Low Back Pain: Why It Happens and How We Approach It
Low back pain can be frustrating-especially if you cannot figure out why it started.
Often patients will say:
“I just woke up with it one morning.”
“I bent over to put on my sock and suddenly felt a sharp pain.”
“I didn't really do anything. Why does my back hurt?”
Those are reasonable questions.
If you have bent over to put your socks on thousands of times without pain, one ordinary movement may not fully explain why your back suddenly became painful. Sometimes that movement is simply the moment when an irritated or sensitive area becomes noticeable.
Low back pain is also more complicated than identifying one damaged structure. About 90% of low back pain is classified as nonspecific, meaning it cannot be confidently attributed to one specific disease or anatomical structure (World Health Organization [WHO], 2023a). Researchers likewise emphasize that, for most people with low back pain, an exact pain-generating tissue cannot be identified with certainty (Hartvigsen et al., 2018). World Health Organization
That does not mean your pain is unexplained, imaginary, or something you simply need to live with.
It means that understanding low back pain usually requires looking at the whole clinical picture rather than assuming that one structure is always responsible.
A note about sciatica: This page focuses primarily on low back pain that remains in the low-back region. If your symptoms travel into the buttock or leg, or include numbness or tingling, our dedicated Sciatica page discusses those presentations in greater detail.
Why Can Low Back Pain Seem to Start Out of Nowhere?
For many people, there is no dramatic injury.
Instead, symptoms may appear during a period when the back has been exposed to different demands than usual.
That might include:
Sitting significantly more than normal
Repetitive bending or lifting
A sudden increase in exercise or physical work
Returning to an activity after time away
Prolonged positions
Reduced activity
Changes in sleep or recovery
Previous episodes of low back pain
Then one ordinary movement seems to trigger the episode.
You bend over.
You get out of your car.
You stand up from a chair.
You put on a shoe.
The movement may have provoked the symptoms, but that does not necessarily mean that movement caused a major injury.
Low back pain is influenced by a combination of physical, biological, occupational, psychological, social, and lifestyle factors. Previous episodes of pain, work demands, physical activity, general health, sleep, and other individual factors can influence both the development and persistence of symptoms (Hartvigsen et al., 2018). PubMed
That is why our evaluation looks beyond the exact second your pain began.
What Can Contribute to Low Back Pain?
There is no single explanation that applies to everyone.
The lumbar spine contains discs, joints, muscles, ligaments, and other tissues that work together to create movement and tolerate load. Different structures or functional problems may contribute to symptoms in different people.
In many cases, we think in terms of patterns and likely contributors rather than pretending that one examination maneuver can identify the precise tissue responsible for every person's pain.
A 2023 systematic review evaluating clinical tests for disc-, facet-joint-, and sacroiliac-joint-related low back pain found that some examination findings can increase or decrease the likelihood that particular structures are involved, but diagnosis remains imperfect (Han et al., 2023). PubMed
Here are some of the patterns we commonly consider.
1. Disc-Related Low Back Pain
Between each of the vertebrae in your spine is an intervertebral disc.
The disc has a strong outer portion called the annulus fibrosus surrounding a softer central portion called the nucleus pulposus.
Discs help:
Distribute forces through the spine
Allow movement between vertebrae
Absorb and transfer loads during daily activity
Like other tissues in your body, discs respond to movement and loading.
For some people with localized low back pain, examination findings suggest that a disc may be contributing to the symptoms. However, determining that a disc is the pain source is not as simple as identifying a disc bulge on an MRI or finding one painful movement (Han et al., 2023). PubMed
One useful part of the examination is observing how your pain changes when you repeatedly move your spine in different directions.
Some patients demonstrate a directional preference. This means that a particular direction of movement consistently:
Decreases pain
Improves movement
Makes an activity easier
Or produces another meaningful improvement in symptoms or function
Directional preference is a recognized clinical phenomenon, although it is not present in every patient and should not be assumed before examination (May et al., 2018). PubMed
For example, one person's back may feel substantially better after repeated extension movements. Another person's symptoms may respond differently.
