Author(s): Alyssa Marulli, MD, Trushti Patel, DO, Surya Gourneni, MD
Originally published: September 20, 2013 Last updated: June 5, 2025
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Disease/Disorder

Definition

Lumbar strain is an injury to muscles, ligaments, and tendons in the paravertebral lumbar and sacral region. Pain is typically well-localized to unilateral region and non-radiating.1 

Etiology

Lumbar strain may occur with physical stress (weight/torque) that is greater than the forces that can be supported by the muscular and ligamentous structures. Injury is more likely to occur if the lumbar spine is at a mechanically disadvantaged position, such as when rotated or fully flexed.

Epidemiology including risk factors and primary prevention

Low back pain (LBP) is the fifth most common reason for all physician visits. In 2020, 619 million people globally developed low back pain at some time in their life. Up to one-quarter of the population will have low back pain in any given year.18 Greater than 80% of the population will experience at least one episode of back pain during their lifetime.1 Risk factors include repetitive or heavy lifting, prolonged abnormal position of the trunk (rotated, flexed, hyperextended), poor body mechanics or ergonomics, core weakness, smoking, and psychosocial issues.3,4

Patho-anatomy/physiology

Muscle pain due to lumbar strain may be due to: 

  • Muscle fiber tearing from indirect trauma, such as excessive stretch or tension. 
  • Muscle fatigue due to overuse. There may be a metabolic component due to an increased presence of lactic acid. 
  • Muscle spasm, which is associated with persistent muscle contraction. The reduction of blood flow with subsequent accumulation of metabolites may stimulate pain receptors in blood vessels. Muscle spasm can be a result of muscle fatigue or occur independently. 
  • Paraspinal muscles becoming deconditioned after injury. Decreased muscle mass results in decreased muscle power, with increased risk for persistent or recurrent muscle injury.3
  • Stress causes injury to soft tissues through forces applied in various directions. Injuries can be along muscles, tendons, myotendinous junctions, and ligaments. Lumbar strain pain is difficult to localize to specific structures due to the multiple structures in close proximity. Traumatic strains can be caused by forcing extension from a flexed position. Overuse of back extensors is common during occupational or physical activity, such as packaging, warehouse work, and gardening. Other injury patterns include twisting and bending, such as in activities like cleaning and sports such as baseball and golf. These forces can lead to muscle and tendon fiber trauma leading to tears/microtears.1

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Different resources characterize chronicity of low back pain and lumbar strains with different time points.4,5,6 The acute stage is from onset to 4 weeks. The subacute stage ranges from 4 weeks to 3-6 months. At the chronic stage, symptoms last greater than 3-6 months. For the purposes of this review, we will consider acute stage up to 4 weeks, subacute stage from 4 to 12 weeks, and chronic stage as greater than 12 weeks.

  • New onset/acute: Many patients can recall the inciting event or activity but up to a third do not recall the exact time of injury. Pain is usually most severe at the time of the injury, or within several hours. Ninety percent of acute low back pain resolves or improves significantly in the first 30 days. In this stage, it is key to identify red flags to avoid complications.
  • Subacute: Most episodes of low back pain due to lumbar strain are self-limited. During this stage, it is important to identify yellow flags that put patients at risk of developing chronic low back pain.
  • Chronic: Up to one-third of patients report persistent back pain of at least moderate intensity one year after an acute episode.28 During this stage, a multifaceted and patient-centered treatment plan is required to address symptomatic relief.

Specific secondary or associated conditions and complications

  • Chronic low back pain may develop with repeated lumbar strain injuries or with failure to pursue appropriate therapies in the acute/subacute phase. Prolonged bed rest after injury may lead to cardiovascular and paraspinal muscle deconditioning. Additionally, failure to incorporate preventive measures to decrease the risk of re-injury could result in more serious or frequent future injuries.
  • “Yellow flags” can help stratify risk of developing chronic pain in patients with acute low back pain. High disability, functional impact, depression, environmental control, duration and severity of pain, and low socioeconomic status are all risk factors for developing chronic pain.

