Key Point

• Low-back pain is not only costly, it’s often hard to diagnose. Taking a proper health history and exploring assessment tools will get practitioners closer to finding an answer for their clients.

Worldwide, low-back pain affects 60–70 percent of people at some point in their lives. The economic impact of these conditions is staggering. Recent research shows worldwide yearly costs to treat low-back pain to be around $26 billion; 126 million of these cases are due to work-related ergonomics.¹ The prevalence of these painful conditions underscores the urgent need for effective prevention and treatment strategies. 

Despite the extreme frequency of low-back pain, there are countless cases in which health-care practitioners are unable to identify the causes. Failure to recognize or correctly diagnose the pain source makes treatment unpredictable at best and detrimental at worst. 

Let’s take a look at the onset of low-back pain, identify the most common conditions that cause it, and outline key assessment principles used for evaluation. While detailed evaluation protocols for each condition are available, they are beyond the scope of this article. Let’s dive in.   

Common Causes 

Low-back pain is a common condition characterized by discomfort or pain in the lumbar region of the spine. This area, known as the lower back, encompasses the vertebrae, discs, nerves, and muscles extending from the lower rib cage to the pelvis. Low-back pain can be acute, lasting a few days to weeks, or chronic, persisting for three months or longer. The pain intensity varies widely, ranging from a constant, dull ache to sharp, movement-limiting sensations.

Multiple factors contribute to low-back pain. Common mechanical causes include muscle hypertonicity (likely underdiagnosed), muscle strains, and ligament sprains. Dysfunctions of the structural elements of the spine, the vertebrae, joints, discs, and associated neural structures (spinal cord and nerve roots) also contribute to pain in this region. 

Injuries from accidents or poor ergonomics and repetitive use frequently lead to low-back pain. Additionally, conditions like herniated discs, spinal stenosis, and osteoarthritis can trigger discomfort. Lifestyle factors such as poor posture, sedentary habits, and obesity increase the risk of developing this condition.

Back injuries typically result from a unique combination of factors. As massage therapists, we must understand these multifaceted causes to tailor our treatments effectively. When addressing low-back pain, we need to consider not only the immediate physical factors but also the broader context of our client’s lifestyles and activities. This comprehensive approach allows us to provide more targeted and effective care, addressing both the symptoms and the underlying causes of low-back pain.

Primary Locomotor Tissues  

Let’s explore the role of biomechanical causes of low-back pain in more detail. Massage and other soft-tissue treatments have an integral role in treating most of these conditions. 

Myofascial Pain

Muscular pain comes from two main factors: muscular dysfunction and muscle strains. Pain in the myofascial (muscular and fascial) tissues accounts for a large percentage of back pain complaints. The back muscles have high demands of stability and movement placed on them. Back pain results when muscles are overwhelmed either from chronic overloading or sudden high-intensity forces. 

There are several ways that myofascial back pain can develop. It usually develops when muscles are acutely or chronically overloaded, and the body senses the potential for injury if the current demands continue. A typical muscular reaction to perceived overload is for the muscle to contract in a protective reaction (spasm). The reaction often exceeds what is needed for protection and creates continual overactivity, called hypertonicity, and subsequent pain in the muscle. 

In some cases, localized areas of tightness, called myofascial trigger points, develop in the muscle and can remain tender locally or refer pain or other sensations. The common factor with these different aspects of muscular pain is excess activity in the neuromuscular system, leading to excess contraction and further pain.

Muscle strains are frequently cited as a cause of low-back pain, but this diagnosis is often overused. Many cases diagnosed as muscle strains don’t match the symptomatic profile or onset consistent with the forces necessary to overstretch or tear a muscle (the definition of a strain). Muscle strains would be more likely in the core stabilizing muscles like the erector spinae or quadratus lumborum (Image 1). Muscle strains may undoubtedly occur in the back, but it’s more likely that general muscular hypertonicity is underdiagnosed while muscle strains are overdiagnosed.

