Follow Dr Huang to Learn Clinical Diagnosis (Case 12)

Recurrent Low Back Pain for Years — Not a Disc Problem, but the Way He Uses His Body

Today I saw a very common case in clinic, but also a very meaningful one to share.

This patient has had left-sided low back pain for about five to six years. The first episode happened before COVID. He was working in the garden and tried to lift something heavy. Suddenly he twisted his back and collapsed to the ground. The pain was severe and he could not stand up. His family took him to the emergency department. No imaging was done. The doctor thought it was a muscle strain and gave him pain relief medication. He went home and rested in bed for more than one month before slowly recovering.

A few months later, he lifted another heavy box at home and injured his back again. This time it was worse. Not only low back pain, but also pain spreading to the left buttock and thigh. He then had an MRI scan, which showed an L4/5 disc protrusion. The specialist told him surgery was not needed and advised conservative treatment. He received acupuncture and physiotherapy, and gradually improved.

From that point on, he started to believe that he had a “disc problem”.

In the past few years, his condition followed a very clear pattern. The pain comes back two to three times every year. Almost always on the left side, and usually triggered by lifting. When it happens, he rests in bed for two to three weeks, and then slowly gets better again.

This time, about one month ago, he was working in the garden again and twisted his back while pulling branches. The same pattern happened. Severe pain, difficulty bending, difficulty getting up from bed or a chair. After two weeks of rest, he improved somewhat. He can walk, but still has pain with movement, especially in the left lower back, buttock, and the lateral thigh.

One of his friends is my previous patient and had recommended him to come for a long time. But he never wanted to come. His belief was very simple: “disc problems cannot be fixed.” This time, his friend brought him in.

When I examined him, I first looked for signs of disc-related nerve irritation. If it is a typical disc problem affecting the sciatic nerve, there should be clear findings.

I performed the straight leg raise test. The result was interesting. On the left side, I could lift his leg to 90 degrees without any pain. On the right side, when lifting to a certain angle, it actually triggered pain in the left lower back. This was already a bit unusual.

Then I checked the pain distribution. He reported pain mainly in the left lower back and buttock, radiating to the lateral thigh. This pattern does not match the typical sciatic nerve pathway. Neurological examination was also normal. Sensation, reflexes, and muscle strength were all intact.

So although the MRI showed a disc protrusion, clinically it did not look like a typical disc-related problem.

I then focused on the muscles. There was mild tenderness in the paraspinal muscles, but nothing significant. The piriformis was also unremarkable. However, when I examined the iliopsoas from the abdomen, the findings were very clear. The left iliopsoas was very tight and thickened. Palpation produced strong pain, around 7 to 8 out of 10, especially near the area medial to the anterior superior iliac spine. The right side had some tension, but much less.

At this point, the picture became clear. Each time he had an “episode”, it looked like a disc problem, but in fact, the recurring issue was likely the iliopsoas.

I did not try to argue with him about the diagnosis. That is usually not helpful. I simply told him I would treat the area and see how he responds.

I released the iliopsoas from the abdominal side and also worked around the transverse processes of the lumbar spine. After the treatment, I asked him to stand up and bend forward again. He paused for a moment and said the pain was much less. Getting up from a chair also became easier.

He said something interesting: “You fixed my disc problem.”

I did not correct him.

This case reminded me of several important points.

First, imaging findings can be very clear, but they are not always the cause of pain. A disc protrusion can be present, but the symptoms may come from somewhere else.

Second, once a patient is labelled with a diagnosis, especially with MRI and specialist opinion, it becomes very difficult to change their belief. Explanation often does not work.

Third, physical examination is still very important. Sometimes the answer is in the body, not in the report.

Finally, although his pain improved after releasing the iliopsoas, the more important question is how to prevent recurrence.

This patient does not just have a “problem in one structure”. The deeper issue is how he uses his body.

Every time he lifts something, he uses the same pattern. He bends through his lower back instead of hinging at the hips. The front chain, especially the iliopsoas, takes over, while the gluteal muscles do not contribute effectively. Over time, this becomes a fixed pattern. The muscles that should work are not working, and the ones that should not overwork are doing too much.

That is why the iliopsoas keeps becoming tight and painful.

So the real solution is not just to treat one muscle, but to change two things.

First, restore proper muscle use — the glutes must start to work again.
Second, correct the movement pattern — bending should come from the hips, not the lower back.

Otherwise, even if this episode improves, the same pattern will bring the pain back again.

Many patients think their problem is “recurrent disc herniation”.

In reality, what keeps coming back is the same way they use their body.