Fix Your Low Back Part 1: What Is Low Back Pain?

Low back pain is one of the most common causes of disability worldwide, responsible for BILLIONS of dollars spent on health care and lost time at work annually.  If you have ever experienced low back pain, you know that it can not only impact your hobbies and ability to remain active, but it can make even the most common of daily activities challenging.  Our goal with this series is to help you better understand the cause of your low back pain, provide real solutions to help you manage it, and show you that there are many care options out there, some you can do at home, that allow you to remain free of prescription drugs and surgery.  

Back pain is not a one-size fits all problem, there are most commons, but your approach to care needs to be as individual as you.  Without a proper and thorough assessment, it is hard to say which approach will work best for you, but through the experience of helping hundreds of people alleviate their low back pain every day, we can focus on a few of the most common causes and their proven strategies for relief.  


When we talk about low back pain and its prevalence, you are more like to experience low back pain multiple times in your life than to never experience it at all.  That being said, the presentation can vary from stabbing, shooting, and radiating type pain to a more dull, achy, and feeling of tightness. However you choose to describe this feeling, the trust is that it can and will disrupt your sleep, daily routines, and your desired recreational activities. There is good news at the end of this rope, and this is that the majority of low back pain sufferers have pain related to posture, overtraining, muscle tightness and is usually our bodies protective response to something it does not like, meaning it is treatable and preventable!  

To lay some foundation for our low back pain discussion, here are a few current statistics:

Low Back Pain is the leading cause of disability worldwide, costing nearly $100 Billion in heatlhcare cost and lost wages.

It is estimated that 80% of people will expereience back pain during their life with over 50% having an episode this year.

Over 90% of low back pain complaints are mechanical in nature and do NOT require drugs or surgery.

Of those who have back surgery, around 27% will require another surgery within 5 years.  

It is estimated that 60-75% of back pain is preventable through exercise, education, and proper work ergonomics.


Back pain, although extremely common, is a somewhat complicated complaint where one very important thing must be understood before we move forward...

…back pain is a SYMPTOM, not a diagnosis.  

Back pain can be dibilitating, but the real goal here is to understand the cause of your back pain so that we can determine what factors need to be modified in your life to prevent future episodes.  

To look at this through a simple analogy, lets say you go out to your car tomorrow and it doesn’t start.  Now, if you called your spouse, friend, or a mechanic, you would tell them your car won’t start (I have back pain), but the real question is WHY doesn’t your car start?  It could be from a dead battery, empty gas tank, or something more severe and deep within the engine. Regardless, your car still will not start. Using this analogy, would you treat each of the above mentioned problems the same?  No! Now, does it make sense to take the same approach when treating low back pain?

Looking at back pain, we typically break it down into 3 categories: Functional, Structural, and Pathological.

  • Functional:  Simply put, how you move, or don’t move at all, is causing repeated stress and now you are pain sensitive, stiff, and in frequent or constant pain.  This is the most commmon group. Letting a condition in this category go unaddressed too long can cause it to spill over into our structural category.  

  • Strutural: Strutural conditions include the things you can see on x-rays and MRI’s.  This is the category that includes arthritis (we all get it, you’re not special), disc bulges and disc herniations.  These can absolutely cause pain but are usually the result of some long term dysfunction. NOTE: As we will discuss later, just because something shows up on an x-ray or MRI, does not mean it is the cause of your pain!

  • Pathological:  This is the least common of the group, making up about 1-1.4% of back pain complaints.  This is often the result of bowel diseases, kidney stones, long term unhealthy habits, and cancer.  These are very rare and should not get your attention at first. Dr. Google will lead you this way but he is very deceptive!  

These groups interact with each other frequently.  For example, lets say you sit at a desk 8 hours each and every day of the week.  From here, you like to lift weights. It has been shown that repeatedly lifting heavy objets with a rounded spine (functional), can lead to disc bulges (structural).  


When we look at the structures of the low back, it is easy to get lost in what all is there. Once we take into account how the core and hip muscles interact and support the low back, it can get pretty complicated.


Most are familiar with the vertebrae, and even more with the disc between each vertebrae. Each of these form a pseudo-joint, and along with the pillars of facet joints down each side, we have the vertebral collumn. We know that muscles move and stabilize joints and restriction, tightness, or a strain/sprain type injury to these tissue can cause a cycle of pain, one caused by the other, and so on.


