What is Causing Your Lower Back Pain? Insights from 10 Years as a PT
"What is causing my lower back pain?" My patients often ask me this. But if we search for the cause, we will often not find it. I don't care how good you are or your doctor; it's been proven that about 10% of back pain can be accurately diagnosed. In that, what you feel matches up exactly with what an X-ray or MRI will show.
Accepting that can be hard but the truth is, we don't need an 100% accurate diagnoses to begin treatment and achieve 100% pain relief. Who really cares as long as you get better? After 10 years of treating patients here is what I have learned.
What Is the Root Cause of My Lower Back Pain? A Physical Therapist’s Insight
The answer is more complex than most people expect. After nearly a decade of treating back pain, I’ve realized that the traditional methods we use to diagnose pain, such as imaging and labels like “degeneration” or “disc bulge,” often miss the mark entirely. We can't see pain in an image, so stop taking pictures and start teaming up with people who will get their hands on you!
Why Imaging Alone Can’t Find the Root Cause of Back Pain
It’s completely normal to want answers—and fast. That’s why so many people seek out an MRI or X-ray. But here’s what you need to know:
X-rays and MRIs often show disc bulges, arthritis, or “degenerative” changes, even in people who have zero pain. Many of these findings are simply a part of aging.
Example: You might be told your MRI shows “disc degeneration” or “bulging,” but did you know that more than 50% of people over 40 have those findings—even if they feel great
When imaging is used without clinical context, it can create fear. You can be left thinking something is “wrong” with their spine, even when your imaging doesn’t correlate with their symptoms. Imaging has several problems associated with it.
Finding the cause of your back pain is one of the hardest things to do, and that's why lower back pain is the most costly, complex, and time-consuming condition to treat.
Quick note: a physician is capable of diagnosing back pain, but what I have seen and what the research shows is that you are likely to receive imaging and not a physical examination (which is more appropriate and cheaper) if you go to a physician first for back pain. I know I am biased by seeing a PT, so they can help you figure it out and start treatment on the same day!
The Causes of Lower Back Pain We Are Good At Diagnosing:
- Stenosis
- Sciatica
- Back strain
- Stiffness and Mobility Deficits
can diagnose back pain, but I have seen and the research show
Spinal Stenosis is a condition of the spine in which the natural space around the nerve starts to decrease, resulting in pain in the lower back, glute, or leg, often in people over 60.
Treatments include reducing pressure on the nerves with flexion-based exercises and nerve glides.
Sciatica
Sciatica is a condition that can involve intense leg pain from a herniated disc or stenosis. It includes pain, weakness, and changes in sensation, such as numbness and tingling. Some say it's a pinched nerve, but it can be very uncomfortable, a leading cause of seeking physical therapy.
Muscle Strain
A classic back strain can be of any muscle in the lower back—there are plenty of them. A muscle strain can make it difficult to move, and it can feel like you're going to wither away! Trust me, I have had plenty. They get better quickly, and if they don't, it's often due to underlying trigger points or disc issues. If you believe you may have a strain, check out this video to help you figure it out!
Often, a strain requires time, rest, and gentle stretching to ensure proper healing and recovery. A good hot pack can also make a difference!
Stiffness and Mobility Deficits
Stiffness and mobility deficits are by far the most common I diagnose. It typically looks like this. Someone with general aches and pain in the lower back and hips. They are typically not super flexible, haven't been exercising, and have a hunch they would feel better if they did some stretching and strengthening.
Free Lower Back Pain Stretching PDF!
Lower Back Pain We Are Not Good at Diagnosing:
- What Level of the Spine is Causing the Pain? For example, L4, L5
- Back pain from CancerBack pain from Degenerative Disc Disease, Arthritis, and Disc Bulge and More
- Other causes including Hypersensitivity Disorders
- These are terms that all mean the same thing and often start in your 20s.
