Lower Back Pain When Twisting: Causes and Exercises

When to get help first

Exercise is for pain that has been checked or is clearly mild and settling.

Get urgent medical help if

Call 999 or go to A&E: loss of feeling or numbness around the genitals or bottom, new trouble peeing or controlling your bladder or bowels, changes in genital sensation during sex or problems with erections or orgasm, or pain, tingling, weakness or numbness in both legs. These are signs of cauda equina syndrome, which needs treating in hospital urgently. Don't drive yourself.
Call 999 or go to A&E: back pain with chest pain, or back pain that started after a serious accident, such as a car crash.
Call 999: sudden pain or discomfort in your chest that does not go away (it can feel like squeezing or pressure inside your chest, burning or indigestion); pain that spreads to your left or right arm, or your neck, jaw, stomach or back; or chest pain and you feel sweaty, sick, light-headed or short of breath. You could be having a heart attack.
Call 999 or go to A&E if breathing suddenly becomes difficult, if pain in your chest or upper back comes on suddenly with breathlessness or a very fast heartbeat, or if someone passes out. These are the NHS's signs of a blood clot in the lungs (a pulmonary embolism) or another serious condition. Don't drive yourself.
Call 999: sudden, severe pain in the tummy or back, which can come with breathlessness, pale or grey skin, or collapse. It can be a burst abdominal aortic aneurysm, most common in men aged 65 or over and in people who smoke or used to smoke.
Call 999 or go to A&E: pain spreading from the tummy to the back, with vomiting.
Call 999 or go to A&E: you get sudden, severe pain in your tummy and the pain is spreading to your back, you have bloating that does not go away or keeps coming back, you have a fast heartbeat or difficulty breathing, or the skin around your belly button, waist or upper outer thigh appears blue or bruised. It can be acute pancreatitis.
Same day (GP or NHS 111): back pain and you feel hot, cold, shivery or generally unwell, or severe pain that starts suddenly or is getting worse quickly.
Ask for an urgent GP appointment or get help from NHS 111 if you think you may have a kidney infection (often pain in your lower back or side, with burning or stinging when you pee or needing to pee more often) and you have a very high temperature or feel hot, cold or shivery, a temperature below 36C, pain in the lower tummy or in the back just under the ribs, blood in your pee, you feel or are sick, you haven't had a pee all day, or you're pregnant. Call 999 or go to A&E if you're confused, drowsy or have difficulty speaking.
Same day (urgent GP appointment or NHS 111): severe pain that usually starts in the side of your tummy or your lower back, may spread to the area at the top of your inner thigh (groin), your testicles or the area around the opening of your vagina, and may come and go, or this pain with a high temperature or feeling hot, cold or shivery. It can be a kidney stone.
Same day: you have or have had cancer, and new back pain that is severe and doesn't let up, is getting steadily worse, is worse at night and disturbs your sleep, is worse when you cough, sneeze or strain, or comes with tenderness over the spine. Contact your cancer team or GP urgently. With cancer, new weakness, difficulty walking, numbness or bladder or bowel problems are an emergency.
Same day: leg weakness that is getting worse.
Same day (urgent GP appointment or NHS 111): new difficulty lifting the front of your foot or toes (foot drop), or a foot that slaps down or catches as you walk, especially if it is getting worse. Weakness in both legs, or with numbness around the genitals or bottom or bladder or bowel changes, is the 999 emergency above.
Contact your GP or midwife urgently: back pain in the second or third trimester of pregnancy, or back pain in pregnancy with a fever, vaginal bleeding, pain when you pee, or pain in one or more of your sides (under your ribs). It could be early labour or an infection.

