Back Pain Care Series: Part 1 - Physical Examination for Back Pain

Introduction

Purpose:
- Provide an evidence-based approach to managing back pain in primary care.
- Ensure high-quality care while reducing unnecessary imaging.
- Decrease unnecessary specialty referrals for nonspecific back pain.
Focus of Video:
- Demonstrate a proper physical exam for back pain patients.

Serious Causes: Patients needing urgent referral and imaging.
Possible Herniated Discs/Spinal Stenosis: May need imaging in the future.
Conservative Therapy Candidates: Largest group, likely nonspecific back pain.

Patient Example: 30-year-old male with sudden low back pain onset 3 days ago.
Steps in the Examination:
1. Inspection:
  - Remove clothes to inspect the back.
2. Palpation:
  - Check for spinal tenderness, warmth, and muscle spasms.
3. Straight Leg Raise Tests:
  - Standard and crossed straight leg raises.

Deep Tendon Reflex and Sensory Exams:
- Focused on L4 to S1 nerve roots.
Motor Exam:
- Knee extension, dorsiflexion of the big toe, and foot plantar flexion.
Reflexes Exam:
- Knee Reflex:
  - Hold quadriceps and strike tendon with reflex hammer.
- Ankle Reflex:
  - Hold foot and strike the Achilles tendon.
Sensory Exam:
- Check lower extremities in three areas for loss of sensation.
- Pathologies:
  - L4 Nerve Root: Numbness over medial malleolus.
  - L5 Nerve Root: Numbness over dorsum of the foot.
  - S1 Nerve Root: Numbness over lateral aspect of the foot.

Guided by:
- Combination of physical exam and patient history.
Key Identifiers for Imaging Decisions:
- Neurologic symptoms such as foot drop, unilateral motor weakness, loss of sensation, or abnormal reflexes.
Patient Group Considerations:
- Patients under 50 without red flags, pain primarily in the back, and no radiculopathy signs likely have nonspecific back pain.