Chronic loading, especially in repetitive motion activities, is the main cause of tendon injuries. These injuries, such as tendinitis/tendinosis or tenosynovitis, are most common in tendons that span joints with a significant range of motion. Thus, they are common in the extremity’s large power muscles that are exposed to high loads and repetitive motions. 

Unlike limb tendons, however, spinal tendons seldom encounter the conditions that lead to overuse tendon injuries. The spinal muscles are used more for trunk stabilization and positioning and less to perform power movements. Spinal tendons are relatively short and small, with minimal range of motion at individual segments. These tendons are rarely overloaded to the extent that tendon injuries develop. Additionally, these tendons don’t have synovial sheaths, meaning they are not susceptible to conditions like tenosynovitis that impact the tendon sheath.

Ligament Sprain 

Ligament sprains, like muscle strains, are often overdiagnosed in cases of low-back pain. After seeing a family physician, clients may get a diagnosis of lumbar sprain/strain. This diagnosis is vague, indicating either a muscle strain, ligament sprain, or both without specifying the affected tissue. This lack of precision makes determining the most effective treatment approach difficult.

A true ligament sprain involves overstretching or tearing ligament fibers, which requires substantial force. While you may feel localized soft-tissue pain near ligaments, actual ligament damage is less common than often assumed. The spine’s major ligaments, such as the anterior and posterior longitudinal ligaments, are large and positioned close to the vertebral bodies, making them resistant to sprains. 

Smaller ligaments connecting transverse processes, spinous processes, and adjacent bones like the pelvis are more susceptible to sprains (Image 2). These smaller ligaments farther away from the body’s center are more likely to suffer an actual sprain. However, pinpointing a specific sprained ligament in the spine remains challenging due to the complex anatomy and spinal mechanics.

Structural Conditions 

Now, let’s review low-back pain that results from structural alteration. While massage plays a primary role in addressing muscle, tendon, and ligament issues, it serves more as an adjunct treatment for structural and systemic conditions. 

Intervertebral Disc Herniation 

Intervertebral disc herniation often comes to mind when discussing back pain. This condition occurs when compressive forces push the inner disc (nucleus pulposus) against the outer cartilage rim (annulus fibrosus). Continued pressure causes the annulus to protrude against nearby structures, mainly nerve roots (Image 3). This pressure typically causes radiating pain down the lower extremity along the affected nerve roots’ sensory path rather than back pain itself. A disc herniation diagnosis as a cause of back pain is not as common as it used to be. MRI studies have shown that disc herniations don’t always correlate with pain, leading to a more measured approach in diagnosis and treatment.

Cauda equina syndrome, a serious type of disc protrusion, requires special attention. Unlike typical disc herniations that protrude posterolaterally, cauda equina syndrome involves straight posterior protrusion, pressing on the spinal cord fibers in the lower back (the cauda equina). Symptoms include bilateral lower extremity pain, sensory and motor disturbances in the pelvic floor region, and potential bowel, bladder, sexual dysfunction, or sensory impairment. Refer clients presenting these symptoms immediately to emergency care to prevent permanent neurological damage.

Degenerate Disc Disease/Spinal Stenosis 

Degenerative disc disease results from the intervertebral disc losing water content and flattening under compressive loads. As the discs flatten, the joints come closer together, decreasing the space where the nerve roots exit the spine (the intervertebral foramen). This condition is known as spinal stenosis and results in the discs pressing on the nerve roots and causing nerve pain. Vertebral contact can also lead to arthritic pain in the joints and the development of spinal tumors or bone spurs, decreasing the space further and leading to more nerve impingement. Age-related changes to the spinal structure often show up in detailed imaging studies.

Facet Joint Pathology

Facet (zygapophyseal) joints are the only direct articulation points between adjacent vertebrae. These are standard synovial joints with an articulating surface and a surrounding joint capsule. Like any joint, they are susceptible to degenerative changes like arthritis. Certain postures, like an exaggerated lumbar lordosis (Image 4), can increase compression on these joints, potentially contributing to low-back pain.

