Back Pain Causes, Categories, Risk Factors & Red Flags|

Woman bending over her desk stretching her back

Prevalence of Back Pain

Up to 75 percent of the population experiences low back pain lasting more than one week at some point in their lives. By the age of 50 years old, about 85 – 90 percent of adults will have degenerative changes in their vertebral discs, and these changes begin to occur in the third decade (in their 30’s) of life.

Office worker with back pain from office syndrome
Office syndrome Infographics. 

In a one year period, the estimate of people with an episode of back pain is about 17 percent. Also the estimate of the people 18 to 24 years having back pain in a one year period is 13 percent.

Back pain is one of the most common medical disorders in industrialized societies. After the common cold, low back pain is the most frequent cause of lost work days in people under 45 years of age.

Some insight can be gained from Dr. Waddel who has commented on the epidemic of low back pain affecting industrialized nations. His travels to an emerging country in the Near East initially suggested that back pain was a modest problem; but when he opened a back pain clinic there, people flocked to the clinic for treatment.

Some studies state that back pain disables 5.4 million Americans each year.

Of people with new onset back pain, 70 percent will recover within one month; and 90 percent will recover in three months.

Symptoms last for greater than six months in only 4 percent of the cases; however, this group represents 85 percent of the money spent on treatment and compensation for back pain.

Only about 50 percent of people with long-standing back pain ever return to work.

By the age of 50 years, about 85-90 parent of adults will be found on autopsy to have degenerative disc disease.

Back Pain from Changes in the Lumbar Spine

The spine is a structure that connects your upper body, including your chest and arms, to your lower body consisting of your pelvis and legs.

The spine provides mobility and strength. The mobility allows you to turn, twist, and bend. The strength allows you to walk, stand and lift. Proper functioning of the spine is needed for almost all activities of daily living.

In the upright position, sitting or standing, with normal spinal curve (lordosis), the ligaments of the body maintain the spine with little need for the muscles to help. However, if the normal curve is flattened (sitting on a flat chair) or accentuated (pregnancy, beer-belly) the weight-bearing muscles must contract. This makes the joints and spine weight bearing, and these changes in body mechanics cause pain.

Back Pain Categories

Back pain can be divided into two basic categories: acute pain (new onset) and chronic pain (long-standing).

1. Acute Back Pain

Acute pain starts quickly, either immediately or a few hours after the initial injury. Acute back pain usually starts with a type of trauma, such as a fall, a motor vehicle accident, or lifting heavy objects — either once or by repetitive lifting. Acute pain usually lasts less than six weeks and goes away without the need to seek medical attention.

2. Chronic Back Pain

Chronic back pain usually comes on slowly and can last months to years. Chronic back pain has a tendency to come and go, but many authors and sufferers state the pain is never far from their minds. Most clinicians diagnose back pain as chronic only when it has been present for more than three months.

Many chronic pain sufferers state the back pain prevents them from participating in the activities they want to do. The complaint of chronic back pain is the most common reason for early social security disability in the United States.

The disability situation is so important, numerous countries and organizations have convened to discuss the problem.

Acute and Chronic Back Pain Can Be Interrelated

Acute and chronic back pain can have different ranges of severity, location, and duration, but oftentimes they are interrelated.

Often acute back pain can occur several times leading to chronic back pain; and, just as often, chronic conditions could set off the symptoms of acute bak pain.

A person with or without a history of back pain could be picking up boxes, vacuuming, working in front of a computer and twisting the body slightly. At the time, the person may not notice any change in the way his or her back feels. However, over time (sometimes long, sometimes short) these types of activities strain the muscles of the back and cause poor posture which can cause and worsen weak spots in the spine.

sitting businessman touching lower back with pained expression
office syndrome concept; businessman sitting at office desk, suffering from backache after working, touching lower back with pained expression.

Pain is the Most Important Symptom of Spinal Disease

Of the several symptoms of spinal disease —

  • pain,
  • stiffness,
  • limitation of movement, and
  • deformity — pain is considered by most to be of most importance.

Four Types of Back Pain

Four types of pain may be distinguished:

  1. Local,
  2. Referred,
  3. Radicular, and
  4. Muscular spasm.

1. Local Back Pain

Most often local pain is described as steady and aching, but it may be intermittent and sharp. It is always felt in or near the affected part of the spine. Usually there are involuntary, protective contractions or spasms of the muscles surrounding the spine.

