Mom was wearing me out again last night. It’s the cross we all bear, I suppose, but she has just proven totally resistant to easy, common sense measures to rid herself of both insomnia and low back (and sometimes hip) pain. So I guess I am kind of working out my frustration by posting this today. It’s a bit of a rushed job— have to get this Milk Street Moroccan lamb stew in the slow cooker for my little worker (don’t skimp on the ginger, double the garlic, omit the water)— so I apologize and will circle back, probably Wednesday, to tune and tighten it up a bit.

All of us have woken up from a long night sleep with that nagging pain through your lower back. We pull our knees to our chest, but no relief. We rotate our lumbar spine hoping for our pain to reduce. Nothing. Maybe it’s that pesky piriformis muscle we all keep hearing about. (Tight piriformis really mostly only causes “sciatic” type pain that runs down the back of the leg— and which you may also feel as a soreness deep in your ass. The right stretch really will help even eliminate this, but only if that’s the culprit muscle. Never really a player in low back pain.) But none of this is alleviating the pain we are having.

What if that pain is stemming from a place very few people associate with lower back pain? We need to look outside the box in order to track down the elusive nature of our pain. Enter the iliopsoas muscle, better known as the hip flexor. The iliopsoas is made up of two muscles, the iliacus and the psoas.  It runs from what we call the “pelvic basin” of the inner hip bone aka ilium (and looks oddly like the inside of a clam or oyster) and then upwards via its “psoas” extension (that to me looks like a nice skirt steak), diverting back behind your innards to attach on the little wings (aka transverse processes) of the spinal discs T12 through L4.

A chronically tight psoas is also a chronically shortened  psoas— its angry, serpentine appendages tugging down, down, down on the discs of your unwitting lumbar spine.

A chronically tight psoas is also a chronically shortened psoas. And oh, how it tugs: not just tilting the hips forward but also yank, yank, yanking (down) on those lumbar discs, one to four. It’s kind of a sadistic design really, guaranteed to give you disc compression if you are a chronic sitter (even chronically stressed or under magnesium-atized) or adverse to or just don’t have time for regular long walks, hikes or runs.

(Conscientious, preventive stretching also, of course, called for— especially after fifty or so. If you are already following the latest dementia prevention advice and walking 4 miles (mix of slow/meditative and more “rushing to catch a bus” up-tempo) daily, you might already be getting all the psoas stretch you need.)

Pulling our knees to our chest or opening the rotation of our spine will have little to no effect on pain generated from this type of restriction. Think about the amount of time we spend these days sitting at our desk, in front of our computer, tablet, or cell phone. Our hips are naturally flexed, putting the hip flexor in a shortened position, allowing it to tighten down and put this tremendous amount of pressure on our spine.

We have all heard or been told that changing positions during the day to stand up and get out of our chair will help to prevent soreness, stiffness, and back pain. Well, there is obviously a method to the madness here. By standing upright we are taking that hip flexor and putting it back onto a more normal, elongated position.

If you’re already following the newest dementia prevention advice and walking four miles daily, you might already be getting all the psoas stretch you need.

Cranking on our lower back to stretch out or performing only stability exercises such as pelvic tilts, crunches, or bridges can help out some aspects of lower back pain, but if you are not assessing your hip flexor mobility you could be missing the boat to fixing this problem. Core stabilization is a very important part of treatment and will assist with maintaining decompression for the long term, but only if you are also working to elongate tight and restricted soft tissues.

One of the best exercises to stretch the hip flexor is the half kneeling hip flexor stretch. (a kind of sexily scruffy but also often quacky even though sometimes interesting Eric Berg (DC) demos on YouTube here).

Or just read this: Assume a half kneeling position with the side to be stretched directly under your trunk and that thigh’s knee pointed straight to the floor. The other leg should be bent at 90 degrees (hip to knee). Next, slowly lean your trunk forward onto the forward leg, allowing the kneeling leg to stretch rearward. (There should be a pretty cool illustration of this at the top of this post: the woman kind of doing yoga with her cat). The stretch should be felt through the front of the hip and thigh.

Given that spinal disc compression and low back pain can come from other factors (but almost never back muscles and almost always hip muscles), it can be really helpful to find someone sufficiently familiar with human anatomy (good luck) to work with you both to suss out the culprits as well as to help you to understand— for future crises— where and how all these muscles, ligaments, tendons and discs interact.

Check out McMaster University (in Ontario, Canada) if you want to make this a vocation. They have an absolutely amazing program that teaches all this. Here is a teaser sample of some of it:

  • “Lumbago” type low back (& sacral) pain: think gluteus medius muscle
  • L5 and S1 “radiculopathy” mimic (might be incorrectly dx’d as sciatica, down lateral leg): think gluteus minimus muscle
  • Notorious “hip hiker” (can also sometimes produce a “pseudo-disc” syndrome): quadratus lumborum *
  • Deep, deep hip joint pain (might be incorrectly dx’d as trochanteric bursitis): think good ’ole TFL (tensor fasciae latae)

* A super cool example of the need to “know where to look” (or have a PT etc. who does) when addressing and trying to alleviate musculoskeletal pain. It’s the only muscle on this list physically located in the lumbar region, but the referred pain pattern it produces is, you guessed it, in the (lateral) hips and (medial &) lower butt!

Mike Barr, a longtime Poz Contributing Editor and founding member of and scribe for the Treatment Action Group (TAG), is a functional medicine practitioner and herbalist in NYC. Reach out to him here. Feel free too to sign up for his carefully curated (and generously discounted) online supplement store.