Do you have lower back pain? If not, you probably will, and sooner than you think. It’s one of the most common afflictions in the U.S., with roughly 85 percent of the population suffering from back pain at some point in their lives. Back pain is also the second most common reason for seeing a doctor in the U.S., following coughs and other respiratory infections. These statistics are similar in other countries.
95 percent of back pain cases (such as muscle spasms or a dull ache in the lower back) are what experts call non-specific. That means that the exact cause is usually elusive and cannot be attributable to an identifiable condition (such as infection, tumor, arthritis, or inflammation, which are specific cases, and the minority). With non-specific low back pain (LBP) being so common and so elusive, it has become a big business with Americans spending at least $50 billion each year on potential treatment and prevention strategies.
That can be a problem. Anytime you talk about an amount of money that large, you’re bound to attract experts – both legitimate and those who are, well, full of it – who claim they a) know the exact cause of your lower back pain, and b) have the cure for it.
You shouldn’t believe them – at least, not right away.
Question the Answers
Consider this: Back pain is most commonly blamed on things like herniated (slipped) lumbar discs, poor postural alignment, lack of core strength, tight hamstrings or hip flexors, and being overweight. And it’s these factors that many popular treatment and prevention strategies claim to improve (or cure).
These “truths” are held as indisputable to the practitioners who promote them. They base their expertise on personal experience and anecdotal results. It’s human nature: If someone you know benefited from seeing a chiropractor, they will always (loudly) proclaim their chiropractor a genius. Same for your friends who got positive results from a doctor, physical therapist, acupuncturist, massage therapist, or personal trainer.
So what’s the problem? When you look at the research with a cold eye, the scientific validity for many of the common claims of low back pain causes and treatments is questionable. To say the least.
What does that mean for you – especially if your back hurts? It means that just because a certain practitioner claims a certain cause is your problem, and they have the perfect treatment, their cause may not be the real cause. Their cure may not be what ultimately makes your pain go away. In some cases, paying a lot of money for these treatments may not be the best option.
Here are some of the common causes of lower back pain, research that dispels many myths surrounding them, and "the takeaway" – what you should do as a result.
Myth #1: Bulging discs, vertebrae fracture and stenosis cause back pain.
BULGING DISCS: A landmark 1994 study in the New England Journal of Medicine found that 82 percent of study participants who were pain-free had positive MRI results for a lumbar disc bulge, protrusion, or extrusion. 38 percent of them had these issues at multiple lumbar levels.
A 2001 study in the Journal of Bone and Joint Surgery showed that MRI scans were not predictive of the development or duration of LBP and that individuals with the longest duration of low-back pain did not have the greatest degree of anatomical abnormality.
What does that mean? You can have disc abnormalities and have no pain. And if you have a bulging disc and back pain? The disc may not be the cause.
FRACTURED VERTEBRA: Two 2009 studies in the New England Journal of Medicine found that vertebroplasty, a risky procedure that injects an acrylic cement into bones in the spinal column to stabilize fractures caused by osteoporosis, to be no better at creating pain relief than a placebo.
SPINAL STENOSIS: While this condition has historically been thought to be an inevitable cause of LBP, a 2006 study in the Archives of Physical Medicine and Rehabilitation found that a narrowed spinal canal does not (alone) cause back pain.
THE TAKEAWAY: You are not doomed by your MRI. Many people with abnormal results are pain free. According to a 2009 research review published in The Lancet, clinicians should refrain from routine, immediate lumbar imaging in patients with LBP without features suggesting a serious underlying condition. For you, that means asking your doctor about what other diagnostic avenues he or she will use besides an MRI. Especially if you’re hearing about your MRI results and the word “surgery” comes up.
Myth #2: Spinal curvatures, pelvic tilts or leg length asymmetry cause LBP.
SPINAL CURVES: A 2008 review in the Journal of Manipulative and Physiological Therapeutics looked at more than 50 studies and found no association between measurements of spinal curves and pain.
According to Eyal Lederman, Ph.D., an osteopath and author of several manual therapy textbooks and research papers, “There is no correlation between pelvic obliquity/asymmetry and the lateral sacral base angle and LBP. But there may be an association between severe scoliosis and back pain.”
