Getting to the bottom of your lower back pain

The idea of having lower back pain strikes fear in most of us. Many people believe that the lower back is fragile and once injured is slow to heal and might result in permanent disability. The lumbar spine is in fact not too different from any other structure in the human body. It’s actually very robust, look at what AFL players put their bodies through! The key is receiving an accurate assessment and diagnosis so you understand your injury, the rehab required and how to prevent lumbar pain from coming back.
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Jimmy Goulis

How common is lower back pain?

Lower back pain is quite common and is the leading musculoskeletal issue in Australia; around 80 per cent of the population is likely to experience it during their lifetime.

What’s also interesting is that roughly 16 per cent of Australians may be experiencing lower back pain symptoms as you read this article!

In close to 50 per cent of cases, low back pain lasts longer than three months, resulting in a poor quality of life and in some instances, ongoing disability.

Living with pain is also known to impact negatively on a person’s mental health.

Here are some further interesting facts about lower back pain:

  • Your chances of experiencing it increase as you get older.
    • Around 6 per cent of 25-34-year-olds live with lower back pain.
    • Around 28 per cent of 55-64-year-olds have pain in the lower back, which is the age when lower back pain reaches its peak.

Research has also shown the number of people experiencing lower back pain is increasing.

Several studies have revealed that its global prevalence has more than doubled in the last 17 years.

The main factors contributing to this increase include:

  • Rising obesity levels and people not maintaining a healthy weight.
  • Sedentary lifestyles and not exercising regularly.
  • Poor diet.

 Anatomy of the lower back

The lower back is also known as the lumbar spine region and is a complex structure.

Understanding how it is put together helps when you want to know what exactly is going on with your lower back when you have pain in the area.

Bones in the lower back

There are five bones are known as vertebrae in the lumbar spine.

Your spine’s vertebrae are numbered L1 to L5 and they sit in a vertical column beneath the upper back, which is also known as the thoracic spine.

These vertebrae are large and solid because they need to protect the spinal cord as it descends.

Discs in lower back

Between each of the vertebrae, there is a disc that acts as a shock absorber and cushions the vertebrae during spinal movement.

Facet joints in lower back

The vertebrae are connected by paired facet joints, which help to stabilise the lumbar spine and enable both forward, backward and side-to-side movement.

Ligaments in the lower back

Ligaments run alongside the bones and help stabilise the lower back.

Muscles in the lower back

Muscles play an active stabilising role in the lower back. They are support the spine with everyday movements like lifting, gardening and sports.

Nerves in lower back

The spinal cord contains motor and sensory nerve fibres that connect the brain and body.

  • The sensory nerve fibres communicate sensations such as touch and pain.
  • The motor nerve fibres are responsible for movement.


The spinal cord of the lower back typically ends at the vertebrae known as L1. The technical term for this area is conus medullaris.

At this point, the spinal nerves continue down to form a bundle of nerve fibres known as the cauda equina, named after its resemblance to a horse’s tail.

The term ‘cauda equina syndrome’ relates to the compression of these nerves and is covered in this article under ‘medical red flags’.

There are five lumbar spine nerves (L1 to L5) each emerging from the spinal column through a small hole in the corresponding vertebrae.

This part of the nerve is known as the nerve root. Each of the five spinal nerves is responsible for certain functions and certain areas of the body specifically:

  • L1 contributes to the movement of the hips and provides sensation to the groin and genitals.
  • L2, L3, and L4 are responsible for hip and knee movement and sensation in the front of the thigh and the inside of your lower leg.
  • L5 contributes to hip, knee, foot, and toe movement, as well as providing sensation in the outside of your lower leg and the top of the foot.

General Lower Back Pain Symptoms

Pain, especially lower back pain, can be complex. A physiotherapist is ideally placed to provide a thorough assessment and diagnosis to help manage and treat your discomfort.

The symptoms of lower back pain vary, with individuals experiencing a range of different sensations.

The most common lower back symptoms are either a sharp pain or a dull ache. The distribution of this pain may be broad or narrow.

Pain may occur just in the lumbar spine area or it may associated with pain in the hamstrings, calves, toes hips, and/or pelvis.

