Back pain

The spine is a column of small bones, the vertebrae, with a cushioning disc between each pair, two small facet joints behind each level, strong ligaments and muscles holding it all together, and nerves leaving it at every level for the legs and the trunk. Any of these can hurt, and the usual causes behave in recognisable ways:

• A strain: non-specific back pain. By far the commonest kind. An awkward lift, a long drive, more exercise than usual, hours in one chair, or no reason anyone can name, and the lower back turns sore and stiff. No single structure can usually be blamed, it does not mean serious damage has been done, and it usually eases over days or a few weeks, though it can return.
• A trapped nerve: sciatica. A disc that bulges, or narrowing where a nerve root leaves the spine, irritates that root, and pain runs from the buttock down the leg, often below the knee, with tingling, numbness or weakness; a foot that is growing weaker is in the same-day list below. Most of it settles over a few weeks to a few months.
• An inflamed spine. In axial spondyloarthritis the joints of the spine and pelvis are inflamed rather than strained: it usually starts in early adult life, builds over months, is worst after rest and better with exercise, and can be hard to tell from ordinary back trouble at first.
• A thinned bone that has broken. In later life, or after high-dose steroid tablets taken for more than three months, osteoporosis can let a vertebra collapse after a small strain, a lift or even a cough, with sudden, severe pain in the back.
• Part of a wider ache. Where the back is only one of many sore places, with tiredness and poor sleep, the question is fibromyalgia, and its guide describes it.
• The rare causes. An infection in the spine, a cancer that has reached the bones, and compression of the bundle of nerve roots at the bottom of the spine (cauda equina syndrome) are uncommon; the warning signs that raise the question are set out under "When to seek help".

The neck has a guide of its own, neck pain, and pain felt in the outer hip or groin may be the hip's, which our hip pain guide covers.

How the pain began and how it behaves usually points to the cause before any test:

• Soreness across the lower back after a strain, easier for rest and changing position, sorer after long sitting or standing, improving over days or weeks: a strained back
• Pain running down one leg below the knee, sometimes with tingling or numbness in the foot, often worse than the back pain itself: sciatica
• Back pain that began before 45 and built over months, worst on waking and in the second half of the night, stiff for half an hour or more after getting up and freer after exercise: an inflamed spine
• Sudden, severe pain in the back of an older person, or of someone on long-term steroid tablets, sometimes after very little strain: a vertebra that may have broken
• Back pain as one part of aching all over, with tiredness and poor sleep: fibromyalgia

These are pointers, not a diagnosis, and two can go together. Any sign in the seek-help lists takes the route the list gives it, and the inflammatory pattern is for a GP.

Assessment starts with your account and an examination, and for most backs nothing more is needed. How the pain started, what eases and worsens it, how it behaves at night and first thing, where it spreads, and what else is going on in your health, a fever, weight loss, an earlier cancer, steroid tablets, an inflamed eye or a bowel condition, separate the strained back from the rarer causes. The examination looks at how the back moves, where it is tender, and the strength, feeling and reflexes of the legs.

Tests come in only where the picture asks for them. Blood tests look for inflammation and related clues where the spine may be inflamed, though normal results do not rule it out. MRI can reveal inflammation in the spine and the pelvis and a pressed nerve root, and Dr Borukhson arranges one where it is indicated; an X-ray may come first where a broken vertebra is suspected. Where a fracture of thinned bone is suspected or found, a DEXA bone density scan measures the bone and guides treatment to prevent the next one.

For a strained back the national guidance and the evidence agree: keep moving. Carrying on with daily life and work as far as the pain allows speeds recovery, and long bed rest tends to slow it. Heat, such as a hot water bottle wrapped in a towel, eases muscle spasm, and a cold pack can help too. An anti-inflammatory tablet such as ibuprofen, taken where it is safe for you, is the medicine the NHS suggests first; paracetamol on its own is not recommended for back pain. If the pain lasts, a structured exercise programme, often with a physiotherapist, is offered, and manual therapy or a psychological approach to coping with pain can sit alongside it, not in place of it.

Where the assessment finds a particular cause, it is treated on its own terms. An inflamed spine has treatment of its own, set out in our axial spondyloarthritis guide: exercise, anti-inflammatory medicine and, where needed, biologic treatment. A broken vertebra is treated with pain relief and with medicine that strengthens the bone. Sciatica is usually treated like a strained back, with time and activity, though anti-inflammatory tablets help it less clearly than they help a strain; an injection or an operation is kept for leg pain that does not settle. Widespread pain follows the fibromyalgia guide. You and Dr Borukhson settle the plan together.

