Whether it’s a sprain, a dull ache or burning sciatic pain that moves down your leg, most of us will suffer back pain at some point. In many cases, it’s a short-term problem, caused by a strain affecting the muscles, tendons or ligaments. But around nine million people in England live with back pain, according to the charity Arthritis Research UK.
It is increasingly common, mainly due to our sedentary lifestyles, says Sammy Margo, a physiotherapist based in North London. ‘People used to get back pain from doing things – now they experience it from not doing things,’ she says.
‘It affects the working-from-home people who no longer commute but who sit down all day; people who no longer go out for a paper but read it on their phones; or those who have their food shopping delivered.
‘In the past, we saw more people with acute injuries such as muscle tears. Now we see tech neck, or chronic lower back pain from sitting at a desk all day.’
She adds: ‘Being sedentary reduces blood flow to the spinal structures and they get weaker. This increases ‘CREEP’ – a term used by physiotherapists for loading pressure that happens when we hold one position for a long time [it stands for continuous and repetitive elongation of the elastic properties of tissues]. This pressure degrades the tissues and reduces flexibility.’
The good news is that in the vast majority of cases, back pain will get better and can be resolved with simple steps within a few weeks or months and won’t recur, says Mehmet Gem, a physiotherapist with Pure Physio in Exeter, and spokesperson for the Chartered Society of Physiotherapy.
‘The most important thing once you have back pain is keeping active and not being scared to move and, in the majority of cases, things will resolve on their own,’ he says.
Consultant Robin Chatterjee says that if your pain is not improving after seven days and trying painkillers, heat therapy and exercise, you should see a doctor, physio or osteopath
He adds that there are a few circumstances where it may be best to stay still initially, such as if you suspect a fracture or if you have a history of osteopenia (weakened bones) or osteoporosis, as movement could make it worse.
David Bell, a consultant neurosurgeon at King’s College Hospital in London, and the private HCA London Bridge Hospital, says in nine out of ten cases, pain will resolve within three months.
‘In the majority of patients, back pain gets better on its own or we can get it better with physical therapies, steroid injections or surgery, depending on the cause.’ Working out what’s causing your back pain is the vital first step to finding the best treatment.
As Sammy Margo points out: ‘Sometimes pain from physical damage to the tissue around the spine can be delayed for several days, too, so it might not be obvious that you’ve pulled a muscle or over-trained, for instance.’
Dr Robin Chatterjee, a consultant in musculoskeletal, sport and exercise medicine at the private Lister Hospital in London, says that unless you experience red-flag symptoms (see box, below) – in which case you need urgent medical advice – if your pain is not improving after seven days and trying painkillers, heat therapy and exercise, you should see a doctor, physio or osteopath.
Many GP practices offer direct access on the NHS to physiotherapists (visit nhs.uk and search for physiotherapy) otherwise you have to see a GP first.
‘Part of working out a diagnosis depends on the nature of the pain,’ says Dr Chatterjee. For instance, if the back pain radiates down the legs, it is probably caused by a trapped nerve.
So which is the best medical treatment for you – and should you try any of the baffling range of gadgets and supplements out there that claim to work?
To help you decide, we joined forces with a panel of experts to bring you this ultimate guide to improving – or stopping – your back pain, based on the latest scientific research.
When to seek urgent help
- Back pain that is associated with a sudden onset of profound weakness and numbness in both legs could be caused by acute pressure on a bundle of nerves at the base of the spine, called the cauda equina, explains Dr Pooja Gulati, a consultant rheumatologist at Chelsea and Westminster Hospital and the private Lister Hospital, both in London.
- Other symptoms include loss of bladder or bowel control and numbness or tingling around the genital area or buttocks. ‘When this happens, it is a medical emergency and may need urgent surgery to prevent permanent damage and paralysis. Go straight to A&E or call 999 if you have any of these symptoms.’
- If you have new, localised pain in the spine with a high fever, chills or night sweats, it could be a sign of a spinal infection. Ask for an urgent GP appointment or call 111.
