An Evidence-Based Approach to the Orthopedic Physical Exam – Part 1: The Lumbopelvic Spine

An Evidence-Based Approach to the Orthopedic Physical Exam –

Part 1: The Lumbopelvic Spine

Christopher B. Roecker, DC, MS, DACO, DACBSP1,2 Rebecca Warnecke, BS 3

Assistant Professor, Palmer College of Chiropractic1

Life Science & Foundations Dept., Davenport, IA 2

Student, Palmer College of Chiropractic, Davenport, IA3

Published:

Journal of the Academy of Chiropractic Orthopedists

December 2016, Volume 13, Issue 2

This article is available from: http://www.dcorthoacademy.com © 2016 Roecker/Warnecke and the Academy of Chiropractic Orthopedists. This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Low back pain is the most common musculoskeletal complaint. Many clinicians attempt to identify the source of a patient’s low back pain to improve diagnostic accuracy and inform management strategies. The purpose of this article is to review the evidence-based orthopedic physical exam for mechanical low back pain. The main categories of low back pain discussed in this review will be: joint dysfunction, discogenic pain, and radiculopathy. This article will also provide an introduction to evidence-based practice and will focus on using likelihood ratios to maximize diagnostic accuracy for the various types of low back pain. It is suggested that clinicians utilize evidence-based diagnostic tools in conjunction with clinical expertise and patient preferences to deliver optimal patient care.

KEY WORDS (MeSH terms): Low Back Pain, Mechanical; Sacroiliitis; Radiculitis; Lumbar Disc Disease; Nerve Root Compression; Degeneration, Intervertebral Disk; Evidence Based Practice;

Introduction

This article is the first in an ongoing four-part series of narrative reviews that intend to provide content related to performing an evidence-based physical examination in each of the following anatomical regions: the lumbopelvic spine, the upper extremity, the cervical & thoracic spine, and the lower extremity.

The foundation of clinical care relies on an accurate diagnosis, and formulating an accurate diagnosis requires clinicians to judiciously use the best available tests. In the world of orthopedic physical exam of the lumbopelvic spine, there are many physical exams (orthopedic tests) reported in the literature; while some of these tests are valuable, many are not. The purpose of this article is to provide an introduction into the evidence-based selection of orthopedic tests within the lumbopelvic spine and discuss orthopedic tests that have demonstrated superior performance.

All avenues of health care are undergoing a paradigm shift toward evidence-based practice. Evidence-based practice explicitly integrates three basic principles: 1.) the best available research evidence, 2.) the clinician’s expertise (judgement/experience), and 3.) the patient’s values or preferences [1]. This approach to clinical decision-making enhances the opportunity for quality care and optimal clinical outcomes.

The diagnostic process involves taking a patient history, developing a working list of differential diagnoses, and selecting specific tests to confirm or deny potential diagnoses. The probability that a specific condition is producing the patient’s complaint is known as the “pre-test probability.” The usefulness of any diagnostic test is the influence that the test has on the probability that the patient’s complaint stems from the suspected condition (e.g. a patient’s radicular leg pain is probably from an acute disc herniation). The most useful orthopedic tests will have a large influence on whether a patient’s complaint stems from any given condition, while a poor test will have little-to-no influence on this probability. We will briefly use an example outside of the lumbopelvic region to discuss how clinical tests influence probabilistic thinking.

A patient’s sore throat (pharyngitis) could be of viral or of streptococcal bacterial origin. For the sake of simplicity, we will say that the probability that the sore throat is due to a streptococcal infection is 25%; this is the “pre-test probability.” If a rapid strep test is performed and comes back positive, it will have a large influence on whether the clinician believes this patient’s complaint is the result of a streptococcal infection. Most sources would say that the test increased the “post-test probability” to nearly 100%.

