Back pain is one of the most common medical conditions in the United States, with between 50 and 80 percent of all adults experiencing back pain at some time, according to the Arthritis Foundation. About 10 percent of all Americans will experience back pain or related symptoms (such as limited mobility or stiffness) in any given year.
A person’s back is composed of the bones, muscles and other tissues that form the posterior part of the trunk, which runs from the neck to the pelvis. The back is held upright by muscles and ligaments that are attached to the bones of the back. These bones, called vertebrae, are stacked on top of one another. Together, these bones are known as the spine, spinal column or vertebral column.
The spine supports the upper body’s weight. It also houses and protects the spinal cord, which transmits electrical signals between the brain and the nerves in the legs, arms and other areas of the body. The spinal cord extends from the base of the brain to just below the rib cage. Small nerves enter and emerge from the spinal cord through spaces between the vertebrae.
The vertebrae are separated by intervertebral discs, also known as spinal discs. These are made up of a strong outer fibrous covering (annulus fibrosis) that surrounds a soft, jelly-like center (nucleus pulposus). The discs cushion the vertebrae and keep them from wearing out.
Several factors can contribute to back pain. Poor posture and ergonomics are common factors. A spasm, sprain or strain in a muscle or ligament can occur when a person lifts an object or overstretches. If the spine becomes overly strained or compressed, this trauma can cause a disc to bulge or rupture. A bulging or ruptured disc may put pressure on one of the dozens of nerves rooted to the spinal canal that control body movements and transmit signals from the body to the brain. Irritated, compressed or pinched nerves cause back pain.
Developmental abnormalities may lead to back pain. Examples include scoliosis (sideways curve of the spine), kyphosis (exaggerated forward curve in the upper back) and lordosis (exaggerated inward curve in the lower back).
Several conditions associated with aging can cause back pain.
- Degenerative disc disease, deterioration of the spinal discs
- Compression fractures due to the bone-thinning disease osteoporosis
- Spinal stenosis, in which spinal passages narrow
- Osteoarthritis, a gradual breakdown of cartilage in joints
- Ankylosing spondylitis, a form of arthritis that can inflame spinal joints
Back pain can also result from chronic disorders ranging from lupus to sickle cell anemia. However, in many other cases, the source of back pain can be difficult to determine. Many people develop back pain for no apparent reason.
Back pain is the second most common neurological ailment in the United States, according to the National Institute of Neurological Disorders and Stroke. Only headaches are more common. Back pain most often occurs in the lower (lumbar) back, which bears more weight and stress than the rest of the back.
Back pain generally can be classified into one of two categories:
Short-term pain that generally lasts for a few days or weeks before subsiding. Most acute back pain results from an injury or trauma to the lower back, or a flare-up of a disorder such as arthritis. Symptoms of acute back pain include muscle spasms and aches, shooting or stabbing pains, limited flexibility and range of motion or an inability to stand straight. In some cases, pain felt in one part of the body may radiate from a disorder or injury located elsewhere in the body. Left untreated, some forms of acute back pain can become more serious and chronic.
Often defined as pain that lasts for more than three months, or longer than is expected for the condition causing the pain. It is frequently progressive, with pain increasing over a period of time. In many cases, the cause of chronic back pain can be difficult to determine as pain can persist even though the underlying condition has healed.
Back pain can travel down nerve pathways through the body. As a result, the pain can appear at sites other than the back. This type of pain is known as referred pain. A person suffering from back pain may also experience:
- Shoulder pain
- Neck pain
- Arm pain
- Chest pain
- Abdominal pain
- Pelvic pain
- Leg pain
A pinched nerve in the lower back often radiates through the lower limb, and a pinched nerve in the cervical region may radiate down the arm.
In some men with lower back pain and testicular and scrotal pain, the cause may be late-stage testicular cancer.
There are many causes of back pain. Often it is difficult to diagnose the source of a person’s pain. However, several factors have been associated with either triggering new back problems or exacerbating existing problems. These include:
- Injury. Various injuries can cause spasms, sprain or strain in muscles or ligaments of the abdomen and the back, such as a sacroiliac sprain. Sources of injury include athletics, household chores, repetitive stress injuries incurred on the job and sudden trauma such as fractures or spinal cord injuries suffered in motor vehicle accidents and other mishaps.
Repeated injuries can result in the formation of scar tissue that is not as strong or flexible as the tissue it replaced. This can leave the back vulnerable to additional injuries in the future.
- Poor posture. Failure to sit or stand properly shifts the body out of balance, forcing just a few muscles and joints to support the entire body. This increases the vulnerability of these muscles to the types of stresses that cause back pain.
