem, or problems, how can you find the right way to go about solving it? I mention problems in the plural because sometimes individuals know they are in pain but are not aware that they can also have what I jokingly call “fleas and lice.” What I mean is that a person with sacroiliac joint derangement may very well also have piriformis syndrome, or that leg length discrepancy can cause musculoskeletal problems. You may be someone whose diagnosis includes more than one major cause of low back pain.
Clearly, some people’s pain calls for a physician’s attention, for professionally administered diagnostic tests, for prescription medi-cations, for physical therapy and other measures. These medical approaches and yoga are not mutually exclusive. In other words, having a problem that yields to medical treatment does not rule out your ability to help yourself by doing yoga. For some who are in acute pain and undergoing treatment, yoga breathing and meditation can be a godsend while the diagnostic and therapeutic processes take place.
If you don’t know what’s wrong, you can go some distance to understanding your own pain by yourself before embarking on a full medical investigation. Nor is it always necessary to wait for an official diagnosis before beginning yoga exercises. However, if your pain has been going on for more than two weeks, if there is progressive numbness in your feet, legs, or pelvic region or you are experiencing changes in bowel or bladder function, or if the pain is at a level you would describe as close to unbearable, seek medical advice before doing any type of physical exercise. As a general rule, I also emphasize that if doing physical yoga produces any type of neurological symptom—numbness, shooting or stabbing pain, tingling, or subsequent weakness—stop doing the pose immediately.
There is musculoskeletal pain, which is often associated with a specific activity, mood, or even a new pair of shoes. If your pain worsens for two or three days and then lessens, it may be that it is musculoskeletal, and yoga will do you good. It bears repeating that shooting pains, numbness, weakness, tingling, and strange sensations are linked with neurological pain, which can have more than one cause. These feelings are red flags. If you experience one or more of them, stop the activity and consult a physician before continuing. It’s important, before pushing yourself in yoga or any other physical exercise, to be aware of the nature of your problem so you don’t exacerbate it. But that doesn’t mean that yoga won’t help. The odds are high that it will. But in the strange land of severe pain, don’t travel far without a diagnosis.
A fuller discussion of the major causes of low back pain I address in this book follows, but first, a note on weakness, a problem that crosses the entire spectrum of reasons people have back pain.
There may be two causes of weakness as it relates to back pain: neurological and musculoskeletal. The signals nerves bring of pressure, pain, temperature, and so on from your arms and legs back to your brain and the signals sent from your brain down to the muscles, blood vessels, and other structures of the arms and legs can be interrupted as they travel along their course. When these interruptions or disruptions take place, there are signs such as lack of sensation and reduction in muscle strength. This, of course, is weakness. Like numbness, weakness may be a symptom of nerve injury that can cause back pain. When an individual has back pain and weakness, sometimes a physician can learn the exact location of the problem along the course of a nerve from the pattern of the weakness in the body. This is weakness as a symptom of back pain.
However, there is something else to note here. Weakness, especially in the legs and in the extensor muscles of the spine, can be a cause of back pain apart from neurological problems. In that case the muscles are feeble, causing posture changes or compromises or adaptations that may bring the spine into a position that causes back pain. Actually this is the most common cause of back pain.
Musculoskeletal pain is frequently brought about by muscles that are too tight—exerting too strong a pull—or muscles that are too weak. Sometimes you can have a combination of the two. An example of that is the individual who has a pinched nerve in her back. Because of that, when she walks she cannot bring her foot up to swing it forward when the other foot is down. So she swings it out to the side and around in front of her, using other muscles that have not been disabled. To keep her balance she lurches subtly to the opposite side with every other step. This makes her change position in such a way that she develops a musculoskeletal problem in her back. Either the muscles that stabilize her spine ache from fatigue, or, if those muscles cease to stabilize the spine, vertebral joints may go out of alignment or develop arthritis. There the chief reason for the back pain is the adaptation, not the pinched nerve.
If you are experiencing weakness, please remember that it may be important—a reason to seek medical assistance. If the problem causing weakness is not systemic, then yoga will almost certainly be useful for helping an individual become stronger. An increase in strength is one of the main benefits of yoga. Some common causes of weakness are:
• Inactivity. This causes overall symmetrical weakness.
• Habitually sitting in chairs with too much support, slouching, reading propped up in bed, bending over for long periods of time may weaken extensor muscles that help arch the back.
• Joint derangement and osteoarthritis may activate inhibitory responses that effectively weaken the muscles around the joint.
• Surgery that cuts through muscles weakens them.
