Back pain can be debilitating and uncomfortable. According to the American Chiropractic Association, approximately 80 percent of the U.S. population will have back pain at some time in their lives (1).

Back pain may be acute or chronic. Acute pain comes on suddenly and lasts no more than six weeks. Chronic pain, which is less common than acute pain, refers to pain that lasts more than three months.

 

Spinal Anatomy

The spine consists of 33 interlocking bones, called vertebrae, that are stacked on top of one another. These bones are separated and cushioned by flat, flexible, round discs of connective tissues. The spine curves in an S-shape, when viewed from the side. These curves are responsible for shock absorption, range of movements, and balance.

The spine is divided into four segments:

  • Cervical spine (neck)
  • Thoracic spine (mid-back) – the area between the base of the neck and the bottom of the rib cage
  • Lumbar spine (lower back)
  • Coccyx (tailbone)

They are held together by a network of nerves, intervertebral discs, tendons, muscles, joints, ligaments, and bones.

The lower back (lumbar region) and the neck (cervical region) are most susceptible to pain. The thoracic region is also vulnerable, but it is less frequently injured than the lower back and neck because it is much more rigid.

Nerves

Nerves extend from the spine to other parts of the body, such as the legs and arms. These “electric cables” travel through the spinal canal carrying messages between your brain and muscles.

The sciatic nerve is the longest. It begins in your lower back and splits to run through your hips, buttocks, into the back of the leg, down to the feet.

The cauda equine, on the other hand, is a bunch of spinal nerve roots that arise from the lower region of the spinal cord.

Intervertebral discs

The segments between the vertebrae of the spine are separated and cushioned with cartilage-like spongy rings called intervertebral discs. They act as flexible shock absorbers, cushioning the vertebrae from rubbing against each other when you move around.

They need to remain elastic to absorb vibrations and pressure put on the spine from the various positions, movements, and situations we put our bodies into. There also needs to be sufficient room to allow spinal nerves to exit from the spinal canal and travel to adjacent limbs.

When these intervertebral discs are injured, it can cause irritation or compression of nerve roots. Depending on which nerve is affected, you may experience pain in numerous locations throughout the body.

Joints

The sacroiliac joint – also referred to as the SI joint – connects your pelvic bones (iliac crests) to your sacrum (the triangular bone between the lumbar spine and the tailbone). This joint absorbs shock between your upper body and the pelvis and legs. It doesn’t move much, but it helps you bend forward and backward.

The facet joints are the joints that make your back flexible and enable you to twist and bend. Nerves exit the spinal cord via the facet joints en route to other parts of the body. The cartilage surrounding it allows the vertebrae to move smoothly against each other without grinding.

The joints are reinforced by rigid ligaments and muscles surrounding it, some of which extend across the back of the pelvis. This network of soft tissues limits the movement of the joint, provides support, and helps absorb impact.

Tailbone (coccyx)

At the bottom of your vertebrae is a pointy triangular bone called the coccyx, also known as the tailbone. When you sit, part of your upper body weight rests on your coccyx.

 

Causes

Back pain may occur when something is wrong with the way your spinal nerves, joints, muscles, and discs fit together and move. It may result from injury, vigorous activity, or an underlying medical condition.

Strains or sprains

Strains or sprains around the spine are the most common cause of acute back pain. It most commonly occurs in the curve of the low back as well as the base of the neck. These sites are prone to strain and sprain because of its weight-bearing function and involvement in moving, bending, and twisting.

Sprains occur when your ligaments are overstretched or torn. Strains, on the other hand, happen when your tendons or muscles are overstretched or torn.

Overexertion, repetitive heavy lifting, or sudden awkward movements can cause you to strain or sprain your back. If you are unfit, the constant strain can cause inflammation, which may manifest as painful muscle spasms. Activities that can lead to strains or sprains include:

  • Lifting something improperly
  • Lifting something too heavy
  • Making an abrupt and awkward movement

People with strains or sprains are likely to experience discomfort that worsens with activity. It may get better with rest.

Poor posture

Back pain can also result from poor posture. This is because the muscles and ligaments in your back have to overwork to keep you balanced when you slouch.