Looking at the muscles, there are too many to mention for our purposes here, but as mentioned above, when looking at low back pain, you must include the core and hip musculature in the conversation and not just the commonly blamed errector spinae and multifidi muscles of the low back. Honestly, there is so much more to low back pain than this, but to stay on track and address the most commons, understanding where the facet joints are, how the hip muscles and core muscles support the low back complex will suffice for our lesson.


  • Low Back Pain is one of the most common reasons a person presents to a doctors office and results in over $100 Billion in healthcare costs and lost work time.

  • Of all the structurs associated with the low back, we can break most complaints down into 3 categories: Structural, Functional, Pathological.

  • Low Back Pain is NOT a diagnosis, it is a SYMPTOM!

Not that we have the basics down, look out for part 2 of our Low Back Pain series where we will cover the most common causes and basic self-treatment options. -> Part 2 <-

Dr. Reheisse is a Board Certified Chiropractic Sports Physician practicing in Cottonwood Heights Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management.

Runner's Knee Bonus: Patellofemoral Pain Syndrome - Not Just For Runners

For several weeks we have been covering patellar femoral pain syndrome (PFPS), or runner’s knee as many like to call it. However, as with many of the conditions we see, it can be found in more than just one population of people. PFPS can also be caused by other physical activities that put repeated stress on the knee. This can include squatting, jumping, climbing stairs, etc. Along with that, PFPS can occur when you have patellar malalignment, which was touched on in Part 1 of our Runner’s Knee series.

With most PFPS we see, it comes from a sudden increase of load placed on the knee. So if you have recently increased your weight at the gym, time on the Stairmaster, or taken on a new activity, if the stress level on your knees has increased you could experience “runner’s knee” even if you do not consider yourself a runner.  With that said, here are a few preventative measures we can implement that could help.


If you are squatting, jumping, or finding difficulty hiking or doing stairs, ensure that you are getting a proper warm up.  In addition to the treatment options listed in Part 3 of our Runner’s Knee series, you can also perform band exercises prior to your activity. Each of these exercises is
beneficial in increasing our mobility and strength, as well as providing our bodies with the proper preparation for the activities we are engaging in. 



An additional preventive measure is to always use proper form. In all things we do, improper form can cause extra strain on our bodies. In all activities, especially lifting and squatting it is important that before we increase weight we ensure that our form is correct. Squatting with our knees in line with our toes, and our back naturally arched allows the weight to be properly distributed throughout, rather than having all the pressure on our knees.


The last preventive measure is simple but effective. It is important that we increase our training gradually and not all at once. If you are a lifter, gradually increase weight. If you are a hiker or climb stairs, increase your distance and pace gradually. Our bodies are adaptable, and with steady increase, it can adjust accordingly.


So for those of us who are experiencing knee pain in the front of our knees and are not runners, there are answers here for us as well. It just so happens that those answers are very similar to those who run many miles a day. So don’t be afraid to dive into our multi-part series about runner’s knee. I think you will be able to find answers to your knee pain as well.

Check out the Part 1, Part 2, Part 3, and Part 4 of our Patellofemoral pain syndrome series here.

Janaye Freeman is a Certified Athletic Trainer & Lead Therapy Technician at Revive Sport & Spine in Cottonwood Heights Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management for the Greater Salt Lake City Utah Valley. 

Runner's Knee Part 4: Treatment, Rehabilitation, & Return To Running

After three exhilarating weeks of discussing Runner’s Knee, we have covered the anatomy, mechanism of injury, hip and ankle mobility, training modifications when injured, and self-care options. This week, we culminate with what happens when self-care is not enough, when you need to seek help, and what that looks like.


When to seek care while dealing with patellofemoral pain is a common question we encounter.  In all honesty, as a runner, our natural tendency is to ‘wait & see’ and try to run the problem away. Furthermore, some will try and rest a week or two, putting training on hold, only to start running again and find the knee pain is still present.  

Not to be all high and mighty, but in my professional opinion, the earlier you seek care, the less likely you are to lose precious training time, and the quicker we can get you over Runner’s Knee.  To help simplify this, here are three rules to adhere to when debating care for your knee pain.

