Why Back Pain Is Ruining So Many Men Under 40, Says Dr Kaye

My patient Graham was 16 when he began an apprenticeship as a bricklayer. From around that time onwards, he also lived with persistent back pain.

Initially, no one considered it unusual. He spent his working days lifting heavy materials and bending over walls, so an aching back seemed an inevitable consequence. When he eventually visited his GP, he was advised to keep active. He followed that advice, but his symptoms continued to deteriorate.

By the time he came to see me at 32, he was utterly worn down. As he explained the pattern of his pain, it became clear that this was not simply the result of years of manual labour or ordinary wear and tear.

Common back pain, sometimes called mechanical back pain, usually follows a particular movement, injury or long day. It tends to worsen with activity and improve when the person rests.

Graham’s symptoms were very different. The pain had developed gradually, without any specific injury. He described a deep ache across his lower back that became particularly severe at night, often waking him. To settle it, he would get out of bed and walk around before trying to sleep again.

Mornings were especially difficult. He told me: ‘I move like my granddad.’ Yet after an hour, a shower and some food, the stiffness began to ease.

Rest made the pain worse, while exercise brought relief. Graham had been pushing himself to train more and more simply to keep his symptoms under control.

The pattern immediately suggested inflammatory back pain caused by axial spondyloarthritis. Further tests confirmed the diagnosis.

Axial spondyloarthritis is an inflammatory form of arthritis that primarily affects the spine. In Graham’s case, it was highly likely that the condition had been present for many years.

His experience is far from unique. I have treated many men under 40 with a similar history: years of pain followed by years of being reassured that they should stretch, lose weight or invest in a more supportive chair.

Around 220,000 people in Britain are thought to have axial spondyloarthritis, but only 60,000 have received a diagnosis, according to Arthritis UK. Approximately 2,000 adults are diagnosed each year. The condition usually begins during the late teens or twenties, almost always before the age of 45, and is more common in men.

Despite this, the National Axial Spondyloarthritis Society says the average diagnostic delay in the UK is eight and a half years.

Why is axial spondyloarthritis so frequently overlooked? One reason is that back pain is extremely common, and most cases are mechanical. When a fit young man reports a painful back, doctors may understandably first suspect a sports injury, gym-related strain or the physical demands of a manual job.

Imaging does not always provide an immediate answer. During the early stages of axial spondyloarthritis, X-rays may appear entirely normal because changes to the bones can take years to become visible.

MRI scans of the lower back may also fail to cover the sacroiliac joints, which sit on either side of the base of the spine and are often where inflammation starts. In addition, blood tests that measure inflammation may show normal results.

Diagnosis must also be made by a rheumatologist, a specialist in inflammatory conditions affecting the joints and musculoskeletal system.

If a GP does not recognise the warning signs of inflammatory back pain, they may not refer the patient to a rheumatologist. Without that specialist assessment, the underlying condition can remain undiagnosed for years.

This delay can ultimately worsen the health of patients like Graham.

Over the years, as the immune system wrongly attacks the spine, this can cause vertebrae to fuse – a debilitating complication called ankylosing spondylitis.

In the most advanced cases the spine becomes a rigid column known as bamboo spine, making simple movements like bending down all but impossible.

Axial spondyloarthritis doesn’t just affect the back and hips either. The inflammation can also strike the heels, knees and ribs, and even the eye.

Many patients also experience severe fatigue.

The toll of axial spondyloarthritis on the lives of young men can be huge. Many patients are in so much pain that they are unable to work. This could have easily been Graham had he not been diagnosed.

That’s because, while there is no cure for the condition, there are a number of effective treatments.

The first step is anti-inflammatory painkillers such as ibuprofen or naproxen, taken regularly at full dose, which help many patients enormously.

For those who don’t improve, biologic drugs can be life-changing. These are injections designed to combat inflammation in the body.

The usual first choice on the NHS is called adalimumab, which is self-injected every two weeks. The drug is not without its risks. Adalimumab dampens the immune system, meaning patients are more at-risk of infectious diseases.

For some, the initial injections have no effect – meaning they will have to try other biologics. However, many patients feel their pain and stiffness lift within weeks.

But no drug replaces movement. Regular exercise is the most powerful tool patients have for staying supple. 

Daily stretching, swimming, Pilates and strength work all help, and physiotherapists can design programmes for spinal mobility and posture. If you smoke, stop: smokers tend to have more severe disease.

In many cases, back pain is down to something ordinary like carrying heavy boxes or sleeping in an uncomfortable position.

But if yours began before 45, came on gradually, is worst at night and first thing, and eases with exercise rather than rest, see your GP and ask whether a referral to a rheumatologist might be necessary.