Your Back Hurts—But Is Your Spine the Problem?
If your back hurts, it’s natural to assume that your pain is coming from your spine. But what if your hip, nerves, muscles, or even the way your body is moving is the real reason why you are experiencing pain? During a physical therapy appointment, our job is to tease out where your pain is truly coming from and differentiate between back pain that is truly coming from your spine vs. pain that is coming from somewhere else. Your back hurts, but is your spine the problem?
What Does “Where Is My Pain Coming From?” Actually Mean?
When you come in for a physical therapy evaluation, our job is not just to find the spot that hurts, but to dive deeper and look at your body as a whole. Yes, we do want to know where your pain is located, but we also want to know more about your symptoms. One thing we want to know is what changes your symptoms for better or worse.
Does bending forward or arching backwards change your symptoms, does rotating or bending left and right change things, does lying down feel good, or does that make things worse and so on. Finally, we want to take a look at how you move, how much mobility you have through your joints, how strong are the muscles around those joints, is there something going on with your nerves in that area, was there some sort of injury to the tissues where your pain is, and anything else that we think may be relevant to understanding what is going on.
Your Spine May Be the Source, But It Isn’t the Only Possibility
There are a few usual suspects when it comes to back pain: it could be coming from your spine, it could be coming from your hips, from your sacroiliac or SI joints, from the nerves that exit your spine or your nervous system as a whole, or it could be coming from somewhere else like muscles, ligaments, or tendons that are sending pain to your back.
The Lumbar Spine
Your lumbar spine is made up of vertebrae (the bones in your spine); discs between the vertebrae that cushion movement; ligaments and muscles that surround and support your spine; and nerves that extend to your muscles to help you move and feel things. An issue in any of these areas can lead to pain and present differently. We perform different tests and ask key questions to help determine whether one of these areas is causing your pain.
Sometimes people think that the best way to learn what is going on with your spine is to get imaging like an X-ray or MRI. This can sometimes be helpful for us to determine if there is a fracture or to look at the state of your spine. However, what your spine looks like does not always correlate to how it feels. If we were to take a room full of people without back pain and get an MRI of each of their spines, we would see some disc herniations or compressions, some pinched nerves, some bone spurs, or other findings that are insignificant because they are not experiencing pain.
All that is said to reassure you that if you get an MRI result that sounds scary, it does not mean that you will be in pain forever or that you need surgery. You could be like those people who have a “bad” MRI, but are pain-free. This is why it is important to have a thorough physical examination to determine where your pain is truly coming from.
The Hip
In many cases, “low back pain” is actually coming from the hip. A good spine examination should typically involve looking at the hip as a source of pain instead of just looking at the low back. One thing we usually check is the strength of the muscles around your hip. Weakness in this area can lead to changes in your daily movement patterns that could be contributing to your pain. Similarly, if you lack range of motion through your hips, you may be compensating with more back movements that could be leading to increased pain. So if you are having symptoms like buttock pain, groin pain, thigh pain, or pain with walking, squatting, putting on your shoes, or getting in/out of the car, your issues may be coming from your hips.
The Sacroiliac or SI joint Region
Your sacroiliac joints are located between your sacrum and your two pelvic bones down towards the bottom of your spine. Pain in this region will be below your spine, closer to your buttocks or near your pelvis, and may be triggered by transitional movements like getting out of your car, getting up from a chair, getting up out of bed, or other similar movements. It can be hard to determine if a person’s pain is truly coming from their SI joint or from another structure; therefore, if your PT suspects that pain is coming from this area, they will use a cluster of tests to determine the cause of your pain.
The Nervous System
Does your back pain also come along with symptoms down the back of your leg, into your foot, or do you ever feel weakness, numbness, or tingling? If this sounds like you, then you might have something irritating or pinching a nerve that is contributing to your symptoms. If your PT suspects that there is some nerve involvement, your therapist may look at your reflexes, check your sensation, look at specific muscles for weakness, and ask you about where you feel your symptoms, what makes them better, and what makes them worse. Knowing if your pain is related to nerves is crucial for your PT as treatment is different for nerve related issues compared to pain coming from something else.
