Why Your Lower Back Pain Isn't Getting Better (And It's Not What You Think)
The hidden truth about back pain most doctors miss
Dr. Alex Morgan
June 17, 2025
Hi, I’m Dr. Alex Morgan, DPT. With over 25 years as a board-certified orthopedic physical therapist, I’ve helped thousands of people overcome chronic pain by focusing on the true causes—how the body moves as a whole. I’m passionate about empowering patients with practical, science-backed strategies that resolve pain and restore real function. Here’s what I’ve learned in decades of practice about persistent back pain, and how you can finally break free from it.
I'll never forget the look on Mike's face when I explained what was really causing his chronic lower back pain.
"Wait—you're telling me my back pain is coming from my ankles?"
Mike, a 53-year-old construction manager, had been battling debilitating back pain for over three years. He'd tried everything: physical therapy, chiropractic care, cortisone injections, even a consultation for surgery. Nothing provided lasting relief.
But the real culprit wasn't his spine. It was movement dysfunction in his ankles, hips, and rib joints—areas no one had properly assessed. His back was simply paying the price, taking on excessive work because other areas weren't doing their job.
Eight weeks later, Mike was back at work full-time, playing with his grandkids on weekends, and hadn't taken a pain pill in over a month.
This story plays out in my practice almost daily. People arrive convinced their back is "broken" when the real problem often lies elsewhere. Their spines are compensating for movement problems in other areas—and until those are addressed, the pain persists no matter how many back-focused treatments they try.
Today I'm going to share what's really causing your persistent back pain, why traditional treatments often fail, and exactly what to do about it. This isn't theory—it's based on decades of clinical experience and research into how the body actually moves and functions.
Here's what most healthcare providers won't tell you: Your spine wasn't designed to function in isolation. It's part of an integrated movement system.
When you walk, bend, or even stand still, your body should distribute forces across multiple joints and muscles. Your ankles, knees, hips, ribcage, and shoulders all play critical roles in supporting healthy spine function.
When any of these areas becomes restricted or dysfunctional, your spine takes on extra work. Over time, this compensation leads to pain, inflammation, and tissue damage—even though the spine itself isn't the original problem.
For Mike, years of wearing heavy work boots had restricted his ankle mobility. His hips had tightened to compensate. His lower back was simply the weakest link in the chain—the place where symptoms appeared, but not where the problem began.
This explains why so many back treatments fail. They focus exclusively on the painful area while ignoring the movement system that created the problem in the first place.
After working with thousands of back pain sufferers, I've identified four commonly overlooked areas that frequently cause or contribute to persistent back pain. These are the real culprits that standard medical exams often miss.
1. ANKLE RESTRICTIONS: THE FOUNDATION OF BACK PAIN
Your ankles should move freely in multiple directions, allowing your body to adapt to different surfaces and activities. When ankle mobility becomes restricted—due to previous injuries, poor footwear, or simply years of disuse—it creates a chain reaction of compensation throughout your body.
Limited ankle dorsiflexion (the ability to pull your toes toward your shin) is particularly problematic. Without this movement, your knees and hips can't bend properly when walking or squatting. Your pelvis tilts abnormally, and your lower back takes on excessive stress.
Signs your ankles may be contributing to your back pain:
You feel unstable on uneven surfaces
You tend to "toe out" when walking or squatting
You have a history of ankle sprains or injuries
Your back pain worsens after prolonged walking
You feel better when wearing supportive shoes
For Mike, a simple ankle mobility assessment revealed that he had less than 10 degrees of dorsiflexion in both ankles—far below the normal range of 20 degrees. Restoring his ankle function was a crucial first step in resolving his back pain.
2. RIB JOINT DYSFUNCTION: THE OVERLOOKED CONNECTION
The ribcage contains 24 rib joints that should move freely with breathing, reaching, and rotating. These connections between your ribs and spine (costovertebral joints) are rarely evaluated in back pain assessments, yet their dysfunction can directly stress your lower back.
When rib mobility becomes restricted, several problems emerge:
Your breathing becomes shallow and upper-chest dominant
Your spine loses essential rotational movement
Your core muscles become inefficient and weak
Your lower back compensates with excessive movement
The result? Persistent pain that doesn't respond to traditional back-focused treatments.
Signs rib dysfunction may be contributing to your back pain:
You have difficulty taking deep breaths
You feel stiff when rotating your torso
Your pain worsens with coughing or sneezing
You've had previous chest injuries or surgeries
You experience mid-back pain in addition to lower back pain
For Janet, a 61-year-old patient with 12 years of chronic back pain, addressing rib mobility was the missing piece. Previous treatments had focused exclusively on her lumbar spine and hips, but restoring normal rib movement allowed her entire system to function properly again, resolving pain that multiple surgeries couldn't fix.
