Back Pain Doctor
Low Back Pain
Low back pain is extremely common and, in most cases, is not a sign of serious disease. The lower back is a complex structure of joints, discs, ligaments and muscles, and pain can arise from several of these without there being a single, clearly identifiable “cause” on a scan.
The most important early steps for most people are staying active within reasonable limits, avoiding prolonged bed rest, and using simple measures to manage pain while the back settles. Physiotherapy and a graded return to normal activity are central to recovery.
Our role is to assess your back carefully, identify any features that need further investigation, and give you an honest plan. Where pain is persistent and has not responded to first-line measures, we can discuss whether additional treatments are reasonable in your situation — always alongside, not instead of, good rehabilitation.
When the sacroiliac joint may be part of the picture
The sacroiliac joints (SIJs) transfer load between the spine and pelvis. They are a significant consideration when pain sits low on one side of the back or around the buttock, particularly if it is aggravated by rolling in bed, stairs, prolonged standing or single-leg loading. Pregnancy, a fall, a change in activity or previous lumbar fusion can also make SIJ-related pain more likely.
The location of pain is not enough to make the diagnosis. We assess the lumbar spine, hips, gluteal tendons and nerves alongside a cluster of SIJ pain-provocation tests, and use imaging selectively to investigate other causes. This is why SIJ pain has its own assessment pathway: read about sacroiliac joint pain, or go straight to the full sacroiliac joint, ligaments and lumbopelvic instability section for the diagnostic reasoning, the rehabilitation protocols and the evidence for each treatment.
Common symptoms
- Pain across the lower back, sometimes radiating to the buttock or thigh
- Stiffness, especially after rest or in the morning
- Pain aggravated by certain postures, bending or lifting
- Difficulty with prolonged sitting or standing
Commonly seen in
Evidence for twelve treatment options in low back pain
This is not a fixed ladder or a package of treatments. Every option is assessed independently against this diagnosis, including treatments with limited direct research that may still be reasonable for a clearly defined tissue target. The evidence level, likely benefit, risks, cost and alternatives are weighed at consultation.
Foundation — diagnosis, education and rehabilitation
The part of care with the broadest relevance. For many people it is enough on its own; other options are judged against it, not automatically added after it.
Diagnosis, education and progressive rehabilitation Working out what is driving the pain, explaining what your imaging does and does not mean, and building a graded loading plan you can actually follow. Core care
What it involves
Assessment to identify the likely pain source, an explanation of what the diagnosis means, adjustment of the loads that aggravate it, and a progressive strength and conditioning plan — with weight management where that is clinically relevant.
What the evidence shows
Every high-quality guideline says the same thing. The American College of Physicians makes a strong recommendation that chronic low back pain be treated first with exercise and multidisciplinary rehabilitation rather than drugs or procedures (Qaseem, Ann Intern Med 2017). An overview of 15 primary-care guidelines found consistent agreement on education, staying active, exercise and reassurance, and on discouraging routine imaging (Oliveira, Eur Spine J 2018). For neck pain the strongest effects also belong to exercise, with strengthening of the neck and upper quadrant showing a moderate short-term effect (Sterling, J Clin Med 2019). Adding pain-science education to exercise improves pain, disability and fear of movement over exercise alone (Bonatesta, J Pain 2021).
Pairing reviewed 2026-09-02.
Where it fits for you
Understanding why the back hurts, and moving well, does more than anything injected. Imaging is used to answer a specific question, not as a starting point — degenerative findings are near universal and frequently unrelated to the pain.
Muscle and symptom-modifying options
Useful only when the examination identifies the tissue they target or when short-term pain control creates a useful rehabilitation window.
Wet needling and trigger point injection (trigger point injection) A fine needle into a tender band of muscle, with a small volume of dilute glucose solution injected through it. Worth discussing
What it involves
The needle is placed into the tender muscle band and a small volume of 5% glucose with 0.02-0.08% lignocaine is injected. Often done in the same visit as your assessment, and usable where the tender area sits deeper. Dry needling — the same technique with nothing injected — is not offered here.
What the evidence shows
For myofascial pain, trigger point injection performed as well as shockwave in head-to-head comparison — a meta-analysis of 10 trials found shockwave better than sham and ultrasound but NO better than trigger point injection, dry needling or laser (Zhang, Arch Phys Med Rehabil 2020). Trials of needling in myofascial pain are small and generally low quality.
