Santa Clause at Risk for Back Pain

Is Santa at Risk for Back Pain

Is Santa at Risk for Back Pain?

Just for fun, I started to think about whether or not Santa Clause would be at risk for back pain.  Based on my experience as a Chiropractor and Athletic Therapist, as well as my experience of treating back pain these are my thoughts.

I feel for Santa, he has a very important job to perform once a year.  Thankfully, Santa has his elves helping him make all the toys for the boys and girls.  It was smart of him to delegate some of the work.  If he had to do all the work himself he would likely experience repetitive strain injuries in his wrists, elbows, shoulders, neck in addition to his lower back.

Sadly though, in the case for lower back pain, the odds are against Santa. Approximately 80% of people will have suffered from back pain at least once in their life.  The occurrence rate is also high among those who have had a previous back injury.

Here are some of the risk factors for back pain that Santa possesses.


Years ago Santa was a smoker. Smoking is a risk factor for back pain.  People who smoke tend to experience degenerative disc disease of the spine. Throughout the body there is a repair and break down balance. While the body is breaking down (catabolic) a part of a structure another is repairing or building (anabolic). Smoking tends to reduced the anabolic activity of cells with is the components of the discs which shifts the balance towards breaking down).

Santa may not be smoking (or he might be hiding it because it is less socially acceptable and would be bad for his image) now but the damage to his spine has already been done. The effectiveness of quitting smoking on the regeneration of a degenerated disc has been shown to have limited benefit on the health of the disc.1

Santa may not be smoking now but the damage to his spine has already been done. The effectiveness of quitting smoking on the regeneration of a degenerated disc has been shown to have limited benefit on the health of the disc.2

On a positive note, the presence of disc degeneration does not necessarily mean that back pain is present. One study 3 found the following

  • 37% of pain-free 20-year-olds have disc degeneration
  • 96% of pain-free 80-year-olds have disc degeneration

In addition, smoking is associated with chronic pain which is often experienced by those who have had a back injury. The current theory is that chronic smoke exposure may decrease pain tolerance and therefore increase pain awareness.4


It is rather evident that Santa is overweight. Every time he laughs his belly jiggles like a bowl of Jello.  The extra weight he carries places added strain onto all of his weight bearing joints, including his spine and the intervertebral discs between his vertebrae. This added strain can lead to an intervertebral disc derangement/herniation  and possibly lead to sciatica down his leg. With his extra weight in his belly his spine needs to extend backwards so he can stay upright.  This can cause abnormal compression onto the joints between the vertebra causing what is known as facet syndrome. It also means the lower back muscles are having to work

If Santa were to work on changing his body composition by increasing his activity levels and changing his calorie consumption there is good evidence that his lower back would improve or even disappear.5

In addition, with Santa being overweight he may be suffering from Metabolic syndrome which has also been associated with lower back pain. In one study the prevalence of metabolic syndrome among chronic lower back pain patients was 36.2%. 6

  Metabolic syndrome is linked to Type II diabetes. Considering all of the cookies that Santa consumes on Christmas Eve he likely has Type II Diabetes (He may want to learn how exercise can help with diabetes).  Santa may also want to consider better eating habits and read this great weight loss success story by my friend Kymberley (She has now lost 80lbs!).


Typically disc herniations occur around 25 and 45 years of age.  Santa has been around for a long time.  His origins begin back to the 4th Century.  That would make him very old.  One might assume that he is from a lineage of Santa Clauses and if that is the case, the white beard likely places him in his 60s or later.  At this age we are more concerned about arthritis of the joints or even stenosis of the intervertebral foreamen where the nerves exit the spine. 

Arthritis of the spine has sometimes been called “grey hair of the spine”.  It is a natural process and thus it is highly expected to be found in Santa’s X-rays . And, sometimes arthritis of the spine can cause back pain.