- Back pain with significant, unexplained weight loss may be a sign of cancer and you should seek an urgent appointment with your GP, or call 111. If you have a history of cancer and develop persistent back pain, see your GP or cancer doctor as soon as possible.
How scans play a vital role
‘MRI scans can be useful for people who have pain that hasn’t settled and hasn’t responded to painkillers and physical therapy, as it can detect trapped nerves and wear-and-tear damage for instance,’ says David Bell, a consultant neurosurgeon at King’s College Hospital, London.
‘If an MRI doesn’t show a clear explanation for back pain, we can do a SPECT [single-photon emission computed tomography] scan, where a dye which is attracted to inflamed joints is injected into the blood.
‘SPECT scans show not just the structure as an MRI does, but also how the back is working. This is predominantly performed privately.’
A SPECT scan costs between £1,000 and £2,000.
What’s causing your back ache?
SPRAINS AND STRAINS
(ACUTE LOWER BACK PAIN)
If you have strained your back, do as much exercise as you can tolerate – ‘the worst thing is to lie down,’ Dr Chatterjee says
FEELS LIKE: You may feel a pop or a tear as you do a particular action, with pain localised to one area and it hurts more with movement. Can also be a dull ache that comes on gradually and worsens.
Back strains are injuries to muscles and tendons, the tissue that connects muscle to bone. When they are stretched and torn – such as from heavy lifting, sports injuries and awkward twisting movements when gardening, decorating or cleaning, for instance – it can cause acute pain.
‘Classically, this type of acute lower back pain can happen when you do something such as lift a suitcase off a carousel, or bend over when gardening, and is usually muscular,’ explains David Bell, a consultant neurosurgeon at King’s College Hospital in London.
TREATMENT: This type of back pain usually gets better in six weeks or less by taking painkillers such as ibuprofen with paracetamol, using hot and cold therapies and having physiotherapy.
‘It’s important to keep moving,’ adds Dr Chatterjee, a consultant in musculoskeletal, sport and exercise medicine at the Lister Hospital in London. ‘Do as much exercise as you can tolerate – the worst thing is to lie down.’
SCIATICA
FEELS LIKE: Stabbing, burning or shooting pain in the bottom, back of leg and foot. Tingling, pins and needles, numbness or weakness
in a leg. Sciatica is caused by compression or pinching of nerves in the lower back, causing inflammation and pain.
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Its main symptom is pain radiating from the buttock and down nerves in the leg. It affects one leg. Symptoms can come and go.
‘This nerve compression can lead to everything from mild irritation to pain so excruciating some people want to have their leg sawn off,’ says Mr Bell.
‘In 90 per cent of cases, sciatica is caused by a herniated, bulging or slipped disc, where the tissue between the spinal vertebrae bulges out and pinches a nerve. Most commonly this is because of age-related wear and tear.’
Other causes include spinal stenosis (abnormal narrowing of the spinal canal). Here, the pain tends to worsen when standing and extending the back (as this further narrows the spinal canal) and is relieved by sitting and bending forward.
TREATMENT: ‘Most cases get better on their own within 12 weeks,’ says Mr Bell. Until then, follow the standard advice of taking painkillers, exercise and applying heat and cold.
‘In cases of sciatica or other types of back pain that have persisted and are having a severe impact on someone’s daily life, we may consider an injection of corticosteroids and local anaesthetic around the trapped nerve or the disc that is inflamed, guided by imaging,’ says Mr Bell.
‘The local anaesthetic will give temporary relief for a day at the most, but the steroid will reduce inflammation for up to six months. So it’s not a case that you’re masking the pain
but genuinely treating the inflammation causing it. These injections are low risk and have high success rates; dampening down the pain in two out of three cases. They can be repeated if needed, but are not a long-term treatment.’ Available on the NHS, or from around £1,000 privately.
OSTEOARTHRITIS
FEELS LIKE: Pain and stiffness in the back and neck, especially first thing in the morning.
Osteoarthritis (called spondylosis when it affects the spine) is where the joints that sit on either side of the spine and cartilage and discs between the vertebrae become thinner through wear and tear: the damage can trigger the growth of bony spurs called osteophytes, which exacerbate the problem.
