The Anatomy of "My Back is Out" and How to Fix It

I spent years as a kinesiologist and medical writer.

©2025 T. Agnew

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.

For most people, back pain is a conundrum and getting a Band-Aid treatment to help stop the pain is often the plan — and this includes chiropractic, surgical procedures, and massage therapy. While not a solution, these modalities can help.

In this article, I’ll discuss my history treating back pain and share my past experience with it, then tell you how I treat it myself.

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 junction in their lifespan.

Each year, approximately 30 million people seek professional medical care for spine problems, and this number should rise over the next decade due to an aging population.

Imaging scans such MRI, CAT, and radiological films, often are recommended by primary care and orthopedic specialists to better understand the condition of the tissues and spine, and to rule out larger issues such as tumors. In 2014, the U.S. saw approximately 34 million MRI scan orders.

Yet, for any practitioner in sports medicine, MRI reports more often confuse patients and cause 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 patients often believe their back dysfunction is worse than it is. Here is an example of an MRI report for the lumbar spine:

L4-L5: Image 21-mild to moderate decreased disc signal and disc height with mild endplate spondylitic change, bulge and a left paracentral disc herniation extruded superiorly, 7 mm AP by 16 mm mL by 14 mm CC, with the left L5 nerve root sleeve impingement in the lateral recess, with severe right more than left facet arthrosis.

It sounds terrible, doesn’t it? The findings show normal spinal changes, and the $400 MRI report probably reveals nothing causing your back pain. How about this:

L5-S1: Image 32-mild decreased disc signal with mild/moderate decreased disc height and endplate spondylitic change, bulge and left paracentral disc herniation, 3 mm AP by 8mm mL, with left S1 nerve root sleeve impingement in the lateral recess, with moderate facet arthrosis. Patent canal and right lateral recess and right foramen with minor left foraminal stenosis. No paraspinal masses or collections.

Stenosis! Call 911! Again, normal 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.) Most patients with an active disk herniation or active stenosis have no pain.

Many of my previous patients 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 usually resolves on its own — with a little help (I’ll get to that soon). Some other interesting facts:

Only 5% of the 56 million Americans with back pain 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 need to address the fascia. Human fascia runs from the back of the skull (occipital) to the toes, and lines the muscles and organs (I wrote about fascia here). We are essentially suspended in a fascia suit (see Gil Hedley’s work where he dissects fascia. I’ve done cadaver work with him — he is a master and a loony but I love 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 send signals across the fascial network. As a protective mechanism, muscles recoil in painful spasms. One of the major culprits of lumbosacral pain is the quadrates lumborum (QL).

The Culprit: 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. This is one of the reasons back pain is so difficult to treat. When the QL is in active contraction, it can skew 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 is 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 patients 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, slouched posture and had difficulty walking. 

Physically, palpating with my thumbs at the twelve rib and then pelvis produced intense pain when pressure was applied. The medial borders of the muscle attachment are always tender and the mass of the muscle feels like a knotted rope.

From a prone position, testing leg length discrepancy always shows a shorter side, after all, the pelvis is locked into a skewed position and the rib cage is usually pushed to one side as well.

Treating Lumbosacral Dysfunction

While back pain can be a more serious issue, if your dysfunction continues into days, it’s best to get medical advice. Yet, it is simple to treat QL spasm and reduce the contractions.

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 out my 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. 

It stabilizes your posture whether you’re standing tall or sitting upright, and it powers each stride when you walk or run. Its close connection to the lumbar vertebrae makes it vital for both mobility and long-term spinal health.

The QL and IP work together to stabilize your movements. Fixing lumbar pain must include the IP as it is often in a locked position due to the QL dysfunction.

To help release the ischemic tissues, active stretching exercises work wonders (see my video here on Active Isolated Stretching (AIS) ). My video was designed to be a study guide, not a follow along fitness program. If you follow the protocol, the exercises isolate each muscle group.

Improving the flexibility of the IP helps release the QL — and vice versa. The internal and external muscles of the hips should also be addressed. Active stretching allows you to get very specific and target all of the fibers of the muscles.

Preventing lumbosacral pain begins with good flexibility and stability. The abdominal core should be strong and toned and the QL can be strengthened with side bending movements with a weight.

Most importantly, the body should be trained in opposites — always. Strengthening opposites, or muscles that work together in concentric and eccentric fashion, makes the body and spine stable, and creates a barrier to tears and strains.

My other mantra is train the body in extension. That is, 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, for example).

The spine needs extension. Gravity pulls the body into a “closed” position — rounded shoulders, hollow chest, etc. This is especially true with computer work, gaming, and phone postures.

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 balanced.

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 place 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 opposites and extension makes the body resilient to sprains and strains

Adjunct massage therapy is beneficial