Low back pain case studies with resources

There is no silver bullet for lower back pain. The fact that it costs somewhere between $50 and $100 billion per year in the United States, according to the Harvard Gazette, when you consider indirect costs like time away from work, makes it clear there’s no simple solution.

One of the problems I’ve seen as a chiropractor is that lower back pain often gets clumped together in research as a catchall phrase, even though we know there are specific types of back pain with different pain generators and different solutions. The challenge is that even clinically, and sometimes with imaging, it can be difficult to arrive at a clear diagnosis. As a result, clinicians often treat every case of back pain the same.

Even clinical practice guidelines in the UK and the United States, such as those from the American College of Physicians, basically put lower back pain into a few broad categories:

• Serious problems (tumors, infection, fracture, etc.)

• Chronic lower back pain

• Acute lower back pain

• Lower back pain with radicular pain (sciatica/nerve involvement)

Physical therapy practice guidelines are improving, utilizing function-based categories to place patients with different “flavors” of lower back pain into subgroups so that care can be more targeted.

The purpose of this post is to demonstrate, with a simple case study, at least two broad categories of lower back pain.

Case Study One: 17-Year-Old Gymnast

A mother brings her 17-year-old gymnast daughter into the office for evaluation of lower back pain. It’s been going on for several weeks, worsens with backbends and extension-type movements, and feels better when she rounds her back forward.

As a clinician, my differential diagnosis list includes things like a pars stress fracture (stress reaction in the spine). For the sake of this example, let’s assume that’s ruled out. Functional exam reveals muscle imbalances and weaknesses that may be contributing to her back pain.

We prescribe anti-extension–based exercises to help her avoid overextending her spine. We also add mid-back mobility work and hip flexor stretching, as these impairments may be contributing to her pain pattern. In-office treatment includes manual therapy to improve mobility, as well as lower back treatment to help with pain. Modalities such as laser therapy or dry needling may also be considered.

Case Study Two: Dad with Lower Back Pain

The gymnast’s father also reports ongoing back pain. Unlike his daughter, however, his pain is triggered by bending forward. He says he “can’t even bend over to tie his shoes,” and it’s been present for several months. Interestingly, bending backward actually makes him feel better.

This case highlights the fact that different pain generators are at play. Unlike his daughter, whose pain is worsened by extension, his pain responds to extension and worsens with flexion.

For him, we prescribe McKenzie method extension-based exercises and integrate the McGill Big 3 core stabilization exercises. This is a very different approach than what his daughter receives.

Clinical Takeaway

These two cases demonstrate why lower back pain should never be treated as one-size-fits-all. The patient’s age and the specific movements that trigger or relieve pain often provide critical clues about the underlying pain generator.

• Anterior column problems (discs, vertebral body, end plates) typically hurt more with bending forward.

• Posterior element problems (facet joints, pars injuries, arthritis) are more likely to hurt with bending backward.

Other conditions like spinal stenosis or spondylolisthesis have their own unique patterns and require different approaches.

Our role as clinicians is to first rule out serious conditions, order imaging when appropriate, and then determine the specific type of back pain through functional testing and history. The two most important patient questions are:

1. What daily activities trigger your symptoms?

2. What activities make your symptoms better?

These answers often provide the best roadmap for individualized care.

If you need help, feel free to reach out using the chat function below to request an appointment. You can also schedule online using the link above. At the time of this post, we have same- and next-day availability Monday through Friday.

Dr. Alex Tapplin

Sports Medicine Specialist Chiropractor

Exercise Video References

Anti-Extension Core Exercises

• Dead Bug: YouTube – Dr. Jo

• Plank: YouTube – AskDoctorJo

• Bird Dog: YouTube – AskDoctorJo

McKenzie Method (Extension-Based)

• McKenzie Press-Ups: YouTube – Bob & Brad

• Standing Extension: YouTube – Bob & Brad

McGill Big Three

• Curl-Up, Side Plank, Bird Dog explained: YouTube – Dr. Stuart McGill

• Demonstration: YouTube – Squat University