podcast Peter Attia 2025-09-01 topics

Lower back pain: causes, treatment, and prevention of lower back injuries and pain | Stuart McGill, Ph.D. (#287 rebroadcast)

Audio

Show notes

Stuart McGill is a distinguished professor emeritus at the University of Waterloo and the chief scientific officer at Backfitpro where he specializes in evaluating complex cases of lower back pain from across the globe. In this episode, Stuart engages in a deep exploration of lower back pain, starting with the anatomy of the lower back, the workings of the spine, the pathophysiology of back pain, and areas of vulnerability. He challenges the concept of nonspecific back pain, emphasizing the importance of finding a causal relationship between injury and pain. Stuart highlights compelling case studies of the successful treatment of complex cases of lower back pain, reinforcing his conviction that nobody needs to suffer endlessly. He also covers the importance of strength and stability, shares his favorite exercises to prescribe to patients, and provides invaluable advice for maintaining a healthy spine.

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We discuss:

Peter’s experience with debilitating back pain [A: 3:30, V: 0:30];
Anatomy of the back: spine, discs, facet joints, and common pain points [A: 14:45, V: 14:11];
Lower back injuries and pain: acute vs. chronic, impact of disc damage, microfractures, and more [A: 24:45, V: 24:48];
Why the majority of back injuries happen around the L4, L5, and S1 joints [A: 31:00, V: 31:30];
How the spine responds to forces like bending and loading, and how it adapts do different athletic activities [A: 36:15, V: 37:20];
The pathology of bulging discs [A: 43:15, V: 45:12];
The pathophysiology of Peter’s back pain, injuries from excessive loading, immune response to back injuries, muscle relaxers, and more [A: 46:00, V: 48:30];
The three most important exercises Stuart prescribes, how he assesses patients, and the importance of tailored exercises based on individual needs and body types [A: 56:15, V: 59:36];
The significance of strength and stability in preventing injuries and preserving longevity [A: 1:08:15, V: 1:12:46];
Stuart’s take on squats and deadlifting: potential risks, alternatives, and importance of correct movement patterns [A: 1:19:30, V: 1:25:33];
Helping patients with psychological trauma from lower back pain by empowering them with the understanding of the mechanical aspects of their pain [A: 1:30:00, V: 1:37:08];
Empowering patients through education and understanding of their pain through Stuart’s clinic and work through BackFitPro [A: 1:39:00, V: 1:46:59];
When surgical interventions may be appropriate, and “virtual surgery” as an alternative [A: 1:46:45, V: 1:56:08];
Weakness, nerve pain, and stenosis: treatments, surgical considerations, and more [A: 1:55:30, V: 2:05:48];
Tarlov cysts: treatment and surgical considerations [A: 2:00:15, V: 2:11:21];
The evolution of patient assessments and the limitations of MRI [A: 2:02:15, V: 2:13:34];
Pain relief related to stiffness and muscle bulk through training [A: 2:07:00, V: 2:18:40];
Advice for the young person on how to keep a healthy spine [A: 2:14:15, V: 2:26:49];
Resources for individuals dealing with lower back pain [A: 2:25:30, V: 2:39:24]; and
More.

Show Notes

Notes from intro :
Stuart McGill holds the title of professor emeritus at the University of Waterloo, where he has dedicated 40 years of overseeing his laboratory and research clinic dedicated to advancing the understanding of back pain
Currently he serves as the chief scientific officer of BackFitPro where he specializes in evaluating complex cases of lower back pain from across the globe
He has authored 245 scientific articles and multiple textbooks
Peter wanted to have Stuart on for the obvious reason that very few people listening to this will have not had their lives impacted by lower back pain Even if it’s just a short bout that lasts for only a few days Sadly, many of you have had far greater impact Perhaps lower back pain has plagued you for many years
In this episode we do a deep dive into all things that pertain to lower back pain
We begin by discussing The anatomy of the lower back How the spine works The pathophysiology of back pain Where people can have issues as it relates to their back
We talk about why Stuart believes there’s no such thing as nonspecific back pain, and why he is so adamant about finding a causal relationship between an injury and pain A physical reason for the pain Not necessarily an acute injury that resulted in it
Ultimately, we talk about why people who are experiencing back pain should be empowered to do something about it
Stuart really believes that nobody should suffer endlessly because of back pain
Peter is very excited about this episode because he knows, even just looking at the relatively small sample population of his patients, that this is a topic that many people will find value in And if you’re not finding value in it today, it might be a podcast you want to come back to when you do experience lower back pain Though he hopes that never happens
Lastly, this is an episode where Stuart shows off a variety of models and positions to better explain what we’re covering in the conversation While the show notes will have all of the images, this may be an episode you want to watch on video
Even if it’s just a short bout that lasts for only a few days
Sadly, many of you have had far greater impact Perhaps lower back pain has plagued you for many years
Perhaps lower back pain has plagued you for many years
The anatomy of the lower back
How the spine works
The pathophysiology of back pain
Where people can have issues as it relates to their back
A physical reason for the pain
Not necessarily an acute injury that resulted in it
And if you’re not finding value in it today, it might be a podcast you want to come back to when you do experience lower back pain Though he hopes that never happens
Though he hopes that never happens
While the show notes will have all of the images, this may be an episode you want to watch on video

Peter’s experience with debilitating back pain [3:30]

Stuart read Peter’s book [ Outlive ] and changed his behavior

A few years ago, Stuart’s family doctor (who is one of his former students) did his blood work, and found he was just on the edge of needing Crestor or Lipitor His physician suggested, “ Let’s run the experiment, ” Stuart loves to work hard physically and finish it off with a beer, which 6 days out of 7, he’s denying himself of that
Long story short, the experiment paid off, and he’s sleeping a little better and is a little more mentally sharp
Peter thinks maybe he doesn’t have to be quite as restrictive He doesn’t necessarily believe in denying all the pleasures of life
His physician suggested, “ Let’s run the experiment, ”
Stuart loves to work hard physically and finish it off with a beer, which 6 days out of 7, he’s denying himself of that
He doesn’t necessarily believe in denying all the pleasures of life

Why the topic of biomechanics for a healthy back is of great interest to Peter

The very abridged version of the story is Peter grew up doing all sorts of really aggressive things and really took to powerlifting when he was about 14 He found himself reasonably strong for a little scrawny kid Between about the ages of 14-19, he really pushed He couldn’t bench press to save his life, but seemed pretty strong in a squat and deadlift He ignored any claims his parents made that maybe he was doing a little too much
Truthfully, Peter had no formal instruction He was just watching the other grown men in the gym who were insanely powerful and trying to replicate what they were doing Peter had no sense of what he was doing
Fast-forward to age 21, and he’s rowing crew, and for the first time in his life he experienced lower back pain This really rocked his world, because he always thought that people who got lower back pain were people who did nothing He never thought that someone who was as active as he was could get it
For about 2 weeks, the back pain completely disabled him He could barely get around As a college student, he didn’t really have any resources and didn’t know what to do This was in the summer, so he didn’t have classes, but he had to stop rowing Otherwise he was able to work
The back pain went away and he thought everything was fine He never thought about it again until the summer 3 years later, when he was 24 years old
He was in San Diego riding his bike up the steepest hill, a patch of mountain called Mount Soledad There’s a section of this thing where you make a sharp right turn, and at that moment it’s about a 25 degree pitch Peter experienced this very sudden pain in his lower back and like a typical idiot, just kept on pushing and climbing to the top and finished the ride
But then went on to experience the exact same thing: for two weeks he was debilitated and couldn’t do a thing other than lay around and walk, but then it got better and he just forgot all about it
Fast-forward to the big one This occurred in Peter’s 3rd year of medical school He’s now 27 years old, and the remarkable consistency of this is not lost on him It is every 3 years by the summer, the summer of ‘94, ‘97 and 2000 He’s riding his bike from class to the gym, he gets to the gym, hops off his bike to lock it up, and all of a sudden he feels that same familiar, horrible pain in his back
But this time it’s a little worse than the previous 2 bouts It was so bad that he did something he’d never done before: he decided not to go into the gym He just slowly got back on the bike and limped his way back to his apartment and wasn’t able to do anything other than just lay in bed
He assumed he’d be fine the next morning and he woke up the next morning and actually couldn’t get out of bed
Luckily, Peter and his roommate each had separate phone lines, so Peter was able to call him from his room
So began a really painful journey over the next couple of weeks where the only place he could find relief was bent at 90-degrees forward, where he would basically stand and bend over the nurses station By this point, he was doing clinical rotations and as every good, gunning medical student knows, there was no way he was going to miss a day He would drag himself to the hospital each day and somehow manage to get through
The nurses and residents took pity on him, and they were injecting him full of Toradol This went on for a month
It got so bad that eventually the pain progressed from just being debilitating in his lower back to a nerve pain that felt like his foot was being skinned It was interesting in that the pain in his lower back started to subside as it was replaced by the feeling of his left foot being skinned from the bottom
This story gets worse and worse before getting better, but needless to say, Peter has a graduate degree in back pain
There is a happy ending to this story, which is after this bout (which took a year to resolve), he made it a mission to figure out what was going on
Fortunately, any time he’s had back pain since then, it has been a very, very short-lived experience
He found himself reasonably strong for a little scrawny kid
Between about the ages of 14-19, he really pushed He couldn’t bench press to save his life, but seemed pretty strong in a squat and deadlift He ignored any claims his parents made that maybe he was doing a little too much
He couldn’t bench press to save his life, but seemed pretty strong in a squat and deadlift
He ignored any claims his parents made that maybe he was doing a little too much
He was just watching the other grown men in the gym who were insanely powerful and trying to replicate what they were doing
Peter had no sense of what he was doing
This really rocked his world, because he always thought that people who got lower back pain were people who did nothing
He never thought that someone who was as active as he was could get it
He could barely get around
As a college student, he didn’t really have any resources and didn’t know what to do
This was in the summer, so he didn’t have classes, but he had to stop rowing Otherwise he was able to work
Otherwise he was able to work
He never thought about it again until the summer 3 years later, when he was 24 years old
There’s a section of this thing where you make a sharp right turn, and at that moment it’s about a 25 degree pitch
Peter experienced this very sudden pain in his lower back and like a typical idiot, just kept on pushing and climbing to the top and finished the ride
This occurred in Peter’s 3rd year of medical school
He’s now 27 years old, and the remarkable consistency of this is not lost on him It is every 3 years by the summer, the summer of ‘94, ‘97 and 2000
He’s riding his bike from class to the gym, he gets to the gym, hops off his bike to lock it up, and all of a sudden he feels that same familiar, horrible pain in his back
It is every 3 years by the summer, the summer of ‘94, ‘97 and 2000
It was so bad that he did something he’d never done before: he decided not to go into the gym He just slowly got back on the bike and limped his way back to his apartment and wasn’t able to do anything other than just lay in bed
He just slowly got back on the bike and limped his way back to his apartment and wasn’t able to do anything other than just lay in bed
By this point, he was doing clinical rotations and as every good, gunning medical student knows, there was no way he was going to miss a day
He would drag himself to the hospital each day and somehow manage to get through
This went on for a month
It was interesting in that the pain in his lower back started to subside as it was replaced by the feeling of his left foot being skinned from the bottom

Peter plants one last seed that we can come back to before we jump into this

If a reasonable person were to look at an MRI of Peter’s spine today at age 50, you would say, “ How does he walk? This person must be in so much pain he doesn’t know his name. ”
But for the most part, Peter is not in pain at all Occasionally, he gets a little tight in his lower back, but he doesn’t have radicular pain
He’s not limited in anything he does
Occasionally, he gets a little tight in his lower back, but he doesn’t have radicular pain

This suggests that the correlation between the image of his back on an MRI and his symptoms is pretty light

Peter adds, “ The fact that you’re smiling so much as I tell you this story tells me not that you’re taking pleasure in my pain, but rather the familiarity of my story. ”
Exactly, Stuart has been doing pattern recognition

There’s only one thing that would account for the repeated acute episodes

Stuart recognizes that in the interim between each episode, Peter was quite fine
Then it shifted to a ridiculous pain and now he’s at the stage of life where it’s more an occasional grumpiness when he crosses what we call the “tipping point”
Stuart asks, “ Did the pain go to your foot, Peter?… Big toes or little toes? ” Yes, it was burning pain that was like the bottom of the foot was being skinned
There’s one detail Peter should have shared that might explain this: when he finally had surgery, it turned out that he had a free fragment that was about 5 cm long from the L5 S1 disc That free fragment had broken off Stuart was going to guess this He was going to ask which foot The 5th route goes to your big toe The unbearable pain Peter was having presumably was because that free fragment was parked on the S1 nerve root Even though it ended up taking 2 surgeries to get that out, and those surgeries ended up causing more damage that needed more repair (that turned into a journey of 1000 cuts) He was on the road to recovery The radicular pain seemed to be directly a result of the S1 nerve root
Stuart is smiling because Peter told him exactly what the pain mechanism was He knew it was a disc switch an open fissured disc bulge It would be on the side of his foot, right or left
Stuart asks, “ What foot was it? ” It was the left
Yes, it was burning pain that was like the bottom of the foot was being skinned
That free fragment had broken off
Stuart was going to guess this He was going to ask which foot The 5th route goes to your big toe
The unbearable pain Peter was having presumably was because that free fragment was parked on the S1 nerve root Even though it ended up taking 2 surgeries to get that out, and those surgeries ended up causing more damage that needed more repair (that turned into a journey of 1000 cuts) He was on the road to recovery The radicular pain seemed to be directly a result of the S1 nerve root
He was going to ask which foot
The 5th route goes to your big toe
Even though it ended up taking 2 surgeries to get that out, and those surgeries ended up causing more damage that needed more repair (that turned into a journey of 1000 cuts)
He was on the road to recovery
The radicular pain seemed to be directly a result of the S1 nerve root
He knew it was a disc switch an open fissured disc bulge
It would be on the side of his foot, right or left
It was the left

Stuart explains, “ You had a posterior left-sided, biased open, fissured disc bulge that would open and close as a function of the flexion postures bending down to lock your bicycle. ”

Before we get into the mechanisms, let’s walk through the anatomy of the back

Anatomy of the back: spine, discs, facet joints, and common pain points [14:45]

Peter remarks, “ You could almost argue it’s a miracle we don’t get more injured even though the frequency with which we do is intense .”
Stuart would almost argue the opposite
There was a TV show where they asked various experts around the world, “ If you got to re-engineer your particular area… How would you re-engineer it and make it better? ” Stuart was the spine guy, and they had a cardiac person, an endocrine person Every expert said they couldn’t, it was perfect Every system in your body comes with a trade-off, and there are rules that manage that trade-off
Stuart was the spine guy, and they had a cardiac person, an endocrine person
Every expert said they couldn’t, it was perfect Every system in your body comes with a trade-off, and there are rules that manage that trade-off
Every system in your body comes with a trade-off, and there are rules that manage that trade-off

The spine

This spine is a series of vertebrae forming a flexible rod
This allows us to dance and move and procreate, tie our shoes, and do all of these wonderful things
But at some point now, say are picking your child out of the crib, you reach across the crib, gather your child, pull them in If you had a flexible rod (consider a series of stacked oranges) it would fall apart You need a flexible rod that you can then stiffen to bear load You cannot push rope, but you can push stone, or in this case an I-beam to bear load
If you had a flexible rod (consider a series of stacked oranges) it would fall apart
You need a flexible rod that you can then stiffen to bear load You cannot push rope, but you can push stone, or in this case an I-beam to bear load
You cannot push rope, but you can push stone, or in this case an I-beam to bear load

All of these things [a flexible rod that can stiffen to bear load] are necessary to have a functional spine

The structure of the discs [intervertebral discs]

Figure 1. Anatomy of a normal intervertebral disc . Image credit: Miami Neuroscience Center

Figure 2. A section of the spine showing multiple vertebrae . Image credit: Wikipedia

Let’s look at the structure of the discs, which are the fabric
The disc actually forms the subcategory of a biological fabric
It’s not a ball and socket joint
Could you imagine if we had vertebrae with ball and socket joints? You would need an enormous musculature around that flexible rod to control all the balls and sockets You would need an enormous motor cortex to coordinate all of these You would be so wide, you couldn’t walk, you couldn’t run, etc.
We have this very slender torso because we have discs
The stress strain curve of a disc starts out with a little bit of a neutral zone in the neutral range
As you approach the end range, the disc provides stiffness, a mechanical stop to motion Fabulous, you didn’t need all this complex musculature to do so
The disc creates tremendous evolutionary efficiency in your spine
Either end of the torso strategically is a ball and socket joint
The ball and socket joints of the hips and shoulders are designed to create power
Power is force x velocity
If you were to watch a sprinter sprint, the extensor muscles explode like a hammer hitting a stone, a stiffened structure If they hit rope, the hips would bulge and you couldn’t run anywhere You can’t even walk without sufficient stiffness in the core
You would need an enormous musculature around that flexible rod to control all the balls and sockets
You would need an enormous motor cortex to coordinate all of these
You would be so wide, you couldn’t walk, you couldn’t run, etc.
Fabulous, you didn’t need all this complex musculature to do so
If they hit rope, the hips would bulge and you couldn’t run anywhere
You can’t even walk without sufficient stiffness in the core

In terms of anatomy, we have a flexible disc that is a fabric, and the great advantage is the efficiency of your dimensions: we’re light, narrow in the waist, we can run, etc.

