There's No Such Thing as 'General' Lower Back Pain

When a new client tells me they have "lower back pain", they have told me almost nothing. It is the physical equivalent of saying "my stomach hurts". The phrase covers a dozen different problems with different drivers, different behaviours, and completely different fixes. The habit of treating them all as one thing, with the same generic advice to rest, stretch and brace the core, is a big part of why so many people carry the same nagging back for years.

Lower back pain is a symptom. It is not a diagnosis. Once you start treating it as a set of distinct, recognisable patterns, it stops being a mystery you live with and becomes a problem you can solve.

"Non-specific" doesn't mean "nobody knows"

Here is where most of the confusion starts. The Lancet's 2018 series on low back pain, the most authoritative summary of the evidence we have, concluded that in the large majority of cases it is not possible to identify a specific structure generating the pain (Hartvigsen et al., 2018). The label clinicians use for this is "non-specific" low back pain, and it is the most common diagnosis on the planet for the single leading cause of disability worldwide.

That word, "non-specific", does real damage, because patients hear it as "they don't know what is wrong with me" and some clinicians use it as "there is nothing to be done". Both readings are wrong. Non-specific does not mean random, and it does not mean unfixable. It means there is no single torn or broken part to point at on a scan. What there almost always is, is a pattern: a way the pain behaves, a set of movements that wind it up and a set that calm it down. That pattern is the diagnosis that matters, and it is the one a scan will never give you.

Sort by how it behaves, not by what a scan says

Forget the anatomical labels for a moment. The most useful way to sort your own back pain is by what it does. Four behaviours cover most people.

The back that hates bending and sitting. Worst when you slump in a chair, bend forward, or climb out of the car after a long drive, and better when you stand up and walk. This is the most common mechanical pattern in younger and desk-bound people, and it usually responds to movement in the opposite direction to the one that hurts.

The back that hates standing and arching. The mirror image: worst with prolonged standing, walking or leaning backwards, and eased by sitting or bending forward. In older clients this often points toward the joints at the back of the spine or a narrowing of the canal they sit in, and the management is almost the reverse of the pattern above. This is exactly why generic "do these three stretches" advice helps one person and flares another: the same exercise is medicine for one pattern and poison for the other.

The pain that travels down the leg. The one to take more seriously. Pain that does not stay in the back but shoots, burns or tingles into the buttock and past the knee, sometimes with numbness or weakness in the foot. This is radicular pain, an irritated nerve root, what most people call sciatica. It often settles with time and the right loading, but it behaves differently from axial back pain and should be handled as its own thing.

The pain that has outstayed every structure. The back that hurts almost everywhere, most of the time, often for months or years, with no clean movement that reliably makes it better or worse. Here the driver is rarely a single tissue. Persistent pain is shaped by sleep, stress, fear of movement and loss of physical capacity as much as by anything mechanical, which is why the Lancet authors are blunt that it has to be managed as a biopsychosocial problem, not a plumbing fault (Foster et al., 2018).

For the first three patterns, there is usually a directional preference: one direction of movement that reliably eases the pain and pulls it back toward the spine. This matters far more than it sounds. In a randomised trial of 312 patients, those given exercises matched to their directional preference were 7.8 times more likely to have a good outcome than those given unmatched or generic exercises (Long et al., 2004). Same person, same back, wildly different result, purely from matching the movement to the pattern.

The scan trap

When a back hurts for more than a few weeks, the reflex is to get an MRI. The report comes back full of words that sound like a structural emergency: disc bulge, degeneration, desiccation, protrusion. Here is the part nobody warns you about.

Brinjikji et al. (2015) pooled spinal imaging from thousands of people with no back pain at all. Among pain-free 20-year-olds, 37% already had disc degeneration and 30% had a disc bulge. By age 80 those figures were 96% and 84% (Brinjikji et al., 2015). Disc bulges and degeneration are, for the most part, the wrinkles and grey hair of the spine: near-universal, age-related, and present in enormous numbers of people who feel completely fine. Finding one on your scan tells you very little about why you actually hurt, and a frightening report can do real harm by convincing a fixable back that it is fragile. Hurt does not equal harm.

The root causes that actually matter

Strip away the mysticism about "weak cores" and crooked posture and the honest list of what drives most mechanical back pain is shorter and less exotic. A body that has lost the capacity to tolerate the loads being asked of it, long hours held in one position without variety and sudden spikes in load it was not prepared for. Sitting on top of those are the amplifiers: poor sleep, high stress and a learned fear of movement, each of which turns the volume up on pain the tissues could otherwise handle. Notice that neither the disc nor the muscles is the villain here. Capacity and load are.

