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Top 5 causes of low back pain. What is the best treatment for each diagnosis?

Sciatica or Sciatic pain is an umbrella term describing the pain pattern from lower back towards the knee or foot. Most common cause of lower back pain seeking medical intervention is lower back disc herniation because of its severity and pain pattern shooting down towards their foot.

However, muscle originated pain is also not uncommon. Piriformis (Hip external rotator), Psoas muscle (Hip flexor) or Quaratus Lumborum (muscle right above your pelvis) muscle over activation/ spasm can be a source of lower back or leg pain. Trigger points (irritated muscle knot) in these muscles can refer the pain to the surrounding area.

OpenStax College [CC BY 3.0 (https://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons

1. Disc Herniation

If the spine is being compressed by tight surrounding muscles and fascia, disc has more chance of bulging outside with wrong sitting or sleeping posture. So, it is important to decrease tension in the body with stretching, ergonomic correction and breathing exercise program.

Pain pattern: pain shoots down from lower back towards knee or foot

Test: Lower back movement limitation is noticeable, Positive Nerve tension test (Straight leg raise and slump test)

Treatment: repeated movement can make the symptom better (Usually lower back extension exercise improves symptom), myofascia release or lower back traction can decrease tension in lower back

Prognosis: symptom moves to the center of lower back and pain diminishes.

Patrick J. Lynch & KDS4444 [CC BY-SA 2.5 (https://creativecommons.org/licenses/by-sa/2.5)], via Wikimedia Commons

2. Piriformis tightness

Sciatic nerve is the biggest nerve coming down from lower back. This nerve passes through piriformis muscle and can be entrapped if the muscle has spasm or tightness which can cause pain, numbness or tingling sensation in lower leg or foot. Piriformis syndrome has a similar test result with disc herniation such as positive straight leg test, slump test and lower back movement limitation. If it is simple muscle spasm or tightness, the symptom will be decreased after releasing the trigger point in piriformis muscle. If it is not better after treatment, lower back disc herniation should be suspected since piriformis can have spasm if sciatic nerve is irritated from herniated disc.

Test: piriformis palpation, figure 4 stretching test, hip rotation range check

Treatment: Myofascia release, trigger point release and stretching exercise

Beth ohara [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/)], from Wikimedia Commons

3. Psoas overactivation/ spasm

Over activated psoas muscle can cause lower back pain radiating down to groin area. Since psoas muscle origins from lower back and inserts into the upper hip bone, shortened psoas bends lower back forward and tilts pelvis anteriorly. You will find difficulty in extending your back straight or backward.

Test: psoas muscle palpation, Thomas psoas length test, back and hip range of motion

Treatment: Psoas muscle myofascia release, trigger point release and stretching exercise

Treatment program should include antagonist and core strengthening program and habitual pattern modification (sitting or sleeping posture education)

4. Quadratus Lumborum (QL) overactivation/ spasm

QL muscle can increase pain in the posterior aspect of lower back which is common in athletes using lower back movement intensively. Key to successful treatment consists of trigger point therapy, education of self trigger point release, stretching program and balancing the surrounding muscles.

Test: trigger point palpation

Treatment: Trigger point therapy, myofascia release, stretching program, core strengthening

Since recurring rate is high, self trigger point release technique, customized exercise program and ergonomic modification are important.

5. Meralgia Parastheticia (Pain or numbness in the anterior thigh)

Patients feel numbness or strange sensation in their upper thigh. The symptom occurs when the lateral femoral cutaneous nerve is compressed in the groin area due to tight structures. The symptom decreases if the tension around inguinal ligament (groin area) decreases with manual therapy and stretching program.

Test: hip flexor/ inguinal ligament palpation and tension test

Treatment: Myofascia release, trigger point therapy, stretching program

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