Problem-Solving Session: Deep Recap (Low Back Pain)
Kristin has had low back pain for ten years.
Ten years! That's a decade of waking up stiff, of modifying every workout, of running downhill and paying for it, of doing all the right things—the group fitness, the hiking, the RDLs, the approximately one million glute med exercises—and STILL BEING IN PAIN. That's ten years of practitioners who probably told her it's all connected and handed her a band and a prayer. Understandably, Kristin gave up on traditional PT a couple years ago, and she came to Dominique Garcia, an evolved coach here in Boulder and owner of Axia Movement, for help.
I'm going to walk you through exactly how I thought about this session, what I found, why I made the calls I made, and—most importantly—what the whole thing actually looks like if you're a coach sitting in a room with someone who looks exactly like Kristin.
This is a long one, but it’s worth it. We solved ten years of back pain in one session. I suggest putting on cozy pants and grabbing a snack.
Before she walked in, I already had a working theory. Actually, I had three.
She's had left-sided low back pain for ten years—sometimes the right side joins in, sometimes it's the whole lumbar region deciding to throw a party. She played soccer in high school. She has a history of labrum tears in both hips, which happened six or seven years before the back pain started. She's active in Boulder—hiking, running, group fitness. I wager she's the kind of person who is never not moving but probably moving in a very narrow range of ways.
That last part is the first thing I'm already chewing on.
Running downhill bothers her, which tells me her knees are getting loaded harder than anything else on descent. Group fitness means there's an almost total absence of hip extension, because the knee almost never ever goes behind the hip in those environments.
(A rear-foot elevated split squat comes close, but it's not significant enough to actually develop hip extension on that back leg, and that's about as aggressive as a group fitness class gets.)
Then she walks in, and I see her feet and knees turned out.
I call this the CrossFit posture, the powerlifting posture. People who have spent years squatting up and down with the ever-present cue of knees out, knees out, knees out until external rotation becomes their default operating system. For me, that's a really big clue.
If you know my tensegrity model, hip flexion usually pairs with external rotation, and hip extension should go with internal rotation and some adduction. So now I'm seeing an even hotter hotspot of a clue: she's demonstrating very little internal rotation in her gait, and she doesn't have great hip extension either. Oh, and she drops her right hip when she’s on her left side. We’ll come back to that hip drop later.
I'm looking at someone who's never spent much time in true hip extension. If she needs to get her knee behind her back and she can't get it from her hip joint, she'll borrow that motion from somewhere else. The low back volunteers.
That's hypothesis one: she's been substituting lumbar motion for hip extension, probably for years, possibly since soccer, and her low back is pissed about it. Her back pain, sitting right around the SI joint, low and specific, is consistent with this.
Hypothesis two: her quad or her soleus might not have the capacity to absorb load on the way downhill. If the load doesn't go into that spring at her knee, it has to go somewhere. (Guess where.) This would explain the downhill running specifically.
Hypothesis three is still forming. The answers are buried in her story somewhere—in things she's told us and in things she's omitted—and my job is to figure out what she hasn't tried yet. "Local problems, local solutions" is going to be the governing ethos of the session.
And yeah, yeah, yeah, I know there's this saying that goes around our community: it's all connected. And technically it is, but not everything affects everything else. Me doing anything to her wrists isn't going to do jack shit for her low back. So that's where our problem-solving is going to center: not her wrists, or anywhere else that cOnNeCtEd but not local.
(that's how it sounds to me, sorryyyyyyy)
Anyway, that is the canvas I'm currently working with.
Now… we FAFO.
I start with her dorsiflexion. She has high arches, and I want to make sure that's not impeding her ankles in any way. She looks fine.
Half kneeling squat (butt to heel), to isolate her quad. Both sides are easy. Her left side sounds pretty grindy. (My knees have sounded similar, I'm not worried.) I note it and file it. I'm looking for glaring weaknesses, some sort of big access point. Something obvious. I run her through it, but she's not failing. There's no smoking gun.
(This is the part of a session where some coaches would decide the quad is fine and move on. I'm moving on too, but I'm not deciding anything. I'm just not finding what I was looking for here. So now we do a different thing.)
Long stride lunge, and now I'm watching her hip extension—does her hip actually extend? Or does her trunk just fold forward to fake it? Her trunk folds a lot. I think she's tilting herself forward to avoid some of that hip extension, like her body has decided it would rather not go there. Same story on the other side. I note it and keep moving.