PELVIC TILT: Many health professionals believe that anterior pelvic tilt and increased lumbar lordosis indicate abdominal weakness and overly strong (or tight) hip flexors. But, according to a 2004 study in the Internet Journal of Allied Health Science and Practice, there is no relationship between lumbar lordosis and isometric strength of the trunk flexors, trunk extensors, and hip flexors and extensors. Several other studies have also had similar findings.
LEG LENGTH ASYMMETRY: According to Dr. Lederman, “Although some earlier studies suggest a correlation, more relevant are prospective studies in which no correlation was found between leg length inequality and LBP. Even patients who have acquired their leg length differences later in life as consequence of disease or surgery had a poor correlation between leg-length inequality, lumbar scoliosis and low-back disorders several years after the onset of the condition.”
THE TAKEAWAY: Many people with poor postural alignment or asymmetry have zero pain while others with better alignment suffer from chronic pain. So, automatically blaming these factors is misguided since physical imperfections seem to be normal variations, not pathology. As Mark Comerford, author of Kinetic Control: The Management of Uncontrolled Movement puts it, “There’s a big difference between dysfunction and simply a variation on normal.”
It’s more accurate to find the specific body positions (if any) that cause back pain, like standing or sitting slouched forcing your back muscles to remain contracted. Also, pain or no pain, we all tend to sit too much. Increasing glute strength and in our mid-back muscles, which are lengthened when we sit, can help us to fight the negative effects of sitting and slouching.
A helpful preventative strategy: Adding barbell and dumbbell rowing variations to your regular workout, along with squats and deadlifts, as long as you can do them pain-free.
Myth #3: Lack of core stability or poor core strength causes LBP.
CORE STABILITY: According to Comerford, “The Transverse Abdominis (TvA) has never been shown to be off or weak, even in patients with LBP. It’s only been shown to activate 50-90 milliseconds late only in people with LBP. We know through the research that the TvA timing delay is NOT the cause of the pain, but a symptom of it.”
Additionally, Stuart McGill, Ph.D. and professor of spine biomechanics at the University of Waterloo, says; “True spine stability is achieved with a balanced stiffening (co-contraction) of the entire trunk musculature, including the abdominals, the latissimus dorsi and the back extensors. Focusing on a single muscle generally results in less stability.”
CORE STRENGTH: According to Dr. McGill, “The differences between those with chronic, recurring back issues and matched asymptomatic controls,” or, people in the studies who have no pain, “have been shown to be variables other than strength or mobility.” In other words, in this research, core strength was not the cause of the sufferers’ pain.
THE TAKEAWAY: There’s no need, nor is it recommended to “draw in” your belly button during exercise or sporting activities. Core strengthening may or may not help you relieve or prevent LBP. As Comerford says, “If all back pain was due to weakness, than the strongest athletes in the world would never have pain, but they do.”
It never hurts to strengthen your core muscles along with the rest of your muscles simply for better health and performance of daily activities. But if you have lower back pain, removing certain core-centric exercises may speed your recovery.
Dr. McGill says, “The first step in any exercise progression is to remove the cause of the pain. For example, flexion-intolerant backs are very common. Eliminating spinal flexion exercises (like sit-ups, crunches, and burpees), particularly in the morning when the disks are swollen after bed rest, has proven very effective with this type of issue.”
Also, improving the quality and efficiency of how you move versus just improving strength can help you to avoid overusing your back. In other words, exercise technique and form matters, especially if you have LBP.
Myth #4: Tight hip flexors (psoas) and tight hamstrings pull on the spine and cause LBP.
PSOAS: Scientific literature reveals that psoas major is a very misunderstood muscle.
In his “Myths and Misconceptions about Psoas Major: Where is the Evidence?” Comerford states, ”There is almost no evidence for psoas being short; it does not produce significant movement in the spine; it has a significant stability role for the lumbar spine, the sacroiliac joint, and the hip; and, like the TvA, the psoas has been shown to have delayed activation in the presence of LBP.” So again, delay in psoas activation is a symptom of back pain, not a cause.
