Dr. Shirley Sahrmann — Deep Dive on Low-Back Issues

Low Back Pain Is a Symptom, Not a Diagnosis

Dr. Shirley Sahrmann, a legend in physical therapy with 60+ years of experience, explains that low back pain is merely a symptom -- the real diagnosis should name the movement that consistently causes the symptoms. She argues that identifying and changing that movement can reduce or eliminate pain, a fundamentally different approach from treating symptoms after a doctor's structural diagnosis.

"The one big objective in it, I've actually been a physical therapist for over 60 years. And during all of that time, I've been through different eras of changes in physical therapy. And where I've sort of gotten to is how movement basically induces pathology. And part of that, trying to explain that and how it works, is also developing diagnostic categories that direct physical therapy treatment. So what this book was about was a first attempt to really put together diagnostic categories that are based on movement and movement as an inducer of musculoskeletal problems. Also kind of working on the background of what are the tissue adaptations that contribute to this. So it really was an organizational attempt to identify for, in the first book, we covered the back and the shoulder and the hip. And so I guess the shoulder is one of the things that he must have been particularly interested in if he's dealing with pitchers. And the shoulder is really quite complex because you've got that shoulder blade as well as the glenohumeral joint. And it's not as easy as muscles just turn on or turn off appropriately. They've got to really be well-coordinated. So I think that putting together this kind of information in a way that could be understood by a whole variety of people. In fact, I was so slow in getting it out that I was grateful that there was the internet and Amazon selling things because if it would have only been sold in medical bookstores, no one like Eric would have ever found it. So that was one of the advantages of being a slow writer. And of course, I learned more while all of that was happening too. How did that attempt, or maybe not attempt, how did that organizational approach and also the maybe reframing of movement in the way that you just described differ from what came before or what was predominant at the time? To be perfectly honest with you, Tim, it's not like this insight has been taken over by even the large majority of the people in my profession. It's still a bit of a struggle to have people move in this direction for a whole variety of reasons. But typically, and even though I wasn't there when physical therapy was first started, I wasn't too far behind. But typically, the role of the physical therapist was the doctor figured out what the problem was, made the diagnosis, and the physical therapist really provided treatment for what I think could fairly be called the symptoms or the consequences of that problem. In fact, I am old enough that I actually saw polio patients. The vaccine had just come out about when I was entering physical therapy school. So we had a role in providing the therapy for the doctor's identified condition. And that's very different than what I'm proposing or have proposed with this book. And I think the other thing that's so important about all this, and I'm sure you are a reflection of this, is in the old days, no one thought lifestyle had anything to do with your health. I always like to point out this story. My family cooked with so much Crisco, I don't know how my blood flows. And if the green beans were too healthy, we had bacon grease to put on them. But I was very fortunate. I worked with a physician for a while who was really leading the way and showing about the role of exercise and nutrition. he did what's really called translational research showing the cellular changes in animals and then also running studies in older people. And it was like an amazing insight for me to realize that your lifestyle had something to do with it. So I think that's behind what's slowly emerging as seeing movement play a different role. I think what I'm like to get across to people, it's not inevitable what's going to happen to you, that you can do things by a lifestyle to improve what your outcome's going to be. I would love to come back to, I believe, and I don't want to misquote you, but something you said, which is the treatment of symptoms. So many offices are treating symptoms, perhaps not root causes. And I have read, and you can't believe everything you read on the internet, so please correct me if I'm getting this wrong. I said a new saying. Yeah. Wow. That you've described low back pain as not a diagnosis, but a symptom. And could you just speak to that? Because I, as someone who currently for the last maybe six to nine months has had a very perplexing constellation of symptoms that I describe as low back pain, this I think will resonate with many people who are listening. So would you mind elaborating on low back pain as a symptom and not a diagnosis? Well, I mean, just what you're saying. You're saying it's low back pain. You're just telling me that you've got pain and you're telling me where you've got pain. That is clearly a symptom. Yeah, right. I am from Long Island, so sometimes I ask the silliest of questions, but got to start with the basics. Well, the nice part is you can actually get reimbursed for making that big, clever diagnosis, even without an MD degree. But where I would be looking at that problem, and I have an idea of what your problem is. Wow. Okay, already. Just because we can talk about that. Okay. I mean, I don't want to sound too glib about it, but what I would be doing is naming your low back pain by the movement that most consistently causes your symptoms, and by changing that movement, reduces or eliminates your symptoms. Then I'm talking to you about a real cause of the problem. Now, it's not going down to the tissue level and saying, well, you know, it's a disc or a facet joint or any of the rest of it. But here again, in some ways, when you have a problem like that, you can't say in the back that one tissue's at fault because a lot of tissues have to change if you're having pain coming from your back region. So the expertise of a physical therapist needs to be what is the movement that's either causing or exacerbating that problem. So I'm curious to, well, maybe we can dive into, you you thought you might know what my, my issue is. That's because I know you're a big exerciser. I, yes, yes, indeed. And do you want me to just give you a ballpark idea? I do. Okay. Absolutely. Well, because would you believe that abdominals can get to be too much, like overdeveloped?"

