27 Reasons Why Your Back Hurts: Low Risk to High Risk
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Having sharp back pain? Is it due to a muscle, nerve, or serious issue? Here we cover reasons for both lower back pain (lumbago) and upper back pain.
Most back pain is not a symptom of a serious underlying disorder, and does not require extensive visits to a doctor, or chiropractor, or X-rays or other imaging. Most of the time you can continue your normal activity while avoiding overly strenuous activity. Until you have recovered, over-the-counter pain medications such as acetaminophen (Tylenol) and NSAIDs (non-steroidal anti-inflammatory drugs) like ibuprofen (Advil, Motrin) and naproxen (Aleve) should provide pain relief. Please see your healthcare provider if:
- You have new pain the spreads down your leg
- Pain which causes you to have difficulty controlling your bladder or bowels
- Pain which causes weakness or problems holding your foot up
- Or pain that is accompanied by other symptoms such as fever
Two categories of back pain - acute vs chronic back pain
The lumbar spine that supports the body’s weight can be prone to injury and pain. Back pain varies from mild to severe depending on the amount of injury. It can also be acute or chronic.
Acute low back pain
Acute low back pain occurs suddenly and normally heals within a number of days to weeks. The source of pain is commonly the muscles and ligaments, joints, or discs. Occasionally, mechanical back pain results from tight muscles, degenerative discs, and inflamed facet joints instead of pinched nerve.
Chronic back pain
Chronic back pain persists for more than 3 months; it may be felt the entire time or worsen with specific activities. Although it can be hard to trace the source, the possible causes may be things like nerve damage, tissue scarring, arthritis, or emotional effects of pain.
How long the back pain lasts is not always the best indicator of how serious the condition might be. Both acute and chronic types of back pain may indicate either minor issues or serious conditions. The list below describes various causes of lower back pain, upper back pain, and middle back pain. Here we’ll talk about lower risk conditions — ones that may not benefit as much from a trip to your healthcare provider. We will also touch on more serious conditions — such as those that may be life-threatening or require immediate medical attention.
Low risk causes of back pain
Easily managed with over-the-counter (OTC) medications
1. Lower back strain
Lower back strain is one of the more common causes of back pain. Strain occurs from overuse or overstretching, both of which may cause small tears in the muscles or tendons of the back. Back pain may start after sitting for too long, or may come from having poor posture (there was a good reason your mother always told you to sit up straight). Sometimes lower back strain is caused by injuries from lifting heavy objects or falling. If you have lower back strain, you should anticipate a full recovery.
2. Mechanical idiopathic pain
Mechanical idiopathic pain is typically caused by muscle strain. This can occur from being really active and moving your body in ways you typically do not — such as lifting a lot of heavy objects or furniture — or running an Iron Man obstacle course when you haven’t trained for it. Chances are that if you spent yesterday helping your best friend move into a 4th-floor walk-up apartment you spent a lot of time bending, lifting, and twisting, so it’s no wonder you woke up this morning with back pain. This kind of mechanical idiopathic pain is typically located in the lower back, or lumbar area, which is the part of your back that literally does the heavy lifting.
3. Premenstrual syndrome (PMS)
Premenstrual Syndrome is that dull, persistent, crampy, achy pain in, under, and around your sacrum (the area of your back between your hips). PMS-related back pain is a visceral pain — one that comes from a body organ (your uterus) instead of from one of the structures of the back. As your uterus cramps, the pain is referred to your back, and you can have back cramps. Back cramps may cause lower back and pelvic pain. Dry heat (such as from a heating pad) and NSAIDs (non-steroidal anti-inflammatory drugs) like ibuprofen (Advil, Motrin) and naproxen (Aleve) will help relieve PMS-related back pain. NSAIDs are most helpful if you start taking them a day or two before the back ache starts; as a bonus, they may also make your period lighter.
4. Muscle knots and strain
Muscle knots are particularly sensitive spots along muscle or connective tissue. It is unclear if the pain of muscle knots is caused by muscle injury, such as muscle strain, or if the underlying cause has more to do with nerve injury. Vigorous massage will often alleviate the pain of muscle knots.
The muscles, ligaments, and discs in the back allow for common activities such as sitting or lifting, which are movements that you do many times throughout the day. Therefore, knots in these areas can grow increasingly sensitive. Activities that can occasionally overextend the muscles or ligaments include shoveling snow or helping your neighbor move a couch, leaving you with strains or sprains. The majority of these injuries heal in a number of days to weeks.