Spondylolysis and Spondylolisthesis 

Spondylolysis and spondylolisthesis are two closely related conditions. Spondylolysis involves a stress fracture in the vertebra’s pars interarticularis (Image 5), typically resulting from excessive compressive loading during spine extension. If severe enough, this can progress to spondylolisthesis, where the vertebral body separates from the posterior vertebral arch and slides (usually anteriorly) on the vertebra below. This condition most commonly occurs at the L5–S1 junction.

Systemic Disorders/Inflammatory Conditions 

Systemic inflammatory conditions are known to lead to back pain; two of the more common conditions in this category are ankylosing spondylitis and rheumatoid arthritis. Ankylosing spondylitis is a chronic inflammatory disease that primarily affects the spine and the sacroiliac joints, leading to pain and stiffness. Over time, this condition can cause the vertebrae to fuse, resulting in a rigid spine and a forward-stooped posture. The hallmark symptom is lower-back pain that improves with exercise but not with rest, often accompanied by morning stiffness that lasts for an extended period. 

Rheumatoid arthritis, on the other hand, is an autoimmune disorder that causes inflammation in the joints, including those in the spine. This condition leads to pain, swelling, and potential joint deformity. Unlike ankylosing spondylitis, rheumatoid arthritis can symmetrically affect multiple joints throughout the body and is often associated with systemic symptoms such as fatigue, fever, and weight loss.   

Referred Pain

In some cases, back pain results not from local movement tissue disorders but from other organs or systems that refer pain to the back. Conditions such as kidney stones and pancreatitis can manifest as significant discomfort in the lower back, even though their primary pathology is elsewhere. For instance, kidney stones can cause sharp, intense pain in the lower back as they move through the urinary tract. Similarly, pancreatitis can lead to upper abdominal pain that radiates to the lower back. Symptoms of nausea, vomiting, and painful urination often accompany both conditions. 

Psychogenic Factors

Psychological factors such as depression, anxiety, or past trauma, rather than direct physical tissue damage, can influence the pain experience and is called psychogenic pain. This type of pain can manifest in various forms, including headaches, muscle aches, back pain, and abdominal pain, often without any apparent physical injury or pathology. Despite the lack of physical evidence, psychogenic pain is genuine and can significantly impact a person’s quality of life. 

The exact mechanisms behind psychogenic pain are complex and involve the interplay between the brain, emotions, and past experiences. For example, stress or anxiety can amplify pain signals, making pain feel more intense or widespread. Similarly, past trauma or ongoing emotional distress can trigger or exacerbate pain symptoms. Treatment for psychogenic pain typically involves a multidisciplinary approach that includes psychotherapy, such as cognitive-behavioral therapy, physical therapy, and sometimes medications to address underlying mental health conditions. Massage is a valuable adjunct treatment in many cases of psychogenic pain.   

Nonspecific Back Pain

Nonspecific low-back pain presents a unique challenge in diagnosis and treatment. This category encompasses many potential complaints and can involve issues of multiple types, not just locomotor tissues. Practitioners often use this label when they can’t determine a specific cause, making it a catchall term for unexplained back pain.

As a diagnostic term, nonspecific back pain sparks debate among experts. Renowned back researcher Stuart McGill argues that the diagnosis results from inadequate assessment, suggesting a more thorough evaluation would reveal a specific cause.² However, others maintain that nonspecific back pain is a legitimate classification, particularly for cases of nociplastic pain (that which does not seem to have a clear cause).

As massage therapists, we must approach nonspecific low-back pain with both skepticism and open-mindedness. While a thorough assessment may reveal a specific cause in many cases, we should also recognize that some pain defies precise classification. In these instances, focusing on symptom management and overall function improvement may be more beneficial than searching for a specific cause. Remember, what one practitioner deems nonspecific might be identifiable to another with different or more advanced assessment skills or perspectives.

Key Assessment Protocols 

Determining the issues contributing to low-back pain is challenging, yet understanding your client’s condition is crucial for effective treatment. Assessment helps rule out serious conditions and potential red flags. While a complete evaluation is beyond this article’s scope, we’ll cover highlights to consider during your evaluation process.

