Why Lower Back Pain Keeps Coming Back

How pelvic and rib cage movement affects walking and breathing

Lower back pain can make standing, walking and bending uncomfortable. You may have tried massage or stretching: your back feels looser for a while, then the discomfort returns. When this happens, we need to understand why the same muscles keep tightening.

The position of the pelvis and rib cage matters. A pelvis held in anterior tilt and lower ribs held up and forwards place the lower back in an extended starting position. Walking and breathing from that position can repeatedly recruit the muscles that maintain extension. To understand why the back keeps tightening, we need to look at how the hips, pelvis and ribs share movement, and how their positions affect breathing

Whole body movement depends on several joints working together

Bending involves the hips, pelvis and spine. Walking requires the body to accept weight through one leg, move over that hip, and transfer weight to the other leg. Breathing requires movement of the diaphragm, rib cage and abdominal contents.For example, reaching for an object beside you requires the pelvis to turn at the hip joints and the thoracic spine to rotate. If hip rotation is restricted, the lower back becomes more involved in completing the turn while remaining extended, increasing the demand on the surrounding back muscles. The important distinction is between completing a task and sharing that task across the intended joints. A person can keep walking while repeatedly using an extension strategy.

Walking requires alternating stance and swing

Stance is the part of a step when the foot contacts the ground and accepts weight. Swing is the part when that foot leaves the ground and the leg advances. The roles alternate, with a period of double support during the transfer. The pelvis and lower spine turn towards the supporting side, while the upper rib cage turns in the opposite direction. These orientations develop and reverse as weight changes sides.

Right stance and left swing

When the right leg supports the body and the left leg advances, the pelvis faces relatively right, with the left side further forwards. The upper thorax counterrotates left as the right arm advances. The right anterior ribs approximate and internally rotate; the left anterior ribs expand and externally rotate.

Left stance and right swing

For left stance, the pelvis orients left and the upper thorax counterrotates right. Left posterior pelvic rotation and left anterior rib internal rotation contribute to the supporting-side configuration. The right side can move into swing. These descriptions concern the relationship between regions, rather than a large twisting movement at the lumbar spine. The lower back participates in the change of orientation; the hips and thorax must also provide their share of movement.

Stance involves movement of the pelvis over the supporting hip

Hip rotation needs a clear reference point. Rotating a freely moving thigh in its socket is different from moving the pelvis over a thigh supported by the ground. On the supporting side, the pelvis moves over the thigh, changing the position of the hip socket around the thigh bone. The hip moves into a relatively inward-rotated relationship as it accepts weight. On the advancing side, the relationship changes towards outward rotation, allowing the leg to move forwards.^[4] This means that left stance involves more than putting the left foot down. The pelvis must be able to move over that hip and accept weight there. If this transition is unavailable, placing the foot on the ground does not by itself restore the missing supporting-side mechanics.

Restricted alternation can reinforce an extension strategy

A common restriction occurs when the left side of the pelvis remains forwards, the left anterior ribs remain elevated, and the body favours right-side support. The problem is persistence of one configuration, with difficulty accessing its counterpart.^[5]When the ribs remain elevated and the trunk remains extended, the lumbar paraspinal muscles continue to maintain that position. The chest and back muscles can also help lift the rib cage during inhalation. Breathing then reinforces the same extension strategy used to support the body.^[6] In this pattern, weight is shifted forwards and more support comes through the front of the feet. The quadriceps, hip flexors and calf muscles face greater demands as the body maintains this position.^[7] Here, the calf muscles are part of a wider strategy for supporting and advancing the body.

Repeated extension loads the structures at the back of the lumbar spine

The facet joints are paired joints between adjacent vertebrae. Extension increases contact loading at these joints. Laboratory measurements of lumbar segments demonstrate substantial facet loading as extension moments increase.^[8] An anteriorly tilted pelvis and elevated anterior ribs provide an extended starting position. Repeatedly adding extension from that position increases the work demanded of the lumbar extensors and adds load to the posterior spinal joints. The next question is therefore specific: which muscles should help the pelvis return from anterior tilt, and which muscles should control the elevated anterior ribs?