Muscle and Other Soft Tissues
In many cases, pain in the low back region can be coming from muscles or tendons along your low back, glutes, hips, abdominals, or legs. During the examination, we will look at the strength of your muscles, but your therapist may also look at balance, coordination, endurance, and how your muscles function during everyday activities like squatting or lifting. We may also dive into how much load your muscles and tendons can tolerate and how sensitive your muscles can be. All of these are just pieces to the puzzle that helps us to understand your pain.
Referred Pain
The human body can be very tricky to understand for many reasons, but one that is related to the topic of low back pain is referred pain. This is pain that is stemming from one location but is felt in another location. Certain spinal structures can refer pain down to the buttock or into the leg; certain hip issues can lead to symptoms in the back, and there are other medical conditions related to internal organs that can present like back pain. Therefore, it is important for your therapist to understand your past medical history and for a thorough physical exam to be performed to ensure we are not missing any red flags.
What About Pain That Isn’t Coming From the Musculoskeletal System?
As I mentioned above, there are times when “low back pain” is actually related to an internal organ or is caused by something more serious that needs to be managed by your primary care physician and not your physical therapist. If you have any of the symptoms noted below you may be referred by your therapist to your doctor or potentially to the emergency room, depending on what they find or how intense your symptoms are.
RED FLAGS NOT TO MISS:
Significant or unexplained trauma, bruising, bleeding, etc.
Fever or systemic illness
Unexplained weight loss
A history of cancer
Progressive loss of strength or balance leading to unsteadiness or falls
New changes to your bowel or bladder function
Numbness around your groin area
Intense pain or any other symptoms that rapidly get worse
So What Happens During a Spine PT Evaluation?
Here is an idea of what an evaluation will look like for someone coming in for back pain.
Step 1: Your History
Your therapist may ask some of the following:
When did it start?
Where do you feel it?
Does it travel?
What makes it worse?
What makes it better?
Activities you are struggling with?
Have you had previous episodes?
What treatments have you already tried?
Sometimes this information alone can cue us in to where your pain is coming from and where we need to dig deeper.
Step 2: Movement Assessment
Next, your therapist may look at:
Spine movement
Hip movement
Squatting
Walking
Bending
Lifting
Other movements relevant to your goals
This helps us to see how you move, which can help us see compensations and weaknesses that we want to take a deeper look at or address.
Step 3: Strength and Neurological Examination
Depending on what symptoms you are having, your therapist may also look at:
Stength
Sensation
Reflexes
Nerve tension
Coordination and balance
Functional capacity
Step 4: Putting it all together
By this point, your therapist will have collected information that should help them to come to some sort of diagnosis or at least know what limitations they want to improve to help you function better. We aren’t just looking at what hurts; we want to know why it hurts, what is leading to the pain, and what we can do to change it.
Why Does This All Matter
No two people are the same, which means that no two evaluations or treatment plans are the same. Depending on what is causing your pain, what your symptoms are, or what goals you have will change the treatment your PT provides. Typically, PT treatment will involve some, if not all, of the following:
Progressive strengthening
Mobility exercises
Neuromuscular retraining
Education on various topics
Activity modification
Graded exposure to feared movements
Manual therapy when appropriate
Return-to-work or sport progression
When Should You See a Physical Therapist?
If you are having any of those red flag symptoms mentioned in section 4, you should seek out medical advise from your primary care physician or go to urgent care or ER depending on the intensity of your symptoms. If you aren’t having any of those red flag symptoms, then here are some reasons why you should consider seeing a physical therapist:
Back pain is interfering with daily activities
Symptoms keep coming back
Avoiding exercise because of pain
Unsure what movements are safe
Persistent hip/back/buttock symptoms
Want to return to lifting, running, sports, or work
Tried treating the problem yourself without meaningful improvement
Don’t Just Treat the Place That Hurts
Back pain is a symptom, not necessarily a diagnosis. A thorough PT evaluation considers the spine alongside the hips, pelvis, nervous system, muscles, movement patterns, and the individual’s goals and history. So, if you’re dealing with persistent or recurring back pain and aren’t sure what’s causing it, a physical therapist can help determine what may be contributing to your symptoms and develop a treatment plan based on your specific needs.
