The problem with how back injuries are commonly treated

Medical professionals commonly treat back injuries with pain killers which do not remove the source of pain and can leave people addicted, they are also quick to call something a specific source of back pain purely based on an MRI image of the spine, for instance, an MRI scan may display a bulging disc and a doctor may label this as the cause of pain without knowing if this is a new wound or old scar which has healed or how it reacts during movement to be able to tell if this is the real source of pain, in fact, many people, including young people, have a bulging disc without any pain, on the other hand, many people have back pain despite a perfectly normal looking MRI scan of the spine. A study was conducted in 2006 where 200 different people with no history of back pain performed an MRI scan of the spine, those who developed severe back pain had another MRI scan taken of the spine and it was revealed that 84% of those people had no changes in their MRI scan results, some people even improved, this places doubt on the reliability of an MRI scan to diagnose the cause of back pain, instead MRI results should be used to help you diagnose the cause of pain, for instance, if you have pain in your lower back only when flexing the spine and MRI results show a bulged disc in your lower spine then it is likely that this bulged disc is the cause of pain, especially if past MRI results didn’t display any bulged discs, however, finding the source of the problem does nothing to healing the injury and prevent it from happening again or getting worse.

Medical professionals are also quick to label back pain as lumbar muscular strains or sprains, and although the muscles of your back may be causing pain it is most commonly due to an injury occurring to the spine which results in an inflammatory response, this has been shown to lead to spasming or contractions of the surrounding muscles, likely to limit excessive movement in the injured area. However, please do not be afraid to see a medical professional about your source of back pain as in severe cases it may be the difference between life and death.

Often back pain leads to a neurological overreaction which increases the sensitivity of pain, meaning that even the slightest spinal movements can cause immense pain in the back. Fascinatingly, back injuries are most common after sleeping which is when the discs of the spine are the most hydrated.

Bulged discs and herniations

The spine is a slightly curved column of bones known as vertebrae, the column is split into 5 sections, but only the top 3 move, these are the cervical vertebrae, the thoracic vertebrae and the lumbar vertebrae. Each vertebra is connected to one another through joints known as facets which are located at the posterior part of the vertebrae, this gives the spine a great ability to move, each vertebrae is also stacked on top of each other with discs in between offering cushioning. The nucleus pulposus is a gel-like substance located in the centre of these discs, it is surrounded by many layers of strong collagen rings which are called the annulus fibrosus, these discs have a thin end plate cartilaginous layer on either side of the disc. A neutral spine position describes when the spine is in an upright posture, however, this shouldn't be considered as one position and instead is a small range of motion between the flexed and extended spine positions. Loading a healthy spine in a neutral position leads to an even distribution of force across the spine’s discs, which means that any damage occurring to the discs is highly unlikely, fascinatingly, pressure on the spine primarily comes from the contractions of its surrounding muscles rather than any actual load placed on it. If the spine is loaded and then moved or loaded in a non-neutral position then the annulus fibrosis can begin breaking down in a process known as delamination and the nucleus pulposus can seep through the newly formed cracks causing the disc to bulge, this is appropriately called a bulging disc, and if it’s allowed to get any worse it can lead to a herniated disc. Disc bulges and herniations are most common in the lumbar spine, it is common to feel as if your back suddenly develops bulges or herniations, maybe when performing a heavy deadlift or when simply bending down to pick up a box, however, this is rarely the case, and disc bulges and herniations usually develop slowly overtime before a sudden particular movement displays its symptoms. A herniated disc or disk bulge can lead to the compression of nerves and cause severe pain which can radiate down to one or both of your legs. Even if a disc bulge has healed and is no longer causing pain it still changes the mechanism of how the spine functions which can lead to more injury. A bulged disc loses stiffness and pressure and it leads to an uneven distribution of load across the spine, meaning that more pressure is placed on the posterior part of the spine, this often leads to more spine injuries, commonly in the facet joints. It is okay not to have your spine in a neutral position as long as you are not generating a lot of power at the spine when moving, the equation for power is force x velocity, so if a large amount of force is placed on the spine, such as during a heavy conventional deadlifts and a rounded back technique is used, it will not mean that an excessive amount of power is generated at the spine as long as you unround your spine slowly, however, rounding your thoracic spine during the conventional deadlift to help you get better leverages and lift more weight should only be used by advanced athletes who perform the deadlift as part of their sport because it still comes with more injury risks then the deadlift with a neutral spine position, it is important to remember that if you do decide to slightly round your thoracic spine during the conventional deadlift you are still not meant to move the weight with your spine, your main focus should be hip extension and your spine should straighten out gradually, normally you should always try your hardest to maintain a neutral spine on almost every exercise you perform.  