Knee pain is worsening with each run, earlier in the run, and lasting longer after each run causing your training to suffering.
Knee pain is not responding with consistent self-care and proper warm-up and cool-down routines.
Knee pain starts to be present during regular daily activities such as walking, taking the stairs, and rising from a chair. 


So, you have decided to seek help with Runner’s Knee.  

Step one: find a doctor that runs!

Now that step one is out of the way, let's talk about the basics of what actually happens and what you can expect from care in a sports medicine/chiropractic office.  

To get us started, let's look at the hardest question first...How long will it take?  That is a hard question to answer because every case is different. Each person presents with a different level of pain, unique exacerbations, varying training volume, intensity, and running age as well as racing expectations and outlook on their condition.  From all of that, nailing down an exact timeframe to peak performance is elusive. However, typical treatment plans range from 2 weeks to 2 months, again depending on goals and time the condition has been present.

Once this is understood, next is to understand that this is a team effort.  For the majority of clinics, you will only be actively receiving care for 1-2 hours per week.  What happens the other 166 hours of the week is up to you, and we discussed that in our last article regarding self-care.

When an athlete presents to a clinic like ours, treatment should be a 3-tiered approach.  

Soft Tissue:  As we have reviewed the anatomy, we know that there is significant muscle ‘issues’ involved in runner’s knee.  For this reason, this is where we start. How to decrease the tension and abnormal pull from muscles so that the patella tracks correctly and decreases joint wear is one part of the puzzle.  There are numerous ways to achieve this and in our clinic, we find Dry Needling, Active Release, IASTM - instrument-assisted soft tissue mobilization, and cupping therapies to provide the best, and quickest, results.  
Joint Mobility & Stability: After the soft tissue is addressed, we look at the structure.  As discussed in our second article, the mobility of the hip and ankle are vital to correcting and relieving runner’s knee pain.  Manipulation is designed to restore normal motion to a joint that is currently not moving properly. Over time, restored joint motion can improve running mechanics and decrease strain and stress placed on the surrounding muscles.  
Rehabilitation Exercise:  Lastly, once we have the muscles and joints under control, a building back up must occur in two ways.  One, we must create stability and control of the joint through muscle strength. Two, training volume must begin to ramp up, slowly and controlled, which we discussed in the third article of this series.  To further address part one, rehabilitation exercises need to be explained and directed.

Below is a basic 3 phase rehabilitation program aimed toward relieving patellofemoral pain, while helping to build back up and prevent future occurrences.

Phase 1:   During the first phase of care, our exercise prescription is aimed at pain relief and mobility improvement.  These exercises should be performed 3-5 times per week, preferably as part of your running warm up if we are able to continue training through care.  We start with 1 set of 10 reps for each exercise and 30 seconds for the wall sit, working up to 2 sets over the course of this phase of care which is typically 2-4 weeks.


Phase 2: The second phase of care focuses on returning to your full running volume while building strength and stability.  We expect to perform these exercises 3-5 times per week again, preferably before running but we will start with 1 set of 15 for each exercise and a 45-second hold for the wall sit.  Over the 2-4 weeks of this phase, we will work up to 2 sets of each exercise.


Phase 3: The third phase is aimed at strength and injury prevention.  At this time, we move to self-care as the patient is released from active care.  Our goal is to perform 2-3 sets of 10-15 reps for each exercise as a warm up before each and every run.  



Once we work thorough care and training is gradually ramping back up, or you have been consistent with home care, how do you know you are ready to return to full, unrestricted running?  To help determine if you can get back out there and get after it, we utilize our return to running assessment.  Our goal here is to complete each of the five exercises without pain.  In this assessment, each exercise must be completed for 60 seconds, with as many repititions as possible.  


Finally, we have covered more information than you could ever want to know about patellofemoral pain syndrome.  Hopefully this has been enough information to keep you out of our office, but...runner's have many other issues and injuries to face and Runner's Knee is but one of them.  Until next time...

Train Smart, Recover Well, Race Great!

-Dr. Reheisse

Dr. Reheisse is a Board Certified Chiropractic Sports Physician practicing in Cottonwood Heights Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management.

