Spine
Back pain and leg pain tend to present together often enough that it makes sense to cover them on one page. Telling them apart is part of the challenge in the first few minutes of an assessment.
Lower back pain is the most common reason people book with me, but sciatica always seems to frighten people more, probably because pain running down a leg feels like a nerve problem, and nerve problems sound way more intimidating. The thing is that neither one usually is. There is also more bad information circulating about these two than about anything else I treat.
What follows is what each one is, what the research currently supports, how to read a scan report, and what I would have you doing between now and next week if you are presenting with any of these.
On this page
Lower back pain is pain felt between the lower ribs and the buttock creases. In most cases no single structure can be identified as the source, which is why it gets called non-specific. That term is not a shrug but means the pain comes from the region rather than from one identifiable culprit.
Non-specific does not mean minor either. Low back pain is one of the commonest presentations in primary care anywhere in the world and one of the leading causes of disability, and the global burden is still climbing.
The advice around it has changed a great deal in twenty years. A fair amount of what people were told in 2005 has since been overturned, so patients often arrive carrying instructions that no longer hold.
Most episodes come down to a combination: tissue that has become sensitive, load that outran what the area could handle at the time, and an alarm system turning up its own volume while things settle. Sleep, stress, workload and previous experience of pain all influence how loud it gets.
Everybody's system works the same way.
The load part is usually obvious in hindsight: a weekend of paving, a longer run than planned, three days behind a steering wheel, or a fortnight of sitting more than usual after a fortnight of sitting less. The area was not damaged so much as asked for more than it had been prepared for.
The alarm part is the part that gets missed. When an area is sensitive the threshold for producing pain drops, so movements that were fine last month can hurt this month without anything new having happened. Hurting and harming are different things, and believing that changes how much you are prepared to move.
Sciatica is leg pain caused by irritation or compression of a nerve root in the lower back, most often at L4, L5 or S1. The leg symptom dominates rather than the back symptom, and it follows a recognisable nerve path. Sciatica describes a pattern of symptoms and not a diagnosis of its cause.
Radicular leg pain has an annual incidence of around 2.2 per cent and a lifetime prevalence above 30 per cent in high-income countries. Plenty of people get it without being able to name anything that started it.
A disc herniation is the commonest cause, though pressure on the nerve is only half the story. Chemical irritation of the nerve root matters just as much as mechanical irritation, and that is why symptoms often improve well before a herniation changes size on a scan.
Sciatica is dominated by the symptoms in the leg. Pain travels below the knee along a recognisable path, often with pins and needles, numbness or a burning quality, and it behaves fairly consistently with certain positions. Back-dominant pain sits across the lower back and buttock, feels achy and spread out, and is harder to map.
Pain in the buttock and upper thigh on its own is more often referred pain from the back than nerve root pain, and it behaves differently. Sorting that out early is important, because the two are managed differently and referred pain is much the commoner of the two.
Testing at the first consultation covers strength, reflexes, sensation and the movements that provoke and ease the leg. That is one way in which an irritated nerve can get separated from a compressed one, and how I begin to work out whether anybody else needs to be involved.
In most cases, no. Current guidance advises against routine imaging for sudden back pain where there has been no trauma and no red flags, because scans seldom change what gets done and often increase worry. I will advise if you need one, based on the consultation and assessment. If you already have a report, please bring it with you.
The reason for that guidance is a systematic review that pooled imaging from 3,110 people with no back pain at all. Degeneration showed up in about 37 per cent of pain-free 20 year olds and about 96 per cent of pain-free 80 year olds. Bulges rose from about 30 per cent at 20 to about 84 per cent at 80.
People with no back pain at all
| Scan finding | Age 20 | Age 80 |
|---|---|---|
| Disc degeneration | 37% | 96% |
| Disc bulge | 30% | 84% |
| Disc protrusion | 29% | 43% |
| Annular fissure | 19% | 29% |
Pooled imaging from 3,110 people with no symptoms whatsoever. Brinjikji and colleagues, American Journal of Neuroradiology, 2015.
Findings like these are closer to grey hair on the inside than to damage. Most people over 50 have them and most of those people have no pain.