The ability of a test to influence the probability that a condition is present is known as a likelihood ratio. More recently, likelihood ratios are being used to describe the usefulness of a multitude of tests, including orthopedic tests. A major benefit in using likelihood ratios is that they incorporate a test’s sensitivity and specificity into one single number, which clinicians can use to quickly and easily evaluate how “good” or “useful” a test is for their needs. Likelihood ratios come in two forms: positive likelihood ratios (+LR) and negative likelihood ratios (-LR); simply use a +LR when the test result is positive or the –LR when the test result is negative. We have provided a brief review of how to interpret positive and negative likelihood ratios in Table 1 [2]. In general, the larger a +LR is the better the test; conversely, the smaller a –LR is the better the test.

+LR

-LR

Interpretation

>10

<0.1

Large conclusive shifts in probability

5 – 10

0.1 – 0.2

Moderate shifts in probability

2 – 5

0.2 – 0.5

Small but sometimes important shifts in probability

1 – 2

0.5 – 1.0

Small and rarely meaningful shifts in probability

+LR = positive likelihood ratio; -LR = negative likelihood ratio

Table 1 – Interpretation of Likelihood Ratios

Traditionally, the goal of an orthopedic physical exam is to identify the source of abnormal tissue that is the cause of a patient’s clinical presentation. While evidence is emerging that using a biopsychosocial model is superior to simply establishing a pathoanatomical cause of pain [3], this article will emphasize which orthopedic tests are most useful in identifying somatic tissue injury as a source of lumbopelvic pain, including lumbopelvic causes of lower extremity pain.

Methods

Information used to write this narrative review of evidence-based orthopedic physical examinations of the lumbopelvic spine were collected from the sources listed in Table 2. As this article focused on background information, authoritative textbooks on the topic of evidence-based physical examinations were the primary source of information, and source articles that were referenced in these texts were obtained for further information related to exam statistics (i.e. likelihood ratios). Source articles were evaluated for quality using the QUADAS scores; when multiple sources existed for a given test, the information with the highest QUADAS score was used for the article. Therefore, we emphasized using the results of the most rigorous studies published on the topic of physical examination procedures for the lumbopelvic spine. Additionally, we used an iOS application, known as CORE – Clinical ORthopedic Exam by Clinically Relevant Technologies, to perform our literature review; this application links orthopedic exams with their source articles on PubMed.gov and provides a synopsis of the exam statistics yielded from each physical exam procedure.

Simel DL, Rennie D. The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. Chicago: McGraw-Hill Professional; 2009

Cleland JA, Koppenhaver S. Netter’s Orthopedic Clinical Examination: An Evidence-Based Approach, 2nd Ed. Philadelphia, PA. Saunders Elsevier; 2011

Cook CE, Hegedus EJ. Orthopedic Physical Examination Tests: An Evidence-Based Approach, 2nd Ed. Indianapolis, IN. Pearson Education; 2013

Glynn PE, Weisbach PC. Clinical Prediction Rules: A Physical Therapy Reference Manual. India. Jones and Bartlett Publishers; 2011

Cool Ce. Orthopedic Manual Therapy: An Evidence-Based Approach. 2nd Ed. Upper Saddle River, NJ. Pearson Education; 2012

Murphy DR. Clinical Reasoning in Spine Pain Volume 1 — Primary Management of Low Back Disorders Using the CRISP Protocols: A Practical Evidence-Based Guide. Pawtucket, RI. CRISP Education and Research; 2013

Table 2: Sources Used for this Narrative Review

Discussion

Categories of Lumbopelvic Disorders

There are two biological factors that have been shown to produce low back disorders: somatic factors and neurophysiological factors. The focus of this article will be on the somatic factors of lumbopelvic disorders, which include: joint dysfunction, discogenic pain, and radiculopathy [4]. We will approach the orthopedic exam of the lumbopelvic region using these three major categories.

Joint Dysfunction

The cause of joint pain is complex. Traditionally, clinicians have sought to locate the source of pain by focusing on injured (somatic) tissues as the cause of nociceptive input and pain perception. Joint pain arises, at least in part, from dysafferentation of a joint; dysafferentation involves an imbalance of nociceptive and mechanoreceptive input being projected from the involved joint, into the central nervous system [5]. It is important to note that joint dysfunction is described differently by many different professions and may also be known as: a chiropractic subluxation, an osteopathic lesion, a manipulable lesion, or joint fixation [6].

