Back Pain: Causes by Location and When to Worry

What back pain feels like

Back pain can be a dull ache, a sharp stab, a burning sensation or a tight spasm. It can stay in one spot or spread into the buttock, leg, ribs or shoulder. Doctors divide it by:

• Location: upper (thoracic), middle or lower (lumbar) back, and one side or both.
• Duration: acute (under 6 weeks), subacute (6 to 12 weeks) or chronic (over 12 weeks).
• Type: mechanical pain that changes with movement and posture, nerve pain that shoots down a limb, inflammatory pain that is worse with rest, and pain referred from internal organs.

Back pain causes by location

Lower back pain

The lower back carries most of the body's weight and bends the most, so it is by far the most common site. Typical causes are muscle strain, disc problems, facet joint arthritis and sacroiliac joint pain. Pain that runs down the back of the leg below the knee suggests sciatica from a compressed nerve root. See lower back pain for detail.

Middle back pain

The middle (thoracic) spine is held firmly by the rib cage, so mechanical problems here are less common. Causes include:

• poor posture and long hours at a desk or phone
• muscle strain from twisting or lifting
• rib joint irritation, which hurts on deep breathing or twisting
• osteoporotic compression fractures, especially in older women
• scoliosis or kyphosis (curvature of the spine)
• referred pain from the stomach, gallbladder, pancreas or aorta

Persistent mid-back pain without an obvious strain deserves a medical check more often than low back pain does.

Upper back pain

Upper back pain, including pain between the shoulder blades, is often linked to neck posture, tight trapezius and rhomboid muscles, and pinched nerves in the neck. Less commonly it comes from the heart, lungs, esophagus or gallbladder.

Pain on one side of the back

Common causes of back pain

Mechanical causes (about 90% of cases)

• Muscle or ligament strain: sudden lifting, twisting or unaccustomed activity. Pain and spasm, worse with movement, no leg symptoms.
• Disc degeneration: age-related drying and thinning of discs. Very common on scans and often painless.
• Herniated disc: disc material bulges and may press on a nerve root.
• Facet joint arthritis: pain worse on bending backward and standing.
• Spinal stenosis: narrowing of the canal in older adults, with leg pain and heaviness on walking that eases on sitting or bending forward.
• Spondylolisthesis: one vertebra slipping forward, more common in young athletes and older adults.

Inflammatory causes

Ankylosing spondylitis and related conditions cause back pain that starts before age 45, comes on gradually, is worst in the early morning or second half of the night, causes stiffness lasting more than 30 minutes and improves with exercise rather than rest.

Bone causes

• Osteoporotic fractures after minor falls, lifting or coughing.
• Cancer spreading to the spine (from breast, prostate, lung, kidney or thyroid) or multiple myeloma: constant pain, worse at night, often with weight loss.
• Spinal infection: fever, severe local tenderness; risks include IV drug use, diabetes and recent surgery.

Pain from organs (referred pain)

• Kidneys: kidney stones cause severe, colicky pain from the flank to the groin. Kidney infections cause fever and flank pain.
• Abdominal aortic aneurysm: deep back or belly pain in older adults, especially male smokers.
• Pancreatitis: severe upper belly pain boring through to the back, often after alcohol or with gallstones.
• Gynecological causes: period pain, endometriosis and pelvic infection.
• Pregnancy: back pain is very common, especially in the second half.

Other contributors

• Fibromyalgia: widespread pain, fatigue and poor sleep.
• Obesity, smoking, physically demanding jobs and inactivity.
• Stress, depression and poor sleep, which amplify and prolong pain.

Back pain and fatigue

Back pain often comes with tiredness because pain disturbs sleep and constant muscle guarding is exhausting. When fatigue is severe or comes with other symptoms, consider fibromyalgia, inflammatory arthritis, anemia, vitamin D deficiency, depression, or less commonly infection or cancer. Back pain with fatigue, fever, night sweats or weight loss needs prompt investigation.

When to worry about back pain

Doctors screen for red flags that suggest something other than simple mechanical pain:

• age under 20 or over 50 with a first episode
• fever, unexplained weight loss or a history of cancer
• pain that is constant, progressive and not eased by rest
• pain mainly at night
• trauma, osteoporosis or long-term steroid use
• IV drug use or a weak immune system
• numbness, weakness or bladder and bowel changes

Without red flags, scans are usually not needed in the first 6 weeks, because they rarely change treatment.

How back pain is diagnosed

A doctor will ask where the pain is, how it started, what makes it better or worse and about the red flags above. They will examine your spine, test leg strength, reflexes and sensation, and may do a straight leg raise test for sciatica. Tests are reserved for specific situations: blood tests for inflammation or infection, X-rays for fractures, MRI for nerve compression or suspected serious disease, and urine tests for kidney causes.

Back pain relief at home

• Keep moving. Bed rest delays recovery. Walk little and often, and return to normal activities as soon as you can.
• Use heat: a heat wrap or warm bath relaxes muscle spasm.
• Pain relievers: ibuprofen or naproxen for short periods, following the label dose, unless you have stomach ulcers, kidney disease or heart problems. Acetaminophen (paracetamol) alone helps little for low back pain but may be used with other measures.
• Gentle stretches such as knee-to-chest and cat-cow, within comfort.
• Sleep on your side with a pillow between your knees, or on your back with a pillow under your knees.
• Stay at or return to work with temporary adjustments where possible.

For ongoing treatment options such as physical therapy and when injections or surgery are considered, see back pain treatment.

Frequently asked questions

When should I worry about back pain?

Get emergency help for back pain with groin numbness, bladder or bowel problems, leg weakness, sudden tearing pain or chest symptoms. See a doctor soon for back pain with fever, weight loss, a cancer history, night pain or pain lasting more than 4 to 6 weeks.

How do I know if my back pain is muscular or kidney-related?

Muscular pain is usually in the lower back muscles, changes with movement and position, and feels sore to press. Kidney pain sits higher, under the ribs at the side, does not change much with movement, and often comes with fever, burning urine, blood in the urine or nausea.

Why does my back hurt when I breathe?

Pain on deep breathing usually comes from a strained muscle or irritated rib joint in the middle back. It can also signal pleurisy, pneumonia, a blood clot in the lung or a rib fracture. Breathing pain with breathlessness, fever or coughing blood needs urgent care.

How long does back pain last?

Most acute back pain improves substantially within 2 weeks and resolves within 6 weeks. About 1 in 3 people have another episode within a year. Pain lasting more than 12 weeks is called chronic and benefits from a structured exercise and physical therapy program.

Should I rest or exercise with back pain?

Stay active. Studies show that people who keep moving recover faster than those who rest in bed. Avoid heavy lifting for a few days, but walk, do gentle stretches and return to normal activity as pain allows.