- Poor body mechanics and ergonomics. Bending the back rather than the knees when lifting objects is a common source of back pain.
- Emotional stress. People who are under stress experience a tightening of the back muscles that can worsen back problems.
- Excessive weight and obesity. Too much weight places strain on the back and stomach muscles, causing them to weaken and stretch.
- Poor muscle tone in the back and abdomen. Weakened muscles cannot properly support the back, leaving the back vulnerable to stresses and injuries.
- Age. As people age, bone strength and muscle elasticity and tone tend to decrease. Intervertebral discs begin to lose fluid and flexibility, reducing their ability to cushion the vertebrae. As a result, back injuries are more likely after age 30.
- Use of heavy packs. Back pain is typically uncommon in children. However, backpacks overloaded with schoolbooks and supplies can strain the back and cause muscle fatigue, resulting in injuries to the back. Oversize purses, heavy briefcases or luggage are common causes of back pain in adults.
In addition, there are many illnesses and disorders that have been associated with back pain. These include:
If the spine becomes strained or compressed, an intervertebral disc may bulge or rupture, depriving the vertebrae of the “shock absorbers” they need. Cartilage from the disc may protrude into the space containing the spinal cord and nerve root, resulting in pain. In more serious cases, disc material may compress the bundle of lumbar and sacral nerve roots at the end of the spinal cord, known as the cauda equina. This condition is called cauda equina syndrome, and it may cause permanent neurological damage if left untreated.
In some cases, a herniated disc may press on one or both of the sciatic nerves, large nerves that exit the spinal column in the pelvis. The sciatic nerves carry nerve fibers to the leg. When the nerve is compressed, it causes shock-like or burning low back pain, as well as pain through the buttocks and down one leg to below the knee. In some cases, it may reach the foot. Sciatica can involve a pinched nerve between a disc and an adjacent bone. Symptoms in such cases are not only painful but may also include numbness and loss of motor control over the leg.
Deterioration of intervertebral discs. This condition is common as people age and can press on nerves.
Narrowing of spinal passages, producing pressure on the spinal cord or nerve roots.
Pain within a joint. Each vertebra is joined to the vertebra above and below by a joint called facet or zygapophyseal joint. Forms of arthritis that can cause back pain include:
- Osteoarthritis. Characterized by chronic degeneration of the cartilage of the joints. Osteoarthritis of the spine may be referred to as spondylosis. This may involve bone spurs (osteophytes).
- Rheumatoid arthritis. Chronic disease marked by stiffness and inflammation of the joints, weakness, loss of mobility and deformity.
- Ankylosing spondylitis. Chronic inflammation of the spinal joints and ligaments.
These produce strain on the vertebrae and supporting muscles, tendons, ligaments and tissues. They include:
- Scoliosis. Abnormal sideways curve of the spine.
- Kyphosis. Severely rounded forward curve in the upper back.
- Lordosis. Abnormally accentuated inward arch in the lower back.
Abnormal loss of bony tissue resulting in porous and brittle bones. Osteoporosis most often affects women after menopause but is also common in elderly men. Osteoporosis may lead to vertebral compression fracture, which can cause severe back pain and kyphosis (“dowager’s hump”).
A stress fracture in a posterior vertebral area called the pars interarticularis. This usually affects the fifth (lowest) lumbar vertebra and is a common source of low back pain in school-age athletes but can affect anyone. Sometimes the damaged vertebra becomes so weak it slips out of place, which is known as spondylolisthesis.
Inflammation of entheses, which are sites where tendons or ligaments attach to bone. Enthesitis is often related to other musculoskeletal conditions such as arthritis or tendinitis.
- Polymyalgia rheumatica. Disorder marked by muscular pain and stiffness in the shoulders, neck and pelvic area.
- Fibromyalgia. Syndrome marked by chronic pain in the muscles and soft tissues surrounding joints, fatigue, and tenderness at specific sites in the body. Patients experience “tender points” in the neck, spine, shoulders and hips.
- Chronic fatigue syndrome. Debilitating condition that frequently involves joint pain and muscle pain.
- Systemic lupus erythematosus. An autoimmune disease that affects many areas of the body. Back pain may result from damage to the kidneys or joints.
- Sickle cell anemia. Inherited blood disease that can cause pain in the back and throughout the body.
- Lyme disease. Infectious tickborne disease that can lead to widespread joint and muscle pain.
- Whiplash. Injury to the neck resulting from a sudden jerking of the head. Whiplash is a common cause of neck pain and can cause back pain as well.
- TMJ disorder. This syndrome, involving the temporomandibular joint of the jaw, can cause orofacial pain, headaches, ear pain, neck pain, back pain and shoulder pain.