The price that you pay though is being a structure of many collagen fibers

Consider Stuart’s shirt, which is a fabric If you wanted to delaminate the fibers, you would have to create stress strain reversals back and forth and slowly you would de-bond the fibers
If you wanted to delaminate the fibers, you would have to create stress strain reversals back and forth and slowly you would de-bond the fibers

This is what happens to people’s discs

They de-bond the fibers with too much load and motion simultaneously
This is what Peter must have done as a younger fellow
The concentric rings of collagen that are held together with collagen-type X (the binding substance) They hold a pressurized gel, which is this incompressible hydraulic fluid that creates the ball That gets pressurized, but it’s always seeking the weakness in the wall
If you delaminate the collagen fibers, then the nucleus seeps through In some situations, the fibers are pulled together and they create a fragment (as Peter described earlier), or if it’s an open fissure and contained underneath the posterior longitudinal ligament, there’s a good chance it’s going to get vacuumed back in and off you go over another 2 or 3 years
They hold a pressurized gel, which is this incompressible hydraulic fluid that creates the ball
That gets pressurized, but it’s always seeking the weakness in the wall
In some situations, the fibers are pulled together and they create a fragment (as Peter described earlier), or if it’s an open fissure and contained underneath the posterior longitudinal ligament, there’s a good chance it’s going to get vacuumed back in and off you go over another 2 or 3 years

Nerves of the spine

If you have a disc bulge, there is the spinal cord centrally behind the vertebra and at each lumbar or spinal joint is a pair of nerve roots [shown in yellow in the figure above]

Peter asks about the point of fixation, which are the facet joints

If anteriorly, this structure is bounded and the vertebral bodies are stuck together through their sharing of the discs on the back, we have these other joints that come from each of them called these facet joints

Figure 3. Facet joint articulation between two vertebrae highlighted . Image credit: Wikipedia

Figure 4. Facet joints of the spine . Image credit: HealthCentral

Stuart uses a model to explain, “ The facet joints are guiding of motion. You can see as I’m flexing and extending and twisting this model spine, these are articular joints in the back that are guiding motion. ”
If Stuart were to look at Peter’s MRI at the level of the disc bulge, the facet joints will now be getting a little thicker, a bit more gnarly looking

Almost always, 2-3 years after a major disc injury, the facets take on much more load

Analogy: think of air in your car tire

If you let a little air out of your car tire it bulges on the road, it gets a bit sloppy to drive your car You have to tune the pressure
You have to tune the pressure

This is exactly what happens with your body: when you lose the controlling stiffness of the disc, you get more work performed on the facet joints and they wear a little bit faster than the adjacent joints, and they grow thicker

Facet pain is very different from disc pain: it’s more of a ache

It comes on a bit more slowly
If you have a wound up facet joint, it can take 2 or 3 months to wind it down versus a disc that can wind down in a couple of weeks

Looking at the model now

Figure 5. Spinal column vertebrae . Image credit: Johns Hopkins Medicine

This bottom disc, L5 is normal
L4 has been damaged. I’m just going to apply a torque to this spine
Stuart asks, “ Do you see how the majority of the motion now is occurring at the joint that’s lost stiffness? ”
Think of it like a knee that has a damaged ACL ligament It no longer has the guidance and the rotation motion of the knee which is normal It now substitutes with shearing motion Shearing motion indicates it’s the metric for instability Now you can see the shearing instability
Now look at the work being performed by the facet joints at the level of the disc being damaged and losing stiffness Now those will get grumpy and they will wear a little bit faster if you continue with the behavior that you did prior to
Injury and this cascade changes the rules a little bit
Initially, the goal was to create power in the shoulders and the hips and transfer it through a controlled spine, but now the game has changed a little bit
Peter is 50 years old and will have a little bit of joint instability
It no longer has the guidance and the rotation motion of the knee which is normal
It now substitutes with shearing motion Shearing motion indicates it’s the metric for instability Now you can see the shearing instability
Shearing motion indicates it’s the metric for instability
Now you can see the shearing instability
Now those will get grumpy and they will wear a little bit faster if you continue with the behavior that you did prior to

It’s more important now to create a muscular girdle around the joint that has lost a bit of stiffness and for the next little while do your core exercises, develop a bit more muscular control, arrest the shearing motions

Stewart remarks, “ You and I are very similar, by the way. I’m in my late 60s now, my pain is gone, so the joint has become so stiff, I can still do everything I want to do, but the joint itself has stiffened up. ”
Professor Kirkaldy-Willis , the famous Canadian spine surgeon, wrote a book called Managing Low Back Pain
He described very well the process that most of us go through, the instability, and the very acute episodes that come every two or three years that are very debilitating to a muscular ache You wake up in the morning on one side with this ache in your back, but if you push one heel away or put a pillow under your waist or something like that, you can get rid of the ache Then if you live a little bit longer and behave by the new rules
You wake up in the morning on one side with this ache in your back, but if you push one heel away or put a pillow under your waist or something like that, you can get rid of the ache
Then if you live a little bit longer and behave by the new rules

“ I don’t have any back pain. I can encourage that you’ll seek that relief as well .”‒ Stuart McGill

Lower back injuries and pain: acute vs. chronic, impact of disc damage, microfractures, and more [24:45]

Give us a sense of the prevalence of acute lower back pain episodes

Is an acute lower back pain episode defined as one that lasts up to some period of time? Two weeks or something like that?

No, Stuart doesn’t define it that way at all
He’s not the guy who can give you those statistics He’s not doing population studies to track incidence
All he worries about is the people who come and ask for help with their back pain
As a younger scientist, he used to study: What is back pain? What is an acute episode? Is it sufficient to be debilitating so you don’t have to work? He was a professor and could have an acute attack and go to work, but if he was a construction work, he couldn’t
Even the definition of whether it was disabling or not gets lost so Stuart didn’t really get into those statistics
He doesn’t categorize pain as being acute lasting a certain period of time, and chronic lasting a longer period of time, because when we measure people with back pain, very rarely do we find chronic back pain
It’s almost always due to them repeatedly insulting their back with many acute attacks and offenses all day long
They think they have chronic pain because it lingers
When we show them a strategy or whatever the treatment happens to be, to stop the insults that occur throughout the day, all of a sudden their pain goes and then they realize, “ I never did have chronic back pain .”
He’s not doing population studies to track incidence
Is it sufficient to be debilitating so you don’t have to work? He was a professor and could have an acute attack and go to work, but if he was a construction work, he couldn’t
He was a professor and could have an acute attack and go to work, but if he was a construction work, he couldn’t

How chronic back pain is different from what most people experience

Chronic back pain is pain that is intransigent, unrelenting Their brains have changed, they’ve been traumatized
Chronic pain does not always having a strong mechanical trigger
The pattern that Peter described of the 2-week disabling, terribly disabling pain, there’s only one thing that that could be: an open fissure disc bulge
Their brains have changed, they’ve been traumatized

The mechanism of disc comfort

Peter asks, “F or example, is that disc actually innervated? Is the pain that’s being perceived due to sensory fibers of the disc or is it the response of the body sensing that damage, going into some protective mechanism that is seizing all the muscles within the proximity of it? ”
It could be either or it could be both
By the way, Stuart explains, “ All these models that I’m using, the highly bio-fidelic models are made by Dynamic Disc Designs .”
When a disc is healthy, people say, “ Well, what’s the number one thing you can do to keep a healthy spine? ” Stuart tells them “ Keep your end plates healthy ,” and they wonder about that Don’t damage your joints Stuart clarifies by email that the vertebral end plates are the top and bottom of the vertebrae [The 1st figure below shows the anatomy of the vertebral column, the vertebral body (circled) make contact with the intervertebral discs via the endplates that Stuart refers to; the end plates are marked with an asterisk] [The 2nd figure below shows a damaged end plate]
Stuart tells them “ Keep your end plates healthy ,” and they wonder about that Don’t damage your joints Stuart clarifies by email that the vertebral end plates are the top and bottom of the vertebrae [The 1st figure below shows the anatomy of the vertebral column, the vertebral body (circled) make contact with the intervertebral discs via the endplates that Stuart refers to; the end plates are marked with an asterisk] [The 2nd figure below shows a damaged end plate]
Don’t damage your joints
Stuart clarifies by email that the vertebral end plates are the top and bottom of the vertebrae
[The 1st figure below shows the anatomy of the vertebral column, the vertebral body (circled) make contact with the intervertebral discs via the endplates that Stuart refers to; the end plates are marked with an asterisk]
[The 2nd figure below shows a damaged end plate]

Figure 6. A section of the spine showing multiple vertebrae . Image credit: Wikipedia

Figure 7. A damaged end plate from a vertebrae . Image credit: Back Mechanic

Stuart refers to Peter’s book and explains that if you damage your knee ligaments, you’ll now have disabled mobility in your last decade The same is true with the spine
Stuart points out in the model, “ If you can look into the nucleus of this model, you’ll see that there are red vessels and yellow nerves. ”
Different papers will say different things: There’s no nerves inside the disk There are nerves in the outer third There are nerves all the way through
Stuart explains why this is: a healthy virgin disc doesn’t have any vascular tissues going into it, nor does it have any nerves The reason is when you squeeze a disc, you build up tremendous intradiscal pressure that kills any kind of vascular sprouts or neural sprouts It’s a healthy environment containing the pressure
The same is true with the spine
There’s no nerves inside the disk
There are nerves in the outer third
There are nerves all the way through
The reason is when you squeeze a disc, you build up tremendous intradiscal pressure that kills any kind of vascular sprouts or neural sprouts It’s a healthy environment containing the pressure
It’s a healthy environment containing the pressure

When you damage the disc and you lose the ability to contain the high pressure, now all of a sudden vascular sprouts grow in and so do nerves

It’s so unfair ‒ you damage the disc and now the body grows a hardware, more nerves to feel pain even more
Then eventually, this just goes to a very fibrous, gnarly structure, highly innervated But now it just basically wrestles to bone and all the pain goes away
But you can see the damage line, the contrast there You can see those fibers posterior laterally on the right that have delaminated
Stuart squeezes the discs (he’s going to squeeze and flex) Do you see the fibers delaminating and allowing the nucleus to seep out? [the 1st figure below shows where the nucleus is in the intervertebral disc] [The 2nd figure below shows 2 vertebrae with a disc between them and damage causing the nucleus to seep out] By email Stuart explains that this 2nd figure shows microfractures of the end plate that occur with an overload of compressive force
But now it just basically wrestles to bone and all the pain goes away
You can see those fibers posterior laterally on the right that have delaminated
Do you see the fibers delaminating and allowing the nucleus to seep out? [the 1st figure below shows where the nucleus is in the intervertebral disc] [The 2nd figure below shows 2 vertebrae with a disc between them and damage causing the nucleus to seep out] By email Stuart explains that this 2nd figure shows microfractures of the end plate that occur with an overload of compressive force
[the 1st figure below shows where the nucleus is in the intervertebral disc]
[The 2nd figure below shows 2 vertebrae with a disc between them and damage causing the nucleus to seep out]
By email Stuart explains that this 2nd figure shows microfractures of the end plate that occur with an overload of compressive force

Figure 8. Anatomy of a vertebral joint with the intervertebral disc and nucleus illustrated in blue . Image credit: Wikipedia

Figure 9. A vertebral joint and type of damage that can occur . Image credit: Back Mechanic

Here’s the antidote

Stay stacked and tall
Stuart squeezes the model, the whole disc bulges in a diffuse bulging pattern, but nothing comes out of the delaminated region

There’s a little bit of an explanation of why some studies will show an innervated disc and other shows they’re not innervated at al l

Think of where you get cadavers from It’s not young, healthy people dying and donating their body It’s almost always older people
Those discs are innervated, unless they’re horribly down the cascade and they’ve grisled, and all the nerves have now disappeared once again Peter was totally unaware of this adaptation ‒ it’s very cruel and quite counterintuitive
It’s not young, healthy people dying and donating their body
It’s almost always older people
Peter was totally unaware of this adaptation ‒ it’s very cruel and quite counterintuitive

Why the majority of back injuries happen around the L4, L5, and S1 joints [31:00]

What is it about the way we interact with the world and the curvature of our spine that tends to produce the majority of injuries at either the interface between L4 and L5, or the interface between L5 and S1?

