Extension Based Back Pain is a B****. And What To Do About It

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It’s no secret that any form of back pain sucks.  Looking at the statistics – it’s been said that 80% of Americans have experienced some form of lower back pain in their lifetime – it’s a safe bet that you know exactly what I’m talking about.

As such if you’re a coach, personal trainer, physical therapist, athletic trainer, a general fitness enthusiast, or, I don’t know, someone who trains bomb sniffing dolphins for a living, you’ve probably heard of the name Dr. Stuart McGill.

If not – and you better have a good reason for why not – for those unaware, Dr. McGill is essentially the world’s Don Corleaone of spine biomechanics and research.  His two books, Low Back Disorders and Ultimate Back Fitness and Performance (now in it’s 4th or 5th edition), not to mention the endless array of studies he’s been involved in as well as his numerous other products have done more to expand the knowledge base with regards to assessment and program design not only for me, but for countless other health professionals than anyone else I can think of.

Note: this isn’t a slight against other “low back specialist” such as Dr. Craig Liebenson or that crazy witch-doctor-prisoner dude from The Dark Knight Rises who, after Bane pile-drived his knee into Batman’s back and more or less paralyzes him, healed Bruce Wayne’s spine with nothing more than some rope and some weird chanting………..in a matter of weeks.

Both of them are the bees knees, and I have without questionlearned a lot from them.  But I’d be remiss if I didn’t say that Dr. McGill’s research has influenced me the most.

Anyhoo…..

I’m not going to belabor the point here, but suffice is to say flexion based back pain tends to get most of the press – and rightfully so.  As I noted, Dr. McGill’s research with regards to repeated flexion, and in particular loaded flexion, have very few detractors.

Ask anyone who spends the bulk of their day sitting in front of a computer screen in one massive ball of flexion or anyone who deadlifts like this……

…..and you’re bound to see they have a history of low back pain.

Which is why, when working with someone with (flexion based) low back pain, my main focus is to re-engrain “spine neutral,” help get people out of a constant state of flexion, and hammer core/spinal stability.

And to not deadlift like the asshat in the video above.

But even though this “anti-flexion” mentality has helped a vast amount of people, we’ve somehow managed to force feed people into thinking that ALL flexion is bad.

Lets be honest:  people are scared of everything.

ObamaCare, increasing gas prices, zombies, Keanu Reeves movies, you name it….we’re scared of it.  And now flexion is no different.

My buddy Dean Somerset wrote a fantastic post not too long ago titled Spinal Flexion is Important for Low Back Health and Strength which I felt did a bang-up job helping to bring the pendulum back to the middle.

Which serves as a nice segue into my topic today.  Extension-based back pain.

We see this a lot in the athletic population – especially in extension-rotation dominate sports like baseball – but also in the meathead and trainer population too.

I wrote about this “phenomenon” (if you want to call it that) a while ago in a T-Nation article titled “Glue” Exercises Gone Wrong.

In it I talked about this concept of REVERSE POSTURING – or an extension dominate posture – that we were noticing in a lot of our clients at Cressey Performance.

Here’s a snidbit from the article:

A few months ago, we picked up on a repeating trend with some of our clients at Cressey Performance.

We started noticing a lot of extension-based back issues, particularly through the thoraco-lumbar (TL) junction. More specifically, we started to observe more of a gross extension dominant posture in many of our athletes and clients.

The chest up position, which we have been taught and have been preaching for the better part of the past decade, might have been an overreaction to the poor posture that many non-exercisers typically exhibit.

Much like what happened with the low fat craze in the 1990’s, the anti-stretching phase from a few years ago, low intensity steady state cardio vs. HIIT, and the never-ending debate over Jessica Alba vs. Jessica Biel, things often get blown out of proportion and taken to the extreme.

