Back Pain: Examination

A comprehensive clinical examination is the basis for selecting further diagnostic steps:

  • General physical examination – including blood pressure, pulse, body temperature, body weight, body height; furthermore:
  • Inspection (viewing).
    • General condition
    • Pelvic position
    • Deformities?
    • Skin (Normal: intact; abrasions/wounds, redness, hematomas (bruises), scars) and mucous membranes.
    • Gait (fluid, limping).
    • Body or joint posture (upright, bent, gentle posture; asymmetries? (pelvic obliquity (= leg length difference < 2 cm), scoliosis); increased or decreased thoracic kyphosis?, lumbar lordosis?)
    • Malpositions (deformities, contractures, shortenings).
    • Muscle atrophies (side comparison!, if necessary circumference measurements).
  • Palpation(palpation)
    • Local musculature and accompanying affected musculature (painfulness? ; tension?).
    • Vertebral bodies, tendons, ligaments; musculature (tone, tenderness, contractures of the paraverebral musculature); soft tissue swelling; tenderness (localization! ); restricted mobility (movement restrictions of the spine); “tapping signs” (testing the painfulness of the processus spinosi (spinous processes), transverse processes and costotransverse joints and the back muscles).
    • Compression pain, anterior, lateral or saggital); hyper- or hypomobility?
      • Warning signs (red flags): pain of vertebral bones on percussion or concussion]
      • Localized tenderness or tapping pain of the spinosus process [suspected fracture/bone fracture)]
    • Sacroiliac joint (SIG; sacroiliac joint): local pain palpation?, pain provocation by compression of the joint? (for pain indication in the gluteal region (buttock region) with or without radiating pain into the thigh, see below sciatica/physical examination).
  • Functional tests (regional tests).
    • Finger-to-floor distance (FBA) – measure used to assess mobility of the spine, hips, and pelvis; used to monitor progression of spinal disorders (e.g., ankylosing spondylitis)
    • Leg raising test (Straight leg raising test): if the test is positive, then shortening of the dorsal leg muscles (pseudolasègue) or the nerve stretching pain to differentiate (true Lasègue).
    • Lasègue test (synonyms: Lasègue sign, Lazarević sign, or Lasègue-Lazarević sign) – describes possible stretching pain of the sciatic nerve and/or spinal nerve roots in the lumbar (lumbar spine) and sacral (sacrum) segments of the spinal cord; Procedure: the patient lies flat on his back when performing the Lasègue test. The extended leg is passively flexed (bent) at the hip joint by up to 70 degrees. If there is a pain response, flexion (bending) is not continued to the physiologically possible flexion. If there is significant pain in the leg up to an angle of about 45 degrees, shooting into the leg from the back and radiating below the knee, the test is considered positive. This is called a positive Lasègue sign.If necessary, also perform the Bragard test: intensification of pain by additionally dorsiflexion (movement of the foot in the ankle joint in the direction of the dorsum of the foot) of the foot (Bragard sign).
    • Modified Schober test: provides information about the mobility of the lumbar spine (LS) in the sagittal plane (plane that intersects the body “sagittally”, i.e., from front to back): the patient is measured standing from the lumbosacral junction 10 cm cranial (toward the head) and 5 cm caudal (downward) (in the Schober test it is only the 10 cm cranial side) and repeated during lumbar flexion (bending). A normal test result is considered to be an increase of more than 4 cm.
    • Test of trunk muscle strength: abdominal muscles and back extensors.
    • Segmental function tests regarding dysfunctions (malfunctions): hypomobility, hypermobility, instability of the lumbar spine segments and/or sacroiliac joints.
    • Mobility tests of the hip joints in terms of rotation (turning movement), flexion (bending), extension (stretching), abduction and adduction (moving a body part away from and towards the body or limb axis).
      • Active and passive mobility testing of the hip joint to test external or rotational ability.
      • Patrick sign (synonym: The quad sign); manual examination method for functional testing of the hip joint and the sacroiliac joint. Performance of the Patrick sign: in the supine position, the foot of the leg to be assessed is placed against the knee joint of the other leg in such a way as to produce a flexion of approximately 45° in the hip joint and 90° in the knee joint. In healthy patients, by taking the described posture from above, a 4 is described.A positive quad sign is found in Perthes disease (juvenile femoral head necrosis) and other diseases of the hip joint (eg coxitis) and sacroiliac joint).
    • Testing for weaknesses and hypertonicity of the hip joint moving muscles, including musculus piriformis testing (piriformis syndrome).
  • Neurological examination – including testing of reflexes and determination of muscle strength (to detect paresis/paralysis).
  • Urological examination [due topossible differential diagnosis: prostate carcinoma].
  • Cancer screening
  • Health check

Square brackets [ ] indicate possible pathological (pathological) physical findings.