This is a good powerpoint presentation from a Family Practice website:
familymedicine.moh.gov.bh/slideshows/Neck%20and%20Back%20Pain.pps
Lower Back Pain
Lower back pain is a very common complaint. The life time prevalence of an episode of lower back
pain is 80%. Many of these episodes are relatively transient in nature and the exact cause of the pain
will never be known. However, there are important causes of back pain that need to be identified.
History is extremely important. There are so called “red flags” that need to be identified. Simialarly
there are “yellow flags” that need to be identified. (table of red and yellow flags)
Comment about the quality of the pain??
The examination of the lower back usually begins with the patient sitting in a chair. Note if
the patient is sitting comfortably or whether they are in pain. Ask the patient to stand from
the chair. If they require than arm rests to stand up then ask the patient to try again but
this time not to use the arm rests. An inability to this is suggestive of proximal muscle
weakness but can be due to severe lower back pain.
Causes of back pain – can we ask for permission to use the Klippel and Dieppe table?
Ask the patient to stand with their back towards the examiner. Look carefully at the back.
Look for a scoliosis, loss of lumbar lordosis or kyphosis.
Next palpate the spine. Initially palpate from the lower thoracic vertebrae towards the
scarum. Palpate each vertebral body individually for tenderness. Palpate the sacrum then
palpate the sacro-iliac joints. These are best felt below the dimples of venus. Next palpate
the paraspinal muscles for tenderness and spasm. Palpate along the posterior iliac crest
again for muscle tenderness and spasm.
Test spinal movements. Begin with forward flexion. Ask the patient to keep their knees
extended and to try and touch the ground. With hypermobility the patient will be able to
place their hands flat on the ground. With disease of the lower spine there is limitation of
flexion. The distance between the floor and the fingertips should be noted. Test lateral
flexion. Ask the patient to slide their hand down the outside of their leg. Their fingertip
should be able to reach the lower aspect of the patella. With nerve root compression the
patient will have pain down the leg on the same side as the lateral flexion. Pain on the
opposite side to flexion is often muscular.
Test extension. Stand behind the patient and ask the patient to lean back. Ask the patient to
stand straight again. Then ask the patient to rotate 45° in one direction and then lean back.
Pain that is elicited in the lumbar spine is suggestive of zygophyseal joint disease. Do this
again with the patient rotated in the opposite direction.
A more objective measure of lumbar flexion is with the schober’s test. (diagram). With the
patient standing, place a tape measure along their lumbar spine. Mark a position 10cm
above the level of the dimples of venus. Firmly hold the tape measure at the distal end of
the spine. Ask the patient to flex forwards with their knees extended. At maximal flexion
the 10cm mark should be at least 15cm.
Test quickly for muscle weakness. Ask the patient to stand of their toes. Inability to do this
suggests calf weakness which could be a L5 or S1 nerve root lesion. Ask the patient to
stand on their heals. Patients are often unsteady but a foot drop will be obvious.
The patient must then be assessed for a specific nerve lesion. The neurological examination of
the lower limb is covered else where.
http://physicalexamination.org/?q=node/86
Musculoskeletal System PE
http://meded.ucsd.edu/clinicalmed/Joints.html
This website includes a series of pictures that are useful for joint exams; it may be overkill here though.
Neurologic Exam:
http://meded.ucsd.edu/clinicalmed/neuro2.htm
Neck and back pain are common, particularly with aging.
Low back pain affects 50% of adults > 60. Symptoms may
simply be local pain, which can be sharp or dull,
continuous or intermittent, depending on the cause and the
degree of concomitant muscle spasms. The reflex
tightening of paraspinal muscles in response to a painful
vertebral column disorder may be more excruciating than
the primary condition. If the spinal cord or nerve roots are
affected, a variety of neurologic symptoms may result,
including paresthesias and weakness. Pain may radiate
distally along the distribution of affected nerve roots
(radicular pain or, in the low back, sciatica).
Etiology
Many conditions produce neck and back pain (see Table 1:
Neck and Back Pain: Causes of Neck and Back Pain );
most can involve both areas, only a few are specific to one
location. Nerve compression, including herniated disk and
spinal cord compression, is discussed in Spinal Cord
Disorders: Spinal Cord Compression. Arthritides and
ankylosing spondylitis are discussed in Joint Disorders:
Seronegative Spondyloarthropathies. Nonvertebral
disorders are discussed in various other chapters in The
Manual.
