Skip to Main Content


Back pain


This section includes low (lumbosacral) back pain and thoracic back pain.


Low back pain (LBP)


The most common cause of LBP presenting to the doctor is dysfunction of the spinal intervertebral joints (mechanical back pain or back strain/‘sprain’) due to injury. This problem accounts for ∼72% of cases of LBP, while lumbar spondylosis (degenerative osteoarthritis) is responsible for ∼10% of cases of painful backs presenting to the GP. Musculoligamentous strain is common but usually settles in days. The management of back pain depends on the cause.

Table Graphic Jump Location
Table B1

Low back pain: diagnostic strategy model

++ Key examination

Follow the LOOK, FEEL, MOVE, MEASURE clinical approach with an emphasis on palpation—central and lateral.


The movements of the lumbosacral spine with normal ranges are:


  • extension 20°–30°

  • forward flexion 75°–90°

  • lateral flexion (left and right) 30°


Perform a neurological and vascular examination of the lower limb/s if pain.

++ Key investigation

This should be conservative, especially in the absence of red flags. Basic screening is:


  • FBE


  • urinalysis

  • serum alkaline phosphatase

  • PSA in males 50–75 years

  • plain X-ray if chronic pain and red flags


Reserve CT scan, MRI or radionuclide scan for suspected serious disease (malignancy and infection).

Summary of diagnostic guidelines for spinal pain

  • Continuous pain (day and night) = neoplasia, esp. malignancy or infection.

  • The big primary malignancy is multiple myeloma.

  • The big 3 metastases are from lung, breast and prostate.

  • The other 3 metastases are from thyroid, kidney/adrenal and melanoma.

  • Pain with standing/walking (relief with sitting) = spondylolisthesis.

  • Pain (and stiffness) at rest, relief with activity = inflammation.

  • In a young person with inflammation think of ankylosing spondylitis, Reiter syndrome or reactive arthritis. Stiffness at rest, pain with or after activity, relief with rest = osteoarthritis.

  • Pain provoked by activity, relief with rest = mechanical dysfunction.

  • Pain in bed at early morning = inflammation, depression or malignancy/infection.

  • Pain in periphery of limb = ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.


About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

Murtagh Collection Full Site: One-Year Subscription

Connect to a suite of general practice resources from one of the most influential authors in the field. Learn the breadth of general practice, including up-to-date information on diagnosis and treatment, as well as key clinical skills like communication.

$145 USD
Buy Now

Pay Per View: Timed Access to all of Murtagh Collection

48 Hour Subscription $34.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.