Why Your Back Pain Keeps Coming Back
WRITTEN BY DR RUSSELL JENSEN Principal Chiropractor - Southside Spine and Sport, Bicton WA
AHPRA Registration: CHI0001927257 Practicing chiropractor since 2015. Trained in Integrative Diagnosis (USA).
Special interest in persistent and misdiagnosed musculoskeletal pain, nerve entrapment conditions, and cases that have not responded to previous treatment.
Full profile: southsidespinesport.com.au/meet-our-chiro
Why your back pain keeps coming back
You have tried rest. You have tried massage. You have had adjustments, possibly from multiple Chiropractors. For a day or two, sometimes a week, it improves. Then it comes back. And you start wondering whether this is just how it is going to be.
The reason it keeps returning is almost never what people expect.
This article is for people who have been through the treatment cycle more than once and want to understand what is actually happening, not just receive another round of the same thing.
The temporary relief trap
Most back pain treatment is directed at reducing pain. That is a reasonable starting point, and there is nothing wrong with wanting relief. The problem is when temporary pain relief becomes the whole strategy.
Pain is a signal, and in most cases, its worth listening to. It tells you that a structure somewhere in the body is more overloaded than it can comfortably manage. When you have an adjustment, or a massage, or take an anti-inflammatory, the signal quiets down. The pain eases. But if the structure generating that signal has not changed, the signal returns when you go back to normal. In my experience, this is the cycle most people are stuck in.
A 2015 systematic review published in the BMJ found high quality evidence that paracetamol is ineffective for reducing pain, disability, or quality of life in people with low back pain. At the same time, around 4 million Australians are currently living with back problems, and musculoskeletal disorders cost the Australian economy $55 billion annually. The gap between how common this problem is and how often it is actually resolved is significant.
The solution is not more of the same treatment. It is finding and addressing the right structure.
The three reasons treatment stops working
In my clinical experience, recurring back pain that has not responded to conservative care almost always comes down to one of three things.
1. The wrong structure is being treated
This is the most common reason, and the one most people never consider. Persistent lower back pain can come from many structures: lumbar discs, facet joints, the sacroiliac joint, the piriformis and deep gluteal muscles, the hip joint, or the sensory nerves that cross the pelvis and hips, including the cluneal nerves and sciatic nerve branches. Each of these requires a specific treatment approach to target it effectively. Treating one when another is the primary driver may provide some temporary improvement, because you are broadly helping the right area, but missing the right structure specifically.
The pattern I see most in clinic is a patient who has had their spine or pelvis adjusted repeatedly with some short-term improvement over many visits, but the relief lasting less and less over time. Most chiropractors are safe and effective at what they do. The issue is not the skill of the practitioner. It is whether the treatment is aimed at the right structure. A good clinician treating the wrong problem will still produce only temporary results, and that is not a reflection on them as a practitioner. It is simply a signal that a fresh set of eyes and a different approach may be what is needed.
2. A nerve is driving the problem and joints are being adjusted
Nerve pain is one of the most commonly misidentified drivers of persistent back and gluteal pain. When a nerve is irritated, adhered to adjacent structures, or sensitised for any reason, it produces pain that can feel very similar to joint or muscle pain, and in many cases the two coexist. Nerve pain can sit right over the sacroiliac joint, deep in the gluteal space, or at the base of the neck, and be completely indistinguishable from a joint problem without specific palpation of the affected structures. That palpation is the only reliable way to tell them apart.
The key difference in how each responds to treatment is what I listen for in clinic. Joints become more mobile with repeated mobilisation, and pain driven by a joint problem should reduce over a course of treatment. Irritated nerves become more reactive with repeated provocation. So if a patient is coming in regularly, the joints are moving better with each visit, but the pain is not improving or is actually increasing, and when I palpate the nerves in the area they are becoming more sensitive over time, that pattern tells me a nerve is likely driving the problem and mimicking a joint complaint. Continuing to adjust the joint in that situation will not resolve it. The nerve needs to be addressed directly.
The patient feels brief relief after each session because the treatment temporarily reduces load on the surrounding tissues. But because the nerve problem has not been specifically addressed, the pain returns and the nerve remains sensitised, becoming more reactive to lower and lower levels of stimulus over time.
