Textbook of Urgent Care Medicine, Chapter 40, Back Pain

Published on November 5, 2026

Original author: Scott T. Burger

Originally published in 2014. Substantially updated and clinically reviewed in 2026.

INTRODUCTION

Back pain is a very common complaint in the urgent care setting.

Most causes of back pain are benign and mechanical, but a small number of cases are caused by serious conditions. Obtaining a detailed medical history and performing a careful physical examination will help the practitioner differentiate the benign from serious conditions leading to back pain.

The urgent care evaluation should identify patients with a neurologic emergency, spinal infection, vertebral fracture, malignancy, or serious extraspinal cause before initiating treatment for presumed musculoskeletal pain.

PRESENTATION

Patients will present with various degrees of antalgic gait. They may be hunched forward, or their torso may be tilted toward one side. In rare instances, patients may present with difficulty lifting one leg.

Pain may be localized or radiate to the buttock or leg. The degree of pain alone does not reliably distinguish a benign presentation from a serious condition.

TRIAGE PEARLS

Check the ABC’s (airways, breathing, and circulation).
Briefly assess for weakness of an extremity or back pain associated with fever.
New urinary retention or overflow incontinence, saddle or perineal sensory change, bilateral neurologic symptoms, or progressive motor weakness raises concern for cauda equina syndrome or another compressive neurologic emergency. Arrange immediate emergency department evaluation, preferably by emergency medical services when deficits are severe or evolving. Urgent MRI is obtained at the receiving hospital; do not delay transfer to obtain tests unavailable in urgent care.
Back pain with fever, systemic illness, recent infection, injection-drug use, immunosuppression, or a recent spinal procedure may indicate vertebral infection or spinal epidural abscess. Patients with concerning findings require emergency evaluation even when the initial neurologic examination is normal.
Patients with back pain and abnormal vital signs—that is, low blood pressure or an elevated heart rate—should be rapidly assessed for a possible vascular or other life-threatening cause. Sudden severe back or abdominal pain, syncope, hypotension, or a pulsatile abdominal mass raises concern for an abdominal aortic aneurysm or acute aortic syndrome; arrange immediate EMS transfer.

HISTORY PEARLS

Is there a prior history of similar back pain?
Is there a history of trauma? If so, what was the mechanism of injury?
Has there been unexplained weight loss or fevers?
Has there been any change in bowel or bladder habits? The main ones to look for are overflow urinary incontinence and inability to initiate push for moving bowels.
Is there any weakness or any sensory disturbance in any extremity or around the genitals?
Are there radicular symptoms? If so, what precipitates them?
What is the patient’s work history? What do they do for a living?
Ask specifically about new difficulty initiating urination, loss of bladder fullness sensation, urinary retention, new sexual dysfunction, saddle numbness, and changes in bowel control. These symptoms can be subtle or incomplete; absence of incontinence does not exclude cauda equina syndrome.
Does the patient have prior cancer, recent systemic infection, injection-drug use, diabetes, immunosuppression, anticoagulant use, osteoporosis, prolonged glucocorticoid exposure, or recent spinal surgery or injection?
Are there additional urinary symptoms?
- Hematuria
- Dysuria
- Increased urinary frequency
Is there a medical history or family history of nephrolithiasis?
Are there any of the following associated with the back pain?
- Abdominal pain
- Chest pain
- Shortness of breath
- Syncope
- Palpitations

PHYSICAL EXAM PEARLS

Always examine these patients when they are in a gown and have removed their pants, shoes, and socks.
Always first look at the skin of the affected area: conditions like varicella-zoster virus may present with only pain, and skin plaques may be the only sign to suggest psoriatic arthritis.
Evaluate the patient’s range of motion:
- Ask the patient to attempt to touch their toes while keeping their knees fully extended.
- Ask the patient to rotate their torso toward the right and then the left while keeping their feet on the ground.
- Ask the patient to bend their torso toward their right side and then left side.
Restricted movement and paraspinal tenderness may support a mechanical cause, but neither finding independently excludes infection, fracture, or other serious pathology.
Ask the patient to walk on their toes and then on their heels.
Check deep tendon reflexes. Asymmetric reductions may support nerve-root involvement; hyperreflexia accompanied by other neurologic findings can suggest an upper motor neuron process.
Complete a thorough sensory evaluation distal to the area of pain.
Document bilateral lower-extremity strength, including ankle dorsiflexion and plantar flexion, gait, reflexes, and sensation; use straight-leg raising when radiculopathy is suspected. Repeat the neurologic examination if symptoms progress.
Any suggestion of decreased sensation in the upper thighs mandates a careful assessment of sacral sensory, bowel, and bladder symptoms. A normal resting anal tone or a low postvoid residual does not rule out cauda equina syndrome and should not be used to defer emergency MRI or transfer.
Examine the patient’s abdomen to assess for any pulsatile mass; also check the femoral and distal pulses.
Consider hip examination and abdominal or vascular findings when the location or character of pain suggests a nonspinal cause.

