Back Examination

By: Mr. Hatim Gamareldin

*You start by introducing yourself, taking permission, and keeping the patient’s
privacy.
*Remember: To expose the back fully, and in each step, compare the left and the
right side.
*Be explicit, express and say what are you going to do, in order to show that you
have the sufficient knowledge regarding the examination maneuvers.

**Positions for the Back examination: Standing > Sitting> Supine.

Standing Position
-Remember: make sure that there is enough space behind the patient before you
start the examination.
-” Confrontation”: after taking permission and asking the patient to stand, you
should stand facing him.
-Rule of Three: I. General examination, II. Gait examination, III. Local
examination.
-Exposure: ideally: the whole back should be exposed.
-Stance: upright, hands by his/her side, knees straightened, and feet together on the
same line.
 I. General examination of orthopedic:
-Rule of Three: 1) Physique (height, weight) 2) shoulders level 3) neck position.

[The general examination of the medicine (4Ds) is not a must here; you could do it
as a completion for your examination.]

“A young gentleman, of average weight/obese/thin, of average height/tall/short,

shoulders are on the same level/one is depressed or elevated, the neck is
central/deviated to one side”.
-Note: Deviation of the neck could be due to: lower limb shortening or spine
deformity.
II. Gait:
(could be done as a part of the neurological examination of the lower limb)
-gait cycle: swing, stance (which is longer, constituting 60%), it is calculated from
one limb.
-How to examine the gait: As the patient walks away from you, observe the limb
and the foot, and as the patient walks towards you, observe his face for pain.
-As he walks towards you look for facial expressions of pain, “Antalgic Gait”.
Another way to assess it is as the patient is walking away you observe the gait
cycle, the stance phase is typically shorter (compensatory mechanism to avoid
pain), and this is the most reliable method as antalgic gait is by definition:
Shortening of the stance phase in response to pain.

III. Local Examination

-You move directly to the back.
*Rule of three: Look, Feel, Move, special tests.
-Look:
-What to look at? Skin, soft tissue, Bone and joints.
1)Skin: Scars, erythema, sinuses, dilated vessels, hypo or hyperpigmentation,
ulcerations, abnormal hair distribution.
 Scar: is it traumatic or surgical (regular, stitch marks, on anatomical plane),
normal or abnormal (hypertrophic, keloid) healing.
 Sinuses: abnormal blind tract extending from the skin and downwards, that
ends with a sac. Presence of it around the joint indicates: chronic Infection
as in chronic osteomyelitis or infection with atypical bacteria (mycobacterial
arthritis).
 You should comment on: is it single or multiple, is active (and describe the
amount and color).

[Note: sinuses are more common in the shoulder.]

 Dilated Veins: it indicates: Compartmental Compression: due to: Swelling or

tumors.
*It is one of the common presenting signs of tumors.
 Hypo/Hyperpigmentation: you need to comment on the size, shape, number,
location.
 Abnormal hair distribution.

2)soft tissue: Paraspinous muscles

 In the back wasting is unlikely, we look for hypertrophy in the paraspinous
muscles. Hypertrophy here indicates: overaction, which happens as a
compensatory mechanism due to abnormal posture. the presence of it should
raise suspicions of disc herniation, in this disease patients take a position that
forces the muscle to take the load off the herniated disc, in order to reduce
the pain, ultimately resulting in hypertrophy.
3)Bone & Joints: Looking for deformity:
-Scoliosis: abnormal lateral curvature of the spine. Signs to look for:
 Skin: Rib hump. where the rib hump goes, this is the site of scoliosis.
Further description for its location (thoracic, lumbar, sacral) is needed. if the
rib hump is in the upper right side of the thoracic spine, this means there is
“Right thoracic scoliosis”.
 Listing: due to the bending, there is a line or a “sulcus” could be present on
the side of scoliosis.
 Scoliosis got different classification: juvenile and adolescent. The adolescent
type is most commonly due to trauma, but could be neurological secondary
to neurofibromatosis type 1, So the presence of Café au lait spots on the
back should raise the suspicion of underlying Neurofibromatosis type 1
leading to scoliosis.

-Move to the lateral aspect to look for kyphosis.

-Feel:
-Before you touch the patient, ask the patient if there is any area of pain.
-we feel for: Temperature, Tenderness, and Spine Step.
 Temperature: over the paraspinous muscles.
 Tenderness: stand by the lateral side of the patient (T-position), hit the whole
spine gently and observe for pain. Or just simply palpate.
 Spine Step: put the ring and index finger on the para-vertebral region and put
the middle finger on the vertebra, then slide your hand to the end of the
back. The step could be visible by inspection, it indicates: Spondylolisthesis
(abnormal forward movement of one vertebra over the one below it, it got
grades, I=25%, II=50%, III=75% (needs surgery), IV=100%), its most likely
post-traumatic due to microfractures.)
-Move:
-Movements of the spine: Flexion/Extension, left lateral flexion (or bending)/Right
lateral flexion (or bending), Rotation (right and left).
 Flexion/Extension: while the patient is standing.
 L & R lateral flexion: Knees and feet should be fixed; hands should be by
the side then ask the patient to slide his/her hands towards their knees.
Normally the hand should reach the knee.
 Rotation: the patient should sit down in order to stabilize the pelvis (as it
will engage in this movement). The part of the spinal column that rotates is
the thoracic (the lumbar spine is very stabilized, held by ligaments and
muscles, so it’s mainly a thoracic movement).

-Special Tests:
*Scoliosis: Could be primary (essential) or secondary (compensatory/functional,
usually due to shortening in the leg).
-in order to differentiate between those two, we do: Adams forward bend test.
1)Adams Forward Bend Test:
-The patient got a rib hump, so you ask the patient to bend > if the back is even,
this means this is secondary scoliosis, secondary to leg shortening.
2)Lumbar Excursion test:
-it tests how extensile the lumbar spine is.
 While the patient is standing, locate the iliac crests, and tell that patient that
you are going to draw on him, we draw a line in between them, and use the
tape to measure 5 cms above it and draw a parallel line. Then ask the patient
to bend. If the increase between the two lines is between 5 -10, it is normal.
 If it’s less than 5 cms, this indicates ankylosing spondylitis.
3)Straight Leg Raising (SLR) test:
-it tests for disc herniation and more precisely for Sciatica.
-it’s a test that is done passively.
-Done while the patient is lying supine.
-we ask the patient to elevate his leg while the knee is extended
 This extension stretches the nerve>leading to pain.
 Normal individuals: will elevate their legs up to 70 degrees pain-free.
 Positive test: painful arc from 30-70 degrees.
 Positive test indicates sciatica or disc herniation.
4)Lasegue Test:
 Done if the SLR test was positive.
 In the same position, we bend the knee, and the pain should be relieved (as
the stretch on the nerve is alleviated).
 Or alternatively, we can dorsiflex the ankle, which in this case will result in
an aggravation of the pain.
5)Femoral Stretch Test:
 Put the patient on the lateral decubitus position, then extend the hip, laying
stretch on the femoral nerve. You should look at the patient’s face.

Lower Limb Neurological Examination

(It’s a must to do here)

*Complete by examining the joint above and the joint below, cover the patient and
thank him.
*Practice it, you won’t learn a skill by reading about it over and over relentlessly.
*Information written here are notes taken by a student, there is a possibility for
errors, if you have doubt in any of the things written here, refer to a valid
reference.