In discussing this matter with my colleague Mark Bubeck, a trainer in Ridgefield, CT, these extension-based types of pain from being locked in that position can be seen in all types of people, especially those with an over-exaggerated lower crossed posture (i.e., excessive anterior pelvic tilt).

The issue is that we’re starting to see this pattern in a lot of trained individuals too, and not just those who “pretend” to work out.

Those who’ve been training “correctly” for many years with what we thought were correct positions have seemingly developed the reverse posture of what we set out to correct in the first place!

Stating it succinctly, we know that the hunched over Neanderthal posture isn’t good, but the reverse (promoting chest way up with a huge rib flare and the movement coming solely from the TL junction) isn’t doing anyone any favors, either.

This, of course, isn’t to say that we shouldn’t still use the same cues as above – especially with those who do exhibit poor posture – but there’s something to be said for not taking things to the extreme.

To that end, here are a few updated cues with regards to the seated row:

  • You still don’t need to be rounding your back. That’s just dumb.
  • You still want to think about keeping the chest up, but also think “ribs down,” locking them onto the pelvis.

Confused? Check out this video to see what I mean:

In a nutshell:  while not done intentionally, many fitness professionals, in an effort to correct faulty posture or flexion based back pain – cueing people to depress and retract their shoulders, over and over, and over again, for example – have helped contribute to the another issue altogether.

What About Those People Who Are in Extension-Based Back Pain!?!?!?

While not the most glamorous or elaborate assessment tool, one of the best ways to differentiate between flexion-based back pain and extension-based is to simply ask the person “do you have more pain while sitting or standing?”

If the former, you can probably ascertain that they lean more towards the flexion intolerant side of the spectrum.

If the latter, ding,ding, ding, you most likely have an extension intolerant candidate!   Using myself as an example, I can tell that after having been coaching on my feet for 6-7 hours standing around on black matting, my lower back is oftentimes killing me.

Another simple “test” would be to have him or her perform a standing toe touch.  People who are extension intolerant will typically have more pain on the way UP.

All of this to say that those with extension intolerant backs typically (not always) have something going down in the facet joints or may have end plate issues (fractures, spondy, etc).

So what are some strategies we can implement to help address the issue?

Glad you asked!

1.  It sounds borderline silly, but being more cognizant of rib position is a huge deal.

Walking around in a “flared” rib position in concert with an excessive anterior pelvic tilt is a one-way ticket to Mybackfuckinghatesmeville, USA.

Case in point, here’s an example of what I mean:

In the first picture my ribcage is flared out and the (imaginary) line between my nipples and belly button is long. Conversely, in the bottom picture my abs are braced and the line between my nipples and belly button is shorter. This is the position I’d ideally like to stay in for most of the day, and especially while exercising.

Now, I’m am NOT insinuating you need to walk around all day “checking” yourself, making sure your abs and glutes are engaged, but I am saying it’s something that should enter the equation.

We all know the saying that we have one hour to “fix” things in the weightroom and 23 more hours in the day to f-things up.  Well, this is part of those 23 hours.

The point above coincides very well with the section above on seated rows. Incidentally it also bodes well for just above everything with regards to lifting heavy things.

Learning to “own your rib position” when squatting and deadlifting can pay huge dividends with how your back feels in the long run.

I wrote an entire article on the topic HERE. (<—- Read It!  Gosh!)

Even something as trivial as how we perform a standard lunge can have an effect.

We’ve always cued people to perform their lunges with their shoulder up and retracted and they chest up:

It’s not inherently wrong, but for those with extension-based back pain doing lunges this way can be murder.

Instead, I like to cue a slightly more forward lean and to think about the shoulders going over the knees rather than the hips.

This way not only is the lower back able to flatten slightly, but more of the load is placed on the hips rather than the lower back itself.

2.  Stop Doing Things Which Cause More Extension

Well, duh!

We all know that benching with an arched lower back is one of the keys to hoisting up big numbers. Powerlifters live by this creed and it’s for good reason.  A good arch means less distance the bar has to travel.