Essentials of Assessment

History/Symptoms

Patients present with axial, non-radiating LBP due to an inciting injury or event. Lower limb symptoms such as pain, numbness, tingling, or weakness are usually absent. Pain is usually worse with movement and better with rest. Screening questions for “red flags” exclude the suspicion for the presence of cancer, infection, fracture, cauda equina syndrome, inflammatory arthritis, or non-mechanical visceral disease. Some “red flag” findings include progressive neurologic deficit, recent bowel or bladder dysfunction, saddle anesthesia, history of steroid use, history of diffuse osteoporosis or compression fracture, pain that is worse when supine, insidious onset, history of cancer, intravenous drug use. Psychosocial factors and emotional distress should also be assessed, as they are strong predictors of poor outcomes and are associated with chronic disability. Being overweight, obese, and smoking are associated with functional treatment outcome failures with physical therapy.7

Physical examination

Physical examination includes inspection of the spine curvature, pelvis, extremities, and gait. In standing, a postural shift may be present. Lumbar range of motion may be limited and painful in one or more planes. There is typically tenderness over the lumbar paraspinal muscles or quadratus lumborum, with absence of focal spinous process tenderness. Strength, reflex, and sensory testing should be normal. Straight leg raises may provoke axial back pain but should not elicit radicular pain below the knee (therefore a negative test). Femoral stretch test should also be negative.  Hip examination and special tests, such as FABER (flexion/abduction/external rotation), compression, distraction, thigh thrust, Fortin’s finger, and Gaenslen’s maneuver can help evaluate for sacroiliac joint etiology of pain.

Functional assessment

Functional evaluation of lumbopelvic core strength can be assessed during the clinical exam through observation of trunk and hip control during single limb stance, presence of Trendelenburg gait, and assessment of ability to perform core exercises such as bridge, plank, and one leg step down.

Laboratory studies

Lab studies are typically not indicated for lumbar strain. Complete blood cell count, erythrocyte sedimentation rate and/or C-reactive protein may be obtained to rule out infection or inflammatory arthritis when such suspicion exists.

Imaging

Imaging studies such as plain radiographs are not indicated for acute axial LBP related to lumbar strain in the absence of red flags as they provide minimal clinical benefit.  In uncomplicated LBP, lumbar CT and MRI have not been found to lead to improved outcomes.8 In addition, they often identify radiographic abnormalities that may be present even in asymptomatic patients and could lead to unnecessary interventions.9 Imaging may be indicated for a patient with LBP in a rehabilitation program for at least 6 weeks without improvement. If a patient has previously discussed “red flag” symptoms, then further imaging such as plain radiographs, CT, and/or MRI should be obtained.10

Supplemental assessment tools

There are a number of assessment tools available to monitor a patient’s functional assessment and progress.  LBP Rating Scale can be utilized to monitor LBP outcomes and includes 3 clinical illness domains: back and leg pain, disability, and physical impairment. The Oswestry LBP Disability Index assesses the impact of LBP on ten aspects of daily life (such as lifting, walking, self-care, and work). The Quebec Back Pain Disability Scale can be used to assess functional limitations related to pain and monitor patient symptoms over time especially if the patient is involved in a rehabilitation program.11

Early predictions of outcomes

Poor prognostic factors associated with chronicity of LBP include higher body weight, previous history of LBP, smoking, general anxiety, depression, physical work and work related to heavy lifting, and LBP-induced disability and functional limitation.12

Environmental

Environmental factors associated with lumbar strain include heavy and/or repetitive lifting, prolonged sitting, and poor ergonomic conditions.

Social role and social support system

When LBP becomes a chronic condition, it can lead to loss of function, vocation, and recreation. Such disability can affect one’s role and interaction within the family and community, contributing to the development of mood disorders such as depression. Increased social support is associated with lower pain severity in patients with chronic LBP.13

Professional issues

Early return to work, even with modifications, is critical to good long-term outcomes and should be addressed at the initial and subsequent visits. Workers who miss six months of work have only a 50% chance of ever returning to their job; the chances decrease to less than 10% if work time lost exceeds one year.14,15 The Back Performance Scale and Biering-Sorenson test are useful tools that can help evaluate readiness for return to work. Psychosocial aspects and work demands should be considered.16

Rehabilitation Management and Treatments

Available or current treatment guidelines

Overall, the goal of treatment of acute low back, and in particular lumbar strains, is symptomatic pain relief, improving function, and reducing debility.

