RSM-REM-013
Written by Hironori Ikeda, MSc Sports Medicine
RSM International Academy · Chiang Mai, Thailand
What Should You Assess When a Client Says “My Lower Back Hurts”?
The client often shows the problem before naming it precisely: they brace before bending, shift weight while standing, hesitate to rise from a chair or point to one side of the low back after walking. Those tasks can be limited by local muscle or connective-tissue load, lumbar joint or disc-related behavior, hip contribution, neural symptoms or a presentation outside massage scope.
I first reproduce a safe version of the client’s actual painful task and compare lumbar movement, hip contribution and neurological signs before treating the tenderest spot. The question is not “which muscle feels tight?” but “which finding best matches the symptom behavior and changes the same task?” Progressive weakness, widespread sensory change, systemic signs, major trauma or cauda-equina features change the plan and require referral.
In this article, you will learn how to assess low back pain, identify what deserves attention as a therapist, choose a defensible treatment region and re-test the same bend, stand, walk or sit-to-stand task.
In This Article
- What Should You Assess When a Client Says “My Lower Back Hurts”?
- In This Article
- 1. Clinical Problem & Differential: Low Back Pain
- 2. Muscle / Joint / Nerve Comparison: QL, Multifidus & Lumbar Spine
- 3. Differential Assessment: Lumbar Motion, Neural Signs & Hip Screen
- 4. Treatment Scope & Clinical Reasoning: Target the Supported Component
- 5. Symptom Re-Test: Repeat the Original Low-Back Task
- Related RSM Clinical Blogs
- Supporting Clinical Notes
- Palpation, Contact and Re-Assessment
- Study Remedial Massage at RSM
1. Clinical Problem & Differential: Low Back Pain
Begin with what the client experiences, when it appears and how it changes. Pain during bending is a different clinical problem from pain after prolonged standing, pain with coughing, pain that travels below the knee, or constant pain that is unrelated to movement.
Clarify onset, recent trauma, previous episodes, load changes, sleep disturbance, systemic illness, medication, unexplained weight change and neurologic symptoms. Ask about numbness, tingling, weakness, altered walking, and changes in bladder, bowel or saddle sensation. Progressive neurologic loss, major trauma, fever or systemic illness, unexplained night pain, suspected fracture, or cancer history with concerning change require medical assessment rather than a massage experiment. New bladder or bowel dysfunction, saddle sensory change, or other suspected cauda-equina features require urgent medical assessment.
Mechanical behavior can guide testing without proving a tissue diagnosis. Note whether walking, sitting, flexion, extension, rotation, coughing or changing position alters the familiar complaint. A pain-free static posture does not rule out a loading problem, and an asymmetry does not establish causation.
New bladder or bowel dysfunction with back or leg symptoms, saddle sensory loss or other suspected cauda-equina features requires emergency assessment. Do not delay that pathway for a manual trial.
2. Muscle / Joint / Nerve Comparison: QL, Multifidus & Lumbar Spine
Quadratus lumborum links the iliac crest, 12th rib and lumbar transverse processes. Multifidus and erector spinae contribute to segmental control and trunk extension. Gluteals, iliopsoas, the hip joint and thoracolumbar tissues can alter the way load is shared through a bend, lift or prolonged stance.
Local tissue sensitivity is more meaningful when it agrees with resisted loading, stretch, movement or a familiar functional task. Tender QL or paraspinals may be part of a protective response rather than the original driver. Treating the most painful point aggressively can therefore increase guarding without improving function.
Joint- or disc-related patterns cannot be identified by palpation alone. Lumbar flexion, extension, side-bending and repeated movement may change symptoms, but no single movement test supplies a complete diagnosis. Leg pain, sensory change, weakness or reflex change increases the need for a structured neurologic screen and referral judgment.
Hip restriction or pain may also alter a squat, gait or forward bend. The therapist should compare hip motion rather than automatically assigning every posterior pelvic or buttock symptom to the lumbar muscles.
The distinction between deep segmental muscles and larger trunk movers can help organise an examination, but both contribute to movement and control. I cannot establish multifidus activation by pressing beside the spine. A supported movement comparison followed by an active bend is more informative than assuming that one deep muscle must be released before the outer muscles can work.
3. Differential Assessment: Lumbar Motion, Neural Signs & Hip Screen
Choose tests from the history rather than performing every available test.