Pairing reviewed 2026-08-30.
Where it fits for you
Directed at a tender muscle band that reproduces part of your pain, alongside the loading work. Not a treatment for the joint, disc or nerve itself.
Ultrasound-guided injections Guidance means we can see the needle reach the target. What goes into the needle depends on the diagnosis. Only for a specific target
What it involves
The injection is performed under ultrasound so the needle can be watched into the target structure. What is injected is decided by the diagnosis — and corticosteroid is used sparingly, for the reasons set out below.
What the evidence shows
For back pain without a specific target, injection is not the recommended path. A current review of chronic low back pain states that epidural corticosteroid injections are not recommended except for short-term relief of radicular pain (Maharty, Am Fam Physician 2024), and the American College of Physicians guideline places exercise, multidisciplinary rehabilitation and a list of non-drug therapies first for chronic low back pain (Qaseem, Ann Intern Med 2017). Where one structure is implicated the question changes, but the reach of ultrasound at lumbar targets is itself a limit: ultrasound-guided medial branch blocks were misplaced 11% of the time and facet joint injections 13% of the time when checked against X-ray or CT (Ashmore, Pain Rep 2022). The most favourable ultrasound-guided report is a single-centre audit of 42 people given facet or nerve root injection, 90% of whom improved by more than 30% at three months — with no control group (Tay, Asian Spine J 2020).
Pairing reviewed 2026-09-17.
Where it fits for you
Not a first step, and not something to build a plan around when the pain has no clear target. Considered where examination and, if needed, imaging point to one specific structure and pain is blocking rehabilitation — and where the target is one ultrasound can actually reach. See the note on cortisone.
V-ACTOR vibration therapy (vibration therapy) Low-frequency vibration applied over tender muscle. Not a shockwave, despite sharing the machine. Plausible — no studies
What it involves
A vibration handpiece is moved over the tender muscle and fascia for a few minutes. It runs from the same STORZ MASTERPULS icon console as radial shockwave but is a separate handpiece delivering a different, gentler form of energy. No needles, no anaesthetic, no downtime.
What the evidence shows
No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.
Pairing reviewed 2026-08-30.
Where it fits for you
A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.
Energy-based treatment options
Radial pressure wave, focused shockwave and EMTT have different targets and different evidence. They are assessed separately rather than treated as one category.
Radial or focused shockwave? Read the overviewRadial shockwave (radial pressure wave) Broad treatment across tender muscle and fascia, close to the surface. Worth discussing
What it involves
A handpiece is moved over the tender tissue while ballistic pressure pulses are delivered, using a transmitter head chosen for the tissue — including heads shaped for fascia and for the muscle either side of the spine. The pulse is strongest at the skin and weakens with depth, so this is mainly a myofascial treatment, though it can reach deeper in some areas. No anaesthetic, no downtime, usually a course of sessions about a week apart.
What the evidence shows
For myofascial pain, a meta-analysis of 8 controlled studies (571 patients, mostly neck and upper back) found shockwave reduced pain and improved pain threshold and neck disability compared with other methods (Wu, Ann Transl Med 2021). A second meta-analysis of 10 trials found it better than sham and ultrasound, but NO better than dry needling, trigger point injection or laser (Zhang, Arch Phys Med Rehabil 2020).
Pairing reviewed 2026-08-30.
Where it fits for you
Directed at a tender muscle contributing to the pain, not at the disc, joint or nerve. No better than needling in head-to-head trials, so the choice is about what suits you.
Focused shockwave (ESWT) A true shock wave converging at depth — for tendon, joint, ligament and bone. Only if relevant
What it involves
A focused system generates an acoustic shock wave that converges at a focal point set at a defined depth, concentrating the energy where the target is. This is the form we use for tendon, joint, ligament and bone. Typically four to six sessions about a week apart, no anaesthetic and no formal downtime.
What the evidence shows
Focused shockwave is not aimed at a disc, a facet joint or a nerve root, and there is no trial evidence for it in these conditions.
Pairing reviewed 2026-08-30.
Where it fits for you
Considered only where examination finds a separate tender muscle or tendon contributing to the pain.
EMTT (magnetotransduction therapy) High-energy magnetic pulses applied over the area. Painless, no contact. Plausible — no studies
What it involves
You sit with the applicator positioned over the area for a short session. Painless, no gel or contact required, and usually delivered as a course — commonly alongside shockwave.