Table 1
Causes of Neck and Back
Pain
L
O
C
A
TI
O
N
CONDITION
N
e
c
k
o
nl
y
Atlantoaxial
subluxation
Referred pain from
carotid or vertebral
artery dissection,
angina, MI,
meningitis,
esophageal disease,
thyroiditis
Herpes zoster
Temporomandibular
joint disorder
Torticollis
L
o
w
er
b
a
c
Lumbar spinal
stenosis
Osteitis condensans
ilii
Osteoporotic
fractures (can also
k
o
nl
y
be thoracic and
occasionally
cervical)
Referred pain from
hip, buttock, or
pelvic disorders
Referred visceral
pain from aortic
dissection or
aneurysm, renal
colic, pancreatitis,
retroperitoneal
tumor, pleural
effusion,
pyelonephritis
Sacroiliac
osteoarthritis
Sacroiliitis
Spondylolisthesis
Ei
th
er
n
e
c
k
or
lo
w
er
b
a
c
k
Ankylosing
spondylitis (usually
lower back and can
also be thoracic)
Arthritis
(osteoarthritis,
rheumatoid;
rheumatoid rarely
affects the lower
back)
Congenital
abnormalities (eg,
spina bifida,
lumbar-ization of
S1)
Fibromyalgia
Intervertebral disk
disease
Infection (eg,
osteomyelitis,
diskitis, spinal
epidural abscess,
infectious arthritis)
Injury (eg,
dislocation,
subluxation,
fracture)
Muscle or ligament
strain
Paget's disease
Polymyalgia
rheumatica
Tumor (primary or
metastatic)
Spinal cord
compression
Most often, neck or back pain derives from benign, selflimited musculoskeletal derangements, such as muscle
strain, and ligament sprain. Other common causes include
fibromyalgia (see Bursitis, Tendinitis, and Fibromyalgia:
Fibromyalgia) and osteoarthritis (see Joint Disorders:
Osteoarthritis (OA)).
Serious causes include infections (eg, infectious arthritis,
osteomyelitis, diskitis, spinal epidural abscess), tumors
(primary tumors of vertebrae or spinal cord), metastatic
vertebral tumors (most often from breast, lung, or prostate),
injuries (eg, fractures, dislocations, subluxations), and
spinal cord compression. Causes of spinal cord
compression include injuries, herniated intervertebral disks
including the cauda equina syndrome, tumors, and
subluxation of the first cervical vertebrae on the second
(atlantoaxial subluxation).
Evaluation
The history and physical examination often suggest the cause of
neck and back pain. Neurologic symptoms and signs are
particularly important to elicit. Tests are obtained based on
findings during examination.
History: The nature of the pain, including location,
exacerbating and relieving factors, and surrounding events,
is elicited.
Pain, numbness, paresthesias, or weakness along a nerve
root distribution suggests nerve root compression.
Weakness or loss of sensation at a spinal level,
incontinence, or urinary retention may suggest spinal cord
compression.
Onset with injury is usually apparent, but some patients do
not connect painful spasm with an apparently minor strain
the previous day. Pain from injury is localized, relieved by
rest, and worsened by motion. Pain from infection and
malignancy is constant, unrelieved by rest, and
progressive. Pain and stiffness that are worse upon
awakening and last > 45 min suggest ankylosing
spondylitis or RA. Pain that is diffuse or changes locations,
particularly if unrelated to other factors or associated with
poor sleep, suggests fibromyalgia. Morning stiffness of the
spine and muscles of the proximal extremities, particularly
in an older person, suggests polymyalgia rheumatica.
Associated symptoms and history are important. Fever and
IV drug use or known immunosuppression suggests an
infectious cause. Weight loss or a history of cancer
suggests a malignant etiology, either metastases or
pathologic fracture.
Physical examination: A general examination is performed,
with particular attention to the spine, as well as careful
neurologic examination.
Spinal examination begins with inspection. If possible, the
patient should also be observed moving (eg, walking into
the office or exam room, undressing) when unaware he is
being scrutinized. The neck and back are normally slightly
lordotic. Contorted posture suggests muscle spasm, which
can be enough to cause scoliosis. Focal erythema may
indicate infection, overuse of local heat or irritant creams,
or, in certain populations, use of ethnic remedies such as
coining or cupping.
