Important History and Physical Examination Pearls of Athletic Back Pain
A) Pain radiating down the left leg
B) Trouble initiating urination
C) Exquisite tenderness to paraspinal muscles
D) Antalgic gait
Table 1. Warning signs of lower back pain that require urgent care evaluation (Cucharillo et al)
After it is evident that there are no concerning (red flag) symptoms, which can often be quickly ruled out, then a detailed, more focused historical evaluation can be performed to ascertain the musculoskeletal cause of the patient’s presentation. This is done by determining the location of the patient’s pain, whether it is midline versus paraspinal versus over the spinal muscles or in other common bothersome areas such as over the SI joints, associated muscles, or related to a hip pathology.
Once history is completed, a detailed neuromuscular examination should be performed to confirm the postulated cause of low back pain for the patient. As with any musculoskeletal examination, the exam starts with inspection for any bruising or deformity of the involved area- in this case the lumbar spine, buttock region, and hip region. Next, a palpatory examination should be done of the following areas: SI joints, piriformis, gluteal muscle, greater trochanter, ASIS, AIIS, midline lumbar spine, and lumbar paraspinal region.
Table 2. Common lumbar spine exam maneuvers
Table 3. Further evaluation of possible lumbar spine diagnoses
Correct answer is B. There are red flags for back injuries that all physicians should know. This includes new onset of back pain at extremes of age (< 20 years or > 50 years), history of cancer, constant, non-mechanical back pain, or pain worse when lying down, presence of neurologic symptoms including weakness and numbness, bilateral symptoms, immunosuppression (i.e. HIV/AIDS, corticosteroids, immunomodulating drugs), IV drug use, change in bowel/bladder function, erectile dysfunction, fever or night sweats, anticoagulant use. Radicular pain, paraspinal tenderness and antalgic gait are not red flags and can be seen following in patients with mechanical back pain as in this case or other non-surgical cases.