Back Pain When You Work With Your Body

You have a back that grumbles, a job that does not let you sit still, and every so often the pain spreads into your hip and the top of your thigh.

Two things are probably on your mind, and I want to deal with both properly.

First: is that leg pain sciatica? Almost certainly not, and section 4 explains what it actually is. I examined the nerves in your leg and they were normal. That is a real finding, not just an absence of bad news.

Second: is your job wrecking your back? You have probably been told it will, more than once, by people who meant well. The evidence is a good deal weaker than that belief, and section 7 goes through it honestly.

This guide is not saying your pain is in your head. Your pain is completely real.

One thing before you start. This guide assumes I have examined you and ruled out the serious causes. If nobody has examined you, read section 14 first.

The short version

• Pain is an alarm. It protects you. It does not measure damage.
• The pain in your hip and thigh is referred pain, not a trapped nerve. Different thing, much less worrying. See section 4.
• Your leg tests were normal. That tells us the nerve roots are not involved.
• "Non-specific" does not mean nobody knows. It means the ordinary working parts of your back, which is the commonest and best behaved kind. See section 5.
• Reviews have not found that manual handling at work causes back pain. Your job is not silently destroying your spine.
• But being busy at work is not the same as being fit. That distinction matters more for you than for most people. See section 8.
• Staying at work beats time off, and there are practical ways to make that work.

1. Pain is an alarm, not a damage meter

Your back has danger sensors. They fire when tissue is stretched, squashed or irritated. They send warning signals to your spinal cord, and then to your brain. None of that is pain yet. It is just information.

Then your brain weighs that information against everything else it knows. What were you doing? What happened last time? What do you think this means? How stressed are you? Did you sleep?

Then it decides: how much danger am I in, and how much pain does this person need to feel to keep them safe?

Pain is the answer. Your brain produces it.

That is why damage and pain match up so badly:

• A paper cut really hurts. There is almost no damage.
• Soldiers get badly hurt and feel very little until they are safe.
• People who have lost a leg can still feel pain in it.

So how much pain you feel does not tell you how much damage there is. It tells you how protective your body is being right now.

2. The pain gate

In 1965, two researchers called Ronald Melzack and Patrick Wall came up with an idea that changed pain medicine. It is still one of the most useful pictures we have.

Picture a gate in your spinal cord. Warning signals from your back have to pass through it to reach your brain.

When the gate is open, lots get through and you feel more pain. When it is closed, fewer get through and you feel less. Nothing in your back has changed. Only the gate has.

What closes the gate

• Touch, rubbing, heat and hands-on treatment. Touch signals travel on bigger, faster nerves than danger signals, and they crowd them out.
• Moving and exercise. They release your body's own painkillers.
• Feeling safe and calm.
• A decent night's sleep.
• Understanding what is going on. Reading this counts.

What opens the gate

• Stress and worry. Especially worry about whether you will still be able to do your job.
• Broken sleep.
• Low mood, and feeling that nobody has listened.
• Being told your job is going to cripple you. People say this to manual workers constantly, and it does real damage.
• Being afraid of a movement, usually bending or lifting.
• Money worry, which for you is tied directly to whether you can work.

Here is the key bit. Your brain does not just receive signals at that gate. It sends signals down and changes the settings. That is why an identical shift is fine one week and floors you the next. Nothing changed in your back. The gate setting changed.

3. When the alarm gets too sensitive

When a pain system has been busy on and off for a long time, it does not wear out. It gets better at its job. The sensors fire more easily. The spinal cord turns signals up. The brain decides there is danger more quickly.

Think of a car alarm. When it was fitted, it went off if someone tried to force the door. Years later it goes off when a cat walks past.

The alarm is not broken. It is not lying. It is just set far too sensitive for the actual level of threat.

That is a large part of what grumbling back pain usually is. And because your body learned it, your body can unlearn it. Sensitivity is a setting, and settings change. The shape of a disc does not.

4. That pain in your hip and thigh

This is the section I most want you to read, because it is the one people get wrong, and getting it wrong is frightening. There are two completely different ways a back problem sends pain into your leg. They feel different, they mean different things, and only one of them involves a nerve.

Referred pain, which is what you have

Every structure in your back has a nerve supply: the discs, the small joints, the ligaments, the muscles. When one of them is irritated, its signals arrive at your spinal cord and converge with signals coming in from other parts of the body at the same level.