See a doctor or physiotherapist if

Sudden new back pain after a minor fall, lift, cough or sneeze, from 50 or past the menopause, or if you take long-term steroid tablets; or height loss, a curved spine or a change in posture: see a GP. It can be a spinal fracture.
Back pain that is persistent and unchanging after following self-care advice, isn't affected by movement, or is worse at night: contact your GP practice, or NHS 111 if it's closed.
Back pain that hasn't improved after a few weeks of looking after it at home, stops you doing day-to-day activities, worries you, or you're struggling to cope.
Pain that doesn't improve with rest or is worse at night, or pain that is worse when you sneeze, cough or poo.
Unexplained weight loss, or a lump, swelling or change in the shape of your back.
Pain, tingling or numbness spreading below the knee that isn't settling after a few weeks, is getting worse or stops your normal activities: see a GP.
Pain at the top of the back, between the shoulders, rather than in the lower back.
Back pain that started before 45 and has lasted more than 3 months, especially if it started before 35, wakes you in the second half of the night, comes with buttock pain, gets better with movement or within 48 hours of anti-inflammatory painkillers, or you have or have had arthritis, pain where a tendon attaches to bone (enthesitis) or psoriasis, or a parent, brother, sister or child with spondyloarthritis. These can point to inflammatory back pain (axial spondyloarthritis, such as ankylosing spondylitis). The National Institute for Health and Care Excellence (NICE) asks GPs to refer people with 4 or more of these 9 features to a rheumatologist, and to do a blood test for the HLA-B27 gene marker if exactly 3 are present, referring if it is positive.
A burning, tingling or painful patch of skin on one side of your back or chest, with or without a rash: get advice from a pharmacist or NHS 111 as soon as possible. Shingles can cause pain a few days before the rash appears, and rarely without one. Try to see a pharmacist within 3 days of the rash appearing.
A teenager in a sport that arches or twists the back, such as gymnastics, dance, diving, volleyball, cricket fast bowling, baseball pitching, weightlifting, football or rugby, with back pain that lasts more than a couple of weeks, is worse arching back or stops them training: get it checked by a GP or sports physiotherapist. It can be a stress fracture in the spine.

Where does it hurt?

Location narrows the likely causes; it does not diagnose.

The low back, across or to one side, came on with a twist, lift or reach, stiff and sore to move, no pain down the leg

Usually ordinary back pain, often called a pulled muscle or spasm, which usually settles within weeks.

Read: Back spasm and pulled back muscle →Pain, tingling or numbness down one leg below the knee, often worse coughing or sneezing

Usually sciatica, often from a disc.

Read: Sciatica →Worse arching back and twisting, from mid-life, or a scan mentions the facet joints

Often labelled facet joint pain. No test can confirm it, and it is managed like other back pain.

Read: Facet joint pain →Low on one side, by the dimple at the back of the pelvis

Possibly the sacroiliac (SI) joint. Only an examination can point to it.

Read: SI joint pain →In pregnancy or after the birth: the back of the pelvis or the pubic bone, worse turning in bed, on stairs and standing on one leg

Usually pelvic girdle pain.

Read: Pelvic girdle pain (SPD) →Worse when you twist and bend at once, or after lifting with a twist

Usually ordinary back pain, set off by the combination. Our bending guide covers lifting from the floor.

Read: Back pain when bending →Mostly when you turn over in bed

Usually ordinary back pain or the SI joint. Our lying-down guide covers turning over.

Read: Back pain when lying down →Between the shoulder blades or in the middle back, on a twist or a deep breath

The upper back, a rib joint or a strained muscle between the ribs.

Read: Middle back pain →Low on the side of the ribs or the tummy wall during a throw, bowl, serve or swing, sore to twist, cough or sit up

Possibly a side strain.

Read: Abdominal strain →A golfer or rower with rib pain on the leading side after a jump in practice

A possible rib stress fracture, which is easily mistaken for a back strain.

Read: Rib injury →A teenager in a sport that arches or twists the back, with back pain lasting more than a couple of weeks

A possible stress fracture of the spine: get it checked, as the warning signs say.

Read: Spondylolisthesis →Sudden back pain after a minor twist, lift, cough or fall from 50, or with long-term steroid tablets

A possible spinal fracture from thin bones: see a GP, as the warning signs say.

Read: Spinal compression fracture →Pain in the side or back with a fever, burning when you pee, or waves of pain into the groin; or pain that doesn't change at all when you move

The kidneys or another cause that isn't the back: get help the same day, as the warning signs say.

Read: Lower back pain on one side →In the gym, after twists, deadlifts or a hard session

The same causes, usually ordinary back pain.

Read: Back pain after deadlifts →The low back and the hip together

The back, the hip or both.

Read: Lower back and hip pain →Back pain for more than 3 months, with good and bad days

Long-lasting (chronic) back pain.

Read: Chronic low back pain →

Sudden, severe tummy or back pain, feeling faint or grey

A possible aortic aneurysm: call 999, as the warning signs say.

A burning or tingling band of pain on one side, with or without a rash

Possibly shingles: see a pharmacist or call NHS 111, as the warning signs say.

Understand it

Why a twist can catch a sore backEmerging evidence

The lower back hardly twists. In a 45-degree turn of the trunk, each lower back joint turned only 1.2 to 1.7 degrees in 10 volunteers scanned lying down, while the upper back turned about 25 degrees in another small study; the hips turn much of the rest. In a twist, the small facet joints at the back of the spine take the strain first, and the trunk muscles start and stop the turn, working harder the faster it is.