I’m not one of those people who feels that benching with an arched lower back is bad.  The lumbar spine has a natural lordotic curve and benching with an arch isn’t the end of the world.

Benching with an excessive arch (in addition to the butt coming off the bench……RED LIGHT!!!), well, that’s another story.

For those who do exhibit extension-based back pain, however, it may be in their best interests to nix the (excessive) arching – at least for now – and bench with a flatter spine.

Don’t worry, I promise you won’t turn into a Jersey bodybuilder. I think.

Likewise if you’re someone who performs their chest supported rows like this:

Is it any wonder why your back is flipping you the middle finger????

Jesus – just stop it!!!!

It may make more sense to do more row variations which won’t allow you to crank through your lower back.  Stricte(r) seated row, half kneeling 1-arm cable rows, and the like would be money here.

3.  Wear Shoes With More Cushioning

Eric Cressey touched on this topic HERE, but I wanted to chime in on it as well.

I get it:  You wear Vibrams everywhere you go – even at the mall – so that everyone within a two-mile radius knows just how hardcore you are.

First off all, you’re a douche.

Secondly, wearing shoes which offer a bit more cushioning may be more advantageous for those with extension-based back pain as it helps serve as a bit more of a shock absorber.

I walk around on hard black, rubber matting all day when I’m coaching and it can be unforgiving on my back. Upon the recommendation of Mike Reinold, I switched to a shoe that offered a bit more cushioning and I could instantly feel a difference in how my back felt at the end of each day.

If you’re someone who has to stand for long periods of time throughout the day, this subtle tip could be a game changer.

4.  Learn to Breath

The people over at the Postural Restoration Institute (PRI for those in the know) have been around for well over two decades, but it’s only been within the last 2-3 years that their “stuff” has gotten a bit more exposure.

While even Gandalf would have a hard time understanding their entire philosophy, I can tell you that one of the major “umbrella themes” is to understand that, based off our anatomy, the human body will never by symmetrical.

Taking things a step further, it’s recognizing that we’re inherently designed in such a way where asymmetry is inevitable, and that how we breath plays a major role in that.

PRI tries to teach people how to breath more efficiently, which in turn, in conjunction with their corrective modalities, will help attempt to bring them back to neutral.

People who exhibit more extension-based back pain tend to have an over-active or dominate Posterior Extensor Chain (PEC Posture), and as weird as it sounds, (unloaded) flexion is one of the best ways to help them.

Tossing in some dedicated breathing drills which help teach people to “breath into their back” can make a world of difference.

These are drills we’ll tack onto an extended warm-up with our athletes and clients before they actually pick up a barbell.

They take all of maybe 2-4 minutes to complete (depending on how many we include), and then it’s off to go crush some weights.

All Fours Belly Breathing

Deep Squat Belly Breathing w/ Lat Stretch

Here I’m going into a “deep squat,” and using the front of my thighs as a guide to keep my rib cage down.  I then take a deep breath through my nose trying to drive me “sternum to the back wall,” which helps turn my upper back into a dome.

I then forcefully exhale all my air which will help to engage my diaphragm to a higher degree.

With both drills I’ll shoot for anywhere from 5-10 breaths, or until someone blacks out.  Hahahahaha.  Just kidding.**

And that’s just the tip of the iceberg.  This post in no way encompasses an all-inclusive list of stuff that can be worked on, but hopefully it gave some food for thought with regards to how to approach back pain from a different viewpoint.

** = or am I?

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Comments for This Entry

  • Barath

    Was that deadlift video made as a joke? Otherwise it baffles me that a guy like him who has clearly spent some time in the gym would do something like that.

    January 17, 2014 at 1:07 pm | Reply to this comment

  • CodieD

    I sit at a desk all day and this is my posture! My MPT always tells me I am the reverse of most of her clients and that she almost has to coach me to slouch, and keep my ribs down. Standing does cause most of my LBP. Thanks for this! I'd be interested in future articles with exercise suggestions. (my PT suggested the shoes thing too...totally helped!)

