Acute and chronic back pain: causes, red flags and treatment

Low back pain is one of the most common reasons people seek help, and in most cases no single specific cause can be identified – this is called non-specific low back pain.[1] The pain can recur or become long-lasting – timely muscle and joint work may help restore movement faster and prevent recurrence. On this page we explain what may keep the pain going, how our methods may help relieve it, and when you need to see a doctor straight away.
Acute and chronic back pain: causes, red flags and treatment

Red flags: when to see a doctor urgently or call 112

  • Numbness in the groin, inner buttocks or genital area (the „saddle“ area) – call 112 or go to the emergency department immediately.
  • New problems with bladder or bowel control: difficulty passing urine, urinary retention, urinary or faecal incontinence – call 112 or go to the emergency department immediately.
  • Rapidly worsening weakness in one or both legs, foot drop, pain or numbness in both legs, or a new problem with sexual function – go to the emergency department immediately.
  • Pain after a fall, accident or other significant trauma; with osteoporosis, also after minor trauma.
  • Unexplained weight loss or a history of cancer.
  • Constant pain that does not ease even at rest and is worse at night.
  • Long-term corticosteroid use or immunosuppressive treatment – higher risk of fracture and infection.
  • With these symptoms we do not perform massage or manual therapy; we recommend a medical assessment first.

Acute vs chronic back pain – what is the difference?

Acute back pain

Back pain lasting less than 6 weeks is called acute; pain lasting 6–12 weeks is called subacute. It often starts after unusual strain or lifting, but it can also appear without an obvious cause. The pain may be sharp and movement limited. Timely muscle and joint work may help ease the pain and restore movement faster. Guidelines advise staying as active as possible and avoiding prolonged bed rest.[2]

Chronic back pain

Back pain lasting more than 12 weeks is considered chronic – either constant or as recurring flare-ups. Here the intensity of pain does not always reflect the extent of tissue damage: changes in muscle function, lack of movement, sleep, stress and the sensitivity of the nervous system may all play a part. High initial pain intensity and psychological distress are associated with a greater likelihood that the pain persists.[1]

Non-specific back pain and common factors

In most cases the pain cannot be linked to one specific structure. Back pain is more common with physically demanding work, coexisting health conditions, smoking and obesity.[1] Degenerative changes or disc bulges seen on imaging are also common in people without pain, so they do not always explain the pain.[1] If pain radiates into the leg with numbness or weakness, nerve root irritation may be the cause – read more on the disc herniation page.

Muscles that may cause or maintain back pain

Myofascial trigger points can cause pain both in the muscle itself and at a distance from it (referred pain). The pain patterns described below are based on Travell and Simons' classic manual of myofascial pain. In a cross-sectional study of people with non-specific low back pain, active trigger points were most often found in the quadratus lumborum, the lumbar part of the iliocostalis and the gluteus medius.[10] The location of pain alone does not determine its cause, so we always assess the muscles together with movement and your history.

Quadratus lumborum

Bends the trunk to the side, stabilises the pelvis and lower ribs, and assists in deep breathing. Trigger points may refer pain to the iliac crest, the sacroiliac (SI) joint area, the buttock and the outer hip. A typical complaint is pain when turning over in bed and when getting up.

Erector spinae and multifidus

Extend the back, control forward bending and provide segmental stability to the spine. Trigger points in the lumbar iliocostalis may refer pain down into the buttock; multifidus points tend to cause deep pain close to the spine that may extend to the sacral area. Prolonged forward bending and lifting load these muscles the most.

Gluteus medius and gluteus minimus

Move the thigh out to the side and keep the pelvis level when standing on one leg and walking. Gluteus medius pain is felt along the back of the iliac crest, over the sacrum and in the buttock. Gluteus minimus trigger points may refer pain to the outer or back of the thigh and down to the calf, so it can mimic sciatica.

Piriformis

Rotates the thigh outwards and stabilises the hip joint. Trigger points may cause pain in the SI joint area, the buttock and the back of the thigh. Because the sciatic nerve runs right next to the muscle, tension in it may also irritate the nerve in some people – read more on the piriformis syndrome page.

Iliopsoas

The strongest hip flexor; it attaches to the lumbar vertebrae and helps control the position of the lower back. Trigger points may refer pain along the lumbar spine, to the upper sacrum, and to the groin and front of the thigh. Prolonged sitting keeps the muscle in a shortened position.