It is common for individuals to experience back pain during the squat as a result of a butt wink, which is when the back rounds in the deep position of a squat, this is not a big deal if it occurs whenever you perform bodyweight squats every once in a while but if it always occurs when barbell squatting, particularly with heavy loads performed quickly then a lot of power will be generated at the spine and the risk of back injury will be high, particularly for disc bluges and herniations. The butt wink is common as form begins to deteriorate due to fatigue build up across a tough set. The cause of a butt wink is usually related to the size and positioning of the femur and the depth of the hip socket to which it is attached, a thick femur and deep hip socket means that as the hips flex the femur will come into contact with the hip socket sooner during the squat and to hit depth the pelvis compensates by rotating around the body, this causes the lumbar spine to round, resulting in a butt wink. To prevent the butt wink from occurring it is important to adjust your form, this may include squatting with a wider stance facing your feet further outwards or by not squatting as deeply as usual, also it is worth testing your ankle mobility by performing the 5-inch wall test, which includes getting into a lunge position with your lead leg 5 inches away from a wall, lunge forward, if you can touch your lead knee to the wall on each leg whilst keeping your foot firmly placed on the ground than your ankle mobility is likely not the problem, otherwise, if you can’t do this it will probably be beneficial to perform ankle mobility exercises, as this is probably not allowing you to let your knees drift over your toes sufficiently when squatting which means that your pelvis is compensating for this by trying to rotate too far forward which makes it come into contact with the femur resulting in a butt wink. Performing the 5-inch wall test is a good exercise for ankle mobility in itself if you hold the stretched position, also soft tissue mobilisation work on the calf muscles, such as by using a foam roller, has been shown to enhance ankle mobility without causing any pain in the achilles tendon, like which happens with static stretches for the ankle.

Spine fractures

Inside each vertebra is a spongy network of many beam-like bones which are called the trabeculae. Compressive forces on the spine cause microfractures in the trabeculae stimulating it to thicken and strengthen in order to withstand a greater amount of force in the future, however, if the vertebra is loaded to a large degree too regularly then the rate of bone breakdown will exceed the rate of it being rebuilt causing fractures, this is very common in those who regularly lift heavy weights, fractures of this type often occur in the end plate of the vertebra, this is part bone, part cartilage, and is the part of the vertebra which is in contact with the discs of the spine above and below the vertebra. The end plate must be strong whilst still being porous enough to allow for blood flow and the delivery of nutrients to and from the disc below. The end plate stretches across the vertebra when a force is applied to this, however, when this occurs to such a large extent too regularly this can cause an end plate fracture and a fracture to the trabecular underneath. Thankfully, if you regularly deload and undergo regular low-volume maintenance periods for 3-6 weeks then fractures in the spine will likely get the time to heal, as soon as you sense back pain which stems from a fracture in the spine it is important to stop loading it as intensely. End plate fractures most commonly occur in the thoracolumbar region of the spine.

Facet injuries

The facet joint capsule is innervated with many nerves to help sense spine position and movement, and any injury to the joint can cause serious pain, in fact, facet injuries are responsible for a large amount of back injuries. The many facet joints in the spine allow for many movements, including rotation, flexion and extension, and any of these movements or any combination of these movements can lead to microtrauma of the facet joint over time. Facet injuries are particularly common due to repetitive excessive extension of the spine such as when overarching in the bench press or leaning too far back to perform an overhead press, this leads to damage of the facet joint and the joint capsule which could lead to arthritis. Facet joints are also particularly common when flexion or extension of the spine is combined with rotation, there are not many gym exercises that purposefully use this movement, however, it can accidentally happen during lifts if you have mobility asymmetries, for example, a mobility asymmetry of the hips may cause the spine to move in a way which stresses the facet joints. Facet injuries, like most spine injuries, are most common in the lumbar spine.

