All things in moderation is great advice. Whether that is food, fitness, spending habits, or even receiving advice, I’ve found that extremes tend to have negative consequences. We treat a lot of sports injuries in our office, especially low back pain from lifting, CrossFit, runners, triathletes, and golf. This can be frustrating because injury can keep you away from performing something you love. A common theme to many injuries we see has to do with spinal positioning. “Neutral Spine” is a concept that has been around for quite some time and is often misunderstood; it is not a singular position, but rather a range where we can safely train. In general, it is the position our spine is naturally designed to be the most biomechanically efficient.
To start, lets review general anatomy of the spine. The spine has 3 major curves in the cervical, thoracic, and lumbar regions. The cervical and lumbar spine normally have lordotic curves, and the thoracic is normally “kyphotic.” Our spine is designed to move into flexion and extension in these ranges, but sometimes our “default” can be an extreme in the opposite. This is extremely important when lifting, and we will focus on some foundational movements (deadlift and squat) and why it is important to be self-aware of how your back is positioned during these movements.
The vertebrae connect to each other through a series of joints called facet joints and are linked together by intervertebral discs (among other things). The facet joints and discs are two of the most common structures we see injured through lifting activities (power, Olympic, CrossFit, etc.). In general, our tissue is tolerant to a certain amount of load. If we go to the edge of what that tissue can handle, it becomes stronger and more resilient. If the load goes beyond this threshold, we can have injury. I believe a large amount of these injuries are due to improper loading or lack of proper form that leads to improper loading. This typically isn’t one specific motion but happens repetitively over a period of time. I don’t know how many times I’ve had someone doing the same lift they’ve done 1000 times, with no difference in form, and they feel an increase in pain after the next workout.
Extreme Flexion of Lumbar
The intervertebral discs most commonly herniate or bulge posterolaterally. This is due to multiple factors, but anatomy is a major contributor. These structures just aren’t designed to repetitively flex over and over again under load, which is what occurs with faulty positioning and/or lifting mechanics. This is a common reason that heavy hinging exercises (KB Swings, Deadlift, Cleans) can cause irritation. Extreme spinal flexion can occur at the bottom of a squat if your tailbone tucks underneath, which we commonly refer to as a “butt wink”.
How does positioning affect the disc anatomy? A common analogy we use to describe a disc is a “jelly donut.” The inside of the disc, or nucleus pulposus, is gelatinous. The outside, or annulus fibrosus, is cartilaginous layers (think of the rings of wood grain). If you think of the disc as a toothpaste tube and I squeeze on one end, the toothpaste shifts, pressure builds and shifts towards the opposite end. Overtime, pressure into the cartilage can allow the gelatinous material to shift into the layers, and eventually bulge or herniate, which is no fun.
Extreme Extension of Lumbar
Another common injury I see is extreme extension. This typically is a compensation commonly from either extremely tight hips that naturally force an increase in lordosis or other mobility limitations. Another compensation I see to create more stability in the spine is arching of the low back. I often tell people you can either use your core musculature or the anatomy to increase stability. Have you ever seen a powerlifter bench press? Arching through the spine create more stability by “locking” the facet joints together. This jams the facet joints together, putting more stress on the pars interarticularis which can lead to facet pain or in extreme cases a spondylolysis or stress fracture of the pars interarticularis. This is what I used to do in high school. I specifically remember arching while performing including press, and a coach telling me “if you keep doing that you’re going to hurt your back.” Low and behold several years later an x-ray revealed a spondylolisthesis.
How do we fix it?
I usually break movement issues into two categories by using a computer as an analogy: hardware, or physical components of moving, and the software, or motor-patterns (aka coordination). With hardware, if you don’t have the physical ability to get into the position (you’re too tight, or you have anatomical differences that don’t allow you to move in those positions) then you need to work on mobility, or modify the position. Some hip conditions limit hip flexion, and you can stretch and mobilize all day, and this won’t change. In this case, you may have to modify the depth of your squat. Software can be trained by either coaching or cuing the basic motion, or correcting components of the basic motion.
The first step is just being aware of what neutral spine is. In the quadruped position or on your back, take your lumbar spine to extreme flexion by “tucking your tailbone” underneath. Do the opposite and arch your back in extension. Now, find the area just in between those two. This is “neutral.” Also, keep in mind this is not a fixed position but a range, if you’re a little outside of that as you’re moving, that’s ok. Your spine is designed to handle some motion, you just want to stay away from the extremes.
The next step is simply watching yourself or having a coach watch you move, while trying to maintain that range. If this fixes it, it may just be a motor control and awareness issue that you need to practice and maintain. Having a understanding for what you should feel, and then simply repeating it may be enough.
Check out this video for additional help:
How to find Neutral Spine
If that doesn’t fix it, you may need to review the anatomy required to move through the positions you’re trying to train.
Supine Hip Flexion with Knee Bent
Have someone passively move your hip into flexion. Can you passively move your hip over 90 degrees with your tailbone staying in contact with the floor? If not, you may have a mobility issue.
Supine Hip Flexion with Knee Straight
Keeping your leg straight, passively have someone raise one to 80-90 degrees of hip flexion. If not possible, you cannot pull a bar from the ground and maintain a healthy spine position.
Check out this video for additional help:
Which hip flexor is the problem?
Here is how to perform a basic hip flexor stretch
Hip Flexor Stretch
When there are no anatomical changes, and when you have a good feel for the position, another common issue we see is form failure from fatigue. When we fatigue, the body will take the path of least resistance or return to the “default” position, creating loss of movement integrity. This can be observed either at the end of a highly repetitive workout, or when training under higher loads. It is very important to be mindful when you feel loss of position. Working on maintaining neutral spine through multiple positions is the best way to train the core. I’ve included a few of my favorite exercises to build a base and work to combat this.
DNS 3 Month