Lower Back Pain: Causes, Diagnosis, And Treatment

Most people will experience lower back pain at some point in their lifetime. It’s the most common musculoskeletal issue worldwide and the primary cause of limited activity and time off work.¹ It also leads to a huge healthcare burden and economic cost.

Acute or chronic back pain

Depending on whether your back pain is short- or long-term, it is described as either acute or chronic.

Acute back pain

This is pain that develops quickly and lasts for days or even weeks. When it is mild and not accompanied by any red-flag symptoms, it usually goes away without any lasting loss of function after a few days of home care.

However, when back pain comes on acutely along with any of the warning signs discussed under the specific conditions below, it requires prompt medical attention.

Chronic back pain

This is the pain you experience continuously for 12 weeks or longer, regardless of the cause or injury you’re being treated for. Around 20% of individuals with acute lower back pain end up developing chronic back pain.²

When you’re experiencing long-term lower back pain, it doesn’t always mean the underlying medical cause can be determined or treated successfully. Regardless of being treated, you can sometimes continue to experience pain.

Now let’s look at what causes lower back pain.

What are the common causes of lower back pain?

Different causes of lower back pain include:

1. Strain or sprain

Sprains and strains are the most common causes of back pain, particularly pain in the lower back.³ Sprains occur when there is tearing of a ligament (attaches bones in a joint), while strains involve tearing a tendon (attaches muscles to bones) or muscle.

A torn ligament or tendon can be due to trauma, such as a sports injury or a fall, or from repetitive stress injury (RSI – the overuse of a joint). Such lower back pain can range from mild to severe and is frequently described as “all-over pain” that even spreads to the buttock area. Movement tends to worsen the pain, and rest usually soothes it.

Along with pain, individuals often experience:

• Muscle spasms

• Muscle stiffness

• Reduced range of motion

Factors that can put you at higher risk of back sprain or strain include:

• Being overweight

• Having weak abdominal or back muscles

• Activities like football or weightlifting that involve pulling and pushing

2. Bulging (herniated) or ruptured disks

Disks work like cushions between the vertebrae, which are the bones in your spine. The soft material inside a disk can rupture or bulge, causing it to press on a nerve. However, you can experience a ruptured or bulging disk without back pain. In those cases, doctors identify disk disease by chance when their patients have an x-ray for another reason. 

The lumbar disk has a jelly-like center that can break through the stronger outer layer. A disk’s herniated portion is full of proteins that can aggravate and cause inflammation when they reach a neighboring nerve root. This inflammation, along with nerve compression, leads to nerve root pain. There’s an abundance of nerve fibers that supply the disk wall. You can experience severe pain if you have a disk that ruptures through this wall.

Lumbar disk herniation affects around 2% to 3% of the population.⁴ It’s the most common diagnosis of all lumbar spine degenerative abnormalities. It’s also the primary reason for spinal surgery among adults.

Risk factors for lumbar disk herniation are:⁵

• Physically demanding work

• Growing older

• Gender (men have it almost twice as often as women)

A ruptured disk may lead to sharp pains that can move into your groin, buttocks, and legs. When it develops in your neck, it can result in pain that spreads down your arm.

Other symptoms you may experience include:

• Numbness

• Muscle weakness

• Tingling

• Loss of bowel or bladder control

3. Osteoarthritis

This is the most common joint disorder in the US.⁶ Osteoarthritis of the spine is a type of arthritis caused by wear and tear of your spinal bone cartilage. As your cartilage wears down, you may feel an aching, throbbing, or dull pain that worsens with movement.

You may also experience crepitus (a crackling or popping sensation). A reduced range of motion and joint stiffness will likely also occur.

Some factors that can put you at a higher risk of developing osteoarthritis include:

• Obesity

• Joint injuries

• Bone deformities

• Repeated joint stress

• Genetics

As the condition progresses, your body will begin creating bony growths to help stabilize the joint. The bone spurs that result can compress surrounding nerve roots and cause tingling sensations and numbness like that of a ruptured disk.

4. Spinal stenosis

It’s not clear exactly how many people suffer from lumbar spinal stenosis, but estimates show more than 200,000 adults in the US have the disease.⁷

As you age, your spinal canal, where your spinal cord is located, can start narrowing as its tissues thicken. Spinal arthritis can cause bone overgrowth within the canal at the same time, leading to spinal stenosis.

If your spinal canal becomes too tight and starts compressing the nerves, you can experience shooting pain in your buttocks and lower back, along with:

• Numbness

• Muscle weakness

• Tingling

• Loss of bowel or bladder control

Other causes of spinal stenosis include:

• Spinal trauma

• Scoliosis

5. Traumatic spinal injury

Traumatic spinal injury (TSI) occurs from injury to the spinal column’s ligamentous, bony, and neurologic structures. Most TSIs are caused by preventable trauma, such as falls, sports-related injuries, and automobile collisions. Damage from these injuries can lead to weakness, loss of feeling, and paralysis. 