It is quite evident that for most of the year Santa is inactive.  He likely has not performed any core exercises to aid in protecting his back and he likely doesn’t have the muscular strength or endurance to perform his job without fatigue. You would think that he needs considerable strength to hold the reins of his flying reindeer and to climb up the chimney after leaving from a house. Inadequate core strength and fatigue results in poor technique and can increase the chance of hurting your back.  The problem with having to work only once a year is similar to the weekend warriors who only play on the weekend and do not exercise any other time of the week.  Weekend warriors are often the ones who get injured.

Uneven lifting

Santa has to carry a heavy sac of toys.   Carrying a sac over one shoulder (likely the same shoulder all the time because of our tendency to be one side dominant) places excessive strain on one said. This would likely result in muscular imbalance and the possibility of back pain due to over use. He should follow the advice of a Chiropractor and use a backpack to evenly distribute the weight across both shoulders but more importantly prepare his body for the yearly one day event

Long sitting followed by heavy lifting

Truck drivers are often at risk for back pain one of the reason is due to the long sitting. They are even more at risk for a lower back injury if they go for long sitting to lifting activities.  The intervertebral discs are more at risk for injury at this time.

Santa must sit for long hours. He has to make his list and even has to check it twice to see see who naughty or nice. Along with long hours sitting in a sleigh. Thankfully Santa needs to get up out of his sleigh frequently to go down another chimney. I often recommend people get out of their chairs at least every 20 minutes and do something active for at least one minute . Our body is meant to move.

In addition, if Santa lifts with poor technique he is further risking himself for injury.  Many people with back pain have poor movement patterns which place more stress on muscles or other tissues that may not be able to hand the stressed placed on them at the time. One of the poor patterns is flexing forwards at the spine rather than at the hips.   Since Santa appears to be an inactive individual most of the year we can assume his movement patterns may be faulty or he may over stress areas of the spine that are not acc.  He needs to learn how to hip hinge.

Stressful job

Stress is another risk factor for back pain.  Santa likely gets very stressed with his job. He has billions of letters to read and he has to watch over every child making sure they are naughty or nice.  The naughty kids must make him want to pull his hair out (I wonder if that is why he wears that hat all the time). For most of the year his job must be pretty thankless.  As Christmas Eve gets closer he has to make sure everything is perfect. In addition, he has a deadline that can’t be extended. He has to get presents to all the boys and girls before they wake up.  If he doesn’t they won’t be very happy. He should try mindfulness meditation to help with his stress.


As you can see the odds of Santa having back pain are high.  Thankfully a number of these risk factors can be controllable while others are completely out of his control.  I highly suggest to Santa that he should seek out some help in managing his weight, developing his core, and developing his strength and endurance.  There are great Chiropractors, Athletic Therapists, Personal Trainers and Physiotherapists out there who can help. In addition he may want to try massage, fascial manipulation, Active Release Techniques, or acupuncture to help manage the back pain.  With a good team of healthcare providers you can manage your back pain more effectively.

Do you have any of these risk factors for back pain and do you have back pain? If so you may want to become proactive in your health seek out a health care professional that you can trust and start your New Year on the road to recovery.
I hope you all enjoyed this fun blog. Have a Merry Christmas!

Dr Notley

P.S. Hey Santa, if your back is hurting on Christmas Eve and you need to see a Chiropractor or Athletic Therapist in Winnipeg I have a table at home.  You know where I live.

originally written in 2010. Updated 2021


How to deal with pain during training

You’ve been training consistently for several months.  You’ve been adding weight to your squat but recently you’ve started to experience left knee pain during your squat. This can be worrisome. You might start thinking you are causing damage. Though this may be true that ,in some cases, pain is an indication of damage in many cases that is not the case.  

Pain is a warning system. It indicates that there is a potential for damage.  Back in the day we looked at athletic/fitness injuries/pain as a result of only biomechanical origins.  Your pain was based solely on the stresses placed on it.  Over the last ten to twenty years the understanding of pain has expanded. There is a “new” model of explaining pain called the biopsychosocial model.  This model indicates that pain is a multi-factorial process that is based on biological (bio-), psychological and environmental (psychosocial) factors.  