Bulging or ruptured discs

A bulging disc – also termed herniated disc, protruded disc, slipped disc or ruptured disc – occurs when the outer fibrocartilage of the intervertebral disc is injured. As a result, the soft material inside (nucleus pulposus) may leak out of its enclosed space into the spinal canal, pinching a spinal nerve. The affected nerves become irritated, often causing pain and numbness. You may also experience pain in the thigh, hip, and butt.

The intervertebral discs in the lower back are most commonly affected, but may also occur in the discs in the neck. It is usually caused by wear-and-tear such as lifting heavy objects, aging, or even whiplash injuries.

Sciatica

Sciatica refers to intense pain that radiates along the sciatic nerve, which branches from your lower back to the hips, buttocks and down the back of the leg. Generally, sciatica affects only one side of your body. It happens when the sciatic nerve is pinched or compressed by a herniated disc or bone spur. It might also be due to spinal stenosis, which is the narrowing of the spinal canal.

Sciatica pain may come and go, but it can be extremely uncomfortable. Some people experience sharp, intense pain, while others feel tingling, numbness, and weakness in the affected area. Symptoms are highly variable.

Spinal stenosis

Spinal stenosis is the narrowing of the spinal canal. It exerts pressure on your spine and nerves. As a result, your legs and shoulders may feel numb. If the spinal stenosis exerts pressure on your spinal cord and nerves, you might feel pain on one side of your back.

It can occur with osteoarthritis or ankylosing spondylitis.

Scoliosis

Scoliosis occurs when the spine curves sideways in an abnormal manner. It results in an uneven distribution of weight throughout the back and may cause back pain.

Scoliosis usually develops in an adolescent during a growth spurt.

Radiculopathy (Pinched nerve)

Also known as a pinched nerve, radiculopathy in the back is usually caused by a bone spur or a herniated disc. It occurs when too much pressure is exerted on the nerve.

Radiculopathy can be caused by a variety of conditions, including:

  • A herniated disc, when a disc protrudes, compressing the nerve root
  • Sciatica
  • Degenerative disc disease
  • Bone spurs
  • Tumors of the spine
  • Osteoarthritis
  • Spinal stenosis
  • Compression fractures
  • Spondylolisthesis
  • Scoliosis
  • Diabetes
  • Cauda equine syndrome
  • Old scar tissue from a previous injury

Radiculopathy may cause shooting pain, numbness, tingling, and weakness, mainly if it occurs in your back or hip. Pain from radiculopathy usually lasts a short period and often results in no permanent damage once treated. However, if there’s persistent pressure on a nerve, you may experience chronic pain and may be at an increased risk of permanent damage.

Osteoporosis

Osteoporosis occurs due to a loss in bone mass. As a result, the bones become brittle and prone to fracture with slight trauma. This condition commonly affects the spine.

When osteoporosis occurs in the spine, the vertebra becomes porous. The weakened structure can break and result in a compression fracture.

In most cases, compression fractures are painful. Symptoms include sudden back pain onset that worsens when standing or walking.

Sacroiliac joint dysfunction

The primary causes of sacroiliac (SI) joint dysfunction include:

  • Too much movement (hypermobility or instability) in the SI joint. It can cause the pelvis to feel unstable. The pain may be felt in the lower back and may also radiate to the hip and groin area.
  • Too little movement (hypomobility or fixation) that causes muscle tension around the SI joint. The pain may be felt on one side of the low back or buttocks and may radiate down the back of the leg.

Symptoms experienced with sacroiliac joint dysfunction include:

  • Lower back pain that feels achy and dull. It could range from mild to severe and usually affects only one side.
  • Pain that radiates to the hips, buttocks, and groin.
  • Sciatica-like pain in the buttocks and back of the thighs. It may feel hot, stabbing, and may include tingling and numbness. The pain rarely extends below the knee.
  • Stiffness and limited range-of-motion in the lower back, pelvis, hips, and groin. It may cause pain with movements such as bending at the waist or walking up the stairs.
  • Worsened pain when exerting pressure on the SI joint, such as running, jogging, climbing stairs, and lying on one side.
  • Instability in the pelvis and lower back. The pelvis to feel like it will buckle or give way when standing, walking, or transitioning from standing to sitting.