According to a population study of 13 million people, traumatic spinal injury led to 167,357 ER visits that resulted in 70,684 hospitalizations and 376 fatalities.⁸ The study revealed that women have a higher risk of TSI than men. It also showed that older individuals are more susceptible to TSI, particularly related to falls, which were found to be the most common cause of traumatic spinal injury.

6. Facet joint dysfunction

You have two facet joints behind each of your disks at every motion segment in your lumbar spine. There is cartilage between the bones in each of these joints. The facet joints are surrounded by a capsular ligament, which is supplied heavily with nerves. The facet joint cartilage can break down and become inflamed. This triggers pain signals in surrounding nerve endings leading to back pain.

If you have facet joint dysfunction, you may feel pain in your:

• Buttocks

• Lower back

• Thighs 

The pain doesn’t typically extend past the knee. Inflammation of these joints can lead to stiffness and trouble getting out of a chair or standing straight.

Estimates show lumbar facet joint pain accounts for around 15% to 45% of all lower back pain.⁹ This percentage seems to increase with age.

There are certain risk factors for this condition, including:

• History of trauma

• Age

• Poor posture

• Degenerative disk disease

• Family history of degenerative arthritis

7. Sacroiliac joint dysfunction

Sacroiliac joint dysfunction (SIJ) pain is a type of mechanical lower back pain that affects between 15% and 30% of people with chronic, nonradicular pain (local back pain that doesn’t involve irritation of the nerve root).¹⁰

Your sacroiliac joint attaches the sacrum (the bone at the bottom of your spine) to your pelvis on each side. It’s a strong, low-motion joint that absorbs tension and shock between your lower and upper body. If it becomes inflamed (sacroiliitis), it can become painful. There may also be a pain if there’s too little or too much joint motion.

Sacroiliitis can lead to pain in your lower back or buttocks that may spread down one or both of your legs. This can worsen when climbing the stairs or standing for long periods.

It can be difficult to tell the difference between SIJ leg pain and that of sciatica (frequently caused by lumbar disk slippage or herniation) since the radiating leg pain can feel similar.

Some risk factors for developing this condition include:¹¹

• Leg length discrepancies

• History of lumbar fusion

• Scoliosis

• Pregnancy

• Sustained athletic activity

• Gait abnormalities

8. Degenerative disk disease

When you’re born, your intervertebral disks are at their healthiest and are full of water. As you age, these disks start losing hydration and wear down.

Over time, they become less able to resist external forces and this can result in tears, leading to weakening or pain that may cause a herniation. Your disk may also collapse, contributing to stenosis.

Common symptoms of this condition include pain that:

• Comes and goes

• Is in your buttocks, upper thighs, and lower back

• Gets better after lying down or changing position

• Feels worse when lifting, bending, or twisting

It can also cause tingling and numbness in your legs and arms and weak leg muscles.

Initial intervertebral disk degeneration can occur in your adolescent years. 20% of young people experience mild signs of this condition, although the incidence increases with age. Around 10% of men aged 50 and above, and 50% of men aged 70 and over are affected by this disease.¹²

9. Abnormal spine curvatures

Conditions leading to abnormal spine curvatures that can result in lower back pain include:

• Kyphosis: Outward curvature of the spine measuring 50 degrees or greater on x-rays

• Scoliosis: A sideways spine curvature that frequently occurs in adolescents

• Lordosis (swayback): Lumbar spine bending that gives the vertebral column an inward curve

Over time, spinal curvatures can cause poor posture that leads to lower back pain since it places pressure on:

• Ligaments

• Muscles

• Tendons

• Vertebrae

Spine curvature disorder symptoms may include:

• Lower back discomfort and pain

• Appearing hunched or swaybacked

• Difficulty moving in certain directions

10. Spondylolisthesis

Spondylolisthesis is a condition of the spine that leads to pain in your lower back. It occurs when one of the small bones in your spine (a vertebra) slips out of place and ends up on the vertebra below. When this occurs, it can place pressure on a nerve, resulting in pain in your lower back or leg.

The pain can result from compression of the nerves that go to your leg or instability of your back. Around 4% to 8% of the general population experience isthmic (caused by a defect in a portion of the vertebra) or dysplastic (caused by a congenital defect) spondylolisthesis.¹³

Experiencing hyperextension (excessive joint movement in one direction) of your lumbar spine or lower back can increase your risk of spondylolisthesis, as can a history of repetitive trauma.

11. Compression fractures

These affect many people worldwide, occurring in around 1.5 million people in the US each year.¹⁴ A cylindrical vertebral fracture where the bone basically collapses in on itself can result in a sudden onset of back pain. This type of fracture typically results from weakened bones (for example,  osteoporosis) and is more common in older individuals.