What the evidence shows
There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that we can point to. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative — a randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).
Pairing reviewed 2026-08-30.
Where it fits for you
Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why we describe it this way.
Biologic and joint injection options
Each injection is assessed independently for the named diagnosis. Cost, uncertainty, likely benefit, risks and alternatives are part of the decision.
Platelet-rich plasma (PRP) Your own blood, concentrated and injected under ultrasound guidance. Evidence mixed
What it involves
Blood is taken from your arm, spun to concentrate the platelets, and injected into the target under ultrasound guidance in the same appointment.
What the evidence shows
The evidence here is for INTRADISCAL injection — into the disc itself — which is a different procedure from the soft-tissue injections done in this clinic. A multicentre randomised crossover trial of 40 patients found intradiscal platelet-rich plasma better than saline for pain and function in discogenic low back pain at 12 months, with every placebo patient crossing over (Navani, Pain Physician 2024). It is small, and it was not blinded after crossover.
Pairing reviewed 2026-08-30.
Where it fits for you
Not something offered here, and not a substitute for the loading and education that carry the evidence in back pain. Where someone has genuinely discogenic pain that has not settled, it is a referral conversation rather than a treatment we provide.
Prolotherapy (dextrose) A course of dextrose injections into and around the structure and its attachments. Evidence mixed
What it involves
Hypertonic dextrose is injected at the tender ligament and tendon attachments, and into the joint where relevant, usually as a series of treatments a few weeks apart.
What the evidence shows
A Cochrane review of five trials and 366 patients addressed exactly this condition. Prolotherapy injections ALONE were no more effective than control injections for chronic low back pain — no difference in pain or disability at six months, and no difference in the proportion improving by more than half. Two trials in which the injections were given alongside spinal manipulation and exercise did show benefit, but the co-interventions make it impossible to attribute that to the injection (Dagenais, Cochrane Database Syst Rev 2007).
Pairing reviewed 2026-08-30.
Where it fits for you
Only ever alongside an active rehabilitation programme, never as the treatment on its own — that combination is the only condition under which the evidence has been positive, and the exercise is doing work the injection cannot do by itself.
Viscosupplementation (hyaluronic acid) A gel-like injection into an arthritic joint. Widely used, and genuinely contested. Not used here
What it involves
One or a short series of hyaluronic acid injections into the joint under ultrasound guidance.
What the evidence shows
Hyaluronic acid has been injected into the lumbar facet joints and compared with cortisone, but only in people whose back pain had already been traced to those joints. A randomised trial of 60 people found sodium hyaluronate no worse than triamcinolone out to six months (Fuchs, J Vasc Interv Radiol 2005), a double-blind trial of 30 found no difference between the two (Annaswamy, Am J Phys Med Rehabil 2018), and a pilot in 13 people found no change in pain or disability at six weeks (Cleary, J Spinal Disord Tech 2008). Pooling 18 studies and 1,496 people, these injections gave little short-term or no benefit overall (Ambrosio, Global Spine J 2022). No trial has tested it for back pain that has not been traced to a particular joint, and there is a reported case of widespread inflammatory joint pain two days after a lumbar facet injection of hylan G-F 20 (Kocak, Am J Phys Med Rehabil 2018).
Pairing reviewed 2026-09-20.
Where it fits for you
Not offered for this problem. Back pain that has not been traced to one specific joint is not a target for a joint injection of any kind.
Nerve-targeted options
Relevant when examination identifies a superficial neuropathic pattern or a compressed peripheral nerve—not simply because pain is present.
Lyftogt perineural therapy (perineural injection therapy) A series of small dilute dextrose injections just under the skin, over tender superficial nerves. Tested by a different route
What it involves
Small injections of low-concentration dextrose, usually 5%, placed just beneath the skin along tender superficial nerves. Given as a series of short sessions.
What the evidence shows
The dilute dextrose used in this treatment has been tested in chronic low back pain, but delivered into the caudal epidural space rather than as a series of small injections just under the skin. In a double-blind randomised trial, 35 people with chronic low back pain radiating to the buttock or leg had a single 10 mL injection of 5% dextrose or saline: 84% of the dextrose group reported at least half their pain gone at four hours against 19% of the saline group, with no difference left at two weeks (Maniquis-Smigel, Anesth Pain Med 2016). Repeating it helped further, with 32 people given an average of 5.5 injections over a year improving by 3.4 points on a 10-point pain scale and 18.2 percentage points on the Oswestry disability index, though nobody in that study went without treatment for comparison (Maniquis-Smigel, J Altern Complement Med 2018). We found no trial of the subcutaneous technique described here in low back pain.
