Back pain, a symptom, is notoriously difficult to “diagnose” as there are so many causes. You may also be unsure where the pain originates from.
Also, there’s no single diagnostic test that can provide an accurate back-pain diagnosis, and doctors aren’t all experts in all the different spinal problems. This means you may have to see a number of different experts. This makes it a trial-and-error journey that can be quite stressful.
When looking for a diagnosis, this is what you should expect:
Physical examination and medical history
Your doctor will take a detailed medical history, and will likely ask you about:
- The frequency, duration and nature of the pain (whether piercing, throbbing, burning etc.).
- When the pain started and whether it’s chronic, acute or recurring.
- Whether it was triggered by an event (e.g. lifting a heavy object or a car accident).
- What worsens the pain (e.g. coughing, walking).
- What relieves it (e.g. lying down, exercise).
- Whether you’ve had previous back-pain episodes or injuries involving your back, neck or hips.
Your doctor will also look for red flags: for example, back pain combined with bladder or bowel dysfunction, a shooting pain, fever, tingling limbs, pain that is worse when you sit down, and/or whether you’ve suffered trauma to the back or neck.
The doctor will then give you a full physical examination and possibly do a neurological examination (e.g. the straight-leg raising test and/or ankle reflexes) before defining your pain pattern and seeing how the pain impacts your body and movement.
They will also look for a physical basis for the pain (e.g. mechanical causes, local inflammation, and muscle tension). When no physical basis can be identified, your doctor will look for a psychosocial cause.
Your doctor may recommend imaging examinations (e.g. ultrasound, X-ray, MRI scans), but is likely to do so only once conservative therapies and treatments have been explored, and there’s still no improvement.
Diagnosing neck and shoulder pain
The diagnostic in-surgery test described by neurosurgeon Dr Stephen Gardner of South Carolina in the video below makes for a simple bedside diagnosis to determine the cause of neck and shoulder pain.
If you have neck, shoulder or arm pain, your first examination will involve the neck. Your doctor will look for tenderness, restriction of motion, and whether certain motions aggravate or relieve the pain. Answers to these questions could point to a mechanical source of pain in the neck joints and the discs themselves.
To see if the shoulder joint is the source of the pain, your doctor will ask you to reach for the ceiling, and test your mobility. For instance, your doctor may ask you to perform a prisoner clasp behind your back (pushing the hands down and back), or check to see how easily you can reach across your chest to pat yourself on the shoulders in a horizontal motion.
If any of these movements are restricted, further evaluation of the shoulder joint itself is needed. The pain may be muscular or skeletal, or due to an inflammatory process of the tendons.
When these causes are ruled out, your doctor may look for a neurological cause related to a compressed nerve root of the shoulder, arm or hand. All the nerves supplying the neck and upper limbs (C1-T1) are important and provide sensation to the upper limbs.
Dr Stephen Gardner specifically highlights the following four major nerve roots that stretch from the neck through to the shoulder, down the arm, and into the hand – all of which could be at the root of your neck or shoulder pain:
- c5 extends from the 4th and 5th vertebrae in the neck above the collar line, and provides sensation (and can cause pain) in the shoulder-pad area. Weakness in this area is confined to the deltoid muscles that elevate the arm, and which can pull it back and down. If you don't have range-of-motion pain, and experience weakness when testing the deltoid by holding the arms horizontally up and pushing down on them, these roots are affected. This is a very fragile nerve that is easily damaged by trauma.
- c6 is related to biceps function. The sensory area that c6 supplies extends from the top of the shoulder blade, around and down the forearm, and into the thumb, index finger and portions of the middle finger.
- c7 relates to your triceps muscle. It’s easily tested by resisting in a fixed position in front of the body, pushing the arms outwards. This tests the triceps reflex and provides the two middle fingers with sensation. Its path from the neck will create pain through the mid-shoulder-blade area and through the back of the triceps, right down the back and into the two middle fingers.
- c8 provides sensation to the pinkie and ring fingers, and is tested through a grip-strength test.
To check for strength, your doctor may ask you to reach up to the ceiling to “unscrew a lightbulb”. This tests the nerve roots’ strength. By checking reflexes and sensory distribution, and listening to your description of the pain experienced as the test is performed, your doctor can determine which nerve root may be affected.
