Back pain diagnosis and causes: what’s really going on in your back

Back pain is one of the most common reasons people come to see us at Zest Chiropractic. Here’s what you need to know about what causes it, how it’s properly diagnosed and when you should seek help.

Key takeaways:

• Around 90% of back pain is mechanical — a movement, load, or posture problem — and responds well to hands-on treatment.
• Diagnosis involves a detailed case history, physical examination, orthopaedic and neurological testing. Scans or x-rays are not always necessary.
• The type and pattern of your pain gives strong clues about which structure is involved — disc, joint, nerve, or muscle.
• Sciatica is a symptom, not a diagnosis. It describes nerve pain travelling down the leg and has several distinct causes.
• Red flag symptoms — loss of bladder or bowel control, saddle area numbness, new back pain with history of cancer — require same-day medical attention.
• NICE guidelines recommend manual therapy, including spinal manipulation, as part of the care pathway for low back pain.

What is the most common cause of back pain?

The most common cause of back pain is mechanical dysfunction — problems with the way the joints, muscles and discs of the spine move and load. Mechanical back pain accounts for roughly 90% of cases. It’s not caused by serious disease; it’s usually a movement problem, a load problem, or a postural problem that has built up over time. The great thing about that is that mechanical causes can respond really well to chiropractic care.

The remaining causes of back pain include:

• Inflammatory conditions such as ankylosing spondylitis, or inflammatory arthritis
• Disc pathology — herniated or degenerated discs putting pressure on nerve roots
• Nerve-related pain, including sciatica
• Referred pain from other organs (less common, but important to rule out)

If you’re not sure which camp your pain falls into, getting a proper assessment is the most useful first step (unless you have red flag symptoms, in which case seek immediate medical attention.) You can get in touch with us here to book an initial consultation.

How is back pain diagnosed?

Back pain is diagnosed through a combination of case history, physical examination and — where needed — imaging. At a chiropractic consultation, this is a thorough process, not a five-minute chat and a quick press of the lower back.

Taking a detailed case history

Before anything is examined, we listen. The story of your pain tells us more than an MRI scan in many cases. When it started, what makes it better or worse, whether it travels into the leg, whether it came on after a specific incident or crept up gradually — all of that shapes the clinical picture significantly.

Key questions we work through:

• Is the pain worse in the morning — suggesting inflammation or disc involvement — or at the end of the day, suggesting postural load?
• Does it radiate down the leg, and if so, how far?
• Is there any weakness, numbness, or tingling?
• Have you noticed any changes in bladder or bowel function? (This is a red flag requiring urgent medical attention at A&E.)

Physical and orthopaedic examination

This involves assessing spinal range of motion, palpating the joints and muscles for restriction or tenderness and performing specific orthopaedic tests to identify the likely structure(s) involved. Tests like the straight leg raise, Kemp’s test, and FABER help us isolate whether the source is in the lumbar spine, the sacroiliac joint, the hip, or the nerve tissue.

Neurological assessment

If nerve involvement is suspected — pain shooting into the leg, or numbness following a specific dermatome pattern — we assess reflexes, muscle strength and sensation to identify which nerve root may be affected.

Imaging (when necessary)

X-rays and MRI scans are not always needed and we’re careful about when we refer for them. Studies consistently show that imaging findings often don’t correlate with pain levels. Many people with significant disc degeneration on MRI have no pain at all. We refer for imaging when there are red flags, when symptoms aren’t improving as expected, or when surgical evaluation may be appropriate.

The different types of back pain and what they mean

The character and pattern of your pain gives strong clues about which structure is involved. Here’s how we think about it clinically.

Sharp, stabbing pain with movement

This typically points to a facet joint problem — one of the small joints at the back of each vertebra that has become restricted or irritated. You’ll usually notice a specific movement, like rotating to one side or bending forward at an angle, that provokes it sharply. Chiropractic adjustments work well for this kind of problem.

Deep, aching, constant pain

More suggestive of disc involvement or significant muscle tension. If it’s disc-related, the ache often builds over the course of the day with sustained sitting, and eases when you get moving. If it’s muscular, there’s usually notable tenderness when the muscles are pressed, and heat, or gentle movement takes the edge off.

Pain that radiates into the leg

This is the hallmark of sciatica — nerve pain travelling along the sciatic nerve, from the lower back through the buttock, down the thigh, and potentially into the calf or foot. The character is often burning, shooting, or electric rather than a dull ache. It’s caused by compression or irritation of one of the nerve roots that form the sciatic nerve, usually at the L4, L5, or S1 level.

