A client of mine had back pain that had taken over his life. Not dramatic, acute injury pain. The kind that just quietly ends things over time. Golf was gone. Moving comfortably was gone. He wanted to get back to both.
We worked together for a while. The problem was he couldn’t really buy in. Showing up consistently was hard. Doing anything on his own between sessions wasn’t happening. The pain made it easy to justify not doing the work, and not doing the work made the pain harder to manage. Eventually he decided surgery was the move.
It went well. He felt great. For a few months. Then the pain came back almost exactly where it was before. This is not a rare story. It’s actually one of the most common ones I hear. Which is either reassuring or depressing depending on how you look at it.
Every Professional Is Looking Through Their Own Lens
There’s a neurosurgeon on YouTube who goes by Goobie, from the channel Goobie and Doobie. Yes that’s his real channel name. Yes Doobie is his dog. MIT-educated, spent a decade performing spinal surgeries, quit because he kept seeing the same outcome. He noticed he could do a perfect surgery and still get wildly different results. The patients who healed were sleeping well, eating reasonably, exercising, managing stress. The ones who smoked, sat on the couch, had no social support, he’d get them temporarily better and six months later they’d be right back where they started.
His analogy was a leaky roof. He was tearing down the damaged drywall, replacing the insulation, rebuilding the wall, but never fixing the leak. So the house just kept getting ruined again. His video has 11 million views. Apparently spine surgeons quitting their jobs and moving to the mountains with their dogs to make nature videos is relatable content.
Here’s the thing though. Everyone is working from their own lens. The surgeon sees a structural problem. The PT sees a muscle imbalance. I see movement patterns and capacity. None of us are necessarily wrong. We’re each holding a different piece of the picture and sometimes we mistake it for the whole thing. If your only tool is a hammer, everything looks like a nail. And in medicine, some people have very expensive hammers.
The research on this is pretty clear. For chronic back pain without nerve compression, infection, or serious instability, spinal surgery is largely unsupported by clinical evidence, and rates of surgery have increased substantially anyway, disproportionately among privately insured patients. That is worth knowing before you schedule something.
[photo: simple graphic showing multiple contributing factors to chronic pain]
More Than You Think Is Fixable
Here’s what I see respond well, and why:
Tendon pain (achilles, patellar, rotator cuff) – Tendons need load, not rest. Rest makes it feel better short term and usually makes the underlying problem worse. Progressively loading the tendon is consistently one of the most effective things you can do here.
Restricted range killing a joint – A lot of shoulder and hip pain lives here. The joint stops moving the way it should, surrounding structures compensate, things get chronically irritated. Restore the range and the pain often follows.
Sciatica and certain nerve compression – People assume this always requires intervention. A lot of cases respond well to the right mobility work and load management. It takes longer than people want and requires actual consistency, but it’s workable.
General deconditioning – This sounds clinical but it’s probably the most common situation I see. Inactivity, weight creeping up, mobility disappearing quietly over years. All of those feed each other. My back client had been slowly dismantling his own foundation for years without realizing it. No single surgery was going to untangle that, and no surgeon was going to tell him that in a 15 minute appointment.
[video: hip mobility drill for lower back pain]
The Shoulder That Wasn’t a Shoulder Problem
A client came in convinced he needed shoulder surgery. Couldn’t use that arm for much of anything. Had basically stopped loading it entirely.
When we assessed what was going on, his shoulder blades were frozen. They barely moved on any exercise. His scapulae were stuck. Every pressing and pulling movement he’d ever done had been done with the shoulder blades locked in place, which over time compressed the joint and limited everything.
We didn’t touch the shoulder directly for the first few weeks. We worked on scapular movement. Getting those things to actually glide, tilt, rotate the way they’re supposed to on loaded movements. Once they started moving, space opened up in the joint. Pain started dropping. Within two months he was loading that shoulder in ways he hadn’t in years.
The surgery he thought he needed would have gone into a joint that wasn’t the actual problem. He still has the shoulder. It works fine. The surgery consult does not know this and probably never will.
[photo: scapular movement demonstration]
The Knee That PT Missed
Another client came in after months of PT that hadn’t done much. Knee pain limiting everything. Her therapist had focused almost entirely on hip strength and glute activation, which are genuinely important. But the knee itself had been almost completely ignored.
Two things had never been addressed. Her tibia mobility, the ability of the lower leg to move properly relative to the knee, was basically nonexistent. And her quad strength was poor enough that the knee was being asked to absorb load it wasn’t built to handle.
Once we added tibia mobilizations and started actually loading the quads progressively, things changed fast. Within a few months she had more resilience in that knee than she’d had in years. She described it as feeling like new knees, which I’ll take.
Three months of PT had done basically nothing. Two things that PT never touched fixed it. I’m not saying that to throw anyone under the bus. I’m saying it because the lens problem is real and it shows up everywhere.
[video: tibia mobilization and quad strengthening progression]
When to Actually Stop and Get Help
Some of these seem obvious until you’re in the middle of a workout and trying to convince yourself that the stabbing sensation in your lower back is probably nothing.
Stop the exercise if:
- The pain is sharp or stabbing, not a burn or muscle fatigue
- It’s above a 4/10
- It gets worse rep by rep during the set
- It feels worse after the session than it did going in
Any of those four, stop. Get it assessed before going back to it.
Go get evaluated if you have:
- Back pain with numbness or tingling traveling down your leg
- Any weakness or loss of control in a limb
- Pain that wakes you up at night consistently with no clear cause
- Pain that is getting progressively worse over weeks with no explanation
These are not things to train around.
When It Actually Does Make Sense
Some things genuinely need surgery. Knee replacements and hip replacements exist because sometimes a joint has deteriorated past the point where conservative care can help. They work well and have strong outcomes for the right situation.
Herniated discs with persistent severe radiculopathy that hasn’t responded to conservative care over several months. Structural instability from trauma. Fractures, infections, tumors. These are situations where surgery is the right answer and the correct tool, not a last resort.
The complicated zone is chronic pain with no clear structural cause. Pain that’s been there for years. Pain that shows up on imaging but may have been there before the symptoms started. Research shows that outcomes after spinal surgery for chronic low back pain are heavily influenced by factors like pain catastrophizing, anxiety, and depression, not just by what the imaging shows. That doesn’t mean the pain isn’t real. It means the picture is more complicated than a single structural fix can address.
[photo: someone working with a trainer, focused and moving well]
The Leak in the Roof
My back client’s surgery fixed his structure. It didn’t fix his inactivity, his weight, his hip mobility, or his relationship with movement. Those things were still there when the post-surgical inflammation settled down. So the pain came back.
That’s not a knock on the surgeon. The surgeon did exactly what surgeons do. But the leak in the roof was still there. And it turns out drywall is not cheap.
If you’re dealing with something that’s been hanging around, the worst thing you can do is keep waiting to see if it fixes itself. It usually doesn’t. Reach out and we’ll figure out where to actually start.