Overlapping Causes of Lower Back Pain Explained

“My scan doesn’t explain why it hurts like this.”

I hear that so often in everyday practice.

Lower back pain is one of the most common reasons people come to see me, and it is also one of the most frustrating for patients. I’ll admit it’s complicated all the components sit close together, and each of them can generate pain. When more than one is involved at the same time, the presentation can feel inconsistent or hard to pin down.

I see this daily. Someone describes sharp pain in one area, burning pain somewhere else, stiffness in the morning, and then shows me a scan that highlights a structural change. It is tempting to let the imaging drive the story. Over time, I have learned not to start there.

Most complex lower back pain is not random. It is overlapping patterns that have not yet been separated.

Rule of thumbs before diagnosis

When someone comes in with lower back pain, I do not begin by trying to name it. I begin by sorting it.

There are six major contributors I keep in mind. Facet joints, discs, sacroiliac joints, hips, nerves and muscle dysfunction. Most presentations sit somewhere within that list. The task is working out which ones are active and which ones are simply present.

One of the first questions I ask is whether the pain is worse in the leg or worse in the back. If it is worse in the leg, nerves move to the top of my list. That pathway often becomes clearer relatively quickly. If it is mainly in the back, I divide the region further. Below the belt line, I think about sacroiliac joints and hips. Above the belt line, I consider facets, discs and then muscle control.

I watch how this changes the conversation in clinic. Once we divide the region logically, the problem already feels more contained.

Then I look at size and distribution. I might ask someone to describe the area in everyday terms. Is it the size of a golf ball, tennis ball, mango or footy? When a patient can point to a very specific spot, the structure underneath that spot is often contributing. When the pain spreads across a wider area, I start considering more than one contributor.

After that, I look at proportionality. Does the pain flare with load and settle with rest in a way that makes mechanical sense? Or does it feel disproportionate to what I see on imaging? When pain is widespread or more intense than expected, I start thinking about amplification within the system.

The combination of history, pain pattern and examination usually gives me a strong working direction. Imaging can support that, but I am careful not to let it lead. Scans show structural changes. They are not very good at telling us which structure is actually driving pain.

That is where I am fortunate in my practice. Once I have narrowed things down to what looks like the most logical structure, I can test that hypothesis with diagnostic blocks. If I block the suspected structure and the pain settles, that gives us confirmation. If it does not, I reassess and adjust. It is a process of refining the diagnosis rather than assuming it.

Over the years, the framework that has helped me most is simple.

Pain equals cause plus amplifiers.

There is usually a structural driver. There are often amplifiers layered over the top. I see this interplay constantly. Metabolic conditions, inflammatory processes, sleep disruption, social and psychological stressors, deconditioning, hypermobility. These factors do not create the structure, but they can turn up the volume of the pain signal.

When lower back pain feels confusing, it is often because we are looking for a single explanation in a system with multiple active contributors.

Separating those contributors is what brings clarity.

When I explain lower back pain this way in clinic, people often relax. The pain has structure. We can identify what looks joint driven, what behaves like nerve irritation, and what might be amplifying the system. From there, we can make decisions. What do we test? What do we treat, cause or amplifiers first?

I see the shift that happens when patients understand the pattern. The story feels less chaotic. The decisions feel more deliberate.

Lower back pain with overlapping patterns requires structured thinking. It requires sorting before labelling and testing before concluding. That is how I approach it in practice.

If your lower back pain has not made sense, or your scan has not matched your experience, it may be worth asking whether more than one structure is contributing and whether something is amplifying the system as well.