Most people who see a health-care provider about back pain have two main questions: “What could be causing this?” and “What can I do to fix it?” Assessing your low back pain with a health-care provider is the first step in answering these questions. Unlike blood pressure or temperature, low back pain is difficult to accurately measure or even describe. Despite this difficulty, if your back is hurting, there’s no doubt that the problem needs to be addressed.
Arriving at the best initial therapy requires some evaluation of the pain to determine its source, if possible. The evaluation also can quickly pinpoint — or rule out — any life-threatening cause. Health-care providers start with the history, the “story” of your symptoms. The history can help your health-care provider determine the cause of your low back pain.
After reviewing your history, your health-care provider will perform a physical examination and may order diagnostic tests to further evaluate your condition. However, identifying the cause of your pain is not always as helpful as it may seem.
Creating A History
In medicine, a “history” refers to a detailed, chronological record of your symptoms, past medical problems, risk factors for disease, medications and allergies. The reason the history is so important and helpful is that certain conditions tend to cause trouble in predictable ways. For example, a disk problem tends to cause radiating pain (pain that spreads) from the lower back down the back of the thigh. Muscle spasm almost never does this. So, even if your history doesn’t identify the cause of your pain, it’s a good starting point for sifting through the long list of possibilities.
When obtaining your history, your health-care provider will typically explore the answers to several questions:
- Who are you? Depending on your gender and age, some causes of pain are more likely than others. For example, if you’re pregnant and in your third trimester, the pregnancy itself, with its attendant stretching of muscles and ligaments, is a common source of low back pain. However, in older people, degenerative joint disease or a compression fracture of a vertebra is a common cause of back pain. If you exercise regularly — particularly if you’re an aggressive weekend warrior — your doctor may immediately suspect a pulled muscle.
- What is the severity and quality of your pain? Is your pain severe? How would you rank it on a scale of 1 to 10? Is it burning, throbbing, intermittent, fleeting, dull or sharp?
- When did your pain begin? Did the pain start suddenly or gradually? Did it follow an injury or a particular movement or activity?
- Has your pain progressed? Has your pain been getting better or worse? Is there a time of day when it is better or worse? Are there days when you do not feel pain?
- What triggers or relieves your pain? Are there things that improve the pain, such as a change in position? Are there things that clearly make your pain worse?
- What features are associated with your pain? Are there areas other than your lower back that are also painful, such as your joints? Does the pain extend into your legs? Have you noticed numbness, tingling or weakness in one or both legs? Have you noticed other problems along with the back pain, such as weight loss, fever or incontinence? (Even if you don’t suspect a fever, checking your temperature a few times when the pain first arises can alert you to an infection.)
- What other medical conditions have you had? Have you had cancer, arthritis or colitis (bowel inflammation)? Have you been injured or had a recent infection?
- Are you taking any drugs? Do you take any prescription or over-the-counter drugs? Do you use any illegal or recreational drugs?
Using Your History
Your health care provider usually can identify conditions that commonly cause low back pain through the features of your history. Typical characteristics of the more common, identifiable causes of low back pain are outlined in the table below.
Unfortunately, for most people with low back pain, no definitive cause is ever found. In these cases, there are rarely any “red flag” symptoms, such as fever, that could point to a serious or even life-threatening cause. The pain is nonspecific — meaning there is no strong suggestion from your symptoms that any one condition is the cause of your pain. In addition, the pain tends to improve on its own or with conservative treatment, such as rest, within a few weeks. However, low back pain of uncertain cause may also become chronic, persisting for months or years. In these cases, low back pain can be a major source of suffering and frustration.
As for whether low back pain (or other types of pain) may be psychological in origin, there is no easy way to know. But a reasonable approach is to accept all pain as genuine, even if its source is difficult to identify.
Relieving pain, regardless of its source, should be the ultimate focus. If your symptoms persist, reassessment over time and regular follow-up with your health care provider may lead to a new or more specific diagnosis or to a change to a treatment that is more effective.
|Cause||Onset||Description||Location||Accompanying leg pain||Relief when leaning forward or sitting||Morning stiffness* that improves with exercise||Age group most commonly affected||Comment|
|Muscle or ligament strain||Often sudden, but onset is highly variable||Highly variable||One or both sides||Absent||No||No||Any age, but especially common in young or middle-aged people||Muscle spasm may worsen with pressure on the involved muscles or with specific movements. It is also worse after exercise.|
|Degenerative joint disease||Gradual||Dull; affected by position or exercise; often worse at night||Middle||Absent (unless complicated by nerve injury)||No||No||Older than 50||Low back pain generally worsens very slowly.|
|Disk disease||Sudden||Sharp; may be worse at night or with bending, coughing or sneezing||Usually one side||Present||No||No||Any age, but more common in older people||Numbness and tingling are common in the affected leg. Disk disease may lead to sciatica.|
|Spinal stenosis||Gradual||Dull; worse with standing or walking||Variable||Absent or present (possibly one or both legs)||Yes||No||Older than 50||Leg pain may be worse than back pain.|
|Spondylolisthesis||Gradual||May be severe||Middle||Present (often includes thighs, hips or back of legs)||No||No||Young adults and older||Back pain is more common in athletes (especially football players, weight lifters and gymnasts) and the elderly.|
|Osteoporosis with fracture||Sudden||Dull, but severe||Middle||Absent||No||No||Older than 60||Back pain may occur in younger persons, especially those with risk factors for osteoporosis.|
|Inflammatory arthritis (rare)||Gradual||Dull or achy; worse in the morning; better with exercise||One or both sides||Absent||No||Yes||20 to 50||Diarrhea, psoriasis, burning with urination or conjunctivitis may be present.|
|Cancer (rare)||Gradual||Constant, but progressively worsening; worse at night||Middle, but variable||Absent (unless complicated by nerve compression)||No||No||Older than 60||Back pain is often accompanied by weight loss, poor appetite and a history of cancer elsewhere in the body. Cancer may cause bowel or bladder incontinence or leg weakness.|
|Infection (rare)||Gradual||Variable||Middle||Absent||No||No||Any age||Back pain is often accompanied by fever and weight loss. There are usually associated risk factors, such as intravenous drug use, a prior medical condition, use of drugs that suppress the immune system or recent injury or surgery.|
|Kidney stone||Sudden||Severe, sharp||One side; spreads into the groin||Absent||No||No||Any age||Blood in the urine may be present.|
*For at least 30 minutes.