First of all, it’s the thickest part of the spine
If Stuart was to take a thin willow branch and bend the willow branch back and forth: no stress

Figure 10. Spinal column vertebrae . Image credit: Johns Hopkins Medicine

Tissues damage because of one metric, and it’s strain

Not the force supplied, not the pressure
It’s just strain on the tissue; that is the metric of when it’s going to disrupt
The radial distance to the neutral axis is thin This is the axis down the middle of that thin rod that doesn’t go into compression or tension, it’s all very low
Now let’s take a thicker stick and we bend it and it shatters right away, because it’s much thicker
This is the axis down the middle of that thin rod that doesn’t go into compression or tension, it’s all very low

Structures can be flexible or good at bearing compression, but not both

Go back to the flexible willow branch: it’s wonderful at bending But don’t ask it to bear compression, because it buckles right away
The thicker stick can bear tremendous compression, but it doesn’t tolerate bending.
Look at the neck, very thin, small diameter vertebra It’s made for bending and mobility, fabulous
But don’t ask it to bear compression, because it buckles right away
It’s made for bending and mobility, fabulous

But as you move down the spine and get to the bottom two where the thickest is, they do not tolerate bending near as much as they tolerate compression

There’s the first anatomic feature that describes why the bending stresses are greatest at the thicker two joints, which are at the bottom

The other things that matter are the shape of the disc

Some discs are ovoid and the bigger the skeleton, they tend to go to a limacon
You have the spinal cord there, and then the two lobes of the limacon
The bigger the spine, the more limacon the disc becomes

When you twist a limacon, you create a stress riser on the edge of each lobe

The bigger the person, you will see they don’t tolerate sit-ups Look at YouTube: who is the man who has the world record for consecutive sit-ups? Do you think he has a thick spine or a thin spine? He won’t be a powerlifter
Stuart has worked with some fabulous powerlifters and strongmen and competitors, and not one of them does a sit-up They train other things to tune their body and make it suitable to that particular training stimulation
Look at YouTube: who is the man who has the world record for consecutive sit-ups? Do you think he has a thick spine or a thin spine? He won’t be a powerlifter
Do you think he has a thick spine or a thin spine?
He won’t be a powerlifter
They train other things to tune their body and make it suitable to that particular training stimulation

We see that shape and thickness determines why L4 and L5 are the target

We know that they don’t twist as well as a slender spine

The facet joints are also very interesting

Figure 11. Facet joints of the spine . Image credit: HealthCentral

Some facet joints are orientated like that in the sagittal plane, while others are orientated more open as we say

If you look at a gymnast

Stuard would never choose to be a gymnast, but you can tell, look at his facets, they’re closed He doesn’t twist very well
When you flex forward and pull a load, those facet joints just glide past one another
A gymnast by definition is someone who has a lot of mobility in their spine You will see that their facet joints tend to be open
He doesn’t twist very well
You will see that their facet joints tend to be open

What patients get spondylolisthesis (the broken pars bone that holds the facet joint on)? [shown in the figures below]

Figure 12. Location of the pars interarticularis bone . Image credit: Spines Dorset LTD

Figure 13. Pars fracture and slippage of vertebral bodies . Image credit: RecoverPhysio

You are going to say, dancers, gymnasts, the very people that had the mechanical advantage to twist
Now when they go into extension, their facet joints are like shingles on a roof They bend the pars bone creating stress strain reversals, and eventually that bone will get a stress fracture or a stress reaction And if they keep going, full-blown spondylolisthesis
They bend the pars bone creating stress strain reversals, and eventually that bone will get a stress fracture or a stress reaction And if they keep going, full-blown spondylolisthesis
And if they keep going, full-blown spondylolisthesis

There are all kinds of reasons, Stuart is just giving a few now as to why those two discs are really stress risers

In his Ph.D. thesis, Stuart developed a very detailed anatomical model of the spine A computer model that hit home loud and clear
Stuart explains, “ We did stress maps of real people moving. The pain in the injury was almost always at the site of the highest stress. ”
A computer model that hit home loud and clear

The metric strain that actually leads to damage, if it is below the tipping point, it actually strengthens you

How the spine responds to forces like bending and loading, and how it adapts do different athletic activities [36:15]

For listeners that might not have a background in engineering, can you explain the difference between stress and strain and what happens under tensile load, compressive loads and things like that?

Let’s now talk about stress and strain So stress and strain are normalized to an area, and we won’t’ get into that
Let’s talk about applied load and deformation
If you apply a force to a structure, it deforms
Mature skeletal bone breaks at a certain amount of deformation A child’s bone breaks at a different level of deformation
When you take a long bone and you bend it, the upper surface goes into tension that’s trying to pull apart The lower surface goes into compression
So stress and strain are normalized to an area, and we won’t’ get into that
A child’s bone breaks at a different level of deformation
The lower surface goes into compression

Some biological structures are stronger in tension than they are in compression

A child is actually weaker in compression in a bending bone, and the adult is weaker on the tensile side For example, a greenstick fracture (or a buckled bone) in a young child would be very rare to see in an adult
For example, a greenstick fracture (or a buckled bone) in a young child would be very rare to see in an adult

The behavior of biomaterials when you load them and how they deform explains a lot of injuries

If you were to put Stuart on the witness stand (as people do occasionally) to explain, is the damage that we see in this MRI (or in the cadaver or whatever) consistent with this particular mechanical alleged scenario, yes or no? That’s how we reconstruct that Tissues, stress and strain, shear, bend, tensile, pull apart, etc. And the deformation causes very specific types of damage
That’s how we reconstruct that
Tissues, stress and strain, shear, bend, tensile, pull apart, etc.
And the deformation causes very specific types of damage

Using concrete as an example

Concrete is so strong in compression and yet in tension , it is so weak that we need to come up with a hack How can we use this material to allow it to be both strong in compression and tension?
If you have a bridge made out of concrete and you’re driving on top of it, the bridge wants to deform
Which means you’re putting the top in compression (which it can handle), but the bottom in tension (it can’t handle)
So we put rebar in because the steel rebar is of course strong in tension The saying is the whole purpose of concrete is to hold the rebar in place
How can we use this material to allow it to be both strong in compression and tension?
The saying is the whole purpose of concrete is to hold the rebar in place

When you think about the spine

Take an axial load on the spine
As Stuart pointed out, the cervical spine is not built for tolerating a big axial load It’s designed more to provide movement It’s a joint for great flexibility
The lumbar spine (for all the reasons just explained) is really designed around taking a large compressive load and in the process it has sacrificed the mobility we have in the neck
It’s designed more to provide movement
It’s a joint for great flexibility

But now let’s talk about load in the context of flexion and extension, where you now do have within the disc, it’s not just pure compression

Flexion is bending forward, and extension is going back
Now if you have an axial load in that position, which you could easily have if you’re deadlifting something or squatting something, any given disc, especially in that lower spine region can be under compression and tension at the same time

Compare a deadlift to a yoga master

When Stuart gives a lecture to a group of radiologists they describe very well all the subcategories of disc bulges and disc deformations and that kind of thing, but they’ve never been taught what the applied load nor the adaptation was
A deadlifter almost always gets a posterior disc bulge A deadlifter is under tremendous compressive load, and if they say get to the bottom of where the hips run out of room, now the femur collides with the pelvis and thereafter the rotation takes place in their low back because the nucleus is under such enormous compressive pressure Remember this model, Stuart had to bend it forward to get the nucleus to squirt back So you’re creating a center of hydraulic effort posteriorly
Now let’s consider a person who’s adapted their spine to do yoga
A deadlifter is under tremendous compressive load, and if they say get to the bottom of where the hips run out of room, now the femur collides with the pelvis and thereafter the rotation takes place in their low back because the nucleus is under such enormous compressive pressure
Remember this model, Stuart had to bend it forward to get the nucleus to squirt back So you’re creating a center of hydraulic effort posteriorly
So you’re creating a center of hydraulic effort posteriorly

“ This is why I say please never mix up deadlifts and yoga .”‒ Stuart McGill

If you adapt your spine to be very flexible, you adapt the type X collagen holding the type I and type II (the heavy grisly collagen and then the elastic collagen), all those fibers together
A powerlifter wants them to be stiff and tough They even wear an exoskeleton of a lifting suit to add even more stiffness and toughness
But for the yoga master, that would be the kiss of death They want nice, viable, flexible spines They soften the ground substance holding the collagen together So when they bend forward in contrast to the disc bulge going backwards, the front of the disc now buckles under compression
Typically, when the powerlifter bends forward and crushes the disc bulge posteriorly
But when the yoga person (or a person with a very flexible spine) bends backwards, the collagen under compression buckles
They even wear an exoskeleton of a lifting suit to add even more stiffness and toughness
They want nice, viable, flexible spines
They soften the ground substance holding the collagen together
So when they bend forward in contrast to the disc bulge going backwards, the front of the disc now buckles under compression

So one gets a disc bulge from extension and the other gets a disc bulge from flexion

Isn’t that interesting?
And it all depends on how they’ve adapted their spine
Stuart’s final point in all of that is, “ Don’t mix up the adaptation schedules. If you want to be a powerlifter, train your hip mobility, shoulder mobility, but torso stiffness, trying not to throughout the day do a lot of bending versus the yoga master, please stay away from the very heavy loads . ”

The pathology of bulging discs [43:15]

What is the pathologic response to the anterior bulging of the disc?

Figure 14. Comparing a bulging disc, a herniated disc, and a free fragment of a herniated disc . Image credit: Miami Neuroscience Center

Peter explains that when you have that posterior bulge … the spinal cord stops quite high up The spinal cord does not run down the entire canal It stops around L2 [A posterior bulge occurs on the back side while an anterior bulge occurs on the stomach side]
So for most of the people experiencing lower back pain vis-à-vis a herniation, fortunately the herniated disc is not hitting your spinal cord It is hitting the nerves that emanate from it
But again, there’s so much real estate in that area
It’s insane because you don’t just have the nerve roots , you have the dorsal roots , you have all of these other tiny little nerves that are going to the facets and to the disc and to the vertebral bodies that’s running musculature into your genitals, of everything that’s important [Nerve roots are shown in yellow in the previous figure]
For the person that is very flexible, who presumably lacks spinal stability, they will go along with their merry life and be flexible The anterior bulge is not as a rule, picking up any nasty nerve root compressions And on the grand scheme, it’s probably a non-clinical issue for them until they want to lift [something heavy] If they were in an emergency situation, they’ve come across a car wreck, someone is in the car and if they don’t get them out, the car’s going to explode We will all be placed into these situations at some point in our life and whether or not we have the physicality to deal with them is another issue That’s the downside of that particular adaptation and lifestyle perhaps
The spinal cord does not run down the entire canal It stops around L2
[A posterior bulge occurs on the back side while an anterior bulge occurs on the stomach side]
It stops around L2
It is hitting the nerves that emanate from it
[Nerve roots are shown in yellow in the previous figure]
The anterior bulge is not as a rule, picking up any nasty nerve root compressions
And on the grand scheme, it’s probably a non-clinical issue for them until they want to lift [something heavy] If they were in an emergency situation, they’ve come across a car wreck, someone is in the car and if they don’t get them out, the car’s going to explode We will all be placed into these situations at some point in our life and whether or not we have the physicality to deal with them is another issue That’s the downside of that particular adaptation and lifestyle perhaps
If they were in an emergency situation, they’ve come across a car wreck, someone is in the car and if they don’t get them out, the car’s going to explode
We will all be placed into these situations at some point in our life and whether or not we have the physicality to deal with them is another issue
That’s the downside of that particular adaptation and lifestyle perhaps

Which of these types of injuries leaves a person more susceptible to the movement of the vertebral bodies in a slipped fashion where we now get that spondylolisthesis?

Spondylolisthesis is when the vertebral body on top moves relative to the bottom (the interior one)
The answer is both

A very flexible spine can get shear translations just the way as a stiffer spine can

So again, we wouldn’t a priori judge and attribute one of those to the symptoms
We always go by the assessment It could be either spine for sure
It could be either spine for sure

The pathophysiology of Peter’s back pain, injuries from excessive loading, immune response to back injuries, muscle relaxers, and more [46:00]

Going back to the story Peter opened with, that very first bout of back pain he had when he was 21 year old It was clearly the previous 7-8 years of really, really heavy lifting Certainly the technical knowledge Peter has today about how to do these things correctly was completely absent
It was clearly the previous 7-8 years of really, really heavy lifting Certainly the technical knowledge Peter has today about how to do these things correctly was completely absent
Certainly the technical knowledge Peter has today about how to do these things correctly was completely absent

If you had to guess (pure speculation), what was the process that led to that injury on that day (that manifestation)?

If Peter had MRIs examining his spine every year starting at the age of 13 until that first real insult at age 21, what would you have seen?

Stuart has done studies on veteran NHL hockey players (11-year veterans) He saw them for low back problems It was a fabulous natural experiment because they brought their MRIs every year
He would look at their MRs from the 1st year, the 2nd year, and then he would watch the cascade He would ask, “ What happened in the 8th year? ” That was the year they started with a trainer and the trainer believed in doing ass-to-grass squats with a heavy weight Stuart could see what happened to the spine When was the last time you saw a hockey player do an ass-to-grass squat in the NHL?
He saw them for low back problems
It was a fabulous natural experiment because they brought their MRIs every year
He would ask, “ What happened in the 8th year? ” That was the year they started with a trainer and the trainer believed in doing ass-to-grass squats with a heavy weight Stuart could see what happened to the spine When was the last time you saw a hockey player do an ass-to-grass squat in the NHL?
That was the year they started with a trainer and the trainer believed in doing ass-to-grass squats with a heavy weight
Stuart could see what happened to the spine
When was the last time you saw a hockey player do an ass-to-grass squat in the NHL?

That was a wonderful experiment to give us insight into what Peter is describing

Stuart is probably one of a handful of people in the world who had available a radiology suite in their cadaver lab We would take cadavers and apply very specific loading scenarios to it and we would watch the cascade of damage over time
He puts both of those together to answer what he expects he would’ve seen
We would take cadavers and apply very specific loading scenarios to it and we would watch the cascade of damage over time

We would’ve seen a lovely young spine in 14-year-old Peter, and then over time we would’ve seen delamination from the inside out

Peter was accumulating the delamination, but on the outside it was still pristine

Peter never knew [about this damage] and the delamination would continue to progress layer upon concentric layer until that day when he was 21, and the last layer was breached and the nuclear gel extruded just a little bit

Development of the spine occurs before the immune system develops

Early after fertilization around the end of the first month (as a blastocyst), that little flat plate rolled (it’s called neurulation ) to create your primitive spinal cord On that day, your mother has not given you an immune system yet Now it’s fused up; that nuclear gel has never seen the immune system yet The end plates are pristine; it’s never seen your blood (which is where the immune system is active)
Now you’re 21; for the first time that nuclear gel comes out and sees the blood immune environment, and it kicks off a hell of an inflammatory response So strong that you couldn’t even move (it locked you up) That takes two weeks to subside
On that day, your mother has not given you an immune system yet
Now it’s fused up; that nuclear gel has never seen the immune system yet
The end plates are pristine; it’s never seen your blood (which is where the immune system is active)
So strong that you couldn’t even move (it locked you up) That takes two weeks to subside
That takes two weeks to subside

Here’s the rub from some of the recent literature on anti-inflammatory medication

Peter was going to ask if he would have been better off if he had taken a Prednisone taper or had some local anti-inflammatory therapy Stuart replies, “ Of course not. But… your logic is fantastic ” The answer is it could have gone either way
The anti-inflammatory might’ve cleaned up the immune response and given you faster resolution
Or what the recent literature is showing: there’s a purpose for that inflammatory response It brings in the immune system and all the macrophages, etc and it starts eating up the extruded material Now that process can go one of two ways as well It can wall off what’s extruded (Stuart thinks Peter experienced that into a free floating body) Or it chews it up (digests it, for lack of a better word)
Stuart replies, “ Of course not. But… your logic is fantastic ”
The answer is it could have gone either way
It brings in the immune system and all the macrophages, etc and it starts eating up the extruded material
Now that process can go one of two ways as well It can wall off what’s extruded (Stuart thinks Peter experienced that into a free floating body) Or it chews it up (digests it, for lack of a better word)
It can wall off what’s extruded (Stuart thinks Peter experienced that into a free floating body)
Or it chews it up (digests it, for lack of a better word)

Stuart wishes he knew Peter then because he bets he could have got Peter to just lay on his tummy and breathe and that vacuums in

Stuart did experiments where they would create partial disc herniations and then if you traction the spine and give a little bit of motion (he would wiggle your legs) You can vacuum in the disc bulge in a matter of 2-3 minutes and people will say you’re dreaming No, we’ve measured it in some types of subcategories that’s actually possible
The answer to the inflams is at least some of the more recent data is showing dispense with the anti-inflammatories
You can vacuum in the disc bulge in a matter of 2-3 minutes and people will say you’re dreaming
No, we’ve measured it in some types of subcategories that’s actually possible

