Back Pain

Target on Physical Exam Strain / Sprain Herniated Disk Spinal Stenosis Bone Disease

Uncommon Conditions Not to Forget Ankylosing Spondylitis Epidural Compression Intra-Abdominal Disease Zoster

HOW TO PROCEED WITH EXAM

Check ROMs of L-S Spine to evaluate level of pain.  Assuming some degree of discomfort and disability:

 1.  Percuss vertebrae

• Focal tenderness to 1 vertebra:  get plain XR

2.  Palpate paraspinous muscles

• Focal tenderness suggests muscle strain / spasm

3.  Test motor strength in both legs, especially 1^st Toe dorsiflexion & plantarflexion

• Unilateral weakness compatible with herniated disk
• Bilateral weakness possible with Spinal Stenosis, also a red flag for Epidural Compression (Cauda Equinae Syndrome)

4.  Inquire re pain radiating to a leg, or paresthesias

• Dermatomal distribution (unilateral) suggests herniated disk
• Decreased sensation in symptomatic dermatome more suggestive
• Don’t test sensation if no radicular symptoms

5.  Test DTRs in legs

• Unilateral diminished DTR suggests herniated disk
• Bilateral hyperflexia a red flag for Epidural Compression

6.  Perform Straight Leg Raise test

• Unilateral positive suggests herniated disk

Most Likely Diagnosis:  Muscle Strain

• No focal tenderness to percussion of vertebra
• No weakness in legs
• No dermatomal symptoms
• Equal DTRs in legs
• Negative Straight Leg Raise