Systematic palpation of the spinal column and adjacent
areas is performed. Focal bony tenderness suggests
infection, tumor, or fracture. Symmetric trigger points
(areas that when palpated reproduce neck or back pain)
over the back, chest, elbows, and knees suggest
fibromyalgia. Trapezius trigger points may be from cervical
disk disease or cervical osteoarthritis affecting the facet
joints.
Active and passive range of motion of the neck and back
are ascertained. Decreased active range of motion often
indicates pain or muscle spasm; intervertebral disk disease
is a particularly common cause. Decreased passive range
of motion indicates structural spinal abnormalities, most
often due to osteoarthritis or multiple osteoporotic
fractures, but possibly from other causes such as injuries,
ankylosing spondylitis, or diffuse idiopathic skeletal
hyperostosis (DISH—see Joint Disorders: Diagnosis). An
electrical sensation that radiates down the spine with trunk
flexion (Lhermitte's sign) suggests spinal cord
compression.
Complete neurologic examination is required. Signs that
suggest spinal cord compression include bilateral reflex,
motor, and sensory abnormalities that occur at a spinal
level or that involve the anal sphincter (ie, poor rectal tone,
decreased bulbocavernosus reflex or anal wink). Spinal
nerve root compression may produce ipsilateral reflex,
motor, or sensory deficits confined to the distribution of
the affected root. In general, among reflex, motor, and
sensory findings, reflex findings are the most objective,
and sensory findings are the most subjective.
Extra-axial joint abnormalities may suggest inflammatory
arthritis, osteoarthritis, or other systemic musculoskeletal
disorders that can affect the spine.
Testing: If symptoms or signs suggest a serious medical
condition (eg, MI, leaking or ruptured aortic aneurysm),
appropriate tests should be obtained. Patients with possible
spinal cord compression or spinal epidural abscess require
immediate MRI; if unavailable, CT or myelography (rarely used)
can be performed. For suspected osteomyelitis, imaging,
usually an MRI, is performed within hours. Plain x-rays are
indicated for bony injuries such as fractures, dislocations, and
subluxations. Plain x-rays may demonstrate bony changes that
can suggest disorders such as osteoarthritis, RA, osteoporosis,
vertebral metastases, some infections, and others. However,
plain x-rays also identify many abnormalities that are unrelated
to symptoms. Testing for the diagnosis of most disorders in
Table 1: Neck and Back Pain: Causes of Neck and Back Pain
is discussed elsewhere in The Manual.
A patient with a clear-cut episode of minor trauma (eg, lifting a
box), no neurologic signs and symptoms, and no risk factors for
pathologic fracture or subluxation may be treated
symptomatically without testing.
NECK PAIN
The most common causes of neck pain are listed above.
Patients with RA, juvenile RA, or ankylosing spondylitis
may have atlantoaxial subluxation (see Neck and Back
Pain: Atlantoaxial Subluxation). Causes of referred neck
pain include angina, MI, arterial dissection, meningitis,
esophageal obstruction, esophageal mass or inflammation,
and thyroiditis. On examination, reproduction of radicular
pain with neck extension and lateral rotation (Spurling's
sign) suggests cervical disk disease. Signs of stroke in the
presence of neck pain, particularly with pulse deficits,
suggest aortic, carotid, or vertebral arterial dissection.
Symptomatic treatment of musculoskeletal neck pain may
require a cervical collar and contour pillow for 10 to 14
days to decrease spasm, then a cervical posture and
stabilization and stretching program.
BACK PAIN
The most common causes of back pain are listed above.
Osteoporotic fractures are a common cause of back pain in
elderly women. Causes of referred pain include ruptured
abdominal aortic aneurysm, renal colic, pleural effusion,
aortic dissection, and retroperitoneal inflammation (eg,
pancreatitis, pyelonephritis) or infiltration (eg, tumor).
However, the etiology is often multifactorial, with an
underlying condition exacerbated by fatigue, physical
deconditioning, and sometimes psychosocial stress or
psychiatric abnormality. Certain congenital abnormalities
of the spine (eg, facet abnormalities) that were formerly
thought responsible for back pain are just as common in
patients without pain.