Your brain now has a problem. Several inputs, one shared junction. It cannot always tell precisely where the signal came from, so it spreads the pain over a wider area than the actual source.

That is referred pain, and it has a recognisable character:

• Dull, aching, gnawing. Not sharp.
• Hard to point to. If I ask you exactly where it is, you rub a broad area rather than tracing a line.
• It spreads and shifts rather than following a neat path.
• It typically centres over the buttock and the top of the thigh. Which is exactly where yours goes.
• No pins and needles, no numbness, no weakness.

The most important thing about referred pain: it does not involve a nerve root being compressed or irritated. It produces no neurological signs at all.

Nerve root pain, which is what sciatica actually means

• Sharp, shooting, electric. Often described as lancinating.
• Travels down the leg in a narrow band, only a couple of inches wide.
• Usually comes with pins and needles, numbness or weakness.

Why your examination mattered

When I saw you I tested the tension on your nerves, your reflexes, your sensation, and the strength of each muscle group in your leg. All of it was normal.

That is not me failing to find anything. It is a positive finding. It tells us the nerve roots are not involved, which means what you have is referred pain, and referred pain is the far less worrying of the two.

One honest caveat. You may have read that referred pain always stops above the knee. That is a rough rule and it is not quite right: referred pain can sometimes spread further down. The better guide is the character of it. Dull, broad and hard to pinpoint, with normal power and sensation, means referred. Sharp, narrow and travelling, with pins and needles, means nerve.

Tell me straight away if the pain changes character: if it becomes sharp and starts travelling in a narrow line, or if you get pins and needles, numbness, or a leg that feels weak.

5. What "non-specific" actually means

This phrase annoys people, and I understand why. It sounds like a shrug.

It is not. It means we have looked for the specific causes, the ones with names and particular treatments, and you do not have them. What is left is pain coming from the ordinary working parts of your back: the joints, discs, muscles and ligaments, all of which are perfectly capable of producing pain without anything being damaged.

This is by far the commonest kind of back pain, and it is the kind with the best outlook. Being told your back pain is non-specific is closer to good news than bad.

6. What scans show

Researchers scanned people who had no back pain at all and counted what showed up.

• At age 20, about 4 in 10 already had disc degeneration. By 60, about 9 in 10 did.
• At age 20, about 3 in 10 already had a disc bulge. By 80, more than 8 in 10 did.

These findings are the inside version of grey hair. They are so common in pain free people that finding one does not, by itself, mean it is causing yours.

There is a second reason this matters, and it matters more for you than for most people. If you do a physical job and someone hands you a report saying degeneration and wear and tear, the conclusion you will draw is that your work has done it and it will get worse. That belief changes how you move, how you plan, and how much pain you feel. It is also, on the evidence in section 7, not well supported.

Scans earn their place when we suspect something specific from section 14. Not as a routine explanation.

7. Is your job wrecking your back?

You have almost certainly been told it is. Probably by family, possibly by a previous clinician, and definitely by whoever tells everyone on site that they will be finished by fifty.

Here is what the research actually shows, and it surprises most people. A systematic review examined 32 studies on whether manual handling at work causes low back pain. It applied a formal framework for judging cause rather than just association. Its conclusion was that the studies did not support a causal link, and that it appears unlikely that workplace manual handling is independently causative of back pain in the workers studied.

Let me be careful about what that does and does not mean.

It does not mean your work has nothing to do with how you feel. A heavy week will leave you sore. A sudden awkward lift can set off an episode. Those things are real.

What it does mean is that your job is not silently damaging your spine in the background. You are not using up a fixed number of lifts. There is no countdown. The idea that manual work inevitably destroys backs has been looked for in the research and has not held up.

What actually seems to matter more than the total amount of lifting:

• Sudden jumps. An unusual task, an unaccustomed load, a covering shift doing something you never normally do.
• Fatigue and poor recovery. The same load on a bad week is not the same load.
• Sleep. One of the strongest predictors of a bad pain day.
• How much say you have over pace and method. Feeling driven is worse than being busy.
• What you believe is happening, which brings us back to the top of this section.

8. Busy is not the same as fit

This one is genuinely useful and most manual workers have never heard it.