There is a counterweight, however. The same research group showed that several of these findings, bulges, degeneration and protrusions among them, are commoner in adults under 50 with back pain than in matched pain-free people. Scan findings are therefore not meaningless. They are simply not enough on their own to explain why you hurt today, and they have to be read against what is normal for your age.
Most episodes improve substantially inside six weeks, and the ones that settle quickest tend to be the ones that keep moving early at a sensible dose. Around one in five people with sudden onset back pain go on to develop pain that interferes with work and daily life, a group we try to spot early to avoid long term issues.
Which is why I ask things at the first visit that have nothing obvious to do with your back: how you are sleeping, how much you have stopped doing, what you have been told about your spine, and whether you believe movement is safe. Those answers tend to predict the course better than the movement testing does.
If you fall into the higher risk group, the plan tends to get tweaked. It gets more education, more structure and a clearer loading programme, and it starts sooner.
Sciatica usually improves without surgery, though slowly and rarely in a straight line. Between 25 and 50 per cent of people still have some symptoms a year on. In a cohort of 622 people followed for four years, 55 per cent still reported symptoms at two years. The good news is that much of what drives that is changeable.
Improving and disappearing are not the same outcome, and I would rather say so at the start than have you decide at week six that something has failed.
In that same four year cohort, 61 per cent of the people whose sciatica had settled still had some low back pain. According to the research the factors that predicted a longer course were quite specific.
What predicts a longer course
Three of the four can be changed, and the first one is directly relevant here. A good number of my patients drive up and down the M13 between Kloof, Hillcrest, Westville, Pinetown and Durban and spend two hours a day in traffic, and nobody has ever mentioned to them that the driving itself is a named predictor. Breaking the drive up, sorting out the seat and building tolerance on purpose counts as treatment away from the consulting rooms.
Yes, at the right dose. Staying active is the foundation of care for both, and walking is the easiest way to do it. Start below the distance that flares you up, walk more often rather than further, and add a little each week. Short frequent walks do more than one long one.
With sciatica, sitting for long stretches loads the nerve root most, so the trouble in the first fortnight is the ninety minute spell at a desk or in a car more than the walking.
For dose I often use tolerance rather than pain. Soreness during and shortly after activity that settles inside 24 hours and does not climb session on session is acceptable. Soreness that climbs day on day means the dose was too high. It does not necessarily mean the walking is doing harm.
Read more: exercise for persistent pain
Usually not. Conservative care is the recommended first option for lumbar radiculopathy and most people improve without an operation. Surgery becomes a real conversation when there is progressive weakness, or when severe pain has not responded to a proper course of conservative treatment. That is usually a decision made alongside a spinal surgeon.
Large herniations often resorb on their own, and the size of one is a poor predictor of how a person will do.
What generally changes the conversation is neurological loss that is getting worse rather than better: a foot catching on the step, a calf losing bulk, weakness spreading instead of settling. Those get referred promptly. I would rather refer early and be wrong than late and be right.
How I work
Care runs in three steps, in this order: working out what is driving the pain, loading the area back up to tolerance, and getting you back to whatever it is you want to do. Hands-on treatment sits inside the loading step to make movement possible sooner. It supports the plan but is not the whole plan.
01
The first job is working out which mechanism is doing most of the work, and explaining it to you in language you can repeat to somebody else. If you have a scan report we go through it line by line, because one frightening word left unexplained can do a lot of damage to how much a person is willing to move.
With sciatica that includes the difference between a nerve being irritated and a nerve being damaged. They are not the same thing and they carry very different outlooks.
02
Tissue adapts to the load you give it. Too much too soon flares things up, and nothing at all leaves tissue less tolerant than it was before. The work is finding the dose in between and moving it up as you improve.
Manipulation, dry needling, ischaemic compression, IASTM and neural mobilisation all sit inside this step. They open a window in which movement is easier and less threatening. What you do inside that window is what tends to ultimately change the outcome.
03
It is important that we identify the thing you actually want back, whether that is a full working day without counting the hours, loading the boot, or finishing a parkrun. Then we build towards it in steps small enough that you keep going through the ordinary bad weeks.