- Gait disturbances. Abnormal patterns of walking. Some gait disturbances cause or are caused by back pain.
- Paget’s disease. Disease in which bones become enlarged and weakened, often resulting in fracture or deformation.
- Prostate problems. Conditions such as prostatitis can cause back pain as well as pelvic pain or sexual pain.
- Kidney infection, stones or disease, such as polycystic kidney disease.
- Diseases of the intestines and pancreas.
Bulging of part of the wall of the aorta, the large artery that directs blood from the heart to the rest of the body. Thoracic and abdominal aneurysms seldom produce symptoms but in some cases can cause back pain. A ruptured aneurysm is often marked by sudden and severe abdominal or back pain.
Several conditions related to diabetes can cause back pain, including focal neuropathy and diffuse idiopathic skeletal hyperostosis (DISH, in which spinal or other ligaments become bony).
This can be due to cancer originating in or near the spine, cancer that has spread (metastasized) from another area (e.g., prostate cancer, breast cancer) or referred pain from some cancers, such as testicular cancer. Benign tumors can also cause back pain.
A group of inherited disorders in which enzyme abnormalities impair the production of an important substance called heme. Heme’s functions including carrying oxygen in the blood. Acute porphyrias affect the nervous system and can cause pain in the back, chest and elsewhere.
In most cases, back pain not involving neurological symptoms will disappear without the need for medical care. Although it may take weeks for the pain to completely resolve, improvement should be evident within 72 hours. If not, patients should seek the care of a physician.
Patients should see their physician immediately if they are age 50 or older, or if they have a history of back pain or cancer. They should also see a physician promptly if back pain:
- Feels constant or intense, particularly at night
- Spreads down one or both legs
- Causes weakness, numbness or tingling in one or both legs
- Causes new bowel or bladder problems
- Is associated with abdominal pain or throbbing
- Results from a fall or a blow to the back
- Is associated with fever or unexplained weight loss
- Does not improve when lying on one’s back
In diagnosing back pain, a physician will review the patient’s medical history and perform a physical examination. The physician will try to determine where the pain is located, how it is limiting a patient’s range of motion and whether or not muscle spasms are present. The patient’s muscle strength and ability to sit, stand, walk and lift both legs will be noted. A rubber hammer may be used to test reflexes.
If the physician suspects a tumor, fracture, infection or other disease, additional testing may be required. These tests can include:
Lab tests used in detecting or ruling out a wide range of conditions, from arthritis to sickle cell anemia.
A painless test in which an image is created of part of the body by using low doses of electromagnetic radiation that are reflected on film or fluorescent screens. Images may show the alignment of bones and whether or not the patient has degenerative joint disease or broken bones. However, these images cannot reveal problems with the spinal cord, muscles, fibrous tissues, nerves or intervertebral discs.
A noninvasive or minimally invasive test that uses sound waves and a magnetic field to produce clear cross-sectional or three-dimensional images of the body’s tissues. Images can be used to examine the lumbar region for bone degeneration. MRI can also help diagnose injury or disease in tissues, nerves, muscles, ligaments and blood vessels.
A noninvasive or minimally invasive test that uses multiple x-ray images, taken from different angles, to create three-dimensional images of body structures. Images may reveal disorders such as herniated discs, spinal stenosis or damage to vertebrae.
Uses high-frequency sound waves to create images of internal organs or tissues. It works by sending low-energy sound waves against tissue. It works by sending low-energy sound waves against tissue. Some waves pass through and some bounce back. As sound waves bounce back, they are recorded and displayed on a computer screen or television-type monitor. Ultrasound can be helpful to rule out the abdominal causes of back pain (e.g., kidney stones).
A type of radionuclide imaging test. Images may reveal bone tumors or compression fractures caused by osteoporosis. To perform the procedure, a physician injects a small amount of radioactive substance into the patient’s veins. After the substance has collected in the bones, a special camera is used to detect bone problems highlighted by the substance.
Measures electrical impulses generated by nerves and the muscles’ response to those impulses. This information can be used to confirm nerve compression resulting from herniated discs or spinal stenosis.
A special dye is injected into a spinal disc that is thought to be causing back pain. The dye highlights damaged areas that are revealed when x-rays are taken. This procedure is often used on patients who are considering spine surgery or whose pain has not responded to conventional treatments. A variation called functional anesthetic discography (FAD) involves injection of anesthetic into the disc.
Insertion of a needle into the spinal canal to extract cerebrospinal fluid for analysis. Spinal tap may be used in diagnosing conditions that can affect the central nervous system, such as Lyme disease or tumors.