A comprehensive assessment includes history, observation, palpation, range-of-motion and resistance testing, and special tests (abbreviated
as HOPRS). Let’s explore the essential factors in
each section, focusing on aspects most relevant to massage therapists.

History 

The history is the most critical part of any evaluation process. Detailed questioning about symptoms, onset, aggravating factors, and previous treatments provides invaluable information. To conduct an effective history, you need in-depth knowledge of various conditions. 

Here are key points to listen for:

• How the pain began is crucial—This information helps determine if the pain was sudden or developed chronically. For acute onset injuries, the client should describe the initiating movement or activity in detail. Your kinesiology knowledge will help you assess the likelihood of specific tissue injuries. Note the amount of potential force in any acute injury. Muscle injuries are more common and occur with less force, while ligament sprains require significant force. More than one tissue type may be involved in an acute injury. 

• Chronic pain points to different suspects—Identify if static postures exaggerate the pain, as this can indicate specific tissue involvement. For example, disc herniation pain often worsens with prolonged sitting due to disc compression and subsequent pressure on nerve roots. Facet joint irritation may increase with extended periods of standing in an exaggerated lumbar lordosis. Conditions like spondylolysis, stenosis, and degenerative disc disease often worsen with prolonged static loading. Conversely, ligament pain rarely results from chronic loading.

• The nature of the pain sensation also provides crucial clues—Sharp, shooting, or stabbing pain, especially if it radiates down the lower extremity, suggests nerve root compression. Radiating pain is common in conditions like disc herniation, stenosis, degenerative disc disease, or spondylolisthesis. Shooting pain to the lower extremity is not typical of muscular or ligamentous injury, indicating neural irritation is more likely.

Taking a comprehensive history is an art that improves with practice. Learning more about various conditions and how to evaluate their etiology through your intake history will enhance your skills.

Observation 

Observation can help identify visual clues that shed light on the client’s complaint, though some conditions lack visible signs. Here are some key physical signs to look for:

• Muscular hypertonicity can produce visual cues like a lateral pelvic tilt from a tight quadratus lumborum. 
• Muscle strains might show swelling, redness, or bruising if the affected muscle is superficial. 
• Ligament injuries are usually too deep for visible signs, but if severe, they can show similar effects as those with strains.  

Watch your client’s movements during the evaluation process. Movement apprehension often indicates pain avoidance. The pattern of these movements can provide essential clues about involved structures. For instance, clients with spondylolisthesis or facet joint irritation typically avoid extension movements because these aggravate symptoms.

Palpation

Palpation is the stronghold of massage therapists, who spend more time palpating soft tissues than almost anyone else in the health-care system. When you combine this skill with anatomical knowledge, you can not only target specific tissues but also gain insights throughout the treatment session. 

Muscle dysfunctions like strains or hypertonicity are commonly identified through palpation. Your anatomy knowledge is essential for determining specific muscles or ligaments involved in strains or sprains. Tenderness and pain reproduction are primary indicators during palpation. Palpation with moderate pressure may also reveal reactive muscle splinting (reactive contractions). Even very gentle palpation can help detect a lack of mobility in superficial fascial tissues, which indicates deeper muscle issues. Some deep structural spinal problems, such as disc herniations and stenosis, cannot be palpated due to their depth. With severe spondylolisthesis, you might feel a bit of the vertebral displacement. 

Range-of-Motion and Resistance Testing 

Range-of-motion (ROM) and resistance testing involve three evaluation movements at each joint: active range of motion (AROM), passive range of motion (PROM), and manual resistive tests (MRT). Specific tissue pathologies often produce characteristic and predictable patterns in these tests. For example, a quadratus lumborum strain typically causes pain during active contraction (concentrically or eccentrically), passive stretching, and a resisted contraction (lateral lumbar flexion on the affected side).

The spine presents unique challenges for motion and resistance tests compared to the extremities. For instance, testing passive elbow flexion is easy by just moving the client’s forearm while they relax. Conversely, passive torso flexion requires getting the client to fully relax while you move their torso, which is quite tricky. Alternative positions can help you achieve these passive movements. 

