Many patients who come to our Lakewood Ranch office describe the same pattern: an acute back episode, several weeks of treatment or rest, and then the pain fading enough to get back to normal. Then it comes back. Maybe six months later, maybe sooner. A different movement triggers it this time. They wonder what they did wrong.
Most of the time, they didn't do anything wrong. The original episode resolved on the surface while a deeper problem was left in place. That problem often lives in a small, segmental group of spinal muscles called the multifidus. If you've had recurring back pain in Lakewood Ranch and no one has assessed your multifidus, that is worth a conversation.
What Is the Multifidus?
The spine has two broad categories of muscles. The global muscles, which most people recognize (erector spinae, lats, core abdominals), produce movement across multiple segments. They're visible on a muscular person's back and they do the work of bending, rotating, and extending.
Then there are the local muscles, the ones you never see in a mirror. The multifidus is the most critical in this group. It runs in short segments up the entire length of the spine, attaching to each vertebra individually. Its job isn't to move the spine in big arcs. Its job is to stiffen each individual spinal segment, millisecond to millisecond, before any movement happens.
That timing distinction matters a lot. When you pick up a bag, your brain fires the multifidus a fraction of a second before the erector spinae or the back extensors fire. The multifidus pre-stiffens the segment so the global muscles have a stable base to work from. No pre-stiffening, no stability. The segment moves in a way it's not built to, and that's where injury happens.
What Happens After a Back Injury
Here is the part that trips most people up. After an acute back injury, whether a disc flare, a muscle strain, or an episode of severe spasm, the multifidus on the injured side atrophies rapidly. Research published in Spine found measurable cross-sectional atrophy on the injured side within 24 hours of the onset of acute low back pain. Not weeks. Hours.
The mechanism is neurological. Pain signals from a disc, facet joint, or ligament shut down the motor neurons controlling the local multifidus at that spinal level. The brain, in effect, turns off the stabilizer closest to the problem. It's a protective reflex in the short term. The trouble is, it does not self-correct.
Researchers who followed acute back pain patients found that multifidus atrophy persisted in people whose pain fully resolved. A year later, their backs felt fine. The muscle atrophy was still there, visible on ultrasound. Their larger global muscles had compensated well enough to get them through daily activity, but the local stabilizer at L4-L5 or L5-S1 was still significantly smaller on the injured side than on the other.
The multifidus doesn't rehab itself the way a bicep does. Once pain shuts it down, it takes specific, targeted input to bring it back online. "Feeling better" isn't enough to restore it.
Why That Sets You Up for Another Injury
A spine without a functional multifidus at a specific segment is like a building with a cracked beam. The floors above it look fine. The weight is distributed to other beams. But apply a load in the wrong direction, or a sudden impact, and the cracked beam fails first.
In practical terms: you had an episode at L4-L5. The pain went away. You went back to your workout, your yard work, your routine. The multifidus at L4-L5 never came back to full strength. Every time you lift, rotate, or load the spine, that segment moves slightly more than it should. Over time, the disc or facet at that level takes more stress than it's designed for. Eventually something gives.
This is why so many people with recurring herniated disc symptoms describe injuries at the same level, over and over. It's also why a new trigger often seems trivial. Reaching for a coffee cup shouldn't throw your back out. But it did, because the stabilizer that would have protected that segment wasn't there.
How We Assess for Multifidus Weakness
In our clinic, we approach this differently from a standard evaluation. When a patient presents with recurring low back pain, we're not just looking at the disc or the joint. We're looking at the control system.
A few things we assess:
- Side-to-side asymmetry in lumbar paraspinal bulk. You can sometimes palpate a meaningful size difference at the same level on the left and right. More definitive tools include diagnostic ultrasound (where available) or the contraction quality on the side of the prior injury.
- Motor control during loaded tasks. We observe how the lumbar spine moves and where it shifts during a simple leg-loading test or a partial squat. A multifidus-deficient segment often shows a subtle hinge pattern at one level instead of distributing motion evenly.
- History pattern. Repeated episodes at the same spinal level, a clear initial injury that seemed to resolve, and then recurring episodes with progressively less provocation: this history alone is clinically meaningful.
- Response to position. Some patients have significant relief in extension. Others do well in flexion. That directional preference can point toward the specific segment and the type of instability.