HAMSTRINGS: A 2012 study in the Journal of Electromyography and Kinesiology concluded there is no evidence to recommend passive hamstring stretching as a means of reducing LBP during prolonged standing.
Many studies have shown hamstring tightness to be related to LBP as a symptom, not the cause. According to Carl DeRosa, Ph.D. and author of Mechanical Low Back Pain, “Many people appear to have tight hamstrings. But, their hamstrings are not tight, their CNS (central nervous system) is causing them to contract their hamstrings to minimize unwanted stress and to protect their spine. You could make someone more symptomatic by stretching their hamstrings.”
Additionally, according to Dr. McGill, “The best performers in athletics have tighter hamstrings then their competitive counterparts. The typical tightness people feel in their hamstrings is actually a neural tightness, not a purely soft-tissue phenomenon.”
THE TAKEAWAY: Attempts to “release” or inhibit the Psoas through manual techniques is misguided. Stretching your hip flexors (illiacus, rectus femoris) is okay, but doing so isn’t stretching your psoas. Also, remember that tight hip flexors have not been shown to be associated with excessive lumbar lordosis, anterior pelvic tilt, or as a cause of LBP.
Dr.McGill recommends “strengthening the core muscles responsible for protecting the spine instead of stretching our hamstrings. This does not mean doing hundreds of repetitions of crunches or other spine-bending exercises since those with back issues tend to have more motion in their backs and less motion and load in their hips.”
Dr. DeRosa recommends strengthening your glutes, (which can improve hip mobility) and your lats, as those muscles can increase lumbar spine stability.
Myth #5: Being old or overweight causes LBP.
OVERWEIGHT: While it seems intuitive that LBP and excess weight could be related, a 2007 paper in the Journal of Rehabilitation Research and Development says the science cannot determine whether they are in fact directly related, under what circumstances they are related, how they become related, the strength of relationship (if one does in fact exist), and the impact of a change in one condition on the other. In other words, we don’t know for sure.
A surprising 2012 study in The Spine Journal found that cumulative or repetitive loading with higher-than-normal body mass (nearly 30 pounds on average) was not harmful to the subjects’ lumbar discs. In fact, a slight delay in L1-L4 disc degeneration was observed in the heavier men, as compared with their slimmer counterparts.
OLD AGE: In a 2009 population-based study of 34,902 Danish twins 20-71 yrs. of age, there were no meaningful differences in the frequency in LBP between younger and older individuals
Although disc degeneration is expected from around age 30 years onward, heredity plays more of a role in disc degeneration. According to, Dr. Lederman, “Research has demonstrated in twins that as much as 47–66 percent of spinal degeneration is due to heredity.”
THE TAKEAWAY: Age or being overweight isn’t a guaranteed back pain sentence. And, back pain shouldn’t be blown off as simply a side effect of these issues. Losing excess weight is always a good idea for overall health, but having LBP while overweight doesn’t mean you won’t have future bouts of back pain after losing the weight.
One thing that is certain? An awful lot of people gain weight as they age. Smart eating combined with regular exercise will help keep you fit and energetic. It just may not prevent lower back pain if you happen to be prone to it.
What to Do When Lower Back Pain Strikes
Chances are, your back will hurt at some point. But it’s a big mistake for health professionals to attempt to prevent or treat LBP based on blanket assumptions related to posture, strength, or flexibility. Instead, every back pain case should be treated and assessed individually by removing specific painful positions and movements while emphasizing pain-free exercises and activities.
The fact is, statistics show that most acute LBP begins to improve after 2 to 5 days and typically resolves itself in less than 1 month with non-steroidal anti-inflammatories (NSAIDs) and (tolerable) activities.
Does that mean you shouldn’t seek treatment when your back locks up? Of course not. Just know that it’s unrealistic to credit any one particular treatment or special exercise method as the magic cure for acute back pain. When a back pain professional says, “I know what your problem is and I know how to cure it,” listen, but be skeptical. This person may be able to help you. But when you consider the time and financial investment involved, remember the scientific facts. No one can predict how one individual will respond to one type of back pain treatment.