While there are many individual joints within the lumbopelvic region that may produce joint dysfunction, we will break them into two categories: 1.) lumbar facet joints and 2.) sacroiliac joints.

  • Lumbar Facet Joint Pain

The lumbar facet joints, also known as zygapophyseal joints, allow for mobility and load transmission in the lumbar spine and are commonly reported as a source of localized low back pain [7]. Facet pain has been shown to be the primary pain-generator in approximately 30% of all chronic low back pain patients and is associated with age-related degenerative changes to the spine [7,8]. The clinical presentation of lumbar facet pain is often referred to as lumbar “facet syndrome” and commonly involves the following clinical features: ipsilateral paraspinal pain which may project into the buttock, thigh, or groin, decreased range of motion with lumbar extension and/or rotation, and increased pain with prolonged standing or sitting [9,10]. Importantly, lumbar facet syndrome may present with a variety of clinical presentations, and the idea that a distinct set of criteria constitutes a formal lumbar “facet syndrome” has been called into question and likely does not exist [9].

Many of the tests that purport to evaluate the lumbar facet joints do so by inducing a version of lumbar extension and/or rotation. Unfortunately, very few orthopedic exams have been evaluated to assess for lumbar facet pain; below is a list of the exams that have demonstrated value in assessing for low back pain emanating from the lumbar facets joints.

  • Extension-rotation test (Kemp test): this test is frequently cited as a test for lumbar facet pain. Kemp test has been reported to have a +LR = 1.29 and -LR = 0.0 [11]. These test statistics indicate that a positive Kemp test has very little impact on the probability that a patient’s low back pain is arising from the facet joint, but a negative Kemp test has a large impact on ruling out facet pain as the source of this patient’s low back pain complaint.
  • Posterior-anterior pressure test (P-A test, Springing test, Spring test): this test simply involves the clinician applying posterior-to-anterior (P-to-A) pressure to the region of the lumbar facet joints as the patients lies prone. While studies exist that describe this exam as having modest inter-rater and intra-rater reliability, we were unable to locate any studies that evaluated the validity of this test for the assessment of lumbar facet pain.
  • Clinical prediction rule for facet pain: while there is no single “gold standard” orthopedic exam that has been shown to confidently identify the presence of facet pain, the combination of other facet pain-related factors has been shown to be useful. Five or more of the following seven criteria has been shown to have a +LR of 9.7 and a -LR of 0.17 [6, 12].
  1. Age ≥ 50 years
  2. Low back pain that is primarily located at the paraspinal region
  3. Positive Kemp test
  4. No low back pain is produced with performing a sit-to-stand
  5. Low back pain is best relieved when walking and/or;
  6. Low back pain is best relieved when sitting
  7. Low back pain due to disc derangement has been ruled out
  • Sacroiliac Joint Pain

The sacroiliac articulations are unique in that they transfer forces between the spinal segments and the pelvis. These large joints are a common source of non-radicular low back pain and represent approximately 15-30% of all cases of mechanical low back pain [13,14]. The clinical presentation of sacroiliac joint pain, also known as sacroiliitis, is variable and traditionally presents with pain in one or both S-I joints. S-I joint pain may also refer pain into the posterior thigh and/or hip region and commonly manifests with restricted passive motion (“joint play”) at the involved joint [15]. Again, many orthopedic tests purport to evaluate the S-I joint [16], but very few have established validity. Table 3 contains a review of orthopedic exams that have established clinical validity related to S-I joint pain [17].