3. HIP ROTATION LIMITATIONS: THE SILENT BACK KILLER
Your hips are designed for both stability and mobility. They should provide a stable foundation while also allowing significant movement in multiple directions. When hip rotation becomes limited—particularly internal rotation—your lower back is forced to move excessively to compensate.
This compensation pattern is so common I see it in nearly 80% of the back pain patients in my practice. Limited hip internal rotation forces your lumbar spine to rotate more than it should, creating wear and tear on spinal joints and discs.
Signs hip rotation limitations may be contributing to your back pain:
Your pain worsens with activities requiring rotation (golf, tennis, etc.)
You have difficulty crossing your legs when sitting
You feel stiffness when getting in and out of cars
Your back "catches" or "locks" with certain movements
You have a history of hip, knee, or foot problems
For Mike, hip rotation measurements revealed severe limitations—less than 10 degrees of internal rotation on both sides, compared to a normal range of 30-40 degrees. These restrictions forced his lower back to twist excessively with everyday movements, creating constant irritation and pain.
4. BREATHING PATTERN DISORDERS: THE INVISIBLE STRESS CREATOR
How you breathe directly affects your spine. Normal breathing involves your diaphragm (the dome-shaped muscle beneath your lungs) descending and your ribcage expanding in three dimensions. This creates proper pressure regulation in your abdomen and supports your spine.
When dysfunctional breathing patterns develop—often due to stress, pain, or previous injuries—your body shifts to shallow, upper-chest breathing. This alters pressure in your core, reduces spinal stability, and creates excessive tension in your neck, shoulders, and back muscles.
Signs breathing dysfunction may be contributing to your back pain:
You tend to breathe shallowly or hold your breath
Your shoulders rise when you inhale
You frequently sigh or yawn to "catch your breath"
Your symptoms worsen during periods of stress or anxiety
Your pain is worse first thing in the morning or late in the day
For Sarah, a 49-year-old office manager with chronic back pain, correcting her breathing pattern was transformative. After years of failed treatments, simply restoring proper diaphragmatic breathing reduced her pain by 70% within three weeks.
WHY TRADITIONAL BACK PAIN TREATMENTS OFTEN FAIL
Understanding these hidden culprits explains why many common back pain treatments provide only temporary relief—or fail entirely.
Physical Therapy That Only Focuses on the Back
Standard physical therapy for back pain typically includes strengthening core muscles, stretching tight back tissues, and improving posture. While these approaches have merit, they often fail because they don't address the underlying movement restrictions in ankles, ribs, and hips that forced the back to compensate in the first place.
It's like fixing a leaky ceiling without repairing the broken roof—the problem will return because the source hasn't been addressed.
Chiropractic Adjustments Without Movement Retraining
Spinal manipulation can provide excellent short-term relief by temporarily restoring better joint position and reducing nerve irritation. However, if the movement patterns that created the problem remain unchanged, the relief is typically short-lived.
Mike had experienced exactly this pattern—feeling better after chiropractic treatments, only to have the pain return within days as his restricted ankles and hips continued forcing his back into dysfunctional patterns.
Anti-inflammatory Medications and Injections
Pain-relieving medications and steroid injections can reduce inflammation and provide temporary comfort. But they do nothing to address the underlying movement dysfunctions that created the inflammation in the first place.
This approach is like taking pain medication for a broken arm without ever setting the bone—you might feel better temporarily, but healing can't occur until the actual problem is fixed.
Surgery When There's No Structural Damage
Perhaps the most concerning treatment failure is surgery performed when the real problem lies elsewhere. Many patients undergo spinal fusions, disc procedures, or other invasive treatments without ever having a comprehensive movement assessment.
Janet had been recommended for spinal fusion surgery before coming to me. Yet her spine wasn't the problem—her restricted rib mobility and dysfunctional breathing were forcing her back to overwork. Addressing these issues resolved her pain without surgery, risk, or recovery time.
THE COMPREHENSIVE SOLUTION: RESTORING YOUR MOVEMENT SYSTEM
The good news is that once these hidden culprits are identified, they can be systematically addressed through a comprehensive approach I've developed over decades of practice. This framework has helped thousands of patients recover from persistent back pain, even after multiple failed treatments.