Why pain persists: possible mechanisms

Myofascial trigger points. Sensitive, taut nodules can develop in an overloaded muscle and cause local and referred pain. In one study, a higher number of active trigger points was associated with more intense pain and poorer sleep quality.[10]

Protective muscle guarding. With acute pain, muscles tighten reflexively to limit movement. In the short term this is protective, but if the tension persists it may itself maintain pain and make movement cautious and stiff.

Reduced mobility and load tolerance. Pain leads to moving less, mobility of the spine and hips decreases and muscle endurance falls. This can make everyday tasks harder and contribute to flare-ups. Releasing muscle tension and restoring joint mobility help make movement free again.

Increased sensitivity of the nervous system. In chronic pain the central nervous system may become more sensitive to pain signals (central sensitisation): pain may arise with less load and spread over a wider area. Sleep, stress and fear of movement may influence this. It does not mean the pain is „imagined“ – the sensitivity of the pain system has changed, which is why a gradual, calm approach suits chronic pain.

How our methods may help

Medical massage

Targeted soft-tissue techniques may reduce muscle tension, improve local circulation and, by stimulating mechanoreceptors, ease pain perception. Clinical guidelines list massage as one of the recommended non-drug treatments.[3][4]

Trigger point therapy

Controlled pressure (ischaemic compression) followed by stretching targets trigger points in the quadratus lumborum, gluteal muscles and other muscles that refer pain. The aim is to reduce muscle sensitivity and referred pain.

Deep tissue massage

Slow, deeper work reaches the deeper muscle layers and connective tissue, for example in a long-term tense erector spinae and the gluteal muscles. It suits chronic rather than very acute pain.

Manual therapy (HVLA)

A short, low-amplitude thrust to a stiff segment of the spine or the SI joint may reduce protective muscle tension and pain via mechanoreceptors. Before an HVLA technique we always carry out a thorough assessment and tests. Gentler mobilisation techniques are used when appropriate.

High-intensity magnetic therapy (EMTT)

The magnetic field reaches deep into tissue where hands cannot. It may improve circulation and cellular metabolism and reduce muscle tension. The procedure is painless and can be combined with hands-on techniques.

Shockwave therapy (ESWT)

Acoustic pulses are directed at painful muscles and tendon attachments. They may reduce pain perception and trigger point sensitivity and improve local blood supply.

Kinesiology taping

Elastic tape gives the skin continuous feedback and may support movement control and confidence in moving between sessions.

What the research shows

Below is a summary of systematic reviews, meta-analyses, randomised trials and clinical guidelines that support the methods we use.

Massage: pain relief and better movement

A Cochrane review (25 trials, 3,096 participants) found that in subacute and chronic low back pain massage reduced pain and improved function more than inactive controls; no serious adverse events were reported.[5]

Manipulation for acute back pain

A meta-analysis (15 trials, 1,711 patients) associated spinal manipulation for acute low back pain with less pain and improved function.[6]

Manipulation for chronic back pain

A meta-analysis (47 trials, 9,211 participants) found that in chronic low back pain spinal manipulation reduced pain and improved function as well as other recommended treatments.[7]

Clinical guidelines

The American College of Physicians guideline recommends non-drug treatments such as massage, spinal manipulation, superficial heat or acupuncture for acute and subacute back pain.[4] The NICE guideline names manual therapy (manipulation, mobilisation or massage) as a recommended option for treating back pain.[3]

Shockwave therapy for chronic back pain

A meta-analysis (12 randomised trials, 632 patients) found that ESWT reduced pain and improved lumbar function at 4 and 12 weeks more than the comparison treatments, with no serious adverse events observed.[8]

Electromagnetic transduction therapy (EMTT)

In a randomised trial of patients with non-specific low back pain, pain and disability decreased in both groups, but conventional therapy combined with 8 EMTT sessions gave better results than conventional therapy alone.[9]

Kinesiology tape

A meta-analysis (10 trials, 627 participants) showed that in chronic low back pain kinesiology taping improved everyday function (disability scores). We use tape to support treatment between sessions.[11]

How treatment progresses

1. 1. Conversation and assessment

At the first visit we discuss how the pain started, how long it has lasted and what it feels like, check for red flags and contraindications, and assess mobility and muscles. If anything suggests a need for medical investigation, we recommend seeing a doctor first.

2. 2. Active treatment phase

Sessions take place 4–7 days apart. Methods are chosen based on the findings: for example medical massage and trigger point therapy, and where appropriate manual therapy, magnetic or shockwave therapy. At the start of each session we assess how your body responded to the previous treatment and adjust the plan.

