Examining lower back pain involves a systematic approach to identify the potential causes and contributing factors. This process includes several key steps, from observation to specific orthopedic and neurological tests.
1. Approach Considerations
- Patient History: Start by gathering detailed information about the patient's pain, including onset, location, duration, intensity, aggravating and relieving factors, and any previous treatments.
- Red Flags: Identify any red flags indicating a serious underlying condition (e.g., cauda equina syndrome, infection, fracture, tumor). These warrant immediate further investigation. Examples of red flags include bowel or bladder dysfunction, saddle anesthesia, progressive neurological deficits, fever, unexplained weight loss, and significant trauma.
2. Inspection
- Posture: Observe the patient's posture from the front, side, and back, noting any asymmetries, scoliosis, or exaggerated spinal curves.
- Gait: Assess the patient's gait for any limping, guarding, or abnormal movements.
- Skin: Inspect the skin for any signs of injury, scars, or skin lesions that may be related to the pain.
3. Motion Testing
- Range of Motion: Assess the range of motion of the lumbar spine in flexion, extension, lateral bending, and rotation. Note any limitations or pain with movement.
- Functional Movements: Observe the patient's ability to perform functional movements such as bending over to touch their toes, twisting, and lifting.
4. Isometric Muscle Testing
- Muscle Strength: Test the strength of key muscle groups in the lower back and lower extremities, including hip flexors, hip extensors, knee flexors, knee extensors, ankle dorsiflexors, and ankle plantarflexors. This helps identify muscle weakness which may be contributing to the pain.
5. Palpation
- Soft Tissues: Palpate the muscles of the lower back, including the paraspinal muscles, quadratus lumborum, and gluteal muscles, for tenderness, spasm, or trigger points.
- Bony Structures: Palpate the spinous processes, transverse processes, and sacroiliac joints for tenderness or malalignment.
6. Tests for Neurological Dysfunction
- Sensory Testing: Assess sensation in the lower extremities to identify any areas of numbness, tingling, or pain. Focus on dermatomal patterns.
- Motor Testing: Evaluate muscle strength in the lower extremities, focusing on myotomal patterns.
- Reflex Testing: Test deep tendon reflexes, including the patellar and Achilles reflexes. Assess for asymmetry or absence of reflexes.
- Straight Leg Raise (SLR) Test: Perform the SLR test to assess for nerve root irritation or compression (e.g., sciatica). A positive SLR test reproduces leg pain when the leg is raised.
- Crossed Straight Leg Raise Test: This is performed by raising the unaffected leg. A positive test, meaning pain is felt in the affected leg when raising the unaffected leg, is a strong indicator of disc herniation.
7. Tests for Joint Dysfunction
- Sacroiliac Joint (SIJ) Tests: Perform specific tests to assess for SIJ dysfunction, such as the Gaenslen's test, Patrick's (FABER) test, and SIJ compression and distraction tests. These tests provoke pain from the SIJ.
8. Muscle Stabilization Testing
- Core Stability Assessment: Evaluate the patient's ability to maintain core stability during functional movements. This can be done through various exercises and observation. Poor core stability can contribute to lower back pain.
By following these steps, clinicians can thoroughly examine lower back pain and identify the most likely causes, leading to effective treatment strategies. It is crucial to consider each patient's unique presentation and tailor the examination accordingly. Further imaging such as X-rays, MRI, or CT scans may be necessary depending on the findings of the physical examination and the presence of red flags.