You are on your feet all day. You probably shift more weight in a shift than most gym members shift in a week. So the idea that you need to train is, understandably, irritating.

But there is a consistent finding in the research called the physical activity paradox: being physically active at work does not give you the same health benefits that exercise in your own time does. In some studies occupational activity looks unhelpful rather than merely neutral.

The likely reasons make sense once you hear them:

• The intensity is rarely high enough to build capacity, but the duration is long enough to be draining.
• There is very little recovery. Training works because of the rest between efforts. Work does not give you that.
• You have little control over when, how heavy, or how awkward.
• It goes on for years without progressing. Your body adapts to it and then stops adapting.

So the practical conclusion is annoying but true: you can be busy all day, every day, and still be under-prepared for the peaks your job throws at you. Being tired is not the same as being strong.

Which is why deliberate strength work, done outside work, still matters for you. Not more activity. Better organised activity.

9. Training for your job

You do not need a complicated programme. You need to be stronger than your worst day at work.

• Strength training twice a week. Whole body. Legs, back, shoulders, grip. Real resistance, heavy enough that the last few repetitions are hard.
• Train the pattern your job uses, then a bit more. If you lift from the floor, train lifting from the floor. If you carry, train carrying.
• Twenty to forty minutes twice a week is plenty. This is not another job.
• Progress it. Add a little each week. Work does not progress, which is why it stops building you.
• Walking on your days off is worth more than it sounds. A large trial found that a regular walking programme nearly doubled the time before back pain came back.

And the part everyone gets wrong: keep it going when your back feels fine. The exercise that prevents the next episode is the exercise you do when nothing hurts. That is where the evidence is strongest, and it is exactly when people stop.

10. Staying at work

Most people with back pain do better at work than off it. The longer someone is off, the harder going back becomes, and that effect is not small.

That does not mean pushing through a genuinely bad episode. It means aiming for changed work early, rather than waiting until you are completely better.

Practically:

• Ask for changes that keep you working, not changes that keep you away. A lighter task for a fortnight. Swapping the worst job with a mate. Splitting a two-person lift properly rather than being a hero.
• Vary what you do across the day where you can. Sustained anything is worse than mixed.
• Watch the unusual shift. Most flare-ups I see in manual workers come from a task they do not normally do, not from their usual work.
• Use the equipment. Not because you are fragile, but because it is a free reduction in load.

If your employer has an occupational health service, use it. And if you get to the point where you are seriously considering leaving your trade because of your back, talk to me first. That is a big decision and it is usually made at the worst possible moment.

11. Pacing and flare-ups

You will have flare-ups. They are normal, and they do not mean you have done fresh damage.

They are usually a pile-up rather than one moment: a hard week, two bad nights, a stressful patch at home, an unusual task.

Your plan:

• Keep moving, gently. Do less rather than stopping. Do not go to bed with it.
• Drop back to what you can manage on almost any day, then build again over a week or two.
• Use whatever settles it: heat, short walks, changing position often, medication as advised.
• Get back to your usual work in steps rather than all at once, if you have had a few days lighter.
• Remind yourself, deliberately, that this has settled before and it will settle again.

Get in touch if it is not settling as it normally does, if the leg pain changes character as described in section 4, or if anything in section 14 applies.

12. Two things worth dropping

Lifting technique. The evidence that lifting with a straight back prevents back pain is weak, and training courses teaching it have repeatedly failed to reduce injuries. Backs are built to bend. This does not mean technique is irrelevant when you are shifting something genuinely heavy. It means the fear of bending has harmed more people than bending ever has.

Core bracing. Holding your stomach tight all day does not protect your spine. Specific core work helps about as much as any other exercise, which is to say it helps, but not because it is stabilising anything. Bracing constantly just makes you stiff and watchful.

13. What treatment does, and what it does not

Hands-on treatment works through everything above. It closes the gate. It calms the sensitivity. It relaxes muscles that have tightened to protect you. It gives you a spell where moving feels easier and safer. That is a real effect and it is worth having.

What it does not do is rearrange your spine. Nothing is out of place. Nothing needs putting back in.

Think of a session as a window. A stretch of time where you can move more freely, and use that to build capacity. The building is what changes things in the long run.