A bedside diagnosis such as this doesn't necessarily lead to surgery. Initially, medical treatment including medication and physical therapy will be prescribed. But, if these don’t work, other diagnostic tools will be employed, such as X-rays and MRI scans. If these prove inconclusive, and the pain is located in the shoulder, EMG and nerve conduction studies will be the next step to determine which nerve roots are affected, and how active or chronic these irritations may be.
Dr David Glick, managing partner at HealthQ2 in Richmond, Virginia says the number-one reason for chronic back pain, or why acute back pain becomes chronic, is failure to diagnose and treat the patient properly.
Here he lists a couple of diagnostic tests that evaluate the spine and which could indicate where the pain stems from:
- Flexion* increases pain: pain could stem from facet or sacroiliac joint problems.
- Forward flexion relieves pain: pain could stem from spinal stenosis or disc herniation.
- Coughing or sneezing causes pain: pain could stem from a herniated disc.
- Extension** increases pain: this could indicate nerve-root compression and facet problems.
*Flexion is movement that decreases the angle between body parts.
**Extension is movement that increases the angle between body parts.
Tools and tests used in diagnosing back pain
- The Keele STarT Back Screening Tool is used by a range of clinicians such as general practitioners, physical therapists, osteopaths and pain-management practitioners to identify individuals “at risk” of persistent symptoms.
- PICKUP chronic LBP tool. Researchers at NeuRA (Neuroscience Research Australia) have developed what’s known as the PICKUP (Preventing the Inception of Chronic Pain) model that calculates individuals’ risk of chronic lower back pain.
Imaging tests for back pain
If pain is severe and doesn’t respond to treatment, or if you have significant leg pain, some imaging tests may be necessary. These may include:
This can help show bone alignment and point to the presence of degenerative joint disease, tumours, infection or injury, in some cases. Plain X-rays will not show if there’s anything wrong with your lumbar discs or nerves.
MRI and CT scans
Magnetic resonance imaging (MRI) and computerised tomography (CT) scans generate images that help reveal conditions involving the bone and the soft tissues, e.g. herniated discs. MRIs can also help detect other causes of back pain, including infection and cancer, and can differentiate scar tissue from a recurrent disc herniation in people who have had back surgery.
But experts are finding that, while CT and MRI scans enable doctors to make a specific diagnosis, it’s also increased the number of evaluations done and lead to an unacceptable rate of false-positive findings. In other words, the scans wrongly show that particular conditions are present. This, in turn, has led to an increase in expensive back surgeries and other invasive procedures (many of which may have been unnecessary).
One of the reasons we fear back pain so much is because of what might show up on an MRI scan at the surgery. Peter O’Sullivan, Professor of Musculoskeletal Physiotherapy at Curtin University, Australia, says that sophisticated MRI scans today can pick up spinal abnormalities and disc degeneration (which most of us have by the age of 50) in almost everybody, including those who have no pain.
His research shows that, when looking at the MRI scans of pain-free people, doctors will find disc degeneration in 91%, disc bulges in 56%, disc protrusion in 32%, and annular tears in 38%. These are all “abnormalities” that they can’t directly link to back pain.2
This means that, through MRI, the discovery of bulging or protruding discs in people with back pain is often coincidental. Also, even though inflammation of a nerve root is quite painful, it won’t show up on an MRI or other imaging. If your MRI scan show disk degeneration, bulges, tears or protrusions, don’t panic. Ask your doctor to zoom in on which of these, if any, is causing the pain and if there isn’t another explanation.
A new generation MRI scanner, the G (Gravity)-scan, holds promise for more accurate and in-depth diagnosis. It’s open-standing and tilts, allowing the individual to stand while the magnets scan the affected area. This allows for a true weight-bearing examination and the possibility of evaluating the role and effect of a patients' weight on the curvature of his or her spine, which cannot be accurately analysed with conventional MRI Machines.
A bone scan is taken after a radioactive substance (tracer) has been injected into a vein to help detect bone tumours, stress fractures or fractures caused by osteoporosis (decreased density of the bones).
Discs suspected of being the source of pain are injected with dye and X-rayed. This technique is generally used only to identify the injured disc as a source of the back pain before the patient undergoes surgery.
