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The 3 minute back exam. Dr Bruce Thompson, Lead GPwSI Southern Orthopaedic ICATS. “Back pain”. Very vague non-specific term “Abdominal pain” would not be described in general terms for diagnosis or treatment.

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The 3 minute back exam l.jpg
The 3 minute back exam.

Dr Bruce Thompson,

Lead GPwSI

Southern Orthopaedic ICATS


Back pain l.jpg
“Back pain”

  • Very vague non-specific term

  • “Abdominal pain” would not be described in general terms for diagnosis or treatment.

  • Need to be as specific as possible – consider inflammatory, spasmodic, neuropathic, mechanical etc

  • Evidence basis suffers for being non-specific – unsuitable treatments applied to patients


Sources of back pain l.jpg
Sources of back pain

  • Intervertebral disc – outer 1/3rd

  • Vertebra – body or posterior structures

  • Muscles

  • Thoracolumbar fascia

  • Dura mater

  • Epidural plexus

  • Ligaments

  • Joints – facet or sacroiliac

  • Intra-abdominal


Discogenic pain l.jpg
Discogenic pain

  • Internal disc disruption is the cardinal pathological basis for lumbar discogenic pain.

  • The prevalence of IDD is 40% in patients with chronic LBP

  • Diagnosis is by +ve disc stimulation at affected level with –ve stimulation above/below



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Disc facts

  • If disc narrowed more force goes on facets

  • 75% of disc hydration lost in 1st hour of waking – protect spine then as 18% loss of strength

  • Compressive force  endplate #

  • Facets limit torsion but can get rim tear of disc

  • Degeneration often genetic – FH of OA

  • Discs are largest avascular structures in the body


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Dural referred pain

  • Dural stimuli cause referred pain to be felt in the “pantaloon” distribution.


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Gross classification of LBP

  • Red flag problem

  • Radiculopathy – acute or chronic

  • Mechanical – acute or chronic


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Red Flags (a)

  • Age <20 or > 55 years

  • Violent trauma  ? #

  • Constant progressive non-mechanical pain

  • Thoracic pain

  • PMH Carcinoma

  • Systemic steroids

  • Drug abuse / HIV


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Red Flags (b)

  • Systemically unwell, weight loss

  • Saddle anaesthesia, GIT / GUS upset

  • Persisting severe limitation of flexion

  • Widespread neurological deficit

  • Structural deformity


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History - ? emotional language

  • Age and occupation – exact details

  • Sports and training / coaching – exact details

  • Onset and duration

  • Site and spread

  • Symptoms – factors affecting

  • Other joint problems

  • PMH / FH

  • Drugs

  • Treatment to date – who, what, when.


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General Observation

  • Face

  • Posture

  • Gait

  • Simple movements

  • Activities


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Inspection

  • Bony deformity

  • Colour changes

  • Wasting

  • Swelling

  • Scars


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Active Movements

  • - for pain, range and willingness – in lumbar spine active “flows” into passive due to gravity

  • Extension

  • Side flexion

  • Forward flexion


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Tests while standing

  • Single leg standing – Trendelenburg’s sign

  • Calf raise – unilateral

  • One-legged hyperextension - spondylolysis

  • Flexibility – quadriceps, hamstrings, adductors, calf muscles


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Supine

  • Hip range of movement

  • Sacro-iliac joint tests – FABER & shear

  • Straight leg raising – add bias

  • Sensation

  • Reflexes


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Lumbosacral dermatomes

  • L4 – big toe

  • L5 – lateral toes

  • S1 – stand on

  • S2 – slip on

  • S3 – sit on

  • S4 - perianal


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Myotomes – maximum force to test power and pain

  • L2 Psoas - hip flexion

  • L3 Quadriceps - knee extension

  • L4 Tibialis anterior - ankle dorsiflexion

  • L5 Ext. Hall. Long. - big toe dorsiflexion

  • S1 Peroneals - ankle eversion


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Prone

  • Hip extension Femoral stretch test

  • Sacral compression

  • Lumbar extension – McKenzie Test

  • Lumbar vertebral extension thrusts

  • Gluteal muscle tone


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Dynamic tests

  • Quick test- drop to hunkering then rise

  • Muscle endurance of flexors, extensors, side flexors

  • Gun-dog, side bridge, bridging

  • Core stability balance and co-ordination

  • Shear stability test



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Malingering?

  • Juddering movements

  • Flip test – SLR then sit with legs extended

  • Hoover test – cup calcaneus in each hand and feel counter-pressure on SLR

  • Axial loading on head / cervical spine

  • Simulated rotation – of legs not spine


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Beware!

  • The bizarre but persistent patient