So a quick twist, a loaded one or one combined with bending asks a lot of a small range, which is why it can bring on pain in a back that is already sore or tired, without meaning that anything has been damaged. That is our reading, and it fits the studies of what sets off back pain.

Sources 1, 2, 3, 4, 5, 6

Usually ordinary back painStrong evidence

The NHS says a common cause of back pain "is an injury like a pulled muscle (strain)", that it "often gets better on its own", and that serious causes are "Very rarely" the reason. In 1,172 people seeing a doctor in primary care with new back pain, 11 (0.9%) had a serious cause, 8 of them fractures.

Pain, tingling or numbness down one leg below the knee is sciatica, usually from a disc. The facet joints are a common label from mid-life that no examination can confirm, and the sacroiliac joint, low by the dimple, is one that only an examination can point to. In pregnancy, pelvic girdle pain is common. No study counts how often each is the cause of pain on twisting.

Sources 7, 8, 9, 10, 11, 12, 13

Twisting at work and in daily life: not shown to cause back pain on its ownMixed evidence

Reviewers of 7 high-quality workplace studies judged twisting "unlikely to be independently causative" of back pain, and a review of 41 reviews found no agreement that physical work causes it. In 861 Dutch workers followed for 3 years, spending more than a tenth of the day twisted by 30 degrees or more gave a small, uncertain rise in risk (a risk ratio of 1.3, which could have been chance); bending and frequent heavy lifting were clearer. In over 400 repetitive industrial lifting jobs, fast twisting with load marked the riskier jobs, a link that doesn't prove cause.

Twisting during a task does seem to matter for people who already have back pain: in 416 people with long-lasting back pain, doing something while twisting raised the odds of a flare by about half (an odds ratio of 1.48). The largest study of triggers didn't measure twisting; being distracted and heavy loads were among the strongest.

Sources 14, 15, 16, 17, 5, 6

"I twisted and slipped a disc" is rarely what happenedEmerging evidence

In cadaver spines, a twist alone damaged the facet joints before the disc, and the authors wrote that "torsion seems unimportant" in disc prolapse. Lab herniations came from repeated bending under compression over thousands of cycles, sometimes with a small twist, and in pig spines twisting alone couldn't start one. A review of mostly animal and lab studies suggests fast, twisting or explosive loading is likely bad for discs, while loading at walking and jogging speeds is likely good. The NHS slipped disc page doesn't list twisting among the causes. These are lab studies, not people.

Sources 3, 18, 19, 20, 21

The ribs, the side of the trunk and teenagers in sportEmerging evidence

Rib stress fractures affect 8% to 16% of elite rowers; in 19 golfers with one, 18 were beginners, most on the leading side, and 2 were first taken for a back strain. Side strains affected over half of 207 fast bowlers, and 30% came back. In teenagers with back pain from sport, 47 of 100 had a stress fracture of the spine, against 5 of 100 adults, and sudden jumps in fast bowling workload raised the odds.

Sources 22, 23, 24, 25, 26

What a scan shows, and what it doesn'tStrong evidence

The National Institute for Health and Care Excellence (NICE) says don't routinely image low back pain, and NHS inform says "you'll not normally need an X-ray or MRI scan". Scans find changes in backs that don't hurt: facet joint arthritis showed in 4% of pain-free 20-year-olds and 50% of 60-year-olds, and disc bulges in 30% to 84%.

No examination test picks out facet joint pain: the twist-and-arch test has "poor diagnostic accuracy", and pain on arching back and turning isn't informative on its own. How often the facet joints are the source depends on the test: 47% responded to one numbing injection but 15% to a confirming second one in 176 people. A magnetic resonance imaging (MRI) scan is for the warning signs, or for sciatica that isn't improving when surgery or an injection is being considered. A urine test, a computed tomography (CT) scan or an ultrasound look for the kidney and aorta causes.

Sources 27, 8, 28, 29, 11, 30, 31, 32, 21, 33, 34, 35

How it usually goesStrong evidence

New back pain improves most in the first 6 weeks: across 33 groups of 11,166 people, average pain fell from 52 to 23 out of 100 by 6 weeks and to 6 by a year, though pain that has already lasted a while improves less. NHS inform says "You should see the biggest change in your symptoms within the first couple of weeks" and most problems should have improved within 6 weeks. Sciatica "usually gets better in a few weeks to a few months". Back pain often comes back, which is why the plan's last stage carries on. No one can promise a date.

