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What Does a Proper Low Back Exam Look Like?

Published on Oct 23, 2021

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Have you ever had the experience of taking your car into a mechanic time and time again, each time something is replaced, and each time your car ends up having the same issues? We would all say that this phenomenon happens because the mechanic didn’t know what was wrong from the outset. This also happens in medicine and that problem usually begins with a poor physical exam. So let’s dig in.

The Average Physical Exam

Physical exam in medicine has become a lost and dying art. Why? With the advent of MRI and other tests and payment pressures from insurance companies, the average physician spends just a few minutes with hands on the patient performing an exam, and some doctors never even get that far. What happens when you don’t really know what’s causing someone’s problems? Treatment is like throwing darts at a dartboard with a blindfold on. For a complex chronic pain issue, this is doubly true.

Now there are certainly times that despite the best physical exam, the doctor still can’t find out what’s wrong. However, starting with a bad physical exam makes the likelihood of misdiagnosis and ineffective treatment that much higher. So what does a proper low back exam look like?

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Time, Time, Time

They say that real estate is location, location, location. For a physical exam, it’s all about time spent with the patient. I see 8-12 patients a day. The average physician in my specialty sees 20-40 patients a day. Given that we’re working the same clinic hours, that means that time with the patient is sacrificed.

For an initial evaluation of chronic low back pain, you should expect to be booked into an hour exam slot. While the doctor may use someone else to get the bulk of the history of what’s been happening and how your problem began, the doctor needs to spend at least 5-10 minutes asking their own questions and then another 10-25 minutes with a hands-on physical exam. Meaning, if your problem is easy to diagnose, then you should be looking at a minimum of about 30 minutes of the physician’s time. On the other hand, if the problem is complex that time should be 30 to 60 minutes.

Hence, if you’re booked into a 20-minute initial evaluation spot (which you can ask the staff to confirm), find another doctor. If you have a complex issue and you’re given a total of 30 minutes with half of that being with office staff getting a history, find another doctor.

The Exam

To make this discussion easier, I’m assuming that we’re talking about a patient with a complex low back issue here that’s been going on for years and that this patient has already seen many specialists and gotten little long-term relief.

History

This is the time that the staff and doctor spend with you asking questions about your problem. Since this part of the exam can take many twists and turns, suffice it to say that your whole history should be covered. That includes which specialists you have seen and what they said, which tests you have had, which treatments you have tried, and what makes your problem better and worse. In addition, your doctor should be able to repeat this all back to you and summarize it.

Physical Exam

This is the time spent with you where the doctor (not an assistant or nurse practitioner) is performing the exam. This needs to include:

Palpation

These are the areas that need to be pressed on to see if they’re tender (both sides):

Every spinal level: L5-S1, L4-L5, L3-L4, L2-L3, L1-L2.
Every spinous process
The PSIS
The lower rib cage
The quadratus lumborum
The SI joints
The posterior-lateral iliac crest
The greater trochanter
The ITB from the hip to the knee
Ischial tuberosity
ASIS
Sacrum, sacrococcygeal

Range of Motion

Low back (at least flexion and extension)
Hips (usually internal and external rotation to rule out that hip arthritis may be an issue)
Hip FABER-Flexion abduction external rotation

Nerves

L1-S1 dermatomes using Wartenberg wheel (pinwheel) comparing side to side and the same side. This is exam should never be “can you feel this” but rather “Is this one the same, more, or less than this other area?”
Straight leg raise and Lasegue’s sign (raising the legs to see the patient’s response)
Tinnel’s sign at any areas where nerve entrapment in the lower extremities may be suspected (taping on the places nerves pass to see if that elicits tingling)

Mobilization

SI Squish-If the SI joints are suspected. This could also be a hip FABER maneuver.
PA springing of all lumbar levels to rule out the possibility of painful facet joints. Here the doctor pushes on each vertebral level in your low back.

Provocative Testing

Which lumbar range of motion provokes which symptoms?
Which patient demonstrated activity provokes which symptoms (i.e. my back hurts here when I get up from a chair)

Other Areas

Are other parts of the kinetic chain responsible for or interacting with the low back problem? Hence, full or partial exams need to be of the following areas:

Knee
Ankle
Foot

Review of Imaging

Your doctor is expected to put your MRIs up on the screen and show you what they think is wrong and why. Reading a report is NOT adequate.

A Clear Explanation

Finally, when all of this is done, you deserve a clear summary and explanation of what’s wrong, what caused it, how it explains your symptoms, and how the doctor can help. I often ask my assistant to send the patient additional blog posts that go into more depth on a specific problem. However, the goal is to use easy to understand language and stay away from using too many medical terms.

This Takes TIME

As you can see, the above exam just can’t be done in a few minutes. Now not everything may be done in every patient and the doctor may choose to delete or even add more things based on the most likely diagnosis. However, without time on the books and advanced training, an exam like this will never happen.

The Regenexx Network

I’m the medical director and Chief Medical Officer (CMO) of the Regenexx network. Hence, I’m putting this exam out there so that every patient knows what they should expect when being evaluated. While we take great care to choose only the doctors with the right training to join the network and then provide massive amounts of additional training, every once in a while I run across patients who report they didn’t get this type of exam from our provider network. THIS IS UNACCEPTABLE and I take these complaints very seriously. The doctor will be asked to fix this issue, get additional training, or if they don’t fix the issue, they will be exited from our network. We take our standards that seriously.

The upshot? The art of physical examination is mostly dead in many areas of medicine. Its epitaph was written when advanced diagnostic tests and insurance time pressures became the norm. However, for patients in chronic pain, that often means a higher chance of misdiagnosis and ineffective treatment. Hence, as a Regenexx patient, you should expect to get the type of exam I have described above. If you don’t get that or something similar, please reach out to me at [email protected]. That email goes directly to my desk.