Specific Levels of the Back Causing Pain is Hard to Identify
You won't find anyone willing to bet exactly what level or where your back is coming from. Everything in the lower back is so close and your brain has a hard time identifying the location as well. Even if you point to your pain, there are at least a dozen structures under your finger.
When we treat its never focusing at one level, we improve the entire spine at once.
Back Pain from Cancer
This is very rare, and less than 1% of those with chronic back pain. That said, I have seen it. This was when I had a patient with a history of cancer, and while their back pain was getting worse, they were also experiencing weight loss, night sweats, and chills. Those symptoms are signs something is going on in your body. Make sure to tell your doctor right away!
Back Pain from Arthritis or Degeneration
No one likes to talk about it, but arthritis or degeneration starts in your 20s! This includes disc bulges, loss of disc height, and facet degeneration.
Now, all isn't lost. While those things do happen, it doesn't mean you will have pain! What makes this hard to diagnose is that many people have these findings on images and will have pain, but their pain will vary. I mean that the pain is terrible one day, and the next day, you're feeling better. Did your arthritis change that quickly? No, but how you think can. That's why, while it is common and no one enjoys hearing they have arthritis, you can treat degeneration without knowing the exact cause.
- Arthritis is normal.
Many people with moderate or severe arthritis have no pain at all. - Degeneration is expected.
Think of it as wear and tear—it happens with time, like wrinkles or gray hair. It doesn't mean you're broken. - “Bone on bone” doesn’t always hurt.
Even this phrase, often used to justify surgery, doesn’t guarantee pain. I’ve seen many patients with these findings live active, pain-free lives.
Hypersensitivity and Related Disorders
This can include fibromyalgia. In my experience, this is a garbage can term that when people don't know what is causing your pain, they mention fibromyalgia to help give you a diagnosis. I don't like to label people. But I will say those with hypersensitivity typically look like this:
- Are very aware of their body and every ache and pain
- Active and unsure why they are not improving
- Multiple areas of their body that are sensitive to touch
- Flexible but not strong
Those are some common traits that I have seen. If that sounds like you, team up with a great physical therapist and help them learn your body so you can find the exact treatment that works for you. Try to be patient with them! :) Also, consider modalities such as dry needling; they can be helpful.
Here is What See When I Treat Actual Patients with Lower Back Pain
Traditional Medicine Often Misses the Mark
The medical system is structured to look for clear, anatomical causes. That works well for fractures or tumors, but not for most cases of lower back pain.
In fact, research shows that in only about 10–15% of cases, we can definitively diagnose the cause of lower back pain.
Conservative Treatments Help—But Aren’t Always Enough
Conservative care like physical therapy, chiropractic, massage, dry needling, and acupuncture can be essential parts of care. I use many of these in my practice. But here’s the truth:
Finding what works for you is hard!
You may have been told your issue is due to “core weakness,” “tight hip flexors,” or “muscle strain.” And maybe you’ve tried endless exercises or stretches that didn’t help—or helped only a little. Everybody is different, and what worked for your friend may not work for you!
Most Need a Holistic, Evidence-Based Approach to Back Pain
In my experience, the most effective way to address persistent back pain is to step back and take a 15,000-foot view of the problem.
Here's what that looks like:
- Comprehensive assessment: Listen to your story and learn about your body
- Dial in what works for you
- Treat the entire body, not just your back
- Focus on what we can change
- Hands-on work such as stretching and mobility
- Massage, manipulation, or mobilization
- Progressive exercise: focusing on hips, back, legs, and nerves
- Take the time needed!
- Most need a few sessions to learn your body then figure out what works best for you!
- Constant feedback between me and you!
- No one in your body is better than you!
Final Thoughts: Finding the Root Cause of Your Pain
The truth? There’s rarely just one root cause.
Back pain is complex, personal, and influenced by everything from how you move to how you think. The best results come from taking an active role in your recovery—not just hoping that a scan, a pill, or a passive treatment will fix it.
If you’re ready to take control of your back pain, start by working with a provider who listens, educates, and empowers you. You deserve more than a label—you deserve a plan.