Spondylolysis

Spondylolysis typically occurs in the lumbar spine due to regularly hyperextending the spine in any movement, including the squat and deadlift. This is a serious injury that occurs when a fracture forms in the part of the spine known as the pars interarticularis, which is located next to the facet joint. If spondylolysis is not given a chance to heal or it gets worse it can lead to spondylolisthesis, which is when the vertebra slips forward. Spondylolysis occurs in roughly 35% of individuals who regularly perform heavy overhead presses, however, the chances of you developing spondylolysis are likely determined by your genetics. It is important to not unnecessarily over arch your back during any lift and stop loading your spine and extending it as intensely as soon as you develop symptoms of spondylolysis and particularly spondylolisthesis.

Nerve pinching from spine injuries

The spinal cord runs in between small gaps all the way through the centre of the spine, projecting out from the spinal cord, through gaps in the spine, are smaller nerves, due to injury these nerves can become pinched and create a painful, burning or tingling sensation which can radiate downwards to your lower body. Compression of the sciatic nerve is characterised by a painful, tingling or burning sensation radiating down the posterior part of the thigh, this is often caused by a disc bulge or due to the piriformis muscle pinching down in the nerve, on the other hand, compression of the femoral nerve often leads to a painful, tingling or burning sensation radiating down the anterior part of the thigh. Once you develop nerve pain it is important to try and avoid any movements which stimulate the pain and replace these movements with ones which demand less of the spine.

How to distinguish your source of back pain

Firstly, it is important to note that if you have access to the help from experts on back pain and to fancy equipment, such as MRI scans, then you would likely be better off going down this route, although, sometimes it is more cost-efficient and simply more practical to find your source of back pain yourself.
 

Your source of back pain must be categorised as a flexion, extension, rotation and extension or load intolerance. Analyse your training and day-to-day activity and note what movements are causing pain and where, also note what is not causing pain in order to help you eliminate what problems you do not have, for example, if you have pain only when loading the spine with heavyweight than this points to a load intolerance, if you have pain only when sitting than this points to a flexion intolerance, if you have pain when you are moving on your feet but no pain when sitting down this points to an extension intolerance, if quick movements, such as sneezing, causes back pain than you likely have a load intolerance as a result of spinal instability. When trying to find your source of back pain bear in mind that it is possible to have more than one cause of pain in your back. Also, in order not to create pain and to stop your injury from getting any worse it is important to avoid any movements which create back pain.
 

After you have analysed and noted what does and doesn’t cause pain during training and your day-to-day activity it’s time to perform some tests to truly identify your type of injury. Start by standing with your normal posture, and take a picture or video of yourself from the side, if your posture looks as if you have excessive flexion or extension of the spine and you feel pain with this posture it is possible that this is because your posture is causing excessive activation of certain muscles to maintain your posture which is placing stress on them and creating pain, if this is the case instead stand with your spine in a neutral position, if this removes the pain then you must learn to stand and sit with this posture.

The next test requires you to sit on a stall, grab either side of the stall and pull up on it hard, first when your spine is in a neutral position, then when your spine is in a flexed position, then when your spine is in an extended position. If you have pain when your spine is in the neutral position then you likely have a load intolerance, if you have pain when your spine is in the flexed position then you likely have a flexion intolerance and if you have pain when your spine is in the extended position than you likely have an extension intolerance. If you have a load intolerance you should stop loading the spine with heavyweight until it heals. If you have an extension or flexion intolerance perform the next step.
 