Runner's Knee Part 3: Training Modification & Self-Care

Over the last two weeks, we have discussed the ins and outs of what Patellofemoral Pain Syndrome is, the anatomy involved, how adjacent joints (hip and ankle) can lead to maltracking issues, and why runner’s are specifically susceptible to this common overuse injury.  You can read Part 1 & Part 2 here.  

Now it’s time to talk self-treatment and training modification.  Our goal is to maintain training (load) if possible when you find Runner’s Knee settling in, but more times than not,  rest and self-care is needed while also modifying our training volume and intensity until symptoms recede.


Let's get the big one out of the way first!  One of the reasons many runners try to avoid visits to a doctors office about one pain or another is the fear that the physician will tell them to stop running.   Depending on the injury, how long it has been going on, current severity, and many other factors, some runner’s are able to continue training during treatment and rehab, albeit modified.  

Without getting too technical, we have to first understand the concept of 'load' and how it changes when we are injured.  As runners, we have a specific language so I am going to explain it in those terms. When our training is on and we are injury free and fit, long runs, speed work, tempo runs, and intervals go well and help us improve.  The amount of load on the knee (and other joints) is well handled and time is ample to recover. Now, let's say you decide to sign up for a race that is in 6 weeks and your training base is less than optimal. In hopes of having a good race, you ramp up quickly, performing hard days back to back, pushing it to your goal race pace over a good portion of your long run, etc., and now...BOOM, knee pain!  What has happened here is that you crossed over the load threshold of what your body will allow and recovery from.

For an interesting read, look into Scott Dyes work.  This is what is commonly referred to the ‘envelope of function’ in the coaching and physician world.

Jumping back that we are injured, our load threshold is lower.  This is why a 5-mile run is painful halfway through when just 2 weeks ago, you were cruising through 10 miles with a few pickups.  If you continue down this path, patellofemoral pain can become so severe that just getting out of bed and navigating stairs are difficult.  When we encounter a runner in this position, we have to have a sit-down and talk training plan, race expectations, and our long-term goals.

While it is never our goal to shut a runner down in the middle of a training cycle, the long-term health and ability of the athlete is top of mind.  Because of this, when discussing training, we tend to cover three things.

Can we gradually ramp up training while continuing to respond to treatment?

When we begin treatment, we have to start with a baseline.  That may be 2 miles, 5 miles, or No miles before the pain sets in.  That is our starting spot. As we follow-through with the suggested treatment plan, this load threshold must also go up.  Rarely does pain go from 100 to 0, meaning, the pain goes from beginning at mile 2, then mile 4, then we find ourselves back up to 8-10 miles with no pain.  This is the progress we look for.

Initial volume should decrease by 50% for the first 2 weeks.

If you are coming to us for knee pain, make a conscious effort to dial it back for a few weeks. This allows you to keep training, but also a little more rest than normal while we get through the first few treatment session.  

Intensity, or pain provoking runs, need to take a full break until volume can increase without pain.

With runner’s knee, we find that the harder, hillier efforts cause the most problems.  While we want to maintain load on the knee while we treat, easy runs are the plan for the first few weeks.  Looking at what we just talked about with gradually ramping up, we need to make sure you can handle a good distance without pain before we start pounding out the speed-work and hill repeats.  And this goes for downhill too!


Now that we have discussed training modification, what can you start doing at home to help with Runner’s Knee?  Honestly, you should be doing all of this already, but pain is a much better reminder to break out the foam roller than a good run.  Your relationship with your foam roller needs to be strong. Your diet needs to be on point. Your bedtime needs to be early. Lastly, you need to realize that weight training is your friend.

Let's discuss a few of the easiest and most common self-treatment options.

Foam Rolling:

I don’t need to further detail my love for foam rolling over stretch or the benefits that regular foam rolling can provide for a runner.  As we address runner’s knee, rolling needs to be frequent, short bursts throughout the day. Meaning, roll the quadriceps, hamstrings, and posterior hip muscles 3-5 times per day.  Again, these are short 2-3 minute sessions. 10-15 rolls up and down over each area. Check the video!

Hip Mobility Drills:

As runner’s, our knee functions is highly influenced and controlled by what is happening at the hip.  If your hip range of motion is limited, this will eventually show up at the knee. Check the video!