Guidelines for treatment of lumbar strain are often considered within the treatment guidelines for low back pain. The following are a few guidelines for reference. In 2007, a Joint Clinical Practice Guideline on LBP from the American College of Physicians (ACP) and the American Pain Society provided recommendations on low back pain treatments. In 2017, the ACP published updated guidelines on non-invasive treatments for low back pain.5 Since the last update, the Department of Veterans Affairs (VA) and Department of Defense (DoD) published guidelines in 2022 on treatment of lower back pain.17 The Journal of Orthopedic Physical Therapy revised guidelines of interventions for management of acute and chronic lower back.2 The WHO released guidelines for evaluation and management of low back pain in the setting of primary care, with a particular focus on the elderly ( greater than 60 years of age).18   These guidelines are explored further in sections below.

At different disease stages

On each presentation regardless of stage, patients should be screened for “red flags” to avoid undiagnosed/misdiagnosed disorders.

Red flags symptoms are often elicited during a careful history and physical exam. Some examples include urinary or fecal incontinence, urinary retention, saddle anesthesia, severe neurological deficits (weakness, sensation changes), signs of infections (fever, chills, history of IVDU, indwelling catheter), and history with a risk of fractures or cancer.

Summarizing recommendations from the Joint Clinical Practice Guideline5 and Journal of Orthopedic Physical Therapy2 for management of LBP; treatment by stage includes:

New Onset/Acute Stage (onset to 4 weeks) 

  • Treatment is focused on reduction of pain and supporting function.
  • Overall, unless red flag symptoms or symptoms of other causes of back pain are present, imaging is not recommended.
  • Nonpharmacologic treatments include activity modification, early mobilization, physical therapy, and cognitive behavior therapy.
  • It is recommended to avoid prolonged bedrest (more than 1-2 days) and resume activities as tolerated. As possible, adjust occupational activities to reduce excessive stress and loading of muscles. Avoid positions that exacerbate pain.
  • Early mobilization is shown to be beneficial, through modalities such as Tai chi and Pilates. Other modalities include acupuncture, and superficial heat and ice application.
  • Pharmacological treatments can include NSAIDs, acetaminophen, and skeletal muscle relaxants.
  • NSAIDs were shown to have a low-moderate improvement on pain and function over placebo.5 The VA has a weak recommendation for use of NSAIDs.17 WHO recommends a conditional use of NSAIDs.18
  • Tylenol was shown to have little to no improvement in pain or function compared to placebo.5 The VA has a weak recommendation against the use of Tylenol.17
  • Muscle relaxants are an option for short-term relief of acute low back pain. Evidence ranges from low to no difference compared to placebo and may be associated with central nervous system adverse effects (primarily sedation).  In the elderly, WHO recommends against the routine use of muscle relaxants (including in subacute phase) due to the low benefit and risk of adverse events.18
  • Opioids: A meta-analysis of 4 studies assessing the efficacy of opioids compared with placebo or a nonopioid control did not show reduced pain with opioids.19 The VA recommends against the use of opioids.17 The WHO recommends against use of opioids, particularly in the elderly.18

Subacute (4-12 weeks)

  • Symptomatic relief continues to play a large role, but therapies begin to focus on improving conditioning, strength, stability, and flexibility to return to normal activities and function.
  • Pharmacological treatments expand upon those used during the acute phase.
  • Antidepressants are occasionally used both for chronic pain as well as often with concomitant psychological disorders with chronic pain. The VA guidelines report a weak recommendation for duloxetine for chronic pain.17 Other reviews show some benefits to tricyclic anti-depressants (TCAs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) such as duloxetine and venlafaxine.6
  • Neuropathic medications can be used as adjunct therapy. Gabapentin and pregabalin are often used for radicular pain, but evidence is inconclusive for acute low back pain.5,6,17

Chronic (> 12 weeks) 

  • Comprehensive treatment should include a biopsychosocial treatment approach due to the high frequency of concomitant depression and deconditioning in this population. Multidisciplinary rehabilitation is mildly superior to non-multidisciplinary rehabilitation or general exercise for improving short- and long-term functional status (up to 60 months). Additionally, cognitive behavioral therapy or mindfulness-based stress reduction have been shown to have moderate benefit in reduction of pain and improved function.
  • Adjunctive medications can be tried, as above.
  • Additional sources report fair and good evidence for acupuncture, spinal manipulation, tai chi, and yoga in chronic pain.5

Coordination of care

In chronic pain situations, care coordination with all treating providers, including physical therapists, occupational health nurses, athletic trainers, case managers, and psychologists/social workers, can optimize a successful return to normal activities.