And I will be straight with you. If you come in every time your back goes, and we settle it each time, and nothing changes in between, then we are managing your episodes rather than reducing them. What you actually want is fewer episodes, further apart, that you handle yourself. That gets built in the weeks when nothing hurts.

One note on progress. Pain scores bounce around. Better questions: how many days did I lose this month compared with last? Did I get through the week? Can I do the task I have been swerving? Function comes back before pain does.

14. When to get urgent help

Almost all back pain, including a bad flare-up, is not an emergency. A few things are.

Go straight to A&E, or call 999

Do not wait to see if these settle. If you are offered a routine appointment, say you are worried about cauda equina syndrome and ask to be seen today.

• Numbness or a changed feeling between your legs, around your back passage or genitals. Including toilet paper feeling different when you wipe.
• Trouble starting to wee. Not being able to feel it coming out. Losing the feeling of a full bladder. Any new loss of control of your bladder or bowels.
• New numbness during sex, or new trouble getting an erection.
• Pain going down both legs at once.
• New or worsening weakness in one or both legs, or your legs giving way.
• Severe back pain straight after a serious fall, a crash, or something falling on you.

Contact your GP or NHS 111 today

• Back pain with a fever, shivering, or feeling generally unwell.
• Back pain with weight loss you cannot explain, night sweats, or a past history of cancer.
• Pain that is much worse at night, wakes you every night, or is not eased by any change of position.
• New weakness, numbness or pins and needles in a leg, or a foot that catches or drags.

Worth getting checked, but not urgent

There is one condition worth knowing about, because it typically starts at your stage of life and gets missed for years. Axial spondyloarthritis is a type of inflammatory arthritis of the spine. It is treatable, and treated early it goes much better.

Mention it if your back pain started before you were 45, has lasted more than three months, and several of these fit:

• It is worse after rest and better once you get moving. That is the opposite of most mechanical back pain, and the opposite of what a physical job usually does to you.
• Morning stiffness lasting more than half an hour.
• Pain that wakes you in the second half of the night.
• Buttock pain, sometimes swapping sides.
• Anti-inflammatory tablets help strikingly well, often within a day or two.
• You or a close relative have psoriasis, inflammatory bowel disease, or repeated painful red eyes.

Everything else, including a bad flare-up, can wait for a normal appointment.

15. If you want to read or watch more

Start here

• Tame the Beast. A five minute animation by Professor Lorimer Moseley. The best possible starting point. tamethebeast.org
• Flippin' Pain. A UK campaign about long lasting pain, with animations and real stories. flippinpain.co.uk
• Retrain Pain. Free, very short illustrated lessons. retrainpain.org
• NHS advice on back pain. nhs.uk/conditions/back-pain

Practical help

• The Pain Toolkit, by Pete Moore, who lives with long lasting pain himself. Very good on pacing and boom and bust. paintoolkit.org
• Recovery Strategies, by Greg Lehman. A free illustrated workbook, one idea per page. greglehman.ca/recovery-strategies-pain-guidebook
• NASS, if the last part of section 14 rang any bells. nass.co.uk The research behind this guide
• Melzack R, Wall PD. Pain mechanisms: a new theory. Science, 1965. The original pain gate paper.
• Bogduk N. On the definitions and physiology of back pain, referred pain, and radicular pain. Pain, 2009. The basis of section 4.
• Causal assessment of workplace manual handling or assisting patients and low back pain: results of a systematic review. The Spine Journal, 2010. The basis of section 7. There is a companion review in the same journal on occupational lifting, which reached a similar conclusion.
• Holtermann A et al. The physical activity paradox: six reasons why occupational physical activity does not confer the cardiovascular health benefits that leisure time physical activity does. British Journal of Sports Medicine, 2018. The basis of section 8.
• Brinjikji W et al. Imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 2015. The scan figures in section 6.
• Pocovi NC et al. An individualised, progressive walking and education intervention for the prevention of low back pain recurrence (WalkBack): a randomised controlled trial. The Lancet, 2024. The walking evidence in section 9.
• Hartvigsen J et al. What low back pain is and why we need to pay attention. The Lancet, 2018.
• NICE guideline NG59: Low back pain and sciatica in over 16s.

Bring any of this to your next appointment. Especially the parts that did not sit right, or that felt uncomfortably familiar.

This guide is general information. It does not replace the advice I give you in clinic.