"What is causing my lower back pain?" My patients often ask me this. But if we search for the cause, we will often not find it. I don't care how good you are or your doctor; it's been proven that about 10% of back pain can be accurately diagnosed. In that, what you feel matches up exactly with what an X-ray or MRI will show.
Accepting that can be hard but the truth is, we don't need an 100% accurate diagnoses to begin treatment and achieve 100% pain relief. Who really cares as long as you get better? After 10 years of treating patients here is what I have learned.
What Is the Root Cause of My Lower Back Pain? A Physical Therapist’s Insight
The answer is more complex than most people expect. After nearly a decade of treating back pain, I’ve realized that the traditional methods we use to diagnose pain, such as imaging and labels like “degeneration” or “disc bulge,” often miss the mark entirely. We can't see pain in an image, so stop taking pictures and start teaming up with people who will get their hands on you!
Why Imaging Alone Can’t Find the Root Cause of Back Pain
It’s completely normal to want answers—and fast. That’s why so many people seek out an MRI or X-ray. But here’s what you need to know:
X-rays and MRIs often show disc bulges, arthritis, or “degenerative” changes, even in people who have zero pain. Many of these findings are simply a part of aging.
Example: You might be told your MRI shows “disc degeneration” or “bulging,” but did you know that more than 50% of people over 40 have those findings—even if they feel great
When imaging is used without clinical context, it can create fear. You can be left thinking something is “wrong” with their spine, even when your imaging doesn’t correlate with their symptoms. Imaging has several problems associated with it.
Finding the cause of your back pain is one of the hardest things to do, and that's why lower back pain is the most costly, complex, and time-consuming condition to treat.
Quick note: a physician is capable of diagnosing back pain, but what I have seen and what the research shows is that you are likely to receive imaging and not a physical examination (which is more appropriate and cheaper) if you go to a physician first for back pain. I know I am biased by seeing a PT, so they can help you figure it out and start treatment on the same day!
The Causes of Lower Back Pain We Are Good At Diagnosing:
- Stenosis
- Sciatica
- Back strain
- Stiffness and Mobility Deficits
can diagnose back pain, but I have seen and the research show
Spinal Stenosis is a condition of the spine in which the natural space around the nerve starts to decrease, resulting in pain in the lower back, glute, or leg, often in people over 60.
Treatments include reducing pressure on the nerves with flexion-based exercises and nerve glides.
Sciatica
Sciatica is a condition that can involve intense leg pain from a herniated disc or stenosis. It includes pain, weakness, and changes in sensation, such as numbness and tingling. Some say it's a pinched nerve, but it can be very uncomfortable, a leading cause of seeking physical therapy.
Muscle Strain
A classic back strain can be of any muscle in the lower back—there are plenty of them. A muscle strain can make it difficult to move, and it can feel like you're going to wither away! Trust me, I have had plenty. They get better quickly, and if they don't, it's often due to underlying trigger points or disc issues. If you believe you may have a strain, check out this video to help you figure it out!
Often, a strain requires time, rest, and gentle stretching to ensure proper healing and recovery. A good hot pack can also make a difference!
Stiffness and Mobility Deficits
Stiffness and mobility deficits are by far the most common I diagnose. It typically looks like this. Someone with general aches and pain in the lower back and hips. They are typically not super flexible, haven't been exercising, and have a hunch they would feel better if they did some stretching and strengthening.
Free Lower Back Pain Stretching PDF!
Lower Back Pain We Are Not Good at Diagnosing:
- What Level of the Spine is Causing the Pain? For example, L4, L5
- Back pain from CancerBack pain from Degenerative Disc Disease, Arthritis, and Disc Bulge and More
- Other causes including Hypersensitivity Disorders
- These are terms that all mean the same thing and often start in your 20s.
Specific Levels of the Back Causing Pain is Hard to Identify
You won't find anyone willing to bet exactly what level or where your back is coming from. Everything in the lower back is so close and your brain has a hard time identifying the location as well. Even if you point to your pain, there are at least a dozen structures under your finger.
