Lower Back Pain — A Complete Guide
Whether your pain came on suddenly or has been building for years, understanding what's happening is the first step to getting better.
Lower back pain is one of the most common reasons people visit an osteopath — and one of the most misunderstood. Whether it came on suddenly after lifting something awkward, or has been building gradually for months, the experience is the same: it affects everything. How you sleep, how you sit, how you move through your day. This guide is written to help you understand what's actually happening, what tends to make it better or worse, and how hands-on osteopathic treatment can help — whether you're in the middle of a flare-up or trying to prevent the next one.
Why I wrote this guide
I've had lower back pain since I was 12 or 13 years old.
As a kid I was relentlessly active — rugby in the morning, football in the afternoon. My back was a constant companion in the wrong way. I saw physios, chiropractors and osteopaths throughout my teens, found most benefit from osteopathy even if I now suspect my diagnosis wasn't quite right, and learned to manage around it rather than through it.
It's only through years of clinical training and obsessive personal research that I've come to understand what was probably happening all along — a disc injury that was never properly identified, influencing everything from how I moved to how much pain I was in on any given day.
I’m actually somewhat injury prone, which is ironic or fortunate considering my profession. I've had the bone-deep, gnawing pain of sciatica radiating down my leg. I've had facet joint episodes so acute I couldn't stand straight for two days. I know what it feels like when back pain stops you doing the things you love. I also know the frustration in not knowing why it happened, what it is and how to fix it.
These days I'm mostly pain free. I can run, swim, lift weights and look forward to playing with my son without my back dictating the terms. My rugby days are behind me — but that's a fair trade. What I've learned is that the goal isn't to fix or cure back pain. We are living, dynamic bodies. We aren't always going to be pain free and that's okay — that's normal. The goal is management, understanding and building a body that's resilient enough to get on with life.
Everything in this guide is the result of years of clinical experience combined with the kind of motivated personal research you only do when you're desperate to fix yourself.
I wrote it because I wish someone had handed it to me when I was a teenager.
Understanding lower back pain
Lower back pain is rarely one thing. The lower back is a complex structure — vertebrae, discs, joints, muscles, ligaments and nerves all working together to keep you upright, mobile and absorbing load. When something goes wrong, it's often a combination of factors rather than a single dramatic cause.
Most lower back pain falls into two broad categories. Specific pain — where there's an identifiable structural cause such as a disc herniation, facet joint irritation or nerve compression. And non-specific pain — which accounts for the majority of cases, where no single structure is clearly to blame but the pain is very real regardless.
The good news is that most lower back pain, even when severe, responds well to hands-on treatment. Understanding what type of pain you have is the first step — and that's exactly what a thorough osteopathic assessment is designed to establish.
What's actually causing your lower back pain?
Most people arrive at this section with the same question — what's wrong with me? The honest answer is that without a proper assessment it's impossible to say. Lower back pain rarely announces itself with a clear label. You just know it hurts, and you want it to stop.
What I can tell you is that most lower back pain comes from a relatively small number of causes. Some of them I've experienced personally. All of them respond well to the right treatment approach. Here's what's most likely going on.
Before we go further — while the vast majority of lower back pain is musculoskeletal in origin, there are symptoms that warrant urgent medical attention. Sudden loss of bladder or bowel control, or incontinence, alongside numbness or tingling in the saddle area — the region you'd sit on a bike — can be signs of cauda equina syndrome, a rare but serious condition requiring emergency assessment. It's worth noting that these symptoms can sometimes occur independently without indicating cauda equina, but together they should always be taken seriously.
Lower back pain can occasionally be a symptom of something other than a musculoskeletal problem. Things to be aware of include unexplained severe weight loss, pain that is unrelated to movement or position, or pain that is progressively worsening without any mechanical pattern. If any of these apply to you, it's worth speaking to your GP before seeking osteopathic treatment.
If you're in any doubt, feel free to contact me directly and I'm happy to advise.