Expert tip
Dr Chatterjee recommends using ibuprofen gel on painful areas, covering with clingfilm for 30 to 40 minutes and carefully applying heat (e.g. with a hairdryer on a low setting). Clingfilm boosts absorption and heat relaxes muscles.
Apply heat using a hairdryer on a low setting
Osteoarthritis is the most common cause of mechanical back pain (the type that feels worse when you move and goes away when you lie down).
It often starts in the late-40s to mid-50s, but it can affect younger people, particularly athletes, or as a result of obesity. The pain often improves within 30 minutes of getting up.
TREATMENT: Exercise such as swimming and weight training can help with flexibility and building muscle strength to support your spine.
Heat and cold therapies as well as painkillers may relieve pain, as well as physical therapies or steroid injections.
FRACTURES
FEELS LIKE: Sharp pain in the vertebrae, pain is worse with movement, but some people don’t feel pain initially. Young people with otherwise healthy spines who suffer an injury during high-impact sport, those injured in car accidents or falls, or older people with osteoporosis (which weakens bones), are the most likely to suffer spinal fractures, says Mr Bell.
‘If you have fragile bones, you can break a vertebra from everyday activities, such as shopping, a minor trip or fall. The bone doesn’t snap but sinks down – a bit like a house with subsidence – the pain usually develops over the course of a day.’
The bone repairs itself naturally with bone-building cells within three to six months.
TREATMENT: ‘In the majority of patients, the pain settles down, so the treatment is mainly painkillers and time,’ says Mr Bell. Other solutions include wearing a back brace and taking non-steroidal anti-inflammatory drugs (NSAIDs) for relief.
‘But a group of patients find the pain is so severe in the early stages that they can’t function or control the pain even with strong painkillers, such as morphine,’ says Mr Bell.
‘Where the patient is in incapacitating pain, we offer vertebral augmentation, where cement is injected into the fractured vertebrae to mend the break.’ If the underlying cause is osteoporosis, patients are offered medication such as bisphosphonate drugs (e.g. alendronic acid) to prevent further bone loss.
INFLAMMATORY BACK PAIN
FEELS LIKE: Pain and stiffness in the lower back and/or buttocks and hips that develops slowly over weeks to months. Stiffness is worse when first waking up or after long periods of rest.
What to eat to beat the pain
Regularly consuming blueberries and strawberries eased musculoskeletal pain
An inflammatory diet – heavy on red and processed meat, refined carbohydrates, fried foods and sugar – may play a role in the development of lower back pain.
A 2022 study in the journal Applied Nursing Research found that over three months, those who reported eating a diet with the highest inflammatory foods were 1.24 times more likely to have experienced 30 days or more of back pain than those who ate the lowest amount.
The theory is that certain foods contain compounds that fuel inflammation in the body, which causes back pain. Meanwhile, eating a low-inflammation diet may reduce back pain. A Mediterranean-style diet eased musculoskeletal pain in adults with osteoarthritis (including in the back), a 2020 review of 17 studies found.
Regularly consuming blueberries, strawberries, fish oils, olive oil and vitamin D capsules had a similar effect.
Dr Chatterjee, at the Lister Hospital, says diet is important to prevent obesity, a risk factor for back pain, and a low-inflammation diet may be useful for inflammatory back pain – but there is not enough evidence to recommend it.
This affects an estimated 5 per cent of the population, mainly starting in people in their 20s or 30s and is caused by inflammatory arthritis that causes lower back pain, among other symptoms.
There are two main types: non-radiographic axial spondyloarthritis (which may not be visible on X-rays but shows up on MRIs) and ankylosing spondylitis (which can be seen on X-rays).
‘It can be debilitating and progressive, so seeing a rheumatologist for early diagnosis and treatment is key,’ says Dr Pooja Gulati, a consultant rheumatologist at Chelsea and Westminster Hospital in London and the private Lister Hospital. ‘They will usually arrange an MRI of your spine and the sacroiliac joints that link the pelvis and lower spine.’
