Common 3 structures in your lower back that you need to know before having lower back surgery.

You have back pain that is tight, stiff, or sharp. Your morning pain could be something you are having a hard time shaking off. Or is it the idea of picking something off from the floor? With many people experiencing lower back pain, there are only a handful of lower back pain diagnosis that account for the majority of the lower back cases. We will be addressing three important structures in your lower back region that is playing a role in your spinal health, rehabilitation, and recovery.

Let us start out by establishing the 5 common diagnosis you may have been told.

  • Lumbar disc herniation, bulge, “slipped” disc, or other various disc related pathologies
  • Lumbar spine stenosis or spondylosis
  • Lumbar spondylolisthesis or instability
  • Sacroiliac joint dysfunction or pain
  • Muscle sprain or strain

These diagnosis are part of a sequence of spinal stress and loading patterns that the lumbar spine goes through but has trouble sustaining and recovering from these load patterns. Basically, you are not trained to do what you are doing or not recovering sufficiently, so the lumbar disc, vertebral body, facets, or neighboring muscles and joints fatigue and “fail”.

We quoted the word FAIL because failure of the anatomical structures has no connection to pain and mobility over the long term. You may feel pain for years, but research have demonstrated with high level of evidence that structures does not equate to severity of symptoms. The interpretation, process, and ability to execute certain movement skills WITH a combination of a comprehensive protocol of sleep hygiene, blood sugar regulation, and emotional health are factors that have been highlighted as being more important to spinal pain.

As we have mentioned the importance of understanding the progression of an inability to handle load and recover, the THREE structures play a role in most lower back pain and the 5 common lower back diagnosis. For obvious reasons, we did not say all lower back pain for conditions such as cancer, high-impact fractures, and inflammatory / auto-immune related diseases.


Lumbar spine vertebral end plate.

The end plate is located at the top and bottom of every vertebral body of the lumbar spine. The role of the end plate is to exchange nutrients to the vertebral body so it can withstand compressive forces. Got jumping or running? Have you heard of gravity?

When the end plate becomes compromised, you get subpar strength to your vertebral spine. Your disc ends up sharing the load. Your spine becomes less stable and the vertebral body fatigues. Your muscles and surrounding protective structures, like ligaments, have to work harder. If you work long hours or perform repetitive tasks, your muscles fatigue along with your spine. What we just laid out are the 5 common back diagnoses that occurs years after an end plate injury.

This is a crucial structure and usually impacted with a lifting, repetitive movement, or fall. The experience tends to bring on high lower back pain and muscle spasm to occur. This is the structure that many people might be feeling as their source of having lower back pain, but the attention tends to go to the surrounding muscles and joints. Vertebral end plate is a crucial structure since it deals with nutrients to your spine, that your lower back will do everything to slow you down. If you slow down and become bedridden, your body can focus on what is truly more important.

The good news is that your body bounces back from an end plate injury over time, because it is an area designed to get lot so attention when it is injured. The severity of ones lower back pain is dependent on the necessary chemical inflammation that happens during the injury. Remember that inflammation is your body’s way of self healing. Your muscle spasm is necessary so you stop your daily life for the triage unit of your immune system to figure out what it needs to do.

The trouble lies in the idea that we rush the acute phase, go back and perform the same reasons why we get hurt in the first place, and/or get mismanaged by medical clinics that provide rushed rehabilitation. The well intentioned clinician may not understand what is presenting to understand your pain presentation. They chase after the spasm but forget to realize that the end plate is the one that needs more attention.

Vertebral end plate thrives off of rhtymic loading and unloading. What do you get when you seek initial treatment? Muscle massage? Ultrasound? Ice or heat?

As this article cannot tackle the concept of daily habits and thought beliefs that drives pain, many rush their care since their spasm is less.

Did you go back to sit a lot?

Did you go back and perform lots of twisting motions?

Are you a go-getter and high achiever, that you need to get back to work or performing without the need to check-in with your body so understand where it is at in the recovery process?

Maybe you do not have the tools to check-in and self evaluate how you are?

These are what a Holistic Physical Therapist brings forth to a rehabilitation process.

Iliolumbar ligament

The iliolumbar ligament connects to your L3, L4, and L5. The other ends attach to your sacrum. Ligaments connect from bone to bone and limits the amount of motion that bones move.