Patient & family education

Patient and family education regarding the natural history of the condition (favorable prognosis) is advised. Efforts should be made to address possible fear-avoidance behaviors, depression, and anxiety, as soon as possible. Incorporation of psychology or social worker services is often helpful to achieve optimal patient and family education.

Emerging/unique interventions

Manual therapies such as myofascial release (MFR) and Mulligan Sustained Natural Apophyseal Glides (SNAGs) can be used in conjunction with strengthening exercise and can aid in pain and restricted function associated with LBP.20

Graded lumbar stabilization exercises are an effective method to decrease pain, improve function, and increase core strength in patients with LBP.21

Non-invasive neuromodulation can be useful in patients with LBP. Transcutaneous electrical nerve stimulation (TENS) has been shown to lower pain intensity in acute LBP though there continues to be ongoing research for long term outcomes.22 Pulsed electromagnetic field therapy has also been shown to relieve the pain intensity and improve functionality in individuals with LBP conditions.23

Regenerative medicine such as platelet rich plasma (PRP) is generally a safe and effective treatment option for LBP, specifically, intradiscal PRP for discogenic LBP.24 Stem cell regenerative therapy is an emerging, viable, and noninvasive treatment option for LBP, though the focus is on cartilage and intervertebral discs.25 There is evidence that supports the use of prolotherapy for treatment of nonspecific low back pain, especially when there is suspected ligamentous laxity or enthesopathy.26

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Clinicians should provide patients with evidence-based information on their expected course, advise patients to remain active, and provide information regarding effective self-care options. Most patients recover within the expected timeframe noted. However, patients presenting with and/or developing additional symptoms, such as lower extremity pain, numbness, tingling, weakness, or saddle paresthesia, require further evaluation, as those are symptoms suggestive of lumbosacral radiculopathy or cauda equina syndrome.

Cutting Edge/Emerging and Unique Concepts and Practice

Cross treatment with lesser studied treatments such as non-invasive neuromodulation and regenerative medicine, based upon greater understanding of tissue healing principles, are becoming more prevalent in treatment of muscle strain injuries.

The use of artificial intelligence (AI) can aid in identifying pain using neurophysiology-based methods. EEG has been used to identify and measure pain intensity. AI powered tools have been shown to assess the quality of pain, monitor opioid use, analyze sleep patterns, suggest self-care techniques, and recommend exercises that would help with a patient’s pain.27

Gaps in the Evidence-Based Knowledge

Treatment controversies include

Exercise

  • type, intensity, and duration of exercise
  • potential benefit and timing of yoga and massage

Modalities

  • optimum number of manipulations for management of lumbar strain
  • duration of heat or cold application
  • role/timing of acupuncture in promoting symptom recovery
  • assessment of other interventions such as low-level laser therapy, electrical nerve stimulation, interferential treatment in promoting symptom relief and tissue healing
  • the role for prolotherapy in acute LBP
  • the role of dry needling (there is no current evidence to support) or trigger point injections for management of lumbar strain

Other

  • benefit of mattress types in alleviating LBP
  • use of dietary supplements to provide healing