Overdeveloped Abs Causing Back Pain: The Counterintuitive Culprit

Sahrmann reveals that overdeveloped abdominal muscles -- common in serious exercisers -- can increase spinal compression and contribute to back pain. She prescribes a simple test: measure rib cage expansion from full exhale to full inhale. If it's less than 2.5-3 inches, the abdominals may be too stiff. She recommends arms-overhead breathing and lateral side bends through the thoracic spine to elongate them.

"You know, it makes some intuitive sense, but it's not something you hear many people talk about. I know, I know. Even within the community of physical therapists, people are really exercising big time. I mean, high-intensity exercise is super popular. I'm all for it because it'll increase our patient load. But one of the things that happens when your abdominals are overdeveloped, because what happens when muscles hypertrophy, they become stiffer and muscles are like springs. So they have a, I mean, I'm using the mechanical word of stiffness. And so when the abdominals get to be too much, they increase the compression on your spine. And so the way you can check me out on this is if you look to see if you take a deep breath, if you go from maximum exhalation to maximum inhalation, you should be able to change the circumference of your rib cage about two and a half to three inches. And if you can't really do that, then it means that the stiffness of your abdominal muscles is so much it's adding to the compression and then if you have any kind of asymmetry if for example if you put your hands on your iliac crest and one iliac crest is slightly higher than the other then you're basically your your spine is in a side bend and if it's in a side bend and you're squeezing on your vertebrae, they're not happy because they aren't lined up as optimally as possible. Do you see what I mean? I do. Absolutely. Okay. So that's the ballpark idea. That also reflects how we're looking at these problems. What is it about the way you move? What is it about the way you've exercised or done things that cause the symptoms? I would love to spend more time on this, selfishly, of course, because the reason I am sitting and not standing for this interview is because of this lower back pain. So it's worse when you're standing than when you're sitting? It is worse when I am standing. Now, I do have, I guess we can jump right into the weeds. I have a transitional segment if I'm using the right terminology in my lumbar. So I do have quite a bit of excessive lower back sway or atypical lower back sway. When you say sway, do you mean an increased curve? Increased curve. Yeah. Like lordosis and kind of guts hanging. And with that anterior pelvic tilt, right? Standing and slow walking, say walking through a museum, tend to aggravate it the most. My brother has the same thing. Although in the last six months or so, when I sit on a very hard surface, like a hard bench or something like that, it also causes this pain. I have had imaging, but maybe we could talk about imaging, how you see some people who look like they've gone through a mulcher on their back MRI, but they're asymptomatic. And then you have the opposite. That's the whole point. So I do have some stenosis around like L4, L5, but the pain feels to me localized around the SI joint. The relief, if this is helpful, I know we're getting a little technical for some folks, but the relief that I've had in the last week was actually from seeing a chiropractor. There's a high degree of variability with chiropractors, but he works with a lot of athletes. And he put me on a machine that provided some traction. And he said, I think it's actually that you may have a disc pressing on a nerve that runs past the SI joint. So you're misattributing the cause to the SI. And I've had quite a bit of relief, but to answer your question, standing, slow walking combined with standing, like going through a museum or a cocktail party, sitting on hard surfaces, those are the three things that hurt. Brisk walking does not hurt. And actually that type of, and this is a primitive interpretation, but sort of repeated stretching of the hip flexors, if I'm getting enough terminal hip extension, feels really good to the back. Those are a few of the things. Have you put your hands on your pelvis to see when you're walking, if it rotates? I have not. I would love to know how to do that properly. It's not rocket science. You know where your pelvis is, you know where your hands are. Just because very often when your hip flexors are not even just not short, just stiff, stiffer than your back, as you walk, it rotates your pelvis and that's where you're going to be getting your symptoms from. And evidently, when you go fast enough, you're not staying static, and you're causing enough equal movement, but that would be the big thing. When you stand up and you're in this anterior tilt, can you contract your abdominals enough to get out of the tilt? I can, yeah. And then does that decrease your symptoms? It does decrease my symptoms. So if my back is bothering me, I'll very often do basically a forward fold or a full squat and then round my back and get into that flexed position. The flexed position and even mild extension does not bother the back. If I do a compression test, like a heel drop test, or I pull myself into a chair, it's standing straight up and with compression that shows that type of intolerance. And I get that pain kind of directly on the lower spine. The other thing to try, Tim, is when you stand up, put your feet apart, separate them out