history and physical examination of the back cover

Important History and Physical Examination Pearls of Athletic Back Pain

Low back pain is a topic that many professionals in the sports medicine world often feel uncomfortable evaluating and managing. Despite this, it is a common clinical entity that almost everyone, athlete or not, will suffer from at some point in their life. In a 2019 study by Fett et al of 181 elite athletes in overhead sports, prevalence rates of low back pain were reported as 85% lifetime, 75% 12 month prevalence, and 58% 3 month prevalence (Fett et al 2019). In another 2019 study of NCAA athletes from 29 teams over one season, Makovicka et al stated that lumbar spine injuries occurred in 59% of women and 73% of men with men being 1.61 more times likely than women to develop lumbar spine pain. Therefore, it is critical that the sports medicine physician is comfortable with evaluating and managing the athlete with low back pain (Makovicka et al 2019).

Case Vignette

A 23 year old baseball catcher presents to your clinic with acute back pain. He states he was trying to block a play at home plate when he collided with another player. He is having trouble ambulating and has been unable to practice the last few days. Which of the following symptoms should prompt further investigation rather than standard symptomatic management?

A) Pain radiating down the left leg
B) Trouble initiating urination
C) Exquisite tenderness to paraspinal muscles
D) Antalgic gait

As with any clinical evaluation, successful treatment begins with a detailed and appropriate history of the athlete’s presenting problem. Warning signs of neurological or organic disease should be identified and rapidly evaluated if warranted as the athlete could develop irreparable damage or even death in certain situations. See Table 1 for a list of warning signs that could indicate a more concerning diagnosis for the athlete.
red flags in back pain and etiology table

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. 

Important questions include if radicular symptoms are noted by the athlete, the distribution of the radicular symptoms, associated weakness, if there was an associated injury, and maneuvers that provoke or palliate symptoms. Associated symptoms such as numbness and a brief review of the functional impact on the athlete should also be ascertained. It is also important to note the age of the athlete as certain age groups are prone to certain types of injuries, such as avulsion injuries which are common to those younger athletes.

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. 

Range of motion in all lumbar planes of motion should be performed including flexion, extension, right and leftward rotation, as well as sidebending in both directions. Range of motion should also be done of the hip joint. Strength assessment should be done for the lower extremity with details noted of any weakness, including subtle weakness as well as a sensory examination of the dermatomes L2 to S2 region. Bilateral reflexes of the knees and ankles should be performed, rated, and documented of any changes from side to side noted. Table 2 shows a brief review of common special tests that can be helpful in ascertaining the primary cause of musculoskeletal pain of the lumbar spine.
special tests for examining the back
special tests for examining the back

Table 2. Common lumbar spine exam maneuvers

After a proposed diagnosis is obtained, further testing should be done. The most common tests done to evaluate the lumbar spine are reviewed briefly below in Table 3.
table of diagnosis and confirmatory test options for back pain

Table 3. Further evaluation of possible lumbar spine diagnoses

Details regarding the definitive management of individual diagnoses discussed are beyond the scope of this paper. Further future reviews will be performed to discuss management of common individual low back and hip disorders. It is important to note that the lumbar spine and hip region can cause symptoms that cause a confusing clinical picture. Therefore, I commonly implement injections to help strategically decrease pain as well as provide diagnostic information on the primary cause of the patient’s pain. The possible injections utilized are vast and can include the following: epidural steroid injections, steroid injections in the facets, medial branch radiofrequency neurotomy, sacroiliac steroid injection, piriformis injection, lumbar trigger point injections, intraarticular hip injection, iliopsoas injection, and greater trochanteric bursae injections among others. Regenerative medicine options are also reasonable to consider. A future review will discuss further interventional management of lumbar back pain.

Case Conclusion

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.

Verhagen, Arianne P., et al. “Red flags presented in current low back pain guidelines: a review.” European spine journal 25.9 (2016): 2788-2802.

Read More

– More Back Pain from Sports Medicine Review: https://www.sportsmedreview.com/by-joint/back/

– Read More: http://wikism.org/Physical_Exam_Back

Author: Clay Guynn, DO FAAPM&R/Sports Medicine

REFERENCES

1. Alquarni et al. Clinical Tests to Diagnose Lumbar Segmental Instability: A systematic Review. Journal of Orthopaedic and Sports Physical Therapy. March 2011, (23)
2. Physical Medicine and Rehabilitation, Third Edition. Sara Cucharillo.
3. Fett D, Trompeter K, Platen P (2019) Prevalence of back pain in a group of elite athletes exposed to repetitive overhead activity. PLoS ONE 14(1): e0210429. https://doi.org/10.1371/journal.pone.0210429
4. Makovicka, J et al. Epidemiology of Lumbar Spine Injuries in Men’s and Women’s National Collegiate Athletic Association Basketball Athletes. Orthop J Sports Med. 2019. Oct 7(10).
5. Makovicka, J et al. Lower Back Injuries in National Collegiate Athletic Association Football Players: A 5-Season Epidemiological Study. Orthop J Sports Med. 2019, June 18.R
6. Pasic et al. Diagnostic Validity of the Physical Examination Maneuvers for Hip Pathology: A Systematic Review. Orthopaedics and Muscular System: Current Research. 2014.
7. Robroy et al. The Reliability and Validity of Clinical tests used to assess individuals with potential labral tears of the hip. The Journal of Arthroscopic and Related Surgery. 2007, June. (23).