Thoughts on back pain from a recovering physio

Hello. My name is Tracy. I’m a recovering physio. I used to believe in and perpetuate the myth of core stability.

My Journey

I graduated from physical therapy school from Washington University in St. Louis in 1997, the height of the low ab / core stability frenzy. Our class spent many hours learning about torso muscle function. Then we spent many more hours learning how to assess lower abdominal strength. All of this done with the assumption that a lack of abdominal strength caused or was a major contributing factor to back pain. I would fix dysfunction by teaching someone to limit spine movement by having stronger lower abs.

As a new graduate, I approached all back-pain patients with this assumption firmly in place. My assessments began on a table and my treatment plan continued with supine table exercises, with the goal of teaching people how to subtly control their pelvis (and by logical extension), pain) with their lower abdominals. Paul Hodges. Shirley Sahrmann. Stuart McGill. All of these practitioners – icons of the physical therapy world — informed my view of “core strength.”

The revelation

Then one day my world-view changed. I was working with a patient who had injured his back lifting something at work. During this time in my life, Derrick Crass (my boss, PT and retired Olympian in the sport of weightlifting) was teaching me to do all of the barbell lifts. I was feeling and seeing how hip and ankle mobility affected torso orientation and spine positioning during any type of lifting from the ground.

It hit me like a ton of bricks: “core strength” wasn’t the cause of or the answer to this guy’s problem. This was more complex problem; a movement puzzle that involved coordination of the entire body. This patient needed help understanding the movement puzzle and then total body physical preparation to solve it. Lower extremity strength. Ankle mobility. Body awareness of hip vs spine flexion. Purposeful, coordinated tension and control of multiple body segments.

A New World View

Humans use many strategies to move themselves and other objects. How your spine and associated structures tolerate any of these activities depends on the experience you have doing them; and how physically prepared you are to move into, through and out of the postures associated with these activities. Athletes must be prepared for the intensity and range of motion required for their sport.

If any part of the coordinated motion is lacking or out of sync, the spine and tissue around the spine can bear the brunt of the effort and be overwhelmed – put into spasm, strained, sprained, thrown-out, jacked-up, herniated. Recovering from any type of back injury, even the most severe, is not about isolating ab muscles and stifling movement; it is about regaining confidence and building the strength, mobility, body awareness and overall physical capacity that we need to navigate life. This being done while letting the irritated tissue heal, of course.

Preventing back injuries isn’t about building maximal abdominal strength or crazy amounts of torso stiffness and strength endurance. It’s about developing graceful, informed (but often involuntary) control and coordination. This includes synergy of tension and relaxation. Distal and proximal control– and everything in between. Effectively using the ground to create and absorb forces. Preventing back injuries and recovering from them is about preparing to solve whatever movement puzzle is in front of you.

Movement vs. muscles

At this point in my career, I now have the privilege of preparing athletes for sport as an athletic development coach and restoring function as a physio. I work at both ends of the spectrum and move among medical and performance professionals. It gives me great pause to see sport and S&C coaches programming long planks, anti-rotational cable walks and holds, and hours of prone and supine work with feet suspended in the TRX — all in the name of core strength. There are athletes in some sports who find it entirely normal to have separate workouts (of an hour or more) of “core” exercises as a second or third training session of their day.

Why are coaches falling into the same trap that rehab and medical professionals have been in for the last two decades – now thinking “core strength” is the foundation of athletic performance? It seems to have become an end in itself for some athletes and coaches, hijacking programming in many sport cultures.

If we want to do better by our athletes, we need to get over the idea that “core strength” is the key to performance and back health. We decrease the risk of back injuries by building robust total body infrastructure and preparing the athlete to meet the demands of the sport. We return them to sport after back injuries by doing the same. Back pain is usually the result of a movement error. The root cause of a movement problem cannot be localized to the area of the pain.

If anything, I’ll take the Herb Brooks view of things: the legs feed the wolf. In most situations, the back and torso are beholden to mobility and strength of the legs.

It took me several years to fully embrace the idea of training movements, not muscles. And to overcome the idea that I am supposed to fix some theoretical torso muscle-firing dysfunction. Stability is easy to observe and measure; and it’s easy to teach in your clogs, khakis and collared shirt. But when you cast off the shackles of the khaki pants and start moving — crawling, lifting, throwing, bounding — you feel the power and possibility of movement. You appreciate the complexity of the human body and you resist the urge to reduce it to this or that muscle dysfunction. And you see the myth of core stability for what it is: a myth.