and see if that changes your symptoms. What is that doing? Number one is this little thing I referred to before. If one iliac crest is higher than another, and it's a test for what we call relative stiffness. So one of the big hip flexors that's problematic is called the tensor fasciae latae iliotibial band. And it's an abductor. So if you put your feet apart, so your hips are abducted, it takes the stretch off of that band. And any kind of asymmetry that you would have, particularly with a transition vertebrae, would be playing into the symptoms. Do you see what I mean? I do. And then if you put them together and your symptoms increase, then you would know that that's what's playing a role in doing this. So I'll add a few more things, just because this is a rare opportunity to get to talk with you about this. So my TFL tends to be very tight and sensitive. Yeah, that's right. The piriform is also very tight. A piece of this that may or may not be helpful, but what gives my back also some release is working on the, very specifically, the iliacus and then some of the adductors so on the inside of the thigh now i don't know how you do that tell me what that means well having someone really dig uh into the abdomen to have me say okay extend the leg it's not you working on it somebody else's no it's somebody else working on it um and then it's not very pleasant for people who are listening and And then some of my adductors, I don't know if it's Magnus Longus or whatever, but also very tight and seemingly potentially weak. But to come back to the height, maybe the asymmetry of the iliac crest, my right side seems to get hiked up a lot and doing wall sits to try to press them maybe back into some symmetry seems to alleviate some of the symptoms as well. I don't know if any of this makes any sense. You've just confirmed one of my thoughts is that if your right iliac crest is higher than your left, but then I would also bet that your right TFL is stiffer than your left. So if that's playing a role, then when you put your feet apart, your iliac crest should level out. That should help with your symptoms. So historically, when I've been recording podcasts, I basically end up in that really wide stance. And so I think I'm... Now is that... I mean, that's useful for maybe temporarily relieving the symptoms if I'm recording a podcast in terms of corrective measures. Let's just say using your... Have you ever tried anything where you're in the quadruped position? I have actually, a long time ago, I did a lot of movement in quadruped position, but I would be curious to hear what you have in mind. Part of what happens when one iliac crest stays higher than another, and I'm not, to be perfectly honest with you, I haven't quite figured it all out yet, but there's some adaptation of the other hip muscles. And I've just found that if you do this in quadruped, you just rock back. Often it will improve the asymmetry. So basically being on hands and knees? Hands and knees, right. And let your hips drop to about 90 degrees. You don't have to go back all the way. You just need to go back a little bit and go back by easily pushing with your hands. Because otherwise, if you activate your hip flexors, it could pull it, contribute to your problems. Okay. And then, can you tolerate prone? Yeah, I can tolerate prone. And then you need to just do, like, just flex your knee. And then you need to laterally rotate your hips. So you're letting your knee flex to 90 degrees, and then let your foot go in towards the other leg. That's lateral rotation. Yep. And that kind of motion will help to elongate the TFL ITD. Interesting. And you're doing that leg by leg? Yeah, one leg at a time. One leg at a time. Okay. Yeah, by bilaterally yeah okay very interesting so you can try those try those things let me know i will i will do i will do both of this so let's if we zoom out just for a moment thank you for that by the way we may come back to it how would you describe the movement systems syndromes approach so the MSS approach? What would the sort of lay description of that be? In 2013, the American Physical Therapy Association adopted the movement system as its identity. And to me, what's really important about all of this is that it's a way of trying to say to the public that there is a body system called the movement system. And it's not like the traditional anatomically defined systems like the cardiovascular system or the musculoskeletal system or the nervous system. It's a system of systems. But that's just like, in my mind, the immune system, which nothing is more important in medicine these days than the immune system. And it's a system of system. It uses many of the different organs in its function. Metabolic system is the same way. And so when you think of it as running from subcellular all the way up to how do you move in your environment, movement is critical. When movement stops, everything stops. And so I think in some ways to me it's like a parallel to the nutrition system because we take for granted doing it. And yet there's right ways and there's wrong ways. And so the whole idea of this is to realize that their movement does involve a system. And just like we were talking about before, movement, if you have a lesion in a system, like you have rheumatoid arthritis or something, or you have a stroke, then you've got pathology in your movement. But as I indicated, movement can also induce pathology. In fact, we know if people don't move enough, they develop the metabolic syndrome and other kinds of things because for lack of movement."