Ankle Mobility Exercises:

As a practitioner, I’m typically a ‘ground-up’ person when it comes to runners.  While the hip controls the show, if the ankle does not move properly, it can not react properly or efficiently when the foot hits the ground causing problems up the chain.  Studies show that just a few degrees difference between ankles is a good indicator of future injury. Work on your ankle mobility - Check the video!

Kinesio Taping:

This is a bit controversial.  As you will hear me say in the demonstration below, the effect of taping is hard to prove.  Don’t get me wrong, I love taping, in the short-term. It is by no means a long term fix for any injury!  With that, you can also find 500 runners at the upcoming Big Cottonwood Marathon or the St. George Marathon that have their knees, shins, hips, and ankles taped that will absolutely swear by it.  With all of that, I just don’t have solid evidence that proves any of that...but placebo is a powerful tool and I do appreciate taping as a means to help someone recovery and cue good movement patterns.  If anything, the tape is a visible reminder to roll, stretch, and rest more. Check the video!

Body-Mass Index:

BMI has to be briefly discussed her because whatever weight we are carrying around affects our knees!  Remember from the part of this series we mentioned that during running, the knee takes on 5-6 x’s your body weight during each step.  While many people us running for weight loss, and other avoid it due to weight, the fact is, those with knee pain will benefit from weight loss if they are in the higher BMI category.  I am not a dietician, we do not push weight-loss in our office, and I can’t tell you how many ‘Clydesdales’ category runners that can kick my tail in a race. Health is more than just pounds, but Runner’s Knee can be helped by a better BMI.  

Psychosocial Influences:

Lastly, psychosocial factors.  Runner’s are among the worst when it comes to injuries and the doom and gloom that comes with it.  Some are severe enough that I have referred out to a professional for guidance. This is not something to be ashamed of and can actually help your recovery and performance.  We now understand pain a bit better than we did 20 years ago, we still have a long way to go, but we know one thing to be true, if you do not think you will get better, you won’t.  You have to buy into the plan, think positive, take the little wins, and know that this will not last forever. Any injury will last longer than we want it to, but you have to realize that by pure running statistics, you will get hurt at some time if you are training consistently, but it will also pass.

Hopefully, this article cleared up a few things regarding your training and the ability to continue through treatment as well as a few ways to care for Runner’s Knee yourself.  Ideally, you can manage this yourself, learn from it, and prevent it from coming back again. As runner’s, we are prone to injury, that is just the way it is. But, we want to make sure you have the necessary knowledge and tools to help yourself before you give up, stop running, and then drag yourself into a sports physician office.  


  • When faced with Runner's Knee, training modifications are a must.  We typically cut the volume by 50% and refrain from intense workouts (intervals, hills, tempo) for the first 2 weeks.

  • Self-care is a must.  It not only helps speed your recovery over your treatment plan but it can help prevent future injury.  

  • Self-care can be as simple as foam rolling a few times per day to running specific mobility, stability, and strength exercises.  


Stay tuned for part 4 where we will discuss when to seek treatment and how we treat Runner’s Knee in our office, as well as a few examples of our suggested rehabilitation exercises.  

Train smart, recovery well, race great!  

Dr. Reheisse is a Board Certified Chiropractic Sports Physician practicing in Cottonwood Heights Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management.

Runner's Knee Part 2: Hip & Ankle Mobility - How It Relates To Patellofemoral Pain Syndrome

In part 1 of our runner’s knee series, we discussed the specific anatomy involved, how and why we experience pain over/in the front of the knee, and most importantly, how running, and specifically downhill running, can hasten your onset of patellofemoral pain syndrome.  ->Read Part 1 Here <-

Today, in part 2, we are going to move away from the knee and look at the friendly joints above and below.  As we know, and you will soon find out, the hip and the ankle are in control of the knee and more times than not, pain at the knee is caused by faulty mechanics, immobility, or strength and stability deficiencies at either or both of these joints.  Read on!


So that we have a starting point, we are going to travel from the hip down.  Mainly because it is more commonly the culprit of running associated knee pain (my own clinical experience) but also because it is the bigger joint with more opportunity for complications.  