Back pain is the main symptom of a compression fracture. You can also experience:

• Worsened pain when walking or standing

• Loss of height

• Difficulty bending your body

• A stooped, curved shape to your spine

12. Infection

Spinal infections are categorized by their location in the spine. These areas include:

• Intervertebral disk spaces

• Vertebral column

• Spinal canal

• Neighboring soft tissues

Infections are caused by viruses, fungal organisms, or bacteria, and they can occur from local trauma, infections spreading from other locations, or following a surgical procedure.

Symptoms depend on the type of infection and its location. For instance, lower back pain can result from vertebral osteomyelitis, an infection within the bone, and it is usually accompanied by redness, swelling, and often fever.

Intervertebral disk space infections often cause few symptoms initially but can develop into severe back pain.

There are also infections of the spinal canal that progress through different stages, starting from mild tenderness, moving to severe back pain and fever, and ending up with paralysis.

Risk factors for spinal infections include disorders that cause a compromised immune system, such as:¹⁵

• HIV

• Advanced age

• Diabetes

• Malnutrition

• Intravenous drug use

• Cancer

Infections like these that cause lower back pain are a serious matter and must not be taken lightly. Seek medical attention right away if you have any signs or symptoms that may indicate infection, such as:

• Ongoing severe pain

• Redness

• Swelling

• Fever

13. Tumor

Tumors result from cells dividing and multiplying unchecked. Spinal tumors are abnormal masses of tissue that surround or are within your spinal column and/or spinal cord. Both malignant and benign tumors in the area of the spine can lead to lower back pain.

The exact cause of primary spinal tumors isn’t known,¹⁶ but certain primary spinal tumors could be due to genetic background, immune conditions, or exposure to cancer-causing agents. 

Most tumors of the spine begin in another area of the body and spread to the spine (metastasis). Tumors that commonly spread to the spine begin from cancer in the:

• Prostate

• Breast

• Thyroid

• Kidney

• Lung

A spinal tumor can cause different symptoms and signs, particularly as it grows. A tumor may affect only your spinal cord, or it can impact your:

• Blood vessels

• Nerve roots

• Spinal bones

With a spinal tumor, you may experience symptoms such as:

• Back pain that frequently radiates to other body parts

• Pain at the location of the tumor 

• Loss of bladder or bowel function, or urinary retention

• Back pain that gets worse at night

• Difficulty walking, which sometimes causes falls

• Mild or severe muscle weakness in different body parts

• Feeling less sensitive to touch, heat, cold, and pain

• Episodes of tingling; a sensation of pins and needles

The most common early sign of spinal tumors is back pain.

14. Autoimmune disease

Back pain is a potential symptom of certain autoimmune conditions, such as:

• Lupus

• Ankylosing spondylitis

• Fibromyalgia

• Crohn’s disease

• Rheumatoid arthritis

Other common autoimmune disease symptoms include:

• Skin rashes

• Fatigue

• Joint swelling and pain

• Swollen glands

• Recurring fever

• Weight loss

• Digestive issues or abdominal/back pain

Certain autoimmune conditions such as rheumatoid arthritis can cause inflammation and back pain due to the joints throughout the body, including those in the spine, being affected.

15. Sciatica

When there’s a herniated disk pressing on your sciatic nerve, it can lead to sciatica. Your sciatic nerve is very long. It starts in your spine and extends down your legs. Any irritation or compression of the nerve where it attaches to the spine can result in sudden pain in your lower back that radiates to your thigh and leg. Some individuals describe the pain as electric, burning, or stabbing. Others report shooting, sharp, or jolts of pain.

You could be at greater risk of sciatica if you:

• Are overweight

• Have an injury or a past injury

• Lack a strong core

• Have an active, physical job

One study looked at a variety of physical conditions and occupational stresses to determine their impact on the risk of being hospitalized due to sciatica. It appeared that individuals who carried or lifted heavy objects and those in sedentary occupations had the highest risk of worsening sciatica leading to hospitalization.¹⁷

16. Cauda equina syndrome (CES)

This condition is caused by the compression of a collection of nerves in the lumbar spine below your spinal cord. It’s a rare but serious condition that requires immediate medical attention and possibly even emergency surgery.

Some potential causes of this condition include:

• Spinal inflammation or infections

• Spinal tumors and lesions

• Birth abnormalities

• Lumbar spinal stenosis

Along with lower back pain, those with this condition may experience certain warning signs, including:¹⁸

• Loss of bowel and/or bladder control

• Urinary retention

• Paralysis, weakness, or loss of sensation in the lower body

• Sexual dysfunction

17. Osteoporosis

As people age and are less active, they begin to lose bone mass quicker than it can be replaced. This makes the bones weak and brittle, and they are more likely to fracture with minimal to no warning. These fractures are particularly common in the spine (vertebral compression fractures).

