Identifying the Underlying Cause of Your Back Pain
In order to find relief from your back pain, you first need to understand 1) what type of back pain you have and 2) what is causing this pain. There are many different causes of back pain, but I have found that there are four broad categories of back pain which most people (>90%) fall into.
Four types of back pain:
- Muscle Pain
- Joint Pain
- Nerve Pain
- Brain Pain
If you can identify which kind of pain you have out of these four categories, not only will you understand the cause of your pain, but you will also be able to better navigate the treatment options that are available.
For example, if you know that your back pain is primarily muscle pain, you can focus on certain exercises and supplements that have been shown to help as well as certain medications or lifestyle modifications.
The problem with low back pain (and many other pain disorders) is that most people and most doctors consider low back pain a diagnosis all on its own. Take a look at a common diagnosis for back pain called “lumbago.” This word simply means low back pain. There is no underlying cause that is identified, yet this word can be used as a diagnosis. When we focus on the symptom (back pain) itself as the diagnosis, our goal becomes to treat the symptom and not the underlying cause. Treating the pain will not alleviate the cause of the low back pain, it will just reduce the symptom of pain. In order to create longer lasting relief or more impactful relief, we need to understand what the actual cause of the pain is.
There are some ways to accomplish this, and I will walk you through my own personal way of accomplishing this with my patients.
Pain Location: Radicular vs Axial
The first thing I try to understand is the location of the pain. Is the low back pain primarily above the belt line, at the belt line, or below the belt line.
The next thing I try to understand is if the pain radiates into the leg or not. If the pain radiates into the leg, we call this “radicular” pain, and if it doesn’t, we call this “axial” pain.
In other words, if you have low back pain with no leg pain, it’s called axial low back pain. However, if you have low back pain with leg pain, it’s called radicular pain.
Once you can establish if you have axial or radicular pain, it becomes easier to narrow down which of the four pain types you have.
If you have radicular pain, it is unlikely that the primary cause of your pain is muscle or joint – it is more likely that it’s nerve pain. This is because nerves from your legs travel up through your back within the spinal cord to get to your brain – and this is where your body perceives pain.
When the pain travels from our back down to our legs, the pain travels along what we call a dermatomal distribution. The dermatome map (see here) shows you where individual nerve roots give sensation in our body. For example, if you look at the L5 dermatome and you realize that you have pain in this same area, then it is likely that you have nerve pain stemming from the L5 nerve.
If you have nerve pain, there are a few common causes that we will delve into. Once you understand the causes you can start to think of the most effective treatment options.
Coming back to the other causes of low back pain. So let’s say that you realize that you just have low back pain with no leg pain. It is very likely that the cause of your pain is either muscle, joint, or brain pain. For now, let’s focus on muscle pain or joint pain.
Muscle pain is the most common cause of low back pain and for the purpose of keeping things simple, I will include muscles and ligaments in this category. When these soft tissue structures are strained or knotted up, they can be a big source of low back pain.
There are certain things that people tell me that help me realize that they have muscle pain as the primary underlying cause of their pain. For example, when people tell me their low back pain is worse as the day goes on (as opposed to being worse in the morning) then it can be a big clue that the pain is muscle pain. This is because muscles get tired as the day goes on. Another clue is that many patients with muscle pain get muscle spasms in their low back or they have knots in their low back called trigger points. It can be very difficult for people with muscle pain to get a good night’s sleep as often times it is hard to find a comfortable position and the pain may keep them awake.
There are specific kinds of muscle pain syndromes that cause low back or buttock pain including myofascial pain, pifiromis syndrome, and ligamentous pain.
Sadly, muscle pain is so common that even people with nerve or joint pain may have muscle pain in addition to these underlying pain causes.
Let’s say that you don’t think your pain falls into the muscle pain category. You don’t have any tender trigger points (or knots) in your low back. The pain isn’t worse at the end of the day. It’s not hard to sleep or find a comfortable position. You don’t have any muscle spasms, etc. Then perhaps you have joint pain.
Typically, when people have joint pain in their low backs, it is due to one of two different joints: the facet joint and the sacroiliac joint. The facet joints are located at and above the belt line and the sacroiliac joints are located at and below the belt line. All people will get arthritis in these joints as we age. There are certain clues that tell me if a patient more likely than not has joint pain as the underlying cause of their low back pain. For example, if they have pain that is worse in the morning, or pain with twisting and turning, or pain when getting up from a sitting position – these scenarios are very common for people with joint pain.
If your pain gets better as the day progresses it is likely that your low back pain is due to joint pain. This is because your joints produce synovial fluid with movement. This fluid lubricates the joints and makes them less painful.
If you think you have low back pain that is due to joint pain, but you’re not sure if it is facet joint pain or sacroiliac joint pain consider the following. Most of the time, if your low back pain is primarily below the belt line, your pain is secondary to sacroiliac joint pain. Whereas if your low back pain is primarily above the belt line, your pain is secondary to facet joint pain. Sometimes this information alone is not enough because joint pain can cause some pain to radiate. For example, people with facet joint pain often have low back pain above the belt line with pain that can extend into the upper buttocks. And similarly, people with sacroiliac joint pain often have low back pain below the belt line with pain that can extend into the upper posterior thighs.
There are some specific maneuvers you could perform to try and see which of these two joints is more responsible for your pain.
Unfortunately, treating low back pain can be challenging for many doctors because they are not trained in the above categorization framework. They may also believe that back pain is a part of getting older or that it will resolve itself in a few weeks. Low back pain can be managed if you can first identify which of the four categories it belongs too.
The one category I haven’t talked about yet is brain pain. I know it sounds weird that brain pain could be a cause of low back pain, but it all makes sense once you understand how pain is generated. What I mean by that is that all pain is produced by your brain. For example, when you stub your toe, the nerves in your toe are sending signals to your spinal cord and into your brain. There in your brain you are told, “hey you stubbed your toe, it’s going to hurt for a bit.” This signaling system is important because it’s how your brain tells you to respond to potentially dangerous situations. In the same way the brain tells you about pain, it’s also got some signals it sends back down to the spinal cord to help your body calm the pain down and not freak out unnecessarily. When someone has Brain Pain, these two signaling systems (the pain being detected in the toe and the brain telling the spinal cord it’s not a big deal) are not working properly. The end result is that a person can become very sensitive to pain and not have the ability to shut that pain down like a person without brain pain.
People with Brain Pain feel pain from things that would not otherwise cause pain. They have a high pain tolerance (because they live with pain all the time) but a low pain threshold (because a lot of things hurt them).
Many times people with Brain Pain will have low back pain that is resistant to all other kinds of treatment. And this is because the treatments they have pursued have not focused on the Brain, but rather the muscles, joints, or nerves.
Usually, when I meet these people and I diagnose them with Brain Pain (Fibromyalgia, Central Sensitization etc.) everything starts to click and they realize that what they have been experiencing is not something foreign or unique. There is an “aha” moment and they realize that they are not alone. From there, we go down the path of treating their Brain in order to treat their low back pain.
So what type of back pain do you think you have:
It is possible to have more than one of the above causes, but try for the sake of simplicity to choose the one that fits you the best.
Step 2: Is It an Emergency?
Next up (and most importantly) you need to be able to identify if you pain is an emergency and something you should address immediately.