Certain movements and postures that counteract the spasm, alter the position of the injured tissues and tend to aggravate the pain. Also, the superficial (closer to the skin) parts of the body in the injured area are tender, and direct pressure evokes pain. Muscles that are continually in reflex spasm may also become tender and sensitive to deep pressure.

2. Referred Back Pain

Referred back pain is pain projected from other parts of the spine or even other organs in the body to the spine.

Pain from the lumbar spine is usually referred or radiated to the buttocks and the back of the thighs. This is due to irritation of the lower spinal nerves.

Pain of this type is usually diffuse (wide-spread) and has a deep aching quality, as well as a more superficial projection of pain.

3. Radicular / Root Back Pain

Radicular / Root Back Pain has some of the characteristics of referred pain, but it differs in its greater intensity, further radiation, and the factors that cause it.

Coughing, sneezing, and straining characteristically evoke this type of pain. The pain is sharp, often intense, and usually superimposed on the dull ache of referred pain. It nearly always radiates from a central position close to the spine to some part of the legs.

4. Muscular Spasm Associated with Low Back Pain Disorders

Pain resulting from muscular spasm usually occurs in relation to local pain. The spam may be thought of as a protective reflex for the injured body part against harmful motion. Muscle spasm is associated with many disorders of the low back. It can distort normal posture. Long standing or sitting can give rise to dull, cramping aches from muscular spasm.

3D Man sitting on a rock next to a question mark
3D Thinking Man 

Causes of Low Back Pain

The causes of low back pain are: trauma leading to strains, degenerative changes, disc herniation, and a few others.

Trauma is Most Common Cause

Trauma is the most common cause of low back pain. This event leads to muscle strain, and these injuries will almost always heal with time.

Degenerative Low Back Syndrome — (formerly called Sacroiliac Strain)

With Degenerative Low Back Syndrome, often the symptoms of low back pain are recurrent and chronic in nature.

This type of pain is regularly made worse by bending or lifting, which suggests postural, muscular, or arthritic factors are playing a role. Degenerative Low Back Syndrome is the most common syndrome seen in orthopedic clinics. What was formerly called “sacroiliac strain” is now known to be due to, in many instances, disc disease.

Herniation of Lumbar Discs – Common in 30’s and 40’s

Herniation of lumbar discs is a major cause of severe and recurrent low back pain and leg pain. People usually experience this in their 30’s and 40’s. The cause is usually a flexion (bending) injury. However, a considerable proportion of patients do not recall any traumatic episode. If sitting makes low back pain worse in a person between the ages of 30 and 50, a herniated disc is a likely diagnosis.

Vertebral (Spine) Fractures are Common in the Elderly

Vertebral (spine) fractures are the most common type of fracture in the elderly accounting for height changes related usually to osteoporosis. These fractures are also the result of bending injuries that may occur such as a fall, an auto accident, or other violent injury. They can lead to chronic back pain.

It is noteworthy that low back pain, buttock pain, and sciatica each have large numbers of cases that are unsolvable.

Businesswoman holding pelvis, neck, back, then shoulder in pain
Businesswoman at workplace in pain with various problems:
pelvic pain, neck and shoulder pain, and back pain from working.

Risk Factors For Back Pain

Risk Factors for Back Pain:

  • Tasks that require heavy and/or repetitive lifting;
  • Exposure to vibration produced by vehicles and industrial machinery, especially prolonged driving;
  • Prolonged sitting;
  • Prolonged standing;
  • Static posture;
  • Smoking, because smoking can weaken the bones.

Diseases Which Increase Risk for Back Pain:

There are also certain diseases which place people at a high risk for back pain, such as:

  • spinal osteoarthritis,
  • spondylitis, and
  • compression fractures.

These conditions are more prevalent in the elderly; and, consequently, older people have a higher risk of developing back pain.

Back Pain Due To Leg Length Discrepancy (Scoliosis):

One of the most common postural problems leading to back pain is a leg length discrepancy which causes a pelvic tilt. When this situation becomes severe it is usually termed scoliosis. Some experts say that anyone that has broken a leg must assume they have a leg length difference, especially if a leg injury occurs during childhood, while the leg growth plates are still growing.