Biological factors consist of:

  1. Nociception 
  2. Inflammation
  3. Fatigue
  4. Training load
  5. Sleep
  6. Illness

Psychological factors consists of

  1. Fear/anxiety
  2. Depression
  3. Stress
  4. Mood state
  5. Expectations
  6. Past experiences 

Social factors consists of:

  1. Knowledge of other people’s experiences
  2. Reactions from others
  3. The environment
  4. Culture

If the stresses placed on the knee during a squat is significant enough and your psychosocial factors consider the stress a threat you will experience pain. 

So if you are experiencing knee pain (or pain anywhere else) in the gym what should you do?  

Don’t Rest 

Resting your knee completely until you are pain free is not recommended. Rest ultimately leads to loss of strength, muscle mass and takes you further away from your goals. If you are experiencing tendinopathies you may see no improvement once you return to activity. Also, if you’ve stopped training because you are experiencing lower back pain, rest may result in worse outcomes in the long run. It’s important to stay active.

Modify training variables

What you need to do is modify the stresses you place on your knee.  Make modifications to your workout that don’t aggravate your knee.  

How can you modify your workout to reduce the overall load on the tissue?

  1. Reduce the weight to reduce the intensity
  2. Reduce the repetitions to reduce overall volume
  3. Reduce the sets to reduce overall volume
  4. Reduce rating of perceived exertion to reduce overall load
  5. Increase the number of repetitions and slow the movement down (3 seconds up: 3 seconds down) this will force you to reduce the weight you can use.
  6. Reduce the range of motion you move the joints through.  For example some people experience knee pain at the bottom of a squat so switching to box squats may help. 
  7. You may need to  drop the exercise and try a different movement.  

Use a traffic light analogy to gauge your activity’s effect on your knees.  If you rate your pain 1 to 4 out of 10 this is a green light situation.  You should be able to perform the activity without further aggravation.  If your pain is between 5 and 7 then this is a yellow light situation.  In this case you might want to pay attention.  There is the possibility that an aggravation can occur. If you are 8 to 10 out 10 then this is a red light situation and you should stop or not perform the exercise, for now. 

Once you discover what modifications will not aggravate your knee then you can begin to slowly expose the area to greater stimulus.  What we are looking for is positive workout experiences that don’t aggravate your knees. Remember you don’t have to be pain free during this process. It’s alright to have some discomfort that doesn’t escalate during training or 24 to 48 hours after training.

Load the area and then monitor.  If there is no aggravation perform this workout a couple more times.  Again, if there is no aggravation, increase the weight.  Remember just like strength training, improvements are not linear.  There may be some days where you might have to take a step back and work at a lower load and then slowly progress forward again.  There is no benefit in being overly aggressive by continuing to increase weight even though you continue to aggravate your knee.   This only lengthens your recovery.  Lastly, understand that for some it may take several months depending on the problem you are experiencing.

Still struggling?

You may also ask yourself

  1. Are you recovering from your workouts adequately?
  2. Are you eating well enough?
  3. Are you sleeping well enough?
  4. Are there other stresses in your life?
  5. Are your fears justified?
  6. Is your training program appropriate for you?
  7. Is there enough variety in your exercise selection?

There may be other factors at play.  Seek out a chiropractor, athletic therapist or physiotherapist who can help you pinpoint training errors in your workouts or discover biomedical reasons for your pain.

Disc herniation versus Disc Bulge

What is the difference between a disc herniation and disc bulge

You just received your MRI results and it says that you have a disc herniation or disc bulge. I’m sure this might be worrisome to you. So what does this mean? 

First of all, these terms are often used interchangeably but, in reality, there is a difference between the two.

Anatomy of the disc

The discs are spacers found between two vertebrae.  They are responsible for movement between the vertebrae; flexion, extension, rotations and lateral bending. 