Her single-leg squat looks great. Moving on…
Her unweighted RDL doesn't cause pain. She needs around 35 pounds before it becomes a problem, and it's worse on the left, though both sides will eventually complain if she's already having a bad day. Noted.
Then we get to rotation. Russian twists, landmine work, anything involving rotation. All of it bothers her, which she describes as the baseline. She says she’s bracing her core, but that still does nothing, which is what I expect.
Here's the other thing I keep noticing: she really likes to bias toward rounding her low back. Every movement, her lumbar spine goes into flexion. Which means I haven't seen her do a single thing yet that puts her lumbar spine into the shape of a valley. And her back has been hurting for ten years. Here’s that third hypothesis that wasn’t immediately obvious in her story: she needs to train more lumbar extension.
I ask if she ever does anything that extends her low back. She foam rolls into extension every day. It feels amazing, she says.
Of course it does. It's the one time all day her low back gets to be in the shape it actually wants to be in.
A quick note on the hip drop I saw in her walking, because I want to address something before we go further.
There is a villainous hip drop that our community loves to make a villain out of. Oh no, hip drop, terrible, glute med, fire it up, here's your clamshell. And I'm not going to pretend hip drop is ideal. But I'm much more interested in WHY it's happening than in the fact that it's happening. Kristin has hip drop. Fine. Why?
I can tell you what I'm NOT going to do: load her up with glute med exercises. She's already done approximately one million glute med exercises. And I don't think my glute med exercises are so cosmically superior to everyone else's that they'll solve a problem that all the previous glute med exercises didn't. So we're going to go find the actual problem instead.
(This is not a knock on glute med training. It's absolutely a knock on assigning glute med training at the first blush of a crooked-looking pelvis or knee. Big difference.)
I put her on the reverse hyper.
First without any instructions. She does it with hip ER. No pain. But not much lumbar extension either.
Then, knees together, feet apart, meaning some hip internal rotation, and I tell her to arch as much as possible.
"I feel like I'm on the verge of, like, all my muscles cramping up in my back."
There it is.
Cramping is generally a clue for me. I like to think of it as a surge protector, as if the muscle doesn't have its own inherent capacity, so the nervous system just slams the breaker: get out of there, you're not strong enough for this yet.
It's like her muscles are the Starship Enterprise and her brain is Scotty
Cramping often means we found something underdeveloped, which means we found something to work on. As long as she's not actually cramping—like, not the full seized-up version—I want to stay in this neighborhood.
We repeat it. "I feel like that just released," she says. "I don't have that sensation as much anymore."
That's good.
The investigation continues!
Then I flip her to supine for a GHD sit-up. She reports some pinching in her low back. I try different positions, cue her into more arch. It's still there. More data.
I come back to the RDL. I want to see her maintain lumbar extension through the movement: create that same valley we found on the reverse hyper, but on her feet and hinged at her hips. Her rounding is immediate and reflexive. Her spine just goes there like it's got a gravitational pull toward flexion. I cue her. She tries. She loses it. I cue her again.
Her body has been doing this for years and you don't overwrite a decade of motor patterning in ten minutes. But we're finding the edges of it, and I want her to understand: the goal isn't just doing an RDL, it's doing her new RDL. The moment she loses that back position, she's done for the set, even if she could keep going. The shape is the standard now.
Then the rotation piece opens up its own chapter.
Kristin shows me the prone rotation work she started with Dom last year when Kristin was Dom’s case study client in the online course. Kristin lies on her stomach and tries to rotate one hip bone to the ground and then the other. What I'm watching for is segmental rotation, each lumbar vertebra moving independently, like a chain. What I'm getting is all bunch of vertebrae moving together, like a door on a hinge. Her ribs and her pelvis going as one package.
Noop. That's not what we want.
So I take over. I place two fingers on her pelvis and I move it for her. My other hand is on her low thoracic spine, feeling for stillness. The test is whether she can actually relax and let me work—and eventually, she does. We start to see something: the beginning of an S-curve like a winding mountain road, her upper spine staying put while the lower spine moves. That's what we want. Her ribs and her pelvis are moving separately.