Orthopedic Exams to Evaluate for Sacroiliac Joint Pain

+LR

-LR

Gaenslen’s test (right leg)

1.84

0.66

Gaenslen’s test (left leg)

2.21

0.65

Thigh thrust test (posterior pelvic pain provocation test)

2.80

0.18

Sacral thrust test

2.50

0.50

Sacroiliac compression test

2.20

0.46

Sacral distraction test (separation test)

3.20

0.49

+LR = positive likelihood ratio; -LR = negative likelihood ratio

Table 3: Orthopedic Exams to Evaluate for Sacroiliac Joint Pain

These S-I joint tests have been performed in unison, and a clinical prediction rule has been developed [17]. The results of this study developed a clinical prediction rule, yielding a +LR of 4.3, when patients were positive for any 3 (of the 6 total) sacroiliac joint tests. While this +LR of 4.3 does not represent a massive shift in the probability that a patient’s S-I joint is the cause of their low back pain or thigh pain, it is currently the best cluster of orthopedic physical exams available to help identify S-I joint pain [17].

Additionally, patients with ankylosing spondylitis (AS) commonly manifest with bilateral S-I joint pain. Ankylosing spondylitis occurs in about 1% of the overall population [18], is about three times more common among males, and onsets during young adulthood (commonly before the age of 40). This condition typically presents with gradually-worsening low back pain and/or S-I joint pain, which alternates between the S-I joints and buttock regions, bilaterally. The pain that accompanies AS is chronic in nature, is worse in the morning, and is mildly relieved with physical activity [19].

A clinical prediction rule has been developed to help clinicians identify patients who are most likely to have AS (see Table 4) as the cause of their low back pain [20]. This clinical prediction rule determined that patients with 3 or more (of the following 4 features) had a +LR of 12.4 for the presence of AS.

  1. Morning stiffness in the S-I joint that lasts longer than 30 minutes
  1. Improvement in low back pain (S-I pain) with exercise but not with rest
  1. Awakening from sleep in the second ½ of the night due to low back pain (S-I pain)
  1. Alternating buttock pain (gluteal pain)

Table 4: Features Associated with Ankylosing Spondylitis

Discogenic Pain (Disc Derangement)

Discogenic pain is reported to be the most common source of low back pain, and it is associated with approximately 40% of all chronic low back pain cases [21]. This form of pain arises from the development of tears within the annulus fibrosis of the intervertebral disc, which may cause inflammation and pain once it advances to the peripheral regions of the disc [22]. This pain sensation, however, is different than pain due to radiculopathy. Radicular pain is derived from the nerve root tissue while discogenic pain emanates from the disc material, itself. Disc derangement, the biomechanical causation of discogenic pain, results from repetitive lumbar flexion, but compressive and rotational forces are also known risk factors. The outer 1/3 of the annulus is densely innervated with nerve fibers. For this reason, subtle tears may have an asymptomatic presentation, while more severe tears into the outer annulus are known to produce discogenic pain [23].

Discogenic pain is diagnosed via the combination of: clinical presentation and the patient’s response to end-range loading tests [24]. Clinicians should focus on two aspects when treating discogenic pain: 1.) to reduce the intensity and/or frequency of the patient’s pain symptoms and 2.) to achieve a “centralization” of the patient’s pain complaint. The centralization phenomenon involves a change in the patient’s pain distribution pattern where the distribution becomes more proximal (towards the trunk) or nearer to midline.

Clinical presentation of the centralization phenomena is fundamental to the diagnosis of discogenic pain [25]. Robin McKenzie is credited with the first introduction of diagnosis and treatment of disc derangement, which prompted him to create the McKenzie Method, also known as Mechanical Diagnosis and Therapy (MDT). End-range loading tests involve spinal movements, in various directions, in search of a movement that produces pain at end-range, but does not produce pain during the arc of motion. During analysis, both a direction of benefit and direction of detriment are established to guide treatment decisions. The direction of benefit, also known as the “directional preference”, is opposite that of the patient’s antalgia; it is associated with reduction of pain symptoms, increased range of motion, and a sensation of obstruction or blockage at end-range. The direction of detriment is in the same direction of the antalgia [26]. It is associated with pain simultaneously during end-range and the arc of motion, increased symptoms of pain, and possible excessive range of motion. A common patient presentation is the pattern of lumbar kyphotic antalgia [27,28], which is associated with an extension directional preference and a flexion direction of detriment. During treatment for this pattern, the patient is instructed to perform a series of extension exercises, beginning in the prone position with eventual progression into the standing position.