Lower back pain is one of the many common discomforts of pregnancy. As the weight and size of your baby (and your belly) increase, there is a tendency to tilt the pelvis forward, exaggerating the curve of the lumbar spine. This posture, called lordosis, puts strain on the lower back muscles and may even cause impingement of the sciatic nerve (sciatica). Pregnancy-related back pain can be relieved by strengthening core muscles, maintaining proper posture, and wearing an abdominal support garment meant for use in pregnancy.
A cold compress and rest can help alleviate headaches and muscle pain during pregnancy, but if you need additional relief, your doctor may recommend acetaminophen (the active ingredient in Tylenol). When this drug is used as directed, it's a safe option. However, it's best to avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (the pain reliever in Advil and Motrin) and naproxen (the active ingredient in Aleve). Some studies suggest that taking these medications near conception or in early pregnancy may increase the risk of miscarriage and birth defects.
Usually managed as an outpatient by your doctor with prescription medication
6. Herniated disc
A herniated disc (also called a slipped disc, ruptured disc, or bulging disc) is a common cause of acute and chronic lower back pain. Disc herniation may occur in the upper back or middle back, but is more common in the lower back. When a disc herniates, or ruptures, some of the gelatinous material from inside of the disc leaks out and irritates the surrounding nerves. Most people recover from a herniated disc, but the period of recovery can be marked by back pain which may limit movement (especially bending over forward, like when tying your shoes). A 2010 study found that Herniated Discs cannot be correctly diagnosed only through a single test.
7. Sciatic nerve pain (also called “sciatica”)
The sciatic nerve is the largest nerve in the human body. The root of the sciatic nerve is located where the lumbar section of the spine meets the sacral section of the spine. This area of the lower back is referred to as the lumbar-sacral region. Sciatica is a symptom of lower back disease or injury, not a disease or injury in and of itself. Any disease or injury that affects the lumbar-sacral region of the spine has the potential to cause sciatic pain.
Sciatic pain usually occurs on only one side of your body. The pain shoots (almost like an electric shock) from your lower back down the back of your leg, and may reach your ankle and foot. Sciatica may cause severe back pain, numbness, or tingling, and less often, it may limit your ability to move your ankle and foot.
8. Kidney stone
Kidney conditions may cause back pain because the kidneys are located toward the back of your body at the level of your mid-back. Kidney stones are small pieces of calcium that form in the kidney. Many people have kidney stones and are never aware of them, as they are small enough to be passed with urination. However, larger kidney stones that grow in size over time can cause excruciating pain as the body tries to work the stone out of the narrow ureter.
9. Kidney infection (also called pyelonephritis)
The symptoms of kidney stones and kidney infections are similar. Both kidney stones and kidney infections can cause back pain on the affected side. Pain related to kidney stones and pain caused by kidney infections may spread from the kidney area to your lower stomach. Both kidney stones and kidney infections can cause some bleeding, which may cause your urine to be pink, red, or brownish. How do you know whether you have a kidney stone or a kidney infection? With a kidney infection you will typically run a low fever, and in advanced cases, you may feel as if you have the flu. These symptoms will not occur if you are passing a kidney stone.
Spondylosis is an all-encompassing term for any degenerative condition of the vertebrae. Spondylosis is, literally, a pain in the neck as it most commonly affects the cervical (neck) and lumbar (lower back) regions of the back. Vertebrae can become damaged resulting in this condition due to bone defects, wear and tear, or overuse through stretching or twisting. As an arthritic condition, it becomes more common with advancing age. The pain from spondylosis gets worse with activity and gets better with rest.
Medium risk causes of back pain
May require an ED visit or hospitalization. Precription medication needed usually.
Fibromylagia commonly affects women. It results when there is a disturbance on the natural way the body manages pain. The pain that most people experience is not a result of a structural abnormality. Often, these pains are instead a result of the impairment of pain-processing mechanisms. It may be that the brain is hypersensitive to arriving sensory input, or that it lacks the natural system to reduce pain.
Pain is one of several fibromyalgia symptoms. Fibromyalgia is a term used to describe a combination of symptoms that can include pain, fatigue, sleeping problems, and emotional distress. We are not sure exactly what causes fibromyalgia, but there is strong evidence that genetics comes into play. With fibromyalgia, there seems to be a problem with the way your central nervous system (CNS) processes pain, thus heightening your experience of discomfort. The pain of fibromyalgia can occur anywhere in the body, which means it may cause pain anywhere in the back.