Lie face down on a flat surface, if you feel pain during this carefully stand up as you likely have an extension intolerance, if during this test you feel no pain or even pain relief then remain here for 4 minutes. If you felt better after performing this you likely have a flexion intolerance, but first test for an extension and rotation intolerance, do this by testing how far you can extend each leg behind you whilst keeping your leg straight and your body facing the ground, if this produced pain record yourself doing this movement on either side, if one leg couldn’t extend as far as the other you likely have an extension and rotation intolerance, if each leg seemed to be able to extend to the same degree with the same amount of effort than try the exercise again but with a braced core and a pillow under your stomach, if you noticed one leg extending further than the other than you likely still have an extension and rotation intolerance. Those with an extension and rotation intolerance due to a lack of mobility at the hips (which this test is able to detect) should perform the anterior banded joint mobilisation exercise, this exercise includes looping a somewhat challenging resistance band around an object, such as a squat rack, then looping it around the leg with poor mobility just under your glutes, face the direction of the band then kneel down onto the leg which has the band around it and place your hand on your hips, maintain an upright neutral posture and brace your core. Begin to squeeze your glutes and gently rock back and forth for 10 to 20 reps in order to free any restrictions in the hip socket, perform the test previously mentioned again, if you feel your pain decrease, your ability to perform hip extension increase or both then this is an exercise worth performing regularly, it may also be worth carefully performing any exercises which commonly cause you back pain to see if the pain caused by these exercises have decreased. To brace the core take a deep breath into your stomach, preferentially in through your nose, until your stomach becomes very tight and strong, this is important to do whenever performing any activities which could pull your spine out of alignment, such as when bending over or loading the spine.

Another test to find any imbalances between either side of the body is to perform the single-leg squat barefoot on each leg, you can perform this on the ground or from a box, the goal is to be able to reach a parallel position on either leg without wobbling and without any back pain, if you can’t comfortably remain stable when attempting to perform a single leg squat on each leg and you felt back pain than any back pain during any other movement may be due to an imbalance in your stability causing uneven forces to be placed on your spine, you therefore must learn to perform the single leg squat, to do this you can simply start by standing on the edge of an object such as a box or plate and cautiously begin descending as you perform the single leg squat until you let the bottom of your feet touch the ground then cautiously come back up, make sure to keep the spine in a neutral position and brace your core, slowly progress by making the object taller and taller every time the current height becomes too easy until you are eventually comfortably performing the single leg squat to parallel, it may also be worth while to perform other stability drills.

Another great test for an extension intolerance in the spine is to place a barbell on your back and stand up straight with a neutral posture, perform the act of spinal extension by rounding your lumbar spine, it this creates pain then you likely have an extension intolerance. Perform a similar test by performing a barbell RDL, pause at the bottom position for a few seconds, if this creates pain on the way down or at the bottom try the exercise again but this time with a braced core with extra attention on hinging at the hips and keeping the spine in a neutral position, if your pain was reduced you likely have a flexion intolerance. On the other hand, if you have pain on the concentric part of the RDL then try the exercise again this time with a braced core with extra attention on hinging at the hips and keeping the spine in a neutral position, if your pain was reduced you likely have an extension intolerance. If adjusting bracing your core and paying extra attention to your spinal position helped to decrease your pain then your form is likely the cause of your back pain and you must adjust it to prevent back pain from occurring again in the future, the best cue is often “hinge at the hips” meaning 99% of the time you bend down you should be performing the act of hip flexion with a little bit of knee flexion in order to keep the spine in a neutral position and not trigger any pain.
 

This next test is a simple one to find if you are suffering from a load intolerance. Simply pick up a weight of between 3-7kg and hold it in front of your body with straight arms, parallel to your shoulders, as you hold it out take a few breaths and if you feel any back pain then try the test again but this time keep the core in a braced position from the moment you lift the weight if you felt your pain significantly reduce by doing this then you likely have a load intolerance, and you need to start bracing your core properly whenever bending down or picking anything up. If your pain wasn’t reduced to a significant degree by bracing your core then you still have a load intolerance but it is likely to a rather large extent, in which case you must reframe from loading the spine in any way until it recovers. The heel drop test is another one used to detect a load intolerance, do this by raising up on the tip toes of your feet with a completely relaxed core and then quickly drop down onto your heels with a large amount of force, after this then perform this test on one leg, if you felt pain in your spine when doing this than perform the test again but this time with a braced core. If you felt you only had back pain when performing the heel drop test without a braced core then you likely simply have an issue with creating stability in the spine, causing small movements in the spine and creating pain, to correct this you must learn to correctly brace your core and perform stability exercises for the back in order to prevent excessive movement of the spine. If your back pain didn’t decrease or even increased when you performed the test with a braced core then you likely have a load intolerance due to fractures in the spine and you should therefore temporarily stop loading the spine until you no longer have a load intolerance, which can be found out by performing these tests again.
 

