The vast majority of people with back pain (up to 85%) have what is known as “non-specific lower back pain of a musculoskeletal nature” – i.e. the specific underlying cause is hard to identify.
That said, the main causes of back and neck pain are related to deconditioned muscles and damaged ligaments and joints. Lack of exercise, excess weight, and poor posture all contribute to a body that’s prone to injury. This is why the physically fit are less prone to back pain and why they also recover faster.
Although a herniated (slipped), bulging or degenerating disc or a trapped nerve caused by injury and wear and tear can cause back pain, this is rarely the case. While the causes of back pain are numerous, it’s important to know that most of them are benign (i.e. not harmful).
The causes of back pain can be summarised as follows:
1. Spinal problems
- Pain from degenerated disks (degenerative disc disease or DDD). Everybody’s disks degenerate to a certain degree and this isn’t always a source of pain. Sometimes the proteins in the disk space cause inflammation – a source of pain that often radiates from the lower back or neck area. Fortunately, this can be resolved. Once a fully degenerated disk no longer has any inflammatory proteins that can cause pain, the disc enters into a stable position. Because of this, pain from degenerating discs rarely occurs after 60 years of age.
- A pinched nerve. In between the vertebrae, small sponge-like pads act as cushions to absorb everyday shocks to the spinal column. The disks have a tough covering and a soft, jelly-like interior. If a disk is squeezed by the vertebrae above and below it, the covering could tear and cause pain. Sometimes the interior of the disk bulges out through the tear. The bulging disk can then push or damage the spinal nerve root next to it. When the disks and vertebrae degenerate, usually due to osteoarthritis, the nerves that emerge through the vertebrae may be pinched. This results in cervical spondylosis or degeneration of the bones in the neck.
- Herniated disc. In between our vertebrae, the small sponge-like pads that act as cushions to absorb everyday shocks to the spinal column can rupture or bulge due to ageing and injury. This can cause pressure on the nerves in the spine, causing significant pain. Sciatic pain (a very specific type of pain) is felt in the sciatic nerve that runs down the leg, and is caused by pressure from a herniated disc. A muscle spasm can also cause sciatic pain and compression of a nerve.
- Arthritis. Osteoarthritis often affects the lower back and can cause painful narrowing of the spinal canal – a condition called spinal stenosis. Rheumatoid arthritis can also cause back pain.
- Cervical sprain (whiplash). This usually results from a sudden movement or motion. The head snaps back suddenly such as when an athlete is tackled while being unprepared, or during a car crash.
- Skeletal irregularities. This includes scoliosis, a curvature of the spine that doesn’t usually cause pain until middle age. Another is lordosis, an abnormally accentuated arch in the lower back.
- Abnormal bone growth. This is seen in diseases such as cancer, osteoarthritis and spondylolisthesis (displacement of one vertebra over another).
2. Emotional stress
When we’re stressed, we tend to hold a lot of tension in our lower back, shoulders and neck. This can severely exacerbate and prolong back or neck pain.
3. Occupation and lifestyle habits
The following can contribute to back pain:
- Heavy bags and thick wallets. Carrying more than 10% of your body weight creates an imbalance in your posture and strains the muscles in your back and shoulders. Likewise, thick wallets inserted into your back pocket are wedges that disrupt the balance of the pelvis and spine, and which can contribute to arthritis.
- Driving. People who drive for more than 4 hours a day are 6 times more likely to miss work due to back problems than those who drive under 2 hours per day. Your car seat could also be a problem. Dr Roger Minkow, a back specialist who redesigns seats for car and aeroplane manufacturers, writes in the Doctor’s Book of Home Remedies: “If you have back problems, the root of your problem could be your car seat. German cars can be the worst when it comes to backs,” he says. “American cars are usually bad, too, but you can fix them (by slipping a lumbar support inside the car seat). Japanese cars, on the other hand, have the best seats, followed by the Swedish cars Volvo and Saab.”
- Sitting. People who sit for extended periods of time (e.g. office workers) have more back problems than those who do manual labour.
- Slouching. Bad posture can put the equivalent of an extra 100kg of stress on your lower back.
- Lifting. The worst thing you can do for your hardworking back is to bend and twist while trying to lift something, which gives the disks in your back no support. This is when they can slip and pinch nerves.
- Wearing high heels. These shoes throw off your posture and spinal alignment, and can cause foot injuries. In turn, these injuries can cause back pain.
- Following a strict vegetarian diet. A lack of vitamin D and an increased intake of foods that contain phytic acid (e.g. nuts, seeds, grains, legumes and beans) can cause osteomalacia – softening of the bones. This can cause pain in the lower back, pelvis, hips, legs and ribs. A 2015 study published in the Indian Journal of Clinical Biochemistry additionally found that low vitamin D levels were strongly associated with chronic back pain in people in whom the cause was unknown. Vitamin D plays an important role in bone metabolism and neuromuscular function. By reversing the deficiency, chronic lower back and musculoskeletal pain (a type of pain that affects the muscles, ligaments, tendons and bones) can be improved.