They are made up of the following parts

  1. Annulus fibrosus – It consists of strong fibrous layers of criss-crossing fibers that firmly attach to the vertebrae above and below.  It is responsible for holding the two vertebrae together and pressurizing the inside of the disc.
  2. Nucleus pulposus.  This is found in the inner core of the disc. It is of jelly-like consistency.  The nucleus really likes water.  It absorbs water when we lay down. This is why we are taller in the morning. That excess water is squished out when we stand up and move around. 

Disc herniation

As you bend forward the pressure on the front of the disc causes the jelly like nucleus pulposus to creep backwards.  With repetitive flexion or flexion and rotation activities fissures can form  and the layers of connective tissue can separate in the annulus fibrosus (known as delamination). The nucleus can then work it’s way down these fissures.  Over time these cracks and fissures can extend out to the periphery of the disc which causes the nucleus to herniate out into the space where the nerves/spinal cord are located.  This is a disc herniation.

Think of it like a jelly filled donut.  Take a bite on one side of the donut and the pressure squirts the jelly out the hold.  If the hole for the jelly wasn’t there the jelly would be contained and not squirt out. 

Interestingly though, when it comes to an intervertebral disc, vertical pressure down on the disc won’t cause the jelly to herniate out but bending forward can.

Disc bulge 

Disc bulges are typically age related.  As we age, the discs have less ability to hold onto water. Less water causes the disc to decrease in height and bulge outwards. 

Think of this like a deflated tire. When a tire’s pressure is less than optimal the  car will sit lower and sides of the tire will bulge out.  If the bulge projects backwards towards the spinal cord. 

Both of these situations may cause back pain when there is nerve irritation (due to chemical irritation or physical compression).  But at the same time, there are numerous people walking around right now with disc herniations or bulges who experience no pain at all.  Their herniations or bulges may be of similar size and shape as yours. So what this means is your disc herniations or bulges may just be incidental findings. 

Be aware that most disc issues get better. Even the worst disc herniations resolve; as a matter of fact they are the most likely to resolve. 

So what can you do? 

Be assessed by a chiropractor, athletic therapist or other professional who can determine what factors aggravate or relieve you.  Seek someone who gets you active, guides you towards self care and makes lifestyle modifications  to manage pain and return you to an active healthy life.

Is it alright to exercise with pain?

“I shouldn’t be doing squats because my knees hurt? “

“I’ve not exercised for several months because I have back pain.”

“I’ve stopped all of my upper body training because my shoulder hurts”

It’s okay to experience pain when you exercise.  How your body responds to that pain dictates whether or not you should continue with the activity.

When helping people dealing with pain I use a traffic light analogy to guide activity. Movement is medicine. 

My treatments help compliment movement. What I do in the office is geared towards getting you back to moving.  Pain shouldn’t stop you from being active but it may require you to modify activity.

Green light activities

It’s okay to perform activities that result in mild degrees of pain.  These activities are typically rated less than 4 out of 10 (10 being blackout pain).  You may experience mild pain after the activity but it quickly subsides within 6 hours.  It’s alright to progress these exercises. Consider a 1 to 10% increase in activity the next time you do it.

Yellow light activities

A yellow light activity is an activity that results in moderate pain. Pain is typically rated a  5 to 7  out of 10.  That pain typically resolves within 24 to 72 hours after activity. 

Continue with active rest on off days. If managed correctly and there is no major loss of range of motion or strength you can attempt this activity again.  

If you experience pain that increases 3 points above your baseline of pain, this is a flare up. You should rest, ice, continue normal activities, avoid new activities, continue to think and speak positively, and avoid negative thoughts and words. You may need to back on this activity for a bit.

Red light activities 

Red light situations are activities where pain reaches 8 or more out of 10.  There is a significant loss of range of motion or strength.  Pain after activity persists for more than a couple of days; maybe weeks. It’s time to stop the activity or modify it. 