Strain or injury to the sacroiliac joint (SI joint) can cause radiating pain in the lower back, hip, groin, and leg area.

Spinal arthritis

Osteoarthritis in the spine occurs when the cartilage of the facet joints undergo gradual wear-and-tear. As a result, the spine bones start to rub together with movement and cause further damage, leading to the formation of bony overgrowth (spurs). In some cases, the space around the spinal cord narrows, resulting in a spinal stenosis.

Psoriatic arthritis

Psoriatic arthritis is a form of arthritis that accompanies psoriasis. Approximately 30 percent of people with psoriasis develop psoriatic arthritis (2).

While psoriatic arthritis is more prominent in the hands and feet, it may also affect the spine. When it concerns the spine, it is referred to as axial arthritis – meaning that the pain can affect the spine, shoulders, or hips.

Enteropathic arthritis

Enteropathic arthritis affects approximately 5 percent of people with inflammatory bowel disease, such as Crohn’s disease and ulcerative colitis.

Symptoms begin with mild low back pain and morning stiffness. It worsens with prolonged sitting or standing and improves with moderate activity.

Infectious arthritis

Also known as septic arthritis, infectious arthritis refers to arthritis that results from an infection within the joint. Typically, infectious arthritis affects a large joint in the body, such as the knee or hip. Less frequently, it can occur in the facet joints of the spine. Symptoms of infectious arthritis usually come on rapidly with intense pain, joint swelling, and fever.

Ankylosing spondylitis

Ankylosing spondylitis is a form of arthritis that causes inflammation in the spine. It tends to affect the sacroiliac joints near the pelvis, as well as the hip joints.

The pain and stiffness in the lower back are mostly due to inflammation of the area where ligaments and muscles attach to bones (enthesitis). In severe cases, the inflammation can eventually lead to the bony fusion of the joints (where the fibrous ligaments transform to the bone, and the joint permanently fuse), significantly limiting mobility. That leads to a hunched posture.

Polymyalgia rheumatica

Polymyalgia rheumatica is an inflammatory condition that causes widespread muscle pain and stiffness. It mainly affects the neck, shoulders, upper arms, lower back, thighs, and hips. The disease often comes only suddenly and resolves on its own in a year or two.

Rheumatoid arthritis

Rheumatoid arthritis is an inflammatory disease of the joints that occurs when the immune system mistakenly attacks the synovium. Although rheumatoid arthritis most commonly affects the joints in other parts of the body, it can also affect the cervical spine (neck) or lumbar region (low back).

In severe cases, the affected joints may be destroyed, allowing the upper vertebra to slide forward on top of the lower vertebra (spondylolisthesis). The slipped vertebra may exert pressure on the spinal cord and the nerve roots where they exit the spine.

Spondylolisthesis

In spondylolisthesis, the vertebra bone slips forward and out of place. It typically occurs in the lower back.

The most common types of spondylolisthesis are known as degenerative spondylolisthesis and spondylosis spondylolisthesis. Degenerative spondylolisthesis occurs as a result of disc degeneration; as the condition develops, the spinal ligament may begin to buckle, causing the disc to loosen and slip. On the other hand, spondylolysis spondylolisthesis occurs when one of the bones in the lower back breaks, causing the vertebra to move forward.

Some people will not experience any symptoms at all. Others may have back and leg pain.

Fibromyalgia

Fibromyalgia is characterized by chronic widespread pain and fatigue. The lower back is commonly affected by fibromyalgia pain.

Myofascial Pain Syndrome (MPS)

Myofascial pain syndrome (MPS) causes chronic pain in the connective tissues (fascia) that enwraps the muscle and may occur within the intervertebral discs. More specifically, pressure on the trigger points (sensitive points in the muscles) causes pain that may be felt deep in the muscle. The pain may also radiate to adjacent parts of the body (referred pain).

Paget’s disease

 

Paget’s disease is a chronic condition that affects bone remodeling processed. Over time, it causes the bone to become fragile and misshapen. The vertebrae are among the few bones that are commonly affected by Paget’s disease.