Evidence suggests that pain causes a decreased activation of the glutes, this is dangerous for the back because the glutes are required to perform hip extension so the erector spinae muscles compensate for this and are instead placed under more stress to perform the act of hip extension which creates back pain, to test if this has happened to you perform the single leg bridge on each leg and hold it at the top for 10 seconds, note if you struggle to perform the glute bridge and hold it, and note if you fill any back pain, also pay extra attention to any differences between each leg, if you run into any problems you will need to perform glute exercises on a regular basis to fix this issue in order to stop back pain or to prevent it from occuring again in the future. Such exercises include the glute bridge and squatting with your bodyweight or a light dumbell/kettbell, during these exercises remember that you are trying to teach your body to activate your glutes, so hold the exercise for 5-10 seconds in a variety of positions throughout the exercise and squeeze the glutes and pay attention to their activation. Evidence also suggests that low back pain causes a sudden, large increase in hamstring activation when they are stretched to a certain degree, also, each of the hamstring muscles has been shown not to display equal amounts of activation due to stretch, in simple terms back pain appears to significantly disrupt the activation of the hamstrings this may affect your movement leading to further injury to the back or even injury elsewhere, to deal with this it may be worthwhile to perform static stretches for the hamstrings for 5 minutes or so every day until you recover, although they will likely not recover until your back pain has gone. It is  important in most cases to not perform any static stretching before exercise because this reduces a muscles force producing capabilities which may decease strength, the ability to perform simulative training and decrease sports performance, instead light dynamic exercises, such as jogging and lunging, has been shown to warm up muscles and make them more liquid and pliable, ready for exercise, without a decrease in force output, the exercises you choose to perform before exercise should raise your heart rate, and get sufficient blood flow to the muscles which you are going to be using without causing any fatigue.

On the topic of hip mobility, restricted hip mobility or differences in hip mobility in either hip can lead to uneven forces being placed on the spine when moving, creating back pain. Uneven amounts of rotation at each hip appear to make people particularly susceptible to back injury, especially in the squat position. To test your hip rotation simply lay on your back on a flat surface, ask help from someone to lift up one of your legs to make a 60-degree angle between the surface and your leg,  on the leg you are testing make sure to bend your knee to about a 90-degree angle before rotating it, from here ask someone to rotate your leg inwards towards the other leg to assess your external rotation and than outwards to assess your external rotation, do this on the other leg and if you notice any mobility imbalances either side you should address them with banded joint mobilisation exercises. Begin by looping a rather challenging resistance band around an object and then looping it around your leg just below your glute on the leg which is experiencing the mobility restrictions, so the band is pulling your leg laterally, this means that you are standing side on from the band, begin by kneeling down on the leg which doesn’t have the resistance band around it, place the hand which is on the opposing side of the body on the floor for extra stability and place the other hand on the knee of the leg with the mobility restrictions, begin by carefully pushing your knee inwards and than back to the starting position, hold it here for about 4 seconds and than push your knee outwards and squeeze your glutes, bring your knee back to the centre, hold this position for about 4 seconds and than repeat for 20 reps, after performing this exercises retest your hip mobility and if it is causing improvements than this exercise should be regularly performed to improve your hip mobility.
 