What actually helps

The single most robust finding in this entire field is dull and inconvenient: movement and graded loading beat rest. The 2021 Cochrane review of exercise for chronic low back pain pooled 249 trials, one of the largest reviews Cochrane has ever produced, and found exercise meaningfully reduces pain and disability compared with usual care, no care or placebo (Hayden et al., 2021).

What it does not find is a magic exercise. When researchers compared the popular methods head to head, motor-control "core" exercise was no better than other forms of exercise for chronic back pain (Saragiotto et al., 2016). The best exercise is not Pilates or McKenzie or dead bugs in the abstract. It is the one matched to your pattern that you will actually do consistently, built with the same structured, progressive approach any other training goal deserves. And for the right person, getting genuinely strong under load is rehabilitation, not risk: an eight-week programme built around the deadlift reduced pain and disability in people with a mechanical pattern of low back pain (Berglund et al., 2015). The exercise so many backs are told to fear is, for many of them, the cure.

When it isn't a training problem

A small number of presentations are not movement problems and need a doctor promptly, not a programme: leg weakness or numbness that is spreading, any loss of bladder or bowel control, numbness around the saddle or groin, back pain with fever or unexplained weight loss, or pain that began after a serious fall or crash. These are rare. If none of them apply to you, and for the overwhelming majority they will not, then what you are dealing with is a movement problem with a movement solution.

What this means for you

Stop asking "what is the damage" and start asking "what is the pattern". Notice which direction eases your pain and which winds it up. Stop letting a scan that would look the same in a pain-free stranger dictate how you move. Load the direction that calms it, rebuild the capacity you lost, and respect that sleep and stress are part of the picture. Most backs do not need protecting. They need training.

Your back is not broken, and it is not a mystery. It is a pattern. Find the pattern, train the pattern, and most backs get better.

At RWC, our coaches build return-to-training programmes around exactly this: identifying how your back behaves, then loading it back to full capacity in your own home, at a pace your spine can keep up with. If a nagging back has been running your training for too long, our injury rehabilitation coaching is built for it. Get in touch and we will find your pattern.

Frequently Asked Questions

Is my disc bulge causing my back pain?

Probably not on its own. Disc bulges show up on the scans of roughly a third of pain-free 20-year-olds and the large majority of older adults (Brinjikji et al., 2015). They are common, age-related findings, and their presence on your MRI does not establish that they are the source of your pain.

Should I rest or keep moving when my back hurts?

For ordinary mechanical back pain, move. Prolonged rest tends to make things worse, and graded movement and loading is the most evidence-backed treatment we have (Hayden et al., 2021). The exception is the small set of red-flag symptoms that need a doctor first.

Are deadlifts and lifting bad for a bad back?

For most mechanical back pain, no. Done with appropriate load and progression, strength work including the deadlift has been shown to reduce pain and disability (Berglund et al., 2015). Loading is part of the solution far more often than it is the cause.

Why does my lower back pain keep coming back?

Recurrence usually means the underlying capacity was never rebuilt, or an amplifier such as poor sleep, stress or fear of movement is keeping the system sensitised. Treating the flare without rebuilding capacity is why the same back keeps returning.

When should I see a doctor about back pain?

If you have spreading leg weakness or numbness, any loss of bladder or bowel control, numbness around the saddle area, back pain with fever or unexplained weight loss, or pain after a significant trauma, see a doctor promptly. Otherwise, most back pain is a movement problem.

References

1. Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. The Lancet. 2018;391(10137):2356-2367. doi:10.1016/S0140-6736(18)30480-X
2. Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet. 2018;391(10137):2368-2383. doi:10.1016/S0140-6736(18)30489-6
3. Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews. 2021;(9):CD009790. doi:10.1002/14651858.CD009790.pub2
4. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology. 2015;36(4):811-816. doi:10.3174/ajnr.A4173
5. Long A, Donelson R, Fung T. Does it matter which exercise? A randomized controlled trial of exercise for low back pain. Spine. 2004;29(23):2593-2602. PubMed: 15564907
6. Saragiotto BT, Maher CG, Yamato TP, et al. Motor control exercise for chronic non-specific low-back pain. Cochrane Database of Systematic Reviews. 2016;(1):CD012004. doi:10.1002/14651858.CD012004
7. Berglund L, Aasa B, Hellqvist J, Michaelson P, Aasa U. Which patients with low back pain benefit from deadlift training? Journal of Strength and Conditioning Research. 2015;29(7):1803-1811. PubMed: 25559899