Sources 36, 8, 10, 37

What helps, and how strong the evidence is

Keep moving: the health-service adviceStrong evidence

The NHS says "Stay active and try to continue with your daily activities" and "do not stay in bed for long periods of time"; NHS inform says don't "brace or hold yourself still - your back is designed to be mobile", and NICE says continue normal activities. The Chartered Society of Physiotherapy puts it plainly: "Don't fear twisting and bending - it's essential to keep moving."

Sources 7, 8, 27, 38

Lifting with a twist: turn with your feetEmerging evidence

The Health and Safety Executive (HSE) says lift "in front of and close to your body, without twisting", "Avoid twisting your back or leaning sideways especially while your back is bent", and "Turning by moving your feet is better than twisting and lifting at the same time". It is regulator advice rather than a tested treatment, and it fits the flare study above.

Training workers in lifting technique didn't prevent back pain in 9 trials of 20,101 workers, so lighter loads, help and changing the task come first, as the HSE also says.

Sources 39, 40, 41, 5, 42

Exercise: it works, and the one you'll keep doing matters mostStrong evidence

Exercise eased long-lasting back pain by about 15 points out of 100 against no treatment (249 trials, moderate certainty), and "core" exercise was no better than other exercise (29 trials). Exercise of many kinds helps; in one large analysis some types did a little better, but the one you'll keep doing matters most. In a network analysis of 217 trials, Pilates, McKenzie therapy and functional restoration did better than other types, and its authors advise doing the exercise you enjoy. NICE suggests considering a group exercise programme, such as strength, aerobic or mind-body exercise.

Exercises that target twisting have thin, conflicting evidence: 4 weeks of rotation classes didn't help 35 women, while movement-control exercise beat general exercise in 39 people whose pain came on with arching and turning. In 312 people, 74% had a direction of movement that eased their pain. So the plan uses general back exercise and brings twisting back gradually, starting in the easier direction (our reading), with NHS inform's dosing of 2 to 3 at a time building to "a maximum of 2 sets of 15".

Sources 43, 44, 69, 27, 45, 46, 47, 48

Keeping it from coming backStrong evidence

Exercise with education roughly halved the chance of a new episode of back pain (a risk ratio of 0.55), while back belts and insoles didn't help. In 701 people, a walking programme with education delayed the next episode (a median of 208 days against 112).

Sources 37, 49

Golf and racquet sportsMixed evidence

The low back is golfers' commonest problem. In the studies, previous back pain, age and body mass predicted it, not swing style or hip movement, and carrying the bag went with back problems in one survey of 703 golfers. These are observational studies.

A 10-minute golf warm-up cut low back pain episodes from about 95 to 16 per 1,000 golf days over 12 weeks in 45 teenage golfers, though the number with any back pain didn't differ clearly. It is one small trial in teenagers, and no trial has tested swing changes for back pain.

Sources 50, 51, 52, 53, 54, 55

Medicines, heat, belts, injections and surgeryStrong evidence

NICE says consider anti-inflammatory painkillers, "Do not offer paracetamol alone", don't offer opioids for long-lasting back pain, and "Do not offer belts or corsets". The NHS says take ibuprofen if it suits you and use heat for stiffness or spasm.

NICE says "Do not offer spinal injections for managing low back pain", and considers a procedure that numbs the facet joints' nerves with heat (radiofrequency denervation) only for selected long-lasting pain after a positive numbing test, partly because one test alone misleads. Surgery is for sciatica that hasn't improved with other treatment, and the NHS says it "is not usually needed" for a slipped disc.

Sources 27, 7, 21, 31

Thin bones: twist smoothlyStrong evidence

The Royal Osteoporosis Society says "Any twisting or rotation movements should be safe if they are smooth and comfortable", and a UK consensus agrees, favouring "'how to' rather than 'don't do'" advice, while sustained or loaded bending to the end of the range should be adapted.

Sources 56, 57

How much pain is OK while you exercise?

Up to about 5 out of 10, settling within an hour, no worse the next morning, and no pain spreading down the legEmerging evidence

This guide uses the back hub's rule. Some discomfort during exercise is fine and doesn't mean you are doing damage; aim for no more than about 5 out of 10, settling within an hour or so, with your back no worse the next morning. If it is worse, do less next time (fewer reps, a smaller range, a lighter load or a slower turn), not nothing. Leg symptoms are the exception: stop or shrink any movement that sends pain, pins and needles or numbness further down the leg.

NHS inform's back exercises use the same band (0 to 3 out of 10 is minimal pain, 4 to 5 acceptable and 6 to 10 excessive), say pain "should be no worse the morning after you've exercised", and suggest "reducing the speed of a movement" if it climbs. In long-lasting muscle and joint pain, exercise that allowed some pain did no worse than pain-free exercise.

