Clinical Examination

Clinical Cornerstone:

• It’s important to view the patient holistically, considering the biopsychosocial aspects of the patient’s condition. When re-evaluating existing patients, especially those presenting with new complaints, a thorough assessment is just as imperative.

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Useful for arriving at a diagnosis:

• Observations: Abnormalities, asymmetries, posture, gait, movements.

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• Red Flags: Examination of signs or symptoms that might indicate a more serious underlying condition (see 'Red Flags' Section).

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• Range of Motion: Lumbar spine's active and passive ROM in all planes (flexion, extension, lateral flexion, and rotation). Consider regional and segmental hypomobility, hypermobility and abherrant movement patterns.

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• Neurological Examination:

  • Straight Leg Raise Test: Assess for sciatic nerve irritation. A positive test may indicate nerve root compression or irritation.

  • Motor Strength: Test the strength of the lower extremities. Pay attention to any asymmetry or weakness that could indicate nerve root involvement or motor neuron pathology.

  • Sensory Examination: Check for any sensory deficits in the lower extremities. Look for patterns of loss that correspond to dermatomal or peripheral nerve distributions.

  • Reflexes: Test the Achilles and patellar reflexes. Asymmetry or absence of reflexes can be indicative of nerve root compression or other neurological conditions.

  • Lower Motor Neuron Signs: Look for signs or lower motor neuron dysfunction such as muscle atrophy, fasciculations, and reduced muscle tone. Symmetrical loss of function may indicate a systemic neurological condition.

  • Upper Motor Neuron Signs: Assess for signs of upper motor neuron involvement like increased muscle tone, hyperreflexia, and the presence of pathological reflexes (e.g., Babinski sign).

  • Clonus: Test for clonus, especially at the ankle, as it can be a sign of upper motor neuron pathology. Sustained clonus is often associated with significant neurological impairment.

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• Imaging/laboratory tests: As indicated (e.g., red flags are present).

 

May help guide treatment:

• Palpation: Lumbar spine and surrounding musculature to identify areas of tenderness, etc.

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• Special/Orthopedic Tests: Select tests to use alongside a comprehensive clinical examination, since the specificity and sensitivity of these tests vary. Examples include: Passive straight leg raise, Well leg raise, FABER (Patrick’s) test, Kemp’s test, Piriformis test, Trendelenburg test, Thomas Test, Gaenslen’s test, Valsalva Maneuver, Prone Instability test, Quadrant test, Schober’s test, Femoral Nerve Traction test, Milgram’s test, Slump test, Single Leg Stance (Stork) test.