    January 17, 2014 at 2:04 pm | Reply to this comment

  • Pedro

    Jessica Alba vs Jessica Biel? that shouldn't even be a debate! Jessica Alba in a heartbeat

    January 17, 2014 at 2:29 pm | Reply to this comment

  • Richard Williams

    Thanks for this post! I have been having back issues for a couple years now and over extension sounds like the problem. I have gone back to the doc 3 times and even after the mri showed no compression of discs plus the fact that I specifically told him rounding my back doesn't hurt as much as the cobra pose yoga move he was having me do he didn't believe extension could be casing me pain. I might forward this to him.

    January 17, 2014 at 11:08 pm | Reply to this comment

    • TonyGentilcore

      I'd also make sure you read Eric's article I linked to Richard. SOunds like you need some dedicated motor control work, so things like deadbugs or anything which RESISTS extension would be in high order.

      January 18, 2014 at 5:49 am | Reply to this comment

  • Noah

    Oh now this has got me thinking! I have been diagnosed with a bulge at L4-L5 and L5-S1. Here I am always keeping my shoulders back and chest out and maybe I'm over doing it. Thanks for these ideas. I'm going to work on them. I will definitely try the softer shoes idea. I've been toying with going without my orthopedics as well. I have been using them for 15+ years except for training. I originally started due to high arches. I'm going to read the other links you provided and I ordered both of McGill's books to read in the near future. Thanks Tony

    January 18, 2014 at 2:35 pm | Reply to this comment

    • TonyGentilcore

      Hey Noah - Glad the article made sense and that you got something out of it. I'd HAMMER deadbugs if I were you, as well a TON of core stability work. In your case, "spinal neutral" is key.

      January 19, 2014 at 4:30 pm | Reply to this comment

  • KateZ

    Great article! I have been trying to solve my low back pain for the last year. Do you think that over tight quads could be the start of it all or be related to all these things you've mentioned?

    January 18, 2014 at 11:07 pm | Reply to this comment

    • Chris

      The quads are definitely an issue for me and I would be curious to hear Tony's perspective on where this issue comes into play and what to do for them. In my case, they are so tight that I am unable to get my pelvis to neutral without bending my knees. Stretching, foam rolling, ROLF, nothing so far has elicited any substantial changes. The breathing drills are something I haven't seen before and will definitely be adding those in.

      January 19, 2014 at 11:09 am | Reply to this comment

    • TonyGentilcore

      Mmmm, it can. As with everything I think it's a bit more complicated than just saying it's because of "tight quads." But it stands to reason that if you do have stiff or short quads, you're in a bit more anterior pelvic tilt. Either way, think your main priority - outside of "some" dedicated stretching - is to hammer glute strength and anterior core strength. Alignment matters. If you stretch your quads and you're just hanging in APT anyways, it won't matter.

      January 19, 2014 at 4:32 pm | Reply to this comment

  • Zach

    "You wear Vibrams everywhere you go – even at the mall – so that everyone within a two-mile radius knows just how hardcore you are. First off all, you’re a douche" This statement makes me sad.... :( I love wearing my Vibrams everywhere I go

    January 19, 2014 at 2:43 pm | Reply to this comment

  • Matt Toohey

    One of your best TG

    January 19, 2014 at 3:47 pm | Reply to this comment

  • Shane Mclean

    Really like the the cue on the hip hinge pattern. Also chest up, ribs down. Gold. What a lot of people don't realize ( i use to be one of those people) is the bad habits people have that play into their pain. Neutral posture is a big deal. Question. Been doing the breathing squat for a while. What is a regression on that? Have lots of clients who cannot even get into that position. Keep up that great work Tony. Reckon this is one of your best blog posts yet.

