I recently finished the 3rd edition Stuart McGill’s “Low Back Disorders.” I’ve followed his work since reading edition 2 and bulk of my back pain treatments are based on, or consistent with it and his more recent research. For those who don’t know, McGill is a Professor of Spine Biomechanics at the University of Waterloo in Canada, for which he focuses entirely on low back pain. Subsequently, more of my back pain blogs reference his research than any other source.
I was wondering what was new in the 3rd and if it were worth buying and reading through. In short, it was both. The basic gist of his treatment hasn’t changed (but there was a lot of additional detail and ideas). Said gist to eliminate back pain is to lessen the injury causing stress from daily activities, while working on exercises (to make the person fit enough) and motor skills (to make them coordinated enough) to better tolerate the rigors of life without reinjury. I 100% endorse those principles.
All the above is all filler, and sets up what I wanted to get too, which was one of the more interesting sections new to the 3rd edition of Low Back Disorders which I have never seen mentioned anywhere else. The observation appears to be anecdotal, but it’s Stuart McGill’s anecdote, which means something, and I also happen to think this observation is often correct. On page 142 he talks about sacroiliac pain (literally pain in the butt) with the following being a few of his quotes:
“Boguk and colleagues (1996) proved that some low back pain is from the sacroiliac joint itself. The following discussion offers other considerations.”
“One possibility worth considering is that the high muscular forces may damage the bony attachments of the corresponding muscle tendons. Such damage has perhaps been wrongfully attributed to alternate mechanisms.”
“It is known that a large portion of the extensor musculature obtains its origin in the SI and posterior superior iliac spine (PSIS) region (Bogduk, 1980). The area of tendon-periosteum attachment area for connective tissue places the connective tissue at high risk of sustaining microfailure, resulting in pain (McGill, 1987).”
“This mechanical explanation may account for local tenderness on palpation associated with many SI syndrome cases.”
McGill didn’t use the the word tendinitis, or more accurately the words tendinosis and tendinopathy. However, when he uses the words “microfailure” of the “tendon-periosteum attachment area” of the spine “extensor musculature” at it’s point of “origin in the SI and posterior superior iliac spine” it sure sounds like he’s describing tendinosis, with the resulting pain being tendinopathy of the spine extensor tendons. So far there is zero research describing tendinopathy in this region, but there is no reason I can think of why it couldn’t be. Also thinking about it, gluteus maximus also attaches right there, along the SI joint region as well, so it’s tendinous region could be involved as well, while all this time it’s been blamed on the SI joint or the piriformis muscle (which I have never seen get better stretches either).
The SI joint as a source of motion or pain has long been a source of debate in physical therapy, with studies and arguments pointing for and against for decades. I’ve never been passionately drawn to either side of the argument. However, I have stress tested a lot of SI joints and rarely do I find those tests positive for pain, and if the tests are painful, I think it’s still hard to tell if the SI joint itself is the source. Also I’m skeptical treatments directed at the SI joint reliably decrease that pain. I wouldn’t go so far as to say they never do, but just not often enough to make such treatments worth routinely doing. I’ll add that sometimes when there is debate and no clear answer, it’s because there’s something amiss and it wouldn’t be the first time that tendinopathy reared it’s head in an unbenounced place. Another reason I don’t usually give SI pain special attention is my SI pain patients generally get all the way better with my somewhat standard low back treatment protocol. So thinking about what McGill wrote above, how I treat back pain and how I treat tendinopathy, I have a idea as to the reason why.
That reason is that my treatment protocol for back pain, bares more than a passing resemblance to my treatment for tendinopathy. In short, I’m basically treating for both already. Besides biomechanical and postural counseling, teaching the person with back pain how to better maintain a neutral spine during the day, I have them work to increase basically total body strength and endurance emphasising spine stability and hip mobility, with an exercise program that is generally 3 sets of 15 reps, with easy-medium-hard resistance levels. I have them progressing the weights on the next visit if the person is able to get all three sets without pain and with good technique on the prior treatment. That’s almost identical to how I treat tendinopathy, with an example being tennis elbow (aka shooter’s elbow described here) or coracoidopathy described here. In both cases I try to increase strength and endurance of all the muscles stabilizing the affected area, followed by focused strengthening of the affected muscle/tendon with 3 sets of 15 reps ( also easy-medium-hard resistance levels).
So if a person has tendinopathy of their spine extensor muscles (or gluteus maximus) where they attach on or near the SI joint, that would explain why my back pain type sets and reps, has hitherto resolved those symptoms without me even considering tendinopathy of the area being a possible cause.
Some considerations I’ll be thinking about going forward is that with back pain I endeavor to never have my patients train through pain, however with tendinopathy I try to use a resistance level that causes some pain, noting that pain almost always stays the same/or lessens in spite of increasing weights from set to set. With back pain, for which I might suspect a bulged (nearly bulged) or herniated disc, training through pain usually results in a worsening the person’s condition from one set to the next. Also with tendinopathy I notice people get better faster if they do the exercises every day rather than three times a week and my observation does have empirical support.
So if there is SI region tendinopathy I think it’s probably better to error on the site of caution and not increase resistance levels if there is any pain, which thus far seems to be working well enough. However, if the person has SI region pain, no lumbar or radicular symptoms (leg pain and tingling) I might consider a slightly more aggressive (slightly more specific tendinopathy) type approach. However, I imagine there is a lot of overlap between both conditions, such that if someone has spine extensor tendinopathy, they very likely have some spine disc or ligament issues as well even if they don’t have pain yet, so daily pain free resistance exercise of the spine and hip extensor muscles (with the spine kept neutral throughout) is maybe the safest and best approach.
For the record, I suspect upper back pain and tenderness where the levator scapula muscle attaches to the scapula is sometimes and maybe often be tendinopathy too. Which seems to resolve with my basic neck pain protocol, which like my back pain treatments includes (your guessed it) progressive resistance training with 3 sets of 15 reps (easy-medium-hard).
As always, if you have any further questions or comments, don’t hesitate to ask.
Chad Reilly, Physical Therapist