TESTING PEARLS

Uncomplicated back pain is typically a self-limited condition that does not require diagnostic imaging or testing.
Do not order routine lumbar radiographs, CT, MRI, inflammatory markers, or urinalysis for uncomplicated acute nonspecific back pain or uncomplicated radicular pain. Imaging is chosen for a specific clinical concern, not for pain severity alone.
Any signs that back pain reflects a visceral disease—pyelonephritis, abdominal aortic aneurysm, diverticulitis—dictate that appropriate testing be done immediately.
If there is suspicion of cauda equina syndrome, spinal infection, major progressive neurologic deficit, or other spinal emergency, arrange ED transfer for urgent MRI or other appropriate evaluation. Tests available in urgent care must not delay transfer.
Trauma, osteoporosis, older age with fracture risk, or chronic steroid exposure can justify directed fracture imaging. Suspected malignancy or infection generally calls for MRI-based evaluation coordinated through a hospital or appropriate specialist.
Persistence beyond six weeks may justify reassessment and consideration of imaging when symptoms are not improving despite care, particularly when an intervention is being considered. Six weeks of pain alone is not an automatic MRI indication.

Table 1. Back Pain: Red Flags and Urgent Care Disposition

Clinical findings	Recommended disposition
New urinary retention, saddle anesthesia, bowel dysfunction, new sexual dysfunction, or severe/progressive weakness	Emergency department immediately for suspected cauda equina or cord/root compression and urgent MRI. EMS when clinically indicated.
Fever or systemic illness with concerning back pain, bacteremia, injection-drug use, immunosuppression, or recent spinal procedure	Emergency evaluation for spinal infection/epidural abscess; MRI and laboratory testing at receiving facility.
Sudden severe back or abdominal pain with hypotension, syncope, pulse deficit, or concern for aortic disease	Immediate EMS transfer; do not delay for outpatient spinal imaging.
Significant trauma, suspected vertebral fracture, known cancer with concerning new back pain, or stable objective neurologic deficit	Same-day ED or expedited specialty-directed evaluation according to severity, stability, and local resources.
Nonspecific mechanical pain or stable radicular symptoms without alarm features or progressive deficit	Urgent care treatment, return precautions, and primary-care/rehabilitation follow-up as appropriate.

The absence of a single red flag does not substitute for clinical judgment. A low postvoid residual and normal rectal tone cannot exclude cauda equina syndrome.

DIAGNOSIS PEARLS

Benign or mechanical lower back pain may be localized or may radiate into the buttocks or thighs. Radiation alone does not establish or exclude radiculopathy; focal neurologic findings and a nerve-root distribution are more informative.
Sciatica refers to radiating leg pain commonly caused by lumbosacral nerve-root irritation or compression and may be associated with paresthesia, weakness, or altered reflexes.
Cauda equina is a surgical emergency associated with lower back pain, bowel or bladder dysfunction, and perineal sensory deficits.
The syndrome may be incomplete. Do not wait for the full constellation of findings before arranging urgent evaluation.
Suspect spinal stenosis when a patient states that the pain decreases when they lean forward and worsens when they stand upright. This is the “shopping cart” sign.
Atraumatic back pain in patients younger than 18 years or older than 65 years should lead the practitioner to consider more serious causes of the pain.
Age alone is not diagnostic; consider the full context, including osteoporosis, fracture risk, constitutional symptoms, and neurologic findings.
Differential diagnosis:
- Back strain or sprain
- Osteoarthritis
- Osteoporosis
- Spinal disc disease
- Spinal stenosis
- Spondylolisthesis
- Immune disorders—ankylosing spondylitis, rheumatoid arthritis, psoriatic arthritis, reactive arthritis
- Neoplastic disease—usually metastatic spread to the spine, although this can be the primary malignancy
- Infection—bacterial, fungal, or tuberculosis
- Referred back pain—endometriosis, peptic ulcer disease, pancreatic disease, renal calculi, aortic aneurysms, aortic dissection, myocardial infarction, pulmonary embolism