STEP 1: ACCURATE MOVEMENT ASSESSMENT
Before treatment begins, we need to identify exactly which joints and movement patterns are contributing to your back pain. This goes far beyond standard medical examinations to include:
Ankle mobility in multiple planes
Rib and thoracic spine movement
Hip rotation and extension capacity
Breathing pattern analysis
Fundamental movement pattern assessment (squatting, bending, rotating)
For Mike, this assessment immediately revealed the true sources of his pain: severely restricted ankle mobility, limited hip rotation, and compensatory overuse of his lower back.
STEP 2: SEQUENTIAL JOINT RESTORATION
Once restrictions are identified, we address them in a specific sequence designed to restore normal movement throughout the entire system. The exact approach varies based on individual findings, but typically includes:
Manual therapy techniques to restore joint mobility
Targeted release of restrictive soft tissues
Guided movement to reinforce proper joint function
Breathing retraining to normalize pressure systems
For Mike, we began with specialized techniques to restore ankle mobility, followed by hip rotation treatments, and finally ribcage mobilization. Each session built on the previous one, gradually restoring normal movement throughout his entire system.
STEP 3: INTEGRATED MOVEMENT RETRAINING
Once joint mobility improves, the body must relearn proper movement patterns to prevent regression. This phase includes:
Foundational movement pattern retraining
Neuromuscular re-education exercises
Progressive loading to build capacity and resilience
Integration of proper movement into daily activities
This step was crucial for Mike. After years of compensating for his ankle and hip restrictions, his nervous system had learned dysfunctional movement patterns that needed to be replaced with healthier alternatives. Specific exercises helped his body integrate the newly restored joint mobility into functional movement patterns.
STEP 4: ENVIRONMENTAL MODIFICATION
The final step addresses the daily factors that contributed to the problem in the first place:
Footwear adjustments to support proper ankle function
Workspace ergonomics to reduce stress on the movement system
Sleep positioning to maintain proper alignment
Activity modification to prevent regression during the healing process
For Mike, switching from restrictive work boots to more mobility-friendly footwear was a simple change with profound effects on his recovery and long-term function.
THE REAL-WORLD RESULTS: CASE STUDIES FROM MY PRACTICE
These principles aren't theoretical—they produce consistent results with real patients suffering from persistent back pain. Here are three brief examples that illustrate the power of addressing the true sources of back pain:
MIKE: FROM DISABILITY TO FULL FUNCTION
Mike came to me after three years of debilitating back pain that had forced him to reduce his work hours and stop playing with his grandchildren. Previous treatments—including multiple rounds of physical therapy, chiropractic care, and pain management—had provided only temporary relief.
Assessment revealed severe restrictions in ankle mobility, limited hip rotation, and dysfunctional breathing patterns. Despite these clear findings, no previous provider had evaluated these areas.
Treatment focused on restoring ankle and hip mobility, normalizing his breathing pattern, and retraining fundamental movement patterns. Within eight weeks, Mike returned to full-time work. By twelve weeks, he was playing basketball with his grandchildren and had discontinued all pain medication.
Two years later, he remains pain-free with minimal maintenance care, having learned how to manage his own movement system.
JANET: SURGERY AVOIDED THROUGH RIB MOBILIZATION
Janet, 61, had suffered from back pain for 12 years following a car accident. She'd undergone two spine surgeries with minimal improvement and was considering a third—a spinal fusion—when she came to me.
Comprehensive assessment revealed normal lumbar spine movement but severely restricted rib mobility and a dysfunctional breathing pattern. These restrictions were forcing her lower back to overwork, creating constant pain.
Treatment focused primarily on restoring normal rib movement and correcting her breathing pattern. Within six weeks, her pain decreased by 80%, and she canceled her scheduled surgery. Four months later, she returned to gardening—her passion—for the first time in over a decade.
SARAH: FROM CHRONIC PAIN TO MARATHON FINISHER
Sarah, 49, developed back pain after the birth of her second child. For seven years, she'd tried "everything"—medication, physical therapy, massage, acupuncture—with only temporary relief.
Assessment revealed normal spinal movement but significant hip rotation restrictions and severely dysfunctional breathing patterns brought on by chronic stress.
Treatment focused on restoring hip mobility, normalizing her breathing pattern, and systematically retraining movement fundamentals. Within three months, her pain resolved completely. Six months later, she completed a half-marathon—something she never imagined possible during her years of chronic pain.
THE FRAMEWORK FOR SELF-ASSESSMENT: IDENTIFYING YOUR OWN HIDDEN CULPRITS
While comprehensive assessment ideally occurs with a qualified practitioner, you can begin identifying potential restrictions with these simple self-checks:
ANKLE MOBILITY SELF-ASSESSMENT
Stand facing a wall with your foot approximately 4 inches from the wall.