No matter why weakness has occurred, finding a way to combat it is essential, not only for the prevention and relief of back pain but for general physical well-being.
Weight Control
As we know, overweight is associated with diabetes, heart disease, respiratory difficulties, and a host of other problems. Many of us gain weight as we grow older, and those pounds, when carried around all the time in the course of daily life, may aggravate old injuries or cause new ones.
If you are pregnant, your doctor will give you an idea of optimal weight gain. For your own health and your baby’s health, I hope you will follow those recommendations.
Even if you gain less weight than your doctor advises, however, you may be subject to back pain in the same way that overweight people are prone to it. Should back pain limit your feeling of well-being, discuss it with your doctor. Then try to find out whether this pain is musculoskeletal in origin or has some other cause. Chapter 13 should be helpful.
Weight gain if you are not pregnant is, of course, another matter. Finding out whether you’re overweight isn’t only a matter of consulting a chart based on gender and height, as it used to be. The government has added body mass to its calculation, along with something beautiful in its simplicity: waist circumference.
The National Center for Chronic Disease Prevention and Health Promotion in the Centers for Disease Control recommends calculating your body mass index (BMI) to determine whether you need to lose weight.1 You can use a calculator.
Divide your weight in pounds by the square of your height in inches. Multiply the result by 703. A person who is 5’7’’ tall and weighs 159 pounds has a BMI of 25. A 5’7’’ person who weighs 191 pounds has a BMI of 30. The range that is considered healthy is 19 to 25.
According to guidelines published by the NIH, a person with a BMI of 25 or greater is considered overweight; with a BMI of 30 or greater, the person is considered obese; and with a BMI of 40 or greater, the person is considered extremely obese. The BMI number applies to both men and women.
The next significant marker is waist circumference, which can be measured at the level of the navel or at the narrowest waist midpoint. A woman with a waist circumference over 35 inches or a man with a waist circumference over 40 inches should lose weight.
Musculoskeletal Pain
Musculoskeletal problems, including strains, sprains, spasm, and subluxation (which I will define and discuss shortly) and backache caused by stress and other emotional problems account for a great majority of low back pain.
How long this kind of pain lasts depends on your age, your general physical condition, the severity of the injury, the environment in which you live, and most important, what you do about it. Pain that is musculoskeletal in origin may disappear by itself after a period of time. It also responds well to over-the-counter painkillers, massage, and other noninvasive treatments like swimming. Yoga is an ideal way to deal with musculoskeletal low back pain, both acute and chronic.
Time is a significant factor in determining whether you have low back pain due to musculoskeletal problems. If you are in pain for more than two weeks, or if your pain is so acute you are having trouble participating in your regular work and leisure routines, then it may have a different cause; you should seek medical advice.
Posture
A pain in your neck, shoulders, ribs, and spine behind the ribs may come from the way you have adapted to a pain in your lower back. When both the lower and upper back hurt, the pain may have a single cause. That is, it is likely to be a result of a problem with posture. Adapting to the pain may have changed the way you stand and walk, brush your hair, bend to pick up a heavy package, or even the position in which you sleep at night.
The lumbar spine extending below the ribs to the coccyx (tailbone) is a weight-bearing structure, but it is relatively flexible, allowing for movement above the more or less fixed and weight-bearing pelvis. Muscles provide support for this part of the back, but its health and well-being are also contingent on an individual’s strength, posture, coordination, and balance. The better these are, the more easily the lumbar spine can help balance weight, resist the pull of gravity, and withstand even greater stresses that movement places on its alignment and structures.
If your posture has changed because of a musculoskeletal injury or problem in the lumbar spine, there may be pain elsewhere. Correcting the original problem in the low back will make pain disappear all over.
Strain
When too much force is applied to the fibers that comprise muscles, ligaments, tendons, joint coverings, or even the joints themselves, these structures are pulled out of their proper alignment or formation. Celebrated physician of physical medicine and rehabilitation Renee Cailliet, in his book Soft Tissue Pain and Disability, describes situations that produce strain.2 Here are the circumstances:
1. Undue force on a normal structure (i.e., lifting an object that is too heavy)
2. Normal force on an abnormally frail joint, muscle, tendon, or ligament
3. Normal stress on a normal but unprepared structure (shoveling snow for the first time in five years)
4. Performance of an awkward weight-bearing activity (lifting a box of books onto a high shelf)
Yoga poses that are excellent for strain include: Viparita Karani and Paschimottanasana, because in my experience these poses promote muscle relaxation and muscle relaxation allows for and leads to healing of strains.
