Back pain is the most common reason why people come to us — and the rarest reason for an operation. The two belong together: with most back pain no structure can be found that could be repaired, and that is good news, not bad. This page explains what can lie behind back pain, how we recognise the few causes that need a targeted treatment, what you can do yourself in the first weeks, and when you should not wait.
Most back pain has no dangerous cause and passes within days or weeks — fastest of all if you keep moving. The art lies in recognising the few cases in which that does not hold.
What lies behind back pain
In more than 85 in 100 people with back pain, no clear cause can be established. Medicine calls this non-specific low back pain, and the word “non-specific” does not mean “imagined” but this: the pain comes from muscles, ligaments, joint capsules and discs that are overloaded, tense or irritated, without any single structure being nameable as the culprit. Such pain is usually dull, spread broadly across the lower back or between the shoulder blades, changes with posture and time of day, and at most radiates into the buttocks or the thighs.
In the remainder a specific cause is found — a structure that explains the pain and whose treatment changes it. The most common are wear-related changes: a herniated disc, a narrowing of the spinal canal, worn vertebral joints, a slipped vertebra, the sacroiliac joint. Rarer are vertebral fractures in osteoporosis, infections, rheumatic conditions and tumours. And occasionally a “back pain” does not come from the back at all, but from the kidney, the pancreas, the abdominal aorta or the pelvic organs. The task of the first examination is not to take an image, but to tell these groups apart.
How we tell where it comes from
The conversation contributes most. Since when, how did it start, where exactly, does it run into the leg and how far? What makes it worse — sitting, standing, walking, bending forwards, bending backwards, coughing, turning over in bed, the night? What makes it better? Is there tingling, numbness, weakness, fever, weight loss, a cancer in your history, a course of cortisone, a fall? Then the examination: posture, mobility, pain on tapping over the vertebrae, strength of the foot and toes, reflexes, sensation, nerve stretch signs, loading tests for the sacroiliac joint and the hip. In the great majority of cases a clear direction emerges from this before any image has been taken.
Imaging is therefore not the first step, but an answer to a specific question. For acute low back pain without warning signs, the National Disease Management Guideline recommends no X-ray, CT or MRI scan; it becomes sensible with warning signs, with nerve deficits, and when the symptoms are no better after four to six weeks despite treatment. The reason is not thrift: imaging shows abnormalities in many people without any back trouble as well. About 20 in 100 of those aged 20 to 40, and more than 80 in 100 of those over 70, have a bulging disc without feeling anything of it. An image taken without a question finds such incidental findings — and turns a back pain that would have passed into a diagnosis that stays.
The most common causes
Non-specific low back pain
The great majority. Typical: a dull, broadly spread pain in the lower back, often after an unaccustomed load, long sitting or an awkward movement, stiff in the morning, better as the day goes on, without radiation below the knee, without tingling, numbness or weakness. It can be fierce — “lumbago” is its acute form — and is harmless nonetheless. Stress, lack of sleep, worries and fear of movement make it stronger and make it last longer; that is not imagination, but the way the nervous system processes pain.
Herniated disc
Typical: a sharp pain that runs from the back along a strip into the leg, often as far as the foot or the toes, worse on coughing, sneezing, sitting and bending forwards, often with tingling or numbness in the same strip, sometimes with a weakness in lifting the foot. The leg pain is usually stronger than the back pain. More on the pages Herniated disc of the lumbar spine and Sciatica.
Spinal stenosis
Typical: in later life, heavy, tired or tingling legs after a certain walking distance, which recover when sitting or bending forwards; cycling works, walking does not; the back hurts on standing and bending backwards. More on the page Spinal stenosis.
Vertebral joints and sacroiliac joint
Typical of the small vertebral joints: a deep low back pain on bending backwards and twisting, stiff in the morning, with radiation into the buttocks and the thighs, but not below the knee, without tingling or weakness. Typical of the sacroiliac joint: a one-sided pain below the belt line that you can point to with one finger, worse on getting up from sitting, on turning over in bed and on standing on one leg. More on the pages Facet joint osteoarthritis and SI joint syndrome.
Spondylolisthesis
Typical: a deep-seated low back pain on standing, walking and bending backwards, which eases when sitting, sometimes with the feeling that the back “will not hold”; in adolescents after sports involving hyperextension. Whether the displaced vertebra is the cause or an incidental finding is settled by the examination. More on the page Spondylolisthesis.
Vertebral fracture in osteoporosis
Typical: from middle age onwards, a sudden, precisely localisable pain in the middle of the back after a trivial load — lifting, coughing, stumbling — which grows worse on straightening up and standing and eases when lying down; the spot is tender to tapping. Often with known osteoporosis, after a course of cortisone or with loss of height. More on the pages Vertebral fracture and Osteoporosis.