References

  1. El Sayed M, Callahan AL. Mechanical Back Strain. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. 
  2. George SZ, Fritz JM, Silfies SP, et al. Interventions for acute & chronic low back pain: 2021 revision. J Orthop Sports Phys Ther. 2021;51(11):CPG1–CPG60.
  3. Borenstein DG, Wiesel SW, Boden SD. Low Back and Neck Pain, 3rd ed. Philadelphia: Elsevier; 2004. p. 229-241.
  4. Frontera WR, et al. DeLisa’s Physical Medicine and Rehabilitation: Principles and Practice. 6th ed. Wolters Kluwer Health; 2019. 
  5. Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treatments for low back pain. Ann Intern Med. 2017. 
  6. Urits, I., Burshtein, A., Sharma, M. et al. Low Back Pain, a Comprehensive Review: Pathophysiology, Diagnosis, and Treatment. Curr Pain Headache Rep 23, 23 (2019).
  7. Chiodo AE, Bhat SN, Van Harrison R, et al. Low Back Pain. Ann Arbor (MI): Michigan Medicine; 2020 Nov. 
  8. Jarvik JG, Gold LS, Comstock BA, et al. Early imaging & back pain outcomes in older adults. JAMA. 2015;313:1143-53. 
  9. Tan A, Zhou J, Kuo YF, Goodwin JS. Imaging variation among PCPs. J Gen Intern Med. 2016;31(2):156-163. 
  10. ACR Expert Panel on Neurological Imaging, Hutchins TA, Peckham M, Shah LM, et al. ACR Appropriateness Criteria® Low Back Pain: 2021 Update. J Am Coll Radiol. 2021 Nov;18(11S):S361-S379. 
  11. Smeets R, Köke A, Lin CW, et al. Functional measures in low back pain. Arthritis Care Res. 2011;63 Suppl 11:S158-73. 
  12. Nieminen LK, Pyysalo LM, Kankaanpää MJ. Prognostic factors for chronicity. Pain Rep. 2021 Apr 1;6(1):e919. 
  13. Saravanan A, Bajaj P, Mathews HL, et al. Social support and pain severity in CLBP. Nurs Res. 2021;70(6):425-432. 
  14. Nguyen TH, Randolph DC. Nonspecific low back pain and return to work. Am Fam Physician. 2007;76(10):1497-1502. 
  15. Shaw WS, Nelson CC, Woiszwillo MJ, et al. Early return to work benefits. J Occup Environ Med. 2018;60(10):901-910. 
  16. Hurri H, Vänni T, Muttonen E, et al. Functional tests predicting return to work. Int J Environ Res Public Health. 2023 Mar 15;20(6):5188. 
  17. Department of Veterans Affairs & Department of Defense. VA/DoD clinical practice guideline for low back pain. 2022. 
  18. World Health Organization. (2023, December 7). WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. World Health Organization. 
  19. Martell BA, O’Connor PG, Kerns RD, et al. Opioid treatment for chronic back pain. Ann Intern Med. 2007;146:1160-127. 
  20. Bhat PV, Patel VD, Eapen C, et al. Myofascial release vs. Mulligan SNAGs for low back pain. PeerJ. 2021 Mar 15;9:e10706. 
  21. Smrcina Z, Woelfel S, Burcal C. Core stability exercises for non-specific LBP. Int J Sports Phys Ther. 2022 Aug 1;17(5):766-774. 
  22. Binny J, Wong NLJ, Garga S, et al. TENS for acute low back pain: systematic review. Scand J Pain. 2019 Apr 24;19(2):225-233. 
  23. Andrade R, Duarte H, Pereira R, et al. Pulsed electromagnetic field therapy effectiveness in low back pain: A systematic review of RCTs. Porto Biomed J. 2016 Nov-Dec;1(5):156-163. 
  24. Machado ES, Soares FP, Vianna de Abreu E, et al. PRP for low back pain: systematic review. Biomedicines. 2023 Aug 28;11(9):2404. 
  25. Soufi KH, Castillo JA, Rogdriguez FY, et al. Stem cell therapy for DDD & LBP. Int J Mol Sci. 2023 May 17;24(10):8893. 
  26. Hauser RA, Lackner JB, Steilen-Matias D, Harris DK. A Systematic Review of Dextrose Prolotherapy for Chronic Musculoskeletal Pain. Clin Med Insights Arthritis Musculoskelet Disord. 2016 Jul 7;9:139-59.
  27. Do K, Kawana E, Vachirakorntong B, et al. AI in chronic back pain treatment. Korean J Pain. 2023 Oct 1;36(4):478-480.
  28. Chou, R., Qaseem, A., Snow, V., Casey, D., Cross, J. T., Jr, Shekelle, P., & Owens, D. K.; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. (2007). Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, 147(7), 478–491.

Original Version of the Topic

Diane W. Braza, MD, Philip Andrew Nelson, MD. Lumbar Strain. 9/20/2013

Previous Revision(s) of the Topic

Diane W. Braza, MD, Philip Andrew Nelson, MD. Lumbar Strain. 8/9/2017

Whitney Luke, MD. Lumbar Strain. 9/23/2021

Author Disclosure

Alyssa Marulli, MD
Nothing to Disclose

Trushti Patel, DO
Nothing to Disclose

Surya Gourneni, MD
Nothing to Disclose