The hamstrings help bring the pelvis back from anterior tilt

The hamstrings that attach to the sitting bone, the semitendinosus, semimembranosus and long head of the biceps femoris, can influence pelvic position when the legs are supported. Their pull on the ischial tuberosity contributes to posterior pelvic rotation and reduced lumbar lordosis.^[9] To help the pelvis return from anterior tilt, we recruit that hamstring pull while reducing the activity that holds the back extended. Bracing the abdomen, pushing hard through the feet or holding the breath can recruit hip flexors and back extensors instead. With the feet supported, the knees move forwards while the hamstrings draw the pelvis back.^[10] The hamstrings work with the gluteal and abdominal muscles. Restoring pelvic control requires this shared activity, rather than a forceful pelvic tuck.

The internal obliques and transversus abdominis control the anterior ribs

The internal obliques and transversus abdominis support the diaphragm by controlling the lower ribs and abdominal wall. During corrective exercise with controlled exhalation, they help depress and internally rotate the anterior lower ribs.^[9,11] For a person held in the common left-sided anterior pattern, the left internal oblique and transversus abdominis help control the flared left anterior ribs. This supports the left diaphragm’s position while allowing expansion elsewhere in the chest.^[14] When learning to support the body over the left leg, the left internal oblique and transversus abdominis can maintain abdominal support while the upper thorax rotates right. Control of the lower ribs and pelvis supports counterrotation of the upper thorax.^[3] Rib movement is regional. The left anterior lower ribs internally rotate, while the left posterior chest retains room to expand during inhalation. Right upper chest expansion also supports the change into right thoracic rotation.^[3,12]

The diaphragm needs support from the abdominal muscles

The diaphragm separates the chest from the abdomen. It contracts and descends during inhalation; during relaxed exhalation, it returns upwards as the respiratory system recoils.^[18] An important part of its mechanics is the area where its fibres lie against the inner surface of the lower rib cage. Abdominal support helps preserve this relationship as the diaphragm contracts. Elevated, externally rotated anterior ribs and insufficient abdominal support reduce its mechanical advantage.^[11] When the lower back stays arched and the anterior ribs stay lifted, the diaphragm becomes more involved in maintaining that posture. Other chest, neck and back muscles contribute more to inhalation.^[1,6] The issue is a change in mechanical role. Efficient breathing requires the lower ribs, abdominal wall and diaphragm to work together, rather than repeatedly lifting the chest and extending the back.

The pelvic floor needs support and movement through the breathing cycle

The pelvic floor forms the muscular base of the pelvis. The puborectalis and pubococcygeus, two of its muscles, move upwards during exhalation and downwards in a controlled way during inhalation.^[13] This coordination depends on support from the hamstrings, hip adductors, gluteal muscles, internal obliques and transversus abdominis. These larger muscles help control the pelvis and its outlet so that the pelvic floor can respond to breathing without excessive descent or rigid holding.^[13]

Posterior pelvic rotation and internal rotation of the anterior lower ribs help restore the mechanical conditions for coordinated diaphragm and pelvic-floor function. Hamstring, adductor, gluteal and abdominal control, together with breathing, makes that position usable.^[9,11,13] The goal is coordinated pressure regulation and movement through inhalation and exhalation. Continually tightening the pelvic floor is a different task.

The psoas and diaphragm share a relationship with spinal extension

The iliopsoas includes the psoas major and iliacus and contributes to hip flexion. The psoas major also attaches to the lumbar spine, placing it within the relationship between leg movement and spinal position. The psoas and diaphragm can both contribute to lumbar extension. When the pelvis remains tilted forwards and the lower ribs remain lifted, their activity can reinforce that extended position. Their effects also change as the body bends sideways and turns.^[14] The psoas also has a useful role in corrective exercise. Its contribution depends on pelvic position, abdominal support and the movement being performed.^[14] The clinical aim is to restore that coordination: hip flexion should occur with control of the pelvis and ribs, rather than repeatedly adding lumbar extension as the leg advances.

