Your Back Isn't Out: Your MRI is Scaring You
Low back pain is big business. Here’s what your doctor won’t tell you.
As a sports medicine practitioner for over two decades, I’ve probably seen more back pain-related issues across the spectrum of professional athletes, musicians, and ballet dancers than any other condition.
In this article, I’ll discuss my history treating back pain and share my own recent experience with it.
The Facts and MRIs
Back dysfunction is a major cause of morbidity and disability in the U.S., with an estimated 80% of the population experiencing lumbar back pain at some juncture in their lifespan.
Spine issues are big business—approximately 30 million people seek professional medical care every year—and that number is expected to increase over the next ten years as people age out.
Primary care and orthopedic specialists often recommend imaging scans such as MRI, CAT, and radiological films to better understand the condition of the tissues and spine, and to rule out larger issues such as tumors. Nearly 40 million MRI scans are performed in the U.S. each year.
Yet, as any practitioner in sports medicine knows, MRI reports confuse patients and often cause more anxiety over the painful condition (my mantra was always there’s no such thing as a good MRI). MRI reports read like a bad novel and leave patients believing it’s the end of the world.
Here is an example of an MRI report for the lumbar spine:
It sounds terrible, doesn’t it? The findings show normal spinal changes, and the $400 MRI report probably reveals nothing causing your back pain—normal age-related bone changes that don’t cause pain.
If Your Back is Out, Where Did it Go?
The good news is that back pain is most often caused by fascial (soft tissue) dysfunction from strains and sprains, and not, as sometimes believed, by disc herniations (bulges) or stenosis (narrowing). For the record, 90% of my patients’ back pain was treated by addressing ischemic tissue (muscle spasm et al.)
Many were in so much pain that they called an ambulance — that’s how painful myofascial discomfort is. You will feel as though you require surgery.
Good news. Back pain not caused by injury or chronic illness usually resolves on its own — with a little help. Some other interesting facts:
Only about 10% of back pain cases actually need surgery
Less than 5–10% of all low back pain is due to a specific underlying spinal pathology
So, no, your back is not out, it’s telling you that you need to address the fascia and musculature. Human fascia runs from the back of the skull (occipital) to the toes, and surrounds muscles and organs. We are essentially suspended in a fascia suit (see Gil Hedley’s work. I’ve studied cadaver anatomy with him ).
The largest sensory organ in the body, fascia has a myriad of sensory organs including nociceptors (pain), proprioceptors (balance), and mechanoreceptors (movement), as well as 250 million nerve endings.
When the receptors in the fascial system sense over exertion, they respond by sending pain signals to the brain, which in turn sends signals across the fascial network. As a protective mechanism, muscles recoil in painful spasms. One of the major culprits of lumbosacral pain is the quadratus lumborum (QL).
The Quadratus Lumborum
Tucked deep within the lower back, the QL muscles anchor the pelvis to the spine and stretch upward to the 12th rib. These powerful, paired muscles flank the lumbar region on either side, driving side-to-side bending and helping to extend the spine. With every breath, they help support and aid the movement of the ribcage.
Because this muscle and its surrounding fascia connect to the rib cage, sneezing or coughing while it’s in spasm causes horrific pain. When the QL is in active contraction, it skews the pelvis to one side. If you look in a mirror, you’d see that your body is shaped like a Z.
Walking, getting out of bed, and putting on clothes or shoes are sometimes impossible. I’ve had dozens of patients that experienced a QL spasm while on the floor performing fitness exercises. They could not get up without help, and many of these people were young. Age has nothing to do with it.
Assessing this dysfunction is simple — and I became a master at seeing it as soon as they entered my clinic. They were always in a Z-shaped, distorted posture and had difficulty walking.
Physically, palpating with my thumbs at the twelfth rib and iliac crest produced intense pain with applied pressure. The medial borders of the muscle attachment are always tender and the mass of the muscle feels like a knotted rope.
Testing leg length discrepancy from a prone position always reveals a shorter side because the pelvis locks into a skewed position and the rib cage usually shifts to one side as well.
Treating Lumbosacral Dysfunction
While back pain can be a more serious issue, if your dysfunction continues into months, it’s best to get medical advice.
Biomechanically, the QL works in concert with the iliopsoas muscle (IP). Deep within the core, the IP muscle runs alongside the spine, extending from the lower back down to the edge of the pelvis (for an excellent anatomy resource, check our textbook).
As it descends, it merges with the iliacus to form the powerful iliopsoas — a key driver of movement and stability. This muscle supports the spine and actively controls hip flexion, external rotation, and lateral bending of the lower back. Its close connection to the lumbar vertebrae makes it vital for both mobility and long-term spinal health.
Fixing lumbar pain must include the IP as it is often in a locked position due to the QL dysfunction. To help release ischemic tissues, active stretching exercises help (see my video here). Improving the flexibility of the IP helps release the QL — and vice versa.
Preventing lumbosacral pain begins with good flexibility and stability. A strong abdominal core is important, and you can strengthen the QL by performing side-bending movements with a weight.
Strengthening muscles that work together in concentric and eccentric fashion make the body and spine stable and create a barrier to tears and strains.
My other mantra is to train the body in extension. Place focus on positions that cause extension. Why? We are born in flexion and spend most of our lives performing flexion movements (when we sit, we are in a flexed position). The spine needs extension. Gravity and poor posture pull the body into a “closed” position — rounded shoulders, hollow chest, etc. This is especially true with computer work, gaming, and phone posture.
In a supine position, pulling the shoulders together, scapula moving towards the midline, helps strengthen spinal erectors. Standing on one leg for one minute at a minimum is something everyone should be able to do. It’s also a wonderful way to make the body more stable.
I always recommend massage therapy in conjunction with stretching (I try to get one a month). Make certain your therapist specializes in deep tissue work. They should focus on the twelfth rib and iliac crest, with deep pressure to the middle belly of the QL.
To sum it all up:
Lumbosacral pain has myofascial origins — always
Stretching and strengthening with a focus on strengthening opposite muscle groups and performing extension movements make the body resilient to sprains and strains
Adjunct massage therapy is beneficial
Sources
Lifetime back pain prevalence and annual U.S. medical visits for spine problems, NCBI Bookshelf, “Back Pain in the United States”: https://www.ncbi.nlm.nih.gov/books/NBK586768/
MRI scan volume, Aran S., Cureus, “A Review of Magnetic Resonance (MR) Safety: The Essentials to Patient Safety,” 2023: https://www.cureus.com/articles/190660-a-review-of-magnetic-resonance-mr-safety-the-essentials-to-patient-safety
Share of low back pain from specific spinal pathology, StatPearls (NCBI Bookshelf), “Low Back Pain: Evaluation and Management”: https://www.ncbi.nlm.nih.gov/books/NBK538173/
Surgery rates for back pain, UT Southwestern Medical Center, “Just 10 Percent of Back Pain Requires Surgery”: https://utswmed.org/medblog/back-pain-surgery-alternatives/
Disc herniations and stenosis in people with no pain, Jensen MC, et al., “Magnetic Resonance Imaging of the Lumbar Spine in People Without Back Pain,” New England Journal of Medicine, 1994: https://www.nejm.org/doi/full/10.1056/NEJM199407143310201
Nerve endings in fascia, ABMP Massage & Bodywork Magazine, “The Fascial Network: Our Richest Sensory Organ”: https://www.abmp.com/massage-and-bodywork-magazine/fascial-network-our-richest-sensory-organ
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