Back pain that changes from day to day — and does not show up on scans
Some days you barely notice it. On others you cannot put your shoes on. It moves, it changes in intensity, and no scan shows anything that accounts for all this.
It is the pattern I see most in the treatment room. On this page I explain how I interpret it, why imaging does not show it, and what usually makes a difference.
If you ticked three or more, the rest of this page is worth reading carefully.
What I mean by "mechanical obstruction"
In your spine there are true joints, called facet joints — small, closed off by a capsule, with lubricating fluid inside and cartilage lining the bony surfaces. On the inside, that capsule forms small folds of tissue, which can fold inwards into the joint itself.
The idea is simple, and it holds for two things at once: a small fragment of cartilage loose in the fluid, or the fold of the capsule itself. While either of them is in a neutral position, there are no symptoms at all. But if, with a particular movement, it becomes compressed between the two surfaces of the joint, that generates pain. As soon as the right movement releases it, it eases.
That is why the pain changes in intensity and place depending on position, and why some days are better than others without anything in particular having happened. The same logic can apply to the disc between the vertebrae — and often the two things contribute at the same time.
The pattern, in detail
What usually makes it worse and what usually eases it. If you recognise yourself in both lists, you already know more about your case than most scans would tell you.
Putting on shoes, brushing your teeth, picking something up off the floor, getting out of bed in the morning. It is the movement I hear described most often.
An hour at the computer or in the car, and the first steps are hard. After a few metres, it starts to loosen.
In a queue, cooking, at an event. Standing still is usually worse than walking.
Stiffness on waking that tends to ease 30 to 60 minutes after getting up and starting to move.
In training it may be harder at the start, improve as you warm up, and get worse again as you cool down.
Weekends on the sofa, long journeys, spells of illness. Less movement usually means more symptoms, not fewer.
Often the simplest and most effective thing. A few minutes' walking and the picture changes.
There is no such thing as the right position. There is only not staying too long in the same one — whichever it is.
There is almost always one direction that eases it consistently. Finding it is a large part of the work of the assessment.
Taking the load off the spine for a few minutes and moving again can reset the picture on a bad day.
Gentle repetitions in the right direction usually do more than a long, forced stretch.
Stopping altogether usually prolongs the problem. The aim is to adjust the load, not to remove it.
Where this number comes from
A study of 3,369 adults, with an average age of 53. Among those who had back pain, 77.8% showed these changes. Among those who had no pain at all, 74.4% — practically the same. Published in 2026 in the medical journal JAMA.
Why this does not show up on scans
Because what causes the pain is not a broken structure — it is a situation that happens in certain positions and disappears in others. An MRI is a photograph taken with the person lying down and still. It does not capture a behaviour.
And there is something they rarely explain: the changes the scan finds — wear and tear, arthritis, a disc bulge — appear in a great many people who have no pain at all. Having wear and tear is not, in itself, a sign that this is where the pain comes from.
What makes the difference is working out whether, right now, there is an active process there irritating the tissue. And that gets assessed with a body in front of me: testing movements, repeating them, and observing what happens to the symptoms in each direction.
The treatment is not to stop. It is to find the right direction.
We identify the positions and movements that ease it, and those that make it worse, and we adjust your day-to-day life accordingly — until the picture settles and your body tolerates again what it used to tolerate.
We test specific positions and movements of the spine, in various directions and repeated, and observe what happens to your symptoms in each one. There is almost always one direction that eases it consistently.
It is not a list of prohibitions. It is working out which specific things you do in your day are feeding the problem, and how to do them differently during this phase.
Usually one specific exercise, with the detail that matters: how many times, through what range, and what you should feel. If it needs adjusting before the next appointment, we adjust it by message.
Mário Pereira, Spine Dedicated Physiotherapist
I work almost exclusively with the spine and persistent pain. I practise on my own — in person at Parque das Nações, in Lisboa, and online. The person who answers your message, the person who assesses you and the person who adjusts the plan is always me.
Professional licence OF 6744, Ordem dos Fisioterapeutas. The stated aim of my work is to reach the point where you no longer need me.
See my backgroundFrequently asked questions
About this particular pattern. If yours is not here, ask me directly.
Is this serious? Will I be like this for ever?
The great majority of spinal pain with this pattern is not serious and does improve. I cannot guarantee you any results — neither I nor anyone else should — but I can tell you that this is one of the pictures that usually responds best once the right direction of movement is found.
Do I need to have an MRI?
For most spinal pain, routine imaging is not recommended. It does not improve treatment outcomes, and it frequently finds things unrelated to what you feel — which only add worry and lead to more unnecessary tests and procedures. But there is an even more practical reason: imaging does not change the direction of treatment. What guides the next step is how you respond to what we are doing, not what appears in a photograph taken at rest, without moving. If during the assessment I find something that warrants a scan, I tell you and explain why.
I have had physiotherapy and it did not work. Why would it work now?
I cannot promise you it will work. What I can tell you is what I do differently: I spend the time needed testing directions of movement and observing what happens to your symptoms in each one, instead of applying the same protocol to everybody. If after a few appointments we are not seeing changes, I tell you so.
Can I carry on training or going to the gym?
In most cases, yes — with specific adjustments to some movements, for a phase. Stopping altogether is rarely the best decision. What we do is vary the direction and the type of stimulus until the picture settles, and then build the load back up.
Nothing on this page replaces an assessment by a healthcare professional. And there are situations that are not a matter for physiotherapy at all:
this calls for urgent medical care, the same day.
A medical appointment the same day, as soon as possible, with neurosurgery or spinal orthopaedics.
This is not a matter for physiotherapy, nor for any other healthcare professional.
And it is not a matter of waiting to see whether it improves. Here, time is what weighs most on the outcome: the sooner you are seen by a doctor, the better.
See every sign, by area, and what to do in each caseDescribe your case to me in two lines.
What hurts, for how long, and what you have tried. I answer, and I tell you frankly whether I think I can help — or whether it makes more sense to point you elsewhere.
Initial conversation free of charge. I always reply — and, most of the time, the same day.
Cashin AG et al. Review on non-specific low back pain. JAMA, 2026. — the proportion of non-specific low back pain and of radiculopathy/stenosis among those seeking care; degenerative changes on MRI in people without low back pain (74.4%) and with pain (77.8%); recommendations on the use of imaging; the effectiveness of exercise in chronic low back pain and of invasive treatments.
Brinjikji W et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR American Journal of Neuroradiology. 2015;36(4):811-816. — the prevalence of degenerative findings in people without symptoms, by age group.
A synthesis of the literature on pain myths and beliefs (Melzack 1999; Moseley 2003; Seki & Ouchi 2020) — the weak correlation between pain and structural changes on imaging, across several regions of the body.
Anything on this page that does not point to these references is my own clinical reading, marked as such throughout the text. No information here replaces an individual assessment.