Future Dr. Ibrahim presents a clinical case to explain the essential points in the evaluation of back pain. Future Dr. Redden adds information about differentiating between a back strain and more serious diseases such as cancer, and Dr. Arreaza shares information about returning to work after back strain.
Written by Michael Ibrahim, MSIV. Editing and comments by Jordan Redden, MSIV, and Hector Arreaza, MD.
You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.
Dr. Arreaza:
Welcome back, everyone. Today’s topic is one that every primary care provider, emergency doctor, and even specialist sees routinely: low back pain. It's so common that studies estimate up to 80% of adults will experience it at some point in their lives. But despite how frequent it is, the challenge is to identify which cases are benign and which demand urgent attention.
Jordan:
Exactly. Low back pain is usually self-limiting and mechanical in nature, but we always need to keep an eye out for the rare but serious causes: things like infection, malignancy, or neurological compromise. That’s why a good history and physical exam are our best tools right out of the gate.
Michael:
And to ground this in a real example, let me introduce a patient we saw recently. John is a 45-year-old warehouse worker who came in with two weeks of lower back pain that started after lifting a 50-lb box. He describes it as a dull, aching pain that radiates from his lower back down the posterior left thigh into the calf. He says it gets worse with bending or coughing, but he feels better when lying flat. He also mentioned some numbness in his left foot, but he denies any bowel or bladder issues. His vitals are completely normal. On exam, he had lumbar paraspinal tenderness, a positive straight leg-raise at 40 degrees on the left and decreased sensation in the L5 dermatome, though reflexes were still intact.
Dr. Arreaza:
That’s a great case. Let’s take a minute and talk about the straight leg raise test. This is a bedside tool we use to assess for lumbar nerve root irritation often caused by a herniated disc. ***Here's how it works: the patient lies supine, and you slowly raise their straight leg. If pain radiates below the knee between 30° and 70°, that suggests radiculopathy, especially involving the L5 or S1 nerve roots. Pain at higher angles is more likely due to hamstring tightness or mechanical strain.
Michael:
Right. So, stepping back: what do we mean by "low back pain"? Broadly, it's any pain localized to the lumbar spine, but it’s often classified by type or cause:
Jordan:
In John’s case, we’re thinking radicular pain, most likely from a herniated disc compressing the L5 nerve root. That’s supported by the dermatomal numbness, the leg pain, and that positive straight leg test.
Dr. Arreaza:
Good reasoning. Now, anytime we see back pain, our brains should run a checklist for red flags. These help us pick up more serious causes that require urgent attention. Let’s run through the red flags.
Michael:
Sure. For fracture, we think about major trauma or even minor trauma in the elderly, especially those with osteoporosis or on chronic steroids. Also, anyone over 70 years old.
Jordan:
Then we have infections, which could include things like discitis, vertebral osteomyelitis, or epidural abscess. Red flags include fever, IV drug use, recent surgery, or immunosuppression.
Michael:
Malignancy is another critical one, especially if there’s a history of breast, prostate, lung, kidney, or thyroid cancer. Clues include unexplained weight loss, night pain, or constant pain not relieved by rest.
Jordan:
And don’t forget about inflammatory back pain, like ankylosing spondylitis, which is often seen in younger patients with morning stiffness that lasts more than 30 minutes and improves with activity.
Dr. Arreaza:
And of course, we always rule out cauda equina syndrome: a surgical emergency. That’s urinary retention or incontinence, saddle anesthesia, bilateral leg weakness, or fecal incontinence. Missing this diagnosis can be catastrophic.
Michael:
Thankfully, in John's case, we don’t see any red flags. His presentation is classic for uncomplicated lumbar radiculopathy. But we must stay vigilant, because sometimes patients don’t offer up key symptoms unless we ask directly.
Jordan:
And that’s where associated symptoms help guide us. For example:
Dr. Arreaza:
So when do we order labs or imaging?
Michael:
Not right away. For most patients with acute low back pain, imaging is not needed unless they have red flags. If infection is suspected, we’d get CBC, ESR, and CRP. For cancer, maybe PSA or serum protein electrophoresis. And if inflammatory back disease is suspected, HLA-B27 can be helpful.
