Standing The standing inspection needs to be performed in 3 directions: front, side, and posterior.

The physician starts at the low back and examines down to the feet. Any exaggerated or flattened normal spinal curves, asymmetries in skin folds or deformities or abnormal curvatures in spine, muscle atrophy, or abnormal hair patterns should be noted. Seated The seated examination takes place with the patient seated on the table with knees and hips bent to !" or seated on the physician#s stool with feet flat on the floor. The physician evaluates for asymmetries of the pelvis. The video below discusses the initial visual inspection of the patient with acute low back pain. A discussion on visual inspection of the patient with acute low back pain.$ying %or the lying portion of the examination, the patient should be prone on the examination table. &n this position, muscle atrophy and leg'length discrepancies can be appreciated. $eg'length discrepancy Apparent leg'length discrepancies can be assessed by comparing the distance on either side between the umbilicus and a distal landmark such as the tibial tuberosity or medial malleoli. True leg'length discrepancy can be assessed by measuring the distance between the anterior superior iliac spine and a distal bony landmark such as the tibial tuberosity or the medial malleolus after ensuring iliac crests are level and any pelvis is perpendicular to the torso. (ait To complete the gait inspection, the patient#s gait should be evaluated from the front, side, and posterior aspects. Antalgic gait patterns can be observed from all 3 positions.

)otion Testing Active range of motion of the lumbar spine is evaluated with the patient standing. The physician should observe motion from the back and side of the patient. The focus is on the lumbar spine* however, motion will also occur at the thoracic and cervical spine. +hile this phase of the examination is performed, pain and motion limitations should be monitored. ,nce full range of active motion is achieved by the patient, gentle pressure can be applied by the physician to check for a further passive range of motion. -xtreme care must be exercised when applying pressure, as this could exacerbate the patient#s symptoms.

)otion of the lumbar spine occurs in 3 planes and includes . directions, as follows: %orward flexion: .!'/!" -xtension: 0!'31" $ateral flexion2side bending 3left and right4: 51'0!" 6otation 3left and right4: 3'57" To help ensure motion occurs only at the spine, the physician should sit behind the patient and stabili8e the patient by placing his or her hands on the iliac crests and pelvis. 9y keeping firm control of the patient#s pelvis, additional motion at the ilium can be eliminated. )otion should be smooth and pain'free. $imitations in motion or evidence of pain need to be examined further. ,nce standing motion is complete, the patient is placed in a supine position on a table. :ip range of motion needs to be evaluated with a hand on the pelvis to detect any motion that may give a false value owing to tilting of the pelvis. Starting on one side, the physician flexes the patient#s hip and knee both to !". &nternal rotation 33!'.!"4 and external rotation 3.!'/!"4 are performed. This is repeated on the opposite side. :ip pain and motion symmetry are noted. The video below discusses the role of range'of'motion testing in the evaluation of low back pain. A discussion of the role of range'of'motion testing in the evaluation of low back pain. ;r< &sometric )uscle Testing Strength testing of the lumbar spine includes the muscles around the spine column and the large moving muscles that attach onto the axial skeleton. The goal of muscle testing is to evaluate for strength and reproduction of pain. To begin, the patient is seated in a neutral position. The physician stands next to the patient and places one arm across the patient#s chest with a hand resting on the anterior aspect of the opposite shoulder. The physician#s other hand is placed in the posterior aspect of the near shoulder. %rom this position, all motions 3flexion, extension, side bending, rotation4 can be tested. The patient is instructed to move in one direction, and the physician applies a counter'force to resist all motions. The patient#s strength can be graded. +hile the patient is still seated, the lower'extremity muscles that cross the hip =oint are tested. The patient is instructed to maintain a set leg position with the hip and knee both flexed to !". The physician places his or her hand on the distal thigh and resists hip flexion to test the hip the flexor muscle complex 3psoas and iliacus4. The physician then places a hand on the lower shin to resist knee extension, testing the >uadriceps muscles. %inally, the physician slides his or her hand around the back of the ankle to resist knee flexion, testing the hamstring muscles. To complete manual muscle testing, the patient is once again placed in a supine position with knees bent. The patient is instructed to perform an abdominal crunch and hold the position for 1 seconds. After holding the position, the patient is instructed to slowly lower

back to the table. This motion causes an eccentric muscle contraction of the rectus abdominis muscle.

The video below is an introduction to the evaluative approach to low back pain. &ntroductory discussion on the examination of low back pain.The initial approach to the patient with acute low back pain is discussed in the video below. A discussion on the initial approach to the patient with acute low back pain.After a detailed history is taken, the physical examination can begin. To start, the physician needs to inspect the entire spine and both lower extremities and gait. &nspection should be followed by range'of'motion testing and manual muscle testing. %inally, palpation and special tests are performed to confirm suspicions. &n addition to the musculoskeletal examination, neurological and vascular systems of the lower extremities need to be evaluated. &n the video below, the potential causes and symptoms based on patients# descriptions of low back pain are discussed. A discussion of potential causes and symptoms based on patients? descriptions of low back pain. These include the straight leg raise test, the $asegue test, the Slump test, and the femoral nerve traction test. Straight leg raise test The straight leg raise test is used to evaluate for lumbar nerve root impingement or irritation. This is a passive test in which each leg is examined individually. &t can be performed with the patient in a seated or lying position. An introduction to and explanation of the straight leg raise test as part of an examination for low back pain is discussed in the video below. An introduction to and explanation of the straight leg raise test as part of an examination for low back pain.+ith the patient in the supine position, the knee is extended and the hip is flexed until a complaint of pain or tightness is reached. The leg is then carefully returned to the table and the contralateral leg is tested in a similar fashion. A positive test is demonstrated when reproduction of symptoms radiating down the leg is produced at 3!'@!" of leg elevation 3see video demonstration below4.A5, 0, 3B The test has a sensitivity of 5C and specificity of 0/C.A0B &f pain radiates below the knee, $.'S5 nerve root impingement has been identified.A5B Demonstration of the straight leg raise techni>ue.To perform a seated straight leg raise