    January 19, 2014 at 4:36 pm | Reply to this comment

  • Guy W

    Excellent article Tony. Along with your recent article on T-Nation regarding arching vs. bracing, this is the kind of info I wish I had understood when I started out resistance training. Having played heaps of cricket from a very young age, I was already incredibly extension dominant, to which I added the mindset that lumber flexion was the devil. Fast forward a few years, and my body now incorrectly associates lumbo-pelvic stability as being the result of using my chronically over-developed spinal erectors to jam my facet joints together.... and who would have guessed it… I ended up with LBP. This has resulted in an incredibly frustrating few months as I was originally unable to address my APT or reduce my pain, irrespective of how much hip flexor stretching or glute activation I did. It turned out that the hours I was putting into "rehab" exercises each day were just "feeding" my dysfunction. As the every single rep, every second of stretching or isometric contraction, the ATP and lumber extension were not just present, but were the fundamental means I was creating lumbo-pelvic stability. The light-bulb moment only came a month or so ago, when I realised that the oblique on my "painful side" was chronically underdeveloped, and I read a Shirley Sharmann quote highlight the obliques advantage positioning in producing PPT. My "rehab" now focuses not on a specific exercise but rather maintaining a neutral pelvis/lumbar spine at ALL times. 24/7, sitting, standing, exercising, laying in bed, in every situation, focus on keeping my obliques “engaged” to achieve a neutral (or even slightly posterior tilted) pelvis and everything is suddenly hunky dory. The challenge is that as soon as stop thinking about my pelvis position, I INSTANTLY revert to the old “ATP+Arch=stable” muscle recruitment, but hopefully over time that won’t be the case. Sorry for writing a novel for a comment, but I want to convey to everybody how valuable Tony’s point is in articles like this, because I know first-hand how easy it is to fall into the trap of being stuck in extension, and the pain/frustration it can cause.

    January 19, 2014 at 9:53 pm | Reply to this comment

    • TonyGentilcore

      Don't be sorry at all Guy. EXCELLENT insight and thanks for sharing. Glad my post struck a chord and that it made sense. I definitely feel it's an issue that plagues more people than we think.

      January 21, 2014 at 2:31 pm | Reply to this comment

  • Why Dancing Sucks For Your Back and What You Should Do About It | The Dance Training Project

    […] written articles debating the inherent evil of spinal flexion, which you can read respectively HERE, and […]

    January 20, 2014 at 9:48 pm | Reply to this comment

  • Michelle

    Okay, i just finished watching the DL video and i had to immediately scroll down and comment on the following 1) WTF??!? i cringed and then laughed.... trouble is, for every 1 of him on youtube, there are 1,000 not on youtube! 2) i love your descriptor of "asshat" for that guy. spot on. and now i will continue to read the rest of the article!

    January 21, 2014 at 1:07 pm | Reply to this comment

  • Josh Landis

    Good piece. One thing I would like to add though, is that "engaging the diaphragm" (more so, never letting it go - shallow breathing) is often a major contributor to core dysfunction. While holding your breath/bracing is good for max effort lifting, it needs to be balanced out with full diaphragmatic breaths, where prolonged exhalation is the emphasis. The diaphragm often works too much in relation to the core musculature. :)

    January 21, 2014 at 7:51 pm | Reply to this comment

  • Brent

    Excellent stuff Tony. Mos def gonna try out that breathing drill. In regards to the toe touch, I was reviewing cook's secrets of the core DVD and he mentions to keep the feet together, abduct legs slight to fit small ball between and crush ball if one needs to. He mentioned it was important feet were together to prevent pronation, and to get a more stable foot position. I'm wondering though how much this matters if someone isn't a pronator naturally? And obviously if you only have a big ball, pretty hard to keep feet together (ha, I make an unintentional gross funny. high five to me.). ps - Jessica Alba was the clear winner until I looked through her book at Barnes and noble (for the health tips obviously). Apparently she suffers from some sort of undiagnosed mental disease, hating on meat because, you know, It's full of toxins. Celebrity science is my favorite kind of science. Tomorrow I shall begin my lemon and cayenne pepper diet. Detox is hella easy when you don't have energy to lift your fork to your mouth. So yeah in summation, go science.