Table 5 lists the positive and negative likelihood ratios associated with repeated end-range loading, which is a key assessment procedure involved with identifying discogenic low back pain. The ratios for the common clinical presentation, loss of lumbar spine extension, are also noted. Regarding repeated end-range loading tests with positive findings, the +LR of 6.7 indicates a moderate to high probability of the patient’s low back pain to be discogenic in origin (see Table 5) [29,30].

Clinical Features Associated with Discogenic Low Back Pain

+LR

-LR

Centralization upon Repeated End-Range Loading

(directions = lumbar extension, flexion, or lateral bending)

6.7

0.63

Loss of Lumbar Spine Extension

(“extension loss”)

2.01

0.84

+LR = positive likelihood ratio; -LR = negative likelihood ratio

Table 5: Clinical Features Associated with Discogenic Low Back Pain

While the orthopedic physical exam may be effective for the diagnosis of non-discogenic low back pain, there is limited evidence supporting the usefulness of orthopedic tests when diagnosing discogenic pain [31]. Due to the lack of robust orthopedic exams to establish that a patient’s low back pain is of a discogenic origin, clinicians are left having to rely more heavily on their clinical experience to make this diagnosis. Additionally, a possibly means of obtaining a discogenic pain diagnosis is to utilize advanced diagnostic imaging, usually MRI, to evaluate for disc degeneration and endplate changes. An aggregative analysis of these studies found a -LR of 0.21, indicating moderate competency to rule out a diagnosis of discogenic pain in the absence of MRI findings [31].

As shown in Table 6, positive signs of centralization have been shown to be indicative of disc derangement upon MRI [29,32]. The positive findings for disc derangement on MRI included: end plate signal intensity changes, morphological disc changes, disc signal loss, and anatomical changes (see Table 6) [33].

Centralization

of Pain

Features of discogenic

pain on MRI

Yes (+)

Features of discogenic

pain on MRI

No (-)

Total

Yes (+)

31

2

33

No (-)

3

2

5

Totals

34

4

38

+LR 1.8(0.8-4.2) -LR 0.18(0.05-0.6)

Numbers represent study subjects included in each category.

Table 6: Relationship Between the Centralization Phenomenon and Evidence of Discogenic Features on MRI

Radiculopathy

Lumbar radiculopathy is often the result of compression or inflammation of a nerve root. Radicular pain typically projects pain into the leg (below the knee), is more intense than the patient’s back pain, and may also present with neurological dysfunction, such as lower extremity paresthesia or a loss of motor and/or sensory function in the lower extremity [34]. While there are various causes of lumbopelvic radicular pain, the two most common causes of radiculopathy are 1.) an acute spinal disc herniation and 2.) lumbar spinal canal stenosis [35].

Acute Lumbar Disc Herniation

A spinal disc herniation, also known as a herniated nucleus pulposus, is likely to produce intense low back pain that is combined with radicular pain and is most common in patients who are 30-50 years of age. Patients with pain emanating from an acute disc herniation have a prolonged history of low back pain with a recent onset of unilateral lower extremity radicular pain, commonly described as “sciatica” [36]. The presence of a disc herniation puts pressure on the associated lumbar nerve root and may also produce pain via inflammatory mediators attracted to the site of herniation. A symptomatic disc herniation produces characteristic findings upon neurodynamic testing, which are also known as “nerve root tension tests” [35]. Procedures that evaluate for a spinal disc herniation are intended to place tension on the tethered nerve root with the purpose of reproducing the patient’s radicular pain complaint [36]. The orthopedic exams that have demonstrated the greatest clinical utility are listed below with their associated positive and negative likelihood ratios in Table 7 [37-40].