To help explain how the hip acts on the knee, I commonly tell patients in the clinic that we have no ‘knee muscle’, but that everything controlling the knee, comes from the hip.  While this is not exactly true, we have some very important muscles like the VMO and popliteus that act very strongly on the knee while not originating from the hip, but hopefully, you can read through that and see my point here.  Control at the knee is primarily governed by the hip.

When we encounter a runner with patellofemoral pain, we will ‘treat’ the knee...but the majority of our work is spent on improving hip mobility, strength, and stability.  What we find is that issues here can lead compensations, deficiencies, and imbalances that contribute to Runner’s Knee.

IT band tightness pulls on the patella causing it to track laterally, or to the outside.
Hip tightness can cause an anterior pelvic stance.  This can inhibit and tighten the hamstrings causing an altered gait that is ‘quad heavy’.  This tilt and tightening can lead to altered mechanics at the knee and also lead to patellofemoral pain.
Hip drop due to a weakness of the glute muscles can lead to  what we are now calling the Miserable Malalignment Syndrome.

Let's talk about that last one for a minute as this is becoming more and more common in running associated knee pain.  Miserable Malalignment Syndrome is the name now given to the cascading breakdown when the hip and ankle fail.  Essentially, when our foot is planted, the glute medius muscle of the foot planted holds our pelvis level.  When this weakens, the hip drops, causing the other side to respond. This response causes an inward rotation of the femur bone, an outward rotation of the tibia (shin bone) in an attempt to compensate, and lastly, a turning out of the foot resulting in a crashing in of the inside of the foot.  

Guess which joint is in the middle taking all of that rotation torque?  

I explain this in the video and picture below.  Now, this condition got its name, not necessarily for runners, but for those who sit too much and exhibit the same pattern, but it fits here.  If anything, this helps explain how important our hip mobility and strength is to the health of our knees. If you remember, as runners, we load the knee with 5-6 times our body weight with each and every step.  Rotation in a joint NOT designed for rotation is destined to cause problems.



Now that we better understand the hip and its relation to knee pain, let's travel down the road a little to the ankle joint.  Without getting into the kinematics of the ankle and the joints that make up this complex area of the body, let's just try to understand one thing...DORSIFLEXION.

Dorsiflexion is your ability to bring the top of your foot toward your shin.  When we run, dorsiflexion allows us to strike the ground, react, and toe-off properly, pushing from our big and second toes.  To help understand this, lets picture what poor dorsiflexion looks like. The next time you are walking around, look for someone who walks with their feet turned outward.  What is usually happening here is that their hip tightness causes their posterior hip muscles (glutes, piriformis, etc.) to pull on the femur, resulting in an outward turned leg and foot.  And...Unless they rode in on a horse, they are not walking with their kneecaps over their feet in this position which leads us to what we just discussed, the foot crashes inward, the kneecap points a different direction of the foot, and we now have pain.  You can now imagine that there is no way this person is walking properly, meaning they are not actually toeing off correctly, but the inside of their foot, now...IMAGINE THIS PERSON RUNNING.

You may have realized that poor ankle dorsiflexion and the lack of hip mobility and stability can cause the same problem.  The truth is, they tend to run together. While we will always treat any and all problems presented to us, it is my job to find the key that unlocks the whole system and more times than not, it is the hips!  




  • Most of the muscular control of the knee comes from the hip.  Lack of mobility and strength here can contribute to patellofemoral pain syndrome.  

  • Lack of ankle dorsiflexion (the ability to bring the foot toward the shin) can cause outward rotation of the foot and undue rotational strain on the knee.  

  • Issues at the hip and knee can lead to what we are now calling the Miserable Malalignment Syndrome.  Essentially, when we run, our hips drop, causing an inward rotation of the femur, a counter-outward rotation of the shin bone, turning out of the foot and crashing in of the inner foot leaving the stress on the knee.  

  • To properly address runner’s knee, we must address these deficiencies at the hip and ankle.


Once you have digested the information we discussed in these last two articles, keep your eyes peeled for part 3 next week as we will begin discussing what to do if you already have patellofemoral pain and when you should seek care so you can continue, or return to, training.

Read Part 3 Here -->

Dr. Reheisse is a Board Certified Chiropractic Sports Physician practicing in Cottonwood Heights Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management.