You may have heard the term "non-specific lower back pain" — a label used when no single identifiable cause can be confirmed. While it's commonly used, in practice most lower back pain does originate from a specific tissue. The challenge is identifying which one. The causes below represent the most common sources and the structures most likely to be involved.
Disc injuries — herniation, prolapse or bulge
The disc sits between each vertebra acting as both a shock absorber and an enabler of movement. That dual function means it bears more load than any other structure in the spine — more than the surrounding muscles, more than the joints. When the outer casing is compromised — through injury, load or gradual wear — the inner material can bulge or push outward, irritating surrounding structures and sometimes compressing nearby nerves.
Disc injuries are far more common than most people realise, and a diagnosis doesn't mean surgery or a lifetime of pain. The vast majority respond well to hands-on treatment, movement and load management. The key is understanding what's happening and addressing it properly.
Read more about disc injuries here: Slipped disc, prolapse, or herniation?
The facet joints run down either side of the spine and guide how your vertebrae move relative to each other. When they become irritated or inflamed — through sudden movement, sustained or extended posture, rotation, or gradual wear — the pain can be sharp, localised and severe. It's often worse bending backwards or twisting, and can cause a visible lean to one side as the body instinctively offloads the painful joint.
I've had episodes where I couldn't stand straight for two days. It feels alarming but it typically settles well with the right treatment.
Read more about facet joint pain here: Facet Capsule Irritation, and back pain?
When disc material irritates the sciatic nerve, pain can travel from the lower back down through the buttock and into the leg — sometimes as far as the foot. Joint and bone irritation can also refer pain into the leg, though through a different mechanism. The quality of true sciatica is distinctive — gnawing, burning, sometimes electric. I've been there. It's one of the most distressing presentations I treat, and one of the most satisfying to resolve. Read more about sciatica here: Understanding Sciatica & what to do — Holland Osteopathy.
What most people describe as a pulled muscle in the back is usually a secondary response — muscle spasm around an injury to another structure rather than a primary muscle tear. True muscle strains are less common in the back than people think. A proper assessment will identify what the muscles are actually reacting to.
The exception is muscular fatigue — common in people sustaining prolonged standing or loaded postures where the lumbar muscles are working continuously. This produces a deep, aching pain that builds gradually under load and is temporarily relieved by movement. A proper assessment will distinguish between the two.
Read more here: Pulled a Muscle in Your Lower Back? It's Probably Not That
Ligaments connect bone to bone and are designed to tough and resistant to load. In the spine they play a crucial role in stability — the posterior longitudinal ligament, for example, acts as a restraint against disc herniation. True ligament sprains in the lower back do occur, typically following significant trauma, but are far less common than people assume. Like muscle pain, ligament pain in the back is often a secondary response to injury elsewhere rather than the primary cause.
Degenerative disc disease
Despite the name, degenerative disc disease isn't a disease and it isn't necessarily a life sentence. It describes the natural ageing process of the discs — they lose some hydration and height over time, which can cause pain and stiffness. Most people over 40 have some degree of disc degeneration on imaging. One study on 15 year olds showed that about 1/3 had some signs of degeneration. So degeneration isn't purely an age related phenomenon either. What matters is how it's managed, not how it looks on a scan. Read more about degenerative disc disease here: Degenerative Disc Disease: Symptoms & Treatment Options?
Spondylosis
Spondylosis is arthritis of the spine — age related changes to the vertebrae and facet joints that can cause stiffness, aching and sometimes nerve irritation. While degenerative disc disease primarily affects the discs between vertebrae, spondylosis describes changes to the bony structures and joints themselves. The two frequently coexist. Like DDD, the presence of spondylosis on a scan doesn't automatically mean you'll be in pain — many people have significant changes on imaging and minimal symptoms. Treatment focuses on keeping you moving well and managing flare-ups.
Read more here: Osteoarthritis of the spine (spondylosis).