Stiffness rather than pain

Morning stiffness that lasts more than 45 to 60 minutes and gradually eases through the day is worth investigating for inflammatory causes rather than purely mechanical ones. Although mechanical causes of back pain often involve stiffness too. Persistent stiffness should be assessed by your GP to rule out conditions like ankylosing spondylitis.

Pain with no clear movement pattern

If your back pain doesn’t follow a consistent pattern — it’s not better lying down, not better sitting, and isn’t provoked by specific positions — it’s worth exploring whether there’s a referred, or systemic cause behind it.

Common conditions that cause back pain

Muscle strains and ligament sprains

The most straightforward cause. Overstretching, lifting incorrectly, or a sudden awkward movement can strain the muscles and ligaments of the spine. The pain is usually localised, tender to touch and improves over days to weeks with appropriate care and movement.

Disc problems — herniation, bulge and degeneration

The intervertebral discs act as shock absorbers between each vertebra. When a disc bulges or herniates, it can press against a nerve root, producing referred pain, numbness, or weakness in the leg. You may also hear of this being called a slipped disc. Disc degeneration — the gradual reduction in disc height and hydration — is a natural part of ageing, but can become symptomatic when it changes how load is distributed through the spine.

Facet joint syndrome

Each vertebra connects to its neighbours via two small facet joints at the back of the spine. These joints have cartilage and synovial fluid, just like a knee or shoulder and when they become inflamed, restricted, or degenerated, they produce localised back pain that’s typically worse with extension and rotation.

Sacroiliac joint dysfunction

The sacroiliac joints connect the base of the spine to the pelvis. It’s a surprisingly common and commonly missed source of low back pain. SI joint pain tends to sit in the lower back and buttock area, sometimes mimicking sciatica. It is often aggravated by prolonged standing, walking, sit to stand movement, or going up stairs.

Sciatica

Sciatica is not a diagnosis in itself — it’s a symptom describing pain that follows the path of the sciatic nerve. Common causes include disc herniation, spinal stenosis, or piriformis muscle tension compressing the nerve as it passes through the buttock. Each cause requires a different treatment approach, which is why proper assessment matters.

Poor posture and sedentary loading

This is where we see the most cases in practice today. Sustained sitting — particularly with a rounded lower back and a forward head position — places the lumbar discs under chronic compressive load and keeps the hip flexors in a shortened, dysfunctional state. Over time, this changes movement patterns and creates the conditions for pain. If this sounds familiar, our post on why your back hurts and what to do about it goes into more detail.

Arthritis

Osteoarthritis in the spine — sometimes called spondylosis — involves the gradual wear of joint cartilage and disc material. It’s very common in people over 50 and doesn’t always cause pain, but when it does, the pattern is typically stiffness and achiness that’s worse in the morning and after periods of inactivity. We work with patients managing arthritis-related back and joint pain regularly, helping to maintain joint mobility and reduce the muscular tension that builds around affected areas.

What are the red flags in back pain?

Most back pain is benign and responds well to conservative care. However, certain symptoms indicate something more serious that requires same-day medical attention. These are known as red flags:

If you are experiencing any of these symptoms they require immediate medical attention. Don’t wait to see if they improve.

Can a chiropractor diagnose back pain?

Yes — chiropractors are trained to diagnose musculoskeletal conditions, including back pain, through exactly the kind of clinical assessment described above. In the UK, chiropractors are regulated by the General Chiropractic Council (GCC) and complete a four-to-five year Masters-level degree that includes clinical diagnosis, orthopaedic and neurological assessment, and differential diagnosis.

What a chiropractic consultation offers beyond a standard GP appointment is time, in-depth examination, and a full body approach to assessment and treatment. A consultation at Zest Chiropractic involves a thorough case history and physical examination, so any treatment plan is tailored to your specific needs. You can also find out more about what to expect at your first appointment before you come in.

What happens after a diagnosis?

Getting a diagnosis is the starting point, not the destination. Once we understand what’s causing your pain, treatment is tailored to you as an individual. It can include spinal manipulation to restore joint movement, soft tissue work to address muscular tension, targeted exercises to build load tolerance and practical advice on posture and daily habits that may be contributing to the development of your condition.

If your back pain hasn’t resolved on its own, the most useful thing you can do is get a proper assessment. You can explore all the conditions we treat or find out more about how we approach back pain specifically.

Frequently asked questions