When we treat its never focusing at one level, we improve the entire spine at once.
Back Pain from Cancer
This is very rare, and less than 1% of those with chronic back pain. That said, I have seen it. This was when I had a patient with a history of cancer, and while their back pain was getting worse, they were also experiencing weight loss, night sweats, and chills. Those symptoms are signs something is going on in your body. Make sure to tell your doctor right away!
Back Pain from Arthritis or Degeneration
No one likes to talk about it, but arthritis or degeneration starts in your 20s! This includes disc bulges, loss of disc height, and facet degeneration.
Now, all isn't lost. While those things do happen, it doesn't mean you will have pain! What makes this hard to diagnose is that many people have these findings on images and will have pain, but their pain will vary. I mean that the pain is terrible one day, and the next day, you're feeling better. Did your arthritis change that quickly? No, but how you think can. That's why, while it is common and no one enjoys hearing they have arthritis, you can treat degeneration without knowing the exact cause.
- Arthritis is normal.
Many people with moderate or severe arthritis have no pain at all. - Degeneration is expected.
Think of it as wear and tear—it happens with time, like wrinkles or gray hair. It doesn't mean you're broken. - “Bone on bone” doesn’t always hurt.
Even this phrase, often used to justify surgery, doesn’t guarantee pain. I’ve seen many patients with these findings live active, pain-free lives.
Hypersensitivity and Related Disorders
This can include fibromyalgia. In my experience, this is a garbage can term that when people don't know what is causing your pain, they mention fibromyalgia to help give you a diagnosis. I don't like to label people. But I will say those with hypersensitivity typically look like this:
- Are very aware of their body and every ache and pain
- Active and unsure why they are not improving
- Multiple areas of their body that are sensitive to touch
- Flexible but not strong
Those are some common traits that I have seen. If that sounds like you, team up with a great physical therapist and help them learn your body so you can find the exact treatment that works for you. Try to be patient with them! :) Also, consider modalities such as dry needling; they can be helpful.
Here is What See When I Treat Actual Patients with Lower Back Pain
Traditional Medicine Often Misses the Mark
The medical system is structured to look for clear, anatomical causes. That works well for fractures or tumors, but not for most cases of lower back pain.
In fact, research shows that in only about 10–15% of cases, we can definitively diagnose the cause of lower back pain.
Conservative Treatments Help—But Aren’t Always Enough
Conservative care like physical therapy, chiropractic, massage, dry needling, and acupuncture can be essential parts of care. I use many of these in my practice. But here’s the truth:
Finding what works for you is hard!
You may have been told your issue is due to “core weakness,” “tight hip flexors,” or “muscle strain.” And maybe you’ve tried endless exercises or stretches that didn’t help—or helped only a little. Everybody is different, and what worked for your friend may not work for you!
Most Need a Holistic, Evidence-Based Approach to Back Pain
In my experience, the most effective way to address persistent back pain is to step back and take a 15,000-foot view of the problem.
Here's what that looks like:
- Comprehensive assessment: Listen to your story and learn about your body
- Dial in what works for you
- Treat the entire body, not just your back
- Focus on what we can change
- Hands-on work such as stretching and mobility
- Massage, manipulation, or mobilization
- Progressive exercise: focusing on hips, back, legs, and nerves
- Take the time needed!
- Most need a few sessions to learn your body then figure out what works best for you!
- Constant feedback between me and you!
- No one in your body is better than you!
Final Thoughts: Finding the Root Cause of Your Pain
The truth? There’s rarely just one root cause.
Back pain is complex, personal, and influenced by everything from how you move to how you think. The best results come from taking an active role in your recovery—not just hoping that a scan, a pill, or a passive treatment will fix it.
If you’re ready to take control of your back pain, start by working with a provider who listens, educates, and empowers you. You deserve more than a label—you deserve a plan.
%20signs.jpg)