Dr Gulati says this type of back pain is different from most forms of mechanical back pain as it is worse in the morning and after periods of inactivity – and unlike osteoarthritis, it doesn’t improve within 30 minutes of getting up. ‘Inflammatory back pain improves with exercise and patients may also complain of neck pain and fatigue,’ she says.
The areas most commonly affected are the sacroiliac joints; the vertebrae in the lower back; the areas where tendons and ligaments attach to bones mainly in the spine, but also the back of the heel, and the cartilage between the breastbone and the ribs, and hip and shoulder joints.
While the cause is unknown, people with the HLAB27 gene have a much greater risk.
TREATMENT: ‘Exercise and physiotherapy often help, as may stronger NSAIDs, or the COX-2 inhibitor etoricoxib,’ says Dr Gulati. (These reduce inflammation.) ‘Patients with moderate to severe disease need drugs with genetically engineered proteins that turn off the inflammation.’
NO OBVIOUS CAUSE
‘Some people with back pain will have normal scans or no obvious trigger – you have to look at them holistically,’ says Dr Chatterjee.
‘There are lots of reasons why people are in pain, including physical causes – where the load going through the lower back exceeds the strength of the surrounding muscle. Or psychological ones, such as stress. Or they might have gained weight due to a sedentary lifestyle or a bereavement and changed their posture because they are sad.’
TREATMENT: This will vary, says Dr Chatterjee. ‘It might be they need to lose weight, manage their stress better, exercise more or get an ergonomic assessment at work – or a mixture of these.
‘If the standard advice [exercise, physiotherapy and painkillers] hasn’t worked, patients can be referred to a pain clinic.’
Three gentle exercises that you can try at home
Pelvic tilt exercises will help strengthen back muscles and improve flexibility
‘Historically, people with back pain were told to rest for six weeks, but we don’t advise that any more as if you do this you will start to lose muscle strength and get stiffer,’ says physiotherapist Sammy Margo.
‘If you keep moving, more blood circulates to the affected area, carrying oxygen and taking away waste products, which helps reduce inflammation.’ Richmond Stace, a physio in London, and author of Understand And Overcome Your Chronic Pain, agrees. ‘Motion is the lotion, is what I tell my clients: but set the bar low – don’t tell yourself you have to do 20 repetitions if it really hurts.’
Sammy Margo says these exercises will help strengthen muscles and improve flexibility.
1. Side to Side Knee rolls:
Lie on your back with your knees bent towards your chest and arms by your sides. Gently rock your knees from the centre to the right, hold for a few seconds, then rock them to the left side. Don’t exceed zero to five out of ten on the pain scale, aim to repeat up to ten times, but spread them through the day. This stretches your back and increases the amount of movement available within the lower back.
2. Pelvic tilts:
Lie on your back, place your hands on your hips and slowly tilt your hips in towards the floor to flatten your back. Count to two and then tilt your hips in the opposite direction. Relax and repeat. Start with three repetitions at a time and build up. This stretches and strengthens your abdominal muscles and helps relieve lower back pain and sciatica.
3. Knee hug:
Lie on any flat surface you find comfortable with both knees bent towards your chest. Raise one knee towards your head, with your arms around it, then raise the other knee and repeat. This exercise elongates tight muscles, reduces soft-tissue tightness and helps ease joint stiffness.
When the issue is being a woman
A number of gynaecological conditions can cause back ache, explains Tania Adib, a consultant gynaecologist at London’s Chelsea Outpatient Centre and Queen’s Hospital. ‘Period pain can cause lower back pain, as prostaglandins – inflammatory chemicals produced during a period to encourage blood flow – can cause nerve irritation in the pelvis,’ says Dr Adib.
‘Painkillers such as ibuprofen and paracetamol help, as can applying heat. Other options include the mini Pill or the Mirena coil [a device containing progesterone that’s inserted into the uterus], which reduce excessive bleeding, reducing pain.’
Fibroids – non-cancerous growths of muscle and fibrous tissue in and around the uterus – can also cause back pain if they’re large and sitting on one of the nerves in the lower back. Dr Adib says ultimately it might be better to remove them with keyhole surgery.