Let the inflammatory response give the patient hell for two weeks

It’s the best medicine for them in the long-term because it is helping to reduce the long-term disc bulge

Peter’s anecdotal experience treating his back pain

These days when Peter has a flare up, what he finds to be the most efficacious is not any sort of anti-inflammatory, but a light muscle relaxant like Baclofen These episodes are really minor and they don’t interfere with what he does other than he would back off on heavy lifting He doesn’t squat, deadlift, or do any heavy stuff like that anymore He doesn’t use a benzo or anything that is sedating, just something that allows the paraspinous muscles to sort of relax a little bit That allows him to do some deep breathing It’s mostly just a vehicle to break the cycle of tension but not the inflammation cycle Peter is not familiar with the literature that Stuart just spoke of, but he’s mindful of the downsides of taking Prednisone He doesn’t want to suggest people shouldn’t take Prednisone, but one needs to be circumspect about the frequency with which they do it
These episodes are really minor and they don’t interfere with what he does other than he would back off on heavy lifting He doesn’t squat, deadlift, or do any heavy stuff like that anymore
He doesn’t use a benzo or anything that is sedating, just something that allows the paraspinous muscles to sort of relax a little bit That allows him to do some deep breathing It’s mostly just a vehicle to break the cycle of tension but not the inflammation cycle
Peter is not familiar with the literature that Stuart just spoke of, but he’s mindful of the downsides of taking Prednisone He doesn’t want to suggest people shouldn’t take Prednisone, but one needs to be circumspect about the frequency with which they do it
He doesn’t squat, deadlift, or do any heavy stuff like that anymore
That allows him to do some deep breathing
It’s mostly just a vehicle to break the cycle of tension but not the inflammation cycle
He doesn’t want to suggest people shouldn’t take Prednisone, but one needs to be circumspect about the frequency with which they do it

Where Stuart thinks Peter is at now with regards to his back

Peter probably has a little bit of micro movement in a shear mode So this joint isn’t translating as it should It’s lost a little bit of height And those are the things that are causing the low-grade aches Not kicking off the heavy acute attacks that Peter used to have as a younger man
So this joint isn’t translating as it should
It’s lost a little bit of height
And those are the things that are causing the low-grade aches Not kicking off the heavy acute attacks that Peter used to have as a younger man
Not kicking off the heavy acute attacks that Peter used to have as a younger man

Stuart wants Peter to come see him

Stuart understands that Peter’s brother has a farm in Canada that he occasionally visits
He invites Peter to spend an extra day, come by Gravenhurst and they’ll have some fun
What he would do with Peter is he would get him to stand just as he is and he would bet Peter stands differently when he gets out of that chair after doing this podcast for a bit versus of when he’s just walking around
There would be forward lean and antalgia and if Stuart were to palpate Peter’s erector spinae, he explains, “ They would be active and I would lift the toe shoe to open up your hips a little bit, ears over your shoulders, shoulders over your hips, and now all of a sudden we’ve achieved that muscular relaxation that you’re after.”

Stuart’s advice for Peter, the next time he needs to take a muscle relaxant

Lay on your tummy, maybe put your hands, palms up under your hips, maybe make a fist Again, Stuart doesn’t know Peter’s spine well enough, doesn’t know where Peter is Stuart suggests finding a nice little relaxation place
Melt into the table every time you exhale Keep doing that and see if that doesn’t remove the ache
We will play with your hands to realign that little shearing micro movement and then stand up
We might open up your hips a little bit with a psoas -specific stretch, and then you will monitor your back muscles and see if you’ve shut them down
But then if Stuart said, poke your head forward, muscles on, pull your chin back, muscles off, soften your knees a little bit
Some people will stand with a strategy of ramming their knees back into heart extension Feel your erector spinae
Maybe it’s just simply jazz knees and soften your knees In other words, those little postural cues
Again, Stuart doesn’t know Peter’s spine well enough, doesn’t know where Peter is
Stuart suggests finding a nice little relaxation place
Keep doing that and see if that doesn’t remove the ache
Feel your erector spinae
In other words, those little postural cues

Stuart has seen Peter enough moving on YouTube and whatnot, that he bets they could hack their way around that without the use of meds

Peter will happily add an extra day to his next Toronto trip when he’s up at his brother’s farm, and he’s sure his brother will want to join as well

The three most important exercises Stuart prescribes, how he assesses patients, and the importance of tailored exercises based on individual needs and body types [56:15]

Explain the McGill big 3 exercises , provide the rationale for them, and talk about some of the hallmarks of your assessment

[Here’s another helpful video: (Do these daily) The McGill Big 3: Full Breakdown with Brian Carroll ]

Peter has been doing these consistently for quite some time and really fancies them The third one (bird dog), he only does occasionally
Peter asks, “ Is this kind of like your core nutrition… everybody should be doing this? You don’t wait till you have back pain to do this. Is that safe to say? ”
No, it isn’t
This is a bit of a myth and something that Stuart has been fighting his whole career
There are some people that are far too stiff and this is not the mechanism of their back pain (we don’t need to go there) Have you ever seen the type of body build where they have a huge pneumatic cushion in front called a belly, it slaps on their thighs, it’s that pendulous Do you ever see spine instability in that type of architecture? Stuart doesn’t Those people have difficulty getting on and off the floor The big three is not for them
Again, the assessment always leads us to the solution
Stuart explains, “ I need to have a discussion of what stability is in terms of creating resilience and performance. Then why are those particular exercises important, and then how to do them. ”
The third one (bird dog), he only does occasionally
Have you ever seen the type of body build where they have a huge pneumatic cushion in front called a belly, it slaps on their thighs, it’s that pendulous Do you ever see spine instability in that type of architecture? Stuart doesn’t Those people have difficulty getting on and off the floor The big three is not for them
Do you ever see spine instability in that type of architecture? Stuart doesn’t
Those people have difficulty getting on and off the floor
The big three is not for them

“ We’re going to talk about non-specific low back pain and how I think it’s a myth and it doesn’t exist. That will take us into the assessment .”‒ Stuart McGill

A basic discussion of stability

Analogy: the example of a backhoe

A backhoe is a machine with a tractor and it has an arm on the back to dig earth
The first thing the operator does is put down the stabilizer bars to lock the tractor into the ground Because if you don’t do that, you can’t pull earth, you just pull the machine around
So what’s the human equivalent of that? We live in a linkage just like machinery In other words, let’s take the bench press muscle pec major [shown below] Pec major originates on my rib cage, spans the ball and socket joint of the shoulder, and inserts on the humerus
Because if you don’t do that, you can’t pull earth, you just pull the machine around
We live in a linkage just like machinery
In other words, let’s take the bench press muscle pec major [shown below] Pec major originates on my rib cage, spans the ball and socket joint of the shoulder, and inserts on the humerus
Pec major originates on my rib cage, spans the ball and socket joint of the shoulder, and inserts on the humerus

Figure 15. The Pectoralis muscles . Image credit: StatPearls

Stuart explains: when I contract and shorten the pec major, it flexes my arm
So if I wanting to do a push or a punch, there it is, on the distal side of the joint
Proximally, that same muscle shortening collapses my rib cage towards my shoulder joint
So all I used was the muscle that spans the joint That isn’t a very effective push All I’m doing is collapsing my own linkage Or as an engineer, we would say, well, you’ve just created an energy leak
I’m now going to build proximal stiffness I’m going to lock my core, create stiffness through my torso, which is proximal to the joint So now when I contract the muscle, 100% of the motion is directed distally Now I’ve got my push
That isn’t a very effective push
All I’m doing is collapsing my own linkage Or as an engineer, we would say, well, you’ve just created an energy leak
Or as an engineer, we would say, well, you’ve just created an energy leak
I’m going to lock my core, create stiffness through my torso, which is proximal to the joint
So now when I contract the muscle, 100% of the motion is directed distally
Now I’ve got my push

So what is the best, most efficient way to create a proximal stiffness?

We searched for years doing all kinds of tests of every abdominal exercise you could think of, back exercises, twisting, power off presses, throwing things, etc.
The three exercises that kept bubbling up to the top in the criteria of sparing the spine while you’re doing them Because these people are hurting, and you don’t have carte blanche to load up their spine It was later in Stuart’s career that we found there is a residual stiffness that occurs
Because these people are hurting, and you don’t have carte blanche to load up their spine
It was later in Stuart’s career that we found there is a residual stiffness that occurs

If you are an NFL football team and if you do the big three prior to practice, you will run and cut just a little bit faster

So you’re on the field, you run and you cut: the stiffer the core when the hips explode into external rotation, you’re now creating a faster directional change

The patient assessment

Stuart will have the patient sit on a stool and ask them if they have any symptoms right now Let’s say they don’t
Next, he asks them to drop their chest down They say, “ My left toe is going numb and I’ve got back pain ”
He asks them to bring their chin down They might say that will increase their pain (or decrease it)
Let’s say they don’t
They say, “ My left toe is going numb and I’ve got back pain ”
They might say that will increase their pain (or decrease it)

The point is that posture created their pain

If that is true, then when they lay on their back and they imprinted their back into the floor doing a Pilates roll-up (for example), that would be their specific pain trigger So it’s not much of a therapeutic exercise
So it’s not much of a therapeutic exercise

The foundation of the modified curl-up

Stuart advises to put your hands under your low back as you’re laying on the ground, lift your elbows Now, hover up your head, neck and shoulders, and we’re going to propel the abdominal contraction Breathe through pursed lips, and allow the diaphragm to become the athlete inside this barrel
Now if the person has a rotator cuff issue, we will hack it and make it tolerable
Now, hover up your head, neck and shoulders, and we’re going to propel the abdominal contraction
Breathe through pursed lips, and allow the diaphragm to become the athlete inside this barrel

Another assessment

Stuart would see people and ask them to take a dumbbell (or a kettlebell) and raise it up laterally in the frontal plane like this for the side of the core
That would trigger pain in a lot of people

We could then do a side plank on the floor

The beauty of the side plank is only half the musculature is heavily challenged; the downside is heavily challenged, the upside is not

You’ve only got half the load on the spine, very spine sparing
Stuart prescribes the side plank on 10-second intervals

Why? We use the Russian training science to show you build endurance through repeated 10-second exposures

You’re not getting tired to the point where you break form, nor do you develop a neural fatigue
And you get a much higher tolerable training level with this, what we call the Russian descending pyramid

The bird dog is for the back muscles

Look at the beauty of the bird dog where you extend one leg, the opposite arm One half of my low back is active, one half of my upper back is active on the other side, we’re developing a nice DNF pattern We’re creating stiffness and stability in the core We’re teaching the brain to disassociate ball and socket joint motion of the shoulders and hips with only half the spine load of say a Roman chair extension or something like that
One half of my low back is active, one half of my upper back is active on the other side, we’re developing a nice DNF pattern
We’re creating stiffness and stability in the core
We’re teaching the brain to disassociate ball and socket joint motion of the shoulders and hips with only half the spine load of say a Roman chair extension or something like that

Then we did experiments where we would train people

We would just have a single session exposure
We would measure the core stiffness prior to doing the big three They’d do the big three on the Russian descending pyramid and then we would remeasure their torso stiffness
They were stiffer and some of my muscle physiology colleagues said, “ Well, you’ve added a turgidness to the muscle .”
But Stuart doesn’t think so He thinks the brain created a lasting neural stiffness And in some people it lasts about 20 minutes, in some people it lasts longer
Some patients will say, “ You know, when I do the big three, I don’t have pain for the next hour. ”
They’d do the big three on the Russian descending pyramid and then we would remeasure their torso stiffness
He thinks the brain created a lasting neural stiffness
And in some people it lasts about 20 minutes, in some people it lasts longer

Stuarts prescription

What you’re going to do is mid-morning, do a 12-minute big 3 session
Mid-afternoon do another 12

These are the little tricks and hacks to slowly wind a person down out of pain; that was the aim of the big 3

Then Stuart started to look at the performance side

If you train a group of athletes versus graduate students (the typical university experiment), not much difference was found in the athletes But in the graduate students, we would see an increase in stiffness over a six-week training trial
But in the graduate students, we would see an increase in stiffness over a six-week training trial

Really interesting things started to happen

If you do isometric holds in the manner Stuart’s described, you punch harder They took a group of Muay Thai athletes and when they did the big 3 and we measured the punching impulse , it was greater after they trained for 6 weeks
When we did dynamic core exercises, it increased the closing velocity The closing velocity is when you first get the first muscle, and then you relax closing velocity, and then you strike with a second bolt, boom, boom
They took a group of Muay Thai athletes and when they did the big 3 and we measured the punching impulse , it was greater after they trained for 6 weeks
The closing velocity is when you first get the first muscle, and then you relax closing velocity, and then you strike with a second bolt, boom, boom

The closing velocity was faster with dynamic core exercises, but the strike force boom at the end was greater

Stuart has studied combat techniques, and he explains 3 styles

Let’s take Joe Frazier and you would see him just always on forward progression, but the punches came from his body weight behind them He would create a beautiful thrust line straight, but his body rotated and he lent his weight into them, and that was his footwork It wasn’t the greatest for getting hit because that means you get hit a lot
Mike Tyson , different body type, a very compact type of a body, but contrast his footwork It was just beautiful He would drop step, drop step, drop step, hook the liver, come back very quickly, hook, boom, and cross, and there was the knockout again All coming from the hips, drop step, boom You see it’s all hips
Then Ali breaks all the rules with the Ali shuffle, and then he would turn, rotate, hang on to it, and then at the end look at a beautiful thrust line all through the stick on core
Stuart can go through athlete after athlete
He never worked with Jagger, but there is Jagger doing the bird dog in his training
Usain Bolt , the fastest man on the planet does the bird dog breeding extensor pulsing power into a stone
He would create a beautiful thrust line straight, but his body rotated and he lent his weight into them, and that was his footwork
It wasn’t the greatest for getting hit because that means you get hit a lot
It was just beautiful
He would drop step, drop step, drop step, hook the liver, come back very quickly, hook, boom, and cross, and there was the knockout again All coming from the hips, drop step, boom
You see it’s all hips
All coming from the hips, drop step, boom

The significance of strength and stability in preventing injuries and preserving longevity [1:08:15]

As he has aged, Peter has become interested in looking at the greatest performers

Peter adds, “ There’s no doubt that the best athletes have a remarkable natural talent that the rest of us don’t have .”
Stuart agrees and he has measured it

The importance of natural stability

Peter thinks that his lack of natural ability has meant that he always suffered from an unbelievable amount of energy leakage In whatever he has done, whether it’s been boxing, swimming, powerlifting
He realizes that there’s such a chasm between himself and the really good ones, and it’s not due to hard work It is due to probably some combination of natural ability and coaching that has allowed the really good ones to do what Stuart has demonstrated Which is a great punch begins in the back foot and it’s transmitted through the hip and it goes into the opposite fist
It’s just hard for people to understand how that through-line of force can’t lose anything along the way
Stuart adds, “ The stories I could tell you about the number of athletes being de-tuned by their trainers and coaches violating this principle that you’re describing, it’s astounding to me. ”
In whatever he has done, whether it’s been boxing, swimming, powerlifting
It is due to probably some combination of natural ability and coaching that has allowed the really good ones to do what Stuart has demonstrated Which is a great punch begins in the back foot and it’s transmitted through the hip and it goes into the opposite fist
Which is a great punch begins in the back foot and it’s transmitted through the hip and it goes into the opposite fist

Peter points out that it’s not just that energy leakage costs you performance (it clearly does), but it predisposes you to injury