Limited thoracic spine mobility has also been shown to create low back pain, this is because in movements where weight is lifted over the head the thoracic spine can not extend to allow this movement to happen, so the lumbar spine instead extends in order to change the movement into more of a bench press type movement which can cause back injuries which are often placed into the extension intolerance category, it is, therefore, useful to test your thoracic spine mobility if you have an extension intolerance, especially if you perform a large amount of overhead movements, if this is in the gym, at work or when playing a particular sport. The seated rotation test is easy to perform and it can be done on your own to assess your thoracic spine mobility, begin by taping an “+” shape on a flat surface, sit in the centre of the plus with crossed legs and face the direction in between two pieces of tape so the tape forms a V shape in front of you, hold a long cylindrical object such as curtain rod on the front of your shoulders similar to a front squat position with a cross grip, rotate as far as you can right and then left, ideally you should be able to rotate your spine so you are in line with one of the pieces of tape, if you are nowhere near doing this or can only do it in one direction than thoracic spine mobility is a likely cause of your back pain. A lack of shoulder mobility is also a common culprit of lower back pain for the same reasons, as a lack of shoulder mobility during overhead movements means that an object can not be lifted overhead due to a lack of shoulder flexion and so the lower back compensates by extending to allow the object to be lifted directly overhead. To test your shoulder mobility sit cross-legged with your back flat up against a wall, hold a light cylindrical object out in front of you with straight arms, a pronated grip and a grip width of just more than shoulder width, keep your core braced, your gaze straight ahead and your spine in a neutral position and begin to raise your arms above your head, making sure to keep them straight, this movement should be effortless and you should finish with your arms directly above your head, if you struggle to do this you likely have a lack of shoulder mobility. If you are suffering from a lack of thoracic spine or shoulder mobility, then the foam roller prayer stretch is a great exercise to perform in order to correct this. Begin by kneeling down with a foam roller placed out in front of you with your hands in a neutral position place them on top of the foam roller at about shoulder width sit down on your heels and roll the foam roller out ahead of you and let your chest sink towards the ground, hold this position for about 30 seconds and then return to the starting position, do this for about 3 or 4 sets, this exercise is also good for individuals with poor lat flexibility, after performing the exercise retest your mobility restrictions to see whether this test has improved them, and if it has this is an exercise which you can perform regularly.

Recovering from injury

Firstly, in order to stop the source of pain from getting any worse it is important to stop any exercises which create back pain, exercising with back pain also commonly leads to poor technique increasing the risk of developing another injury, back pain has also been proven to decrease our sense of spinal position meaning that we may position our spine in an unsafe posture during an exercise without even realising. Whilst stopping exercises which create back pain usually leads to the recovery of the source of pain over time it does not do anything to prevent the cause of back pain, meaning that back pain will likely reoccur in the future once you return to regular training.
 

There are many muscles that create the core, even including the lats and glutes, it is in the coordination of these muscles which are responsible for core stability, which means that the spine can maintain in a strong neutral position when moving or when challenged by a load, in order to prevent injury, better transfer force from the lower to upper body and to squeze out an extra phew reps during sets, this is because their is evidence that a common cause of failure during a set of compound lower body exercises, such as the squat, is from a sudden drop in core stability, which can manifest itself in a sudden rounding of the spine or in shifting of the hips to the side, which inhibits neural drive to your muscles. If a core muscle is not performing it leads to more stress placed on the other muscles in the core. One of the most important things to learn for core stability is what is called bracing. When partaking in exercises, especially ones which load the spine throughout the entire duration of a set, such as the squat or RDL, it is important to take a couple of breaths in between reps (not during), so your blood pressure does not rise too high, which often results in blackouts. When taking a couple of breaths in between reps it is important not to exhale fully to keep the spine stable.