Both women and men lose bone mass as they get older. However, postmenopausal women tend to lose it much quicker and are at a higher risk of osteoporosis.

Symptoms of osteoporosis include:

• Back pain

• A stooped posture

• Loss of height

• Bones breaking more easily

There are both controllable and uncontrollable risk factors for this condition:¹⁹

Those you can control are:

• Weight loss

• Inadequate nutrition

• Stress

• Smoking

• Drinking alcohol

• Lack of physical activity

Those you can’t control are:

• Older age

• History of falls

• Gender

• Past fractures

• White ethnic background

These are just some of the numerous causes of lower back pain. However, these conditions are not always accompanied by pain. For instance, degenerative disk disease or osteoarthritis could show up in imaging studies, but the individual doesn’t report pain.

How is lower back pain diagnosed?

A complete medical history and physical examination, including a thorough neurologic exam, can typically identify any severe conditions behind a person’s lower back pain. In some cases, the cause of chronic low back pain is hard to identify even after a thorough evaluation.

Imaging tests aren’t required in all cases, but doctors may order them to confirm or rule out specific conditions or causes of pain, including spinal stenosis and tumors.

Tests may include:

Blood tests

Lab tests aren’t routinely ordered for patients with lower back pain, but your doctor may use them to look for signs of infection, inflammation, arthritis, cancer, or other associated conditions.

Bone scans

These can help doctors detect and monitor a fracture, infection, or bone disorder. The doctor injects a small amount of radioactive material into the bloodstream, which gathers in the bones, especially in locations with some abnormality. Specific areas of abnormal blood flow or irregular bone metabolism can be identified with scanner-generated images. They can also be used to measure joint-disease severity.

Diskography

This involves the injection of contrast dye into the specific spinal disk believed to be causing your lower back pain. The pressure of the fluid in the disk will reproduce your symptoms if the disk is the cause. The contrast dye will then help the doctor to see the damaged areas on a CT scan.

Computerized tomography (CT)

This test can reveal soft tissue structural abnormalities that can’t be seen on standard x-rays, such as spinal stenosis, disk rupture, or tumors.

X-rays

This imaging method helps show a misaligned or injured vertebra or a broken bone.

Magnetic resonance imaging (MRI)

This type of imaging provides a computer-generated image of soft tissues and bony structures such as ligaments, muscles, blood vessels, and tendons. Your doctor may order this test to evaluate for inflammation, infection, tumor, pressure on a nerve, herniation, or rupture.

Myelograms

These enhance the imaging of CT scans and x-rays. A contrast dye will be injected into your spinal canal, which allows the doctor to see nerve and spinal cord compression or other abnormalities caused by fractures or herniated disks.

How is lower back pain treated?

While no two types of backaches are exactly the same, there are certain basic differences between back pain caused by arthritis and back pain caused by injury. These differences help your doctor identify and effectively treat these challenging health issues.

Whether you’ve strained the muscles in your back by lifting a heavy box or you’re experiencing diffuse, sporadic twinges that can occur with spinal nerve compression, it is wise to seek professional medical guidance and intervention.

Physical therapy and rest will often help ease symptoms. Your doctor may suggest anti-inflammatory medication to treat your back injury or arthritis.

If your lower back pain is so severe that it’s disrupting your day-to-day functioning, more invasive procedures may be suitable. Consult with your doctor about treatment options to see how to best ease your pain and take care of the underlying cause. Being treated will allow you to get back to your day-to-day activities and regain freedom of movement.

Most individuals recover from lower back pain with minimal help from their doctor, but surgery may be required when the back pain doesn’t respond to initial treatment.

A few common procedures include:

• Spinal fusion: A bone graft promoting the fusion of the vertebrae.

• Diskectomy: Removal of part of a herniated disk (minimally invasive lumbar discectomy or microdiscectomy).

• Spinal laminectomy: Lamina removal to reduce inflammation and irritation and to create more space. The lamina is the section of your vertebral arch that forms your spinal canal roof.

The lowdown

You may not be able to avoid lower back pain, particularly with certain types of jobs or as you get older and your back loses some resilience and strength. Fortunately, there are various ways you can obtain relief, regardless of the cause.

Keep in mind that red flag (warning) symptoms include:

• Loss of control of your bowel or bladder

• Weakness or paralysis

• Loss of sensation or numbness and tingling

• Abnormal gait

• Fever

• Weight loss

• Changes in mental state

If any of these occur, seek immediate medical attention.

Consult with your doctor about the pain you’re experiencing and if it’s acute or chronic. They can provide you with a diagnosis and come up with an effective treatment plan that works best for you.