TREATMENT AND DISPOSITION PEARLS

Patients should be encouraged to remain mobile while undergoing treatment for musculoskeletal back pain. Prolonged immobilization does not improve outcomes or shorten the duration of acute pain.
Reassurance, activity as tolerated, superficial heat, and gradual return to normal activity are reasonable initial measures. Bed rest and routine bracing are not recommended.
If medication is required for acute musculoskeletal back pain:
- When medication is necessary, a nonsteroidal anti-inflammatory drug (NSAID) is generally preferred if there is no contraindication. Use the lowest effective dose for the shortest appropriate duration and consider renal, gastrointestinal, cardiovascular, pregnancy, anticoagulant, and dehydration risks.
- Acetaminophen alone has limited demonstrated benefit for acute nonspecific low back pain; do not assume that combining it with an NSAID is substantially better than an appropriate NSAID regimen for every patient.
- Routine opioid prescribing is not recommended. If unusually severe acute pain warrants a short opioid course after assessing other options, weigh functional benefit against sedation, overdose, dependence, and other risks. Opioids should not be used for chronic low back pain.
Oral corticosteroids are not recommended routinely for nonspecific low back pain or sciatica; evidence of benefit is limited and adverse effects are possible.
Muscle relaxants may be helpful for acute back pain associated with significant muscle spasms.
If a short course is considered, discuss sedation, dizziness, falls, driving impairment, and additive effects with alcohol, opioids, or other sedatives. They should not be the default treatment for every episode.
Tricyclic antidepressants and gabapentinoids should not be started routinely for nonspecific low back pain or sciatica in urgent care. Persistent disabling pain should be managed longitudinally with a primary care clinician or appropriate specialist.
If pain persists or recurs and impairs function, encourage an individualized exercise-based physical therapy program or other appropriate rehabilitation.
Exercise-based rehabilitation may be appropriate for persistent or recurrent symptoms. Manual therapy is optional and should not replace exercise or evaluation of red flags. Routine epidural or facet injections are not an initial urgent care treatment.
All patients with back pain should be instructed to seek immediate medical attention for worsening symptoms, any weakness, persistent sensory disturbance, bowel or bladder dysfunction, or other symptoms that are new and associated with their back pain.
Patients with radicular symptoms should be referred to an appropriate specialist or back to their primary care provider to ensure that symptoms are resolving.
All patients with back pain should be encouraged to focus on a healthy lifestyle that includes regularly engaging in cardiovascular exercise, strengthening the core muscles, improving flexibility, and, for those patients who are obese, reducing weight.
Patients should be encouraged to quit smoking. Tobacco use has been implicated as a risk factor for back pain.
Work-related lower back pain: Assure the patient that this is common and has an excellent prognosis. Some job modifications may be necessary, but patients should be encouraged to return to work as soon as possible, as this leads to the best outcomes. In the absence of red flags for more serious pathology, most low back injuries can be managed conservatively by the urgent care provider.
Patients should have their pain validated by the provider. Reassurance that their symptoms will decrease is important. However, setting unrealistic expectations about how quickly they will recover can lead to frustration for both the clinician and patient.
Most episodes of acute nonspecific low back pain improve over weeks, but recovery is variable; establish a realistic function-based plan and reassess if pain persists or the clinical picture changes.

Table 2. Practical Initial Management for Uncomplicated Acute Back Pain

Measure	Urgent care approach
Activity and self-care	Remain active, avoid prolonged bed rest, use superficial heat, and resume usual movement or work as tolerated.
Medication	Consider a short NSAID course when appropriate; assess contraindications. Avoid routine opioids, systemic steroids, gabapentinoids, and benzodiazepines for sciatica.
Selected adjuncts	A brief muscle-relaxant trial may be considered for severe spasm after counseling about sedation and other risks.
Follow-up	Follow up with primary care or rehabilitation if function is not improving; reassess sooner if symptoms worsen or new features develop.
Return precautions	Immediate emergency evaluation for new urinary retention, saddle numbness, loss of bowel control, progressive weakness, fever with systemic illness, syncope, or severe abdominal/back pain.

MEDICOLEGAL PEARLS

Documentation of IV drug use or previous infection is important in patients who may have a spinal epidural abscess.
Documentation of lack of saddle anesthesia and urinary or fecal incontinence is critical in patients with back pain.
Also document direct questions about urinary retention, altered bladder sensation, bowel change, and sexual dysfunction, along with motor, gait, and sensory findings. Do not document “cauda equina ruled out” solely because rectal tone or postvoid residual is normal.
Plain-film x-rays are of little value except in patients with direct trauma, compression, or axial-loading-force events or other clinical reasons to suspect fracture.
Record the rationale for imaging or not imaging, response to treatment, reassessment of neurologic findings when indicated, follow-up arrangements, and explicit emergency return precautions.

REFERENCES