“ When I exercise today, I don’t care about the performance. I care about the preservation and longevity of my body for whatever number of years I have left. So this is really where I think stability matters .”‒ Peter Attia

What are the exercises that we need to be doing so that as we age and we walk up a flight of stairs or carry something heavy, we don’t hurt ourselves? (Because we don’t have that core stability that can resist the deformation that’s going to allow energy to seep out of the system)

Stuart shares a story that shows the arrogance that exists among some medical staff

Stuart was teaching a class and showing some data from an elite athlete and there will be therapists and clinicians in the room who say, “ We don’t deal with elite athletes, we deal with the elderly or we deal with sick people. ” But Stuart was showing them what the human body has the potential to do
Occasionally a medical group or a hospital will ask Stuart to assess 3 patients in the auditorium in front of all of their medical staff
He was at a facility in Europe, and the first person was a rugby player He had 20 minutes to declare what he thought was going on
The next one was a woman in her early 70s, clearly distraught Her posture and carriage showed that she was defeated by the world
She came onto the stage and Stuart asked her to tell her story She said a little few sentences, and then she said, “ But the therapist says that I have to leave my home now. When I get off the toilet, I’m a bit unsteady and she’s afraid I’m going to fall on the floor. I can’t get off the floor by myself and I’m just going to lay there and no one will discover me. I have to leave my home. ” She started to cry at this point and she said, “ What’s going to happen to my cat? ” and all this sort of stuff
Stuart asked someone to bring him a stool to be the simulated toilet She turned and had no idea how to move and just sort of plopped and collapsed on the toilet Stuart wants you to see his lower body kinematics as he’s moving Then Stuart asked her, “ Would you get up off the chair? ” Her knees were together, and she just sort of collapsed and he had to help her She was going to collapse onto the floor
Stuart said to her, “ I want you to humor me now. You’re my mirror .” When he coaches, he tries to use minimum words
He told her, “ Do this with your hands. Put your knee cap between your thumb and your hands as you slide your hands down. Good. Now, I want you to be a leaning tower. Leaning tower, forward and backwards and play with the curve of your back. Do you have any pain now? ” She said, “ No .”
He said to her, “ Watch my shoulders. You’re shrugged. I want you to anti-shrug. ” She did that
Next he said, “ Pull your hands up your thighs by pulling your hips through. Don’t lift with your back, pull your hips through .” She had it done in three repetitions That was now her pattern
Then he said, “ Okay, think of what we’ve just done and sit on the toilet. ” He added, “ Whoops, spread your feet apart. ”
And there she went, slid her hands down and then she put her knees together and he said, “ Now stand up. ” And she was going right back to the incompetent movement that caused her inability and disability before Stuart said, “ Spread your knees apart and pull your heels underneath you. Sniff some air, now lean forward and do what you now know how to do. ” And she did a perfect squat
Stuart asked her, “ Do it again .”
By the third repetition, a big smile came on her face
Stuart said, “ What’s up with you? ” She said, “ I don’t have to leave my home, do I? ” He said, “ No .”
Do you know many of those hard baked surgeons and clinicians started to cry as well? For the first time they realized all Stuart did was teach her weightlifting 101
And remember how this story started with the arrogance of some of our colleagues who say, “ I don’t want to hear stories about elite athletes. I deal with old people or sick people, ” and that’s why they continue to not have the skillset to help their people
But Stuart was showing them what the human body has the potential to do
He had 20 minutes to declare what he thought was going on
Her posture and carriage showed that she was defeated by the world
She said a little few sentences, and then she said, “ But the therapist says that I have to leave my home now. When I get off the toilet, I’m a bit unsteady and she’s afraid I’m going to fall on the floor. I can’t get off the floor by myself and I’m just going to lay there and no one will discover me. I have to leave my home. ”
She started to cry at this point and she said, “ What’s going to happen to my cat? ” and all this sort of stuff
She turned and had no idea how to move and just sort of plopped and collapsed on the toilet Stuart wants you to see his lower body kinematics as he’s moving
Then Stuart asked her, “ Would you get up off the chair? ” Her knees were together, and she just sort of collapsed and he had to help her She was going to collapse onto the floor
Stuart wants you to see his lower body kinematics as he’s moving
Her knees were together, and she just sort of collapsed and he had to help her
She was going to collapse onto the floor
When he coaches, he tries to use minimum words
She said, “ No .”
She did that
She had it done in three repetitions
That was now her pattern
He added, “ Whoops, spread your feet apart. ”
And she was going right back to the incompetent movement that caused her inability and disability before
Stuart said, “ Spread your knees apart and pull your heels underneath you. Sniff some air, now lean forward and do what you now know how to do. ” And she did a perfect squat
And she did a perfect squat
She said, “ I don’t have to leave my home, do I? ”
He said, “ No .”
For the first time they realized all Stuart did was teach her weightlifting 101

All Stuart did was learn from the best weightlifters in the world, people who know how to move load, learn what the efficiency was and turn it into a hack to change a person’s life

Honda used to race F1 cars and the reason was they learned about automotive technology, and the gearshift change in your Honda Civic came from the F1 racetrack

“ So that’s why we work with elite athletes so I can bring it down. ”‒ Stuart McGill

Stuart loves working with them, of course they just give it away free to us
Yet some of our colleagues are just so closed off, they don’t want to hear about elite performance
Peter reacts, “ That’s an absolutely beautiful story… I think the saddest part of that story is how many of those patients don’t get the chance to sit on a stage with you for 30 minutes and learn that movement. ”

Peter feels optimistic that we are in a place now where people are starting to appreciate the importance of strength and stability and that we’re less afraid of this

There’s more discussion of the importance of resistance training and that it’s not a “young guy” thing to do It’s an “everybody” thing to do
It’s an “everybody” thing to do

Peter asks, “ Given the arc of your career, am I being just sort of delusional or do you really think that we’re in a coming of age here? ”

Stuart tries to answer every question with, “ What’s the evidence and what’s the application? ”
The evidence at the university with all our first year students, one of their first courses they took was on just basic fitness evaluation, range of motion, strength, hand grip, VO 2 max, some of these markers, They would measure each other, and we kept the scores year after year of the incoming class The students got terribly soft (as shown by that data)
Now, whatever year was the year where the students had grown up with the personal computer, it was right at the very late ’90s All of a sudden we saw the incoming class fitness plummet
Then something happened
They were a soft bunch for about five years, and then slowly to your point, they started to come back
Stuart thinks Peter’s perception is right on It did go to a terrible state however many years ago that was, 15 or 20 years ago, but it is coming back
Now some of our colleagues are terribly misguided as well They think (because they heard on social media), “ Oh, you’re not a real woman until you can deadlift twice your bodyweight. ” Well wait a second; if they could come here and see the number of people who’ve been caused by overzealous trainers and going bonkers on deadlift magnitude
They would measure each other, and we kept the scores year after year of the incoming class
The students got terribly soft (as shown by that data)
All of a sudden we saw the incoming class fitness plummet
It did go to a terrible state however many years ago that was, 15 or 20 years ago, but it is coming back
They think (because they heard on social media), “ Oh, you’re not a real woman until you can deadlift twice your bodyweight. ”
Well wait a second; if they could come here and see the number of people who’ve been caused by overzealous trainers and going bonkers on deadlift magnitude

Stuart’s take on squats and deadlifting: potential risks, alternatives, and importance of correct movement patterns [1:19:30]

Peter is conflicted when he thinks about particular squats and deadlifts

He has no desire to do anything that he deems stupid anymore
His days of gritting through painful anything are long over, and he knows the difference between discomfort that is worth pushing through and pain that is not
On the one hand, he now feels that he is so tuned-in to how to do a deadlift movement correctly that it’s a wonderful audit for his stability system He’s embarrassed about how much he didn’t know when he was deadlift At no point did he understand the importance of tension in the arms, intra abdominal pressure, the variability and foot pressure on the ground It was just pure brute force stupidity Today he knows things that allow him to modulate force and on a good day, push the envelope a little bit
On the on hand he thinks he should be deadlift his whole life He doesn’t need to deadlift 400 lbs anymore But he should be deadlift because it’s this great audit
On the days that he doesn’t feel it, he backs off There’s a lower risk approach to get it
He’s embarrassed about how much he didn’t know when he was deadlift At no point did he understand the importance of tension in the arms, intra abdominal pressure, the variability and foot pressure on the ground It was just pure brute force stupidity
Today he knows things that allow him to modulate force and on a good day, push the envelope a little bit
At no point did he understand the importance of tension in the arms, intra abdominal pressure, the variability and foot pressure on the ground
It was just pure brute force stupidity
He doesn’t need to deadlift 400 lbs anymore
But he should be deadlift because it’s this great audit
There’s a lower risk approach to get it

In other words, deadlifting is valuable, but you have a narrow operating window in which you can potentially hurt yourself

Peter still will go periods of his life where he’ll deadlift every week and then he’ll take 3 months off feeling like he doesn’t want to push it

How would you advise a middle-aged person or even a non-middle-aged person who’s thinking through this particular issue?

Stuart has so many thoughts going through his mind
With a 50-year-old who has back pain, he wants to know, “ What are your goals? ”

Stories about Ed Coan (the greatest powerlifter of all time)

Stuart was with Ed a couple of weeks ago
When Ed would set a personal best , he’d take a couple of months off afterwards To set a personal best is so demanding of your body If you set a true personal best, most people experience micro fracturing just underneath the end plate of the trabecular bone If you look at the great strength athletes, they train deadlift If you go to our website , look at the testimonials at the bottom the number of world class deadlifters who were on there Stuart has worked with quite a few of these people through their injuries
To set a personal best is so demanding of your body If you set a true personal best, most people experience micro fracturing just underneath the end plate of the trabecular bone
If you look at the great strength athletes, they train deadlift If you go to our website , look at the testimonials at the bottom the number of world class deadlifters who were on there Stuart has worked with quite a few of these people through their injuries
If you set a true personal best, most people experience micro fracturing just underneath the end plate of the trabecular bone
If you go to our website , look at the testimonials at the bottom the number of world class deadlifters who were on there
Stuart has worked with quite a few of these people through their injuries

Those microfractures could be a good thing or a bad thing

The professional powerlifter will take a week off
They train heavy deadlifts or squats once a week because it takes a week for the bone callus to not only attach through the chemical electro attraction, but to really scaffold on takes a week
If you deadlift in another three or four days the way some trainers do, that allows those micro fractures to accumulate until finally you’ve got a full blown endplate fracture
These are the people that come here and then Stuart will say, “ How about this for a goal? Do you have kids? ” Stuart has since learned about Peter’s centenarian decathlon , which he loves
Stuart asks clients, “ Would you rather as your goal, have the ability to play with your grandchildren on the floor when you’re 80 and get off the floor and pick them up? ” They pause for a minute and they’ll say, “ Yeah, I like that goal .”
Stuart tells them they can’t have both If you think you’re going to continue having deadlift personal bests, you’ll have artificial hips and all of these other things Because how many old powerlifters do you know? Do you really want to be like that group of athletes?
Stuart can talk them into changing their long-term goals
Stuart has since learned about Peter’s centenarian decathlon , which he loves
They pause for a minute and they’ll say, “ Yeah, I like that goal .”
If you think you’re going to continue having deadlift personal bests, you’ll have artificial hips and all of these other things Because how many old powerlifters do you know? Do you really want to be like that group of athletes?
Because how many old powerlifters do you know?
Do you really want to be like that group of athletes?

“ Now is the time to get on the program and make sure you get there. If that’s the case, we eliminate deadlifts .”‒ Stuart McGill

The monster walk

Stuart saw an athlete yesterday ‒ they’re at the end of their career and he took them out and they went for a 10-minute walk to a hill
He explained, “ Here’s why you’re not going to do deadlifts, but here’s what I want you to do ,” and he showed them the monster walk
He told them to go to the bottom of the hill, lean back into the hill, walk backwards He instructed them to align your foot, ankle, knee and hip and push through the knee, through the knee, through the knee, backwards up the hill
Do you know after 30 meters, they were absolutely done
He instructed them to align your foot, ankle, knee and hip and push through the knee, through the knee, through the knee, backwards up the hill

Here they are doing all this deadlifting and they don’t even have the leg strength endurance to walk backwards 30 meters

It’s totally inappropriate stimulation of their athleticism to make it through to 80
They walked down the hill, and they did three sets
They could hardly walk

Next, they played the neurological grip, which Stuart likes to do a lot of now

He instructed, “ Walk forwards up the hill, but pretend you have 100 dollars in your butt cheeks. Don’t let anyone take it. Now, walk forwards up the hills .”
They say, “ I’ve never felt this before. ”
The brain perceives exhausted quads It now has to go and get the glutes; it’s the only thing left
Quite often we’ll do an exhaustion focus to stimulate the thing that we really want to stimulate
It now has to go and get the glutes; it’s the only thing left

Stuart convinced that person to train to get a well-rounded and sustainable athleticism that will spare their joints

They still have great training capacity, but their athleticism is going to go through the roof
Stuart has taken some very accomplished powerlifters and taken out all the squats and just do sled work, backwards walking uphill Some of these old-time techniques
Some of these old-time techniques

Their joints settle down, they get a sustainable fitness, and they lose this idea of maximum effort, squats and deads, and now they’re thinking of the word sufficient strength, sufficient mobility, sufficient endurance

Stuart explains, “ We’ve been doing this long enough now that we’ve tracked them, and those are the ones that are getting through .”

Ask an orthopedic surgeon who they are replacing hips on

It’s 50-year-old Caucasian women who have done yoga for 30 years, and men around 50 who’ve done deadlifts all their life
Who are they not replacing hips on? The middle of the road moderates Not the ones who’ve rusted out and not the ones who’ve worn out
The middle of the road moderates
Not the ones who’ve rusted out and not the ones who’ve worn out

This idea of sufficient fitness

Stuart believes we are all called upon to do things in life at certain times
It’s more fun to just to be able to continue to do those things
Stuart doesn’t do deadlifts, but he picks up 100 pound bucked-up logs (as an example) That’s his stone lift He will load that into the log splitter; he still splits his own wood People comment on his hands ‒ an athlete who came in yesterday shook his hand and he couldn’t fit his hand around Stuart’s That’s from 65 years of splitting firewood
When Stuart was young, he didn’t have dumbbells, his dad would give him cinder blocks
He’ll take grip strength any day over how much you deadlift
That’s his stone lift
He will load that into the log splitter; he still splits his own wood
People comment on his hands ‒ an athlete who came in yesterday shook his hand and he couldn’t fit his hand around Stuart’s That’s from 65 years of splitting firewood
That’s from 65 years of splitting firewood

Best proxy for longevity

People often ask Peter why he thinks grip strength is such a great proxy for longevity
And he explains that it’s the same reason he thinks VO 2 max is a great proxy for longevity

Those are probably the two best biomarkers we have, and it sounds crazy that your VO 2 max and your grip strength are better predictors of how long you’re going to live than whether or not you smoke, drink, and what your family history is for cancer

Those things all matter, but it’s amazing how dwarfed they are by those two
Peter’s best explanation for it is that those are the best two integrators for the work you’ve done You can’t cram for a VO 2 max the week before If you have a high VO 2 max, you have done the work to get it If you have a strong grip, you didn’t just buy little grip squeezers on Amazon and filter away at them while you were on calls on Zoom You had to do the work You had to be carrying heavy things, whatever it be, chopping wood, carrying cinder blocks, doing farmer carries And of course, that also speaks to stability that you have to be able to transmit force from the torso right to the hand
You can’t cram for a VO 2 max the week before
If you have a high VO 2 max, you have done the work to get it
If you have a strong grip, you didn’t just buy little grip squeezers on Amazon and filter away at them while you were on calls on Zoom You had to do the work You had to be carrying heavy things, whatever it be, chopping wood, carrying cinder blocks, doing farmer carries
And of course, that also speaks to stability that you have to be able to transmit force from the torso right to the hand
You had to do the work
You had to be carrying heavy things, whatever it be, chopping wood, carrying cinder blocks, doing farmer carries

Helping patients with psychological trauma from lower back pain by empowering them with the understanding of the mechanical aspects of their pain [1:30:00]

The psychological trauma that exists in the patient with lower back pain

Peter is thinking very specifically about some of his patients or friends who have been in the throes of lower back pain
And if nothing else, Peter takes a great degree of comfort from his third injury (the one in 2000) because it lasted so long and because it was so debilitating, and because he’s here today without pain
His confidence around small recurrences is so high that he doesn’t tend to awfulize about it and work himself up
But he has great empathy for a person who doesn’t have that knowledge

Peter doesn’t know how to help someone sometimes because he can’t tell what is mind and what is body at this point

How can we help those patients?