Everyday habits help a sore back mend and lower the odds of a repeat:

• Stay on the move: walking and your normal routine, within what the pain allows, are part of the treatment, not a risk to the back
• Build back up bit by bit: add a little more each time instead of holding off until the pain has gone, and without pushing through it
• Heat or cold: a hot water bottle or a cold pack, each wrapped in a towel, for the worst of the pain or the spasm
• Ask a pharmacist about painkillers: ibuprofen or another anti-inflammatory tablet where it is safe for you, which is not everyone; they can upset the stomach, and the signs of a bleed are in the lists below
• Strengthen and stretch: regular exercise for the back, the core and the legs makes another episode less likely
• Look after the rest of you: keeping to a healthy weight, stopping smoking and making time to manage stress all help the back

Back pain often returns, and a flare is not a sign of new damage. Most episodes pass, and trust in your back grows again as you keep active.

Self-care is the right start for almost all back pain, with a routine appointment if it lingers. The lists below give a route to the few pictures that need more: squeezed nerve roots at the bottom of the spine, an infection, which can become sepsis, a broken vertebra, a stroke, a serious accident, the heart felt in the back, a bleed from the stomach on an anti-inflammatory painkiller, the pancreas reacting to steroid tablets, and a severe allergic reaction to a medicine.

Treat any of these as a 999 or A&E emergency: call 999 and do not drive yourself to A&E.

• Severe illness with suspected sepsis: a high fever with shaking, confusion, rapid breathing, or feeling dramatically worse over hours
• With a fever or feeling unwell, a rash that does not fade when you press it, a stiff neck with eyes that cannot bear bright light, or skin, lips or tongue turning blue, grey, pale or blotchy, since these can be signs of meningitis or sepsis; on black or brown skin the rash and the change of colour may be easier to see on the palms of the hands or the soles of the feet
• Numbness or tingling around the back passage, genitals or inner thighs, new difficulty passing urine or controlling your bladder or bowels, a change in feeling during sex, or pain, tingling, weakness or numbness in both legs, since these can mean pressure on the nerves at the base of the spine, which needs emergency treatment
• New trouble with walking, unsteady or clumsy rather than simply sore, with the back pain, since the nerves at the bottom of the spine may be under pressure
• Back pain that began after a serious accident, such as a car crash or a fall from a height, or that comes with chest pain
• Vomiting blood, or bleeding from the back passage that is heavy or will not stop, most of all with faintness, confusion or pain in the abdomen, or vomit that is black or dark brown, since anti-inflammatory painkillers, which the NHS suggests first for back pain, can make the stomach bleed
• Lips, mouth, throat or tongue that suddenly swell, a throat that feels tight, very fast breathing or a struggle to breathe or to swallow, skin, tongue or lips turning blue, grey or pale (on black or brown skin this may be easier to see on the palms of the hands or the soles of the feet), becoming suddenly very confused, drowsy or dizzy, or fainting and not being able to be woken, since this can be a severe allergic reaction, anaphylaxis, which can follow a dose of any medicine
• Sudden weakness or numbness on one side, a drooping face or difficulty speaking, a sudden severe headache, sudden confusion or a seizure, or sudden loss of vision, any of which can be a stroke, even if it stops after a short time, and a leg that suddenly goes weak or numb, with no back or leg pain to explain it, is one of these signs
• An eye that suddenly and completely loses its sight

Any of these needs an assessment that is urgent, on the same day, from your GP or NHS 111:

• A fever, feeling hot, cold or shivery, or generally unwell, with the back pain, since an infection in the spine has to be found the same day
• Severe back pain that started suddenly or is getting worse quickly, including after a small strain or lift if you have osteoporosis or take steroid tablets, since a fracture has to be found the same day; on steroid tablets, pain in the abdomen or back that comes on suddenly and severely is a 999 or A&E emergency, since the pancreas can react to prednisolone: call 999 and do not drive yourself to A&E
• Fresh back pain after even a minor fall or knock, if axial spondyloarthritis has stiffened your spine, since a stiffened spine breaks more easily and a fracture has to be found
• A leg that is growing weaker, or a foot that has begun to drag or slap down, with sciatica, since a nerve root under that much pressure needs to be seen the same day; weakness or numbness in both legs belongs to the first list
• Black or dark red stools, on anti-inflammatory tablets, since a bleed in the stomach or gut has to be found that day
• A new red, painful eye, or sight that has blurred, dimmed or changed, which needs an eye casualty or urgent eye clinic the same day, as does an eye that light hurts, since axial spondyloarthritis, which this guide names among the inflammatory causes, can set off inflammation inside the eye; the signs are in our uveitis guide