Tell A Doctor About Your Back Pain

The most important pieces of information concerning back pain to tell a health care provider are:

  • the onset,
  • duration,
  • quality (sharp or dull pain),
  • severity,
  • location,
  • radiation (movement of the pain from one place to another), and
  • any loss of function.

Red Flags that Back Pain Warrants Further Evaluation

Red flags that may indicate a serious problem that warrants further evaluation are:

  1. Pain at rest,
  2. no positional relief,
  3. pain that wakes you from sleep,
  4. progressive weakness in the legs,
  5. bowel and/or bladder incontinence,
  6. fevers,
  7. weight loss,
  8. history of cancer, and
  9. morning stiffness that lasts more than 30 minutes.

Treatment of Back Pain

Conservative Therapy for Back Pain

Conservative therapy for low back pain is as follows: rest for three or four days; alternate applying heat and ice; use NSAIDs (aspirin, ibuprofen. . . unless you are pregnant), or use acetaminophen (Tylenol). After a few days, try to get back to your daily routine.

Believe it or not, the more time you spend off your feet, the longer it will take your back to heal. Physical therapy and specific exercises are of good use. If the pain is not improved in a week or two, you may want to see a care-giver.

Physical Therapy for Back Pain

The key decision point in treatment of low back pain is six weeks after an injury. Back pain should spontaneously improve in this time. If not, the person with bak pain should be reassessed. Referral to physical therapy programs are helpful.

Surgery for Back Pain

Surgery should be considered a last resort for most people. Surgery may be beneficial for people who have not responded to a good, active, functional restoration program or for someone who shows signs of progressive injury.

Discuss Ways to Prevent Future Back Pain

Fortunately, most people with low back pain have a complete recovery in 3 – 4 weeks. It is important to discuss ways to prevent recurrent attacks. Areas of discussion include:

  • posture,
  • weight control,
  • exercise, and
  • work activities.

More Flexibility = Less Back Pain

People may need to modify work or play activities once an episode of back pain occurs. Certain factors such as improper lifting technique, poor posture while sitting and standing, and prolonged sitting may predispose people to injury.

Cartoon of woman sitting in office chair stretching her arms over her head
Pretty blonde woman doing exercise in the office chair. Business woman in healthy warm up pose. Vector illustration.

A good regimen to follow to reduce existing back pain or prevent future back pain is a daily routine of stretching. The more flexible a person is, the less likely they are to experience pain.

Links to more info about back pain

For more information about back pain and musculoskeletal pain, you can visit the National Institutes of Health, National Institute of Arthritis and Musculoskeletal and Skin Diseases at

For more information about back pain, check out this link to the Mayo Clinic:…/syc-20369906

You can also check out the WebMD Back Pain Health Center:

Woman stretching legs and doing push-ups at desk
A young woman in the office performs exercises to strengthen the arms and legs using the desktop. Isolated on white background.

Quotes from the Literature:

1.  Back Pain is the most common Worker’s Compensation Claim in the U.S. –  Am. J. Ind. Med. 28:602, 1995

“Back pain is the most frequently filed worker’s compensation claim in the United States. The total lost on back pain was $50 – $100 billion in 1990. National estimates . . . representing 22.4 million cases and a prevalence rate of 17.6 percent during the one year period were studied. We estimate that a total of 149.1 million workdays were lost (due to back pain) in the one year period.”

Am. J. Ind. Med. 28:602, 1995

Back pain is not limited to the older worker – Am. J. Ind. Med. 20:602, 1995

“People between 25 – 40 years old had between 16 – 18 incidence of back pain. The prevalence of back pain in the youngest group studied (18-24 years old) was 13 percent for females and males.

“Our report indicated that about 50 percent of those who had experienced a back pain episode did not seek medical attention. Therefore, compensated cases are a relatively small part of all back pain patients and are not likely to be representative of all workers with back pain.”

“We conclude that back pain is not a health problem limited to the older worker.”

Am. J. Ind. Med. 20:602, 1995

2.  Back pain affects 1/5 of U.S. Workers – Bureau of the Census, 1993

“Our analysis shows that the health and economic impact of back pain have been previously underestimated. Nearly one fifth (1/5) of U.S. workers may suffer an episode of back pain for a week or more during a one year period, and workdays lost by cases alone may cost more than $13.3 billion.”