Stuart is certainly much more conscious of the point Peter is making now than he was 30 years ago

A patient who the medical system had given up on

This story illustrates something that happens very often
Peter mentioned earlier how MRIs don’t show you the mechanism of pain and Stuart can give all kinds of reasons why
A patient came to see Stuart and he said, “ Hi doc, I hear you’re different. I’ve got this pain. I’ve been everywhere. I went to the pain clinic, they gave me narcotics, and now they say, ‘The pain is in my head.’ I can live with the physical pain. I cannot live with someone telling me the pain is in my head because that means I’m crazy. And if I’m crazy, I don’t deserve to live. You’ve got two weeks, and in two weeks, I’m blowing my brains out .”
Now there’s a heavy psychosocial challenge and a little bit of a story of what the system does to people And it’s not unusual for someone to come to his clinic suicidal
In the evaluation, the patient did not have any point right now
When asked about what causes his pain he explained, “ Well, it’s when I do a certain movement that I get a flash of pain and it feels like someone has broken a beer bottle and have ripped open my hamstringing muscles. It’s awful. ”
Stuart asked him to show him what creates this pain so he could understand it Stuart used a muscle EMG over the torso, the glutes, etc., and they put on the 3D spine monitor
The patient stood there and did a very weird thing, he would himself around in a circle, and when he got to the top, dead center he let out a cry of pain and Stuart heard a little cavitation, a little pop come out of his back That was the crack of the sciatic nerve He was in a bad way Stuart laid him, prone on a table and tried to give him a bit of decompression before he went home
Stuart explained, “ I know exactly what the mechanism of your pain is. Here’s what you should do over the next 3 days, but I want you to come back, but promise me you aren’t going to do anything silly. ” (remember his earlier threat?) Stuart called him later that night and again the next day, just to make sure
When he came back, Stuart explained what the data showed and what the mechanism was As he was winding himself around, he was using muscle Muscle is stiffening and stabilizing It’s centrating of the joints As he got to top dead center, he shut all his muscles off He completely relaxed And then was a little shear translation or a clunk (and that’s what we heard), and that’s what trapped the sciatic root
Stuart coached him, “ Okay, you have no pain. Push my fingers out harder. Good. Hold that. Now talk to me, and keep talking to me with that controlling .” He asked him to keep the tone and go through the motion that causes his pain, and as he came to the top, dead center, he encouraged him to keep control He didn’t clunk
It took him about 4 months to wind down the ache, but he never had another clunk or trap
10 years later, he brought his daughter in to see Stuart He brought Stuart a case of beer and Stuart asked how he has been Fabulous, he never had another episode
Some people will think that that’s a fantastic impossible story But he was so coachable, he understood, he was a mechanical mind
And it’s not unusual for someone to come to his clinic suicidal
Stuart used a muscle EMG over the torso, the glutes, etc., and they put on the 3D spine monitor
That was the crack of the sciatic nerve
He was in a bad way
Stuart laid him, prone on a table and tried to give him a bit of decompression before he went home
Stuart called him later that night and again the next day, just to make sure
As he was winding himself around, he was using muscle Muscle is stiffening and stabilizing It’s centrating of the joints
As he got to top dead center, he shut all his muscles off He completely relaxed And then was a little shear translation or a clunk (and that’s what we heard), and that’s what trapped the sciatic root
Muscle is stiffening and stabilizing
It’s centrating of the joints
He completely relaxed
And then was a little shear translation or a clunk (and that’s what we heard), and that’s what trapped the sciatic root
He asked him to keep the tone and go through the motion that causes his pain, and as he came to the top, dead center, he encouraged him to keep control
He didn’t clunk
He brought Stuart a case of beer and Stuart asked how he has been Fabulous, he never had another episode
Fabulous, he never had another episode
But he was so coachable, he understood, he was a mechanical mind

This was a suicide case from the medical system not having a sufficient evaluation procedure to really get at what the mechanism of his pain was, to a point where they defaulted, and said, “We’ve tried everything with you. It’s not working, therefore, the pain is in your head.”

“ It was a process of understanding the mechanism, giving him a strategy to address the mechanism, and the psyche just changes. It empowered him .”‒ Stuart McGill

A police officer with debilitating back pain

Stuart was giving a lecture in England, and there was a fellow off to the side, and he was slumped down Now, if you get a clinical psychology textbook, the picture of depression is this: knees together slumped down in that demeanor Also, if you have a posterior disc bulge, that is not a good position to be
He was starting with clinical depression beating a disc bulge, and those two don’t go together
During the break, he came over to Stuart, he was a very quiet spoken fellow, and he said, “ I hear what you’re saying. Do you have 30-seconds for me to tell you my story? ”
The man used to be a police officer, he hurt his back and went through the NHS system They only gave him exercise that hurt him more Finally, they gave him a pamphlet, How to Live With Your Back Pain , and he explained, “ That book destroyed me. What do you mean I have to live the rest of my life with my back pain? And no one’s ever touched me or shown me any of this. ”
Stuart showed him the squat procedure (the one he went through with the older woman, discussed earlier), and he encouraged him to sit tall in his chair
At the end of the lecture, he went over to him and asked him how’s your pain? He said, “ It’s gone, ” and he started to cry Because he realized now what the system had done to him In the meantime, he lost his job and he realized that he’d been stolen from, and those are his words He said, “ They stole my career from me, giving me that book, ‘How to Live with My Back Pain.’ Why didn’t anyone show me what my pain was like? You just did in 30 seconds. ”
Stuart has been watching this pattern for so many years You could see it a mile away
Now, if you get a clinical psychology textbook, the picture of depression is this: knees together slumped down in that demeanor
Also, if you have a posterior disc bulge, that is not a good position to be
They only gave him exercise that hurt him more
Finally, they gave him a pamphlet, How to Live With Your Back Pain , and he explained, “ That book destroyed me. What do you mean I have to live the rest of my life with my back pain? And no one’s ever touched me or shown me any of this. ”
He said, “ It’s gone, ” and he started to cry Because he realized now what the system had done to him In the meantime, he lost his job and he realized that he’d been stolen from, and those are his words
He said, “ They stole my career from me, giving me that book, ‘How to Live with My Back Pain.’ Why didn’t anyone show me what my pain was like? You just did in 30 seconds. ”
Because he realized now what the system had done to him
In the meantime, he lost his job and he realized that he’d been stolen from, and those are his words
You could see it a mile away

Those are two stories to link the mechanics, and ultimately what we’re trying to do is to empower people in showing them they have the ability within themselves. They just need to understand the mechanism. And most of the time they are able to mitigate the cause, and then build a robust foundation .

Empowering patients through education and understanding of their pain through Stuart’s clinic and work through BackFitPro [1:39:00]

Stuart wrote Back Mechanic , and he started the experimental research clinic at the University of Waterloo

He’s never heard of another clinic where they follow-up with every single patient that they ever saw
We did a two-year follow-up with every single patient who came in, and we subcategorized them, because we assessed everyone into the mechanism of their pain pathway
We gave them an appropriate exercise prescription
We followed up to see did they even comply, because some people didn’t, and then how are you doing after two years?

Stuart’s experience on the efficacy of empowerment and they psychology issue

If you were in the subcategory that everything has failed, you’ve been told you need surgery, so you’re at the end of the road now, you’re a surgery case In the two-year follow-up, following the plan that he just described, with this thing called virtual surgery (which is part of it) 95% reported that they avoided surgery and they were glad that they did
In the two-year follow-up, following the plan that he just described, with this thing called virtual surgery (which is part of it) 95% reported that they avoided surgery and they were glad that they did

What stands out to Peter in most of these stories is Stuart’s consistent, adamant drive toward understanding the mechanism of pain

It’s a question of, “ How do we break this down into a physics and biology problem? ”

Peter asks, “ Is your Ph.D. through the School of Kinesiology? ”

It is, but there is a lot of mechanical engineering in there
When Peter thinks of all the different practitioners that interact with patients who have lower back pain; ranging from neurosurgeons, orthopedic surgeons, chiropractors, physical therapists, kinesiologists There are so many people And Peter never wants to suggest that the profession determines the school of thought He really thinks there are great people, and there are lousy people, within all of those categories
In all of Peter’s bouts of misery, nobody ever explained to him what was going on
Even as a medical student, he could look at the MRI and see the fragment It had come out, and it might’ve taken months for it to be reabsorbed
There wasn’t a discussion of, “ We need to understand the ‘why’ this is happening, so that we’re going to fix the underlying behavior that’s causing it .”
There are so many people
And Peter never wants to suggest that the profession determines the school of thought He really thinks there are great people, and there are lousy people, within all of those categories
He really thinks there are great people, and there are lousy people, within all of those categories
It had come out, and it might’ve taken months for it to be reabsorbed

What are the characteristics that you see driving that type of search for a true mechanistic understanding of the pain?

Is that a function of the individual or of the school of training?

Both

No billing code exists for an assessment of back injury mechanism (you can’t bill an insurance company)

When Stuart started the experimental research clinic, he set aside 2 hours to see a back-pained person That’s all he ever saw patients for, 2 hours He had not been through medical school training, and had only have ever been a guest professor at a medical school
That’s all he ever saw patients for, 2 hours
He had not been through medical school training, and had only have ever been a guest professor at a medical school

His medical colleagues asked what he was with patients during that 2 hours

Stuart had spent 30 years figuring out how to test shear, tolerance to compression, pulling a nerve root one way and the other Is is flossing? Is it friction? Etc.
He set a handful of people in the world that would take cadaveric spines and create the injuries
Is is flossing? Is it friction? Etc.

So he knew how to measure them, and what to look for in terms of the full pattern

The first political impediment to all of this is there’s no billing code

Therefore, you’re left with clinicians who are billing for a procedure that they’ve been trained to perform
Stuart explains, “ If you have nonspecific back pain, it’s an absolute crap shoot . Whether a manipulation for mobility, an exercise prescription for stability, just a movement tool, not to create a stress riser or a stress concentration on the tissue that is sensitized. Simple as that. ”

The solution is to train clinicians, and that’s what Stuart has been doing through BackFitPro

He doesn’t care if you come from a chiropractic, physical therapy, coaching, training, physiatry, neurology, radiology even, background
All he cares is that you have passion

It’s a 50-hour online course of Stuart going through anatomy, physiology, neurology, psychology, biomechanics, etc., and then, the probably 100 subcategories of pain mechanisms

Then how do you test for all of these, and then how do you coach them?
After all of that, we have three days together where we do hands-on skills training at a table
There’s no subcategory in the medical rubric that trains how to assess back pain from the perspective of biomechanics, psychology, neurology, physiology, etc. (they don’t exist) That was Stuart’s challenge
It’s called the Summit course , and you can read about it on backfitpro.com
That was Stuart’s challenge

Peter asks, “ Is it only for practitioners, or is there a variant of that course that an individual can take to become sort of the master of their own domain? ”

Stuart has only known clinicians to register for it
He doesn’t think they would stop a member of the lay public from taking it
However, the gatekeeper of all of this is there’s a fairly extensive written exam at the end Also, there’s a practical exam, where the person must assess a real patient, usually online with one of Stuart’s examiners They have to come up with a written explanation of the pain pathway, and then a program of what they’re going to do with the person, and then they have to coach elements of it So they have to see the coaching scale, as well
Stuart is agnostic in terms of preparation There are fabulous chiropractors and there’s the absolute opposite. There’s fabulous therapists, there were fabulous professors and terrible professors
Peter thinks this is a very interesting course and would love to figure out a way to make the time 50 hours online and 3 days in person
Also, there’s a practical exam, where the person must assess a real patient, usually online with one of Stuart’s examiners
They have to come up with a written explanation of the pain pathway, and then a program of what they’re going to do with the person, and then they have to coach elements of it So they have to see the coaching scale, as well
So they have to see the coaching scale, as well
There are fabulous chiropractors and there’s the absolute opposite. There’s fabulous therapists, there were fabulous professors and terrible professors
50 hours online and 3 days in person

When surgical interventions may be appropriate, and “virtual surgery” as an alternative [1:46:45]

We’re not talking about surgery without understanding how you got there
It should always be assumed that you want to understand how you got there [understand the mechanics of the pain]

What are the indications in your mind for where a patient is better off getting a surgical procedure?