- Record the client’s familiar pain location, intensity and aggravating task.
- Compare lumbar flexion, extension, side-bending and rotation.
- Use repeated movement only when appropriate, noting centralisation, peripheralisation or no change.
- Compare hip flexion, internal and external rotation when hip referral is plausible.
- Use straight-leg raise or slump as symptom-response comparisons when leg symptoms suggest neural involvement; neither test alone confirms a compressed nerve root.
- Check region-appropriate sensation, strength and reflexes when neurologic symptoms are present.
- Palpate QL, paraspinals, gluteals or other tissues only after the movement pattern is clear.
- Select one functional baseline: bend, sit-to-stand, walk, squat, lift setup or standing tolerance.
A positive test is not a diagnosis in isolation. The value comes from convergence: the history, symptom distribution, movement response, neurologic findings and local loading should tell a coherent story. If they do not, reduce certainty and widen the differential.
I do not begin a low-back session by asking which muscle feels hardest. I first find a safe movement that reproduces the client’s actual limitation. Then I compare the lumbar spine, hip and neural response. When joint stiffness appears relevant, I use a comfortable low-amplitude mobility input and immediately repeat the original movement; a click or cavitation is never the treatment goal. The hands-on work is selected after that comparison, not before it.
4. Treatment Scope & Clinical Reasoning: Target the Supported Component
If the assessment supports a local muscular component, treatment may include controlled work to QL, erector spinae, multifidus region, gluteals or relevant hip tissues. Contact should respect the 12th rib, iliac crest, abdominal contents and lumbar bony landmarks. Pressure is adjusted to irritability and purpose; deeper is not automatically more specific.
If hip contribution changes the original task, include the relevant hip tissue or movement strategy rather than remaining fixed on the painful lumbar area. If neural symptoms dominate, aggressive stretching or compression along a sensitive interface may be inappropriate. When joint or disc-related behavior is suspected, massage can address associated muscle guarding, but it should not be presented as “putting the disc back” or correcting a vertebral position.
Current evidence supports, at most, a role for manual therapy in short-term symptom and function change for selected low-back presentations. Long-term management normally requires appropriate activity, loading, education and self-management. Avoid promises that one release corrects the underlying cause permanently.
When a posterior muscle finding matches the complaint, I support the trunk and use a short, broad contact within the rib, iliac-crest and paraspinal boundaries. If a low-velocity, small-amplitude non-thrust input is appropriate within my training, I follow it with active use of the comfortable range. Neither a click nor a softer region substitutes for the original functional comparison.
5. Symptom Re-Test: Repeat the Original Low-Back Task
Repeat the same safe baseline with the same setup and instruction. Compare:
- familiar symptom intensity and location;
- lumbar or hip range used in the task;
- guarding and movement confidence;
- leg symptoms or neural response, when relevant;
- tolerance of bending, standing, walking or sit-to-stand.
An immediate change is useful information, not proof of a corrected structure. Record which treatment and movement input preceded the change. If the task is unchanged, reconsider the hypothesis instead of adding pressure. The primary limitation may involve load tolerance, joint behavior, neural sensitivity, another region or a non-musculoskeletal source.
Related RSM Clinical Blogs
Browse all Remedial Massage clinical guides
▷ Hip Pain or Pain Referred From the Back? — Remedial Massage · Broaden the differential assessment.
▷ Low Back Pain While Cycling: Hip ROM, Trunk Endurance & Bike Position — Sports Massage · Connect the findings with the sport task and training exposure.
▷ Limited Hip Extension: Anterior Hip vs Lumbar Compensation — Deep Tissue Massage · Examine supported hand position and tissue contact.
Supporting Clinical Notes
Palpation, Contact and Re-Assessment
▷ A Functional Outcome Diary Between Massage Sessions
Study Remedial Massage at RSM
In practical training, learn to connect lumbar and hip findings with a defensible contact choice and a functional follow-up. Work through the task, anatomical landmarks and hand-position choices with a clear reason for the next assessment.
▷ Remedial Massage — course details and entry requirements
About the Author
Hironori Ikeda, MSc Sports Medicine
Founder and lead instructor of RSM International Academy, Chiang Mai, Thailand. His teaching connects functional anatomy, clinical palpation, movement assessment and sports medicine manual therapy.