Dynamic core exercises, such as sit-ups and Russian twists are good at strengthening and growing the muscles of the core, but this is rarely the problem, in fact, isometric exercises are best at increasing core coordination and endurance which is best for creating core stability and preventing back injury. “The big three” was invented by Dr Mcgill and it refers to three core exercises which work to enhance the endurance and coordination of every muscle in the core, and they also place minimal stress on the spine meaning that they can usually be performed even if you are currently suffering from a back injury, these exercises are the curl-up, side plank and bird-dog. Before working on strengthening the core it is important to address any mobility restrictions that you have which can be creating back pain, to perform these look at the previous section. The cat camel exercise is recommended to be performed before any of the big three core exercises, even if you are not suffering from any mobility restrictions, this is done in order to improve back stiffness and the range of motion of the spine, this reduces pain when performing any exercise and could possibly increase their effectiveness. Perform the cat camel exercise by going down on your hands and knees, and begin to slowly round the spine as much as possible and hold this position for a few seconds, then drop down and arch your back in an extended position and hold this position for a few seconds, make sure when doing this part to look straight ahead, perform 5 or 6 repetitions of this exercise before moving onto the big three, stop performing the exercise if you are experiencing any pain. Now for the first exercise, the curl-up, begin by laying down on your back with one knee bent and one leg out straight, it doesn’t really matter which leg is bent and which one is straight, although, if you have pain which radiates down one leg I would recommend keeping that leg straightened out, place the palms of your hands on the ground underneath your lower back, now gently lift your head slightly off the ground and keep a strong, tight core, and breath slowly, taking small sips of air in order to keep the spine safe, hold this position for as long as you comfortably can and than return to the starting position, this should be about a 10-second hold for most people, do this exercise for three reps and three sets. A lot of exercises require you to breathe in and hold your breath throughout a repetition, the curl up exercise requires you to take small breaths of air, this is to teach the body how to keep the spine in a stable protected position without the need for holding your breath, which is more reasonable to perform throughout your day-to-day life. The curl-up does well to target the anterior core muscles, but there is still more to target. The next exercise targets the lateral part of the core, this exercise is the side plank. To perform this lie on your side, with your knees bent and rest on the side of your forearm, with your opposing hand on your hip, raise your hips, so that your body is elevated off the ground, and hold this position for 10 seconds and then return to the starting position, do this for as many reps as possible, but if you find this too easy and you can perform over 10 reps than you should make the exercise more difficult by performing it from your feet rather than your knees. You can perform this exercise for 2-3 sets on each side. The final exercise is the bird dog, which is unique from the other exercises as in it teaches the spine to remain in a stable, safe position during movement, meaning that it has good carryover to sports performance and everyday activities. To perform this exercise go down on your hands and knees, begin by slowly raising one of your arms straight out in front of you, so it's pointing directly ahead, as you do this kick the opposing leg on the other side of your body out straight behind you, hold the position for 10 seconds and then slowly bring your arms and legs back to the starting position, this time let your hand meet your knee underneath your stomach and then do another repetition, do this exercise for about 6 repetitions and 3 sets, and I would also recommend switching which leg and arm is extending out regularly, for instance, you can switch which leg and arm you do this exercise on each time you perform it. If this exercise brings out pain or is too difficult you can simply perform this exercise with only your legs, on the other hand, if the exercise is too easy you can draw a square in the air with your outstretched arm and leg to make it more challenging. It is important to remember that the big three core exercises are not just there to help you recover from an injury, but they are also useful in preparing the core before exercise, and in preventing an injury although it is likely only necessary to perform the big three about once per week if you are not experiencing any symptoms of back pain. It is tempting after a back injury just to sit and do little activity, however, the big three core exercises and a healthy walking routine is best for recovery. Your walking routine however shouldn’t be excessive when recovering from an injury, at first a brisk 10-15 minute walk is sufficient.
 

Once you are symptom-free it is time to progress to more difficult exercises which really challenge the core in order for it to adapt further and prevent injury from occurring again, but do not jump straight into the deep end, instead, perform gradually more and more challenging exercises cautiously until your back to normal training. It is recommended that you perform a push, pull, carry and anti-rotation exercise, which challenges the core in different planes of motion which will challenge different muscles, which is required for an optimally strong core.

The carry and anti-rotation exercises place a significant amount of force on the spine, so please be extra careful when performing these and slowly make them more challenging so as not to revert your progress, this is not to say though that you shouldn’t be careful for the push and pull exercises.

Exercise examples:

Push - goblet squat, front squat, back squat, sledge push, good morning, back extensions

Pull - deadlift, inverted row, stiff-legged deadlift

Carry - suitcase carries, lunge

Anti-rotation - pallof press, one arm row

Performing lifts which are intentionally unstable improves proprioception of the spine meaning that the spine is less likely to fall out of its neutral position when exercising and during day-to-day activities. The earthquake bar was specifically created for the purpose of creating instability, also, dangling chains from a barbell creates instability and offers similar benefits.