We also use chiropractic assessment of segmental motion, looking at which spinal levels are restricted and which are hypermobile. A hypermobile segment, one that moves more than its neighbors, often has a failed local stabilizer.
What Targeted Care Actually Looks Like
Addressing the multifidus requires a two-part approach. First, restore the structural integrity of the segment. Second, give the nervous system specific, low-load input to re-activate the muscle. Doing only one without the other rarely holds long-term.
Structural side: If there's a disc component driving the atrophy through ongoing pain signaling, we need to address the disc. For many patients with recurring disc-related back pain, non-surgical spinal decompression in Lakewood Ranch reduces the disc pressure that's keeping the pain signal active. When the pain signal quiets, the nervous system has a much easier time re-engaging the local muscles.
Chiropractic adjustment also plays a role here, restoring proper segmental motion at the affected levels and at adjacent segments that may have taken on compensatory load.
Neuromuscular re-activation: This is the piece most people skip. Once the pain is gone, they assume the work is done. It isn't. The multifidus needs deliberate, isolated re-activation exercises that specifically target the local stabilizer, not the global movers that have been covering for it.
The starting exercises are almost embarrassingly low-load. We're talking about gentle abdominal bracing combined with slow single-leg raises in supine position, or prone arm-and-leg extensions with careful attention to not rotating the pelvis. The point isn't to challenge the global muscles. The point is to give the nervous system a clean, low-noise environment to start re-mapping the local stabilizer.
Electrical muscle stimulation (EMS) is sometimes useful here as well. Applied at the correct parameters and placement, it can provide additional motor neuron input to a muscle that the nervous system has partially switched off. This isn't a passive modality in this context: it's used in combination with active contraction, not instead of it.
The Timeline Patients Should Expect
Multifidus re-activation is slower than most patients want it to be. The research suggests meaningful cross-sectional recovery takes 8 to 12 weeks of consistent, targeted exercise. In our experience, functional improvement in stability often happens sooner, but the muscle bulk itself takes time.
What patients typically report along the way:
- Reduced frequency of minor "micro-flares" at the affected level, usually within the first 3 to 4 weeks
- Better tolerance of activities that previously triggered symptoms (lifting, sustained walking, extended sitting)
- A qualitative sense of "not having to brace as hard" to feel secure during movement
- Fewer episodes of morning stiffness at the problem level
For patients who also have sciatica driven by the same spinal level, the nerve pain often improves alongside the stabilization work. The two problems frequently share the same segmental root.
When Imaging Helps (and When It Doesn't)
An MRI will show a disc herniation, a facet effusion, or spinal canal changes. It will not show multifidus atrophy unless the radiologist is specifically looking for it and reporting on paraspinal muscle cross-section, which most standard back pain reads do not include.
This means a patient can have an MRI that shows "mild degenerative changes, no significant canal stenosis" and still have significant multifidus weakness driving their recurring instability. The scan is not the full picture.
That said, imaging is appropriate when there are red flags: progressive neurological deficit (increasing leg weakness, foot drop), bowel or bladder changes, a history of cancer, or an onset after significant trauma. Those need urgent evaluation. A healthy adult with a familiar pattern of recurring back flares at the same level typically does not need an MRI before starting a stabilization program.
Practical Takeaways
If your back pain keeps coming back at the same level and the same side, and you've had at least one significant episode in the past, consider the following:
- Ask whether your provider has assessed local spinal stability, not just joint mobility or disc status
- Look critically at any rehab program you've been given: does it start with low-load, isolated exercises, or does it jump straight to global strengthening? Low-load comes first
- A flare resolving doesn't mean the underlying problem is resolved. The atrophy window after an acute episode is when a targeted stabilization program does the most good
- Pain relief is the beginning of recovery, not the end. The nervous system needs specific input to re-activate what it turned off
After 23 years in practice, Dr. Banman consistently finds this pattern: patients who had the acute injury addressed but never received targeted stabilization work for the local muscles. They felt better, went back to their lives, and then came back six months later wondering what happened. The answer is usually in what didn't get addressed the first time.
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Back pain that keeps returning deserves a real answer.
Dr. Banman evaluates local spinal stability as part of every recurring back pain workup. Most patients have a plan within one visit.
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