Bruised or broken tailbone (coccydynia)

An injury can bruise the coccyx, or even fracture it if the harm to the bone is severe. When it’s bruised, you can feel a shooting pain in the spine when you put pressure on the tailbone, such as when you sit down. Leaning forward may help relieve pain as it takes the pressure off the area.

Other causes

There are other potential but rare causes of back pain, including:

  • Cauda equina syndrome. Symptoms include a dull ache in the low back and upper buttocks. You may also feel numbness in the buttocks, groin, and thighs.
  • Tumor of the spine may press against a nerve, resulting in back pain.
  • Spinal infection. A fever coupled with tenderness in the back could be due to spinal infection.
  • Other infections. Infection in the pelvis, bladder, or kidney may also cause back pain.
  • Sleep disorders. People with sleep disorders may experience back pain.

 

Risk Factors

These factors may put you at higher risk of developing back pain:

  • Older age
  • Lack of exercise and sedentary lifestyle
  • Obesity
  • Improper lifting
  • Underlying diseases, such as arthritis and cancer
  • Psychological conditions, such as depression
  • Smoking
  • Occupational activities
  • Pregnancy
  • Strenuous physical activities, especially if done incorrectly
  • Genetic factors

 

When to see a doctor

If your back pain doesn’t improve with home treatment and self-care within two weeks, it may be time to see your doctor. There are times when back pain could be a symptom of a severe underlying medical condition.

Seek medical attention if you have:

  • Severe or persistent pain that does not improve with rest
  • Pain and numbness or tingling that radiates down the legs, groin, or arms
  • Pain when you cough or bend forward
  • Difficulty walking or standing
  • Swelling of the legs, ankles, or feet
  • Unexplained weight loss
  • Sudden loss of bowel or bladder control
  • Fever
  • Irregular heartbeat
  • Shortness of stress
  • Traumatic injury, such as a fall
  • Throbbing pain in the abdomen

Also, see your doctor if you have a history of cancer, osteoporosis, or substance abuse.

 

Diagnosis

Diagnostic testing is usually ordered when the pain persist for more than two weeks and is severe. Likewise, if the pain radiates to the extremities, it is essential to rule out severe conditions such as spinal disc injuries.

Physical exam

During the physical examination, the doctor may test your:

  • Spinal range of motion
  • Ability to stand and walk
  • Reflexes
  • Ability to detect sensations in the legs
  • Leg strength

X-rays

An x-ray of your spine may reveal a bony overgrowth (bone spur) that may be pressing on a spinal nerve. The x-ray will also show the alignment of your spine – whether there are any structural abnormalities or broken bone.

MRI or CT scans

An MRI or CT scan can show any problems with the intervertebral discs, muscles, ligaments, nerves, tendons, and blood vessels. It can detect soft-tissue damages, such as herniated discs.

Electromyography (EMG)

EMG measures the electrical nerve impulses and the responses of your muscles to find nerve and muscle damage. It is helpful for the diagnosis of disc herniation or spinal stenosis.

Bone scan

A bone scan may detect bone tumors or compression fractures (caused by osteoporosis).

 

Treatment

Back pain usually resolves with home remedies and lifestyle modification, but sometimes medical treatment may be necessary. If home treatments aren’t effective after several weeks, your doctor might prescribe stronger medications or other therapies. Treatment for back pain depends on whether the pain is acute or chronic.

Pain relievers

Your first treatment option should be over-the-counter pain relievers. The following are the common types of medications used for back pain:

  • Non-steroidal anti-inflammatory drugs (NSAIDs) can relieve acute back pain and inflammation. Over-the-counter formulations include ibuprofen, naproxen sodium, and ketoprofen. Prescription pain relievers such as COX-2 inhibitors may be necessary if the pain is debilitating. Long-term use of NSAIDs is associated with stomach irritation, ulcers, diarrhea, heartburn, and water retention.
  • Analgesic medications are designed to relieve pain. Examples include OTC acetaminophen and aspirin, as well as prescription opioids such as oxycodone, hydrocodone, codeine, and morphine. Opioids should only be used for a short period and under a physician’s supervision. People can develop a tolerance to opioids. Chronic use of opioids may also be detrimental people with back pain because they can aggravate depression, which may lead to a worsening of the pain.