First restore access to neutral

The first objective is to regain a position from which the pelvis and rib cage can change direction. This includes access to posterior pelvic rotation, control of the anterior lower ribs and breathing without adding lumbar extension. Corrective exercise can begin this process in supported positions. Hamstring activation and abdominal activity during exhalation are used to reposition the pelvis and ribs.^[9] This means active care starts during the initial repositioning stage. Neutral is a usable transition between movement options. The body must be able to pass through it and move into either supporting-side configuration. Achieving that position once does not establish competence in both stance phases.^[4,15]

How chiropractic care fits into this process

At Eugene Chiropractic, manual care is integrated with movement assessment and corrective exercise. Where joint pain or restricted mobility is part of the presentation, treatment addresses those findings, and movement is reassessed afterwards. Chiropractic adjustments are combined with exercises that help the patient control the pelvis and ribs. The patient takes an active role in maintaining and using the movement gained during care.^[16],Hands-on techniques can also assist rib cage movement and the position of the diaphragm, helping establish a more useful starting position for breathing.^[11],Manual care can assist the conditions for movement. Using those conditions independently during standing and walking requires the patient’s active participation.

Then train the transition between the two sides

Exercise progresses from finding the position to controlling it while accepting weight, reaching and stepping.,In a left-stance task, the left hamstrings help control posterior pelvic rotation. The hip adductors and gluteal muscles help control the pelvis over the supporting hip. The left internal oblique and transversus abdominis maintain anterior rib control while the chest retains access to expansion.^[10,13],Reaching can then help integrate this position with thoracic movement. Reaching forwards with the left arm can help the upper rib cage turn right and the left posterior chest expand while the left abdominal muscles maintain support.^[3],Both sides need usable stance and swing. Exercise selection follows the movements that are missing on each side; a right-sided activity is not necessarily a mirror copy of the left-sided activity.^[15],Progression into standing and walking connects hip control, foot contact, thoracic movement and breathing. Repeated practice develops the ability to transfer weight and use the restored movement without continuous instructions. Motor-learning research supports evaluating retention and transfer to other tasks, rather than judging success only by an immediate change.^[17]

Passive care cannot substitute for practising these transitions yourself. Restoring access to movement and learning to use it are connected stages of care.

Recurring lower back pain deserves a movement assessment

Relieving pain helps a person move more comfortably. To address the repeated mechanical demand described here, assessment also needs to identify how the hips, pelvis and rib cage share walking and breathing.,At Eugene Chiropractic, we assess the painful area alongside spinal and hip mobility, pelvic and rib cage control, breathing and weight transfer. Treatment and exercise are then directed towards the movements that need to change. If massage or stretching provides only temporary relief, understanding why your back keeps returning to the same extension strategy is a useful next step.

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Supporting sources

Links used to check the anatomical and movement descriptions. The labels below describe the topics covered by each source.

1. Diaphragm function in chiropractic rehabilitation — Skip George (2022). View source

2. Pelvic and rib cage movement during walking — Henning, Massé and Mangino (2017). View source

3. Arm reach, chest expansion and abdominal control — Kurt Weidauer. View source

4. Hip socket movement over the supporting thigh — Dan Houglum. View source

5. Pelvic and rib cage asymmetry in movement — Sean Light. View source

6. Breathing and the extended spine — Lisa Bartels. View source

7. Back and calf muscle demands in an extended posture (2007). View source

8. Lumbar facet loading — Schendel et al. (1993). View source

9. Hamstring and abdominal activation in lumbopelvic pain — Tenney, Boyle and DeBord (2013). View source

10. Hamstring-assisted posterior pelvic tilt — Ron Hruska. View source

11. Diaphragm mechanics and lower rib support. View source

12. Expansion of the back of the chest — Jen Platt. View source

13. Pelvic-floor movement and muscular support — Lori Thomsen. View source

14. The relationship between the psoas major and diaphragm. View source

15. Movement control after initial position changes — Dan Houglum. View source

16. Combining chiropractic adjustments and active exercise — Skip George. View source

17. Learning and retaining changes in walking (2021). View source

18. Breathing exercises and trunk control — Boyle, Olinick and Lewis (2010). View source