Spondylolisthesis
Spondylolisthesis occurs when one vertebra slips forward over the one below it. This can happen as a result of trauma, a stress fracture in the vertebral arch, or gradual degeneration of the facet joints and discs that normally keep the vertebrae aligned. Depending on the degree of slippage, it can cause local lower back pain, stiffness, and in some cases nerve symptoms if the displaced vertebra narrows the spinal canal or compresses nearby nerve roots. It's less common than the other causes covered here but worth knowing about — particularly if your pain came on after significant trauma or has a notable instability quality to it. Most people with spondylolisthesis manage well with the right conservative approach.
Read more about spondylolisthesis here: Spondylolisthesis — What It Is and What It Means for Your Back
Does this sound like you?
Lower back pain doesn't affect everyone the same way — what's driving it, and what tends to help, often depends on how you use your body day to day. The patterns below aren't rigid categories; they're tendencies, not rules, and many people will recognise themselves in more than one. Find the one that sounds most like you to start.
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Pain that flares with rotation, sprinting, or impact often comes down to training load rather than lasting damage. Rotational sports and running load the spine through repeated impact and twisting, which tends to aggravate disc and facet joint tissue rather than cause new injury outright. The key distinction I'm looking for is whether this is a load management issue — pain that builds with volume and eases with rest — or something needing more caution, like pain that doesn't settle with reduced training or comes with neurological symptoms. Most sports-related back pain responds well once we identify what's driving it and adjust load accordingly, not by stopping activity altogether.
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Pain under load often ties back to lumbar flexion or bracing technique rather than the weight itself. Lifting puts the spine under compressive and shear forces, and how well you tolerate that comes down largely to technique — particularly how much lumbar flexion happens under load, and how effectively you're bracing. Interestingly, technique often isn't the problem when things start — it's what happens as fatigue sets in. I regularly see people with genuinely good form who hold it together for most of a session, then lose it on the last few reps or the last set of the day, and that's exactly when injury tends to happen. This is rarely about lifting being "bad for your back"; it's about the specific pattern — and the point in a session — where tissue gets loaded unevenly. Part of what I do here is identify whether it's a technique issue, a fatigue-management issue, or an underlying tissue sensitivity that needs addressing before you load it further.
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Growing bodies have their own back pain causes, and this age group needs a different lens entirely. Growth-related changes, conditions like Scheuermann's, and a higher relative risk of spondylolysis (particularly in sports involving repeated extension, like gymnastics or fast bowling) mean teenagers need their own assessment approach rather than a smaller version of adult treatment. Disc injury is also far more common in this age group than people expect — mine started as a teenager, and it's often where the whole picture begins for a lot of people I see. I wrote this guide partly because I wish someone had explained this distinction to me at that age — persistent pain in a teenager is worth taking seriously and looking at properly, not just waiting out.
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Pain in this group tends to show up in one of a few ways: a dull ache that builds gradually through the day or week, a flare after an unaccustomed activity (a long walk, a weekend of gardening, moving furniture), or pain that seems to come from nowhere. That last one is worth a caveat — most pain that "comes out of nowhere" actually has a build-up we didn't notice, whether that's weeks of poor sitting posture, tightening hip flexors, or general deconditioning quietly lowering your tissue's tolerance until something ordinary tips it over. This group frequently benefits as much from addressing movement habits and hip/core conditioning as from hands-on treatment alone.
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What's driving your pain often shifts with age, and it's worth knowing which pattern fits you. Younger backs more commonly present with disc-driven pain — the disc is more hydrated and load-bearing capacity is high, so injury here tends to dominate. As we age, degenerative changes shift more load onto the facet joints, and presentations become more commonly facet- or stenosis-driven, with different aggravating factors (extension and standing tend to worsen facet/stenosis pain, whereas flexion often worsens disc pain). Neither pattern is fixed to an age — it's a tendency, not a rule.
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