Last reviewed: 24 Dec 2021
Last updated: 10 Sep 2020



History and exam

Key diagnostic factors

  • obesity, stress, and psychiatric comorbidities
  • history of prior lower back pain
  • history of prior treatment
  • pain radiation does not extend beyond the knee
  • absence of red-flag symptoms
  • absence of fever, fluctuance, exquisite tenderness to palpation
  • sensory, motor, and deep-tendon reflex exams within normal limits
  • negative straight- or crossed straight-leg raise test

Other diagnostic factors

  • dull, gnawing, tearing, burning, or electric pain associated with muscle spasms
  • lack of pain on flexion or relief on extension
  • scoliosis or kyphosis
  • negative FABER, Gaenslen, or Schober testing

Risk factors

  • obesity
  • family history of degenerative disk disease
  • poor musculotendinous flexibility and abnormal posture
  • stress and psychiatric comorbidities
  • increasing age, up to 60-70 years
  • female sex
  • heavy physical and occupational activities
  • tobacco use
  • prolonged standing
  • vitamin D levels

Diagnostic investigations

Investigations to consider

  • lumbar spine MRI
  • lumbar spine x-ray
  • lumbar spine CT
  • myelography
  • CBC
  • erythrocyte sedimentation rate (ESR)
  • C-reactive protein (CRP)
  • urinalysis and culture
  • blood cultures
  • radionuclide bone scan
  • electromyogram (EMG)

Treatment algorithm



Andrew Sherman, MD, MS

Professor and Vice Chair

Department of Physical Medicine & Rehabilitation

University of Miami Miller School of Medicine




AS declares that he has no competing interests.


Dr Andrew Sherman would like to gratefully acknowledge Dr Robert W. Irwin, Dr Louise Thwaites, Dr Karen Walker-Bone, Dr Joanne Borg-Stein, and Dr Philip Chiou, previous contributors to this topic.


RWI, LT, KWB, JBS, and PC declare that they have no competing interests.

Peer reviewers

Jennifer Baima, MD

Staff Physiatrist

Orthopedic and Arthritis Center

Brigham and Women's Hospital

Chestnut Hill



JB declares that she has no competing interests.

Alexios G. Carayannopoulos, DO, MPH

Interventional Spine Physiatrist

Pain Medicine Specialist

Medical Director

Spine Center

Lahey Clinic




AGC declares that he has no competing interests.

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