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Back Pain: What Tissue Is The Issue

    Do you want to know what tissue to blame for your pain (Disc, Bone, Ligament, etc)? We can provide some help and hopefully save you some money, time and radiation exposure from medical imaging in the process! Learning how to relieve pain however will require you to look beyond the tissue.

    If you are like me, you tend to be searching for some sense of certainty wherever you can get it. Pain provides a great deal of uncertainty when we don’t know what the culprit is. We falsely assume that identifying a herniated disc, arthritis or a ligament tear with an MRI will “fix” the problem. In most cases it just provides us with a scapegoat. Something we can blame the pain on.

    Early use of medical imaging, such as MRI or X-Ray should be reserved for symptoms consider “red flags.” Those are the scary ones…

    … Such as, changes in bowel or bladder function, numbness, muscle weakness, weight loss or intense night pain.

    In cases where you have attempted high quality rehabilitation without success, medical imaging can help your doctor decide if surgery is warranted.

    Skilled medical providers, whether it’s an Orthopedic Medical Doctor, Physical Therapist, Chiropractor, etc. are exceptional at predicting what tissue is injured based on your examination. Our society is so focused on speed and technology that the art of a good evaluation often gets sidestepped. If you’ve ever spent 2 hours in your physicians waiting room followed by a 10-minute visit you know what I am talking about.

    This is not to say that I totally disregard the injured tissue in our treatment sessions, whether that is a disc, nerve, joint, ligament, etc. Having a better understanding of the tissues that may have been injured helps us understand the BEST treatment strategy for YOU.

    In our last blog post we discussed the relationship between back pain and Position Intolerance. If you need a quick catch up click here. Now we will help you understand what tissues are likely injured based on the POSITIONS and MOVEMENTS that worsen your pain.

    If you take nothing else away from this post, understand that the real goal is to learn how to modify Movement and Position to relieve pain.


    Flexion Intolerance (Spine Rounding)

    Aggravating Movement

    Pain with spine rounding motions, such as tying your shoes, bending over to pick something up, sit ups, toes to bar, poor lifting technique.

    Aggravated Tissue

    Disc Issue (bulge or tear)

    • Slow onset of pain throughout the day or sharp pain with bending forward.
    • “Catch” or “locking” of the back may indicate instability at the spine. This is common with disc injuries.

    Nerve Compression and/or Irritation (i.e. Sciatica or Femoral Nerve)

    • Radiating pain down the back of the leg and into the foot (sciatica) or into the front of the thigh (femoral nerve irritation).
    • Tears in the disc can cause fluid to leak onto the nerve causing sciatic like symptoms.
    • Compression of a nerve by a disc in the presence of inflammation can also cause nerve irritation.


    1. Finding relief by stretching the back muscles.
    • Rounding the back when stretching can provide a feel good sensation, BUT it often continues to stress the disc. This is because you are repeatedly performing the same motion that irritated the disc in the first place.
    1. Regular spine manipulations
    • Another feel good activity that provides a temporary reduction in pain, but can aggravates the disc.
    • What’s often overlooked is that injury to the disc has the ability to cause mild instability at the joint.
    • This is why we emphasize stability exercises and hip mobility with most back injuries rather than over emphasizing stretching of the back muscles and spine manipulations. We need to create stability for long term relief and learn how to move from the hip joints (i.e. hip hinging). 

    Recommended Exercises

    1. Lying on your stomach or “upward dog” can help, as can self-traction (i.e. hanging from a pull up bar). Short duration holds of about 15-30 seconds are a good start.
    2. Those with “Catching” or “Locking” (instability) would benefit from stabilization exercises.


    Extension Intolerance (Spine Arching)

    Aggravating Movement

    Lying on your stomach, rotating from the lumbar spine, arching your back while sitting/standing, or during any exercises (squatting, finishing a deadlift, kettlebell swing, kipping pull up, GHD Sit up).

    Aggravated Tissue

    Facet Joint

    • Sharp pain with extension and rotation movements
    • Often times, facet irritation can be secondary to a previous disc injury. The disc injury likely caused some instability at the spine, causing you to compensate with increased facet joint loading. Eventually the facet joint gets angry.

    Nerve Compression and/or Irritation

    • Bone spurs at the facet joint can cause compression at an exiting nerve root.
    • Active inflammation (or bleeding) from the joint can leak onto a nerve and create “sciatica” like symptoms.


    Over-reliance on lumbar spine extension (arching) during your workouts, rather than hip extension.

    Recommended Exercises

    Learn to move from the hip joint rather than the lumbar spine. Start with some bridging. Learn more here.

    *** For some, your pain may be secondary to Spondylolisthesis.

    • This is when a fracture occurs at the spine causing one vertebrae to slip forward on another. This is a more significant form of instability common in hyper-flexible people that move through extreme ranges of motion. For instance, gymnasts or yogi’s. Weightlifters that are loading their spine in excessive spine extension or flexion are also susceptible.
    • In this case, we would also promote stabilization exercises and emphasis on exercising in more neutral spine postures. With focus on moving from the hip joint.

    Some of this information can be a little hard to grasp. The point is to help you see that the real goal is to correct the source of the pain. If we can do that we can relieve the pain.

    If you are interested in diving deeper check out The Back Mechanic, written by Dr. Stuart McGill.

    Interested In Setting Up An Appointment? Click here to for cost and availability.

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    Michael Infantino, PT, DPT

    Doctor of Physical Therapy

    Rehab Renegade Physical Therapy and Performance 




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