This document provides a summary of examination findings and differential diagnoses for a patient presenting with low back pain. Key examination findings included limited range of motion of the lumbar spine, diffuse tenderness over the lumbar paraspinals and bilateral greater trochanters/SI joints, and normal strength and sensation tests. The document then reviews gait, provocative tests, and muscle grading to further evaluate the patient. Common differential diagnoses for low back pain are listed, along with descriptions of relevant anatomy and neurological patterns.

2.  The exam is where you have a chance to
narrow down your differential
 So what is your differential for Low Back pain?

3.  Lumbar Spondylosis
 Lumbar Spondylolisthesis
 Lumbar Radiculopathy
 Muscle Strain
 Sacroiliitis
 Scaroiliac dysfunction
 Spinal Stenosis
 Spinal tumor
 Cauda Equina
 Glut max tendinosis
 Greater trochanteric bursitis
 Hip OA
 Myositis ossificans

4.  Gait: able to heel and toe walk, gait intact
 ROM: limited AROM of the L spine in all planes
 Motor: 4/5 b/l hip extension and abduction 5/5 strength in the
bilateral lower extremities including
HF,KE, KF,AD, EHL, PF, inversion, eversion
 Sensation: intact to light touch in all dermatomes tested from L2-
S1 bilaterally
 Reflexes: 2+ b/l patella and Achilles, plantar response down
going, proprioception intact
 Palpation: Diffusely tender over lumbar paraspinals -TTP over
the b/l greater trochanters and bilateral SI joint
 Tone: normal in the b/l LEs
 Lymph: no lymphadenopathy at groin or popliteal fossa
 Provacative tests: - SLR, seated root (slump test), Kemp, FABER
testing, FADIR testing, Ely's test to 0 degrees, Ober's negative
bilaterally

5.  Gait Eval
 Look at feet, ankle, and knees
 Heel strike, lat foot, then cross over medially to
big toe off
 Look at shoe wear
 What is trendelenberg ?

6.  Trendelenberg
 Marilyn Monroe
 Weak Glut med
 Hip Abductor
 Sup gluteal N
 L4/L5 S1

7.  Controversial if should do this, can worsen
pain
 Flexion 90 degrees
 Extension 30 degrees
 Lat Bending 30 degrees

8.  Muscle Grading
 5 full strength and full range
 4 less than full strength, full range
 3 against gravity full range
 2 gravity eliminated, full range
 1 twitch
 0 nothing

9.  HE; one of the core muscles
 Range 0-30
 Glut max
 Hamstrings
 How isolate hamstring? Does it matter?
 Glut max prime mover (inf gluteal nerve L5,
S1, S2)
 What is the most common herniation?

10.  HF
 Range 0-125
 Iliopsoas (iliopsoas nerve L2,L3) prime hip
flexor
 Rectus femoris, sartorius (fem nerve L2,L3,L4)

11.  KE
 Range degrees
 Quads (Rectus femoris, vastus lateralis, vastus
intermedius, vastus medialis oblique) femoral
nerve L2/L3/L4

12.  KF
 Range 0-135
 Need greater than 90 degrees to stand up out of
chair
 Hamstrings:
 Semimembranosus (sciatic, tibial portion
L4/L5/S1/S2
 Semitendinosus (sciatic, tibail portion L4/L5/S1/S2
 Biceps Femoris(Long head (sciatic, tibial portion
L5/S1/S2, SHORT head common fibular portion
L4/L5/S1/S2

13.  AD
 Range 0-20
 Tibialis anterior, deep peroneal nerve
L4/L5/S1

14.  EHL does toe extension
 Deep fibular nerve L4/L5/S1

15.  PF
 Range 0-50
 Muscles Gastroc/Soleus primarily S1

16.  Inversion
 Tibialis posterior, tibial nerve L4/L5/S1
 More subtle than AD

17.  Eversion
 Peroneus longus and brevis, superficial fibular
nerve L4/L5/S1

18.  Patient with AD weakness and HE weakness,
where is the lesion?

19.  Dermatomes
 Useful to differential muscle weakness vs nerve
involvement vs myopathy

21.  Lumbar paraspinals
 Consistent with muscle sprain and facet issues

22.  Greater Trochanter
 Bursitis versus gluteus medius tendinosis

23.  SI joint
 SI joint or gluts

24.  What is tone?
 What is spasticity?

25.  What do you rule out here?
 What maneuver’s can you double up on
 Check pop fossa during SLR
 Check groin during FABER

26.  SLR/Seated Root
 Positive from 30 to 70 degrees

27.  Kemp/facet loading

28.  FABER: Flexion/Abduction, External Rotation
 Opp SI joint, or hip pain

29.  Ober’s
 Check’s TFL tightness
 Press on TFL to find tender points which also
signifies tightness
 Found a lot in runners
 Changes running mechanics

30.  FADIR
 Flexion, ADduction, Internal Rotaion

31.  ELY’S test, tests quad tightness
 Causes pelvic tilt
 Putting more stress on facets

32.  Fellows now pair up