Sprain
When strain goes a step further, muscle fibers, tendons, ligaments, or joint capsules may be pulled so far that some of them actually tear. Sprained structures often repair themselves over time, but not in every case. Since they heal slowly and because they are so painful, sprains can be more serious and difficult to deal with than fractures.
Gentle range-of-motion exercises, like Trikonasana and (for particularly stiff individuals) Dandasana, are yoga poses that may help if you have a hamstring sprain. If your problem is muscular, you can begin doing gentle yoga immediately. It will also reduce spasm.
Spasm
It happens when you’re least expecting it. Suddenly something in your back clenches. It hurts! It’s one muscle or it’s a group of muscles in your back. They take over, and without conscious orders from you, they contract on their own. This intense, involuntary action causes what feels like an extreme cramp that can last a few seconds, a few minutes, or much longer.
A muscle in spasm is contracting, hard and involuntarily. It can happen in the back when you’re gardening. It can happen in the thigh or the calf. A charley horse is a muscle spasm. This may be no laughing matter. A muscle spasm can last six months, or longer. This is a good example of why diagnosis is so important. For undiagnosed pain, two weeks is the limit before seeing a doctor. But once diagnosed, e.g., as a spasm, a long, gentle, self-administered course of yoga may be the safest and most effective treatment.
The tiny blood vessels that run through the muscle to nourish it and remove the waste products are squeezed during a muscle spasm, and therefore they have difficulty doing their job. Since blood flow is restricted, it cannot remove a typical, local, and temporary buildup of lactic acid. That causes the muscle to tighten further. The vicious cycle—spasm producing acids, acids increasing spasm—has begun, and may continue until the spasm becomes chronic.
Stretching is one of the most immediate, effective, and innocuous ways to interfere with that cycle of spasm, acid buildup, and more spasm. It is also a means of prevention of future spasm. All yoga poses involve stretching, but some are more suited to helping relieve spasm than others. If you think you have spasm in a muscle in your back, try doing Janusirsasana and Adho Mukha Svanasana. Use common sense when doing any yoga pose. Remember, yoga can add insult to injury if you stretch too much. Yoga should help you gain, not lose, control.
Subluxation and Dislocation
Soft tissues, muscles, sinews, and bands that connect and cover joints aren’t the only possible problems: Sometimes the bones themselves are out of joint. When there is excessive or unusual pressure on a joint, one or more of the bones can slip out of their proper positions. A small amount of displacement is subluxation, or partial dislocation. It’s dislocation when the surfaces are entirely separated.
The Emotional Component
As you probably already know, low levels of depression and high levels of stress can contribute to low back pain. Your problem may be as simple as a touch of Seasonal Affective Disorder (SAD) brought about by the cold, dark days of winter. It may be that you’ve started a new romance or moved your residence or changed jobs. Hatha (physical) yoga, breathing exercises, and meditation can be extremely effective in helping alleviate depression and in calming nervous tension due to stress. You are likely to feel a difference after just a few sessions.
Yoga is the only serious self-improvement program I know of that mandates: “Be contented” and “Be cheerful.” This implies that mood is at least to some extent under a person’s voluntary control. Dr. John Sarno, Dr. Harold Koenig, and Ernest Holmes, to name a few, have found effective ways to treat individuals by addressing anger, tension, pain, and even cognitive aspects of their personal lives. After all, these emotions and others are reflected in posture. You can see this for yourself just by looking in a full-length mirror. Yoga works not just on the physical and gross physiological features of the practitioner, but its goal is also spiritual. In my years as a practitioner of yoga and a doctor I have seen it significantly benefit emotions and mentality.
Herniated Vertebral Disc (“Pinched Nerve”)
Horror stories abound about the pain of pinched nerves and herniated discs but actually these conditions account for only a little more than 10 percent of doctor visits for low back pain.3 A herniated disc—also called a slipped disc or ruptured disc—always involves gelatinous disc material oozing out of the stiffer, fibrous covering of the one- to two-centimeter-high cylinder that separates the vertebral bones. This causes inflammation and swelling, which may compress a nerve or nerve roots at the spot where they emerge from the spinal column. What a pinched nerve and a “slipped,” or herniated, disc have in common is that they cause all kinds of neurological symptoms, from a feeling of pins and needles to weakness, from severe pain to no feeling at all in the areas where that particular nerve’s fibers end.