There may be pain in the back of the leg, or there may be a feeling of lower back pain and leg weakness.

Sometimes pain in these areas without lower back pain can still be the result of an issue in the lumbar spine region. This is known as referred pain.

Some people may also experience a feeling of tightness or muscle spasms in these areas as well.

Often musculoskeletal back pain is associated with movement, for example twisting or flexing your spine or when you move from a sitting to standing position, or vice versa.

Acute back pain vs chronic low back pain

Another way of describing the type of pain you are experiencing is based on the length of time you have had it and its onset.

Pain that comes on suddenly and lasts for a short period of days or a few weeks is known as acute pain. As the body heals, the pain lessens and eventually dissipates.

Subacute pain typically lasts between six weeks and three months.

Chronic back pain, on the other hand, is pain that lasts longer than three months and is often slow to respond to treatment. Finding the cause of a chronic pain can be more challenging and requires the physiotherapist to consider both mechanical and medical causes.

Lower back pain diagnosis

There are several aspects to the assessment of your condition. Obtaining a history of your back pain and taking a physical exam of the lower back are essential to making a proper diagnosis.

At Pollinate Health, we would identify whether your pain likely to be driven mostly by issues with your bones, muscles, ligaments or nerves. These are known as musculoskeletal causes.

We also screen you for other potential causes of lower back, like medical issues.

Here’s a summary of the difference between musculoskeletal and medical causes of back pain.

Musculoskeletal causes of lower back pain

Mechanical back pain:

This type of pain is usually experienced in the lumbar spine, buttocks and legs.

The characteristics of mechanical pain can vary depending on the type of movements you make, such as bending, straightening and twisting.

Mechanical pain can also be aggravated by everyday activities such as turning in bed, sitting for long periods or prolonged standing.

Radicular back pain:

This type of pain is associated with an inflamed or impinged nerve. It will often radiate down one leg and is commonly called sciatica.

This is often felt as a burning pain or sharp pain and can be accompanied by weakness, numbness and tingling.

Medical causes of back pain that may be a serious medical problem

One of the first things the physiotherapist will do as part of your assessment is screen you for red flags. These usually relate to the potential medical causes of back pain and may require the input of a GP or specialist and further diagnostic tests.

One of the advantages of seeing an advanced musculoskeletal physiotherapist for a thorough assessment is they will be skilled in considering all of the potential causes of lower back pain, both musculoskeletal and non-musculoskeletal.

The red flag conditions that the physiotherapist screens for including:

  • Infections: When you have an infection, it can manifest as pain in the lower back. Your physiotherapist screens for infection by asking about fevers, chills, rigors, night sweats and general malaise.

 

  • Cancer or tumour: Pain in this area can be a symptom of cancer or tumour. Your physiotherapist screens for this by asking about things such as unexplained weight loss and your family history.

 

  • Inflammatory conditions: There are a number of inflammatory conditions including rheumatoid arthritis and ankylosing spondylitis (AS), which that can result in pain in the lower back region. To assess for inflammatory conditions, your physiotherapist might look for bilateral (on both sides of your body) or cyclical symptoms (happening in cycles), or a strong family history.

 

  • Vascular conditions: Lower back pain can be a symptom of three serious vascular conditions, abdominal aortic aneurysm (AAA), pulmonary embolism (PE), and deep vein thrombosis (DVT).

 

  • Visceral conditions: The most common is renal colic. Also known as kidney stones, it can cause pain that radiates into the lower back. This pain can be severe in nature.

 

  • Cauda equina syndrome: Cauda equina syndrome is a rare and serious medical condition that needs immediate medical attention. It occurs when the nerve roots in the lower part of the spinal column (the cauda equina) become compressed.

 

This can result in any number of symptoms, such as severe pain, changes to your bladder and bowel function including loss of bladder or bowel control, or sexual dysfunction. Your physio should ask you about any of these symptoms.

What if your lumbar spine pain is musculoskeletal?

By questioning you for red flag risk factors, you can be confident that your health care professional has ruled out medical causes when making a diagnosis that the pain is musculoskeletal in origin.

