hello welcome to our six part series on back pain care the purpose of these videos is to present a standard evidence-based approach for managing patients with back pain in primary care practices at UCLA the videos have been designed to ensure that patients receive high-quality care while reducing unnecessary imaging another goal of these videos is to decrease unnecessary specialty referrals for the majority of our patients who have nonspecific back pain that is likely to resolve with conservative management in this video we will demonstrate a proper physical exam of a patient with back pain just as with the history the physical exam is critical in helping you to separate patients into three categories the minority of patients with unusual and serious causes of back pain who need urgent referral and imaging patients who may have herniated discs or spinal stenosis who may need imaging in the future and the largest group patients who will likely benefit from conservative therapy we will demonstrate a general approach to a physical exam for a back pain patient without any red flag symptoms by history of course the patient was worrisome symptoms consistent with serious conditions such as cauda equina syndrome or osteomyelitis will require a more detailed exam as prompted by the history here we are demonstrating a physical exam on a thirty year old male patient who had sudden onset of low back pain three days ago the first step of the general examination for a patient with low back pain is to inspect the back with clothes removed second palpate for spinal tenderness warmth and muscle spasms around the areas of reported pain third have the patient demonstrate a straight leg raise next have the patient demonstrate acrost straight leg raise we will now demonstrate the molder deep tendon reflex and sensory exams for the l4 to s1 nerve roots which are the anatomic areas most commonly involved in low back pain for the motor exam have the patient perform a knee extension dorsiflexion of the big toe and foot plantar flexion for the deep tendon reflexes exam check the bilateral knee reflexes and ankle reflexes for the knee reflex hold the quadriceps with one hand while striking the quadriceps tendon with the reflex hammer for the ankle reflex hold the relaxed foot with one hand while striking the achilles tendon with the reflex hammer for the center exam touch the patient's lower extremities in three areas to determine whether they report loss of sensation pathology of the l4 nerve root may involve numbness over the medial malleolus pathology of the l5 nerve root they involve numbness over the dorsum of the foot pathology of the s-1 nerve root may involve numbness of the lateral aspect of the foot finally asking the patient to walk on their heels in front of you is a good way to assess for unilateral foot drop your clinical assessment of the patient as determined by the combination of the physical exam demonstrated here as well as the history as described in the first video will guide clinical decision-making in particular identifying patients with neurologic symptoms such as foot drop unilateral motor weakness loss of sensation or abnormal reflexes is helpful in making decisions about whether the patient needs imaging and when to order it as described in video number four almost all patients who are less than fifty years old without any red flag symptoms with the majority of their pain in the back rather than a leg and without any signs of radiculopathy on exam we'll have nonspecific back pain video number three provides a standard protocol for managing patients with acute back pain