Something many patients don’t know is that neurological pain can be referred. That means that it can originate anywhere along the spine, but it may be felt as far away as the big toe. If, while walking to the bathroom in the middle of the night, you stub your toe on a chair leg, you won’t have any doubt about which foot—the left or the right—is affected. Nor will you wonder where the impact occurred. Because of the way our nerves work, what happens in the spine can be more complex. The point of the injury may be in your low back, but the damaged nerves may report painful sensation to the brain as coming from another place, far away from the spot where the injury occurred, for example to your outer left calf. If some of the fibers of the sciatic nerve are torn while exiting a specific part of the spine, for example, you may feel nothing there. Your back could be symptom-free, may feel so normal that it may even be hard to believe there could be an injury there. In this case, the pain or other unpleasant symptom will feel as if it’s coming from the calf, because the brain misinterprets the signal as if it comes from the calf, where every previous signal those fibers carried has originated. You don’t feel pain at the site of the injury. The cause of the pain is in the lumbar spine, but the manifestation is where the nerve endings lie, in the calf.
The word sciatica was coined in Renaissance Florence, where, of course, people also suffered from backache and from neurological symptoms originating in the back. The word ischiatica suggested the ischeal bones had a role in back pain. It was used because it was thought that sciatica came from tuberculosis involving the muscles near those bones. Now, of course, we know that sciatica can take many forms, and can originate in the back as a nerve root injury or in the piriformis muscle as compression of the same nerve fibers in the buttock. Similar pain may come from the sacroiliac joint in which case the pain rarely crosses the knee. It can change in type and location, can be intermittent or constant.
Sciatica is not a diagnosis. It’s a symptom of a neurological problem somewhere along the anatomical length of the sciatic nerve. But sciatica has become a catch-all word to describe neurological symptoms that begin in the back and travel down the nerves into the lower extremities. These symptoms are many and varied. They include:
• Numbness, or a problem with nerve impulses traveling as they should, from skin to brain. Reduced or absent skin sensitivity usually occurs in legs and feet, and it may be hard to notice. Numbness is important, frequently providing a more reliable guide than pain for physicians seeking a diagnosis for back pain.
• Paraesthesias are strange sensations, including burning and tingling, and “crawling,” which are due to abnormal signal patterns reaching the brain. They are analogous to referred pain in that their point of causation is far from the site of the sensation. The strange sensations are located on the skin.
• Weakness (see above).
• Burning. Without clear and visible skin injury, a burning sensation may come from a pinched nerve root in the lumbar spine or a large peripheral nerve, resulting in mild to intolerable discomfort on the trunk, low back, buttocks, genital area, legs, and feet.
• Electric shock. This feeling is often caused by a structural problem like a radiculopathy (see below) and may occur at the moment the thousands of fibers that make up a nerve are compressed, causing them to discharge all at once. Sometimes electric shock–like pain is constant, but in each short burst there is a beginning, a middle, and an end. It also has a direction; for example, it may go from the buttock to the calf. This lightning-bolt type of pain may come and go with changes in position or pressure, for example when lifting heavy objects.
Arthritis
Osteoarthritis (degenerative joint disease). Normal wear and tear eventually leads to this form of arthritis for most of us. In addition, postural or other problems, or overuse, may hasten this painful condition of the joints. Why? An X ray or MRI of the hip joint shows nearly perfect spheres. The cartilage on the surface of the hip joint and the pelvis is made by cells in a similar arrangement underneath each half of the joint.
If the cartilage on the surface is injured, it’s no big deal. Like a fingernail or a hair, it is replaced by the cells underneath. However, if the underlying cartilage is injured, two problems occur. One part of the joint surface becomes uneven, and then can rub against the other surface, injuring it. Deeper injury may deform the cells that actually produce the cartilage. As a result, the formation of the cartilage will be chronically irregular. The original smooth, spherical shape will be lost. Once this process begins, and it is inevitable for everyone, it goes further and further. One abnormal surface is sure to cause abnormalities in the other, which will soon return the favor. Yoga appears to slow this process and to make the joints more functional.4
Yoga is beneficial for osteoarthritis, because it appears to stretch the joint capsules and the muscles around them—in the case of the spine, for example, the multifidus, iliocostalis, and quadratus lumborum muscles. Range of motion can be increased for restricted joints by doing yoga. It has been suggested that yoga may reduce the immune system’s proclivity for attacking joint components and therefore may benefit individuals suffering from rheumatoid arthritis. Yoga unquestionably increases range of motion, decreases pain, and improves function in this condition.