For twisting (our suggestion, built on the same rule): turn first in the direction that is easier, then the other way, within a range that stays at about 5 out of 10 or less; add range before speed, and speed before load. A dull ache or stiffness at the end of a turn that eases when you come back to the middle is fine; a sharp catch that stops you means a smaller, slower turn for now, and turning with your feet for everyday jobs. Judge yesterday's twisting, gardening or golf by the next morning.

Sources 48, 58

The exercise plan: 3 stages

Start at the first stage. Each move opens a full guide with a 3D demo.

Stage 1

Settle: keep moving, and turn gently in the easy direction

About the first 2 weeks, little and often. Walk several times a day, move the back gently in every direction that is comfortable, keep the twist in the upper back and hips, and turn with your feet for everyday jobs, as the written steps below say. With pain down a leg, our sciatica guide's first stage suits better; with thin bones, keep every twist smooth and unloaded.

Treadmill walking demonstrated on the 3D figure

3D demoTreadmill walkingBeginner · Cardio machine

5 to 10 min, several times a day · As in our back pain guide. Walking outdoors or around the house counts

Harder: Treadmill jogging

Hip windshield wipers demonstrated on the 3D figure

3D demoHip windshield wipersBeginner · No equipment

10 slow passes side to side, 2 rounds, in a small range · The move page's dose (an editorial starting point); NHS inform's knee rolls move the same way. Start towards the easier side

Easier: Supine heel slide · Harder: 90/90 switch

3D demoCat-cowBeginner · No equipment

8 waves, slower than feels natural, in a small range · The move page's dose. NHS inform's back exercises include the same curl and uncurl on hands and knees

Harder: Half lord of the fishes (Ardha Matsyendrasana)

Pelvic tilt into bridge demonstrated on the 3D figure

3D demoPelvic tilt into bridgeBeginner · No equipment

The tilt first: 2 to 3 at a time, building to sets of 8 · NHS inform's pelvic tilt, with its pacing

Harder: Glute bridge

Single knee-to-chest stretch demonstrated on the 3D figure

3D demoSingle knee-to-chest stretchBeginner · No equipment

Hold 20 to 30 s, 2 to 4 times each side, only if bending forward eases it · The move page's dose, an editorial starting point; NHS inform's knee hug. Leave it out if it sends pain down a leg, as the move page says

Harder: 90/90 hip lift-off

Thoracic rotation demonstrated on the 3D figure

3D demoThoracic rotationBeginner · No equipment

6 rotations each side, moving with the breath, in a comfortable range · The move page's dose. The upper back is where most of a twist should come from

Easier: Side-lying open book · Harder: World's greatest stretch

Move on when: You can walk for 15 to 20 minutes, everyday turning with your feet is comfortable, and your back is no worse the next morning (the first and last are the back hub's test).

Follow along: a timer, a cue and the next move, one step at a time.

Stage 2

Build: resist a twist before you make one

About weeks 2 to 6, 2 or 3 sessions a week, walking on most days. Trunk and hip strength from the back hub's second stage, with a press that resists twisting and a lying upper-back turn.

Bird dog, one limb at a time demonstrated on the 3D figure

3D demoBird dog, one limb at a timeBeginner · No equipment

3 sets of 6 to 8 each side, with 3 to 5 s holds; then the full bird dog · As in our SI joint and back pain guides

Easier: Side-lying tummy draw-in · Harder: Bird dog

Dead bug heel taps demonstrated on the 3D figure

3D demoDead bug heel tapsBeginner · No equipment

2 sets of 6 to 8 each side · As in our back pain guide

Easier: Bent-knee fall-out · Harder: Forearm plank

Knee side plank demonstrated on the 3D figure

3D demoKnee side plankBeginner · No equipment

3 holds of 15 to 20 s each side · As in our back pain guide; compare the two sides

Harder: Side plank

Half-kneeling Pallof press demonstrated on the 3D figure

3D demoHalf-kneeling Pallof pressBeginner · A band + An anchor point

2 to 3 sets of 8 to 10 each side · As in our back pain guide. It trains the trunk to resist twisting

Harder: Pallof press

Side-lying open book demonstrated on the 3D figure

3D demoSide-lying open bookBeginner · No equipment

8 to 10 slow openings each side, pausing 2 s at the end · The move page's dose (an editorial starting point)

Harder: Thoracic rotation

Glute bridge demonstrated on the 3D figure

3D demoGlute bridgeBeginner · No equipment

2 to 3 sets of 10 · As in our back pain guide

Easier: Pelvic tilt into bridge · Harder: Single-leg glute bridge

Move on when: Every set is controlled, reaching behind you (a seat belt, a bag on the back seat) is within the pain rule, and your back is no worse the next morning (editorial).

