Everything and nothing causes low back pain
Low back pain is often discussed as if there were a single cause or a single fix, but there isn’t one clear answer. After years of debate, many clinicians still disagree about the root cause and the best way to treat it. In truth, there isn’t a universal recipe that fits all cases. Even with ten doctors or physical therapists, you’ll likely hear ten different opinions about the root cause and what to do about it. Some blame delayed firing of the Transverse Abdominis, others point to posture or tight hamstrings. But these explanations are often too simplistic. Often there isn’t one culprit at all. Hamstrings get blamed a lot, but that isn’t the whole story. In fact, you could (with less evidence) blame many things, including coffee, for low back pain. The point is: there is no single right way to approach this, and treating every case as if it’s the same is a mistake. There’s a wide range of factors at play, and what helps one person may hurt another. As Dr. John Rusin notes, there is no one-size-fits-all solution; the idea that all low back pain is the same or should be treated the same is a big mistake. Most readers aren’t clinicians, and personal trainers should not diagnose. If you’re a trainer who starts diagnosing, you should stop and defer to qualified health professionals. Still, trainers are often the first to notice faulty movement, weakness, and imbalances, and they’re in a good position to help clients with low back pain.
There’s a lot we can do to help people. Here’s a concise look at what has worked for me, simplified.
1) Rest is overrated
Rest is frequently the worst advice. There are times when a short pause helps, but telling someone to rest indefinitely or to “learn to live with” the pain is defeating. It’s better to back off when needed and give the body time to heal, but not to resign yourself to a life of pain. A good starting point is not to fixate on a strict “neutral spine” forever, since life requires moving in and out of various positions. Strength and movement can be corrective, and stagnation is often the real problem. The body is designed to adapt, and gradual, appropriate stress and movement are key to long-term improvement. Sitting around all day won’t help.
2) Move, but move well
Movement has three important components: structure, coaching/technique, and programming. Everyone is unique, and anatomy varies—hip shape, shoulder mobility, and even how the body chooses to move can affect back health. Efficient movement isn’t always better movement; it can mean using the body in a way that protects the spine rather than optimizes length and leverage. Coaching matters: tailor exercises to the lifter, not the other way around. Programming matters too: if someone lacks hip flexion, a conventional deadlift may not be the best choice; if shoulder mobility is limited, overhead pressing might be problematic. Even simple cues during a plank or dead bug can reveal important movement issues and guide adjustments. The goal is to find a training approach that provides a meaningful training effect while respecting the individual’s abilities and limits.
3) Finding spinal neutral (pain-free ROM) is important
A practical goal is to identify a pain-free range of motion and help the person own it. Start by finding actions that are comfortable and then gradually test what causes symptoms. For example, someone who prefers flexion might, when tested, find that excessive spinal flexion worsens pain. The fix is to coach better posture and to build spinal endurance and strength with movements like planks, while avoiding sustained positions that aggravate symptoms. For those who tend to extend the spine, it’s useful to assess how they move into extension and then work toward maintaining spinal neutral. Both groups can benefit from exercises that promote posterior pelvic tilt and control during setup for squats and deadlifts, as well as controlled, unloaded spinal flexion. The goal is to develop a safe, tolerable range of motion and gradually expand it in the weight room as symptoms subside. The main point: pay attention to spinal neutral and pain-free ROM, then expand from there.
4) Don’t treat people like a patient
I still find value in the deadlift for many people with low back pain. The deadlift is a hip hinge movement that teaches the body to dissociate hip motion from lumbar motion. It doesn’t have to be a heavy, floor-to-lift exercise; it can be performed with manageable loads and alternative setups that suit the individual’s capabilities. If someone understands spinal neutral and can maintain it, there’s room to progress. Tools like kettlebells, trap bars, and bands can make deadlifting more accessible. Other effective options include farmer carries, suitcase carries, shovel holds, offset-loaded exercises (one-arm presses or rows, lunges, or Romanian deadlifts with a single dumbbell), and even less traditional movements that still challenge the core without compromising form. The key is to stay out of risky positions and pick a training approach that delivers a real training effect and a trainable routine for the person.
The bottom line is that low back pain has many possible causes, and there is no single root cause or universal fix. Yet there are big, practical principles that can greatly improve outcomes: avoid over-reliance on rest, move with intent and proper form, find and maintain a safe spinal range of motion, and use varied, individualized training to build resilience. I hope this helps.