Period pain can cause lower back pain as chemicals produced during menstruation can cause nerve irritation in the pelvis, explains consultant gynaecologist Tania Adib
Endometriosis, a condition where tissue similar to the lining of the womb grows elsewhere, such as the ovaries, can also cause back pain when the tissue is shed each month, as with a period. Treatments include painkillers, hormone therapies and surgery.
Adenomyosis, where tissue similar to the lining of the womb grows into the muscular wall of the uterus, can also cause chronic back pain that’s worse before and during a period. Treatments include strong painkillers or having a coil fitted.
Hot and cold therapy
Non-painful sensations, such as hot and cold, can override pain signals being sent to the brain. Applying ice (a bag of frozen peas or an ice pack, wrapped in a tea towel) may bring relief in the first 36 hours.
This is better than heat at this point, as it narrows blood vessels to calm inflammation. Do this for 15 minutes, every three to four hours a day, says Jose Bascones, lead outpatient physiotherapist at HCA Healthcare UK.
‘The cold reduces inflammation in the back muscles and swelling.’
After 36 hours, apply heat via a hot water bottle wrapped in a cloth, or take a hot bath. ‘You could also try rubbing in a cream, such as one containing menthol, says physiotherapist Sammy Margo.
‘Heat will increase blood flow to the affected area and may help to improve tissue healing in all types of back pain.’ A sauna might also be helpful by inducing relaxation and easing muscle spasms, researchers in Korea found.
A pill, spray or gel… what works for YOU?
Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen, or ibuprofen in combination with paracetamol, help by reducing inflammation. Always check with your doctor that it is safe to take NSAIDs.
Ibuprofen gels, creams and patches can be applied to the skin and are just as effective as tablets, according to a study comparing 5 per cent Ibugel with 400mg ibuprofen tablets – and may be better tolerated. Discuss with your pharmacist if ibuprofen gel is safe for you.
Doctors may prescribe stronger painkillers, though guidelines say those with chronic lower back pain should not have opioids, gabapentin, pregabalin or low-dose antidepressants (the drugs also carry a risk of dependency). Strong painkillers such as co-codamol should not be taken for more than three days because of the risk of addiction.
If all else fails… Should you get an operation?
If efforts to improve your back pain with lifestyle and diet changes or medication have not been successful, you may have to consider surgery, either on the NHS or privately.
FOR SLIPPED DISCS AND SCIATICA
If injections don’t work, a small operation can be done to remove the little bit of the disc that has protruded and pinched the nerve.
‘Around 85 to 90 per cent of people experience improvement in their sciatic pain or it goes away afterwards,’ says David Bell, a consultant neurosurgeon at King’s College Hospital, London. Available on the NHS, this surgery costs up to £15,000 privately.
Very rarely, severe cases of slipped discs may be offered spinal fusion. This is an operation used to join two vertebrae together (it’s also used to treat spinal stenosis) – a piece of bone from elsewhere in the body, or from a donor, or a piece of manmade bone substitute is inserted.
The aim is to prevent excessive movement between two adjacent vertebrae, which otherwise causes irritation and nearby nerve compression and pain.
Screws and rods are sometimes used to hold the bones in place. Recovery is equivalent to a hip or knee replacement – up to about three months – but the results can be variable and this operation doesn’t work for everyone, says Mr Bell.
Downsides include a risk of injury to blood vessels and nerves in the spine, pain at the graft site and return of symptoms. Available on the NHS, or upwards of £20,000 privately.
If efforts to improve your back pain with lifestyle and diet changes or medication have not been successful, you may have to consider surgery
FOR STENOSIS
This is a narrowing of the spinal canal most commonly due to osteoarthritis. This can be relieved with a laminectomy, to remove overgrown bone that is putting pressure on the spinal nerves.
‘This helps open up the spinal canal and relieves the pressure on the nerves,’ says Mr Bell.
Suitable for people with spinal stenosis that interferes with their normal daily life. Available on the NHS, this costs around £10,000 to £15,000 privately.
More severe cases may be offered spinal fusion.
