Last Updated on February 26, 2025 by MASSAGE Magazine
Low back pain syndrome is one of the most common complaints addressed by massage therapists. Based on a 2018 National Health Survey, 28% of men and 31.6% of women aged 18 and older experienced lower back pain in the three months prior to the survey.1
Low back pain is a common issue that many people experience, and massage therapists frequently treat. A key factor in low back pain is how the pelvis moves and supports the spine. When the pelvic joints don’t move properly, it can lead to uneven force distribution in the body, putting extra stress on the lower back. This stress can cause problems like disc herniations or sacroiliac joint pain. By focusing on how the pelvis functions as a link between the legs and spine, and addressing muscle imbalances such as tight adductors, we can better understand and treat low back pain.
Lower back pain was listed as the leading cause of disability in the 2017 Global Burden of Disease Study.2 Because of its prevalence and impact, it’s always valuable to deepen our understanding and expand our toolbox to assess and treat its causes.
I will assume you already have a great grasp of different hands-on techniques you could apply and instead focus on deepening how to think about the body. Empowered with a more comprehensive understanding of structure and function, therapists can more effectively apply their favorite tools and techniques to produce the desired results.
Pelvic Biomechanics & Low Back Pain Syndrome
Let’s dive into the functional biomotion and structural relationships that play a role in low back pain syndrome.
First, we consider the structural relationships involved: the spine to the pelvis, the pelvic halves to each other, and the pelvis to the femurs. Of course, every part of the body is in relationship with every other part of the body.
We could consider how the foot is relating to the ground and lower leg or how the thoracic spine is relating to the head and lower back. But to keep us from spiraling out into the infinite interconnectivity of the body, we’ll focus our attention around the pelvis.
The pelvis acts as a fulcrum between the three longest levers in the body: the two legs and the spine. In order to balance and distribute forces among the legs and spine, the pelvis must simultaneously be adaptive and stable.
It accomplishes this by relying on subtle movement in the internal joints of the pelvis: the sacroiliac joints, pubic symphysis and sacrococcygeal joint. It also relies on movement in the external joints of the pelvis: the acetabulofemoral joints and the lumbosacral junction.3
Appropriate and balanced movement in these joints allows force distribution through the ligaments and muscles in, above and below the pelvis.
Effective force distribution implies that no single articulation is managing too much force or a trajectory of force for which it is ill-equipped. Consistent imbalance in motion and force distribution has the potential to lead to more serious conditions, such as disc herniations, labral tears or acetabulofemoral arthritis.
Think of a Newton’s Cradle (that swinging ball gadget people have on their desks). The force from the sphere you lift and drop is translated through the middle unmoving spheres and moves the sphere at the other end. The momentum is conserved. Similarly, when you take a step and your foot strikes the ground, it is translated through the entire body.
Now, unlike the unmoving spheres, each joint and its accompanying soft tissue has the opportunity to disperse that force, essentially dividing the force among multiple articulations rather than all the force landing in one place. Sometimes, articulations that should move do not—in which case, like the ball at the other end of the Newton’s Cradle, some structure (like a lumbar disc) far from the point of contact ends up experiencing more of the force than is optimal.
What does this have to do with lower back pain syndrome? Discs don’t just bulge or herniate themselves. This is either a response to blunt force trauma, or, more commonly, imbalanced usage over time that eventually leads to uneven compression of the disc, migration of the nucleus pulposus and weakening in the annulus fibrosis.
When addressing low back pain syndrome, we can therefore look for a lack of motion or imbalanced relationships elsewhere that burden the low back structures.
Causes of Sacroiliac Joint Pain
Consider the foundation for the spine: the sacrum. Just as the foundation of a building is fundamental to the structural integrity of any building, the sacral orientation and motion informs spinal orientation and motion.
The spine perches on the sacrum like a diver on a spring board, relying on balanced sacral nutation to provide force absorption. When we flex at the hip (like doing a squat, landing from a jump, or swinging and stepping onto the leg to walk), there is nutation (a nodding) in the sacrum and a few millimeters of movement in the sacroiliac joint. The sacrum is suspended in a web of ligaments throughout which force is dispersed during sacral nutation.3
If the sacroiliac joint is restricted, it impedes the movement of the sacrum and the dispersion of forces. The lumbar spine is then living on an uneven foundation, and greater force translates to the lumbar discs and joints with an imbalanced trajectory.
