Back Pain

Updated 25 January 2019

FAQs about back pain

We answer a few frequently asked questions about back pain.

1. What’s causing the ‘click’ sound in my neck and knees? Should I worry about it?

No one knows exactly what causes the common sounds of joints cracking and popping. It could be caused by tendons returning to their original position, or ligaments stretching and releasing. It could also be caused by escaping gasses that form bubbles in the joint spaces. It generally isn’t harmful, but if it’s accompanied by pain, you should see a doctor.

2. Is slouching really so bad?

Yes. Slouching (i.e. when your shoulders and upper back are rounded forward) can cause chronic muscle strain symptoms: spasms, pain, as well as inflammation of the neck, upper back and shoulders. Keeping your upper body’s muscles strong and activated can help you to avoid slouching and give you a better, healthier posture.

3. My one leg is shorter than the other. Could this be causing my back and hip pain?

Yes. Leg length discrepancy (LLD) is a very common condition. In fact, most of us have some degree of limb inequality, either in terms of structure or function. The average discrepancy is less than 1.1cm and most of us easily compensate for this. However, when the discrepancy is larger, it can result in uneven and excessive loading of the knee joints as well as the joints in the hip and spine, specifically in the lower back.

LLD is associated with scoliosis, lumbar herniated discs, hip arthritis and foot pronation, among other conditions.

A physical therapist will be able to determine whether you have a LLD and confirm if it’s causing lower back, hip, knee or leg pain, and whether you need to be referred further. Smaller discrepancies can easily be treated with a heel lift in the shorter leg’s shoe. Technicians who make these prostheses can help you.

4. I tend to stoop, even when walking. How can I improve my posture, or is my spine curved?

You may have what is known as “rounded shoulders”. This most often develops due to overstretching of the upper back and neck muscles (i.e. slouching) for a prolonged period of time (often years).

When your shoulders slouch, the joint rotates inwards while your head is pushed forward. It usually develops in adolescence or during the early adult years. Girls may adopt an awkward posture to hide breast growth, and when they don’t get out of this phase, they could be stuck with rounded shoulders for the rest of their life.

It’s also common in cyclists, drivers who spend hours in poorly designed or unsupported car seats, in people who sleep in a curled-up position, those who work in front of a computer with their hands on the desk, and pregnant women.

You can correct your stooping posture through a series of home exercises that will improve your posture. Talk to a physiotherapist who could design a workout plan for you.

5. I have back pain that shoots down my leg. Why does this happen?

This could possibly indicate that there’s nerve involvement. Your nerves run from your brain, down your spine. From the spine, they branch out through your body and into your arms and legs. The nerves can sometimes be felt when there’s stiffness in surrounding tissues. 

The best you can do is to keep moving, even when you experience discomfort. If there isn’t a positive response within a few days, you should visit your doctor or physiotherapist.

6. What can I do on my own to make back pain better?

All back pain, including chronic back pain, can be managed conservatively (i.e. without surgery) by moving more, losing weight, and standing and walking more than you sit in a day (even if you experience discomfort). Yoga, massage, specific exercises, and physical therapy are all excellent for reducing back pain.

If you pulled a lower back muscle, ice and pain medication can help. If you experience numbness or paralysis down your legs, or experience bladder or bowel control problems in addition to back pain, you should consult your doctor immediately. 

7. Should I take pain medication? If so, which medicines would be best?

Your doctor is likely to encourage you to manage the pain through exercise, yoga, physical therapy and/or massage. But if the pain is related to osteoarthritis, an injury or even depression, pain medication can provide temporary or additional relief.

Non-steroidal anti-inflammatory drugs (NSAIDs), which come in the form of tablets, gels, sprays and plasters, are the go-to drugs for pain secondary to inflammation and can be purchased over the counter. They help to reduce pain, swelling and inflammation in the muscles and around damaged discs and arthritic joints. Carefully follow your doctor’s prescription, as these drugs do have side effects.

If the pain becomes severe, you may be prescribed an opioid. These drugs interact with receptors in the nerve cells to help reduce pain. Note, however, that opioids are highly addictive and come with serious side effects, so they should be a last (and short-term) resort.

