Current advice for management of low back pain encourage individuals to stay active, to avoid investigation, and to not seek care by a health care professional. This recommendation is based on the premise that most back pain recovers and that medicalisation of the problem can lead to worse outcomes. Although this has foundation in the literature, are we at risk of worsening outcome for some if early consultation is discouraged? Two lines of recent research provide some insight. The first is a cohort study of the transition from an acute episode to persistent low back pain. The second relates to new physiological understanding of changes in back muscles after back injury. Data from the cohort study confirm that recovery is less optimistic than often assumed and that risk for transition to chronicity can be predicted at baseline, by features that are potentially modifiable, if identified and addressed early. The physiological work highlights that after a back injury, a sequence of pathological processes is initiated that ultimately leads to structural changes in back muscles that compromise their functional capacity. The underlying mechanisms include neural and immune changes, which can be largely prevented by early exercise intervention. Together these observations highlight that intervention commenced early may have important application in improving the long-term outcome in low back pain. Although it is clear that language used in early back pain needs to be optimsed to reduce catastrophisation, fear and medicalisation; early evaluation and tailored intervention to reduce potential for transition to chronicity may be critical, but not afforded by current recommendations.