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Lower Back Physical Exam:
What you Need to Know
June 8, 2014
2014 BCCFP Spring
Family Medicine Conference
Teri Fisher
BSc, BEd, MSc, MD, Dip Sport Med
Assistant Clinical Professor
Family, Sport & Exercise Medicine
University of British Columbia
Presenter Disclosure
• Relationships with commercial interests:
– None
• Disclosure of commercial support:
– None
• Potential for conflicts of interest:
– None
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Objectives
• Review the approach to lower back
conditions
• Review lower back physical
examination
Overview – Lower Back Pain
• Affects up to 85% of population
• Est annual cost $40 Billion (US)
• Most common disability <45 yo
• Often NOT possible to make PRECISE
anatomical/pathological diagnosis
• Pain generators:
– Disc (nucleus pulposus, anulus fibrosus),
facet joints, ligaments, muscles, nerves,
synovium
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Causes – Lower Back Pain
• Common:
– Degenerative disc, facet joint, stress
fracture (spondylolysis), SI joint,
paravertebral muscle
• Less common:
– Spondylolisthesis, spinal stenosis, disc
prolapse, vertebral fracture, fibromyalgia,
rheum/GI/GU/Gyne pain
• Not to be missed
– Malignancy (primary, metastatic), osteoid
osteoma, multiple myeloma, severe OP
Case 1 –
The Grad Student
• 28 year old female grad student with lower
back pain
• Started while writing her thesis
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Lower Back Pain History
• Mechanism of onset
– Trauma? Gradual?
• Position
– Anatomical location
• Quality
– Sharp? Dull? Burning?
• Radiation
– Distally? Dermatome?
• Severity
– 0-10 (10 = worst pain imaginable)
• Timing
– Onset? Trauma? Constant? Intermittent?
• Aggravating
– Activity? Rest?
• Alleviating
– Rest?
• Neuro symptoms
– Numbness? Weakness? Bowel/bladder Dysfunction?
• Inflammatory signs
– Morning Stiffness? Fever? Iritis? IBD? Other joint involvement? Weight
loss? Malaise? Night pain?
History
• Started 2 weeks ago
• Lower back pain, right side
• Aching quality
• No radiation
• Severity ranges from 3-6/10 (depending on
activities)
• Worse while studying/typing
• Improved with stretching
• No weakness, no paresthesia
• No bowel/bladder dysfunction
• No morning stiffness
• No systemic symptoms
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Physical Exam
• Inspection:
– Gait, foot type, knee alignment (varus, valgus),
bruising, erythema, scars, atrophy, skin changes,
scoliosis
• Palpation:
– Spinous processes, Paraspinal muscles, posterior
iliac crests, Facet joints, SI joints
• Range of Motion:
– Active
• Functional Tests:
– Toe walk, heel walk
• Special Tests:
– Trendelenberg, SLR,
Bowstring, Lasegue’s Tripod, Slump, Facet load,
Faber’s, Leg lengths
• Neuro Screen:
– Sensation, motor function, reflexes
Dermatomes
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Dermatomes/Myotomes/Reflexes
Level Sensory Area Myotome Refle
x
L2 Mid-anterior thigh Hip flexion
(iliopsoas)
L3 Medial knee Knee extension
(quadriceps)
Knee
L4 Medial ankle Dorsiflexion
(Tibialis anterior)
Knee
L5 1st toe webspace Toe extension
(EHL)
S1 Lateral ankle Platarflexion
(gastroc, soleus)
Ankle
Back Physical Exam
• Demonstration
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Physical Exam
• No scoliosis
• Tender L3-L5, R paraspinal
• N back ROM
• N sensation
• N Strength (5/5)
• SLR neg
• Fabers neg
• Reflex 2+, symmetrical
Case 1 - Investigations
Required? NO!
• Indications:
– Suspected traumatic fracture,
stress fracture, spondylolisthesis,
cancer
– Pain not responding to treatment
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Back Strain – Treatment
• Reduce pain and inflammation
– Rest, NSAIDs, Electrotherapeutic modalities (i.e.
Ultrasound), taping
• Address contributing factors
– Poor posture when sitting or standing
– Poor lifting technique
– Working in stooped positions
– Bed with poor support
• Restore full-range pain-free movement
• Achieve optimal flexibility and strength
• Maintain fitness
• Physiotherapy
Case 2 –
The Construction Worker
• 48 year-old construction worker
• Sudden Back pain
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History
• Started yesterday when lifting concrete block
• Lower Back
• Central spine
• Sharp quality
• Shooting pain to R foot
• Severity ranges from 7/10
• Worse when sitting, bending, coughing,
sneezing
• Improved when lying down/standing
• “pins and needles”, numbness in foot
• N bowel/bladder function
• No systemic symptoms
Physical Exam
• In obvious discomfort
• Protective scoliosis
• Tender L5-S1, midline
• Decreased back flexion ROM
• Decreased sensation R dorsal foot,
1st toe
• Strength 4/5 Toe extension
• SLR +, Bowstring +, Lesague’s +,
Slump +, Tripod +
• Fabers neg
• Reflex 2+, symmetrical
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Case 2- Investigations
• X-ray
• MRI
Acute Disk Prolapse
• Nucleus pulposus extruded
through defect in anulus fibrosus
into canal
• Often occurs in disks previously
injured
• Usually age 20-50
• L5-S1 > L4>L5
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Acute Disk Prolapse -
Management
• Rest in position of maximum
comfort (lie down; avoid sitting)
• Analgesia
– NSAIDs
• Physiotherapy
• Transforaminal epidural
cortisone injection
• Surgical Referral (persistent
symptoms, cauda equina)
Case 3 –
The Gymnast
• 18 year-old gymnast
• Chronic back pain
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History
• Chronic back pain x 1 month
• Right-sided low back pain
• Worse with back extension
• Sharp quality
• Severity 4-7/10
• No numbness
• Normal bowel/bladder function
• No weakness
Physical Exam
• Excessive lordotic posture
• Tender near L L4 facet
• Decreased/painful back
extension
• Painful facet load
• Normal sensation
• Normal reflexes
• SLR negative
• No systemic signs
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Case 3- Investigations
• X-ray – often unremarkable
• SPECT scan
• CT scan
Spondylolysis
(pars interarticularis stress fracture)
• Management
– Rest from sport
– Restrict responsible
athletic activity
– Hamstring/gluteal
muscle stretching
– Abdominal/back
muscle strengthening
when pain-free
– Identify and correct
causes
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Spondylolisthesis
(pars interarticularis stress fracture)
• Slipping of part or all of 1 vertebrae
• Often associated with bilateral pars defects
• Usually develop in childhood - ages 9-14
• Usually L5 slips forward on S1 (Grades I-IV)
• Imaging: Lateral x-ray
Spondylolisthesis
- Treatment
• Grade I/II
– Rest from aggravating activities
– Core/back strengthening, hamstring stretching
– Physiotherapy
– Antilordotic bracing
• Grade III/IV
– Symptomatic treatment as above
– Avoid high speed/contact sports
– If progression, consider spinal fusion