When other tests are inconclusive, injections (e.g., facet joint injections) are sometimes done to diagnose the condition.
Each year, Americans spend about $24 billion on treatments for back pain, according to the Arthritis Foundation. Most back pain can be successfully treated at home. These treatments should begin to relieve pain within 72 hours, although it may take weeks before the pain completely disappears.
Medications including acetaminophen can ease pain, and nonsteroidal anti-inflammatorydrugs (NSAIDs) such as aspirin or ibuprofen can reduce inflammation, swelling and stiffness. Even over-the-counter acetaminophen or NSAIDs are not without side effects, especially in higher doses, so talking to a physician before taking these medications is recommended.
Start with cold compresses before moving on to hot compresses (or using hot baths instead of hot compresses). This technique can soothe sore and inflamed muscles. Cold treatment should be used first. Upon injuring the back, ice should be applied several times a day for up to 20 minutes at a time. Ice should not be applied to the back directly – there should always be at least a thin barrier between the ice and the skin. Cold treatments should be used as long as spasms persist.
Once acute pain has subsided – or after two or three days – heat from a heating pad or heat lamp should be used to loosen tight muscles. Again, applications should last no longer than 20 minutes. Although not scientifically proven to actually resolve back pain, these treatments do appear to reduce pain and inflammation and increase mobility for some patients.
Light activity speeds up healing and recovery. Immediately stop any activity that aggravates the muscles. A physician, physical therapist or exercise physiologist can suggest appropriate exercises, which may include stretching, swimming or walking. Prolonged bed rest – more than one or two days – should be avoided.
In some cases, home remedies will not be enough to soothe back pain. If home remedies fail to offer any improvement in symptoms after 72 hours, patients should seek medical assistance. A range of medications or therapies can be used to help relieve back pain.
Prescription NSAIDs and muscle relaxants can be used to relieve mild to moderate back pain. In most cases, these medications are taken orally. However, they may also be given as counter-irritants. These medications are applied topically to the skin as a cream or spray. They are designed to stimulate the nerve endings in the skin to provide sensations of warmth or cold and to dull a patient’s sense of pain.
Other medications sometimes prescribed to treat back pain include:
These drugs, primarily used to treat seizures, may also be effective in treating certain types of nerve pain. Anticonvulsants are often prescribed with analgesics.
Some antidepressants, particularly tricyclic antidepressants, can relieve pain and assist with sleep. The U.S. Food and Drug Administration (FDA) has cautioned that antidepressants may increase the risk of suicide. People taking antidepressants should be monitored for unusual behavior.
Prescribed to manage severe pain, they should be used only for short periods of time under close supervision of a physician, as they can have numerous side effects, including drowsiness, decreased reaction time, impaired judgment, depression and potential for addiction.
- Spinal bracing. This may be used for conditions ranging from scoliosis to spinal cord injuries.
- Electrical stimulation (e-stim). A small device can be used to deliver electrical stimulation to the muscles of the back, relieving pain caused by muscle spasms and strains. Transcutaneous electrical nerve stimulation (TENS) may be used to suppress pain from a pinched nerve, such as sciatica. These treatments should be performed only by trained healthcare professionals, who can instruct patients in use of TENS at home. For severe cases, e-stim devices can be surgically implanted in the back.
- Manipulation therapy, physical therapy and exercise. Chiropractors can manipulate and massage back tissues to reduce pain. Massage therapy may also offer relief. Chiropractors or physical therapists can offer modalities such as deep-heating ultrasound therapy or iontophoresis, the use of electricity to deliver medication through the skin. As the pain improves, the therapist or physician can work with the patient to create an exercise program that will strengthen the back and abdominal muscles, increase flexibility and improve posture. Instruction in body mechanics will help prevent reinjury.
- Occupational therapy. If back pain limits daily activities such as self-care and household chores, occupational therapy can improve adaptation and maximize independence.
- Cognitive behavioral therapy. Patients learn to replace negative thoughts with positive ones. This treatment may benefit people with chronic pain.
Some patients with back pain also seek alternative approaches to treatment. These include:
Needles the width of a human hair are inserted into trigger points around the body. Advocates of acupuncture say that it releases natural painkilling molecules. Some clinical studies have found acupuncture helpful in relieving back pain. A variation is a needle-free treatment called acupressure.
A special electronic machine is used to help train patients to become aware of and gain control over muscle tension, heart rate and skin temperature. The purpose is to help patients change their response to pain through relaxation techniques.
A range of approaches are used, including injections of local anesthetics or corticosteroids into soft tissues, joints or nerve roots. In some cases more complex nerve blocks and spinal cord stimulation are used. Spinal cord stimulation may be another option.