(For anyone who coaches rotational sport athletes—baseball, volleyball, tennis, any of them—this is something I deal with constantly, even at very high levels. People who rotate a lot but not accurately. Instead, the whole torso goes at once. If we speak to probabilities, I'd guess Kristin hasn't been getting true rotation for a while despite doing “rotational exercises.”)
I start asking her to take over 1% at a time. Aaaaaand she does what everyone does: she goes from passenger to full driver in about half a second and immediately reverts to exactly what she was doing before.
"That was 20%, I say. "Try 1%."
We slow way, way down. The reason I use such small percentages is that when you try to move with a really high neural signal, there's a lot of noise in it—and that noise doesn't result in movement accuracy. When the signal is low, almost like just imagining the movement, it's cleaner. So we build it there first. I try different angles—leg flexion to create leverage. I'm looking for any door into this pattern. I'm just tinkering. There are always multiple doors.
She walks around after. "I feel more open in the front of my hip."
She takes two more laps, and I use this time to reassemble the chessboard. What does the picture look like now, and what are my next options?
I get her back on the GHD.
The pinching is significantly better now. It's not gone, but she notices the difference immediately without me prompting it. That's the kind of feedback you want to see.
The same pattern emerges in seated rotation: she rounds before she can rotate, like her spine has to collapse before it's willing to twist. I anchor her into extension and let her rotate from there.
"It feels better but this position is really hard for me."
I like hard and not painful. Those are my two favorite words in a session.
We try Russian twists with the same intervention: if she can maintain her lumbar curve through the rotation, the whole thing is manageable. But the second she loses extension, her back tightens up. I'm connecting dots. The rotation problem and the RDL problem aren't separate issues—or maybe they are, but they rhyme. She's been living in flexion so long that her body treats it as neutral.
I tell her what I'm seeing and ask her what she's taking away from all of this. She says: "It sounds like I round my back a lot." Yes. In almost every movement pattern she's built over the last decade. Yes.
Downhill running is a different problem, so I shelve it for now. There's only so much you can solve at once, and trying to solve everything at once usually means solving nothing.
There's one more thing I want to check.
I get her in a side-lying position and test her hip abduction and that glute med thing. It seems fine, unremarkable. Then I rotate her pelvis to bias the TFL specifically, aka the anterior part of the hip abductor complex, aka the one that also internally rotates, aka her problem side.
She's shaking.
"That feels like a weakness."
Her other side? Breezy.
The TFL is an abductor and an internal rotator, and this is starting to give me little clues about where the load is actually going. I think back to her soccer years. When you plant and kick, you basically create a hip drop pattern—maybe that started this hip drop thing? Over and over, thousands of reps, and your body just learns to live with that loading asymmetry. And the TFL never gets strong because it never has to be. It could go as far back as that. Or it was something else entirely. Your guess is probably as good as mine, to be honest. What matters is that we found it.
I ask her to walk around, take her body for a test drive.
"When I walked in this morning, I was aware of this feeling with every single step. I've had it for a while. Now walking just feels effortless. I don't feel anything impeding my gait."
Dom sees it too: Kristin has less hip drop and more internal rotation access. Her gait looks different.
So here's what we've got.
The biggest lever is lumbar extension. Kristin needs more of it everywhere—RDLs, reverse hyper variations, and eventually threaded through her rotation work too. The extension-biased reverse hyper with internal rotation, the one that almost made her cramp, is probably her highest-value homework right now. I recommend she do three to five sets to fatigue, every two to three days, then let it linger. A big dose on Monday should carry through until Wednesday or Thursday before the effects start to fade, then another big dose. Her nervous system needs time to absorb what it just learned, so we don't want to grind it into the ground six days a week.
The rotation piece is slower and more cognitive. This is the kind of thing where you work on it for six weeks and feel like nothing is happening, and then one day it just clicks. 1% at a time takes a fuck ton of patience. She can do this every day if she wants.
The TFL piece is the one I'm most excited about because nobody found it before. I recommend she side plank with the pelvis rotated forward to bias that anterior abductor before every run, every time, without exception.
So that's three findings: two of them are probably connected and the other has likely been hiding in plain sight for however many years.
If things get better, we've chipped away at a ten-year problem in about an hour of actual work. And if they don't—well, then we eliminate the variables we just found, adjust the hypothesis, and start again. With each successive session, we'd be basically eliminating variables and moving ever closer to solving the problem.