Sacroiliac Joint Derangement
We’re prone to having these two crucial joints below our waists and above our buttocks become misaligned in part because they support the whole weight of the body above the waist. These complex, irregular joints have a tiny range of motion. Any strenuous activity—twisting, pulling, running, lifting—may force one part of these structures beyond its normal range of motion and concentrate weight where it doesn’t belong. This may be extremely painful. Usually the pain is along the margins of the joint, but sometimes it is so severe that it spreads to the low back, hip, and/or abdomen and mimics neurological sciatica.
One characteristic of the pain of SI joint derangement is that it gets worse with certain motions, for instance lifting the feet to get into or out of a car, getting out of bed in the morning, bending down with locked knees and reaching up while in a standing position. If you have neurological signs such as numbness or tingling, chances are it isn’t due to SI derangement.
Fortunately, if do you have SI derangement, you can work on it over time with many different yoga poses. Three of my favorites for this condition are Floating Tadasana, Marichyasana, and Gomukhasana. Unlike a dislocation in, say, your shoulder joint, it is unusual for the sacroiliac joint to “pop” back into place and pain to cease at that moment. The more usual course is that the bones move little by little over a period of time until the pain completely disappears.
Spinal Stenosis
Tiny nerves and their roots can be squeezed in openings too narrow for them, causing all sorts of neurological consequences from pain and paraesthesias to numbness and weakness.This is spinal stenosis, a neurological condition, like a pinched nerve. There is a difference, however. A pinched nerve is the compression of a nerve root or nerve roots at the point where it exits it the spinal canal and travels out into the body. Spinal stenosis is nerve compression that occurs inside the spinal canal, involving nerves that come down vertically from the brain. In the lumbar spine these are the same nerve fibers or rootlets that form inside the spinal canal at the T11, T12 level and exit the spine at lower levels. If these fibers are compressed after they join together, it’s a radiculopathy or “root disorder.” If the compression occurs during the fibers’ vertical transit from the brain, before they form the root, the condition is known as spinal stenosis. These nerve(s) are squeezed into a small space before they exit the spinal cord, causing pain that is often localized far away in the areas they serve.
Why does this narrowness occur? The problem may be congenital; the space the nerves travel through may just be narrow from birth. However, as people get older, and often by the time an individual reaches the age of sixty-five or seventy-five, everyone’s spine gets narrower due to osteoarthritis: The bones get thicker, the spaces that separate them get smaller. This isn’t a problem unless the nerves rub against the inside of the spinal canal, become irritated, and swell. That makes them fit even less well and causes more friction. This is the beginning of a vicious cycle.
The spinal nerves in question are thickest when the spine is straight. Like rubber bands, they stretch and get thinner if you arch your back. If you have spinal stenosis, pain is usually worse when you’re standing up or lying down—that is, when the spine is straight. When you’re sitting the pain is likely to abate, at least somewhat, because your arched back stretches and thins the nerves so that they take up less space inside the bony spinal canal. Other manifestations of spinal stenosis may be numbness, weakness, tingling, and burning, usually located more or less symmetrically in both feet and ankles and the outsides of the calves or thighs. Sometimes there is also loss of bowel and bladder control. A combination of MRI and EMG (electromyography) is a good way to diagnose spinal stenosis. In my opinion, a combination of medications such as steroids and yoga is the first treatment of choice. Unfortunately and fortunately, surgery is frequently necessary and usually quite successful.
Progressive spinal stenosis is best treated surgically, before the point where pain is increasing and ability to withstand surgery is diminishing. Widening the canal is the simplest, safest, and most effective surgical option, but there are a number of cases where it is not indicated or doesn’t work. Fusion of vertebrae is now safer and more beneficial than it has ever been throughout its checkered history.
Other Causes of Neurological Pain
In individuals who have osteoarthritis, a condition that often strikes older people, the spinal canal may gradually but progressively narrow the spinal column in diameter. Radiculopathies and stenosis can also result from a trauma like a fall, or from a fracture or a tumor. Physical yoga may be recommended to treat side effects of a tumor. It can be helpful, if done with care, for a fracture. In my opinion yoga can help reduce the likelihood of fractures by counteracting osteoarthritis. I have included a number of poses that may help relieve pain and sciatica from radiculopathies and stenosis, especially if caused by osteoarthritis and herniated disc.
There are other instances where sciatica strikes that have nothing to do with the back. I have been studying piriformis syndrome for more than twenty years. Sciatica is often caused when the piriformis muscle in the buttock presses on the sciatic nerve. The muscle can go into a lengthy spasm, causing a lot of pain at the site and sometimes producing pain that shoots down the leg.