That is why we test rather than guess.
2. Joint-Related Low Back Pain
The lumbar vertebrae are also connected by small joints called facet joints.
These joints help guide spinal movement and share load as you bend, extend, and rotate.
For some patients, these joints appear to contribute to localized low back pain.
Certain movements or positions may be uncomfortable, and the examination may reveal restricted or painful spinal motion. However, there is no single symptom or routine physical examination test that can prove with certainty that a facet joint is the source of someone's pain (Han et al., 2023). PubMed
Instead, we consider:
Where the pain is located
Which movements reproduce it
Which movements are restricted
Whether particular positions improve or worsen symptoms
How the spine is moving overall
How the patient responds to treatment
This information helps us determine whether improving spinal motion may be useful as part of the treatment plan.
3. Muscle and Soft-Tissue Pain
The muscles surrounding your low back and pelvis work constantly throughout the day.
They help you:
Maintain posture
Lift
Bend
Walk
Exercise
Transfer forces between your upper and lower body
During an episode of low back pain, these muscles may become painful, sensitive, or guarded.
Sometimes patients describe:
Tightness
Aching
Muscle spasms
Fatigue
Tenderness
A sensation that the back is “locked up”
Muscular symptoms do not necessarily mean that the muscle itself is the entire cause of the problem.
Guarding can also be the body's response to another painful or sensitive structure.
That distinction matters because simply trying to “loosen the muscles” may provide temporary relief without addressing the movement or loading problem that contributed to the symptoms.
4. Movement, Strength, and Load Tolerance
Sometimes the most useful finding isn't one specific painful tissue.
It's discovering what your back is having difficulty doing.
For example, one patient may struggle to control their trunk during lifting.
Another may have adequate strength but poor muscular endurance.
Another may have restricted hip mobility that changes how they move through their lumbar spine.
Another may feel fine during normal daily activity but develop pain whenever their workload suddenly increases.
We may evaluate:
Trunk strength and endurance
Movement coordination
Hip mobility
Spinal mobility
Lifting mechanics
Balance and control
Tolerance to sustained positions
Activities specific to your work, exercise, or sport
This helps us determine what needs to improve, rather than simply telling every person with back pain that they have a “weak core.”
Exercise guidelines for low back pain include several different approaches, including trunk strengthening and endurance, movement-control exercise, specific trunk-muscle activation, aerobic exercise, and other forms of progressive activity (George et al., 2021). PubMed
The right choice depends on the individual.
What About Arthritis and Degenerative Disc Disease?
This is an especially important subject because many patients arrive at our office after having an X-ray or MRI.
They may have been told they have:
Degenerative disc disease
Disc bulges
Facet arthritis
Loss of disc height
Bone spurs
Other “wear-and-tear” changes
Those findings can sometimes be relevant.
But they don't automatically explain why your back hurts.
A large systematic review examined imaging findings in people without back pain and found that degenerative changes become increasingly common with age. Findings such as disc degeneration, disc bulges, and facet degeneration can therefore be present in people who feel perfectly well (Brinjikji et al., 2015). PubMed
At the same time, another systematic review found that several degenerative MRI findings occur more frequently in people with low back pain than in people without pain, meaning imaging findings should not simply be dismissed either (Brinjikji et al., 2015). PubMed
The important concept is context.
An MRI finding may matter.
It may also represent a common age-related finding that is not the primary reason you're currently hurting.
That is why we compare imaging—when imaging is appropriate—with:
Your symptoms
Your history
Your examination
Your movement
Your function
Your imaging is one piece of the puzzle, not necessarily the entire answer.
How We Evaluate Low Back Pain
At Warner Chiropractic, we don't begin treatment by assuming that everyone with low back pain has the same condition.
We first want to understand your presentation.
Step 1: Listen to Your Story
Your history gives us important information.
We may ask:
When did your pain begin?
Was there an injury?
Have you experienced this before?
What movements make it worse?
What makes it feel better?
Is sitting uncomfortable?