Keeping your heel flat on the floor, attempt to touch your knee to the wall.
If you cannot touch the wall without your heel lifting, you likely have restricted ankle mobility.
Repeat on the other side and compare.
Limited ankle mobility often contributes to back pain by forcing compensations up the movement chain. If you identified restrictions, ankle mobility exercises should be part of your recovery plan.
HIP ROTATION SELF-CHECK
Sit on a firm chair with good posture.
Without moving your lower back, rotate one knee inward as far as comfortable.
Normal hip internal rotation allows the knee to rotate 30-40 degrees inward.
Repeat on the other side and compare.
Restricted hip rotation is extremely common in back pain sufferers and forces the lower back to twist excessively during daily activities.
BREATHING PATTERN ASSESSMENT
Lie on your back with knees bent.
Place one hand on your chest and one on your abdomen.
Breathe normally and notice which hand moves more.
Proper breathing is diaphragmatic—the abdominal hand should rise more than the chest hand.
Dysfunctional breathing patterns directly impact core stability and spinal function. If your chest moves more than your abdomen, breathing retraining should be part of your recovery approach.
RIB MOBILITY SELF-CHECK
Sit with good posture and place your hands on the sides of your lower ribcage.
Take a deep breath and feel for symmetrical expansion of your ribs.
The ribcage should expand in all directions—front, back, and sides.
Restricted rib movement often correlates with back pain and breathing dysfunction.
Limited rib mobility reduces thoracic spine function and forces the lumbar spine to compensate, creating excessive stress and eventual pain.
THE PRACTICAL RECOVERY PLAN: WHERE TO START TODAY
Based on your self-assessment findings, here's a simple framework to begin addressing the hidden culprits behind your back pain:
FOR ANKLE MOBILITY RESTRICTIONS
Calf Stretch with Towel:
Sit with legs extended
Loop a towel around your foot
Gently pull toes toward shin while keeping heel on floor
Hold 30 seconds, repeat 3 times each side, twice daily
Wall Ankle Mobilization:
Stand facing wall with foot 4 inches from wall
Bend knee forward, trying to touch wall while keeping heel down
Hold end position 2 seconds, return
Perform 15-20 repetitions each side, twice daily
FOR HIP ROTATION LIMITATIONS
Seated Hip Rotation:
Sit on firm surface with good posture
Without moving lower back, rotate knee inward
Hold end position 2 seconds, return
Perform 15-20 repetitions each side, twice daily
Figure-4 Stretch:
Lie on back with knees bent
Cross one ankle over opposite knee
Gently pull underneath leg toward chest
Hold 30 seconds, repeat 3 times each side
FOR BREATHING DYSFUNCTION
Diaphragmatic Breathing Reset:
Lie on back with knees bent
Place hands on lower ribcage
Breathe slowly, focusing on expanding ribcage in all directions
Perform for 5 minutes, twice daily
90/90 Breathing:
Lie on back with feet on wall, hips and knees at 90 degrees
Place hands on lower ribcage
Breathe slowly, focusing on lateral rib expansion
Perform for 5 minutes daily
FOR RIB MOBILITY RESTRICTIONS
Sidelying Rib Expansion:
Lie on side with knees bent
Place hand on upper side of ribcage
Breathe deeply, focusing on expanding ribs into your hand
Perform 10 breaths, repeat on other side, twice daily
Seated Rib Rotation:
Sit with good posture
Place hands on opposite shoulders
Rotate torso to one side while maintaining upright posture
Hold 2 seconds, return, alternate sides
Perform 10 repetitions each side, twice daily
BEYOND EXERCISES: THE CRITICAL LIFESTYLE FACTORS
While targeted exercises address specific restrictions, certain lifestyle modifications are equally important for long-term resolution of back pain:
FOOTWEAR CHOICES
Your shoes can either support proper movement or reinforce dysfunction. Consider these guidelines:
Minimize time in restrictive footwear (high heels, narrow dress shoes, etc.)
Choose shoes with flexible soles that allow natural foot movement
Ensure adequate width in the toe box to permit proper foot function
Consider temporarily reducing heel height if you typically wear elevated shoes
For Mike, simply switching from rigid work boots to more flexible footwear with the same safety rating made a substantial difference in his recovery.