Also talk about what you think are the best indications for discectomy, fusion, etc. versus where would you take a contrarian approach, where many people would say, “Yes, surgery,” and you would say, “Let’s push a little bit harder before. ”

In the follow-up visits with patients at Stuart’s clinic, 95% of the people who were told they needed surgery avoided it

Patient 1: a stay-at-home mom with two young kids who every day has to go to the gym and ride the elliptical for 20 minutes as a stress reliever

Stuart will tell her to get the surgery and ask if they are going back to the gym the next day No, they would lay in bed and behave like a post-surgical person Then they would slowly build themselves back
In other words, surgery may work for them because it’s forced rest
Stuart recommends, “ Now I’m going to give you a tool that will mimic the forced rest. It’s called virtual surgery . Tomorrow, here’s the plan. Here’s how you’re going behave. We are going to desensitize, strategically, the pain mechanism as we’ve measured it, and we’re going to retune your body with strategic mobility and stability plus movement skill, so we don’t replicate the stress concentrations that caused your problem in the first place. Let’s see how you are .”
No, they would lay in bed and behave like a post-surgical person Then they would slowly build themselves back
Then they would slowly build themselves back

If they can do that, 95% will avoid surgery

Peter asks, “ What are the patients who you would not offer that virtual surgery to? ”

We don’t take patients off the street, ever They always come through physician referral So Stuart is hoping they’ve been checked for red flags He adds, “ Do you know how many have not, even though we state in the referral directions to the referring medic? ”
1 – Looking for obvious red flags is #1
2 – Number two is when the pattern doesn’t fit
Stuart was smiling when Peter was telling his original story, only because it was such a familiar spot on pattern consistency Peter fit the pattern, and Stuart knew exactly what it was
When it doesn’t fit the pattern, Stuart will send them back to their doc Maybe there’s a turgidness under the patient’s liver, and they’re not able to move that pain by moving stress concentrations around the spine So it’s not a nerve It’s nothing vertebral or facet
They always come through physician referral
So Stuart is hoping they’ve been checked for red flags He adds, “ Do you know how many have not, even though we state in the referral directions to the referring medic? ”
He adds, “ Do you know how many have not, even though we state in the referral directions to the referring medic? ”
Peter fit the pattern, and Stuart knew exactly what it was
Maybe there’s a turgidness under the patient’s liver, and they’re not able to move that pain by moving stress concentrations around the spine So it’s not a nerve It’s nothing vertebral or facet
So it’s not a nerve
It’s nothing vertebral or facet

In terms of patients who need surgery

Stuart sees far too many post-surgical patients Maybe their surgery was botched When Stuart sees a horrible scar on the outside of the skin he wonders what carnage has gone on inside
Sometimes it’s a “shit happens” story The nerve scarred in and adhered Or the post-rehab was terrible Maybe they’re given toe touches after a micro disc surgery and now they’re re-herniated
Maybe their surgery was botched
When Stuart sees a horrible scar on the outside of the skin he wonders what carnage has gone on inside
The nerve scarred in and adhered
Or the post-rehab was terrible Maybe they’re given toe touches after a micro disc surgery and now they’re re-herniated
Maybe they’re given toe touches after a micro disc surgery and now they’re re-herniated

The surgeons are at their best in cases of a real heavy stenosis

So there’s not much room in the neuro canal
The facet joints are thick in behind, so you’ve got encroachment from behind
You’ve got a calcified disc bulge coming from the front
Surgeons are best at providing a couple level laminectomy to give the nerve some space

Some of the spondylomalopathies are obvious surgery cases

An obvious one is post-trauma, and they need a little bit of hardware to stabilize their spine, but it may also be spondylolisthesis The listhesis, or the shear translation, is just choking off the cauda equina , or another nerve In that case, we recommend surgeons who we have really good luck with
The listhesis, or the shear translation, is just choking off the cauda equina , or another nerve
In that case, we recommend surgeons who we have really good luck with

Peter asks, “ In that situation, if the spondylolisthesis is significant enough, is the only treatment a fusion? ”

Yes
Peter asks about any stability you can generate in the paraspinous muscles , in the QL , in the psoas to compensate for that?
He would assume that there’s some threshold: 1 mm of spondylolisthesis might be tolerated, and at some level they would say, “ No, it’s too unstable. ”
Stuart wouldn’t agree with that ‒ it’s not the distance at all You go with the assessment
You go with the assessment

Evidence Stuart offers

In the clinic they are inundated with athletes who are taperin now for the Olympic trials
They come in pairs
We might have 2 young women who are competing for a place on the U.S. Olympic Team in gymnastics, both have the same spondy One they’ll recommend 6 months off of gymnastics, and a heavy stabilization program The next one really wants to make it to the trials Stuart can predict with 100% accuracy, who’s going to make it
He wouldn’t say at all that we don’t try a heavy exercise stability program, regardless of the amount of slippage And he’s done that with people trying to make the Special Forces in the U.S. You’ve got to do a speed sit-up test and all of these things with a heavy spondy He gives them the program to try and get there, and they might make it
One they’ll recommend 6 months off of gymnastics, and a heavy stabilization program
The next one really wants to make it to the trials
Stuart can predict with 100% accuracy, who’s going to make it
And he’s done that with people trying to make the Special Forces in the U.S. You’ve got to do a speed sit-up test and all of these things with a heavy spondy He gives them the program to try and get there, and they might make it
You’ve got to do a speed sit-up test and all of these things with a heavy spondy
He gives them the program to try and get there, and they might make it

Weakness, nerve pain, and stenosis: treatments, surgical considerations, and more [1:55:30]

What about nerve pain?

Patients who are either having weakness (such as a foot drop) or significant pain (like Peter had)

Stuart sees them all the time
If he can get the nerve pain to move on the assessment, please don’t have surgery Let the clinic have a try at it, and most of the time they will be pleased
Let the clinic have a try at it, and most of the time they will be pleased

“ If I can get the nerve pain to move on the assessment, please don’t have surgery. ”‒ Stuart McGill

Rules Stuart plays by …

Hypothetical assessment: a person who’s having intermittent sciatic pain , and the assessment reveals a ruptured annulus , a protruding segment of disk that depending on activity is getting nearer to the nerve root (that’s driving the sciatic pain)

Peter assumes that during the assessment, what Stuart is getting at is through some of those positional things (such as laying the person on their front, manipulating the legs) is getting the herniation to retreat into the annulus

So you’re saying if you can demonstrate resolution under a changing movement pattern, that gives you enough confidence that this doesn’t need to be removed surgically?

Stuart is not looking for resolution, but if he can move the pain a little bit; and, “ Can I make it worse, and can I make it better? Now I’m starting to understand the variables that make it worse, make it better, and I play with those. ” He’s not trying to sound boastful He’s trying to be scientific
Not long ago, during the NHL playoffs, Stuart flipped on the TV and listened to the announcer He recognized two of his patients in the NHL playoff series
A little bit later, he flipped to the Tennis Tour and saw another of his patient’s
That night on UFC, he saw another patient
He’s not trying to sound boastful
He’s trying to be scientific
He recognized two of his patients in the NHL playoff series

Stuart explains, “In one day I see three different pro sports. Every single one of them had sciatica when they came to me. That’s some evidence that I can offer.”

Stuart remembers one of those players in the NHL

If he fully flexed, he would stir up sciatica, and increase the risk of a full-blown acute attack
So we got him to move well, he played hockey, mindful of a skating style that he didn’t get too flexed up
We didn’t allow him to tie his own skates He said, “ Tying my own skates really set my back up. ” Now, NHL players are very particular about how they tie their skates, but they coached one of the training staff to tie a skates for him Some people will laugh at that, but that was all part of the plan to keep the capacity as high as he could to utilize in the game
How he sat on the bench was also instructed
He said, “ Tying my own skates really set my back up. ”
Now, NHL players are very particular about how they tie their skates, but they coached one of the training staff to tie a skates for him Some people will laugh at that, but that was all part of the plan to keep the capacity as high as he could to utilize in the game
Some people will laugh at that, but that was all part of the plan to keep the capacity as high as he could to utilize in the game

Another fellow in the UFC was no slouch

Jiu Jitsu really put his spine in a place where it could fire off an acute attack You do not want to be in the cage fighting for your life and having an acute attack
We would limit the mat time on Jiu Jitsu
He would stand up, do all kinds of things to minimize the cumulative stress on the disc bulge causing sciatica
He competed
Stuart is not afraid of nerve irritation, sciatica, etc., and it certainly doesn’t fall into the category of, “you need surgery.” We’ve proven that far too many times
You do not want to be in the cage fighting for your life and having an acute attack
We’ve proven that far too many times

Heavy instability, and when we fail to arrest the shearing movements, trapping nerves, a stenosis and it’s gone on for quite a time; when we can’t hack our way around it, it’s best to see a surgeon

Many different forms of stenosis

Central stenosis
It might be a foraminal stenosis and a bit of arthritic activity, where they can just basically take a dremel tool and burr out around the foramen or the hole at the lateral nerve comes out

Tarlov cysts: treatment and surgical considerations [2:00:15]

A Tarlov cyst

A lot of medical colleagues say, “ Well, a Tarlov cyst (the neural cyst), they don’t cause pain. ”
Stuart will prove to you very quickly whether or not that’s causing pain by pulling the nerve root one way or the other
Typical pattern recognition might be a physio: might do a slump test (which is you straighten one leg and you flex the spine and neck)
But the net stress in the middle of the cord is zero
You’re pulling it one way; you’re pulling it the other way It just goes into a little bit of tension If that’s a Tarlov cyst that won’t be triggered
A Tarlov cyst doesn’t like being pulled one way
That patient on an exam might say, “ I don’t get pain with a slump test, but I can’t stand driving my car .” When Stuart asks them to tell him about their car, they say, “ Well, I sit upright, put my head back, and extend my leg to push on the accelerator. ” He explains that they’re pulling the nerve root one way and asks, “ Where is the pain? ” In their big toe
Stuart is now going to inform his inspection of the MRI, because radiologists missed it They’re not going to find a Tarlov cyst distal on the fifth root But Stuart knows that the symptom and the assessment took him there logically to say, “ I know there’s something hanging up there that’s directionally specific. It’s not a friction, it’s a direction-specific tension. ” And he’s found a Tarlov cyst
The surgical procedure there is to try and drain the cyst Typically it comes right back But there’s a doc in Dallas who they refer all their patients with Tarlov cysts to
It just goes into a little bit of tension
If that’s a Tarlov cyst that won’t be triggered
When Stuart asks them to tell him about their car, they say, “ Well, I sit upright, put my head back, and extend my leg to push on the accelerator. ”
He explains that they’re pulling the nerve root one way and asks, “ Where is the pain? ” In their big toe
In their big toe
They’re not going to find a Tarlov cyst distal on the fifth root
But Stuart knows that the symptom and the assessment took him there logically to say, “ I know there’s something hanging up there that’s directionally specific. It’s not a friction, it’s a direction-specific tension. ”
And he’s found a Tarlov cyst
Typically it comes right back
But there’s a doc in Dallas who they refer all their patients with Tarlov cysts to

The evolution of patient assessments and the limitations of MRI [2:02:15]

Patient assessment

Stuart explains, “ After the first year of the experimental research clinic (running 2 years), I changed it to a 3-hour consult. ”
He needed more time
If the person was an old athlete, and they still had films He asks, “ Remember how we used to get MRIs? ”
They go through all the medical images
He asks, “ Remember how we used to get MRIs? ”

What are the things you are looking for in the MRI that maybe aren’t as readily apparent or obvious to the radiologist?

Peter presumes the can explain to somebody what the MRIs are showing But it’s showing axial cuts, coronal and sagittal cuts They’re T1-weighted They’re T2-weighted, so they highlight the disc A nice healthy disc looks white on the MRI Peter’s discs are jet black
But it’s showing axial cuts, coronal and sagittal cuts
They’re T1-weighted
They’re T2-weighted, so they highlight the disc A nice healthy disc looks white on the MRI Peter’s discs are jet black
A nice healthy disc looks white on the MRI
Peter’s discs are jet black

What are things you are picking up on that MRI read?

All of those things

The very last study he ever published as a professor was exactly that

He didn’t do very much cervical spine-specific work; most of it was lumbar
We took whiplash patients, and every single one of them had been denied compensation because they’re now more than 2 years post whiplash
They still continue to have symptoms
The medical profession and the legal system was declaring them pain magnifiers Saying they were exacerbating their pain for financial gain (terrible)
Saying they were exacerbating their pain for financial gain (terrible)

The MRs said, “There’s no reason for your pain.”

Really? The MR is a static picture. What do you expect?
We took video fluoroscopy, which is a real-time, moving X-ray We’re watching the bones move now and we would have them move through their pain And their pain wasn’t very rarely at the end range of motion It was actually somewhere in the middle of the range They would move their head like this and then the spine would clunk, and then they’d go, “ Ugh ,” and then they continue to move through
On the video of fluoroscopy, we’d watch the rotations occurring between every vertebra
We’re watching the bones move now and we would have them move through their pain
And their pain wasn’t very rarely at the end range of motion It was actually somewhere in the middle of the range They would move their head like this and then the spine would clunk, and then they’d go, “ Ugh ,” and then they continue to move through
It was actually somewhere in the middle of the range
They would move their head like this and then the spine would clunk, and then they’d go, “ Ugh ,” and then they continue to move through

But we know what instability is: it’s when the rotation stops and the shear begins. The ratio of rotation and shear is the marker of that cervical instability

Stuart shows with his hands: here would be the neck moving, rotating well, and then it would clunk It was the clunk that corresponded 100% with the shot of pain
Now, you and I both know that when a muscle contracts, it does 2 things: it creates force but it also creates stiffness
It was the clunk that corresponded 100% with the shot of pain

The body uses stiffness to control motion

Stuart asks us to observe him (you can play along if you like)

Lightly stack your ears over your shoulders and have a pitch to your head that’s neutral
Stare straight ahead
Now, lightly touch yourself under your jaw, just above your Adam’s apple. Don’t retract your two stiff feet
Relax
Now, push your tongue hard to the roof of the mouth behind your front teeth You felt the deep flexors activate Now corners of your mouth, grimace down
Do this to your neck
Now keep that
Imagine the person who’s rotating and then has the clunk
Keep that controlling stiffness and repeat the offensive movement
You felt the deep flexors activate
Now corners of your mouth, grimace down

Would you believe in most people the clunk was arrested? It was gone, proving that the MRI had no ability to pick up that dynamic pain trigger.

We just proved what their pain trigger was
You can imagine the psychological relief that they had to know that it isn’t in their head
The medical profession was wrong
And finally, they’re empowered now, because they have a strategy to start learning just a little bit of a strategy to take the clunk out

If you arrest the clunk over time, the joint will stiffen. The bad news is you don’t move so well through that joint. The good news is the pain clunk is gone.

Pain relief related to stiffness and muscle bulk through training [2:07:00]

If you’re in your early 50s

Things are going to be stiffening in your body, and you’re going to be experiencing this now over the next 15 years particularly
The good news is your pain will go

You know who really gets this?

Stuart has worked with a couple of former Mr. Olympias That’s the top professional level of bodybuilding
They put a lot of mileage on their joints
They don’t really get joint pain when they’re competing because the muscles are so big, so bulky They have enormous wrench handle moment arms and the stiffness holds the joints together
When we work with them tapering down back to civilian life, some of them don’t look that different than you and me
Believe it or not, they ache like hell All their joints have these shearing translations to them now
That’s the top professional level of bodybuilding
They have enormous wrench handle moment arms and the stiffness holds the joints together
All their joints have these shearing translations to them now

The cure is getting a little bit of the muscle bulk back to add some controlling stiffness and all their aches go away

Stuart doesn’t know if that answered Peter’s question on instability, sciatica, brachial plexus nerve traps, numb thumb and first finger
They’re not indicators for surgery at all
Try some of these voluntary skills and let nature take its course Most of the time it will work out well with some patience and skill
Most of the time it will work out well with some patience and skill

Peter’s experience going through his MRI

One of the really good spine surgeons Peter knows, she is happy not to operate The really good surgeons are really happy to not operate on somebody Partly what makes them so good is their judgment about when to and not to operate
Peter goes through all his MRIs with her, even if it’s not a dedicated spine MRI
They’re always collectively amazed at how bad his spine looks on MRI, relative to the fact that he doesn’t have any symptoms
One of the discussions they had prompted her to contrast Peter’s back with that of another patient she had who has no obvious disc pathology, and yet is in debilitating pain She explained, “ Look at the difference in the musculature of your psoas, your QL, your erector spinae. These are big beefy muscles here, and now compare it to this other patient. First of all, the muscles are about half the size and they look like Wagyu. They’re very fatty. ” Her interpretation was that this person never lifted anything in their life, and though they don’t have any disc pain, their discs haven’t been decimated like Peters, but they’re more debilitated She explained, “ Their inactivity has led to instability and tremendous pain .”
The really good surgeons are really happy to not operate on somebody
Partly what makes them so good is their judgment about when to and not to operate
She explained, “ Look at the difference in the musculature of your psoas, your QL, your erector spinae. These are big beefy muscles here, and now compare it to this other patient. First of all, the muscles are about half the size and they look like Wagyu. They’re very fatty. ”
Her interpretation was that this person never lifted anything in their life, and though they don’t have any disc pain, their discs haven’t been decimated like Peters, but they’re more debilitated
She explained, “ Their inactivity has led to instability and tremendous pain .”

Both Peter and Stuart agree that both the deadlift till you drop strategy and the do nothing strategy are bad. Can you speak to why that person might be in pain?

