If your back hurts you need an x-ray or an MRI, right? You need to know exactly what the problem is, right? Not exactly. Read this to see what the proper diagnosis sequence should be for back pain.

The Truth About Low Back Pain

Items to focus on:

1.     Common misconceptions around back pain, sciatica, and herniated discs
2.     Professional recommendations regarding physical therapy and conservative management

Weekly, almost daily, someone shares with me that they hurt their back doing some activity that they “shouldn’t have been doing.” They’ll attribute this to a herniated disc, slipped disc, sciatica, or some other malady. Or, they attribute it to some random motion they did the day prior or the fact that they sit at a desk most of the day. Often times, they share that this back pain is severe, know someone who’s had this type of pain before, and ended up having to get surgery. Well… that escalated quickly. Talk about a self-fulfilling prophecy. It’s amazing to me that no-one told them how beneficial physical therapy can be for back pain. This is the point in the conversation where I politely ask to put the brakes on and then slowly we back up to what actually happened.

I want to start this off with a question. If you are experiencing severe back pain try asking yourself, have I undergone a serious injury? (car accident, hard fall, etc.)? Keep your “yes” or “no” answer in mind as you continue reading scenario


Jim is cleaning up his backyard of his newly purchased home. What he didn’t realize when he made the purchase is that there were so many large rocks that he would have to move in order to put in a lawn and sprinkler system. He was going to hire a gardener to do this, but hey, he just finished watching “Rocky,” he’s feeling strong, and he doesn’t find the sense in paying someone to move some puny rocks if he can do it himself.

So Jim goes and throws rocks around for a few hours. By the time he’s done, he’s developed a sharp pain on the mid to lower left side of his back. It’s debilitating. He can now barely bend over to put his socks on. He needs to lie on his bed just to get his pants on.

Two days go by and it’s really not much better. He starts to become concerned and remembers that bending, twisting, and lifting is “bad.” He remembers that his own father had back pain and that it NEVER went away. He starts to think about his job, “what if I can’t stand sitting for > 1 hour, how am I going to drive to work?” This then causes him to question “what if I lose my job!” All of these thoughts are permeating through Jim’s mind. He wonders if he needs an x-ray or an MRI.

Ok, let’s pause again. Does Jim need the x-ray or MRI? Yes or no?

The answer is…..

Most likely not. Jim does have the occasional jolt that goes down his leg, but this is pretty normal in the instance of back pain. In the absence of progressive numbness, tingling, weakness, pain, loss of bowel and bladder, loss of reflexes, or a dangerous (fall, car accident) mechanism of injury, imaging is likely not necessary.

This excerpt is from the American Academy of Family Physicians going into more detail of when something is a “red” flag, please read it carefully!


Don’t do imaging for low back pain within the first six weeks, unless red flags are present. (Red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected.)

Low back pain is the fifth most common reason for all physician visits. Imaging of the lower spine before six weeks does not improve outcomes, but does increase costs.

Supporting Information

Low back pain is one of the most common reasons for an outpatient visit. The evaluation for low back pain should include a complete, focused medical history looking for red flags, which include, but are not limited to: severe or progressive neurologic deficits (e.g., bowel or bladder function), fever, sudden back pain with spinal tenderness, trauma, and indications of a serious underlying condition (e.g., osteomyelitis, malignancy). It is also important to rule out nonspinal causes of back pain, such as pyelonephritis, pancreatitis, penetrating ulcer disease or other gastrointestinal causes, and pelvic disease. Fractures are an uncommon cause of back pain; they are associated with risk factors such as osteoporosis and steroid use.

Most patients with radicular symptoms will recover within several weeks of onset. The majority of disc herniations will regress or reabsorb within eight weeks of onset. In the absence of progressive neurologic deficits or other red flags, there is strong evidence to avoid CT/MRI imaging in patients with non-specific low back pain.”(1)

You’re probably thinking, “well that’s nice to know, what do I do then if my back hurts?” Well, you’re in luck, because the answer is pretty simple. I would tell Jim to keep moving. While it is tempting to “rest” our backs when they hurt, this is actually the opposite of what we should be doing in many cases. If you are the rare bird who deadlifts 5 times per week, then a bit of rest might do you well. If you are everyone else, then rest is probably the opposite of what you need.

In 2011, it was estimated based on a survey of 49,000 individuals in the US that only 20.6% of people get the recommended minimum of exercise per week. This includes aerobic activity which includes walking, biking, running, swimming, etc, and strength training such as lifting weights and various gym regimens.(2)

If you do fall into the category of people who have back pain and don’t get the recommended levels of exercise here is a sample of what you can do to help make you feel a bit better while your back pain resolves.

  1. Go to work. Individuals who take time off of work for lower back pain are more likely to develop persistent pain problems.
  2. Go for daily walks, 20-30 mins.
  3. Modify your gym routine. If you were doing a certain exercise and it hurt too much to complete, change it up a bit. There are infinite ways to modify exercises so you can complete your workouts!
  4. Recognize that most people will experience back pain at some point in their life and that in most cases it will go away.
  5. There are plenty of other things that are also very important to living a healthy and fulfilling life. These are equally as important than the above recommendations for lower back pain:
    1. Nutrition — eating healthfully and thoughtfully
    2. Sleep — getting enough of it
    3. Stress — developing stress management skills — we cannot eliminate all stress but we can learn how to manage it well
    4. Spirituality — religious practices, meditative practices, and other types of spirituality is important for our overall well-being
    5. Healthy relationships
    6. Self-reflection and personal development

The above list will be developed further in future articles. I hope that the information in this article was valuable to you, and, if you’d like more information please shoot me an email or leave a comment below.

Nathan is a Doctor of Physical Therapy focusing on orthopedics with a particular passion for the education and treatment of low back pain. Nathan is a former football player turned amateur powerlifter and has worked with dozens of individuals with persistent and acute pain.


  1. American Academy of Family Physicians. Imaging For Low Back Pain. Choosing wisely campaign. Received from:https://www.aafp.org/patient-care/clinical-recommendations/all/cw-back-pain.html
  2. Centers for Disease Control (May 3, 2013). Adult Participation in Aerobic and Muscle-Strengthening Physical Activities — United States, 2011. Morbidity and Mortality Weekly. Report. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6217a2.htm?s_cid=mm6217a2_w