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Lower Back Physical Exam:What you Need to Know

June 8, 20142014 BCCFP Spring

Family Medicine Conference

Teri FisherBSc, BEd, MSc, MD, Dip Sport Med

Assistant Clinical ProfessorFamily, 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 backconditions

• Review lower back physicalexamination

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 PRECISEanatomical/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 lowerback 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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Surface/Bony Anatomy

Anatomy - Muscles

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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 Reflex

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 extrudedthrough defect in anulus fibrosusinto canal

• Often occurs in disks previouslyinjured

• Usually age 20-50• L5-S1 > L4>L5

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Acute Disk Prolapse -Management

• Rest in position of maximumcomfort (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 strengtheningwhen pain-free

– Identify and correctcauses

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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

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References and ImagesBrukner, Peter and Karim Khan. Clinical Sports Medicine. 3rd Ed. 2007.

http://hscweb3.hsc.usf.edu/blog/2012/05/31/1979/

http://modernhealthandfitness.com/how-do-i-treat-sciatica-pain/

http://www.lumbarspinalstenosis.com/lumbar-radiculopathy-symptoms-causes-treatments-low-back-leg-pain.html

http://www.ochsner.org/services/orthopedics/

http://www.studyblue.com/notes/note/n/chapter-22-musculoskeletal/deck/1329298

http://www.eastvicparkphysiotherapy.com.au/Blog%20Images/lower-back-pain.jpg

http://www.unisa.edu.au/Media-Centre/Releases/Study-aims-to-ease-the-burden-of-lower-back-pain/#.U3Kd2jmhA5Q

http://www.sciatica-clinic.com/wp-content/uploads/2013/03/SCIATICA-FROM-HERNIATED-DISC.jpg

http://alexsimotasmd.com/conditions/spondylolisthesis

Questions?• teri.fisher@ubc.ca