Involves the use of weights to apply a force intended to “pull” the skeletal structure into better alignment.
In rare circumstances, patients may need surgery to relieve their back pain. Patients who may benefit from surgery include those who have severe, consistent pain or progressive muscle weakness caused by nerve compression. Common spine surgeries include:
- Laminectomy and laminotomy. Part of a vertebra is removed to relieve pain caused by bone spurs or disc fragments that protrude into the spinal canal and press on the nerve roots within the spine.
- Discectomy. All or part of an intervertebral disc is removed.
- Fusion. Two vertebrae are joined to eliminate painful movement. Various metal implants may also be used to help reinforce the fusion.
- Vertebroplasty or kyphoplasty. These minimally invasive procedures inject cement-like material into vertebrae damaged by compression fractures, such as those caused by osteoporosis.
- Disc replacement. A synthetic disc is inserted between two vertebrae.
- Implantation of a spinal pump. In severe cases, a pump that delivers pain medication around the spinal cord can be surgically attached to the back.
There are many steps that people can take to help reduce the risk of back pain. These include strengthening the back and abdominal muscles through exercise and learning new ways to sit and stand.
People who have suffered a back injury also can prevent additional damage to their back by increasing strength and flexibility. Patients should work with their physician and other experts, such as a physical therapist or a personal trainer, to help create a safe and effective program that includes the following elements:
Helps increase the strength and endurance of the lower back. It is best to engage in regular aerobic exercise that does not strain or jolt the back, such as walking, swimming or biking.
Proper weight training can help strengthen abdominal and back muscles, allowing them to serve as a natural corset for the back. Stretching, yoga, tai chi and other exercises can increase flexibility in the hips and upper legs, which allows for proper pelvic bone alignment.
Excess weight strains the back muscles and increases back pain.
Smoking reduces the level of oxygen that reaches spinal tissue, thereby hindering the healing process when back muscles are strained or injured.
Measures such as using seatbelts and not diving into shallow water can reduce the risk of back pain.
Adequate intake of nutrients including vitamin D, calcium and magnesium may reduce the risk of osteoporotic fractures. Several recent studies suggest that carotenoids (found in orange and yellow vegetables and fruits) and certain enzymes in cruciferous vegetables (the broccoli and cabbage family) could protect the joints and help stave off arthritis. Some research indicates the mineral selenium, found in foods including seafood and meat, may help in preventing osteoarthritis.
The risk of injuring the back can also be reduced by such simple changes as learning to lift heavy items properly and maintaining good posture.
- Lifting from the knees, not the back. When lifting heavy objects, keep the back straight and the load close to the body. Do not twist the back while lifting. Bending from the waist to pick up even lightweight objects from the floor can strain the back. If an object is heavy or awkward, do not lift it without a partner’s help.
- Using proper posture when standing and sitting. When standing, maintain the pelvis in neutral position. People who stand for long periods of time should alternate placing each foot on a footstool. This can take some of the pressure off of the back. When sitting, choose a seat with good lower back support, arm rests and a swivel base. A rolled-up towel or pillow in the small of the back (lumbar area) can help maintain its normal curve. Individuals should also try to keep their knees and hips level.
- Sleeping on a medium-firm mattress. Recent studies indicate that sleeping on such a mattress is better for the back than sleeping on a firm mattress. Pillows can offer good support, but only if they do not force the neck up at a severe angle.
In some cases preventive medications are recommended to avert sources of back pain. For example, patients requiring long-term corticosteroid therapy may be prescribed bisphosphonates to reduce their risk of osteoporosis and vertebral fractures.
- Try to continue with daily work or school schedules to the extent possible. Use care in resuming normal activities.
- Avoid strenuous activity for 6 weeks.
- After healing, an exercise program will help prevent re-injury.
No special diet. A weight reduction diet is recommended if obesity is a problem.
Many other conditions besides lumbosacral strain can cause low back pain. These include cardiovascular, respiratory, gastrointestinal, urological and gynecological disorders. Pain originating in the spine could be from tumor, infection, inflammatory conditions, metabolic disorders, degenerative disc disease, instability, spondylosis, and spondylitis.
Physical therapy, three times a week, for a period of two to four weeks, or chiropractic treatment for two to four weeks.
Physiatrist, orthopedic surgeon, neurologist, rheumatologist, internist, sports medicine specialist, and anesthesiologist.
- You or a family member has mild, low back pain that persists for 3 or 4 days after self-treatment.
- Back pain is severe or recurrent.
- New or unexplained symptoms appear. Medications used in treatment may cause side effects.