See a GP within days, rather than waiting weeks, if you are over 50 and the pain is constant, worse lying down at night and not eased by changing position or getting up, if you have lost weight without trying, if you have had cancer, if the pain is high up between your shoulder blades, or if it is worse when you cough, sneeze or open your bowels, since those patterns need a closer look; with pain in the chest as well, or with sweating, feeling sick or breathlessness, pain between the shoulder blades is a 999 or A&E emergency, since a heart attack can cause pain in the back: call 999 and do not drive yourself to A&E. Take the inflammatory pattern, back pain that began before 45, has built over months, is worst on waking and in the night and eases with exercise, to a GP without leaving it for months, since that is how an inflamed spine shows itself. See a GP too if the pain has not eased after a few weeks of looking after it at home, if it does not ease with rest, if you are worried about it or struggling to cope, if it is stopping your day-to-day life or keeps returning, or if there is a lump or swelling in your back or its shape has changed. No referral is needed to be seen here; next-working-day appointments can almost always be arranged, and same-day appointments are sometimes possible. If you cannot tell how urgent something is, asking is never a mistake.

A rheumatologist is not needed for most back pain, and this page would not pretend otherwise. Where an assessment pays off is the back that does not follow the usual course: an inflamed spine mistaken for a strain, a vertebra broken by very little force in an older person, leg pain that needs a scan and a plan, or an ache that turns out to be part of something wider. Telling these apart from the everyday strain means reassurance can be given with confidence where it fits, and the right treatment started early where it does not. If your back pain is lasting, coming back, or not behaving as a strain should, that is the time for a review.

When does back pain need 999 or A&E?

Numbness or tingling around the back passage, the genitals or the inner thighs, new trouble passing urine, or losing control of the bladder or bowels, a change in feeling during sex, pain, tingling, weakness or numbness in both legs, or new trouble with walking: any of these with back pain is a 999 or A&E emergency, because the nerve roots at the bottom of the spine may be squeezed and need treating at once. So is back pain that began after a serious accident, such as a car crash or a fall from a height, or that comes with chest pain; so is pain between the shoulder blades with sweating, feeling sick or breathlessness; and so are the signs of a stroke, among them a leg that suddenly goes weak or numb with no back or leg pain to account for it, and, on steroid tablets, pain in the abdomen or back that comes on suddenly and severely, since the pancreas can react to prednisolone. Call 999 and do not drive yourself to A&E. Short of those, a fever or feeling unwell with the back pain, or severe pain that came on suddenly or is fast getting worse, needs your GP or NHS 111 the same day. The lists under when to seek help give the rest.

How can I tell an inflamed spine from ordinary back pain?

By how the pain behaves through the day. The back pain of axial spondyloarthritis usually begins in early adult life, often between 18 and 40, and creeps up over months; it is at its worst after rest, stiff on waking for half an hour or more, may disturb you in the small hours, and loosens with exercise and movement. A strained back tends to do the reverse: easier for rest, sorer for use. That inflammatory pattern is one to take to a GP without leaving it for months, because the condition is treatable and can be hard to tell from ordinary back trouble, which delays the diagnosis; our axial spondyloarthritis guide covers it.

Is bed rest a good idea?

No. Long spells in bed tend to slow recovery from back pain rather than speed it. The advice is to keep as active as the pain allows, carry on with day-to-day life where you can, and use an anti-inflammatory painkiller where it is safe for you, with heat or a cold pack for the worst of it. Moving may hurt at first, but it does the back no harm.

Will I need a scan?

Usually not. Most back pain is diagnosed from what you describe and from an examination, and a scan of a recently strained back rarely changes the plan; the national guidance advises against routine imaging. A scan becomes worthwhile when the picture raises a different question: an MRI where a pressed nerve is not recovering or the spine may be inflamed, an X-ray where a broken vertebra is suspected, and the tests the warning signs call for. Dr Borukhson arranges one where it is truly indicated, with blood tests and a bone density scan where the pattern needs them.

Sciatica: what is it, and when is it urgent?

Sciatica is pain that runs from the back or buttock down a leg, often below the knee, sometimes with tingling, numbness or weakness, because a nerve root is irritated as it leaves the spine, usually because a disc is bulging. Sciatica in both legs, weakness or numbness in both legs, numbness around the genitals or back passage, or a new problem passing urine, or with bladder or bowel control, is a 999 or A&E emergency. Call 999 and do not drive yourself to A&E. A leg that is growing weaker, or a foot that has started to drag or slap down, needs your GP or NHS 111 the same day. Short of those, it usually hurts more than it harms, and most episodes ease over a few weeks to a few months with keeping active; see a GP if it has not improved after a few weeks of home treatment, is getting worse or is stopping normal life.