Rare but important causes
Infection — a bacterial infection of disc and vertebra (spondylodiscitis) causes an increasing pain that persists at night and at rest as well, often with fever, exhaustion, or following an infection or a procedure. Rheumatic condition — axial spondyloarthritis (ankylosing spondylitis) usually begins before the age of 45 with a creeping low back pain that wakes you at night and in the second half of the night, with morning stiffness lasting more than half an hour, and that improves with movement and worsens with rest. Tumour — an unremitting pain at night in someone with a known cancer, with unintended weight loss or night sweats, points to a spinal metastasis. Internal organs — colicky flank pain with blood in the urine (kidney), belt-like pain from the upper abdomen to the back (pancreas), a sudden tearing pain with circulatory collapse (the aorta in the abdomen), cycle-dependent pain (the pelvis) belong to other specialities.
- Broad across the low back, changeable, no leg, no tinglingPoints to non-specific low back pain.
- A strip down to the foot, coughing makes it worsePoints to the disc.
- Heavy legs when walking, better when sittingPoints to a narrowing of the spinal canal.
- Deep in the low back on bending backwards, one spot below the belt linePoints to the vertebral joints or the sacroiliac joint.
- Sudden, one vertebra tender to tapping, from middle age onwardsPoints to a vertebral fracture.
- At night, at rest, with fever or weight lossPoints to infection, rheumatic disease or tumour — to be assessed.
These patterns are rules of thumb, not diagnoses. They help you describe your symptoms — we make the attribution together after the examination. More than one cause at the same time is possible, and in older age common.
Warning signs
With three signs, back pain is not a case for the waiting list but for the emergency services: numbness in the area of the buttocks and perineum, a new problem passing water or opening the bowels, a paralysis that increases within hours or days. You should have the following assessed within a few days: new weakness in the leg or foot, pain with fever, pain after a fall or an accident, a new back pain with a known cancer or osteoporosis, pain with unintended weight loss, and pain that does not ease at night and at rest. More on the page Warning signs.
What you can do now
- Keep moving. Bed rest makes the symptoms last longer. Walk as far as you can, stay active in daily life and break up sitting every half hour. Pain on movement does not mean damage.
- Warmth. A hot water bottle, a heat patch or a warm bath relaxes the muscles and eases things for a few hours.
- Painkillers, targeted and brief. An anti-inflammatory medicine for a few days at the lowest effective dose, provided nothing speaks against it — so that you can move, not so that you can lie down. Ask at your GP practice or pharmacy what fits with your other medicines.
- Check the foot. Once a day: stand on your heels, stand on your toes, lift the big toe. If that gets weaker, get in touch.
- No image on your own initiative. An MRI scan without a question answers no question. It shows changes that almost everyone has, and creates worries that were not there before.
- Once it has settled: train. Without training, about 50 in 100 people get low back pain again within a year; with regular training, about 30 in 100. Regular walks lower the frequency almost as well.
When you should make an appointment
If the pain is not clearly better after about two to four weeks, if it runs into the leg or tingling, numbness or weakness are added, if it stops you sleeping or working, if it keeps coming back, or if you simply want to know where it comes from. You need neither a referral nor an MRI scan for that. Bring what you have — images on CD, doctors’ letters, your list of medicines — and come even if you have none of it. What happens at the first appointment is on the page Your first appointment.
How it usually goes on
Non-specific low back pain usually settles within a few days or weeks. About half of those affected get low back pain again within a year without regular training — that is the normal course of a complaint that comes in waves, and not a sign that something has been missed. The guidelines distinguish acute pain up to six weeks, subacute up to twelve weeks and chronic beyond that. With chronic pain the treatment shifts: away from the search for the one structure, towards training, coping with pain and — where needed — a combined treatment of exercise, pain medicine and psychological support. Specific causes have their own course, which is described on the respective pages. An operation is not the first step with any form of back pain — and with non-specific low back pain it is no step at all.
The matching conditions
If you have recognised yourself in one of the patterns, you will find here the detailed pages with course, diagnosis and treatment with and without an operation:
- Herniated disc of the lumbar spine — the pain that runs into the leg, with what you should know about waiting, injections and surgery.
- Spinal stenosis — the narrowing of the spinal canal with the short walking distance.
- Facet joint osteoarthritis and SI joint syndrome — pain from the joints of the back and the pelvis.
- Spondylolisthesis — the displaced vertebra and the question of whether it is the cause.
- Vertebral fracture and Osteoporosis — the fracture without an accident and the condition behind it.
- Spinal metastases — back pain with a cancer.
- Warning signs — the few signs with which you should not wait for an appointment.
With a rheumatic cause, an infection or pain coming from the internal organs, we refer you on to the appropriate speciality — the examination that establishes this takes place with us.