12. Rheumatoid arthritis
Rheumatoid arthritis causes pain and stiffness in your joints — usually in smaller joints like those in your hands, wrists, and feet. Rheumatoid arthritis is caused by the immune system attacking the lining of the joints (synovium). This results in inflammation and expansion of the joint lining that can destroy cartilage and bone. This can also allow for weakening and stretching of nearby ligaments. Over time, the cartilage loss continues, the space between bones becomes smaller, and eventually the joint becomes painful and unstable. The cervical spine, or neck, can be a target of rheumatoid arthritis. If the cervical spine becomes damaged, the connecting nerves can also send out pain signals, resulting in back pain.
13. Scoliosis and hyperkyphosis
Scoliosis causes a side to side curvature of the spine, while hyperkyphosis causes a forward curvature of the upper back (think “hunchback”). These curves may be formed as your spine develops during growth or because of disease in your spine or the muscles of your back. In extreme cases, these abnormal curves may limit your ability to move about normally or even limit your ability to breathe easily.
14. Ankylosing spondylitis
Let’s face it: smoking has never made any condition better. Did you know smoking might be making your back pain worse? Smoking worsens the pain associated with ankylosing spondylitis — a type of inflammation that can cause fusing of the vertebrae. The pain of ankylosing spondylitis may be in your neck or lower back, is typically chronic, and will progressively become worse over time. With ankylosing spondylitis, you gradually lose flexibility throughout the body, especially in the back, and may ultimately experience spinal cord compression.
15. Spinal stenosis
The bones of your vertebrae column surround your spinal cord. The spinal cord is a group of nerves that send signals between your brain and body. If the room around your spinal cord gets narrower, it can exert pressure on the nerves and result in pain. The most common cause of this type of pain is osteoarthritis, which can result in bony growths known as spurs that press into the room around the spinal cord. Spinal stenosis can be a result of arthritis, or sometimes a result of injury. The word “stenosis” refers to narrowing of a passage in the body of any kind, such as an airway passage. In the case of spinal stenosis, pain can arise from nerve compression caused by a narrowing of the spinal canal or of the spaces between your vertebrae. Nerve compression causes pain with numbness or tingling from the lower back and down both legs. Even if your pain is on both sides it may be worse on one side than on the other.
16. Degenerative disc disease
With degenerative disc disease, the term “disease” is somewhat of a misnomer. Degenerative disc disease is not a disease. It is part of the normal aging process and occurs from normal “wear and tear” on the discs. It is the condition of the discs in which they lose their water content and sponginess with age. It can result in osteoarthritis, herniated discs, or bulging discs. While you can’t avoid aging, there are things you can do to slow the progress of disc degeneration. We know that smoking and being overweight make the discs break down earlier and faster; stopping (or better yet, not starting) smoking and maintaining a normal weight are the best ways to prevent disc degeneration.
Osteoarthritis is more common than other types of arthritis, such as rheumatoid arthritis. As with degenerative disc disease, being overweight increases the risk of osteoarthritis. Osteoarthritis can be debilitating. In osteoarthritis, there is a breakdown of cartilage — tissue that sits in your joints, between bones, in order to prevent them from rubbing together. Osteoarthritic pain occurs (often in the lower back and hips) as the cartilage breaks down. Osteoarthritis can affect the joints in the spine known as the facet joints. It can as well affect your knees or wrists. As you grow older, your discs break down and shrink. The facet joints may begin to stroke against one another. Your back may feel rigid when you wake up or pain after standing or walking.
Osteoporosis is sometimes referred to as “brittle bone disease," in that increased bone weakness over time leaves bones more susceptible to breaking. You may think of osteoporosis as something that happens to older women. It is true that osteoporosis is most common in older women, but men may have osteoporosis as well. As the bones lose density, or mass, they become weak and more likely to break. The bones of your lower back might break even without any obvious injury, causing lower back pain. It is easier to prevent osteoporosis than it is to treat it. Getting plenty of exercise (at least 150 minutes per week), maintaining a normal weight, avoiding smoking and alcohol, and ensuring an adequate amount of calcium in your diet are some of the best prevention measures.
19. Vertebral compression fracture
A vertebral compression fracture occurs when a back-bone collapses, usually because it is weakened by osteoporosis. Often, there is no obvious injury that breaks the bone(s). Pain from a vertebral compression fracture varies in where and how extreme the pain will present itself. It can be a dull or sharp pain that starts slowly, usually in the lower back, and may spread to the stomach. Vertebral compression fractures are often found not because you have pain, but because you become shorter, often because of aging or osteoporosis.