FOR OTHER TYPES OF BACK PAIN
If all other options have failed, one option may be radiofrequency ablation – using heat to destroy nerves and stop them sending pain signals back to the brain. Radiowaves are transmitted through a needle in the back, guided by imaging.
This is used for people with long-term back pain that’s not responded to other methods, including for arthritis of the spine (spondylosis) and pain in the sacroiliac joint. Available on the NHS, or it costs around £5,000 privately.
Another option is an implant called a spinal nerve modulator – here, wires with electrodes are implanted into the epidural space (a fat-filled area around the spinal cord that protects it): these are connected to a battery that produces a small electrical current that blocks pain signals to the brain. The patient can operate this with a remote when they feel pain.
Available in specialised NHS centres, spinal nerve modulators cost £35,000-plus privately.
AND COMING SOON…
FOR ARTHRITIC OR WORN-OUT DISCS
Basivertebral nerve ablation (BVNA) is a new treatment expected to come to the UK next year. A specific radiofrequency energy is used to destroy the basivertebral nerve (the nerve within the vertebrae that sends pain signals to the brain), via a small incision.
‘It is a good intermediate treatment that could mean people avoid surgery, and it looks like it can deliver long-lasting pain relief at minimal risk – but we have to be cautious until we get more real-life experience of using it,’ says Mr Bell.
It’s estimated to cost £10,000.
FOR LOW BACK PAIN AND SCIATICA
Platelet-rich plasma (PRP) is a treatment made from the patient’s own blood, specifically proteins called growth factors that can aid the healing of damaged tendons, ligaments, bones, muscles and joints. PRP can be injected into joints which connect the verterbrae, ligaments and muscles.
It will be available only in private clinics and estimated to cost between £200 and £450 per injection.
Pain-relief gadgets that really could help
Physiotherapist Sammy Margo says some gadgets may offer relief for back pain (even if part of the benefit may be down to a placebo effect). Here, she selects three that might be helpful…
SciatiCalm £39.95, sciaticalm.com
Designed by a UK orthopaedic surgeon, this battery-operated portable device can be placed on the painful area. It passes high-frequency pulse vibrations through the skin to the sciatic nerve, scrambling pain signals, so they don’t reach the brain. Studies suggest that vibration therapy can reduce the severity of sciatica pain.
Ortho Joint Relief Infrared Belts for Back Pain £89, orthojointrelief.com
Combines infrared heat with vibration massage to penetrate deep into muscle tissue and it may help optimise the conditions for healing most kinds of chronic pain. One 2015 study found infrared cut back pain significantly over four weeks. ‘You could get a similar effect from a hot water bottle, but this may be more convenient,’ says Ms Margo.
Titanium Back Support £19.99, easylife.co.uk
This is made of neoprene with titanium for keeping warmth in aching muscles – promoting good posture and support, reducing the strain on back muscles.
Great for patients recovering from spinal injuries or surgery. Not meant to be worn all the time or long-term.
Do natural remedies ever work?
A study found that Devil’s claw, a plant native to South Africa, reduced pain as effectively as a daily 12.5mg dose of Vioxx (a strong painkiller)
The highly respected Cochrane network conducted a review of studies on herbal remedies and found these may help back pain:
- Devil’s claw, a plant native to South Africa (60mg a day), reduced pain as effectively as a daily 12.5mg dose of Vioxx (a strong painkiller). It has anti-inflammatory properties.
- Willow bark extract (120mg a day) and salicin (a compound similar to aspirin, 240mg a day) work better than a placebo.
- Lavender essential oil massage appeared to reduce back pain and improve flexibility, according to a study in 2004.
- Capsaicin (from chillies) plasters (e.g. Elastoplast ABC heat plaster, which contains 11mg) reduced pain more than a placebo, according to a 2003 study: 60.8 per cent of those given the plasters reported at least a 30 per cent reduction in pain after three months.
- Comfrey: A study in the British Journal of Sports Medicine of 120 patients with lower back pain given comfrey cream three times a day for five days had a 95.2 per cent reduction in pain, compared with 37.8 per cent in the placebo group. It contains anti-inflammatory chemicals.
Next week: Your guide to tackling coughs and dental problems