Orthopedic Exams to Evaluate for Symptomatic Disc Herniation

+LR

-LR

Straight Leg Raise Test (SLR) [37]

2.23

0.05

Crossed Straight Leg Raise (CSLR or Well Leg Raise) [38]

14.3

0.50

Slump Test [39]

1.82

0.32

Femoral Nerve Stretch Test [40]

5.7

0.34

Crossed Femoral Nerve Stretch Test [40]

≥9.0

0.91

+LR = positive likelihood ratio; -LR = negative likelihood ratio

Table 7: Orthopedic Exams to Evaluate for Symptomatic Disc Herniation

It is worth noting that a positive finding for the straight leg raise (SLR) test involves the reproduction of the patient’s radicular pain between 30-60 degrees of elevation from the table. It’s recommended that SLR test and the crossed straight leg raise (CSLR) test be performed concurrently. While the SLR test is highly sensitive (97%) for disc herniation, it is not particularly specific (57%). This means that a negative SLR is more useful at ruling out an acute disc herniation, but a positive SLR should be followed-up with a specific exam. An exam that is specific for disc herniations is the CSLR test. While the CSLR has a relatively poor sensitivity (43%), a positive CSLR is highly specific (97%) for an acute disc herniation.38 In summary, a negative SLR is most useful for ruling out a disc herniation as the cause of radicular pain, while the CSLR is most useful for ruling in an acute disc herniation.

Clinicians should be aware that the overwhelming majority (98%) of all lumbar disc herniations occur in the lower lumbar spine, while the remaining 2% involve the L1-L4 nerve roots [36]. Lower lumbar disc herniations may cause neurological disturbance in the regions of the lower extremities supplied by the L5 or S1 nerve roots. Neurological disturbances involving L5 or S1 nerve root irritation are likely to produce pain, paresthesia, or numbness along their respective dermatomal distributions (see Figure 1) [41]. Lumbar disc herniations may also produce muscle weakness and abnormal deep tendon reflexes in the lower extremities (see Table 8) [36,42].

Figure 1: Dermatomal Patterns of the Lower Extremities

Nerve Root

Pain or Paresthesia

(sensory)

Weakness

(motor)

Reflex

L2 & L3

Anteromedial thigh

Hip flexion (L2) and

Knee extension (L3)

Diminished knee jerk (patellar reflex)

L4

Anterior thigh and medial foot

Knee extension

Diminished knee jerk (patellar reflex)

L5

Lateral leg and dorsum of foot

Great toe and ankle dorsiflexion

Changes are uncommon or are absent

S1

Posterolateral, leg, heel, and foot

Ankle and great toe plantarflexion

Diminished ankle jerk (Achilles reflex)

Table 8: Review of Selected Lumbar Spine Nerve Root-Related Exam Findings

Sensory impairment from nerve root compression is most notable in the distal extremities; therefore, clinicians are advised to include sensory evaluation on the medial aspect of the foot, the dorsum of the foot, and the lateral aspect of the foot via pin-prick and light touch examinations [36].

Notably, evaluating for weakness on dorsiflexion (L5) or plantar flexion (S1) should be performed while the patient is supine on the examination table; this method has been shown to be more reliable than assessing for weak dorsiflexion by having the patient “heel stand” or “toe walk” [43].

The SLR and CSLR tests are most appropriate for evaluating these lower lumbar disc herniations, while the femoral nerve stretch test and crossed femoral nerve stretch test are most appropriate for evaluating patients who are suspected of having the rarer mid-to-upper lumbar disc herniations (L2-L4 nerve roots) [36].

Astute clinicians should be aware that not all disc herniations detected on advanced imaging (CT or MRI) are symptomatic and relevant to the patient’s care. A systematic review identified the presence of disc protrusions in 29% of all asymptomatic 20-year-olds and 43% of asymptomatic 80-year-olds who underwent advanced imaging [44]. This highlights the importance of correlating clinical exam findings with findings from advanced imaging.

