hi I’m dr. ball deep saying I’m an internist here at Stanford and today we’re going to talk about the physical exam portion of a patient presenting with low back pain given that most low back pain originates from the lumbar vertebral area where the Peris – muscle we’re going to be focusing primarily on the musculoskeletal portion of the exam today but at the end we will review some can’t-miss diagnosis to round out the differential so today Steve is going to be joining us to help us demonstrate some key aspects of the physical exam we’re going to try to focus on four specific areas inspection palpation some key provocative tests and end with the neurological exam let’s start with inspection so Steve if I can have you stand this way first thing you want to notice is the contour of the spine focusing on kyphosis any caiaphas or lumbar lack of lumbar lordosis as those can contribute to low back pain next you’ll have the patient bend over Steve if I can have you bend over looking for any scoliosis in which case you will notice that one side of the spine may be raised in comparison to the other side next we’ll move to the palpation portion so try to focus on two areas and we’re going to palpate either push or tap directly on the spine looking for tenderness specifically and then start to place some pressure on the Peris – muscles to differentiate potentially a spinal cause of pain versus a pair of spinal cause of pain in this portion we are going to review some key provocative portions of the exam starting with the tripod sign so while the patient is remaining seated we’re going to try to lift the affected side in this case let’s say the patient is describing radicular plane down the right leg so by elevating the right leg if the patient has pain note that that both arms thin hence causing a positive tripod sign next to confirm our finding with the tripod sign we will proceed with the straight leg sign elevate the affected side to between 30 and 60 degrees beyond 60 degrees it may be a false positive as you elevate the leg you should elicit pain if someone has some evidence of significant lombardi kalapa the– on the affected side then to confirm that you can also drop the foot by 15 degrees and dorsiflex foot confirming our positive straight leg sign next we’re going to be doing the femoral stretch test the femoral stretch test is very helpful when considering a diagnosis of lumbar radiculopathy in the l2 to l4 region this the straight leg and tripod signs are very helpful in l5 and s1 radiculopathy but if you suspect l2 to l4 which is much rarer you would take the leg bend the knee grab the base of the knee and extend the leg up if the patient complains of pain on the anterior thigh and responds to this maneuver is very suggestive of l2 to l4 radiculopathy in patients with low back pain typically conservative treatment is very commonly prescribed as most patients improve with that however in some cases if the patient has a concerning history for more serious radicular pain you may want to proceed with a neurological exam as this may result in further imaging or consultation we are now going to be focusing on the neurological exam focusing primarily on three key areas the motor exam a sensory exam and reflexes given that the vast majority of lumbar radiculopathy comes from three levels l5 l4 l5 and s1 we will be focusing most of our time on those areas starting with the motor exam we’re going to focus on three areas l4 l5 and s1 to test l4 we’re going to have the patient bend the knee and kick out there by 10 setting up the quadriceps checking for l4 you want to always compare to the opposite side go ahead Steve and kick so you can compare both sides to make sure they’re equal next we’re going to proceed to l5 in which the case the patient will dorsiflex foot and the big toes comparing both sides putting quite a bit of pressure in order to listen any subtle difference between the two sides finally we’ll end with s1 where we have the patient plantar flex or push down as hard as possible on both hands again comparing both sides to see if there’s any s1 discrepancy to confirm the findings on the neurological exam we just demonstrated will now assess l5 and s1 in a different way so what I’ll do is I’ll have Steve walk across the room walking on his heels looking at both toes to see if one foot is dropped go ahead Steve if there’s an l5 weakness we’ll see that one foot will drop in relation to the other next to assess for s1 we’ll have Steve stand on both toes and walk across the room looking at the heels to see if one heel is dropped in comparison to the other if that is the case is suggestive of a significant weakness of s1 next we’re going to be going to the sensory portion of the exam focusing on l4 l5 and s1 to start with we will try to take a monofilament or pin and try to distinguish if there’s any numbness on one side as compared to the other in the case of l4 we’re going to be focusing on the anterior lateral aspect of the thigh looking for any discrepancy in the dermatomes patient we’ll say that one side is number than the other moving to l5 the space between the first and second toe again looking for any discrepancy in the dermatome patient would describe numbness and finally ending with s1 which is the lateral aspect of the foot next we’re going to be moving to the reflex portion of the exam focusing again on l4 l5 and s1 for l4 we would bend the legs patient’s legs slightly while they’re lying down and while their leg is very relaxed try to elicit a patellar tendon reflex next for l5 put your fingers across the medial hamstring trying to elicit the medial hamstring reflex looking forward the hamstring to activate above your hand and finally for s1 we would bend the leg dorsiflex the foot and again with the patient relaxed tap the Achilles looking for a jerk in the Achilles tendon if the neurological exam is normal usually you don’t need to proceed to advanced imaging such as MRI we can usually start with simple treatments such as anti-inflammatories and physical therapy and see how the patient does if the patient continues to do poorly patients symptoms persist we can typically have the patient come back in six to eight weeks to reassess and thereby decide if we need to do further testing later finally while by far in a way issues with the vertebra or muscles are the major causes of low back pain be sure to look for these can’t miss diagnosis malignancy infections such as osteomyelitis or epidural abscess where patients may present with signs and symptoms of infection inflammatory arthritis and lastly or very rarely other areas that can mimic low back pain such as prostatitis of the confirmatory disease kidney stones and they order gander ISM or gastrointestinal disease that concludes our video on the low back examination I would like to thank Steve for helping us demonstrate key aspects of the low back exam today for future videos please visit the Stanford 25 website the preceding program is copyrighted by the Board of Trustees of the Leland Stanford junior University please visit us at med.stanford.edu you

62 thoughts on “Approach to Low Back Pain Physical Exam – Stanford Medicine 25”

  1. thanks a lot for your kind offer of very instructive lessons however by experience I suggest humbly if you could kindly give some thought about the coccyx as on many occasions it is the culprit along with l4 l5 and s1 but very often ignored during diagnosis. Best regards

  2. actually I 'm suffering lower back pain (pain more in SI joint ) since last 3months.. I don't know what's the reason.. I'm 21years old woman.. I will take x-rays but their is no deformities.. sir please reply

  3. Around the 3 minute mark, testing for foot drop while walk on heels the toes, the box reads normal on both; isnt this not normal?

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  5. ALWAYS consider AAA, esp. in the patient with risk factors, first. The only way of clearly excluding it is with imaging. If the pt. is using anticoagulants, consider compression from hemorrhage.

  6. Is He Just Check the L4 Mayotome with knee extension… I think L4 is dorsi flexion if i am wrong correct me plX

  7. Excellent video very informative. I would like to see one video that the patient fell back pain for demonstration

  8. Thank you thank you! I'm an acupuncturist and needed a quick review. Lbp is one of the most common complaints of my patients.

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