Many patients with back pain know the cycle well. Severe low back pain appears, an MRI shows a disc herniation or facet arthritis, an epidural steroid injection provides temporary relief, and then the pain returns.
This does not mean the treatment failed or that surgery is the only remaining option. It often means the underlying mechanical driver was not fully understood.
Back pain is rarely just one isolated problem. The spine may be the painful area, but the source can involve the hips, pelvis, sacroiliac joints, connective tissue, nerves, inflammation, or movement patterns that keep re-irritating the same structures.
Why the Pain Keeps Returning
The lower back often becomes the victim of a larger biomechanical pattern.
One common driver is the hip-spine connection. Tight hip flexors can pull the pelvis forward into an anterior pelvic tilt. This can increase the arch in the lower back, add pressure to the lumbar facet joints, and place more stress on the discs.
Pelvic ring instability can also contribute. When the sacroiliac joints or hips are hypermobile, sprained, or unstable, the surrounding muscles may tighten to protect the area. What feels like a primary muscle spasm may be the body’s attempt to stabilize a joint that is not moving well.
Anatomical variants can add another layer. Bertolotti syndrome, for example, involves a transitional vertebra near the base of the spine that may create a painful contact point with the sacrum or pelvis. This can be missed when the workup focuses only on the disc or the MRI report.
Why Imaging Is Only Part of the Workup
A standard MRI shows anatomy while the patient is lying still. It does not always show how the spine behaves under gravity, movement, or load.
A more complete spine workup may include flexion-extension X-rays to evaluate dynamic movement. If vertebrae shift with bending, that instability may be part of what continues to irritate discs, joints, or nerves.
What a Proper Workup Requires
A proper workup starts by mapping the pain. The care team should identify each distinct pain pattern, what triggers it, what relieves it, and whether it behaves like a disc, joint, nerve, muscle, or instability problem.
A hands-on physical exam is also essential. Neural tension, joint mobility, muscle guarding, hip mechanics, and pelvic alignment all provide clues.
In some cases, targeted diagnostic blocks can help clarify the pain generator. Temporarily numbing a specific joint, nerve, or ligament can provide strong evidence about what structure is contributing to the pain.
Our Approach at MPM
At Manhattan Pain Medicine, we evaluate back pain through a diagnosis-first lens, helping patients identify whether the pain is coming from the spine itself, the hips, the pelvis, instability, nerve irritation, inflammation, or a layered mechanical pattern.