Take these pain medications only as directed by your doctor. Overuse can lead to serious side effects.

Muscle relaxants

If mild-to-moderate back pain doesn’t improve with OTC or prescription pain relievers, your doctor might also prescribe a muscle relaxant. These medicines reduce muscle spasm and pain. Muscle relaxants dampen pain receptors in the central nervous system. They help to relieve the muscle spasms in the back. Muscle relaxants may be particularly useful for the treatment of acute back injuries (such as straining your back while diving).

Topical pain relievers

These are cream or sprays that you can apply to your skin at the site of your pain. Topical products might be highly effective at reducing back pain. Many of these contain active ingredients like ibuprofen and lidocaine.

Antidepressants

Low doses of tricyclic antidepressants (e.g., amitriptyline) may relieve some types of chronic back pain.

Cortisone injections

If your back pain radiates down your leg, you may need an epidural corticosteroid injection into the epidural space (the space around the spinal cord). Unlike oral medication, an epidural injection goes directly into the painful area and therefore provide prompt relief. Chronic use of epidural injections may lead to functional impairment.

Nerve block therapies

Nerve block therapies relieve chronic pain in the spinal nerves. The range of nerve block therapy includes injection of local anesthetics, botulinum toxin (botox), or steroids into the affected area.

Cognitive-behavioral therapy

Cognitive-behavioral therapy (CBT) can help manage chronic back pain by encouraging positive thinking. Studies have found that patients who underwent CBT tend to be more physically active, resulting in a lower risk of back pain occurrence.

Surgery

Surgery is rarely necessary for back pain. You might benefit from surgery if your back pain radiates into the legs or you have progressive muscle weakness caused by nerve compression. Otherwise, surgery is usually reserved for structural abnormalities such as spinal stenosis or a herniated disc that hasn’t responded to conventional therapy.

 

Lifestyle modification and home remedies

Complementary home therapies may be used alongside conventional treatments or on their own.

Hot or Cold Packs

The combination of hot and cold compresses facilitate blood circulation to the affected area, which may help relieve pain.

Ice packs may relieve discomfort and help reduce inflammation in acute phases of back pain that occur shortly after an injury. Apply a cold compress or ice pack for 10-20 minutes at regular intervals throughout the day.

Once the inflammation has subsided after 48 hours, you can begin applying a warm compress or heating pad or heat lamp. Heat packs increase circulation, which relieves tension and improves healing in strained muscles. Apply the heat pack 10-20 minutes each time, and repeat every 2 hours.

You may alternate between applying ice and heat to help reduce swelling and inflammation.

Compression

Compressing the muscles can help keep the inflammation down, and that, in turn, helps keep the pain under control. Use a back brace for effective compression.

Don’t put the brace on too tightly and don’t leave it on all the time. Your muscles need adequate blood flow to heal.

CBD oil

There’s some evidence that cannabidiol (CBD) may influence the body’s endocannabinoid system (3). Not only does the endocannabinoid system affects how we experience pain, but it also contributes to brain functions like mood and memory.

Research shows that topical CBD application to specific areas of pain may provide consistent levels of CBD without extensive systemic involvement (4).

While very few clinical trials have investigated the pain-relieving effects of CBD oil, a study found that cannabis-based medicines may provide some benefit in the treatment of chronic neuropathic pain (5).

Essential oils

The following essential oils can help alleviate pain.

Peppermint oil is one of nature’s most potent pain relievers. Its menthol undertone is widely used for various types of pain, including back pain (6).

Wintergreen oil. A close relative to peppermint oil, the wintergreen oil confers similar analgesic properties. It contains methyl salicylate, which is similar to aspirin (7).

Lavender oil may also reduce pain more than placebo (8).

Ginger oil. A randomized controlled trial in Thailand has shown that Swedish massage with aromatic ginger oil is effective for relieving chronic low back pain (9).