Pairing reviewed 2026-09-16.
Where it fits for you
Considered where examination finds tender, hypersensitive skin over the low back rather than deep or leg-dominant pain. The randomised evidence above is for a deeper injection, so what is offered here carries less certainty than those numbers suggest.
Ultrasound-guided nerve hydrodissection Fluid placed around a nerve to free it from the surrounding tissue. Worth discussing
What it involves
Under ultrasound, fluid is placed in the plane around the nerve to separate it from the tissue that is tethering or compressing it.
What the evidence shows
The evidence sits in identifiable subgroups rather than in non-specific back pain. In 36 people with superior cluneal nerve entrapment — an overlooked cause of low back pain — ultrasound-guided dextrose hydrodissection produced initial success in 77.7%, with symptoms returning in a quarter of those and recurrence more common where there was scoliosis (Wu, Insights Imaging 2023). A retrospective comparison of 33 patients with the same neuropathy found perineural dextrose better than corticosteroid for pain and Roland-Morris disability at one week (Yıldırım Uslu, Cureus 2024). In myofascial low back pain, all 58 patients in a retrospective cohort received hydrodissection of longissimus lumborum trigger points and both arms improved at 12 weeks (Chen, BMC Musculoskelet Disord 2026), but no group went without it. We found no trial testing hydrodissection against placebo in low back pain.
Pairing reviewed 2026-09-06.
Where it fits for you
Considered where examination and ultrasound identify a specific target — most often superior cluneal nerve entrapment at the iliac crest, or a painful thoracolumbar fascial plane — rather than for back pain in general.
This is general information only and suitability is assessed individually. Treatments with limited or condition-dependent evidence may still be discussed, but only with clear explanation of the uncertainty, the expected benefit, risks, cost and alternatives. Red flags, progressive neurological symptoms or suspected serious pathology require a different pathway.
Every treatment above is described in full on the non-surgical treatments page, including what each one is used for and what the evidence supports. Ratings apply to the named diagnosis; an adjacent muscle, tendon, joint or nerve problem is assessed as a separate target.
Corticosteroid injection is reviewed separately for each diagnosis.
Cortisone reliably reduces pain in the short term, and that can be genuinely useful when pain is stopping you sleeping or moving enough to rehabilitate. Beyond that window the picture changes. A systematic review of 41 randomised trials and 2,672 participants found that corticosteroid injection reduced pain in the short term but that the effect reversed at intermediate and long term; in pooled analysis for lateral epicondylalgia the short-term effect was large (SMD 1.44, 95% CI 1.17 to 1.71) while no intervention was favoured at 26 weeks (-0.40, -0.67 to -0.14) and at 52 weeks (-0.31, -0.61 to -0.01) (Coombes, Lancet 2010). In a randomised trial in lateral epicondylalgia, 83 per cent of the corticosteroid group had completely recovered or much improved at one year against 96 per cent given a placebo injection, and recurrence ran at 54 per cent against 12 per cent; adding physiotherapy made no significant difference at one year (Coombes, JAMA 2013). In joints, repeated corticosteroid injections have been associated with cartilage loss. It does not repair anything.
So we do not build treatment plans around it. Where an injection is the right call, we review the specific diagnosis and target, discuss what is being injected and why, keep the number low, and pair it with the loading work that changes the longer-term course.
When we would still consider it
- Pain severe enough to block rehabilitation
- A clear inflammatory or bursal target on imaging
- A specific short-term goal — a trip, a procedure, a return to work
- Diagnostic use, where the response tells us where the pain is coming from
When a cortisone injection is worth doing, and when it is not
Other back conditions
Pain in the same area can come from more than one source, and the label matters less than what the examination and history point to. These are the other guides for this region.
Frequently asked questions
Do I need an MRI for my back pain?
When should I be concerned about back pain?
Will I need surgery?
Could my low back or buttock pain be coming from the SIJ?
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Your assessment focuses on understanding the likely source of your pain and the most appropriate non-surgical options for your diagnosis, with the aim of reducing pain and improving function.
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