Your pancreas is the organ in your abdomen that makes insulin — a hormone required by your cells to use sugar (glucose) from carbohydrates in food for energy. While the pain from pancreatitis starts in the upper abdomen, which it does in about half of all people with pancreatitis, the abdominal pain will travel to the back, and will usually be on the right side. Pancreatitis does not cause back pain without other symptoms (stomach pain, nausea and vomiting). Pancreatitis is serious enough that you will probably be admitted to a hospital for treatment.
High risk causes of back pain
Life threatening and death is possible. Intensive Care Unit (ICU) care often needed.
21. Broken neck (cervical fracture)
If you dive into shallow water and hit your head on the bottom of the pool, you can break your neck. The same is true if you fall from a significant height. Any extreme trauma to your neck (think car accident or violent, traumatic injury) may cause your neck to break. Usually, there is an obvious event that causes the bones of the neck to break. It is a serious injury that causes pain and potentially paralysis. A broken neck requires emergency medical attention.
22. Cauda equina syndrome
Cauda equina syndrome is a group of spinal nerve roots that start from the lower end of the spinal cord. Individuals with cauda equina syndrome feel a dreary pain in the lower back and upper buttocks, together with analgesia (absence of feeling) in the buttocks, genitalia, and thigh. These occasionally result in bowel and bladder function disturbances. Cauda equina syndrome is another condition which requires immediate medical attention. Prompt medical attention can help to prevent permanent damage or disability. Many different mechanical and malignant conditions can cause cauda equina syndrome (damage to the bundle of nerves that spread out from the base of the spine). The hallmark symptoms are progressively worsening, severe lower back pain accompanied by weakness, numbness, or tingling in both legs, and loss of bladder and bowel control.
23. Abdominal aortic aneurysm/aortic dissection
An abdominal aortic aneurysm is a bulge in the wall of the abdominal aorta, the large vessel that carries oxygenated blood from the heart to the lower body. This bulge increases the risk that the aorta will rupture. The pain from an abdominal aortic aneurysm or rupture is sudden. It is felt in the lower back (and abdomen), and is often described as a tearing sensation. Immediate medical attention (ideally before the aneurysm ruptures), can be life-saving. White men over age 65 who smoke are at the highest risk for an abdominal aortic aneurysm.
Meningitis is an infection of the meninges (the membranes that cover the brain and spinal cord). The infection may be caused by a virus or by bacteria. You would feel more stiffness than pain from meningitis and the stiffness will be primarily in the neck area. You may also have a fever or headache and it may bother you to look at bright light. There are vaccines available for children and adults that protect against bacterial meningitis.
25. Heart attack
When you think of a heart attack, do you visualize an older man clutching his chest, sweating and talking about feeling crushing chest pain as if “being stepped on by an elephant?” Think again. Yes, crushing chest pain is the most common heart attack symptom in both men and women. However, you may not (especially if you are a woman), experience this kind of powerful chest pain or any sensation in the chest during a heart attack. Women may instead have less typical symptoms, such as upper back pain or pressure.
26. Metastatic cancer
If you have cancer, you are probably aware that your cancer might spread. Cancers of the breast, kidney, prostate, lung, or thyroid often spread, or metastasize, to the bones in the back. Metastasis to the back causes pain because of nerve compression or because the metastasis has caused the bones to fracture. It becomes a medical emergency if cauda equina syndrome occurs, which is a serious condition that describes extreme pressure and swelling of the nerves at the end of the spinal cord.
27. Vertebral osteomyelitis
When bacteria infect the bones of the spine (the vertebrae), osteomyelitis (meaning “bone infection”) develops. The infection usually starts somewhere else and spreads into the vertebrae. The symptoms of osteomyelitis include back pain and fever.
Anatomy of the human spine
To fully understand back pain, it is helpful to know a little bit about the back's anatomy. The human back is made up of many vertebrae, the spinal cord and nerves, discs, muscles, tendons and ligaments. The 33 vertebrae (or bones) are circular bones with discs wedged between them that surround the human spine. The vertebra serve to protect the all-important spinal cord.