Follow along: a timer, a cue and the next move, one step at a time.

Stage 3

Twist with control and load: lift, turn, swing and carry

From about week 6, 2 or 3 sessions a week, then ongoing. Turning under light load, lifting without twisting, carrying on one side and rotational sport, while gardening, the car and golf or racquet sports come back by the written steps below. How they come back is our suggestion.

Standing trunk twist demonstrated on the 3D figure

3D demoStanding trunk twistBeginner · No equipment

Hold each turn about 5 s, 5 times each side · The move page's dose: the NHS's seated upper-body twist. Standing twists come back

Harder: Cobra pose (Bhujangasana)

Cable press and rotation demonstrated on the 3D figure

3D demoCable press and rotationIntermediate · A cable machine

2 to 3 sets of 8 to 10 each side, light and slow · Editorial: the move page gives no dose. Hold the Pallof press square first, as the move page says

Easier: Half-kneeling Pallof press · Harder: Cable wood chop

Cable wood chop demonstrated on the 3D figure

3D demoCable wood chopAdvanced · A cable machine

2 to 3 sets of 8 to 10 each side, light and controlled · Editorial. The move page asks for standing trunk turns and the Pallof press first

Easier: Standing trunk rotation with a ball

Suitcase carry demonstrated on the 3D figure

3D demoSuitcase carryIntermediate · A dumbbell + A kettlebell

3 walks of 20 to 30 m each side · As in our back pain guide: if you can't stay level, the weight is too heavy

Easier: Farmer's carry · Harder: Overhead carry (waiter's walk)

Kettlebell deadlift demonstrated on the 3D figure

3D demoKettlebell deadliftBeginner · A kettlebell

3 sets of 8 to 10, light to start · As in our back pain guide: lift square, then turn with your feet

Easier: Hip-hinge practice · Harder: Dumbbell Romanian deadlift

Landmine 180 (landmine rotation) demonstrated on the 3D figure

3D demoLandmine 180 (landmine rotation)Intermediate · A barbell + An anchor point

2 to 3 sets of 8 to 12 each side, little or no weight at first · The move page's dose (an editorial starting point); for golf and racquet sports. Control the bar rather than letting it swing, as the move page says

Easier: Cable press and rotation · Harder: Barbell pike rollout

Move on when: Our suggestion: add one thing at a time (range, then speed, then load), bring back long gardening jobs, golf and racquet sports in short sessions, keep two strength days a week, and drop back a stage for a few days if a big day flares it, rather than stopping.

Follow along: a timer, a cue and the next move, one step at a time.

What to change for now

Lifting and turning for now (written steps)

Our 3D figure can't show these. They come from the NHS, NHS inform, the Health and Safety Executive and an NHS physiotherapy leaflet; where a step is our suggestion, it says so.

1. Keep moving, and don't hold your back rigid (the NHS and NHS inform).
2. Lift square: face the load and the way you're going, keep it close to your waist, and turn with your feet, not your back, especially while your back is bent (the Health and Safety Executive).
3. Put a load down, then turn; adjust it once it's down (the Health and Safety Executive).
4. In everyday life, move your feet when you turn rather than twisting your spine (the NHS, for pregnancy, and an NHS physiotherapy leaflet).
5. Loading the boot or lifting a child from a car seat: get close, hold the load near your waist and turn with your feet (our suggestion, from the Health and Safety Executive's principles).

Sources 7, 8, 39, 40, 59, 60

The car, the desk, bed, the garden and the house (written steps)

These come from an NHS pain clinic leaflet, the Royal Osteoporosis Society, the Health and Safety Executive and NHS inform.

1. The car: getting in, put your bottom in first and then swing both legs round; getting out, swing your legs round and use the door to help you up (an NHS pain clinic leaflet).
2. Get out to reach the back seat or the boot rather than twisting round from the driver's seat (our suggestion; the Royal Osteoporosis Society says try not to twist to reach the back seat).
3. The desk: screen and keyboard straight in front of you, a chair that swivels for reaching, and get up and move often (the Health and Safety Executive and NHS inform).
4. Bed: sit on the edge, then lower yourself onto your side; to get up, roll onto your side or tummy and push up with your hands (NHS inform). Our lying-down guide covers turning over.
5. Gardening and housework: spells of 10 to 15 minutes with breaks, a kneeling stool, a wheelbarrow and a hose instead of a heavy can (the Royal Osteoporosis Society, written for people with spinal fractures). Walk with the vacuum cleaner rather than reaching and twisting (our suggestion).