Special Tests 

Special tests are specialized evaluation procedures designed to indicate the likely presence or absence of specific conditions. While numerous spinal special tests exist, recent research has questioned the accuracy of many of these. The tests are less commonly used for muscular hypertonicity, strains, or ligament sprains and more often for structural conditions like neural involvement from disc herniation or stenosis. Tests like the straight leg raise or slump test may provide helpful information about potential nerve involvement in back pain. 

Special tests should only be used in conjunction with a comprehensive assessment and not as a shortcut in the evaluation process. In light of recent research on their validity, I now place greater emphasis on information from other aspects of the HOPRS assessment process. Developing your assessment skills will significantly enhance your treatment success and clinical decision-making.

Conclusion

Understanding how and why low-back pain occurs and its various causes is at the heart of finding an effective treatment plan. This knowledge allows us to choose the best treatment approaches and techniques that match the physiological and pain presentation of the client’s condition. 

Treatments for low-back pain are as diverse as the myriad types of pain they address. Treating these conditions runs the gamut from soft-tissue manipulation to corrective surgery. However, soft-tissue therapies continue to be effective treatments for acute and chronic low-back pain. They can even be helpful when the cause is unknown. 

Massage therapy, in particular, offers a unique approach to acute and chronic low-back pain. The massage therapist’s ability to specifically palpate tissue and target key problem areas with hands-on treatment is incredibly therapeutic. The extensive time spent with clients also allows massage therapists to apply more comprehensive treatment. Additionally, the relaxing environment maximizes the effects of descending modulation in the healing process. 

Notes

1. Ningjing Chen, Daniel Y. T. Fong, and Janet Y. H. Wong, “The Global Health and Economic Impact of Low-Back Pain Attributable to Occupational Ergonomic Factors in the Working-Age Population by Age, Sex, Geography in 2019,” Scandinavian Journal of Work, Environment, and Health 49, no. 7 (August 2023): 487–95, https://pubmed.ncbi.nlm.nih.gov/37634250.

2. Stuart McGill, Low Back Disorders: Evidence-Based Prevention and Rehabilitation, 3rd ed. (Human Kinetics, 2015).

Common Mechanical Factors Leading to Low-Back Pain

Acute-force trauma

Heavy lifting

High force loads

Improper mechanics 

Prolonged sitting

Repetitive movements

Twisting movements

Other Contributing Factors

Age 

Obesity 

Physical condition

Psychological factors

Resources

Chou, R. “Low Back Pain.” Annals of Internal Medicine 174, no. 8 (2021): ITC113–ITC128. https://pubmed.ncbi.nlm.nih.gov/34370518.

Fatoye, F., T. Gebrye, and I. Odeyemi. “Real-World Incidence and Prevalence of Low Back Pain Using Routinely Collected Data.” Rheumatology International 39, no. 4 (April 2019): 619–26. https://pubmed.ncbi.nlm.nih.gov/30848349.

Jenkins, H. J. et al. “The Available Evidence on the Effectiveness of 10 Common Approaches to the Management of Non‐Specific Low Back Pain: An Evidence Map.” European Journal of Pain 26, no. 7 (August 2022): 1399–411. https://onlinelibrary.wiley.com/doi/full/10.1002/ejp.1974.

Lyu, F-J. et al. “Painful Intervertebral Disc Degeneration and Inflammation: From Laboratory Evidence to Clinical Interventions.” Bone Research 9, no. 7 (2021).
www.nature.com/articles/s41413-020-00125-x#citeas.

Swain, C. et al. “No Consensus on Causality of Spine Postures or Physical Exposure and Low Back Pain: A Systematic Review of Systematic Reviews.” Journal of Biomechanics 102 (March 2020): 109312. https://pubmed.ncbi.nlm.nih.gov/31451200.

Vingin, R. et al. “Current Evidence for Diagnosis of Common Conditions Causing Low Back Pain: Systematic Review and Standardized Terminology Recommendations.” Journal of Manipulative and Physiologcal Therapeutics 42, no. 9 (November 2019): 651–64. https://pubmed.ncbi.nlm.nih.gov/31870637.