Why Does My Back Hurt More When I Rest?
Most back pain comes from strain and settles with time. Back pain that is worse after rest, stiff in the early morning and better with exercise follows a different pattern, one a rheumatologist should check.
Back pain is very common, and most of it is mechanical: it comes from muscles, ligaments, discs or joints in the spine, and it usually gets better with time. Inflammatory back pain is less common, but it is important to recognise because it has a specific cause and specific treatment.
What is inflammatory back pain?
Inflammatory back pain is caused by inflammation in the spine and in the sacroiliac joints, where the spine meets the pelvis. Doctors look for a pattern. A group of experts called ASAS (the Assessment of SpondyloArthritis international Society) lists five features:
- the pain began before age 40;
- it came on slowly, not after an injury;
- it gets better with exercise;
- it does not get better with rest;
- it is present at night and eases when you get up and move about.
Having four or more of these makes inflammatory back pain more likely. When deciding whether to refer someone for possible spondyloarthritis, guidelines such as NICE NG65 use a slightly wider age limit: back pain that started before age 45 and has lasted three months or more.
Other clues include buttock pain that switches from side to side, heel pain, a painful red eye, psoriasis, or long-standing bowel inflammation. A family history of ankylosing spondylitis or psoriasis also matters.
Mechanical or inflammatory?
Most people have mechanical back pain. The table below shows how the two types usually differ.
| Feature | Mechanical back pain | Inflammatory back pain |
|---|---|---|
| Age when it starts | Any age, often after 30 | Usually before 40–45 |
| How it starts | Often sudden, after lifting, twisting or strain | Slowly, over weeks or months, without injury |
| Morning stiffness | Short, usually under 30 minutes | Long, often more than 30 minutes |
| Effect of exercise | Often worse with activity | Better with exercise and movement |
| Effect of rest | Usually better with rest | Worse with rest or sitting still |
| Night pain | Uncommon, unless you change position | Common in the second half of the night |
| Other features | Usually none | Heel pain, red eye, psoriasis, bowel symptoms, family history |
Common causes of back pain
Mechanical causes
- Muscle or ligament strain from lifting, posture or long hours of sitting.
- Disc problems and sciatica: pain that spreads down one leg, sometimes with tingling.
- Wear-related changes in the small joints of the spine (facet joints), more common with age.
Long-standing mechanical or nerve-related back pain may be helped by physiotherapy and, in selected cases, by our interventional pain specialist.
Inflammatory causes
- Ankylosing spondylitis / axial spondyloarthritis: the most common inflammatory cause.
- Psoriatic arthritis can affect the spine as well as other joints.
- Spondyloarthritis linked with bowel inflammation (such as Crohn’s disease or ulcerative colitis).
A note on HLA-B27
HLA-B27 is a gene marker that is common in people with ankylosing spondylitis. However, many people who carry HLA-B27 never develop the disease, and some people with the disease do not carry it. A test result alone does not make or rule out the diagnosis.
When is it urgent?
Emergency: go to the nearest emergency department immediately if back pain comes with new weakness in the legs, numbness around the genitals or buttocks (the “saddle” area), or new problems passing or controlling urine or stools. These can be signs of cauda equina syndrome, which needs emergency treatment. Also seek same-day care for back pain with fever, back pain after a major fall, or a painful red eye with blurred vision. Do not wait for a clinic appointment if you have cauda equina warning signs. For the other same-day problems, call +91 93386 53086 during clinic hours (Mon–Sat, 9 AM–2 PM & 4:30–9 PM), or go to the nearest emergency department.
Which doctor should you see?
- Back pain that started before 45, has lasted over three months, and is worse with rest: see a rheumatologist first. At OARC, Dr. Jyoti Ranjan Parida (Saheed Nagar) or Dr. Debashis Maikap (Sailashree Vihar).
- Long-standing mechanical or nerve pain (for example sciatica) where inflammatory disease has been ruled out: an interventional pain specialist and physiotherapy. At OARC, our pain management specialists.
- Back pain after an injury or fall, or a suspected fracture: an orthopaedic surgeon or emergency department. OARC does not offer orthopaedic surgery.
When to book an appointment
Book a rheumatology appointment if your back pain has lasted more than three months, started before age 45, and is stiff in the morning or better with exercise. Bring any X-ray or MRI reports and a list of medicines you have tried. If you have heel pain, eye inflammation, psoriasis or bowel symptoms, mention them too.
Back pain that eases with movement but returns with rest deserves a proper diagnosis, not just painkillers.
Inflammatory back pain: common questions
See a rheumatologist in Bhubaneswar
OARC has two centres in Bhubaneswar, with an in-house lab, Immunix Labs (working with NABL-accredited partner labs), pharmacy, imaging and physiotherapy. Bring any previous reports, X-rays or scans and a list of your current medicines.
Saheed Nagar (Main Centre)
Dr. Jyoti Ranjan Parida consults here
A/90 Saheed Nagar, opp. Ayakar Bhavan, Bhubaneswar 751007
Mon–Sat 9 AM–2 PM & 4:30–9 PM · Sunday closed
Sailashree Vihar, Chandrasekharpur
Dr. Debashis Maikap consults here
P-13/14 Sailashree Vihar, Chandrasekharpur, Bhubaneswar 751021
Mon–Sat 8–9 AM & 5–6 PM · Sunday closed
References
- Sieper J, et al. New criteria for inflammatory back pain in patients with chronic back pain: a real patient exercise by experts from the Assessment of SpondyloArthritis international Society (ASAS). Ann Rheum Dis 2009;68:784–8. doi.org/10.1136/ard.2008.101501
- NICE. Spondyloarthritis in over 16s: diagnosis and management (NG65), 2017. www.nice.org.uk/guidance/ng65
- NICE. Low back pain and sciatica in over 16s: assessment and management (NG59), 2016, updated 2020. www.nice.org.uk/guidance/ng59
- NHS. Ankylosing spondylitis. NHS website. www.nhs.uk/conditions/ankylosing-spondylitis/
- NHS. Back pain. NHS website. www.nhs.uk/conditions/back-pain/
This page gives general information and is not a diagnosis. Please see a doctor about your own symptoms. Read our editorial policy to learn how we write and review medical content.