Muscle relaxants can work in the short term to treat muscle spasms. Antidepressants (e.g. duloxetine, venlafaxine and amitriptyline) are also sometimes used to manage pain. Certain anti-seizure drugs (e.g. pregabalin and gabapentin) have been found useful for nerve pain.

Your doctor will advise you on your best treatment options, depending on the mechanism of your pain experience.

8. I experience severe back pain at night, which disrupts my sleep. What should I do?

To help you get a better night’s rest, invest in a medium-firm mattress. Be sure to sleep on your side rather than on your stomach, and use a small pillow to support your spine. You can also put a pillow between your knees to take pressure off your pelvis when you sleep on your side. If you sleep on your back, bend your knees and place a pillow under them.  

If the back pain doesn’t resolve by itself, visit a doctor who can evaluate you. If there’s a suspicion of cancer, infection or abnormal growths, you’ll be referred for special tests and start with medication immediately. These conditions are extremely rare, but you need to rule them out.

A physiotherapist or back pain specialist can make a valuable contribution towards understanding and explaining your problem, and prescribing a solution. This usually includes a combination of manual therapies, exercises and advice on how to best approach daily activities.

9. My child has scoliosis. What’s best in terms of a schoolbag – a trolley bag or a backpack?

If your child has scoliosis, they will greatly benefit from attending a scoliosis exercise programme, offered by a physiotherapist. The Schroth Method, which aims to elongate the trunk and correct imbalances of the spine, is especially helpful and designed for children.

When it comes to backpacks, specialists agree that pulling a school case on wheels is healthier than carrying it. In fact, too heavy a backpack can worsen a child’s scoliosis.

When pulling a trolley bag, make sure your child pulls it with both arms simultaneously and that he or she doesn’t pick it up with momentum if it’s heavy. Make sure that the bag isn’t overloaded, as your child will still have to pick it up when going up stairs or when getting in and out of the car. If they have to pick it up, it’s better to carry the backpack over both shoulders instead of just one.

10. I suffered from undiagnosed, severe back pain for five years and then an MRI pointed to a herniated disc. However, my surgeon says I have improved and that I don’t need an operation anymore. Could this be true?

The human body is absolutely amazing. In fact, it’s far better than all the machines in the world put together. We think we can see what’s wrong by doing an MRI, but we only see the tiniest tip of the iceberg by peeping into the spinal column and brain. Be thankful that nothing serious is wrong and that you don’t have to go through surgery, which often isn’t successful (you may still suffer pain afterwards).

Try to start moving around, even if it’s still a bit painful. Our brains often translate discomfort into pain, telling us that we’re going to end up crippled. When we believe this, we start to avoid the discomfort by not moving. The stiffness in the muscles and joints then increases, leading to more discomfort, and a vicious cycle is set in motion. The only way out is to beat your brain’s interpretation of the discomfort by believing the MRIs and the surgeon’s interpretation. 

This isn’t a quick fix, but it’s important to address your anxiety about your back pain. Talk to a back pain specialist about ways to improve your sleep, reducing your stress levels, and doing exercises that will help you to function optimally again.

11. I have a sore tailbone. Is this as a result of sitting for long periods of time?

This can be from an injury (e.g. a fall onto the tailbone), but usually a poor posture is to blame (i.e. not sitting up properly and slouching).  

The best way to relieve the pressure off the area is to sit on a ring pillow. You can buy one at your pharmacy, or make one yourself with a towel. Also talk to your doctor or physiotherapist about a set of exercises that can improve your posture permanently.

12. Is rhizotomy safe for pain that results from herniated discs that are pressing on a nerve? The bottom two disks are involved.

During this surgical procedure, the nerve roots in the spinal cord that run to the bony spine and joints are severed. The procedure could provide temporary relief, if done for the right reasons, but there are more risks involved in this invasive procedure compared to physiotherapy, exercise and painkillers.

If possible, move your “deadline” for pain relief out by a few months, and give conservative treatment a chance.