But the story doesn’t begin or end there. (It never does in the body, does it?)
Why is the sacroiliac joint restricted? We can assess this by assessing the positioning and movement of the ilia relative to each other. In cases of lower back pain, we commonly find that one pelvic half moves with significantly less freedom than the other.
There are about 35 muscles that attach to each pelvic half, relating them to the legs, trunk and each other. Any of them could be contributing to the positioning and restriction of movement, but there are some strong usual suspects: the adductor and hip flexor groups.
Therapists tend to be more familiar with the hip flexor contribution, due to their tendency to anteriorly tilt the pelvic half (which would also prevent it from moving relatively to the sacrum). Within this group, the iliopsoas will play a different role than the tensor fascia latae, rectus femoris or sartorius, and each can be assessed and addressed individually depending on their contribution.
However, the often-overlooked adductors are potentially a more significant contributor to pelvic half restriction and lumbar spine dysfunction. It cannot be overstressed: The adductors are often a major key to resolving lower back pain syndromes.
The origins of the adductors span the superior and inferior pubic rami all the way posterior to the ischial tuberosity. That’s a significant opportunity to pull on and restrict the ilia in relation to the femur. Pelvic half-movement is not a simple sagittal plane movement, it is triplanar.
When restricted, the adductors can hold the pelvic half in an anteriomedial tilt relative to the femur. The resulting asymmetrical alignment and function of the pelvic halves place the sacrum under slight torque, which is translated to the lumbar spine. This pattern also contributes to the sacroiliac joint pain and hip-and-labral issues we tend to see coinciding with the lower back pain syndromes.
We could continue pulling this thread and ask, “Why are the adductors tight?” but we’re not going to do that in this article. Due to the biomechanics and structural relationships laid out above, the adductors are a significant contributor to lower back pain syndromes and deserve their moment in our treatment spotlight. (Psoas and piriformis have had plenty of time in the limelight even though their contribution is truly not as significant as that of the adductors.)
You don’t have to take my word for it: Apply your favorite tools for effective myofascial release with the restricted adductors followed by functional release, if that’s in your tool belt, and observe the restoration of structural integrity and function in the pelvic and lumbosacral relationships.
Restore Thoracic Spine Extension
One final thought: I’d be remiss not to mention the thoracic spine’s role in all of this. We are a flexion-based society, sitting on the couch, at the computer, in the car. The thoracic spine has minimal opportunity to practice its mobility through extension, rotation and lateral flexion.
Just as with the lumbosacral relationship, this lack of mobility in the thoracic spine shunts the work of excessive force dispersion and even motion into the lumbar spine.
Restricted thoracic extension and tight adductors often pair together, putting the lumbar spine in an impossible predicament; therefore, a complete approach to addressing lower back pain syndromes includes structurally and functionally addressing the adductors and restoring thoracic spine extension.
Get Maximal Results
We do not move through life on a massage table, unfortunately, so massage, in addition to releasing tension, should optimize the body for everyday function. Pain patterns and injuries are functional issues.
To deepen your practice and improve your results, expand your understanding of functional biomotion and structural relationships. This empowers you to know exactly when, why and how to apply your hands-on techniques for maximal results.
Footnotes
1. “QuickStats: Percentage* of Adults Aged ≥18 Years Who Had Lower Back Pain in the Past 3 Months,† by Sex and Age Group—National Health Interview Survey,§ United States, 2018.” Centers for Disease Control and Prevention. cdc.gov/mmwr/volumes/68/wr/mm685152a5.htm. Accessed Oct. 15, 2022
2. “Findings from the Global Burden of Disease Study 2017”. Healthdata.org. . Accessed Oct. 24, 2022.
3. Franklin, E. Dynamic Alignment Through Imagery, 2nd Edition., 2012. Human Kinetics, Champaign, IL.
About the Author
Ann Teachworth, LMT, RYT-500, FME, is cofounder of advanced continuing education company Trunamics.com. She is an educator for massage therapists and yoga teachers, among other integrative and movement therapists, with an emphasis on embodied functional anatomy, kinesiology and mindbody training. She also facilitates cadaver labs with a focus on embodied application.