Many people come to us for back pain carrying a whole bag of imaging: X-rays, an MRI disc, a few sheets of normal results. The first episode is often just bending down to tie a shoelace. The back locks up, and you can’t stand up straight all morning. A few days later it eases. A few months later the pain comes back, this time after a long ride. The question we hear most often is: if the scans are clear, why does my back keep hurting again and again?
The spine is only one of many places that can produce pain in the lower back.
Back pain is common and often comes back
Low back pain is the leading cause worldwide of people losing the ability to work and carry on normal daily life, according to the review by Hartvigsen and colleagues in the Lancet (2018). Most new episodes recover fairly quickly. The difficulty is that it often returns, and a small share turns into persistent pain.
Pain that is very severe from the start, or that comes with psychological stress or with pain in several places at once, is more likely to last. How the brain adjusts pain signals and how a person thinks about the pain also play a part.
Why it hurts when the scans are normal
The same review shows that in almost everyone with back pain, medicine cannot identify one specific lesion as the culprit. Only a small share have a clear disease cause, such as a vertebral fracture, cancer or a spinal infection.
An X-ray shows bone, including the curves of the spine, bone spurs, joint spaces and compression fractures. It cannot show a muscle in spasm or a nerve that is being irritated. A normal X-ray therefore only says that nothing is wrong with the bones yet. Why you hurt still has to be found.
The reverse is also true. People with no back pain at all who have a magnetic resonance imaging (MRI) scan may still happen to show a bulging disc or mild degeneration. The doctor has to set those results alongside where it hurts, the kind of pain and the physical examination before drawing a conclusion. Foster and colleagues (2018), summarizing international guidelines, advised focusing less on spinal abnormalities seen on imaging and noted that imaging is still being overused.
Sources of pain outside the spine
Fallen arches in the feet can force the spine to change its posture to keep balance. Glasses with the wrong prescription or a habit of clenching the jaw act in a similar way, and we have written about that mechanism in detail in Neck, shoulder and back pain that never goes away: where it hurts may not be where the problem is.
Surgical scars on the abdomen and back
The abdominal and back muscles hold up the trunk together, like the two walls of a cylinder. An old surgical incision on the abdomen (a cesarean section, an appendectomy, an inguinal hernia repair) or on the back can affect how these two muscle groups work together. Few people bring up an operation from ten years ago when they come in for back pain, because they don’t usually think it is related. That is why we ask about it, look at the scar and check whether the scar area is linked to the pain.
Long hours of sitting and poor sleep
Eight or nine hours at the computer, then more sitting on the ride home: the back and hip muscles hold almost the same position all day. The muscles slowly tire and stiffen, even if you sit fairly straight.
Sleep also needs careful questions, because pain wakes people in the night, and with broken sleep the muscles never get a chance to fully relax. Psychological stress also makes back pain more likely to last, and people under long-term stress often tense their back muscles without noticing (how stress affects the body). If you often get back muscle cramps at night or calf cramps, the doctor also considers magnesium deficiency.
The lower back in traditional medicine
The Su Wen (素问 / 素問, Basic Questions) says “the lower back is the residence of the Kidney” (腰者，肾之府 / 腰者，腎之府, yāo zhě, shèn zhī fǔ). The common saying that back pain means weak kidneys comes from here.
That is only partly true. The Kidney in traditional medicine is linked with essence and qi (精气 / 精氣, jīng qì), with the bones and marrow, and with stamina as we age; it is different from the kidney you see on an ultrasound, and not everyone with back pain has a Kidney problem. Pain from cold and dampness gets worse when it rains. Pain from blood stasis (血瘀, xuè yū) after an injury stays fixed in one spot and is sharp when pressed. Kidney deficiency (肾虚 / 腎虛, shèn xū) brings a dull ache with tired knees, and it eases with rest. That is why two people with back pain may receive two different prescriptions.
When to go to the emergency department or see a doctor soon
Back pain rarely signals a serious illness, but it can. The serious spinal conditions to keep in mind are cauda equina syndrome (compression of the bundle of nerve roots at the lower end of the spinal cord), cancer, vertebral fractures and spinal infection. The international consensus framework by Finucane and colleagues (2020) notes that they are rare, but the consequences are serious if they are found late.
Go to the emergency department right away
- Numbness around the anus, the genitals and the inner thighs (the area that touches a saddle, often called the saddle area);
- Being unable to pass urine, or losing control of your bladder or bowels;
- One or both legs getting weaker, tripping often when walking, or finding it harder to lift your foot day by day.
See a doctor within a few days
- Back pain with a fever;
- Weight loss with no clear reason;
- Past treatment for cancer;
- Pain after a fall or an injury, especially in older adults or people known to have osteoporosis;
- Pain that gets worse at night and doesn’t ease with rest;
- Pain spreading down the leg below the knee, with numbness or weakness in the leg.
Yusuf and colleagues (2019) pooled 40 studies with more than 2,200 cases of spinal infection and found that only just over half had a fever. Having no fever therefore does not rule out infection, especially in people with diabetes or a weakened immune system. A single sign on its own does not settle anything, but you should let a doctor examine you in person.
