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I’ve Got Your Back: Six Reasons You May Not Want It

That expression is heard frequently, inspiring confidence on the battlefield or between friends, and a cause for trepidation in politics where it often means the opposite! In aviation, “I’ve got your six” is a way of saying the same thing; I will ensure you get no pain from your back. Well, here are six reasons you may suffer pain in your back in the absence of a bogey coming at you from behind.

The back is a very complex structure with multiple components, any one of which can develop a squawk and cause discomfort. First, there are 33 vertebrae, the bones that balance your head up top and keep your pelvis pointing in the right direction. Between the bones are spongy “discs” that consist of a tough, outer layer and a jelly-like interior; they act as shock absorbers, preventing bone-on-bone damage. The vertebrae are tied together by fibrous ligaments, and multiple muscles link the spine to the skull, chest, abdomen, pelvis, and the lower limbs. Within the hollow part of the vertebrae runs the spinal cord and from this, nerves emanate and pass through bony windows, heading to various parts of the body. There are also blood and lymphatic vessels and organs in front of the spine in the chest, abdomen, and pelvis.

Back pain is very common and up to 80% of us will have it at some time or another. I remember showing some kids a fancy soccer move...well, in my head it was a fancy soccer move. In reality, there was a very unpleasant sound and I truly thought a bogey at my six had shot me with a cannon. The next six was the six weeks I spent in utter misery. So, I have empathy as well as sympathy; back pain sucks!

When seeing a doctor for back pain, some people think their physician is crazy: “That pain you feel in your shoulder is coming from your diaphragm,” or “I know you have knee pain, so we are going to replace your hip.” This phenomenon is called “referred pain” and is quite common – it is a function of the way our nervous system is built.


So, here we go with our six!

  1. Muscles and ligaments – The soft tissues that hold the spine together are a frequent source of pain. Sudden movements, like pulling a plane from your hangar, bending to pick up a chock or similar can tear these tissues, causing intense discomfort. I always wonder about the word “strained” – it brings to mind cooking spaghetti, not ripping muscles; maybe that is why people use it. A “strain” is a pull or tear of a muscle or tendon (the part of a muscle attached to a bone) and a “sprain’ is the same thing when a ligament is affected. Another common cause is carrying something heavy. Like yourself. Losing weight and ensuring your core muscles are strong is a good way to prevent these problems. Additionally, make sure you bend at the hips to pick up items, and when pulling that heavy plane out into the daylight, keep your back straight and use all your muscles. Or a power tug. Or other people! Therapy usually consists of rest, painkillers, and medications to relax the muscles as resultant spasm can make things feel even worse. Sometimes “TENS” (transcutaneous electrical nerve stimulation) is helpful – small electrical stimuli delivered via electrodes applied to the back. Local heat helps, as does a firm mattress.
  2. Discs – The term “slipped disc” is widely known, frequently stated, and totally incorrect! Discs don’t “slip”; they either bulge into the area where nerves live, or the outer part rips and the internal jelly protrudes and hurts the nerve. The mechanism of injury is similar to those noted above, but can lead to really nasty long-term pain and other problems. First, the pain will likely be “referred” to the area of the body supplied by the nerve that is being squeezed. The term “sciatica” is where the sciatic nerve roots are hurting, and although the source is in the spine, the pain will be in the hip and down the outer part of the thigh. Second, if nerves supplying bladder or bowel are affected, one may have problems going to the toilet – this is a medical emergency and merits immediately seeing the doctor. Third, if discs are damaged, then over the longer term the joint between afflicted bones is more prone to wear and tear. Treatments are a challenge – in the short term it is the same as for muscular problems, but adding local injections of painkillers and steroids is often indicated. Various surgical approaches are often employed but results vary widely and often do not resolve all the symptoms. Newer modalities that use implanted electrical stimulators to “modulate” the way pain is experienced are showing promise. However, prevention, as usual, is better than cure.
  3. Bones – The various joints between each set of vertebrae and in the pelvis can be the site of wear and tear arthritis or inflammation of the joint. This can cause chronic, unremitting pain and is often part of other joint problems in hips and knees. Keeping weight under control is a primary issue; otherwise, one is left with few options to treat this very common affliction – painkillers, local heat, and TENS. Sometimes in disc disease, the bones on either side are already arthritic and surgeons have no option but to remove the diseased tissue and fuse the bones together. This might mitigate pain but will throw spine dynamics out of balance and that can lead to further problems.
  4. In some people there is an abnormal curvature of the spine such as a   scoliosis, where a side-to-side curve throws abnormal stresses on joints, rendering them more susceptible to repetitive trauma. With age, bones may become less dense, and this is known as osteoporosis. Although more common in women, men are not exempted. These more fragile bones are apt to fracture and that can lead to paralysis. It is worth getting tested – especially if you are of short stature, not heavy, and have smoked. Preventative measures include doing high-impact exercise, and if diagnosed there are medications one can take that still allow you to fly.
  5. Cancer –Malignant disease can sometimes present as bone pain and unfortunately, the spine is a frequent site. Most cancers in the spine do not originate there; in fact, so-called “primary” tumors of the vertebrae, discs, muscles, etc., are rare. Cancer in the spine is usually due to “secondary” deposits of tumor cells that have migrated from elsewhere, the prostate being a common source. If one has unremitting pain in the back, with tenderness, immediately seek medical attention. Malignant deposits can lead to bony collapse and paralysis, just as with osteoporosis
  6. Given that a bunch of organs live in close proximity to the spine, diseases there can manifest as back pain. For instance, an “aneurysm” (swelling) of the aorta, the main artery in the body, can present with chronic back pain. Similarly, kidney diseases such as infections, stones, or cancers can first present with low back pain. A chronic cough can cause back pain but treating that rather than addressing what is causing the pain is missing the point.
  7. And commonly: A lot of back pain is a result of poor posture, especially among sedentary workers who spend a lot of time seated, working at a computer, for instance. Poor sleeping habits – or mattresses – play a role, as does stress. And importantly, physical fitness. Doing exercises that strengthen the “core,” such as Pilates, helps prevent a lot of muscle and disc problems.

So, if you want to keep the bogeys away, make sure your airframe is sturdy and well maintained, and have a trusted wingman at your side...your trusty physician! 

Jonathan Sackier

Dr. Jonathan Sackier is an expert in aviation medical concerns and helps members with their needs through AOPA Pilot Protection Services.

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