LOW BACK PAIN EXAMINATION

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1 LOW BACK PAIN EXAMINATION John Petty, M.D. Medical Director Department of Physical Medicine & Rehabilitation Kettering Medical Center February 8, 2014

2 PRE-TEST QUESTION What part of the low back physical examination is the least frequently used in making a diagnosis? 1. Straight leg raising 2. Anatomical palpation 3. Lower extremity motor examination 4. Lumbar positioning and movement 5. Lower extremity sensory examination 10 Countdown

3

4 MUSCLE STRAIN Back position - listing to the side of the strain Pain location - diffuse over the involved muscle Tenderness diffuse over the muscle involved Straight leg raising could cause back pain, no leg pain Neuro exam intact

5 LIGAMENTAL SPRAIN Back position listing to the side of the sprain Pain location - more focal over the specific ligament Tenderness localized to the ligament Straight leg raising could cause low back pain, no leg pain Neuro exam intact

6

7 LUMBAR FACET JOINT SYNDROME Back position listing away from the involved side Pain location - over the involved facet joint Tenderness focal over specific facet joint Straight leg raising negative unless facet joint swelling could cause foraminal stenosis Neuro exam intact Miscellaneous increased pain with extension, less pain with flexion

8 SACROILIAC JOINT DYSFUNCTION Back position listing away from involved SI joint Pain location - around the SI joint Tenderness very localized to the joint Straight leg raising may produce low back pain; rarely leg pain Neuro exam intact Miscellaneous - positive SI joint stress testing. SI joint doesn t move

9 LUMBAR DISC PROTRUSION Back position listing away from the involved side Pain location - over the involved segment Tenderness focal over specific segment Straight leg raising low back pain Neuro exam may be intact

10

11 RIGHT L5-S1 DISC HERNIATION Back position listing to the left Pain location - right low back, radiating posterior right leg pain Tenderness right L5-S1 segment Straight leg raising leg pain on the right Neuro exam weak gastrocnemius, absent ankle jerk, decreased sensation lateral foot Miscellaneous Sciatic scoliosis. Lateral disc herniation may involve the L5 nerve root. Is disc protrusion reducible with lumbar extension?

12 RIGHT L4-5 DISC HERNIATION Back position - listing to the left with sciatic scoliosis Pain location - right low back, radiating lateral right leg pain Tenderness - right low back Straight leg raising leg pain on the right Neuro exam - weakness of extensor hallucis longus, numbness over dorsal foot, diminished biceps femoris jerk Miscellaneous - If lateral, could affect the L4 nerve root

13 RIGHT L3-4 DISC HERNIATION Back position - listing to the left Pain location - right anterior thigh and anterior knee Tenderness right L3-4 segment Straight leg raising - may be negative Neuro exam weak hip flexors, hip adductors, and quadriceps groups; absent knee jerk; numbness over the anterior thigh Miscellaneous Typically does best with lumbar flexion

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15 LUMBAR CENTRAL STENOSIS Back position lumbar flexion Pain location - frequently without back pain, pain can be localized to bilateral posterior legs Tenderness frequently without tenderness Straight leg raising frequently negative Neuro exam may be negative Miscellaneous Increased pain with lumbar extension; full lumbar flexion may be possible

16 LUMBAR SPONDYLOLISTHESIS Back position lumbar flexion Pain location - midline back pain, pain may radiate into bilateral posterior legs Tenderness midline tenderness at involved segment. can palpate drop-off Straight leg raising frequently negative Neuro exam may be negative Miscellaneous Increased pain with lumbar extension; full lumbar flexion possible

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18 MALINGERING Back position may be in any position Pain location - diffuse and rarely localized; exaggerated; the hand sign Tenderness diffuse, non-anatomical Straight leg raising positive bilaterally at 5 degrees. When sitting with hip flexion, full knee extension Neuro exam giveaway weakness Miscellaneous The patient doesn t know the anatomy The value of an EMG Can tell when the patient isn t trying

19 POST-TEST QUESTION What part of the low back physical examination is the least frequently used in making a diagnosis? 1. Straight leg raising 2. Anatomical palpation 3. Lower extremity motor examination 4. Lumbar positioning and movement 5. Lower extremity sensory examination 10 Countdown

20 What part of the low back physical examination is the least frequently used in making a diagnosis? Straight leg raising Anatomical palpation Lower extremity motor examination Lumbar positioning and movement Lower extremity sensory examination First Slide Second Slide

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