The Injury That Changed Everything
When I was 16, I was a national-level athlete competing in both track and field and basketball. The problem? I thought I had to do everything—lifting with both teams. I didn't tell my coaches, fearing they’d make me choose.
It worked, until it didn’t. Overuse injuries crept in, and I ended up with stress fractures in my low back—bilateral pars fractures at L4 and L5. The medical term is spondylolysis, and it was the first serious setback of my athletic career.
A year of rehab followed: bone stimulators (which were experimental and... not great), back braces, no-impact training, and—most importantly—physical therapy. I went to PT three times a week for nine months. It wasn’t just recovery; it was the start of a new passion. That experience lit the fire for me to become a physical therapist.
Ever since, back pain has been a recurring theme in my life. But instead of becoming a victim to it, I’ve made it my mission to understand it—and help others beat it.
How I Evaluate Back Pain at HIDEF
When it comes to treating low back pain, I see people overcomplicate the process all the time. My framework? Keep it simple and tactical. It all starts with creating a differential diagnosis. That means figuring out the top 2-5 things that could be causing the pain, then ranking them by probability. You need a starting point, and statistics are your best friend.
For example:
Someone walks in with back pain that’s worst in the morning, radiates down the leg, and eases with sitting but flares back up after driving—chances are, we’re dealing with discogenic pain (disc-related).
I prioritize what's most likely first, because this isn’t just guesswork—it's math.
Treating Low Back Pain: The Power of Directional Preference
I’m not married to any one method, but I’ve found McKenzie-based concepts (like directional preference) work wonders, especially early in the process. For disc injuries, that usually means focusing on extension-based movements.
I also use the “string” analogy with patients:
Imagine a string running from your back to the point in your leg where the pain stops (say, your calf).
As we do specific exercises, I ask if that string feels like it’s shortening (pain moving toward the back) or getting longer (pain spreading further down the leg). If the pain centralizes toward the spine, we’re on the right track. If it doesn’t, we adjust.
Here's the deal: Don’t get stuck on one movement pattern. Early in my career, I thought finding the right movement (say, extension) meant sticking with it forever. Big mistake. Injuries evolve, and what worked in the beginning might stop working—or even make things worse—later on.
Don’t Overcomplicate. Hit the Low-Hanging Fruit First.
This is where a lot of therapists mess up. They rush into fancy exercises—hip hikes, farmers carries, lumbar strengthening—before the basics are dialed in. My advice?
Nail the low-hanging fruit.
Then start building complexity.
Throwing too much at a patient too soon? You’ll never know what’s helping or what’s making things worse. Rehab is about controlled progression. You have to pull the right levers at the right time to get meaningful results. If you load too fast—let’s say someone maxes out at a 50 lb deadlift during PT, then jumps straight to 350 lb outside the clinic—that’s a recipe for disaster.
At HIDEF, we focus on gradual exposure to loads. If a patient used to deadlift 400 lbs, getting them back to that weight isn’t about throwing them under a bar on day one. It’s about scaling their progress so they can safely work their way back.
Treating the Person, Not the Pain
Physical therapy isn’t just about anatomy and biomechanics—it’s about meeting people where they are. Some days, a patient can crush 50 lbs on leg extensions. Other days, stairs might set them back. Your plan needs to reflect that. Adaptability is the name of the game.
This is where we separate physical therapists from personal trainers. Every session is a new data point.
If today’s movement didn’t work, cool. We shift gears and try something else.
If the exercises we prescribed caused more pain, I’m not afraid to admit, “We went the wrong way,” and adjust the course.
That’s the art of PT—understanding when to pivot.
The Problem with Graduating Too Early
One of the biggest pitfalls I see? Clinics discharging patients too soon. They think, “Great, the patient’s not in pain anymore. We’re done!”
No. The real work starts when pain is gone. If someone’s goal is to get back to deadlifting 400 lbs, stopping at 50 lbs in the clinic is nowhere near enough. At HIDEF, we keep patients longer to bridge that gap between where they are and where they need to be. If we don’t, they’re more likely to re-injure themselves. The best predictor of future injury is past injury.
Final Thoughts: Progress Is Everything
Everything we do at HIDEF comes back to progressive overload—a principle borrowed from strength and conditioning. Whether it’s back pain or knee rehab, the question is the same: What’s the highest safe entry point for this person? Once we find it, we build from there, tracking every detail.
I document every session:
What weight did we use?
What was their RPE (Rate of Perceived Exertion)?
Did the exercise cause pain?
This helps me identify what’s working and what’s not. It also allows me to show progress in a tangible way. If a patient hit 100 lbs at an RPE of 7 two weeks ago, and now it’s a 4? That’s progress.
Rehab Is Both Science and Art
Injuries aren’t one-size-fits-all. Two therapists might treat the same back injury differently—and both might be right. That’s the beauty of this profession. It’s about choosing the most logical path forward based on the patient’s response, then adjusting as needed.
So if you’re a PT, personal trainer, or even just someone dealing with back pain—my message to you is this: Don’t be afraid to load. Don’t overcomplicate things. Adapt every step of the way. And, above all, track your progress.
Zach Smith, PT, DPT
Founder | Doctor of Physical Therapy
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