Bureau of the Census, 1993

3.  Back pain is the 5th most common reason for doctor visits – National Ambulatory Medical Care Survey, 1995

“Mechanical low back pain is the fifth (5th) most common reason for all physician office visits. Nonspecific low back pain was the most common diagnosis (56.8 percent) of these cases.”

National Ambulatory Medical Care Survey, 1995

4.  Low back disorders are common in all societies – Orthopedic Clinics of North America, Vol. 22, No. 2, April 1991:

“Today major literature from virtually every developed country of the world describes prevalence, incidence, risk factors, and natural history of low back pain and sciatica.”

“The basic premise of this article is that low back disorders are extremely prevalent in all societies, and probably have not increased substantially over the past two decades. What has increased is the rate of disability, the reasons for which are uncertain. Not only has this phenomenon heightened the awareness of low back pain, but it has lead to an explosion in costs.”

“The future challenge if costs are to be controlled, appears to lie squarely with prevention and optimum management of disability, rather than perpetrating a myth that low back pain is a serious health disorder.”

“An Overview of the Incidences and Costs of Low Back Pain,” by John W. Frymoyer, M.D., et al. 

5.  Tips for recovery from low back pain – National Health and Nutrition Examination Survey, 1995

“For a rapid recovery from low back pain, maintain minimal bed rest, make changes in the workplace, and follow simple educational tips to avoid re-injury.”

National Health and Nutrition Examination Survey, 1995

6.  “Classifications of low back pain with or with sciatica” –  lists the following types of back pain / sciatica:

“Transient – Self-limited; duration is hours to days; comes to medical attention when episodic (when an episode of pain occurs).

“Acute – Self-limited, but protracted; duration is days to weeks; often seen by physicians; treatment is symptomatic; most recover spontaneously; evaluation and treatment require severe symptoms.

“Persistent – Lasts more than 3-6 months; does not relent with time; high correlation with spondylitis (degeneration of the spine) disease; surgical intervention occurs mostly in this group.

“Chronic Pain Syndrome – Lasts more than 6 months; worsens with time; associated with major co-morbidities (other conditions that also cause the same problem).”

Textbook of Pain, 4th Edition, 1999, Chronic Back Pain, by Donlin M. Long

7.  90% of budget spent on 10% of back pain patients – “Approach to the Patent with Back Pain,” O’Sullivan

“Low back pain is becoming a growing problem in industrialized countries, accounting for up to $50 billion spent per year in the U.S. alone. 90 percent of the budget is spent on 10 percent of those patients who have persistent pain lasting longer than three months.”

“In 85 percent of cases, an underlying cause for low back pain is not established.”

“It is easy to become confused by conflicting diagnoses and different terms used by various care-givers, such as medical doctors, chiropractors, osteopaths, and physiotherapists.”

“It is important to note that hurt does not equal harm.”

Kelley’s Textbook of Internal Medicine, Fourth Edition, 2000, Chapter 171: “Approach to the Patient with Back Pain,” by Glen S. O’Sullivan

Back pain is the most common complaint in developed countries – Bigos, et al., 1994 

“Chronic back pain, often with associated leg pain, is the most common medical complaint in developed countries.”

“In spite of the obvious importance of back pain as a complaint, the problem is poorly understood; and few treatments have been validated.”

Bigos, et al., 1994

Risk factors for back pain can be minimized – Cholewicki and McGill – 1996

“There is reasonable evidence that overt instability while sitting and standing causes back pain and elimination of that instability will reduce pain.”

Cholewicki and McGill -1996
Office worker with back pain, neck pain, shoulder pain, and headache
Incorrect posture and office syndrome infographic,vector illustration of incorrect sitting posture, driving posture, bending forward and down while using the smart phone, and incorrect lifting.

Good posture can minimize risk of back pain

“Back pain is the leading cause of disability for people under the age of 45, with 80 percent of all Americans suffering from back pain at some point in their lives.”

“Most people are completely unaware of all the things they habitually do that contribute to this problem.

“What set it up (back pain) to begin with, though, was some sort of postural dysfunction that already existed and actually created a weak spot in the spine.”

Bell and Rothman, 1984; Basmajian, 1989

Every move you make can cause or prevent back pain 

“The spine affects and is affected by every movement your body makes. The way you stand, the way you sit, the way you move, the way you pick up and carry objects — all these things have the potential to help or hurt your back.”

Mary Pullig-Schatz, M.D., Medical Staff President at Centennial Medical Center in Nashville, Tennessee

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