Eventually the area can become so reactive that even light treatment causes a flare-up. This is often the point at which patients are told it must be something else, or referred elsewhere, when in fact they simply needed a different treatment aimed at a different structure.
3. The rehabilitation phase was never done
Joints and muscles that have been in pain for weeks or months adapt. The body learns protective movement patterns, optimising the way it moves to minimise load on the painful structure. Over time this can overload other structures that are not ideally positioned to take on that job, creating secondary problems on top of the original one.
Even when the primary pain driver has been correctly identified and treated, these movement adaptations remain. If the patient returns to normal activity without addressing them, the same loading pattern that created the problem in the first place returns, and so does the pain. If the movement adaptations are not addressed, secondary issues can develop or the original problem recurs.
This is the phase most people either skip entirely because they feel better and stop treatment, or never reach because the primary driver was never correctly identified in the first place.
It is not a complicated phase. It does not require months of physiotherapy or a gym membership, though both can be helpful if the exercises are specific, progressive, and done correctly. What it does require is a targeted approach rather than generic or general exercises used as a substitute for the right ones. For patients who need more structured support in this phase, we have excellent physiotherapy contacts we can refer to when that is the right next step.
The structures that get missed most often
If your treatment isn't working and you've been told it's your disc, your sacroiliac joint, or general muscle tightness, here are some specific structures worth investigating that we work on regularly.
The cluneal nerves
Small sensory nerves that exit the lumbar spine and cross the top of the pelvis before supplying the skin of the lower back, glutes, and hips. Because they run directly over the sacroiliac joint and iliac crest, their symptoms can be almost identical to sacroiliac joint problems. They don't show up reliably on imaging and require specific palpation to identify. When they are irritated and treated as an SIJ problem, the result can be escalating sensitivity rather than improvement. This is one of the most commonly missed sources of lower back pain I see in clinic.
Read more on our cluneal nerve pain page.
The sciatic nerve in the deep gluteal space
Sciatica is typically thought of as a disc problem, and often it is. But the sciatic nerve can also become irritated in the deep gluteal space, deep to the piriformis muscle and superficial to the deep hip rotators. In some cases it can also become affected in the hamstring region, between or deep to the muscle bellies on its path down the leg. The symptoms can be identical to disc-related sciatica: pain, numbness, and tingling into the leg. The treatment is completely different because the nerve is being affected outside the spine entirely. If you have been treated for disc-related sciatica without lasting improvement, deep gluteal syndrome is worth investigating.
Read more on our sciatica page and piriformis syndrome page.
The spinal accessory nerve
In the neck and upper back, the most commonly missed cause of persistent pain that is not a disc or joint problem, in my experience, is the spinal accessory nerve. This is a cranial nerve that runs from the brainstem through the neck into the upper trapezius. When this nerve is affected or adhered, the trapezius muscle it supplies can remain guarded and tense, altering head position and contributing to a more forward head carriage, producing persistent upper trap tension and mid-back aching regardless of how much massage or how many adjustments are applied. This is extremely common in anyone who spends significant time at a desk, and it is not always a joint problem.
Read more on our spinal accessory nerve page
Morning lower back pain: the psoas, thoracolumbar erectors, and cluneal nerves
A specific pattern worth mentioning is lower back pain that is worst first thing in the morning and eases after five to ten minutes of sitting up and moving around. In my experience, this is commonly driven by loading of the psoas and thoracolumbar erectors during sleep, with irritation of the cluneal nerves also contributing significantly. If this is your pattern, your mattress matters, and it may be worth asking us about your sleep setup at your next visit.
What an accurate diagnosis actually involves
Standard imaging, X-ray, MRI, and CT, is useful for ruling out serious pathology: fracture, disc herniation with cord compression, infection, and malignancy. It is much less useful for identifying the specific structures that generate most persistent musculoskeletal pain. Collectively, this kind of pain often falls under the label of nonspecific low back pain, a term that is commonly used in the healthcare landscape but, in my opinion, not a particularly helpful one. It tends to mean the imaging didn't find anything obvious, not that there is nothing to find.