What happens when you walk?
Does bending bother you?
Does standing bother you?
Is your sleep affected?
Has your activity recently changed?
What activities can you no longer do comfortably?
Most importantly, what do you want to get back to doing?
Those answers help determine what we examine next.
Step 2: Make Sure the Presentation Is Appropriate for Conservative Care
Most low back pain is musculoskeletal and does not represent a dangerous condition.
But part of evaluating back pain is recognizing when further investigation may be necessary.
Your history and examination help us screen for findings that could suggest conditions such as fracture, infection, cancer, or another problem requiring additional medical evaluation.
Current guidelines generally recommend against routine imaging for uncomplicated low back pain unless the history or examination suggests a serious underlying condition or imaging is otherwise likely to change management (Department of Veterans Affairs & Department of Defense, 2022). Health Quality
That means an X-ray or MRI is not automatically necessary simply because your back hurts.
Step 3: See How Your Back Moves
Next, we examine how your spine and surrounding regions function.
Depending on your presentation, this may include:
Lumbar range of motion
Repeated-movement testing
Hip mobility
Trunk strength
Muscular endurance
Movement coordination
Palpation
Orthopedic testing
Functional movements
Neurological testing when appropriate
We're not simply asking:
“Which test hurts?”
We're asking:
“What information does this give us about how your back is functioning?”
If a movement consistently makes you feel better, that's useful.
If another position consistently provokes your pain, that's useful too.
If we identify a mobility, strength, endurance, or movement-control deficit, that can help determine what we should address.
How We Treat Low Back Pain
After the examination, we explain what we found and develop a plan with you.
There isn't one Warner Chiropractic “low-back-pain protocol.”
Two people can walk into our office with pain in almost the exact same location and leave with different exercises and treatment recommendations.
That's intentional.
Exercise Based on Your Examination
Exercise is an important component of managing many presentations of low back pain.
But simply saying “exercise is good for back pain” isn't specific enough.
The exercise needs to make sense for the person.
Depending on what we find, your program may emphasize:
Direction-specific movements
Mobility
Trunk strength
Muscular endurance
Movement control
Hip strength
Progressive resistance
Lifting mechanics
Gradual return to normal activity
Clinical practice guidelines support several types of exercise for low back pain rather than identifying one universally superior exercise program (George et al., 2021; WHO, 2023b). PubMed
Our goal is not to hand every patient the same sheet of generic “core exercises.”
It's to identify what you need to work on.
Chiropractic Manipulation and Mobilization
When appropriate, chiropractic manipulation or mobilization may be incorporated into your treatment.
Manual treatment may help reduce symptoms and improve function or make movement more comfortable for some people with low back pain.
Spinal manipulation is included among nonpharmacologic treatment options in major low-back-pain clinical practice guidelines (George et al., 2021; Qaseem et al., 2017). PubMed
But we don't view an adjustment as the entire solution.
If treatment allows you to move more comfortably, the next question is:
What can we do with that improved movement?
That might mean reinforcing it with:
Exercise
Strengthening
Movement practice
Gradual return to activity
The hands-on care and active care should support one another.
Soft-Tissue Treatment
Muscles around a painful area commonly become sensitive or guarded.
When appropriate, soft-tissue techniques may be incorporated to:
Reduce discomfort
Improve tolerance to movement
Address areas of muscular tenderness
Help a patient participate more comfortably in active rehabilitation
These treatments are typically used as part of a broader treatment strategy, rather than as the entire solution to low back pain.
Other Treatment Options
Depending on your examination and individual needs, we may also incorporate other services available in our office as an adjunct to the primary treatment plan.
The important word is adjunct.
Passive treatment can sometimes help someone feel and move better, but our long-term goal is to help you restore function and develop strategies you can use independently.
Why Education Is Part of Treatment
We want you to leave our office understanding your back better than when you walked in.