Jordan:
Yes, imaging should be delayed for at least six weeks unless red flags or significant neurologic deficits are present. When we do image, MRI is our go-to especially for suspected radiculopathy or cauda equina. X-rays can help if we’re thinking about fractures, but they won’t show soft tissue or nerve root issues.
Michael:
In the example from our case, since the patient doesn’t have red flags, we’d go with conservative management: start NSAIDs and recommend activity modification. As this is the acute setting, physical therapy would not be recommended.
Jordan:
For the acute phase, research shows no serious difference between those with PT and those without in the long term. However, physical therapy is really the cornerstone of management for chronic back pain. It’s not just movement: it’s education, body mechanics, and teaching patients how to move safely. And PT can actually reduce opioid use, imaging, and injections down the line for patient struggling with long term back pain.
Dr. Arreaza:
Yes, and PT is not one-size-fits-all. PT might include McKenzie exercises, manual therapy, postural retraining, or even neuromuscular re-education. The goal is always to build core stability, promote healthy movement patterns, and reduce fear of motion.
Jordan:
Let’s take a minute to talk about the McKenzie Method, a physical therapy approach used to treat lumbar disc herniation by identifying a specific movement, (often spinal extension) that reduces or centralizes pain. A common exercise is the prone press-up, (cobra pose for yoga fans) where the patient lies face down and pushes the upper body upward while keeping the hips on the floor to relieve pressure on the disc. These exercises should be done carefully, ideally under professional guidance, and discontinued if symptoms worsen.
Michael:
For our case patient, our working diagnosis is mechanical low back pain with L5 radiculopathy. No imaging needed now, no red flags. We’ll treat conservatively and educate him about proper lifting, staying active, and recovery expectations.
Jordan:
We also emphasized to him that bed rest isn’t helpful. In fact, bed rest can make things worse. Keeping active while avoiding heavy lifting for now is key.
Dr. Arreaza:
Return-to-work recommendations should be individualized. For example, an office worker, positioning while working, or work hours may be able to return to work promptly. However, those with physically demanding jobs may need light duty or be off work.
Ice: no evidence of benefit. Heat: may reduce pain and disability in pain of less than 3 months, although the benefit was small and short.
And we should always teach safe lifting techniques: bend at the knees, keep the load close, avoid twisting. It's basic knowledge, but it is very effective in preventing recurrence.
Jordan:
Now, if a patient fails to improve after 6 weeks of conservative therapy, or if they develop new neurologic deficits, that’s when we think about referral to spine specialists or surgical consultation.
Michael:
And as previously mentioned: in cases where back pain becomes chronic (lasting more than 12 weeks) a multidisciplinary approach works best. That can include:
Jordan:
We can’t forget the psychological toll either. Chronic back pain is associated with depression, anxiety, and opioid dependence. Increased risk factors include obesity, smoking, sedentary lifestyle, and previous back injuries.
Dr. Arreaza:
Well said. So, let’s summarize. Michael?
Michael:
Sure! Low back pain is common, and most cases are benign. But we have to know the red flags that point to serious pathology. A focused history and physical exam are more powerful than many people realize. And the first step in treatment is almost always conservative, with a strong emphasis on maintaining physical activity.
Jordan:
And don’t underestimate the value of patient education. Helping patients understand their pain, set realistic expectations, and stay active is often just as important as the medications or therapies we offer.
Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week!
_____________________
References:
Chou, R., Qaseem, A., Snow, V., Casey, D., Cross, J. T., Shekelle, P., & Owens, D. K. (2007). Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, 147(7), 478–491. https://doi.org/10.7326/0003-4819-147-7-200710020-00006
Deyo, R. A., Mirza, S. K., Turner, J. A., & Martin, B. I. (2009). Overtreating chronic back pain: Time to back off? Journal of the American Board of Family Medicine, 22(1), 62–68. https://doi.org/10.3122/jabfm.2009.01.080102
National Institute for Health and Care Excellence. (2020). Low back pain and sciatica in over 16s: Assessment and management (NICE Guideline No. NG59). https://www.nice.org.uk/guidance/ng59
Qaseem, A., Wilt, T. J., McLean, R. M., & Forciea, M. A. (2017). Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 166(7), 514–530. https://doi.org/10.7326/M16-2367
UpToDate. (n.d.). Evaluation and treatment of low back pain in adults. Wolters Kluwer. https://www.uptodate.com (Access requires subscription)
Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.