- Smoking, lack of exercise and increased alcohol intake can all contribute to the onset of osteoporosis pain caused by a spinal compression fracture (where the bone collapses onto itself).
- Obesity is one of the primary causes of back pain. Extra weight puts a lot of stress on the joints as well as the lower back.
4. Referred pain
Sometimes back pain is caused by referred pain from problems in other organs (usually the organs near the spine). These conditions include peptic ulcers, kidney disease, pancreatitis, infections, inflammatory bowel disease (Crohn’s disease, ulcerative colitis), pregnancy, menstruation, and other gynaecological problems such as ovarian cysts.
5. Myofascial pain syndrome (MPS)
MPS is a chronic disorder that affects the muscles and which involves trigger points that are painful when touched. Causes could be an overuse of muscles, injury, stress, anxiety and depression that prevents you from relaxing your muscles throughout the day. Pain is felt deep within the muscle, and you may feel a knot or knots.
The primary symptom of fibromyalgia is musculoskeletal pain throughout the body, which persists for several months and frequently affects the joints, neck and back. The pain is often accompanied by stiffness, which is characteristically worse in the morning and which may last all day. Fibromyalgia and myofascial pain syndrome are closely linked.
7. Other diseases that could cause back pain
Only 15-20% of people have worrying causes of back pain such as tumours, inflammatory diseases, infections (e.g. spondylodiscitis), or a deformity such as scoliosis in which the spine is curved. Use this chart to see which diseases could cause your back pain:
Possible causes of back pain
Degenerative – related to ageing
Discogenic disease (from a damaged spine); spinal stenosis (spinal canal is narrowed); facet joint arthritis (degenerative arthritis or osteoarthritis of the spine)
Traumatic – related to an injury or an accident, including motorcycle accidents, diving accidents and sports injuries
Vertebral fractures; lumbar strains and sprains; ligamentous injuries; musculoskeletal injuries
Inflammatory – usually a chronic type of inflammation
Arachnoiditis (inflammation of one of the membranes that surrounds and protects the nerves of the spinal cord); arthritis (e.g. ankylosing spondylitis)
Infective – a bacterial or viral infection
Meningitis; vertebral osteomyelitis (disk-space infection); epidural abscess; urinary tract infection; intervertebral discitis (inflammation between the intervertebral discs)
Congenital – people are born with these conditions, which may be caused by infections during pregnancy or injury at birth; it also covers disorders inherited from parents
Tethered cord syndrome (tissue attachments that limit the movement of the spinal cord); spina bifida (a neural tube defect)
Developmental – these become more apparent in adolescence
Scoliosis; sacral agenesis (affecting the sacrum, the part of the spine just above the tailbone); Scheuermann's kyphosis (abnormal growth in the upper back)
Metabolic bone diseases – disorders of bone strength, usually caused by abnormalities of minerals such as calcium or phosphorus, vitamin D, bone mass or bone structure
Osteoporosis; Paget's disease (where the replacement of old bone tissue with new bone tissue is disrupted); diabetes; osteomalacia, parathyroid disorders; rickets (softening and weakening of bones as a result of vitamin D deficiency)
Either benign or malignant. A malignant tumour can be primary or metastatic – in other words, it can originate in the spine or spread to the spine from another part of the body
Causes of lower back pain according to the duration of symptoms
The US National Institutes of Health provides the following summary of lower back pain (LBP) causes according to the duration of symptoms (acute vs. chronic):
Acute lower back pain (lasts up to 12 weeks):
- Strain or tear of ligaments or muscles
- Compression fracture (a result of osteoporosis)
- Herniated disk
- Spinal stenosis
- Scoliosis or kyphosis
Chronic lower back pain (lasts 12 weeks or more):
- Extra wear and tear on the spine from work or sport
- Past injuries
- Past surgery
- Herniated disk
- Spinal stenosis
- Scoliosis or kyphosis
Reviewed by general practitioners Dr Lienka Botha and Dr Suzette Oelofse, FX Health. April 2018.
- Evaluation of low back pain in adults, Uptodate.com.
- Lumbar Degenerative Disc Disease. Spine-health.com.
- Lodh M et. al. Assessment of Vitamin D status In Patients of Chronic Low Back Pain of Unknown Etiology. Indian J Clin Biochem. 2015 Apr;30(2):174-9. doi: 10.1007/s12291-014-0435-3. Epub 2014 May 25.
- Low Back Pain Fact Sheet. US National Institute of Neurological Disorders and Stroke.