A significant disc bulge on MRI may be coincidentally found and completely asymptomatic. An irritated cluneal nerve will not show on any scan.
An accurate clinical examination for persistent back pain involves a detailed history, including what treatments have been tried and how the pain has responded, specific palpation of likely structures, not just the broad area of pain but the specific structures known to generate that particular pain pattern, and provocation testing to reproduce symptoms.
This takes longer than a standard appointment. It requires detailed anatomical knowledge, specific enough to palpate individual nerves, tendons, muscles, and the borders between them. And it requires honesty and openness about what the problem is, what it isn't, what can be done about it, and where the job finishes, including when a referral is the right next step.
How we approach this at Southside Spine and Sport
Every patient who comes in with a history of recurring pain that has not responded to previous treatment receives a full clinical assessment before any treatment starts. The most important part of that assessment is identifying which specific structures are generating the pain, because the treatment is completely different depending on the answer.
If the driver is nerve entrapment at the iliac crest involving the cluneal nerves, we treat the nerve using targeted soft tissue therapy directly at the site, not the SIJ.
If deep gluteal syndrome or sciatic nerve involvement is suspected, we work directly on the nerves to free and mobilise them in the deep gluteal space, not adjust the lumbar spine.
If the spinal accessory nerve at the level of the upper trapezius is suspected, we release the nerve where it is adhered rather than simply massaging the muscle.
If a joint restriction is contributing alongside a nerve problem, we address both.
Once the primary driver has been resolved, we move into a targeted rehabilitation phase to address the movement patterns that either contributed to the problem developing or emerged as a result of it. Where more complex or structured rehabilitation is required, we refer to physiotherapy contacts we trust to continue that work effectively.
I will also tell you when the problem is outside my scope. If assessment suggests the pain is coming from a structure that responds better to physiotherapy, surgical assessment, or investigation by a GP or specialist, I will say so and help you get there efficiently. The goal is for you to get better, not to keep coming back indefinitely.
Learn more about our soft tissue therapy, adhesion release, and shockwave therapy approaches.
Frequently Asked Questions
Why does back pain keep coming back after treatment?
Back pain that returns after treatment usually means one of three things: the wrong structure is being treated, a nerve is driving the problem and is being mistaken for a joint issue, or the rehabilitation phase was skipped and the movement patterns that contributed to the problem in the first place were never addressed. Good clinicians treating the wrong structure will still only produce temporary results. It is not a reflection on their skill. It is a signal that a different approach is needed.
What structures are most commonly missed in persistent back pain?
The most commonly missed structures are the cluneal nerves, which cross the pelvis and are frequently mistaken for sacroiliac joint dysfunction and the sciatic nerve in the deep gluteal space, which is often mistaken for disc-related sciatica which is a common driver of persistent back pain. None of these show reliably on imaging. All require specific clinical examination and palpation to identify.
How do I know if my back pain is coming from a nerve rather than a joint?
The key sign is how the pain responds to treatment over time. Joints become more mobile with repeated mobilisation and pain should reduce. Irritated nerves become more reactive. If you are having regular treatment, movement is improving, but the pain is not reducing or is getting worse, and the area is becoming more sensitive rather than less, a nerve is likely the primary driver.
When is back pain likely to keep coming back?
Back pain is most likely to keep recurring when the underlying structure generating it has not been correctly identified, when treatment is directed at the symptoms rather than the cause, or when the movement patterns and loading deficits that allowed the problem to develop are never properly addressed.
If your back pain keeps returning despite treatment, the most useful next step is not more of the same treatment. It is a proper assessment to identify what structure is actually driving it.
Book an assessment online or send us a message
We are based in Bicton and see patients from across Perth's southern suburbs, including Fremantle, Melville, East Fremantle, Cockburn, and surrounding areas.
Written by Dr Russell Jensen, Principal Chiropractor (AHPRA: CHI0001927257), Southside Spine and Sport. Published June 2026.
This article is for general information only and does not constitute medical advice. Always consult a qualified health professional for diagnosis and treatment.
Clinical reference: Machado GC, Maher CG, Ferreira PH, et al. "Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials." BMJ, 2015;350:h1225. View at PubMed: pubmed.ncbi.nlm.nih.gov/25828856