Weather and Pain

Often I have patients who claim they can predict the weather or that their pain is influenced by the weather. I often assumed that the patient was seeing a correlation that didn’t really exist possibly because they have been told by others that weather influences joint pain. This subject, even in the area of research is controversial. Results of studies have shown connections while others show no effect. I decided to see what some of the research says.

From what I have learned from some of my research is as follows:

1. Low temperature, more often than not, has some effect on pain (osteoarthritis, rheumatoid arthritis)
2. Low temperature makes those 50 – 65 year old 15% more likely to experience rheumatoid arthritis pain
3. Relative humidity has a significant association with hand osteoarthritis pain
4. Absolute change in atmospheric pressure is associated with pain.
5. Limited evidence between fibromyalgia and weather conditions

I admit this isn’t not an exhaustive study of the subject but it is food for thought. Feel free and read the abstracts found below

Dr Notley

Influence of weather on osteoarthritis of the hands

Background: The aim of this work was to investigate the association between meteorological variables and pain, stiffness, and function of the hand in patients with osteoarthritis.

Methods: The survey was carried out over 2 months in 2009, covering July and November. The patients filled out a questionnaire, consisting of visual analogue scales covering the three categories of symptoms that primarily determine the situation with rheumatism of the hands: function, joint stiffness, and pain. The questionnaire was completed on Monday, Wednesday, and Friday for every week in July and every week in November. The meteorological variables recorded included atmospheric pressure, air temperature, relative humidity of the air, and precipitation. The climate records were checked against the variables of functional evaluation of the hands from each patient using bivariate analysis and multiple regression analysis.

Results: In general, air temperature and relative humidity were the variables that displayed statistically significant higher association in all evaluated aspects of the hands, being explained by the influence of temperature in 40-88% (r) and relative humidity in 39-85% (r). In the multivariate analysis, there was a reduction in the number of weather variables that influenced pain. The variation of pain was explained by the average atmospheric pressure of the day of the questionnaire and the temperature the day before and the day after the questionnaire (52-88% [R2]).

Conclusions: The results implied individual variation in perception and quantification of function, stiffness, and pain. The lowest temperature associated with worsening of symptoms of pain and function in osteoarthritis of hands was the variable weather most frequently observed.

Weather conditions may worsen symptoms in rheumatoid arthritis patients:
The possible effect of temperature

Lydia Abasolo, Aurelio Tobías , Leticia Leon, Loreto Carmona, Jose Luis Fernandez-Rueda, Ana Belen Rodriguez, Benjamin Fernandez-Gutierrez, Juan Angel Jover

Objective: Patients with rheumatoid arthritis (RA) complain that weather conditions aggravate their symptoms. We investigated the short-term effects of weather conditions on worsening of RA and determined possible seasonal fluctuations.

Methods: We conducted a case-cross over study in Madrid, Spain. Daily cases of RA flares were collected
from the emergency room of a tertiary level hospital between 2004 and 2007.

Results:245 RA patients who visited the emergency room 306 times due to RA related complaints as the main diagnostic reason were included in the study. Patients from 50 to 65 years old were 16% more likely to present a flare with lower mean temperatures.

Conclusions: Our results support the belief that weather influences rheumatic pain in middle aged patients.

Influence of weather variables on pain severity in end-stage osteoarthritis

Stephen A. Brennan, Thomas Harney, Joseph M. Queally, Jade O’Connor McGoona, Isobel C. Gormley, Fintan J. Shannon


Patients often attribute increasing pain in an arthritic joint to changing weather patterns. Studies examining the impact of weather on pain severity have yielded equivocal and sometimes contradictory results. The relationship between subchondral pseudocysts and the role they play in this phenomenon has not been explored.


Fifty-three patients with end-stage osteoarthritis of the hip completed daily pain severity visual analogue scale (VAS) scores over a one month period. Radiographs were reviewed to determine the presence of pseudocysts. Data pertaining to precipitation, atmospheric pressure and temperature were collected from the nearest weather station. A generalised linear mixed model was used to explore the relationship between weather variables, cysts and pain severity.