Guidelines overwhelming recommend that patients experiencing pain from an acute lumbar disc herniation should stay physically active and should initiate a six-week trial of conservative care, while clinicians are recommended to avoid imaging during this initial six-weeks of care [45]. Importantly, patients who present with red flags, demonstrate progressive neurological dysfunction, or do not improve following six-weeks of conservative care should pursue advanced imaging or more invasive management procedures [45].

Lumbar Spinal Stenosis

Lumbar spinal stenosis is another common cause of radiculopathy that is most likely to present as a source of pain among older individuals (>50 years) secondary to degenerative changes of the spine, such as osteophytosis or ligamentum flavum hypertrophy. These degenerative changes may narrow the spinal canal or the intervertebral foramen, which causes compression or irritation of the nerve roots of the cauda equina. Lumbar spinal stenosis characteristically produces neurogenic claudication, which is radicular or cramping pain in the legs while standing or walking, along with other neurological defects such as numbness or weakness of the lower extremities [36,46]. A systematic review of commonly-reported features of lumbar spinal stenosis (LSS) has been performed, and the most relevant features are explained in Table 9 [47].

Clinical Features Associated with Lumbar Spinal Stenosis

+LR

-LR

Older than age 65

2.5

0.34

No pain when seated

7.4

0.57

Pain improves when sitting forward (lumbar flexion)

6.4

0.52

Bilateral buttock or leg pain

6.3

0.54

Neurogenic claudication

3.7

0.23

Wide-based gait

13

0.60

Positive Romberg test

4.5

0.67

+LR = positive likelihood ratio; -LR = negative likelihood ratio

Table 9: Clinical Features Associated with Lumbar Spinal Stenosis

While radicular pain may arise from either an acute lumbar disc herniation or lumbar spinal stenosis, there are a few key differences between these conditions, which may help clinicians quickly prioritize whether a patient’s radicular pain is originating from either condition. Patients with lumbar spinal stenosis tend to be older adults, while patients with an acute disc herniation tend to be middle-aged adults. Radicular complaint secondary to lumbar spinal stenosis is most likely exacerbated with lumbar extension, while the radicular pain originating from an acute disc herniation is most likely to be exacerbated with lumbar flexion [36]. Lastly, the radicular pain associated with lumbar spinal stenosis tends to be a chronic pain condition and presents with a bilateral pain distribution; this contrasts with the radicular pain associated with disc herniation which tends to be unilateral, of an acute onset, and of short duration (≤ six weeks) [36].

Limitations

This paper is a narrative review of literature; therefore, the selection of relevant reference articles may have been subject to selection bias, and the search results are less reproducible than systematic methods. While an attempt was made to select reference articles with the highest methodological rigor, these articles were not formally evaluated or graded.

Conclusion

As health care continues to evolve, evidence-based practice (EBP) is becoming increasingly supported and adopted across health care professions [48]. While clinicians engaged in EBP are challenged with staying current with the published literature, it is important to remember that research is not the only focus – use of EBP must also incorporate the clinician’s experiences as well as the individual patient’s desires or values [49]. The intent of this article is to provide clinicians, who are involved with evaluating low back pain-related disorders, with a review of useful information related to performing an orthopedic exam for these disorders. We would like to emphasize how incorporating evidence-based orthopedic exams is intended to save clinicians’ time, while improving their diagnostic accuracy. Currently, a plethora of orthopedic tests are said to be useful for assessing low back pain, but it is worth noting that most of these tests have yet to be evaluated to establish validity. We are not claiming that the orthopedic exams left out of this report are without value and should be omitted, but clinicians should be aware that findings from other orthopedic tests may be tenuous. Performing a focused orthopedic examination while using a short list of evidence-based tests is intended to provide the busy clinician with the most useful information in the shortest amount of time. When applying the tests with useful likelihood ratios or useful clinical prediction rules, clinicians can be increasingly more confident that they have achieved an accurate diagnosis.