SITTING HABITS
How you sit directly impacts your movement system. Make these adjustments:
Limit uninterrupted sitting time to 30 minutes when possible
Position your chair to maintain natural spinal curves
Consider a sit-stand desk to vary positions throughout the day
Ensure feet are flat on floor with knees slightly below hip level
These simple changes reduce the stress that prolonged sitting places on your movement system.
SLEEP POSITIONING
Nighttime positions can either support recovery or reinforce problems:
Avoid stomach sleeping, which stresses the spine and neck
If side sleeping, place a pillow between knees for proper alignment
If back sleeping, consider a small pillow under knees to reduce spinal stress
Ensure your mattress provides adequate support without excessive softness
For Janet, addressing her sleep position was crucial—her habit of stomach sleeping was reinforcing her rib and breathing dysfunction every night.
STRESS MANAGEMENT
Chronic stress directly impacts breathing patterns and muscle tension:
Implement regular stress reduction practices (meditation, gentle movement, etc.)
Practice brief breathing resets throughout the day
Consider stress-specific approaches like progressive muscle relaxation
Recognize the connection between emotional stress and physical tension
For Sarah, addressing the chronic stress that drove her dysfunctional breathing pattern was as important as the physical interventions for her recovery.
THE RECOVERY TIMELINE: WHAT TO REALISTICALLY EXPECT
Recovery from persistent back pain follows a predictable pattern when the true causes are addressed. Understanding this timeline helps set appropriate expectations:
INITIAL PHASE (1-3 WEEKS)
During this period, expect:
Some symptom fluctuation as the body adapts
Initial improvements in mobility measurements
Possible temporary symptom increases during adaptation
Gradual improvements in morning pain and stiffness
For Mike, this phase brought noticeable improvements in ankle mobility but only modest changes in his pain levels—an expected pattern as his body began adjusting to new movement options.
INTERMEDIATE PHASE (3-8 WEEKS)
This period typically includes:
More consistent symptom improvement
Significant gains in joint mobility measurements
Noticeably improved movement quality
Reduced reliance on pain medication or other symptom management
Mike's recovery accelerated during this phase as his nervous system began integrating the restored ankle and hip mobility into normal movement patterns. His pain levels decreased substantially, and he resumed light work duties.
ADVANCED PHASE (8-16 WEEKS)
The final phase usually involves:
Resolution of primary pain complaints
Return to normal daily activities
Integration of proper movement patterns into everyday life
Development of self-management strategies for long-term success
By this point in his recovery, Mike had returned to full work duties, resumed recreational activities, and developed confidence in managing his own movement system. His pain, while occasionally present at low levels, no longer limited his function or quality of life.
MAINTENANCE PHASE (ONGOING)
Long-term success requires:
Periodic self-assessment to identify returning restrictions
Consistent application of key mobility exercises
Attention to environmental factors (footwear, sitting habits, etc.)
Proactive intervention at the first signs of regression
Two years after his treatment, Mike maintains his recovery with a simple daily mobility routine and periodic self-assessments. When he notices early warning signs—usually stiffness rather than pain—he increases his mobility work to prevent regression.
THE BIGGER PICTURE: REFRAMING YOUR RELATIONSHIP WITH BACK PAIN
Perhaps the most important outcome of this approach is a fundamental shift in how you understand and relate to your back pain. Rather than viewing it as a mysterious affliction or evidence of a "broken" spine, you recognize it as your body's signal that the movement system needs attention.
This reframing transforms back pain from a source of fear and limitation into an understandable and manageable process. You move from feeling victimized by unpredictable pain to empowered with specific tools and knowledge.
For Mike, this shift was profound. "I spent three years being afraid of my back," he told me during our final session. "Now I understand what it needs and how to take care of it. The pain isn't controlling my life anymore—I'm controlling it."
This outcome—empowered self-management rather than dependence on treatments—represents true success in resolving back pain.
NEXT STEPS: YOUR PATH FORWARD
If you're dealing with persistent back pain that hasn't responded to traditional approaches, consider these steps:
Perform the self-assessments outlined above to identify potential hidden culprits
Begin the appropriate exercises based on your findings
Implement the lifestyle modifications that support proper movement function
If available, seek evaluation from a healthcare provider who understands movement system assessment and treatment
Track your progress objectively using both symptoms and functional measures
The path to resolving persistent back pain isn't always quick or simple, but it becomes navigable when you address the true causes rather than just treating symptoms. By restoring proper function throughout your movement system, you create the conditions for your body to heal—often after years of failed treatments focused solely on the pain site.
As Mike discovered, the solution to persistent back pain often lies not in more aggressive treatment of the back itself, but in restoring proper function to the overlooked areas that forced the back to compensate in the first place.
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