Back pain

Back pain is common, but some symptoms require urgent care. Seek emergency medical assessment for new loss of bladder or bowel control, numbness around the genitals or buttocks, severe or worsening weakness in both legs, or back pain following major trauma. Prompt assessment is also important when pain occurs with fever, unexplained weight loss, a history of cancer, significant immune suppression or rapidly worsening neurological symptoms.

What is back pain?

Back pain describes discomfort arising from the muscles, joints, discs, nerves or other structures of the back. Low back pain occurs between the lower edge of the ribs and the buttocks and may spread into one or both legs. It can be acute, subacute or chronic, depending on how long it lasts.

Most low back pain is described as non-specific, meaning that no single disease or damaged structure fully explains the symptoms. The World Health Organization estimates that this accounts for about 90% of low back pain. A smaller proportion has a specific cause such as fracture, infection, inflammatory disease, cancer, nerve-root compression or pain referred from another organ.

Common presentations and causes

Muscle and soft-tissue pain

Pain may begin after lifting, a sudden movement, unfamiliar physical work or prolonged time in one position. Muscles and other soft tissues can become painful and movement may feel restricted. The severity of pain does not always indicate the amount of tissue injury.

Disc and nerve-related pain

Spinal discs change naturally with age. A disc can sometimes irritate or compress a nearby nerve root, causing pain that travels into the leg. Sciatica may include sharp or electric-shock-like pain, tingling, numbness or weakness. Many disc changes are also seen on scans of people who have no pain, so imaging findings must be interpreted alongside the clinical examination.

Spinal stenosis and degenerative change

Narrowing around the spinal nerves can cause back or leg symptoms, particularly during standing or walking. Osteoarthritis and age-related changes may contribute. Treatment depends on symptom severity, function and the presence of neurological problems.

Specific medical causes

Less common causes include vertebral fracture, infection, inflammatory conditions, cancer and pain referred from organs in the abdomen or pelvis. Osteoporosis can increase the risk of compression fractures. Pregnancy can also place additional strain on the lower back. These situations require assessment tailored to the underlying cause.

Symptoms

Back pain can present as a dull ache, stiffness, muscle spasm or sharp pain. It may limit bending, standing, walking, sleep, work and other daily activities. Pain that spreads into a leg may be accompanied by numbness, tingling or weakness.

Many episodes of non-specific acute low back pain improve over time, but recurrence is common. Persistent pain can affect mood, sleep, social participation and confidence in movement. These factors are relevant to assessment and recovery and do not mean that the pain is imaginary.

When to seek medical attention

Arrange timely medical assessment if pain is severe, persistent, worsening or accompanied by neurological symptoms. Urgent or emergency assessment is particularly important for:

• new difficulty controlling the bladder or bowel;
• numbness around the saddle area;
• new or progressive weakness in the legs;
• fever, chills or other signs of infection;
• major trauma or suspected fracture;
• unexplained weight loss or a history of cancer;
• pain with significant immune suppression; or
• severe pain that is rapidly worsening or markedly different from previous episodes.

Assessment and diagnosis

A clinician will ask about the onset and location of the pain, symptoms in the legs, medical history, medicines, recent injuries and the effect on daily life. The examination may assess movement, strength, sensation and reflexes, as well as signs suggesting a specific cause.

Imaging is not routinely required for uncomplicated low back pain. X-rays, CT scans or MRI may be considered when the result is likely to change management, when serious pathology is suspected, or when neurological symptoms require further investigation. Routine scanning can identify common age-related changes that are not necessarily the source of pain.

Management

Treatment depends on whether the pain is specific or non-specific, how long it has been present and how it affects the individual. A healthcare professional should help tailor the plan when symptoms are severe, persistent or complex.

Activity and exercise

For most non-specific low back pain, prolonged bed rest is not recommended. Remaining active within tolerable limits and gradually returning to normal activities can support recovery. An appropriate exercise programme may improve strength, movement and confidence. The best form of exercise varies according to the person’s preferences, abilities and health conditions.

Education and self-management

Understanding the condition, pacing activities, improving sleep and making practical adjustments at work or home can help. Persistent pain often benefits from a combined approach that considers physical, psychological and social factors. Support should focus on restoring function and participation rather than promising a complete or immediate cure.

Physical and manual therapies

Physiotherapy may include graded exercise and advice on movement. NICE recommends considering manual therapy—such as manipulation, mobilisation or soft-tissue techniques—only as part of a treatment package that includes exercise, with or without psychological therapy. It should not be presented as a stand-alone cure.

Medicines

Medication decisions should account for age, pregnancy, allergies, kidney or stomach disease, cardiovascular risk and other medicines. Painkillers are not the only treatment and may not be the first choice for every person. A pharmacist or clinician can advise on whether a medicine is suitable, the lowest effective dose and the shortest appropriate duration. Do not combine products or exceed labelled doses.

Procedures and surgery

Most people with non-specific low back pain do not need surgery. Specialist procedures may be considered for selected conditions—for example, persistent nerve compression with significant symptoms—after appropriate assessment and discussion of benefits and risks. Surgery is directed at a defined cause rather than back pain in general.

Supporting recovery and reducing recurrence

• Stay physically active and build activity gradually.
• Use safe lifting techniques and adjust loads or tasks when necessary.
• Change position regularly during prolonged sitting or standing.
• Maintain healthy sleep habits and address stress or low mood when these affect recovery.
• Avoid smoking and seek support to stop if needed.
• Work with a clinician or physiotherapist when pain repeatedly limits daily activity.

No single posture, mattress or exercise prevents every episode of back pain. A sustainable plan that keeps the person active and addresses individual risk factors is more useful than rigid rules or fear of movement.