What the doctor checks when you come to Tam Duc Clinic
The first visit takes about 30–45 minutes and begins with questions: how the pain started, which movements make it worse, how long you sit each day, what operations you have had, how you sleep and what medicines you are taking.
The modern medical examination includes watching how you stand and walk; asking you to bend forward, lean back, bend sideways and twist your trunk; raising each leg straight while you lie on your back to see whether a nerve root is irritated; and checking tendon reflexes, skin sensation and the strength of both legs. Alongside this, the doctor carries out the four examinations of traditional medicine: looking, listening, asking and taking the pulse.
At our clinic, we use Applied Kinesiology muscle testing. You place your hand on the suspected area, for example an old surgical scar, and the doctor compares the strength of a muscle before and after the touch. Muscle testing adds one more layer of information; imaging and lab tests remain the foundation for any conclusion (Why the doctor tests your muscles, even when your arm is strong).
When the examination suggests that more information is needed, the doctor will recommend:
- X-rays when the bones need to be checked, for example if a compression fracture or a slipped vertebra (spondylolisthesis) is suspected;
- MRI when nerve compression is suspected or there are warning signs, because MRI can show the discs, nerve roots and soft tissues;
- Blood tests when an infection or an inflammatory disease is suspected;
- Electromyography (EMG) when it is necessary to confirm whether a nerve root is being compressed.
Treatment at the clinic
Acupuncture and moxibustion
For long-lasting musculoskeletal pain, acupuncture relieves pain more clearly than sham acupuncture, and the effect is still there after one year (Vickers and colleagues, 2018). People whose pain gets worse in cold, damp weather receive moxibustion (warming points with burning mugwort) to warm the lower back, done by the doctor personally.
Herbal decoctions
The herbal decoction is modified, with herbs added or removed to suit each person’s type of back pain, and it can be cooked for you at the clinic. If you take blood thinners or aspirin, tell the doctor from the start. These are the medicines that most often interact with herbs (Ulbricht and colleagues, 2008).
Micronutrients and exercises
If tests or the examination show a micronutrient deficiency, the doctor adjusts your diet first. Supplements, when used, come with a clear dose and duration. You will also be shown a few exercises within your ability for the abdominal, back and hip muscles, which you try at the clinic before doing them at home.
What you can do at home
International guidelines put returning to normal activities and staying active first (Foster and colleagues, 2018). Grandparents often advise lying still on a hard wooden bed. Lying down for a few hours when the pain is acute is fine, but lying down for days on end makes the muscles weaker and stiffer. Once your back feels a little better, walk slowly every day at a level that doesn’t clearly increase the pain, and when you sit at work, get up and move around every so often. If every movement causes severe pain, you should see a doctor.
Frequently asked questions
My back pain just started. Do I need a scan right away?
Usually not, if you have none of the signs listed under going to the emergency department or seeing a doctor soon. The doctor examines you first and orders imaging only when the result could change how you are treated.
What about back pain during pregnancy or after giving birth?
You should see a doctor rather than using painkillers or topical creams on your own. The clinic does not use acupuncture needles while you are pregnant. During pregnancy and while breastfeeding, the doctor considers each herb individually.
Worth keeping
- For one week, write down when you go to bed, when you wake up and how many times pain wakes you;
- List your past operations, including a cesarean section or an appendectomy from many years ago;
- Put your X-rays, MRI disc and old results together in one bag to bring to your visit;
- The three signs that need emergency care right away are numbness in the saddle area, problems controlling your bladder or bowels, and legs getting weaker.
If your back pain has come back many times, it is worth having one thorough examination that covers both the spine and other areas (Our treatment methods).
The medical content of this article is overseen by Dr. Dinh Ngoc Duc (MD, MSc in Traditional Medicine).
References
- Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet. 2018;391(10137):2356-2367. https://doi.org/10.1016/S0140-6736(18)30480-X
- Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018;391(10137):2368-2383. https://doi.org/10.1016/S0140-6736(18)30489-6
- Finucane LM, Downie A, Mercer C, et al. International framework for red flags for potential serious spinal pathologies. J Orthop Sports Phys Ther. 2020;50(7):350-372. https://doi.org/10.2519/jospt.2020.9971
- Yusuf M, Finucane L, Selfe J. Red flags for the early detection of spinal infection in back pain patients. BMC Musculoskelet Disord. 2019;20(1):606. https://doi.org/10.1186/s12891-019-2949-6
- Vickers AJ, Vertosick EA, Lewith G, et al. Acupuncture for chronic pain: update of an individual patient data meta-analysis. J Pain. 2018;19(5):455-474. https://doi.org/10.1016/j.jpain.2017.11.005
- Ulbricht C, et al. Clinical evidence of herb-drug interactions: a systematic review by the Natural Standard Research Collaboration. Curr Drug Metab. 2008;9(10):1063-1120. https://doi.org/10.2174/138920008786927785
