Back pain can be scary, and a big reason is 1) fear of the unknown and 2) confusing terminology. I’m going to walk through my back pain valuation process, try to give insights on what is known, and try to standardize the terms commonly thrown out there.
REMEMBER, if you are experiencing ANY of these, go to the ER
Three Parts to the Evaluation
1) History
2) Neuro Screen
3) Movement Screen
History
This is the most important part of an exam. You tell me what happen. Based on what you describe, I get a pretty good idea of what is wrong with you. I use the rest of the exam to confirm or deny my suspicions.
Most back injuries are some type of bending and twisting injury. Bending and twisting separately put compression through the spine, so when you combine them, it’s like an order of magnitude more compression. That’s not good or bad, but if you add in trying to pick something up from an awkward position, the compression PLUS the weight of the item can lead to injury. A common story is someone had to get in some weird position to pick up some item with an awkward weight distribution.
I also need to know other characteristics about your pain so I can establish a pattern. I’ll need to know:
#1 Is your pain constant or intermittent?
It isn’t uncommon for someone to say “it hurts all the time” when in fact it doesn’t. So really think, are there even brief moments, in specific positions, where there is NO pain.
#2 Where is your pain located?
The back is from the bottom of the butt cheek, up. Leg pain is bottom of the butt cheek, down. It can be both, we have to figure out which one dominates the picture.
#3 What movements/activities increase your pain?
Does sitting/bending increase your pain, or standing/walking? This is the final piece to establish your pattern. And its good to know because if you hurt from sitting and bending, then you can stand if you need relief. And vice versa.
Once I have a pattern, I can use that to guide the treatment. See the patterns below, go to the substack for more info. You identify these things yourself. The purpose of the pattern is to be able to control your symptoms.
Neuro Screen
Generally your first health care provider will do this. Check reflexes, sensation, and strength. I typically do this regardless if I’m the first person to ever see you or not. It is easy, and I think my screen is much much much more thorough than anyone that isn’t a neurologist. And I have the luxury of time (a full hour), which many MD’s do not have.
Reflexes
This is like the old school tap the knee with a hammer and you kick. For the back, I’ll check the knee and the calf. I find this to be the least reliable since people have such wide ranges of responses. I still do it, one day I may find something that blows my mind.
Sensation
As you sit in a chair or off the table, I’ll have you close your eyes as I lightly touch different parts of your legs and feet to ensure 1) you CAN feel it and 2) both sides feel the same. Same as reflexes, such a wide variety of responses. I look for things that immediately jump out at me.
The only major sensation thing to worry about is saddle paresthesia noted in the RED FLAGS above. Below is the “saddle” area.
Strength
I will test this in a variety of positions, making you hold different positions/muscles that control the hips, knee, and feet. I’ll actually hold for about 10 seconds because I want to see if there is weakness associated with fatigue. Supposedly this is true neurological involvement. If you are not strong, this muddies up the waters.
Self test - stand on your toes, take 10 steps each. Stand on your heels, so toes up, and walk on your heels, 10 steps each side. That’s usually good enough to see if any back involvement is serious or not.
Another indicator of something bad is a FOOT DROP with walking. You can’t pull your toes up, so you foot will actually drag on the ground. Go to the ER.
Straight leg raise (SLR) and slump test (ST)
These determine if your have tension from a neural structure in the spine. Neural is fancy work for nerve root. If nerves around the spine are irritated/inflamed, they won’t like being tugged on.
To perform the SLR, lay on your back, slowly lift the leg up until you recreate the pain your typically feel. That part is important - YOUR pain, not some other random pain. If you get to about 70 degrees and don’t feel anything, hold it there, then lift your head up, bringing your chin to your chest. Does that recreate YOUR pain? If no, that’s a negative test, if yes, positive test.
Slump Test
The ST is a different variation of the SLR. I try to do both, but some people can only tolerate one. Sometimes, if my history is good enough, I don’t need either. Again, I’ll do both because 1) my eval is systematized and 2) something wild may JUMP out at me.
A video on how you can do it yourself.
These tests aren’t great, that’s why you use them together. They are sensitive - good at making your pain increase, but not specific - give a good indication of WHAT structure is actually involved. The results don’t particularly change the treatment, but if gives you an idea of things that may or may not increase your pain. That can make normal, everyday activities easier.
Movement Exam
Alright, this is truly how I confirm the pattern and determine if you have a “directional preference.” A movement that helps reduce your pain.
#1 forward bend - bend down, touch your toes, get as close as you can get. Does this increase your pain? When, going down, or on the way back up?
#2 lumbar extension - hands on hips, lean back. Does this increase your pain? When at the end, or on the way back?
Repeated Motions
Now I’ll do the same motions, just 10x each. The goal is to see if your symptoms change and get an idea of your irritability. Some possible results:
#1 The pain doesn’t change
If this is you, you are either not irritable (can’t recreate your pain) or super irritable and it gets no worse. Either way, movement doesn’t really affect you, so proceed with things as you can tolerate.
#2 The pain gets worse - you are irritable, so keep that in mind and realize that you won’t be able to go 100 mph without consequences.
#3 The pain reduces - this is great, when you pain is increased, you can do this movement 10x as needed and it makes you feel better.
Treatment
I rarely give back specific exercises unless we’ve seen that that movement actually reduces you pain. We spend more time talking about modifying activities so you don’t increase your pain too much. Here are the 3 main ones that I give out:
#1 - repeated motions - discussed above. the exam showed us this helped reduce your pain. General back pain, often times repeated flexion feels better for most people. I’ll give repeated extension or a sustained cobra position hold typically for people with leg pain. Sometimes that helps reduce it. Of course it usually it never that cut and dry.
#2 Scheduled rest/ Z-lie - if you are super irritated, you’ll actually have to take what is called “scheduled rest.” You lay on your back, unloaded, with your legs up. This could be for 10-15 minutes, 30, who knows, whatever it takes. Some people have to do this every 10 minutes every 2-3 hours, or a 10-15 minute session before you have to go and do something important.
The name is because the position looks like a Z. You have to find the happen medium on how much Z you want to be in and find that point where you can actually feel the low back relax.
#3 Nerve Glides - This is more for leg pain, often referred as sciatica, a word the medical literature is trying to go away from that word since it is non specific, FYI.
With this move, you are “gliding” the nerve through the body. It looks a lot like the SLR and the leg up puts more tension through those nerve-y structures. Toes to face, more tension, toes away, less tension. If you can’t tolerate the toes towards you, bend the knee a little more to give some slack. 10-15 reps a couple times a day. Don’t let this one increase you pain.
Summary
In conclusion, really unless you have any of those red flags, I wouldn’t even say you have a medical problem. Leg pain I’d consider it, but that still doesn’t mean you NEED a medical intervention. Luckily, most back pain resolves on its on, so my focus on acute back pain is 1) make sure it isn’t a red flag, 2) see if you have movements that change your pain (and do or do not do them), 3) gradually restoring normal movement and 4) try to reassure you nothing is seriously wrong.