Peter doesn’t want anybody to come away from this podcast feeling, “O h, I better not lift weights ,” because that’s clearly the wrong message
Stuart would want to know this person’s training program or daily routine in physical terms
He’s willing to bet she’s a mobility monster She keeps pushing the end range, softening the joints even more So, on MRI, they look plump and pristine He bets if we put her under a load, or we put her in bed, and she had this instability that he’s showed earlier, and she lays in bed, and the joints just fall like that a little bit, she’ll get a hell of an ache to her back
His first question would be, “ When you roll over in bed, do you ever have a sharp pain? ” That question is so indicative of if she has nice plump discs, but micro movements
Asking, “ How many pillows do you go to bed with at night? ” is a wonderfully telling question The more the pillows, the more the joint instability It’s a quite high correlate
If he had a conversation with her, he bets we will get some real insight from that, versus the person who has a mature strength history, and the joints are held together, a little bit of arthritis
She keeps pushing the end range, softening the joints even more
So, on MRI, they look plump and pristine
He bets if we put her under a load, or we put her in bed, and she had this instability that he’s showed earlier, and she lays in bed, and the joints just fall like that a little bit, she’ll get a hell of an ache to her back
That question is so indicative of if she has nice plump discs, but micro movements
The more the pillows, the more the joint instability
It’s a quite high correlate

“ People are going to nail me for this one, but a little bit of arthritis is good for adding certain amount of joint stability and holding it all together. ”‒ Stuart McGill

Stuart had a fracture of C4 as a young fellow

He would have some terrible episodes checking his blind spot or craning his neck to back a trailer up or something
He has zero pain now
His neck is bulletproof again
It looks horrible on a CT or an MR

His point is the arthritis has now stabilized the joint. All the pain’s gone. He doesn’t move it very well, but he doesn’t worry about it.

Another example where an MRI is not predictive of pain or activity level

Stuart’s sister is a vet, and she sends him the X-rays of a dog Terrible
A you know, spine arthritis and nerve compromise in dogs is very breed specific They lose their hind end It just atrophies just like in a person
She says, “ What do you think this dog’s doing right now? ” And Stuart said, “ Well, it’s just laying in its bed. ” She goes, “ No, that just won the frisbee catching championship .”
Terrible
They lose their hind end
It just atrophies just like in a person
And Stuart said, “ Well, it’s just laying in its bed. ”
She goes, “ No, that just won the frisbee catching championship .”

So again, Stuart keeps coming back to the assessment

Stuart doesn’t want to see another MRI of his spine unless the pattern doesn’t fit and he can’t move the pain anymore An MRI of his spine doesn’t look so good; he’s got a few miles on his back
Stuart does everything he wants to do with certain guidelines He’s not 16 and he doesn’t have infinite capacity So, he plays with that tipping point all the time
An MRI of his spine doesn’t look so good; he’s got a few miles on his back
He’s not 16 and he doesn’t have infinite capacity
So, he plays with that tipping point all the time

Advice for the young person on how to keep a healthy spine [2:14:15]

What would you say to the person who’s watching or listening to us right now, who is in their 20s or 30s; how would you counsel them with respect to what they could do to maximize the longevity of their spine?

Stuart replies, “ A young fellow comes into your office with a cigarette hanging out of his mouth, what would you say to him that he hasn’t already heard? I would love to take you over to the cancer ward at the hospital and I want to show you how your last days are going to look. That might convince a few of them on the lunacy of what they’re doing to themselves. It won’t be a hundred percent effective, and I would hazard a guess it wouldn’t be close to a hundred percent. ” That’s how he answers this question
That’s how he answers this question

Stuart doesn’t have very good luck when he sees someone who’s just all balled up

A 30-year-old called him last week, all balled up, he says, “ Whenever I do exercise, I’m just exhausted. ”
Stuart asked the caller to get someone to hold his cellphone away from him so he could see all of him, and he asked him, “ When you sit at your chair, sit upright. Do you have any pain? ” No
Next he said, “ Good. Drop your chest down and slouch and lower your head. Do you have pain? ” Yeah, I do
Stewart replied, “ Now, don’t you think I just proved to him what caused your pain? ” He said, “ Well, I’ve heard that before. I’ve sat like a cashew since I was 14 .”
Stuart coached him to sit up, and also lay on his tummy for a bet to let this thing calm down
He asked him what he does when he gets up in the morning The man gets a cup of coffee and drives to work
Stuart replied, “ Tomorrow I want you to get up half an hour early and go for a walk. ” Do you know he was bucking on that?
No
Yeah, I do
He said, “ Well, I’ve heard that before. I’ve sat like a cashew since I was 14 .”
The man gets a cup of coffee and drives to work
Do you know he was bucking on that?

The point is, Stuart doesn’t think he changed his behavior one little bit and he’s going to have to suffer more before he comes to a realization that he does have the power to do something

Peter shares this sentiment exactly
That’s why he’s often referred to his third bout of back pain (the one that lasted a year), as the best worst experience of his life He wouldn’t wish that duration or depth of pain on anyone But what was so good about it is that it lasted for so long that it created a lifelong change in behavior, and an appreciation for something which is without that experience, this idea of a centenarian decathlon wouldn’t exist
Peter explains, “ You have to sort of see what a life looks like with immobility and pain. Because even though I was only 27, I lived that year as though I was 87. And a year is long enough that it imprints .”
If it was only a week, no matter how bad it is, he doesn’t think it would’ve imprinted
He’s said this before many times, “ But to this day, I still enjoy parking as far away as possible in the parking lot, even if there are plenty of spots close to the grocery store or wherever. Because I remember what it was like to not be able to walk from the car to the grocery store .”
He wouldn’t wish that duration or depth of pain on anyone
But what was so good about it is that it lasted for so long that it created a lifelong change in behavior, and an appreciation for something which is without that experience, this idea of a centenarian decathlon wouldn’t exist

Peter thinks it’s probably the nature of our species in that it’s very difficult to make a short-term sacrifice for a long-term objective without a more pressing reason

The larger population listening to this are people who have experienced back pain personally or watched someone they care about go through this

What are the best resources we can point people to that can help with the types of exercises, maybe some do’s and don’ts around lower back pain?

Peter loves that he clarified the big 3 are great if you need stability

But if you need mobility, we might need something different

Stuart challenged himself with exactly the same issue 15 years ago just as the internet was getting going

“ But here’s the thing: There is no such thing as nonspecific back pain. ”‒ Stuart McGill

And if that’s what the person operates on in their strategy, this nonspecific thing, it will only be dumb luck if they’re able to come up with a strategy to mitigate it

They have to have an assessment; they can go and see someone who is very knowledgeable in converging on an understanding of their pain most of the time

This is why Stuart wrote Back Mechanic

Now it’s not on the internet, and the reason is they have to have some background understanding of how their back works and then go through a series of self tests That’s what the book does
The first thing is it just says, “ Draw a table. What are activities that cause you pain? What are activities that either take your pain away or are neutral? Write them all out. ”
That’s what the book does

Here is how you pattern recognize activities that cause you pain

All of those activities involve you bending backwards
Change a light bulb overhead, and that triggers your pain? We’re starting to learn a little bit about what could the candidates be
Then we take them through some physical tests Sit on a chair, slouch, extend, drop one shoulder back Hold five pounds out at front with arms straight (so that’s a compression test) Then we do a few self-shear tests
Then we do some nerve tensioning postures to start converging on subcategories of their pain
Then we say (for a simple one), “ If you have this subcategory, you get pain when you sit in front of your computer. Going for a walk is relieving .”
The next person sitting in the computer is their relief, and they go for a walk and that causes their pain Probably more in the stenosis older person kind of category The other one is a younger dynamic disc bulge
We’re starting to learn a little bit about what could the candidates be
Sit on a chair, slouch, extend, drop one shoulder back
Hold five pounds out at front with arms straight (so that’s a compression test)
Then we do a few self-shear tests
Probably more in the stenosis older person kind of category
The other one is a younger dynamic disc bulge

Advice

1 – Stick with lumbar support
2 – Have a strategic exercise session that you do every day You’re going to do the big three We’ll mobilize the hips
You’re not going to sit longer than an hour at your computer You just cannot reach a stage of sufficient health if you continue with that behavior, etc.
So, that’s why you won’t find it on the internet
You’re going to find a lot of people who do not have the expertise but offer a quick fix for your back pain
You’re going to do the big three
We’ll mobilize the hips
You just cannot reach a stage of sufficient health if you continue with that behavior, etc.

Stuart has a little bit of good news for Peter in terms of his back

Stuart retired early; he retired at age 60
He reached a stage where he realized what his job was
He started as a professor in 1986
Student meeting meant students came to see him, and they would get up and they’d work through things They’d do things in the laboratory and whatnot
Students started to migrate to this idea, “ Oh, sir, could we have an online call for student hours? ” His answer was, “ No, you can’t. You get down here. ”
In other words, Stuart’s job turned into a sitting job and it was killing him
He realized his health and fitness was declining
He still walked to the university He strategically bought a home right on the edge of campus so he would have a 20-minute walk to and from
Still, he was declining
So he walked away; he shut the door to his office
He never thought anyone would ever ask him again, as he’s not producing new data anymore
But he was wrong on that estimate
They’d do things in the laboratory and whatnot
His answer was, “ No, you can’t. You get down here. ”
He strategically bought a home right on the edge of campus so he would have a 20-minute walk to and from

The point is, he healthier now than he ever was in the latter 15 years of his computerized work life

He rarely goes on the computer and it’s fabulous

“ But my point in this story is I think you’re going to look forward to a resurgence of your health. Maybe you’ve got it dialed in… maybe you don’t. ”‒ Stuart McGill

Stuart suggests that retiring doesn’t mean leaving your whole medical family and expertise
He’s still working, and he sees patients 2 days a week, but the other 5 days, he lives a healthy life

Resources for individuals dealing with lower back pain [2:25:30]

Many people listening are going to say, “ You know what? I am not happy with the assessment or lack thereof that I’ve received. I’m not happy with the care that I’m receiving with respect to my lower back injury. I need to go and see Dr. McGill. ”

What is involved in arranging that type of consultation with you?

Stuart feels awkward saying this, but that is why he wrote Back Mechanic
He doesn’t see anybody until they’re read the book
Most of them say, “ I don’t need to see you now. ” They’ve been through the self-assessment They’ve got enough out of it
If they’re not getting enough from the book, on his website ( backfitpro.com ), we have two layers of clinicians
1 – We have the Certified Clinicians who’ve taken that 50-hour course They’ve gone through the hands-on skills training They’ve written the exam But Stuart has never worked with them personally
2 – We have a different level called Master Clinicians Stuart has worked with every single one of those people and trained them He’s seen patients with them They have his confidence now that he can send them any patient and they will subcategorize them and know pretty well what to do with them Stuart will continue to train those individuals He seeks out stars or people who have the passion and the skill to study with him and become one of their master clinicians
They’ve been through the self-assessment
They’ve got enough out of it
They’ve gone through the hands-on skills training
They’ve written the exam
But Stuart has never worked with them personally
Stuart has worked with every single one of those people and trained them
He’s seen patients with them
They have his confidence now that he can send them any patient and they will subcategorize them and know pretty well what to do with them
Stuart will continue to train those individuals
He seeks out stars or people who have the passion and the skill to study with him and become one of their master clinicians

How many master clinicians are there in North America?

12-15 (not many)
They are all identifiable on the website
The number of certified clinicians are growing all the time There’s 30-40 of them They add to that every couple of months
Stuart’s book is a quick read, but it was a very difficult book to write Writing medical textbooks for medical colleagues is easy: you putin references, you make your points, you show the strength of evidence But you can’t do that with the public You have to give them enough of the truth to guide an effective strategy You can’t overwhelm with with jargon, and that’s why those things are difficult to write
There’s 30-40 of them
They add to that every couple of months
Writing medical textbooks for medical colleagues is easy: you putin references, you make your points, you show the strength of evidence But you can’t do that with the public You have to give them enough of the truth to guide an effective strategy You can’t overwhelm with with jargon, and that’s why those things are difficult to write
But you can’t do that with the public
You have to give them enough of the truth to guide an effective strategy
You can’t overwhelm with with jargon, and that’s why those things are difficult to write

Stuart’s book ( Back Mechanic ) is his solution to this conundrum

Going to the internet (the “wild west”), you can get screwed up as much as you can be helped

Selected Links / Related Material

BackFitPro : Back Pain Rehabilitation, Injury Prevention & Exercise | BackFitPro (2023) | [1:15]

Book by Professor Kirkaldy-Willis : Managing Low Back Pain by William Kirkaldy-Willis, 4th edition (1999) | [24:15]

Anatomy models of the spine : Dynamic Disc Designs (2023) | [27:45]

Partial disc herniations corrected with traction and motion : Disc prolapse: evidence of reversal with repeated extension | Spine (J Scannell & S McGill 2009) | [52:30]

Stuart’s big 3 exercises : Stuart McGill’s “Big Three” Low Back Exercises | Chiro Center (2023) | [56:15]

Stuart recommends this video explaining his big 3 exercises : 3 Core Exercises You Should Do EVERYDAY! (The McGill Big 3) | YouTube (elifts, B Carroll 2021) | [56:15]

Muay Thai athletes punch harder after doing McGill’s big 3 : Effect of long-term isometric training on core/torso stiffness | Journal of Strength and Conditioning Research (B Lee & S McGill 2015) | [1:02:00]

Testimonials on Stuart’s website : Testimonials | BackFitPro (2023) | [1:23:00]

The monster walk : The Monster Walk Exercise Targets Your Entire Lower Body With Just a Mini Band | Caroline Juster, Livestrong (2023) | [1:25:00]

Stuart’s book : Back Mechanic by Stuart McGill (2015) | [1:39:00, 2:20:48, 2:27:30]

Stuart’s Summit Course : McGill Method Summit | BackFitPro (2023) | [1:44:15]

Additional training for clinicians : Become A McGill Method Provider | backfitpro.com (2023) | [1:44:15]

Stuart’s study on whiplash patients : Digital tracking algorithm reveals the influence of structural irregularities on joint movements in the human cervical spine | Clinical Biomechanics (C Balkovec et al 2018) | [2:03:30]

Articles written for the layperson on Stuart’s website : Category: McGill Articles | backfitpro.com (2023)

People Mentioned

Kirkaldy-Willis (Canadian spine surgeon who wrote Managing Low Back Pain ) [24:15]
Joe Frazier (one of the greatest heavyweight boxers) [1:06:45]
Mike Tyson (world heavyweight champion from 1987 to 1990) [1:07:00]
Muhammad Ali (famous British boxer) [1:07:30]
Usain Bolt (sprinter and world record holder) [1:08:00]
Ed Coan (widely regarded as the greatest powerlifter of all time) [1:22:15]

Stuart McGill earned a Bachelor of Physical Education from the University of Toronto. He earned a Masters in Science at the University of Ottawa to earn a Masters in Science, then a Ph.D. at the University of Waterloo. Dr. McGill stayed at the University of Waterloo as a professor of Kinesiology and Health Sciences for 32 years. He is now a distinguished professor emeritus.

His laboratory and experimental research clinic investigated issues related to the causal mechanisms of back pain, how to rehabilitate back-pained people and enhance injury resilience and performance. During his academic career he authored over 240 peer-reviewed scientific journal papers, received many international awards, and mentored over 40 graduate students.

His work continues at Backfitpro Inc. where he is the chief scientific officer. He sees elite athletes and people with difficult back cases. He has also authored several books on the mechanics of pain, fitness, and performance as it pertains to the back including: Ultimate Back Fitness and Performance , Low Back Disorders , Back Mechanic , and Gift of Injury . [ backfitpro.com ]

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