If your ligaments are sprained and stretched out, your bones will move more than it should. When the iliolumbar ligament is injured, your L3, L4, L5, or Sacrum will move more than it should. Your lower back may be okay with this, but not over time.

Your sacrum promontory is the shelf of which the L5 sits on. The sacrum is tilted at an angle of 30 degrees, which the L5 needs to understand to rest in the neutral and middle of the sacral promontory. Imagine parking a car on a hill. If you have tight muscles or tight hips, your sacrum angle can be as much as 40-50 degrees sloping downward. Imagine parking your car in San Francisco!

Your iliolumbar ligament’s role is to help your lower lumbar spine from moving too much forward. We see this in athletes and patients with an arched, or hyperlordotic, posture. Common sports that promote this posture include gymnastics, volleyball, sprinters, water polo, and rotational sports. Females tend to demonstrate this posture.

As your spine has to control more lumbar movements, muscle fatigues happen. You feel back spasms. It goes away and your push on. Your disc is pointed as the villian to your pain. But the role of the disc is to absorb shock and share the forces of movement to your joints and muscles. As you can see how the disc is getting the brunt of the blame as your iliolumbar ligaments are not supporting the necessary forces.

Is it the posture that drives the iliolumbar ligament stress or the ligament impacting the lower back movement pain dysfunction? The answer is that it does not matter. You have to address the whole entire system. They feed off of each other, but the important takeaway is that you might have to do more smart spinal exercises and dose it properly to allow more support to make up for an under rehabilitated iliolumbar ligament.

Spinal dura

Your spinal dura is the sheath that surrounds your spinal cord. This is the same structure when you here the word “epidural” or “dura” injections.

The reason why this is important to your lower back pain is that your spinal cord connects to all your sensory and motor spinal nerves, including your brain. As we specialize in skull and nerve manipulation, any impact to your nervous system can place more sensitivity in your dura system.

  • Got carpal tunnel nerve pain?
  • Got stingers?
  • History of numbness or tingling anywhere in your body, even years ago?
  • Concussion?
  • Car accidents? Whiplash?
  • Play contact sports”
  • Got epidurals in the past?
  • Back surgery that your feel “failed” you?

All of the above scenerios are just a short list of nervous system events or experiences that impact the dura. You cannot impact the arm dural without impacting the lumbar spine dura. There is a part of your thoracic spine that narrows that tends to limit the amount of freedom your dura and nerves can move up and down the spinal column space. This correspond to the diaphragm muscle, or your breathing muscle. If you have a tough time getting deep inhalation of 5-7 seconds or exhalation of 10 seconds, you might have a restriction in this segment of your spinal column. You got a reason to practice your deep respiration and breathing exercises.

There is a specific way to test for dural mobility and health. Seek a trained physical therapist and ask them to check your lumbar spine dura. Or you can reach out to us and we would happy to guide you through a spinal dural test sequence, called a slump test.

We commonly find a dural restriction in all of the 5 common lumbar spine disorders, and is one of the holistic care that the people we help receive.


There you have the three structures that will result in more load onto the lumbar spine, which may result in your Spine surgeon, neurologist, or Orthopedist to diagnose you with the 5 common lumbar pain conditions mentioned at the top of the article.

We specialize in getting to the root cause of your lower back pain. You need to understand how and why your lower back is hurting and this is how you will get lasting relief. If you compare your body to a car, it is not the engine or brakes that is not allowing you to drive the car well. Yes, you need to get that fix by a mechanic, but if that is done, and your brakes can still squeak in a matter of a couple of months. The key is understanding the nuances and impact of the little things that impact the obvious experiences.

Do you need to get back to lifting?

Are you an athlete that is worried about how your golf or baseball swing will trigger a massive back spasm?

Do you wish to run but have been told that this is bad for your spine?

Reach out to us and we will guide you through these complex and confusing times.

We specialize in recurrent muscle tightness and the pain the comes with it. Get your expertise second opinion with a click of the orange button below.


Danh Ngo PT, DPT, OCS, SCS

Doctor of Physical Therapy

Board Certified Specialist in Orthopedic and Sports Medicine

Onbase University Certified Pitching Specialist

Certified Advanced Movement Specialist – RockTape

Certified Mobility Specialist – Rocktape

Mind Body Health Results Coach