Effective patient care revolves around a sound diagnosis and treatment plan. We recommend that clinicians become familiar with the current state of the evidence surrounding the numerous orthopedic tests related to diagnosing the various forms of low back pain. We have assembled a review sheet (see Appendix 1), which may be useful within a clinical setting. In the end, incorporating the highest quality of orthopedic exams into practice is intended to aid clinicians in their ability to provide the highest level of patient care and improve patient outcomes.

List of Abbreviations

+LR = positive likelihood radio

-LR = negative likelihood ratio

S-I = sacroiliac joint

SLR = straight leg raise test

CSLR = crossed straight leg raise test

L2 = second lumbar nerve root

L3 = third lumbar nerve root

L4 = fourth lumbar nerve root

L5 = fifth lumbar nerve root

S1 = first sacral nerve root

Competing Interests

The authors declare that they have no competing interests related to this work.

Author’s Contributions

CBR contributed to the conception or this project, performed the literature review, and participated in the drafting and revisions of this work. RW contributed to the literature review, drafting, and revisions of this work. Both CBR and RW met criteria to substantiate their authorship of this manuscript.

Acknowledgements

None. Also, no funding was provided to support the authors in their performance of this work.

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Appendices

Appendix 1 – Exam Summary for Low Back Disorders

Lumbar Facet Pain

Clinical Presentation: ipsilateral paraspinal pain which may project into the buttock, thigh, or groin, decreased range of motion with lumbar extension and/or rotation, and increased pain with prolonged standing or sitting

Extension-Rotation Test (Kemp test)

+LR = 1.29

-LR = 0.0

P-A Pressure Test (Springing test)

+LR = N/A

-LR = N/A

≥ 5 positives of the following:

  1. Age ≥ 50 years
  2. Low back pain that is primarily located at the paraspinal region
  3. Positive Kemp test
  4. No low back pain is produced with performing sit-to-stand
  5. Low back pain is best relieved when walking and/or;
  6. Low back pain is best relieved when sitting
  7. Low back pain due to disc derangement has been ruled out

+LR = 9.7

-LR = 0.17

Sacroiliac Joint Pain

Clinical Presentation: pain in one or both S-I joints, which may project into the posterior tight and hip region

≥ 3 positives of the following:

  1. Gaenslen’s test (right leg)
  1. Gaenslen’s test (left leg)
  1. Thigh thrust test

+LR = 4.3

-LR = 0.80

  1. Sacral thrust test
  1. Sacroiliac compression test
  1. Sacral distraction test

Discogenic

Clinical Presentation: lumbar kyphotic antalgia associated with an extension direction of benefit and flexion direction of detriment

Centralization with repeated end-range loading

+LR = 6.7

-LR = 0.63

Loss of lumbar spine extension

+LR = 2.01

-LR = 0.84

Disc Herniation

Clinical Presentation: pain radiating into the leg (below the knee) that is more intense than the back pain itself possibly accompanied by neurological dysfunction such as lower extremity paresthesia or loss of motor or sensory function

Straight Leg Raise Test

+LR = 2.23

-LR = 0.05

Crossed Straight Leg Raise

+LR = 14.3

-LR = 0.50

Slump Test

+LR = 1.82

-LR = 0.32

Femoral Nerve Stretch Test

+LR = 5.7

-LR = 0.34

Crossed Femoral Nerve Stretch Test

+LR = ≥9.0

-LR = 0.91

Lumbar Spinal Stenosis

Clinical Presentation: radicular or cramping pain in the legs while standing or walking, along with neurological deficits such as numbness or weakness of the lower extremities

Older than age 65

+LR = 2.5

-LR = 0.34

No pain when seated

+LR = 7.4

-LR = 0.57

Pain improves when sitting forward (lumbar flexion)

+LR = 6.4

-LR = 0.52

Bilateral buttock or leg pain

+LR = 6.3

-LR = 0.54

Neurogenic claudication

+LR = 3.7

-LR = 0.23

Wide-based gait

+LR = 13

-LR = 0.60

Positive Romberg test

+LR = 4.5

-LR = 0.67