Back Pain

Target on Physical Exam

Uncommon Conditions Not to Forget


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 1st 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