70% of Back Pain Comes From the Hip: Why Movement Matters More Than Structure

Sahrmann estimates that at least 70% of back pain cases stem from suboptimal hip movement. When hips lack mobility, the lumbar spine compensates, leading to injury. She emphasizes that exercise alone won't fix movement patterns -- you must change how you move in everyday activities, from walking to getting out of bed, which requires sustained attention and patient re-patterning.

"And because it's not just, is it one iliopsoas that's problematic or both of them, one tensor that's pulling more strongly than the other. And that's the passive tension, not just the active tension. And that's what you have to know. Just a quick thanks to one of our sponsors and we'll be right back to the show. This episode is brought to you by AG1, the daily foundational nutritional supplement that supports whole body health. I do get asked a lot what I would take if I could only take one supplement. And the true answer is invariably AG1. It simply covers a ton of bases. I usually drink it in the mornings and frequently take their travel packs with me on the road. So what is AG1? AG1 is a science-driven formulation of vitamins, probiotics, and whole food sourced nutrients. In a single scoop, AG1 gives you support for the brain, gut, and immune system. So take ownership of your health and try AG1 today. You will get a free one-year supply of vitamin D and five free AG1 travel packs with your first subscription purchase. So learn more, check it out. Go to drinkag1.com slash Tim. That's drink AG1, the number one, drinkag1.com slash Tim. Last time, drinkag1.com slash Tim. Check it out. Now, you were asking about my breathing and the deep breath. When I met with Eric, and I could be totally screwing up this terminology, so you may need to rein me in, but he had me take off my shirt, and I think it was at a very low, it might be high, but infrasternal angle. So I have a bit of a depression in the chest. I have a very minimal ability to expand my ribcage. I'm a belly breather, and I've had a number of people note that it's likely when I breathe, I kind of rotate my entire rib cage backwards, which also causes that excessive, exactly, that excessive hinging at the lumbar. What do you do with somebody who's got this type of predicament or pattern?"