As I speak with more clinicians, I get wider and wider views of what the tissue (soft tissue or inert) source in low back pain.  For sake of this post, let’s say chronic low back pain…dubbed non-specific low back pain. The most common answers are the:

1. Intervertebral disc

2. Facet joints

3. Myofascial

4. Sacroiliac joint

5. None (unless symptoms are acute, pain does not equal tissue damage)

Training, type of patients, treatment approaches, research, media, and beliefs all play a combined role in creating a bias.  Two of my mentors are on exact opposite ends of the spectrum.

For instance, here is an example of the diversity in ratio:

Clinician 1: Sacroiliac Joint (80%), Facet Joint (10%), Myofascial (10%)

Clinician 2: Intervertebral Disc (30%), Facet Joint (60%), Sacroiliac Joint (10%)

DePalma et al in 2011 estimated the prevalence rates of discogenic, facet and sacroiliac joint in chronic low back pain patients whom have been in motor vehicle accidents.  After having diagnostic procedures that are “criterion standard” for diagnosing either of the 3 conditions above, here are the results:

Of the 27 patients, 15/27 (56%) were diagnosed with discogenic pain, 7/27 (26%) with sacroiliac joint pain, and 5/27 (19%) with facet joint pain.

The author’s conclusions:

Our study is the first to demonstrate that diagnostic spinal injections can identify particular spinal structures, namely the intervertebral disc, facet joint, and sacroiliac joint, as the specific source of chronic low back pain due to inciting motor vehicle collisions. The most common source of motor vehicle collision-induced chronic low back pain appears to be the disc followed by the sacroiliac and facet joints.

Granted this is a subgroup of chronic low back pain patients (small n too), but based on this data…

Clinician 3: Intervertebral Disc (55%), Sacroiliac Joint (25%), Facet Joint (20%)

Quite the variability right?

I want to know what YOU think.

I have had success in the past with polls (EBPpre-manipulation hold, and osteopractor word of the year), so I hope to get lots of engagement!

You know you see low back pain.

You know you have an opinion.

So let’s ALL engage to get a true sense of what clinicians think ALL over the world.

To participate, choose your TOP tissue choice of low back pain.  Then in comments, provide a ratio as I did above, your profession and explanation behind your rationale.



  1. Most studies that I have seen similar to DePalma’s paper have reported similar numbers. The IVD being the pain source in ~40+% of cases, the SIJ in ~20% of cases, and the facet joint in ~15% of cases.

    The one thing that I find interesting about DePalma’s paper is that in all 27 cases a definitive source was identified. I don’t know of another study that looked at these 3 sources of LBP and found a diagnosis for every participant. Perhaps that is a factor of the small sample size.

    I am also intrigued by the high number of respondents who chose “none, pain does not equal tissue damage.” Far too many people with chronic low back pain have been given bad advice, such as “if it hurts, don’t do it” It is much healthier to encourage those with chronic low back pain to resume their normal activities with advice such as “pain does not equal tissue damage”, or, as I prefer to say, “hurt does not equal harm.” That is true for someone with a stiff knee after a patellar fracture, someone with adhesive capsulitis, and for those with chronic low back pain (regardless of the presence or absence of a definable tissue source.)

    My point is this: I don’t necessarily see educating patients about the pain sciences as being exclusive to the possibility of an anatomical source of low back pain. I think we should be putting tools together. Use Laslett’s approach which is not only to correlate physical exam findings with the SIJ, but also the IVD and the z-joints.

    In my practice I will refer people to physiatry for injections should there presentation appear to warrant it. More often than not we are able to help people with the combination of PT and injections, when injections alone don’t work.

  2. If you are looking to do a study similar to Laslett and Aprill’s work, I’d suggest looking at comparing the results of a physical examination to analgesic discograms. Previous works have shown some correlation between centralization or peripheralization and provocative discography. However, there have been reports of false positives with provocative discography.

    BTW, I am in Greensboro, NC. Not too far from you.

  3. Paul,
    Good ol North Carolinian! I’m actually from Virginia so tough to get away from my roots but NC is very similar.

    I like your comment about pain science above. I am going to put out another post and ask, if there is no tissue source…how do we treat? We still need to stay physical and not JUST talk about it…


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