Pain from osteoporotic fractures is constant but usually not
progressive, may improve when supine, and usually
improves over 4 to 12 wk; it can occur without a history of
trauma (see Osteoporosis). Pain and stiffness in the
morning in a young man suggests ankylosing spondylitis
or other spondyloarthropathy. Worsening with back flexion
suggests intervertebral disk disease. Worsening with
extension suggests spinal stenosis, facet arthritis, or
retroperitoneal inflammation or infiltration. Aggravation of
lumbar and posterior thigh pain with walking suggests
spinal stenosis.
On examination, kyphosis (dowager's hump) suggests
osteoporosis. Muscle spasm induced by straight leg raising
suggests intervertebral disk disease; pain induced by
straight leg raising may also suggest this but is less
specific. A pulsatile abdominal mass, particularly with
signs of shock, suggests ruptured abdominal aortic
aneurysm. Flank tenderness suggests pyelonephritis.
Diagnostic studies may be deferred in patients with no
signs or symptoms of concern if the patient is < 50, has no
motor or reflex neurologic deficits, no sphincter
complaints, no history of cancer, and no fever or weight
loss. However, if pain persists for > 6 wk, an imaging study
(if the etiology is not clear) or other diagnostic workup
(directed at a specific etiology if one is clinically suspected)
should be considered. The choice may depend on causes
suspected. For example, if osteoporotic fracture is likely,
x-ray may be adequate. Whether imaging studies should
begin with plain x-rays or MRI if no specific etiology is
suspected is not clear. A definitive diagnosis cannot be
established in many patients.
In most people with a single acute attack of low back pain,
the cause is a self-limited musculoskeletal condition or is
nonspecific and multifactorial, and recovery usually occurs
over several days to 1 wk. In these patients, attacks may
recur or symptoms may become chronic, especially if
patients engage in activities beyond their physical
capacities. Chronic pain (see full discussion in Pain:
Chronic Pain) is a complex phenomenon often involving
peripheral and central sensitization and neurologic
remodeling, as well as depression and sometimes
secondary gain (eg, litigation).
Initial symptomatic treatment of acute nonspecific
musculoskeletal back pain usually includes 1 to 2 days of
rest (only if needed to minimize pain) and a subsequent
lumbar stabilization program. More prolonged bed rest,
traction, and corsets are generally not indicated. Exercises
that strengthen abdominal and lower back muscles, along
with instruction in work posture, are indicated when
symptoms permit, to strengthen the supporting structures
of the back and decrease the likelihood of the condition
becoming chronic or recurrent.
Reassurance about the benign prognosis of acute
nonspecific musculoskeletal back pain can relieve anxiety.
The physician should be thorough, kind, firm, and
nonjudgmental. A low-dose tricyclic antidepressant may
improve disturbed sleep and relieve chronic muscle pain. If
depression or secondary gain persists for several months,
psychological evaluation should be considered.
http://www.merck.com/mmpe/sec04/ch041/ch041a.html
Back
Straight Leg Raising (L5/S1 Nerve Roots)
1. Ask the patient to lie supine on the exam table with knees straight. ++
2. Grasp the leg near the heel and raise the leg slowly towards the ceiling.
3. Pain in an L5 or S1 distribution suggests nerve root compression or tension
(radicular pain).
4. Dorsiflex the foot while maintaining the raised position of the leg.
5. Increased pain strengthens the likelihood of a nerve root problem.
6. Repeat the process with the opposite leg.
7. Increased pain on the opposite side indicates that a nerve root problem is
almost certain.
FABER Test (Hips/Sacroiliac Joints)
FABER stands for Flexion, ABduction, and External Rotation of the hip. This
test is used to distinguish hip or sacroiliac joint pathology from spine
problems. [10] ++
1. Ask the patient to lie supine on the exam table.
2. Place the foot of the effected side on the opposite knee (this flexes, abducts,
and externally rotates the hip).
3. Pain in the groin area indicates a problem with the hip and not the spine.
4. Press down gently but firmly on the flexed knee and the opposite anterior
superior iliac crest.
5. Pain in the sacroiliac area indicates a problem with the sacroiliac joints.
http://medinfo.ufl.edu/year1/bcs/clist/extrem.html#AA32