13. Can I avoid surgery?

This is a question that can only be answered after a thorough clinical examination. A decision cannot be made based on MRI results only.

Your doctor will need to take all your bio-psychosocial contributors into account (i.e. the whole person and not just the back). This includes your age, general health, your sensation, reflexes and strength (checked by means of a neurological examination), your pain and the progression of your pain, your function and available movement, as well as the impact of the situation on your work, social activities and sleep.

Your response to physiotherapy is also very important, as your pain could clear up after this type of therapy. It’s important to find a therapist with a special interest in orthopaedic manual therapy and/or chronic pain management. Don’t just opt for the nearest therapist.

Surgery might be necessary if you start losing strength, if your bladder and bowel function becomes affected, or if you can’t work or sleep without taking pain medication, despite having tried physiotherapy and other conservative management strategies. If you’re not here yet, relax and give yourself a year or two.

14. What is the best home care for whiplash? When should I see a doctor?

At the moment there’s no clear consensus on the conservative management of whiplash. However, most research shows that an active approach to rehabilitation leads to better long-term outcomes. Rest makes us rusty.  

That being said, it’s always better to be reviewed by a clinician after a whiplash injury to check that there’s no structural damage. A doctor will also guide you towards the correct avenues for rehabilitation. Note that early rehabilitation leads to fewer long-term symptoms and an earlier return to normal functioning.

Doing stretches and strengthening exercises are also important. After initial guidance from a physiotherapist, these exercises can be continued at home.

15. I have a bladder infection and lower back pain. Are they related?

They could be. If a urinary tract infection is severe and affects the kidneys, it’s often felt in the back. You may also experience associated symptoms such as fever and frequent urination.

A urine test and clinical examination should lead to the correct diagnosis and treatment. If the pain doesn’t resolve after the infection has been treated with antibiotics, there’s probably an additional cause for the pain.

16. Is surgery required for a bulging disc?

No, surgery isn’t always necessary, especially if there isn’t a change in sensation or muscle power. Depending on the severity of your symptoms, it’s a good idea to attempt conservative management for about two months before considering surgery.

Although surgery could potentially offer more immediate relief, research shows that, over a period of 10 years, individuals’ ability to work is similar, regardless of whether they received surgery or not.

17. What is the best treatment for muscle spasms?

Muscle cramps and spasms can be caused by a number of factors. This can make it difficult to identify a single best treatment at first. The cause or mechanism first needs to be investigated, and should then be addressed. Your medical history must be taken into account, and a clinical examination and certain laboratory tests will have to be done.

Certain medications could cause spams (e.g. anti-cholesterol medication), while lack of exercise, poor posture, dehydration, and deficiencies in certain micronutrients could also contribute. A multimodal approach will most likely provide the most relief.

18. Do I need a MRI scan or X-ray for my back pain?

The American College of Physicians as well as the American Pain Society recommend against routine imaging for individuals with non-specific lower back pain. Various research studies have shown that doing X-rays or MRI scans without good reason (such as severe or progressive neurological symptoms) doesn’t improve outcomes.

19. Is my back pain caused by a pinched nerve or tight muscles?

This can be determined by assessing your symptoms and doing a few clinical examinations. Muscle pain tends to be localised to the areas around the muscle, whereas nerve pain tends to radiate down towards the legs or arms.

The pain also tends to be different. Muscle pain can feel stiff and aching, whereas nerve pain tends to be sharp or stabbing. You may experience electric shock pain or burning, and nerve pain may also be associated with a tingling or pins-and-needles sensation. Your doctor or therapist may ask you to perform certain movements to test for nerve irritation. If there’s any doubt, it’s a good idea to consult a specialist.

20. I have back pain. Should I stay in bed and rest?

No. Research shows that people with acute back pain who rest in bed have slightly more pain and slightly slower or less functional recovery than those who stay active. Sometimes just resuming your normal activities can give you the best long-term outcome (as much as the pain permits, of course).

Reviewed by general practitioners Dr Lienka Botha and Dr Suzette Oelofse, FX Health. April 2018.