That means understanding:
What we found during your examination
What appears to aggravate your symptoms
What seems to improve them
Which exercises you should perform
Which activities you can continue
Whether anything needs to be temporarily modified
How we plan to progress your activity
What you can do if symptoms begin returning
Modern low-back-pain recommendations emphasize education, remaining active, exercise, and self-management as important parts of care (WHO, 2023b). World Health Organization
We don't want to make you afraid of your back.
We want to help you understand it.
Our Goal: Get You Back to Doing What You Love
Improvement means different things to different people.
Maybe you want to:
Sleep through the night
Pick up your child or grandchild
Work without constantly thinking about your back
Sit comfortably during a long car ride
Get back to the gym
Golf
Run
Garden
Travel
Work around the house
Those goals matter.
They give treatment a purpose.
Our job is to identify what appears to be limiting you, help reduce the barriers that are preventing comfortable movement, and progressively improve your ability to tolerate the activities that matter to you.
Sometimes that involves hands-on care.
Sometimes it involves changing how you move.
Sometimes it involves improving strength or endurance.
Sometimes the most important first step is simply helping someone understand that their back is capable of recovering.
Most often, it involves a combination.
Struggling With Low Back Pain?
If localized low back pain is keeping you from working, exercising, sleeping comfortably, or doing the things you enjoy, we'd be happy to evaluate what's going on and develop a plan based on your individual presentation and goals.
[Schedule an Appointment]
References & Supporting Research
Brinjikji, W., Diehn, F. E., Jarvik, J. G., Carr, C. M., Kallmes, D. F., Murad, M. H., & Luetmer, P. H. (2015). MRI findings of disc degeneration are more prevalent in adults with low back pain than in asymptomatic controls: A systematic review and meta-analysis. American Journal of Neuroradiology, 36(12), 2394–2399. https://doi.org/10.3174/ajnr.A4498 PubMed
Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., Halabi, S., Turner, J. A., Avins, A. L., James, K., Wald, J. T., Kallmes, D. F., & Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36(4), 811–816. https://doi.org/10.3174/ajnr.A4173 PubMed
Department of Veterans Affairs, & Department of Defense. (2022). VA/DoD clinical practice guideline for the diagnosis and treatment of low back pain. U.S. Department of Veterans Affairs & U.S. Department of Defense. Health Quality
George, S. Z., Fritz, J. M., Silfies, S. P., Schneider, M. J., Beneciuk, J. M., Lentz, T. A., Gilliam, J. R., Hendren, S., & Norman, K. S. (2021). Interventions for the management of acute and chronic low back pain: Revision 2021. Journal of Orthopaedic & Sports Physical Therapy, 51(11), CPG1–CPG60. https://doi.org/10.2519/jospt.2021.0304 PubMed
Han, C. S., Hancock, M. J., Sharma, S., Sharma, S., Harris, I. A., Cohen, S. P., Magnussen, J., Maher, C. G., & Traeger, A. C. (2023). Low back pain of disc, sacroiliac joint, or facet joint origin: A diagnostic accuracy systematic review. EClinicalMedicine, 59, 101960. https://doi.org/10.1016/j.eclinm.2023.101960 PubMed
Hartvigsen, J., Hancock, M. J., Kongsted, A., Louw, Q., Ferreira, M. L., Genevay, S., Hoy, D., Karppinen, J., Pransky, G., Sieper, J., Smeets, R. J., & Underwood, M. (2018). What low back pain is and why we need to pay attention. The Lancet, 391(10137), 2356–2367. https://doi.org/10.1016/S0140-6736(18)30480-X PubMed
May, S., Runge, N., & Aina, A. (2018). Centralization and directional preference: An updated systematic review with synthesis of previous evidence. Musculoskeletal Science and Practice, 38, 53–62. https://doi.org/10.1016/j.msksp.2018.09.006 PubMed
Qaseem, A., Wilt, T. J., McLean, R. M., & Forciea, M. A. (2017). Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 166(7), 514–530. https://doi.org/10.7326/M16-2367 PubMed
World Health Organization. (2023a, June 19). Low back pain. World Health Organization. World Health Organization
World Health Organization. (2023b). WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. World Health Organization. World Health Organization