Low Back Pain Care Pathway

7. Physical Examination

 

A comprehensive physical examination should consider the biopsychosocial aspects of the patient’s condition, cultural considerations, and the necessity of obtaining informed consent. This approach is crucial for both new and existing patients, especially when they present with new complaints. Obtaining informed consent involves explicitly addressing the purpose and process of the examination, ensuring the patient understands and agrees to the procedures. Special care should be taken when contact is made in sensitive areas, prioritizing the patient’s comfort and understanding throughout the examination. Additionally, cultural awareness is essential in healthcare, as a patient's cultural background can significantly influence their perception and response to treatment. Practitioners should adapt their examination techniques and interactions to be respectful and sensitive to cultural differences, tailoring their approach to meet the specific needs and considerations of each patient.

 

Observation:

Abnormalities, asymmetries, posture, gait, movements, facial expression.

 

Range of Motion:

Lumbar spine's active, passive, and resisted ROM in all planes (flexion, extension, lateral flexion, and rotation). Consider regional and segmental hypomobility, hypermobility and aberrant movement patterns.

 

Palpation:

Identify areas of tenderness in the lumbar spine and surrounding musculature.

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Neurological Examination:

Motor Strength:

• Key Observations: Asymmetry or weakness indicating nerve root involvement, particularly focusing on:

  • L2: Hip flexors (hip flexion).

  • L3: Quadriceps (knee extension).

  • L4: Tibialis anterior (foot dorsiflexion).

  • L5: Extensor hallucis longus (big toe extension).

  • S1: Gastrocnemius (plantar flexion).

  • S2: Hamstrings (knee flexion).

• Record the clinical findings for each. E.g., L5: Extensor hallucis longus (EHL) strength: L5: EHL – L 3/5, R 5/5.

 

Sensory Examination: 

• Key Observations: Check for sensory deficits in lower extremities, corresponding to specific dermatomal distributions:

  • L3: Medial thigh at the knee.

  • L4: Medial side of the calf.

  • L5: Top of the foot and toes.

  • S1: Lateral side of the foot and little toe.

• Record the clinical findings for each. E.g., "Patient reports that they perceive the same for sharp, light, and vibration for L3, L4, L5, and S1." "Patient reports a loss of perception of sharp and light for S1 on the right with all other sensations intact."

 

Reflexes: 

• Key Observations: Asymmetry or absence of reflexes can indicate nerve root compression or other neurological conditions.

  • L4: Patellar reflex.

  • L5: Medial hamstring reflex.

  • S1: Achilles reflex.

• Record the clinical findings for each. E.g., L5: R 2/4, L 3+/4.

 

Lower Motor Neuron Signs:

• Key Observations: Muscle atrophy, fasciculations, reduced muscle tone, symmetrical loss of function. May indicate a systemic neurological condition (e.g., radiculopathy, peripheral neuropathy, ALS, spinal muscular atrophy).

• Record as: E.g., "LMN signs: Atrophy (yes/no), Fasciculations (yes/no), Muscle tone (reduced/normal), Function loss (symmetrical/asymmetrical)."

 

Upper Motor Neuron Signs:

• Key Observations: Increased muscle tone, hyperreflexia, pathological reflexes (e.g., Babinski sign, Clonus). May indicate conditions affecting the central nervous system (e.g., cervical spondylotic myelopathy, multiple sclerosis, stroke, spinal cord injuries).

• Record as: E.g., "UMN signs: Muscle tone (increased/normal), Hyperreflexia (yes/no), Babinski sign (positive/negative), Clonus (yes/no)."

 

Special/Orthopedic Tests:

Select tests to use alongside a comprehensive clinical examination; the validity and reliability of these tests vary. Record: For all tests, note the side tested, whether the test is positive or negative, and include an observational note for the responses to the test to also inform the clinical picture. E.g., “SLR R(-), L(+) patient reports pain to left heel.” Tests include:

 

Tests for Nerve Root Compression and Irritation (Radiculopathy):

1. Passive Straight Leg Raise: Positive test: exacerbates leg pain at or below 45° of hip flexion.

2. Slump Test: Positive test: neurological symptoms (e.g., shooting pain, numbness, or burning down leg).

3. Milgram Test: Positive test: cannot lift legs, unable to hold up legs, or symptoms reproduced in the affected limb.

4. Valsalva Maneuver: Assesses presence of potential space-occupying lesion (e.g., disc herniation). Positive test: exacerbates person’s back pain, leg pain, or both.

5. Femoral Nerve Traction Test: Positive test: reproduces symptoms (e.g., pain in low back, buttock, posterior thigh).

6. Directional Preference:

   • Back dominant flexion intolerant: bending forward increases pain (pain may increase with both bending forward and bending backward in some cases) (e.g., disc-related pathology).

   • Back dominant extension intolerant: bending backward increases pain (e.g., facet joint pain).

   • Leg dominant pain that is constant and pain with all movements: nerve root compression.

   • Leg dominant pain that is intermittently worse with walking/standing: neurogenic claudication (or a previous Leg Dominant Constant Pain that is improving).

 

Tests for Sacroiliac Joint (SIJ) Dysfunction:

1. Thigh Thrust Test: Positive test: reproduces pain in SIJ region.

2. Compression Test: Positive test: reproduces pain in SIJ region.

3. Distraction Test: Positive test: reproduces pain in SIJ region.

4. Sacral Thrust Test: Positive test: reproduces pain in SIJ region.

5. Gaenslen’s Test: Positive test: reproduces pain in SIJ region.

6. FABER (Patrick’s) Test: Positive test: test leg remains above opposite leg.

7. Piriformis Test: Positive test: pain in buttocks, radiating pain into leg.

8. Gillet Test: Positive Test: asymmetry in sacral movement or restriction in SIJ movement.

 

Tests for Lumbar Spine and Hip Function:

1. Kemp’s / Quadrant / Extension-Rotation Test: Positive test: pain in the lumbar region, or referred pain into the lower extremity.

2. Trendelenburg Test: Positive test: dropping/lowering of the hip region.

3. Thomas Test: Positive test: affected thigh raises indicating a loss of extension in the hip.

4. Prone Instability Test: Positive test: pain is reduced by actively lifting legs.

5. Schober Test: Positive test: small amount of lumbar flexion difference (e.g., <4 cm).

 

Tests for Myofascial Pain:

1. Myofascial Trigger Point Examination: Positive test: localized pain and referred pain upon compression of trigger points.

 

Advanced Diagnostics:

Imaging: Generally not recommended within the first six weeks unless red flags are present, to avoid unnecessary radiation exposure, overdiagnosis, and costs. ​Currently, there is insufficient evidence in the scientific literature that routine imaging improves patient outcomes. Discuss the benefits and risks of imaging with patients, educating them on the role of imaging and reasons for deferring it initially when applicable. Imaging used in specific contexts should be discussed through shared decision-making (e.g., persistent pain and functional limitations).