Eucalyptus oil has been shown to have potential effects against pain and inflammation (10).

Stay active

While bed rest may soothe your back pain initially, resting for longer than a couple of days can cause your muscles to become weaker and stiffer. Resume light activities as soon as possible while avoiding movements that may aggravate back pain.

People who stay active without bed rest following the onset of back pain tend to have better back flexibility compared to those who rested for a week.

Strengthening and stretching exercises

If your back pain chronic or subacute, you will benefit from light stretching and isometric exercises. Strengthening both your abdominal and back muscles help stabilize your spine.

Try to hold a stretch for at least 30 seconds without jerking, bouncing, squatting, or twisting. It’s also important not to stretch too deeply, as this may make symptoms worse.

Physical therapy

Once the pain dissipates, your physical therapist can curate a rehabilitation program to prevent pain from recurring.

Physical therapy programs are designed to:

  • increase flexibility and mobility
  • strengthen back, and abdominal muscles
  • improve posture

Exercising in water is exceptionally safe and beneficial for a sore back. This is because the water supports some of your weight (which makes you more comfortable), and it offers gentle resistance (which builds your strength).

Spinal manipulation and mobilization

Chiropractors use their hands to massage, mobilize, adjust, or stimulate the spine and the surrounding tissues.

Chronic back pain may be temporarily relieved with these techniques; on the other hand, acute or subacute back pain may not respond as effectively. Spinal manipulation and mobilization are also not appropriate when you have an underlying medical cause for the back pain (e.g., osteoporosis, pinched a nerve, arthritis).

Acupuncture

The FDA has approved acupuncture as a treatment for back pain (11). The practitioner inserts hair-thin needles into specific points in the body to stimulate blood flow. As a result, this process helps to stimulate the production of natural pain-relief chemicals such as endorphins, serotonin, and acetylcholine.

Massage

Massage can help relieve tense or tired back muscles. It also stimulates the release of pain-relieving hormones known as endorphins.

One of the types of massages that is effective for back pain is known as Shiatsu, which is a finger pressure therapy. It is a type of massage where pressure is applied along energy lines in the body.

Biofeedback

Biofeedback involves the attachment of electrodes to the skin and the use of an electromyography machine that allows you to be aware of your physiologic processes such as heart rate, blood pressure, breathing, and muscle tension. With practice, you will learn to relax your muscles and reduce tensions, which may help relieve pain.

Transcutaneous electrical nerve stimulation (TENS)

Transcutaneous electrical nerve stimulation (TENS) is an excellent treatment for people with chronic back pain. The TENS machine delivers electric pulses into the body through electrodes placed on the skin. Electrical impulses will, in turn, block incoming pain signals from the peripheral nerves. It may also trigger your body to produce endorphins. TENS is considered safe, noninvasive, inexpensive, patient-friendly, and appears to reduce pain.

 

Prevention

Your back works hard for you. The better you take care of your back, the lower your risk for developing back pain.

Exercise

Regular low-impact aerobic exercises – those that don’t strain or jolt your back – can increase strength and endurance in your back. Walking and swimming are good options. Core strengthening and flexibility exercises may also help to reduce the risk of back pain.

Improve Posture

Good posture can reduce stress on back muscles. Don’t slouch – keep the vertebrae aligned.

If you are standing for extended periods, place a foot on a stool to relieve the load on your lower back.

While standing, keep your back upright, head facing forward, and balance your weight evenly on both feet.

Sit Smart

Choose an ergonomic chair with adequate lower back support, armrests, and a swivel base. Place a pillow behind the small of your back to maintain its normal curve. Maintain your knees and hips level and keep your feet flat on the floor. Change your position frequently, at least once every hour. Chairs of appropriate height with excellent lumbar support are preferable.

Lift smart

When you lift a heavy object, keep your back straight and bend only at the knees; hold the load close to your body. Avoid lifting and twisting simultaneously.

 

The Bottom Line

Back pain is a common ailment. With treatment, most episodes of acute back pain will resolve on their own. In cases of chronic back pain or injury, you may need to see a doctor for a proper diagnosis and treatment plan.