Pain levels increased as a function of absolute change in atmospheric pressure from one day to the next
. Precipitation, temperature and the presence of subchondral pseudocysts were not shown to influence pain severity.


This data supports the belief held by many osteoarthritic patients that changing weather patterns influence their pain severity.

Influence of Weather on Daily Symptoms of Pain and Fatigue in Female Patients With Fibromyalgia: A Multilevel Regression Analysis

Ercolie R. Bossema, Henriët van Middendorp, Johannes W. G. Jacobs, Johannes W. J. Bijlsma, Rinie Geenen


Although patients with fibromyalgia often report that specific weather conditions aggravate their symptoms, empirical studies have not conclusively demonstrated such a relationship. Our aim was to examine the association between weather conditions and daily symptoms of pain and fatigue in fibromyalgia, and to identify patient characteristics explaining individual differences in weather sensitivity.


Female patients with fibromyalgia (n = 333, mean age 47.0 years, mean time since diagnosis 3.5 years) completed questions on pain and fatigue on 28 consecutive days. Daily weather conditions, including air temperature, sunshine duration, precipitation, atmospheric pressure, and relative humidity, were obtained from the Royal Netherlands Meteorological Institute. Multilevel regression analysis was applied.

In 5 (10%) of 50 analyses, weather variables showed a significant but small effect on either pain or fatigue. In 10 analyses (20%), significant, small differences between patients were observed in the random effects of the weather variables, suggesting that symptoms of patients were, to a small extent, differentially affected by some weather conditions, for example, high pain with either low or high atmospheric pressure. These individual differences were explained neither by demographic, functional, or mental patient characteristics, nor by season or weather variation during the assessment period.


There is more evidence against than in support of a uniform influence of weather on daily pain and fatigue in female patients with fibromyalgia. Although individuals appear to be differentially sensitive to certain weather conditions, there is no indication that specific patient characteristics play a role in weather sensitivity.

On the belief that arthritis pain is related to the weather (1996)

D A Redelmeier and A Tversky


There is a widespread and strongly held belief that arthritis pain is influenced by the weather; however, scientific studies have found no consistent association. We hypothesize that this belief results, in part at least, from people’s tendency to perceive patterns where none exist. We studied patients (n = 18) for more than I year and found no statistically significant associations between their arthritis pain and the weather conditions implicated by each individual. We also found that college students (n = 97) tend to perceive correlations between uncorrelated random sequences. This departure of people’s intuitive notion of association from the statistical concept of association, we suggest, contributes to the belief that arthritis pain is influenced by the weather.

Does rain really cause pain? A systematic review of the associations between weather factors and severity of pain in people with rheumatoid arthritis.
Smedslund G, Hagen KB.


To examine the association between weather and pain in rheumatoid arthritis (RA).


Systematic review of longitudinal observational studies (up to September 2009) with data on the association between weather variables and severity of pain in RA. The methodological quality was rated independently by the two authors according to an adapted Newcastle-Ottawa Scale. We analyzed the data on an aggregated (group) level with a meta-analysis of correlations between pain and weather, and at an individual level as the proportion of patients for whom pain was significantly affected by the weather.


Nine studies were included. Many different weather variables have been studied, but only three (temperature, relative humidity and atmospheric pressure) have been studied extensively. Overall group level analyses show that associations between pain and these three variables are close to zero. Individual analyses from two studies indicate that pain reporting in a minority (<25%) of RA patients is influenced by temperature, relative humidity or atmospheric pressure. We were not able to relate the findings to methodological quality or other aspects of the studies.


The studies to date do not show any consistent group effect of weather conditions on pain in people with RA. There is, however, evidence suggesting that pain in some individuals is more affected by the weather than in others, and that patients react in different ways to the weather. Thus, the hypothesis that weather changes might significantly influence pain reporting in clinical care and research in some patients with RA cannot be rejected.

Previously published August 1 2013