A dye injected into the spinal canal shows up herniated discs or other lesions on X-rays or a CT scan. This procedure has largely been replaced by MRI scans, but is still used in individuals who had undergone a previous spinal fusion using stainless-steel implants.
Higher-frequency ultrasound technology may be used to image soft-tissue structures and internal organs as well as tendons, ligaments, nerves, bones and joints. There’s no risk of radiation, and the technology produces good-quality images and accurate diagnoses.
Electrical tests, such as EMG (electromyography), are used to study nerve conduction pathways. These tests can confirm nerve compression as a result of spinal conditions (e.g. herniated discs or stenosis) and peripheral conditions (e.g. diabetic neuropathy or peripheral nerve compression).
Blood and urine samples may be used to test for conditions such as infections, cancer or arthritis.
When to see a doctor
Generally speaking, if you have severe back pain that doesn’t improve with rest or which doesn’t subside within a week of home treatment, you should be checked out by a healthcare professional. If your back pain is due to a fall, an accident or a blow to the back, you should see a doctor immediately.
Also, if you have a medical condition that puts you at high risk for a spinal fracture, such as osteoporosis, you need to see a doctor immediately if you experience back pain. Your doctor will make sure that there’s no structural damage or conditions that require immediate treatment.
Sometimes back pain can point to a serious medical problem.
Red flags for back pain
If you have back pain and experience any of the red flags below, you should see a doctor as soon as possible:
- Bladder or bowel control problems (such as difficulty passing urine)
- Numbness in the groin or in the vicinity of the anal region
- Weakness, numbness or pins and needles in the legs
- Rapid weight loss
- A history of cancer
- Abdominal pain
- Pain running down one or both legs
- Feeling unsteady on your feet
- Increased pain when lying down
- Pain that wakes you up at night
- Pain that’s unrelated to movement
- Pain that’s localised in the upper back (thoracic spine)
- A history of prolonged corticosteroid use
- A history of intravenous drug use
- A history of urinary tract infections (UTIs)
- In a child: any severe back pain that persists for more than three days
Questions to ask your doctor
The following questions will help you to make the most of your doctor’s visit:
- What is causing my back pain?
- What is the significance of my back pain? Is it a sign of ongoing damage?
- Are there any other symptoms I should look out for that could indicate a more serious condition?
- Are there activities I should start, continue or temporarily or permanently avoid to ease my back pain?
- Could my work (either my work station or manual work) be causing or contributing to my back pain?
- Should I get bed rest while my back hurts?
- What treatment options can I consider for my back pain?
- How long should I take medication or do special exercises for my back pain?
- Are there alternative therapies that I could consider?
- What can I do to prevent back pain from returning?
Yellow flags for back pain
Yellow flags are related to our beliefs about pain. They primarily have to do with our psychological response to the experience of pain – in other words, our fear of movement, our expectations in terms of the management of the problem, and our social behaviours and interactions. They include attitudes and beliefs, emotions, behaviours, and family and workplace factors.
If you experience any of the following, it’s important to discuss and address these problems with your doctor. These factors could play a key role in your rehabilitation and recovery:
- Continuous negative thoughts, where you believe back pain is dangerous or could be severely disabling
- Avoiding certain movements, reducing your activity levels, or not exercising due to fear of causing further damage
- Expecting that passive treatment like medication, massage or surgery, rather than active treatment, will be beneficial
- Feelings of depression, low morale or anxiety, and social withdrawal
- Social or financial problems
- Unsupportive work environment and/or overprotective or critical partner
- Use of extended rest
- Anxiety about heightened body sensations
- Impaired sleep
- Believing that pain is uncontrollable
- Misinterpreting physical symptoms
- An increased intake of alcohol or other substances since the pain started
Yellow flags are often difficult to identify and manage. Seeking help may assist you in addressing these factors more readily.
Reviewed by general practitioners Dr Lienka Botha and Dr Suzette Oelofse, FX Health. April 2018
- David M Glick. Differential diagnosis of back pain. Painweek.org.
- Peter O’Sullivan. Acute low back pain - Beyond drug therapies. Pain Management Today. January 2014, Volume 1, Number 1