The evidence for that order
The PACBACK trial randomised 1,000 adults with recent back pain who screened at raised risk of becoming long-term cases, and followed them for a year. A personalised programme of pain education, exercise, relaxation and activity guidance, delivered by chiropractors and physiotherapists, prevented disabling chronic back pain better than either standard medical care or spinal manipulation on its own.
Here are five things you can do this week, none of which need equipment. Move in short frequent bouts instead of one long effort. Change position before the ache asks you to. Use heat for comfort in the first week or two. Watch how far down the leg symptoms travel. And protect your sleep.
Five to ten minutes, several times a day, in whatever range you have. Frequency does more than duration in the first fortnight, and it is easier to keep up on a bad day.
Every 30 to 45 minutes or so, whether or not you have started to feel it. By the time the ache prompts you, you are already past the point where the change would have helped.
Heat is endorsed by most guidelines for sudden low back pain and it is worth trying. It makes movement easier for a while, and that is what it is for. It is not treating the problem underneath but gives you an opportunity to move, which is where the gold is.
With sciatica this is the most useful thing to track. Symptoms retreating up the leg towards the back is a good sign even when the intensity has not dropped yet. Symptoms travelling further down means you should probably come back and be reassessed.
Sleep loss reliably raises pain sensitivity the next day. It is one of the few places where a small change makes a disproportionate difference, so it is an important part of the plan rather than just a part of a list of general advice.
Green
Soreness during or shortly after activity that settles within 24 hours and is not climbing session on session. Carry on. This is what adaptation feels like.
Amber
Soreness still up after 24 hours, or creeping upward week on week. Hold the dose where it is for a week instead of increasing it. Do not stop.
Red
New weakness, new numbness, or any of the symptoms in the section below. Stop and get assessed.
Guidelines support spinal manipulation for back pain as part of a package of care rather than on its own, and reviews of sciatica support a multimodal approach combining education, manual therapy, exercise and neural mobilisation. So yes, with the caveat that no single technique carries the result by itself.
I am a first-contact practitioner, so no referral is needed and you do not need a scan before booking. The first consultation runs 45 to 60 minutes, and a good part of it is history, orthopaedic and neurological testing, and ruling things out.
If what you have needs a GP, a spinal surgeon, a biokineticist or a psychologist, we will chat about the options and reasons for my recommendations. Most of my patients come from across the Upper Highway and Outer West and so making a referral to a colleague in the area is quick and easy.
I am also an approved provider on the Discovery Health Spinal Conservative Care Programme. That is Discovery's out-of-hospital pathway for back and neck pain, run through a network of chiropractors and physiotherapists with a particular interest in spinal pain, and it exists because good conservative care keeps a lot of people out of theatre.
Discovery Spinal Conservative Care Programme
If you have had that notification from Discovery, bring it to the first visit and we will work through the assessment. If you are on Discovery and have not heard anything, the programme is not open to you at the moment and normal consultation rules apply. Discovery sets out the current terms in its Spinal Conservative Care Programme guide, and there is more on my medical aids page.
Go to an emergency department the same day for loss of bladder or bowel control, numbness in the saddle area between the legs, or weakness in both legs that is getting worse. See a doctor promptly for unexplained weight loss, fever or night sweats alongside back pain, or new weakness in a leg.
See a doctor promptly too for pain that is unrelenting at night and does not change with position or movement, for significant trauma, for minor trauma if you have known osteoporosis, or if you have a history of cancer, long-term corticosteroid use or a significantly compromised immune system.
All of this is uncommon. It is set out here so that you know what does need urgent attention, which makes it easier to stop worrying about the rest.
Although I have an extensive knowledge of pain pharmacology, questions about medication are better aimed at your doctor or pharmacist rather than at me. I am not allowed to script any medication.
Next step
If your back or leg has been sore for weeks and nobody has explained it to you properly, that is what the first consultation is for. It runs 45 to 60 minutes and no referral is needed.
Phone 031 035 1165 · WhatsApp 064 820 5203 · A1a Meyrickton Park, 2 Meyrickton Pl, St Helier, Hillcrest, 3610
This page is general information and is not a substitute for personalised medical advice. Always consult a healthcare provider about your specific condition.