Sources 61, 62, 63, 40, 8

Golf, racquet sports and the gym (written steps)

The warm-up and the bag come from studies; the rest is our suggestion, as no trial has tested swing or gym changes for back pain.

1. Warm up for 10 minutes before you play (a golf warm-up cut back pain episodes in teenage golfers; our golf warm-up uses the same idea).
2. Use a trolley rather than carrying the bag on your shoulder.
3. While it's sore: fewer full swings and shorter range sessions, half swings and short irons first, then build up gradually.
4. In the gym: keep twists slow, light and smooth; Russian twists, wood chops and cable turns come back last, after the Pallof press (our suggestion; a lab study found trunk muscles work harder the faster the turn).
5. After a flare: keep walking, take an anti-inflammatory such as ibuprofen if it suits you, use heat for spasm, and drop back to stage 1 for a few days (the NHS for the first three).

Sources 54, 53, 4, 7

Positions to swap, and why

Habit or position	Why it matters	Instead
Twisting while lifting, especially from the floor or a car boot	The Health and Safety Executive says avoid twisting "especially while your back is bent", and twisting during an activity went with more flares.	Face the load, keep it close and turn with your feet.
Reaching round to the back seat from the driver's seat	The Royal Osteoporosis Society says try not to.	Get out and open the back door.
Fast, heavy Russian twists while it's sore	Fast, loaded twisting is the version to be careful with, and the move page says leave it out with osteoporosis.	The Pallof press, which trains the trunk to resist twisting.Try: Half-kneeling Pallof press
Deep lying twists that send pain down a leg	The move page says go gently with disc or SI joint problems and get checked if twisting brings on leg symptoms.	Smaller knee rolls.Try: Hip windshield wipers
A full round of golf or a long range session straight away	Rib stress fractures followed sudden jumps in practice, and a warm-up cut back pain episodes in teenagers.	Short sessions after a 10-minute warm-up, half swings first.
Carrying a golf bag on your shoulder	Carrying the bag went with back problems in a survey of 703 golfers.	A trolley.
Sitting twisted at a desk	The Health and Safety Executive says "Screen and keyboard central - don't twist your back".	Screen and keyboard straight in front, and a swivel chair.
Staying in bed, or bracing to avoid all twisting	The NHS says don't stay in bed for long periods, and NHS inform says don't brace or hold yourself still.	Short walks through the day.Try: Treadmill walking
A back belt for lifting and twisting	NICE says "Do not offer belts or corsets", and belts didn't prevent back pain.	Strength, walking and turning with your feet.
Asking for a scan to find the joint that's out	NICE advises against routine imaging, and scans show changes in backs that don't hurt.	Get checked if a warning sign appears.

Routines to follow

Spine mobility routine: neck to pelvis, every direction

A 15-minute routine that moves your neck, upper back and lower back through bending, arching, side bending and twisting, then holds the spine steady.

15 minBeginner12 movesNo equipment

Beginner core workout

A 15-minute beginner core workout on the floor: dead bugs, bird dogs, knee planks, side planks and curl-ups.

15 minBeginner6 movesNo equipment

McGill big 3 core routine

The McGill big three for the core: curl-ups, side planks and bird dogs, each held for 10 seconds at a time in falling sets of 5, 3 and 1 reps.

12 minBeginner3 movesNo equipment

Golf warm-up

A 10-minute golf warm-up: brisk marching, then the hip and trunk turns, hinge, side bend, lunge and jump from the one trial of a golf warm-up, twice through.

10 minBeginner9 movesA wall

Golf strength and power workout

A 45-minute golf gym session: jumps, a medicine-ball throw and kettlebell swings for power, then squats, hinges, rows, push-ups, fast rotation and carries.

45 minIntermediate14 movesMedicine ball, A kettlebell

Racket sport warm-up

A 12-minute warm-up for tennis, padel, squash or badminton: skipping, leg swings, trunk turns, band shoulder work, forearm circles, shuttles and landings.

12 minBeginner10 movesA wall, A band

More moves for this area

Questions people ask

Why does my lower back hurt when I twist?

Usually it's ordinary back pain, often called a pulled muscle: the lower back turns only a degree or two at each joint, so a quick or loaded twist can catch a back that's already sore. It often gets better on its own within weeks. Pain down a leg, a fever or pain that doesn't change when you move needs checking.

I twisted my back. What should I do?