The vertebrae are divided into five regions:
- The cervical spine (neck), which has 7 vertebrae
- The thoracic spine (upper back), which has 12
- The lumbar spine (lower back), which has 5-6 vertebrae
- The sacrum (the triangular bone at the base of the back that is situated between the tips), which has 5 fused ones
- And the coccyx (the tail bone), which has 3 vertebrae
The side view of an adult spine is S-shaped. The neck (cervical) and low back (lumbar) regions have a minor concave curve, and the thoracic and sacral regions have a gentle convex curve. The curves function like a coiled spring and absorb shock, maintain balance, and permit range of movement throughout the spinal column. Spinal curves maintain their natural state with muscles and good posture. Good posture requires you to train your body to stand, walk, sit, and lie. This ensures that the spine is not over-strained during movement or weight-lifting activities. Excessive body weight, weak muscles, and other forces can drag at the spine out of its natural alignment.
- An abnormal curvature on the lumbar spine is referred to as lordosis or swayback.
- An abnormal curvature on the thoracic spine is referred to as kyphosis or hunchback.
- An abnormal curvature from one side to the other is referred to as scoliosis.
The spinal cord sits within the hollow tube which is formed by the vertebrae, and connects the brain to the rest of the body. The 23 spinal discs are rubbery, gelatinous sacs. Being situated between the vertebrae, the discs provide cushioning and shock absorption between the back bones. The discs allow the spine to move and flex. Without discs, the bones would rub and grind together, causing major pain and the eventual breakdown of the bone. This becomes apparent in diseases of the spinal discs.
The soft tissues of the back — the back muscles, tendons, and ligaments — provide structure and support for the back, and promote movement and flexibility. Lower back anatomy includes bundles of nerves that flow off of the spine, innervating the entire body.
With so many interdependent, moving pieces, it is no wonder that there can be so many reasons for back pain.
Examination and treatment
Examination at the doctor's office
A number of general practitioners or primary care physicians will be able to diagnose back pain after a physical examination and consultation with the patient. In a good number of instances, imaging scans are not essential.
A careful medical exam is usually completed to figure out the type and cause of your back pain, and to decide on the best treatment options. A diagnostic evaluation includes a medical history and physical exam. Sometimes imaging scans (e.g., X-ray, bone scan, MRI or CT scans, Electromyography or EMG) and tests to check muscle strength and reflexes are used.
Treatment of low-back pain
The treatment of back pain starts with self-care and nonsurgical procedures. These treatment strategies are aimed at correcting the issue, restoring function, and preventing future occurrence.
Physical therapy can help you return to full activity as soon as possible and prevent re-injury. Physical therapists will guide you to use the right lifting and walking techniques, including exercises that strengthen and stretch your back, leg, and abdominal muscles. Massage, ultrasound, diathermy, heat, and traction may also be recommended for short durations.
- A review of evidence-based clinical studies found that nondrug therapies including spinal manipulation, together with exercise, massage, and physical therapy can be used in the management of low-back pain
- A study found that yoga may benefit people with chronic low-back pain.
- A 2011 Cochrane review of 26 clinical trials found that spinal manipulation is effective in the treatment of chronic low-back pain, reducing pain and improving function.
- Surgical treatments are not frequently required unless you have muscle weakness, a diagnosed disc herniation, severe stenosis, cauda equina syndrome, or severe pain that does not go away after some time of nonsurgical treatment.
- Percutaneous neuromodulation therapy (PNT) is a recently investigated minimally invasive, office-based treatment for low back pain in which electrical stimulation is administered to the paraspinal peripheral nerves.
Back pain frequently goes away with rest, application of ice or heat, massage, pain relievers, and gentle stretches. If self-care treatments aren't producing the desired results within the first few days, visit your doctor.
A number of people make use of over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprofen (Advil, Motrin), or naproxen (Aleve). A muscle relaxant may be recommended for spasms. Steroids can reduce the swelling and inflammation of the nerves and can be taken orally or given by injection.
Dr. Peter Steinberg is a board-certified urologist and the director of endourology and kidney stone management at Beth Israel Deaconess Medical Center. He is also an Assistant Professor at Harvard Medical School. He received his undergraduate degree in biochemistry from Middlebury College (1999) and graduated from University of Pennsylvania Medical School (2003). He completed a urology residency at Dartmouth Hitchcock Medical Center (2009) and an Endourology Fellowship at Montefiore Medical Center (2010). Beyond training residents and medical students, his research interests include medicolegal and malpractice aspects of urology, quality improvement in urologic surgery, and reducing the no-show rate for kidney stone patients and communication in the operating room. He also enjoys skiing, sailing, squash, running, tennis, stand-up paddleboarding and personal finance.