3. 3. Restoring movement and load

As the pain eases, we focus on releasing muscle tension and restoring mobility, and give advice on everyday activity. The number of sessions depends on your condition and how you respond to treatment.

4. 4. Maintenance phase

After active treatment, regular maintenance sessions help keep the result and prevent flare-ups; appointments can be arranged as needed.

What you can do yourself

  • Stay as active as you can – short walks are generally better than prolonged bed rest.[2]
  • In acute pain, superficial heat (such as a heat pack) may ease the pain.[4]
  • When sitting for long periods, change position often and stand up briefly from time to time.
  • Increase your activity gradually and avoid staying still for long periods.
  • Pay attention to sleep and stress, as they affect how pain is perceived.
  • If the pain does not ease within a few weeks, gets worse, or red flags appear, see your GP.

Book an assessment

If back pain is limiting your daily life, we start with a conversation and assessment and put together a treatment plan that suits you. Appointments are available at Viimsi Hospital (Ravi tee 4) and in Pärnu (Rüütli 47); your therapist is Roman Gussev, a massage therapist with a level 6 professional certificate and an assistant nurse.

Frequently asked questions

Yes, if there are no red flags. With acute pain we work more gently and focus on reducing protective muscle tension. If the pain started after an injury, see a doctor first; with numbness in the groin or new bladder or bowel problems, call 112 or go to the emergency department immediately.
It depends on how long the pain has lasted, what is causing it and how your body responds to treatment. In the active phase sessions are 4–7 days apart, and at the start of each session we assess your condition and refine the plan. Chronic pain usually changes more slowly than acute pain.
For non-specific back pain, imaging is usually not needed and clinical guidelines advise against doing it routinely. If you have results from previous scans, please bring them. If red flags are present, a medical assessment is necessary.
The click (cavitation) is the release of gas in the joint fluid and does not show whether the technique was successful. Before an HVLA technique we always carry out a thorough assessment and tests.
Yes, recurrence of back pain is common. Regular movement, gradually increasing load and changing position during long periods of sitting may reduce the risk. If the pain returns, it is worth seeking help early, before it becomes long-lasting.

Related services and topics

References

  1. Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet. 2018;391(10137):2356-2367. doi.org/10.1016/S0140-6736(18)30480-X
  2. Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018;391(10137):2368-2383. doi.org/10.1016/S0140-6736(18)30489-6
  3. National Institute for Health and Care Excellence (NICE). Low back pain and sciatica in over 16s: assessment and management. NICE guideline NG59. 2016 (last updated 2026). www.nice.org.uk/guidance/ng59
  4. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514-530. doi.org/10.7326/M16-2367
  5. Furlan AD, Giraldo M, Baskwill A, et al. Massage for low-back pain. Cochrane Database Syst Rev. 2015;(9):CD001929. doi.org/10.1002/14651858.CD001929.pub3
  6. Paige NM, Miake-Lye IM, Booth MS, et al. Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis. JAMA. 2017;317(14):1451-1460. doi.org/10.1001/jama.2017.3086
  7. Rubinstein SM, de Zoete A, van Middelkoop M, et al. Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials. BMJ. 2019;364:l689. doi.org/10.1136/bmj.l689
  8. Liu K, Zhang Q, Chen L, et al. Efficacy and safety of extracorporeal shockwave therapy in chronic low back pain: a systematic review and meta-analysis of 632 patients. J Orthop Surg Res. 2023;18(1):455. doi.org/10.1186/s13018-023-03943-x
  9. Krath A, Klüter T, Stukenberg M, et al. Electromagnetic transduction therapy in non-specific low back pain: A prospective randomised controlled trial. J Orthop. 2017;14(3):410-415. doi.org/10.1016/j.jor.2017.06.016
  10. Iglesias-González JJ, Muñoz-García MT, Rodrigues-de-Souza DP, et al. Myofascial trigger points, pain, disability, and sleep quality in patients with chronic nonspecific low back pain. Pain Med. 2013;14(12):1964-1970. doi.org/10.1111/pme.12224
  11. Li Y, Yin Y, Jia G, et al. Effects of kinesiotape on pain and disability in individuals with chronic low back pain: a systematic review and meta-analysis of randomized controlled trials. Clin Rehabil. 2019;33(4):596-606. doi.org/10.1177/0269215518817804

This information does not replace a doctor's assessment or diagnosis; if you have red flags or worsening pain, see a doctor.