Keep moving gently, take an anti-inflammatory such as ibuprofen if it suits you, and use heat for muscle spasm; don't stay in bed. Most new back pain eases a lot within 6 weeks, with the biggest change in the first couple. Call 999 for numbness around your genitals or bottom, new bladder or bowel problems, or weakness in both legs.

Is twisting bad for your back?

No: reviews found no proof that twisting causes back pain on its own, and the Chartered Society of Physiotherapy says "Don't fear twisting and bending". What's worth avoiding is a heavy lift with a twist while your back is bent: turn with your feet instead.

Did I slip a disc when I twisted?

Probably not: most back pain that starts with a twist is ordinary back pain, and in the lab a twist alone loads the small joints at the back before the disc. A disc pressing on a nerve usually causes pain, tingling or numbness down one leg below the knee.

Why does my back hurt when I twist to one side?

Something on one side is being squeezed or stretched, often a sore muscle or joint, but the side rarely names the cause. Start your exercises turning towards the easier side. Pain on one side with a fever, burning when you pee or waves of pain into the groin may be the kidney, and our one-sided guide covers it.

Why does my lower back hurt when I twist and bend?

Bending and twisting together asks the most of a sore back, which is why the Health and Safety Executive singles it out for lifting. Get close, keep the load near your waist and turn with your feet. Our bending guide covers lifting from the floor.

How should I lift without twisting?

Face the load and the way you're going, keep it close, lift smoothly, then turn by moving your feet; put it down before you adjust it. Use lighter loads, help or a trolley while your back is sore: training in technique alone didn't prevent back pain.

Is it my back or my kidney?

Back pain usually changes with movement and position and eases over days to weeks. Kidney pain usually comes with a fever or shivering, burning when you pee, or waves of pain from the side into the groin. NHS inform says see a GP if back pain isn't affected by movement.

Why does my back hurt after golf?

The low back is golfers' commonest problem, and previous back pain, age and body mass predicted it, not swing style. Warm up for 10 minutes, use a trolley, keep range sessions short while it's sore, and build back gradually. Rib pain on the leading side after a jump in practice can be a stress fracture.

What exercises help lower back pain when twisting?

Walking and gentle turns first, then strength that resists twisting (bird dogs, side planks, the Pallof press), then turning under light load. Exercise of many kinds eases long-lasting back pain; in one large analysis some types did a little better, but the one you'll keep doing matters most. With education, exercise roughly halves the chance of a new episode.

Do I need a scan?

Usually not: NICE advises against routine imaging, and scans often show changes in backs that don't hurt. A scan is for the warning signs, or for sciatica that isn't improving when the result would change treatment.

When should I worry about back pain after twisting?

Call 999 for numbness around your genitals or bottom, new bladder or bowel problems, weakness in both legs, sudden severe tummy or back pain, or back pain with chest pain; get help the same day for a fever, feeling unwell or severe pain that is getting worse quickly. See a GP if it hasn't improved after a few weeks, or after a minor twist from 50 or with long-term steroids. In the US, call 911 where this page says 999.

When to get help first

Get urgent medical help if

See a doctor or physiotherapist if

Where does it hurt?

Understand it

Why a twist can catch a sore backEmerging evidence

Usually ordinary back painStrong evidence

Twisting at work and in daily life: not shown to cause back pain on its ownMixed evidence

"I twisted and slipped a disc" is rarely what happenedEmerging evidence

The ribs, the side of the trunk and teenagers in sportEmerging evidence

What a scan shows, and what it doesn'tStrong evidence

How it usually goesStrong evidence

What helps, and how strong the evidence is

Keep moving: the health-service adviceStrong evidence

Lifting with a twist: turn with your feetEmerging evidence

Exercise: it works, and the one you'll keep doing matters mostStrong evidence

Keeping it from coming backStrong evidence

Golf and racquet sportsMixed evidence

Medicines, heat, belts, injections and surgeryStrong evidence

Thin bones: twist smoothlyStrong evidence

How much pain is OK while you exercise?

Up to about 5 out of 10, settling within an hour, no worse the next morning, and no pain spreading down the legEmerging evidence

The exercise plan: 3 stages

Settle: keep moving, and turn gently in the easy direction

Build: resist a twist before you make one

Twist with control and load: lift, turn, swing and carry

What to change for now

Lifting and turning for now (written steps)

The car, the desk, bed, the garden and the house (written steps)

Golf, racquet sports and the gym (written steps)

Positions to swap, and why

Routines to follow

Spine mobility routine: neck to pelvis, every direction

Beginner core workout

McGill big 3 core routine

Golf warm-up

Golf strength and power workout

Racket sport warm-up

More moves for this area

Questions people ask

Related exercise guides

Other pain guides

Sources