Low Back Pain

The most common problem in musculoskeletal medicine

Low back pain is the most common reason patients come to see me, the leading cause of disability worldwide, and one of the most misunderstood conditions in all of medicine. Roughly four out of five adults will have a significant episode at some point. Most episodes get better — the majority improve substantially within six weeks — and most are not caused by anything dangerous or permanently damaged.

That last sentence matters more than it sounds, because what you believe about your back measurably affects how it recovers. People who understand their back as strong, adaptable, and safe to move recover faster than people who understand it as fragile and degenerating. This isn't wellness talk; it's one of the more consistent findings in back pain research. So this article's first job is accuracy, and its second job is de-catastrophizing — which, for the low back, happen to be the same thing.

Most low back pain is not caused by a single dramatic event. It builds — from sustained postures, deconditioning, load spikes the tissues weren't prepared for, stress and poor sleep (both of which turn the pain volume up), and how the body compensates for restrictions elsewhere in the chain. The lumbar spine sits between a thoracic spine and a pelvis that both owe it mobility and stability; when either stops paying, the low back covers the debt.

Common causes

Somatic dysfunction. The bread and butter of what I treat: lumbar and pelvic segments that have lost their normal motion, neighbors compensating with too much motion, and protective muscle guarding layered over the top until the guarding itself is the loudest pain. None of this appears on imaging, which is why a "normal MRI" and a back that doesn't work are old friends.

Sacroiliac joint dysfunction. The SI joint is a common source of low back and buttock pain — after pregnancy, after a fall, in people who sit long hours. Imaging shows little; the hands-on exam tells the story.

Facet joint irritation. The small paired joints along the back of the spine, causing pain that's worse with extension (leaning back) and often referring to the buttock or thigh. In older backs, facet-driven pain is common and frequently mislabeled.

Disc problems. Discs bulge, herniate, and irritate nerve roots — and when there's real leg-dominant pain, numbness, or weakness, that's its own topic. But here's the essential context: disc bulges and degeneration are normal findings in pain-free adults — by middle age, most people walking around comfortably have them on MRI. A disc finding on your scan is a description, not automatically an explanation.

Muscle and fascia. The thoracolumbar fascia connects the low back to the glutes, lats, and core, and myofascial pain refers broadly across it. Usually a consequence of the pattern underneath rather than a standalone diagnosis — which is why massage helps and doesn't hold.

The deconditioned back. Perhaps the most common modern pattern: a back asked to do a weekend's work on a desk-year's capacity. Tissue tolerance shrank quietly; the demand didn't.

The red flags — a short, serious list

A small minority of back pain signals something that shouldn't wait. Go to an emergency department for loss of bowel or bladder control or numbness in the saddle area (cauda equina syndrome — a surgical emergency) or rapidly progressive leg weakness. Come in urgently for back pain with fever, after significant trauma, with a history of cancer, unexplained weight loss, or in the setting of osteoporosis or long-term steroid use (fracture risk), or night pain that's constant and unrelieved by any position. None of these are common. All of them are why "just rest it" isn't an evaluation.

What the MRI can and cannot do

Guidelines across every major medical body agree: routine imaging for ordinary low back pain, in the first weeks, without red flags, does not improve outcomes — and there's evidence it makes them slightly worse, by handing people a frightening vocabulary ("degeneration," "desiccation," "bulging") for what is largely normal aging, and by funneling them toward interventions they didn't need. Imaging earns its place with red flags, with true radiculopathy that isn't improving, and when planning a targeted injection or surgery. Our fuller take is in When Imaging Helps.

How we approach it

Hands on, whole chain. Every low back patient gets a structural exam covering the thoracic spine, ribs, pelvis, sacrum, and hips — because low back pain is frequently the symptom of a problem living above or below it. Then OMM on the first visit: restoring motion where it's lost, unloading the segments working overtime, calming the guarding. Many patients improve substantially with manual treatment plus a movement plan alone.

Build the back that doesn't relapse. The single best-evidenced long-term treatment for recurrent low back pain is exercise — and not gentle-stretch-token exercise, but progressive strengthening of the hips, trunk, and back itself, at real intensities, over months. The back is not fragile; it is the strongest region of the body when trained, and training it is the closest thing we have to a recurrence vaccine. We build the actual program and progress it.

Targeted interventions for the minority who need them. Ultrasound-guided injections when a specific generator (an SI joint, a facet region, a stubborn myofascial source) is blocking progress — as a bridge into rehab, not a subscription. Shockwave therapy for chronic myofascial pain. Electrodiagnostics when nerve involvement needs clarifying. And honest referrals when a back needs a surgeon — which is far rarer than the number of spine surgeries performed would suggest.

The systemic layer. Sleep debt, chronic stress, and low fitness each measurably amplify back pain — the nervous system sets the gain on every signal from the back. Addressing them isn't a consolation prize; it's mechanism.

What you can do right now

Move. Gentle walking is one of the best treatments for an aching back, starting today, in whatever doses you tolerate. Bed rest — the old prescription — reliably makes back pain worse. Motion is lotion.

Don't fear positions; vary them. No chair posture is damage and no single posture is salvation. Change position every 30–45 minutes, and keep doing your life at whatever level the back allows this week — activity avoidance shrinks tolerance and feeds the cycle.

Calm the flare, then load. Heat, easy movement, and time settle most acute episodes over days to a few weeks. As it settles, begin rebuilding: walking volume first, then hip hinges, carries, and progressive strength work.

Don't panic about imaging you already have. A report full of "degenerative changes" describes a spine that's been used. We'll translate what — if anything — on it actually relates to your pain.

When to come in

Come in if the pain isn't clearly improving after two or three weeks, if it's limiting work, sleep, or the activities you care about, if it keeps recurring in waves every few months, or if anything radiates below the knee or brings numbness, tingling, or weakness. And come in immediately for anything on the red-flag list above. The earlier a stuck pattern is found and treated, the shorter the road back — and the sooner we can get you building the back that doesn't do this every year.