Once this diagnosis is made your physiotherapist will consider possible musculoskeletal sources and causes. They consider each of the components of the lumbar spine, including bones, muscles, joints, and nerves.

The most common sources of musculoskeletal lower back pain

The common causes of lower back pain are an injury or degenerative processes.

Degenerative processes

The ageing process and can lead to changes in the spinal structures, such as the intervertebral discs, vertebrae, and facet joints. These changes can cause a variety of symptoms, including lower back pain, stiffness, and limited mobility.

  • Degenerative disc disease: Degenerative disc disease is a condition where the discs that act as shock absorbers between the vertebrae, begin to lose water content and become less flexible over time. This can lead to disc herniation, nerve root compression, and lower back pain.

 

  • Spinal Stenosis: Spinal stenosis is a condition in which the spaces within the spinal canal, through which the spinal cord and nerves pass, become narrowed. This narrowing can put pressure on the spinal cord and nerve roots, causing a variety of symptoms.Spinal stenosis can be caused by a number of factors, including the natural ageing process, degenerative changes in the spine, a herniated disc, thickened ligaments, bone spurs, or tumors. It most commonly occurs in the lower back or the neck (cervical spine).

 

  • Osteoarthritis: Osteoarthritis is a degenerative joint disease that can affect the facet joints, which connect the vertebrae in the spine. Osteoarthritis can cause pain, stiffness, and limited mobility and persistent back pain.

Injuries to the lower back

  • Acute muscle strain: Acute muscle strain can sometimes cause lower back pain. But more frequently, muscles are a secondary symptom of discs and joints being injured and inflamed and putting pressure on surrounding tissues.

While your physio still needs need to treat the muscle tension, the primary cause will still need to be addressed.

  • Discogenic pain: Discogenic pain arises from the discs that sit between the bones in your spine, and accounts for around 40 per cent of back pain. Discogenic pain can be brought on when you twist and lift a heavy load, or can be brought on by degenerative processes.If you injure your disc you often feel pain when you bend forwards or sit for long periods. Coughing and sneezing can also aggravate discogenic back pain at times.
  • Facet joint pain: Facet joints connect the bones in your lower spine and are a common source of back pain. You would normally report pain with bending backwards rather than bending forwards if you have facet joint pain.
  • Sciatica or sciatic pain: This is also called radicular pain. It radiates along the path of the sciatic nerve, which descends from the lower back to the buttocks and down into the back of the legs. Sciatica is often caused by an acute disc injury, which leads to irritation of the nerve root. This can be a direct mechanical compression of the nerve, or it can be an inflammatory or chemical compression of the nerve root.
  • Sacroiliac joint (SIJ) pain: SIJ pain is where the sacrum and iliac bones join. Discomfort is typically felt in the buttock, usually on one side. It’s probably under-diagnosed and under considered, so a thorough assessment should be conducted by your physio to determine whether your back pain is being caused by your sacroiliac joint.
  • Piriformis Syndrome: Piriformis Syndrome is sciatica that results from pressure on the sciatic nerve by the pisiforms muscle of the lower back. It can present as buttock pain or can also be referred down the back of the leg, just like sciatica.
  • Spondyllolisthesis: Spondylolisthesis refers to the slipping of one spinal vertebra forward on another. It usually develops in early childhood and there is a strong genetic component. Spondylolisthesis can also be caused by repetitive athletic activity like gymnastics and is often associated with stress fractures. Xrays can clearly determine if there is spondylolisthesis present and the severity of the slip. Symptoms of spondylolisthesis may include lower back pain, muscle spasms, stiffness, and difficulty standing or walking for long periods of time. In more severe cases, nerve compression can lead to more severe symptoms like radiating pain, numbness, or weakness in the legs

Where you can find support for your back pain

When you are experiencing back pain and seek assistance from a physiotherapist, it is vital that a thorough assessment is completed. Consider dropping in to see an experienced physio at Pollinate Health.

We will consider all of the elements discussed, which should give you confidence and reassurance in, not only the diagnosis and your treatment options.

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