    January 22, 2014 at 12:53 am | Reply to this comment

  • Michael Mullin

    Brilliant Tony! Very well done and spot on with your cues, positional changes and adding all the critical ingredients for great technique and results, top to bottom. Plus it friggin' cracked me up! Cheers. . .

    January 23, 2014 at 9:34 pm | Reply to this comment

  • CorinaSoareFitness

    Resourceful as always! Great article!

    January 25, 2014 at 5:53 pm | Reply to this comment

  • Worth reading or watching January 2014 | Anthony Dexmier

    […] Gentilcore proves once again that his blog kicks ass. He wrote a very entertaining but very informative article on extension-intolerance related low-back pain. I often talk about flexion intolerance so it’s a nice contrast and it gives you new […]

    January 26, 2014 at 2:29 pm | Reply to this comment

  • Lauren L

    This and EC's article were so helpful for me. It's good to have some discussion on the extension side of the spectrum. As a trainer and pre-nursing student, I spend a lot of time standing in the gym and in the hospital and feel RELIEF when I go into those flexed postures. I've been working on ribcage position awareness during those times and will start building those exercises into my workouts now too. Thanks! (ps- the grammar nerd in me wanted to let you know that it's "breathe" when you're talking about how people 'breathe into their back, etc.' Sorry, I have a problem I know)

    January 26, 2014 at 8:36 pm | Reply to this comment

  • Laura ThisisFit

    I love everything in this article, both for myself and application with clients. Thank you!

    February 24, 2014 at 11:23 am | Reply to this comment

  • AZ Devil

    Jessica Biel.....hands down.

    May 19, 2014 at 12:03 pm | Reply to this comment

  • Exercises You Should Be Doing: Split Stance 3D Hamstring Mobilization w/ Reach

    […] – Too, you need to own your rib position (something I explain in more detail HERE). […]

    November 5, 2014 at 11:40 am | Reply to this comment

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    December 31, 2014 at 8:37 am | Reply to this comment

  • James

    Been struggling with a herniated disc for 3 years now. My new pt's are just starting to identify that it's the extension that's killing me, as the every other doctor/pt/surgeon (I've probably seen about 15 different people for this) have been telling me I need to be working on extension. Thanks for the help. Excited to try some of these tips and get back to living.

    February 19, 2015 at 7:16 pm | Reply to this comment

    • TonyGentilcore

      Glad to hear you found someone who has a more "outside the box" way of thinking James. Good luck!

      February 23, 2015 at 11:01 am | Reply to this comment

      • RichG

        Hi, great info. One question. I'm an extension based low back pain sufferer and my PRI practitioner told me to flex my low back while doing similar exercises to the ones in this article. Each time I go into flexion it makes my pain worse. I'm effectively in pain either way with no relief whatsoever!! I also have bilateral pars defects at L5 and wondering if this has something to do with it? Any insight from yourself would be greatly appreciated.

        July 10, 2016 at 6:42 am | Reply to this comment

        • TonyGentilcore

          I'd recommend talking to your practitioner and letting him or her know this information.....;o)

          July 11, 2016 at 12:40 pm | Reply to this comment

          • RichG

            I have! Their communication skills are about as good as a chocolate kettle!

            July 12, 2016 at 4:18 am

          • TonyGentilcore

            Sorry to hear that. Well, it's really hard for me to make any concrete suggestions over the internet (and without seeing you in person). The only thing I can hope to help you on is directing you to reputable therapists in your area. Where are you located?

            July 12, 2016 at 8:30 am

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    May 21, 2015 at 10:38 am | Reply to this comment

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