test, the patient is seated on the examination table with the hips and knees bent to !" and legs hanging freely over the edge of the table. The physician slowly extends one knee from the !" starting position. -xtension of the leg continues until pain or reproduction of symptoms is appreciated down the tested leg. A positive test result is defined as reproduction of symptoms prior to reaching full extension. +hile performing the straight leg raise test, the physician may produce symptoms in the contralateral leg being tested. 6eproduction of symptoms in the opposite leg being tested is termed crossed straight leg raise test result 3see video below4 and indicates a large central lumbar disc herniation. This test has a sensitivity of 07C'0 C and a specificity of 77C' !C for nerve root impingement.A0, .B -xplanation of the crossed straight leg raise in the evaluation of low back pain.$asegue test The $asegue test is also used to evaluate lumbar nerve impingement or irritation. &t is performed in the same fashion as the straight leg raise test, and the setup is the same as that for the lying straight leg raise. The one modification is that, once a complaint of pain or tightness is reached, the leg is slowly lowered 1C'5!C or until radicular symptoms vanish.A.B +hile holding the leg in this lowered position, the examiner dorsiflexes the foot. A positive $asegue test result is demonstrated with reproduction of symptoms in this modified position. &n the literature, the methods for performance of this test vary, leading to a sensitivity of 31C' @C and a specificity of 5!C'5!!C.A.B Slump test The Slump test is used to evaluate for lumbar nerve root impingement or irritation. &t begins with the patient seated on the table with both hips and knees positioned at !". The examiner stands to the side of the patient. The patient is instructed to slump forward while maintaining the head and neck in neutral position. The physician extends one leg with one hand while using the other hand to apply overpressure to the patient#s thoracic spine* thus exacerbating the curvature of the spine. ,nce in this position, the patient is instructed to lower the chin to the chest, producing cervical flexion. A positive Slump test result is demonstrated with the reproduction of radicular symptoms. The sensitivity ranges from ..C'7.C and has a specificity of 17C'73C.A.B The test is then repeated on the contralateral side. %emoral nerve traction test The femoral nerve traction test is used to evaluate for pathology of the femoral nerve or nerve routes coming out of the third and fourth lumbar segments. The setup begins with the patient lying on the unaffected side with the unaffected limb slightly flexed at the hip and knee. The patient#s back is in a non'hyperextended position. +hile the patient#s neck is slightly flexed, the examiner passively extends the hip while standing behind the patient. %inally, the examiner flexes the knee, putting tension on the

femoral nerve. 6eproduction of radicular symptoms down the anterior thigh demonstrates a positive test result. Ease reports in the literature correlate a positive femoral traction test result in 7.C' 1C of patients with nerve impingement* however, tight iliopsoas or rectus femoris muscles can lead to false'positive results.A1B Tests for Foint Dysfunction These include the one leg standing test 3stork stand4 and the ;atrick'%A9-6 test 3flexion abduction external rotation test4. ,ne leg standing test 3stork stand4 The one leg stand test, or stork stand test, is used to evaluate for pars interarticularis stress fracture 3spondylolysis4. &t begins with the physician seated behind the standing patient. The physician stabili8es the patient at the hips. The patient is instructed to flex one leg at the hip and knee as if taking a marching step. +hile holding this position, the patient is asked to arch his or her back into extension. 6eproduction of pain on the stance leg is a positive finding. The test is then repeated on the contralateral side. The sensitivity of this test is 1!C'11C, and its specificity is ./C'/7C.A/B ;atrick'%A9-6 test 3flexion abduction external rotation test4 The flexion abduction external rotation 3%A9-64 test is used to evaluate for pathology of the sacroiliac =oint. The patient lies supine on the examination table and is asked to place one foot on the opposite knee 3placing the hip in flexion abduction external rotation4. +hile supporting the pelvis with one hand, the physician presses firmly down on the flexed knee while supporting the pelvis at the opposite anterior superior iliac spine. A positive finding or this test is pain in the sacroiliac =oint of the leg being tested. ,ne study found the sensitivity to be 1.C'//C and the specificity to be 15C'/0C.A@B )uscle Stabili8ation Testing This consists of the Trendelenburg test. Trendelenburg test The Trendelenburg test is used to evaluate for weak or in=ured gluteus medius and minimus muscles. &t begins with the patient in a neutral stance. The physician is seated behind the patient with his or her hands placed behind the patient#s hips with the thumbs resting on the posterior superior iliac spine. The patient is instructed to flex at the hip, raising the knee as if taking a marching step. +ith the patient in this stance, the physician evaluates for pelvic drop on the side opposite the stance leg. &f a pelvic drop is observed, pathology of the stance leg gluteus medius and minimus has been identified.