Mechanical Low Back Pain Differential Diagnoses

  • Author: Everett C Hills, MD, MS; Chief Editor: Rene Cailliet, MD   more...
 
Updated: Jan 12, 2012
 
 

Differential Diagnoses

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Contributor Information and Disclosures
Author

Everett C Hills, MD, MS  Vice Chair, Department of Physical Medicine and Rehabilitation, Medical Director for Outpatient Services, Penn State Hershey Rehabilitation Hospital; Assistant Professor of Physical Medicine and Rehabilitation, Assistant Professor of Orthopaedics and Rehabilitation, Penn State Milton S Hershey Medical Center and Pennsylvania State University College of Medicine

Everett C Hills, MD, MS is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Physical Medicine and Rehabilitation, American College of Physician Executives, American Congress of Rehabilitation Medicine, American Medical Association, American Society of Neurorehabilitation, Association of Academic Physiatrists, and Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

J Michael Wieting, DO, MEd  Professor of Physical Medicine and Rehabilitation, Professor of Osteopathic Principles and Practices, Director of Program Development, Director of Sports Medicine, Associate Director of Physician Assistant Program, Department of Osteopathic Principles and Practice, Lincoln Memorial University-DeBusk College of Osteopathic Medicine

J Michael Wieting, DO, MEd is a member of the following medical societies: American Academy of Osteopathy, American Academy of Physical Medicine and Rehabilitation, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Osteopathic Academy of Sports Medicine, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, and International Society of Physical and Rehabilitation Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Patrick M Foye, MD  Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society

Disclosure: Nothing to disclose.

Kelly L Allen, MD  Medical Director, Medevals

Disclosure: Nothing to disclose.

Chief Editor

Rene Cailliet, MD  Professor-Chairman Emeritus, Department of Rehabilitation Medicine, University of Southern California School of Medicine; Former Director, Department of Rehabilitation Medicine, Santa Monica Hospital Medical Center

Rene Cailliet, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Pain Society, Association of American Medical Colleges, International Association for the Study of Pain, and Pan American Medical Association

Disclosure: Nothing to disclose.

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Magnetic resonance image of the lumbar spine. This image demonstrates a herniated nucleus pulposus at multiple levels.
Diskogram showing examples of an intact disk and a disrupted disk at the lumbar level.
Sagittal magnetic resonance image showing loss of intervertebral disk height at L5/S1. Herniations of the nucleus pulposus are noted at L4/5 and L5/S1.
Degenerative changes of the lumbar spine, including decreased signal intensity and disk bulging at the L-3/4, L-4/5 and L-5/S-1 disks.
The process of disk degeneration following internal disk disruption and herniation.
The various forces placed on the disks of the lumbar spine that can result in degenerative changes.
Table 1. Functional Muscle Testing
Nerve RootMotor ExaminationFunctional Test
L3Extend quadricepsSquat down and rise
L4Dorsiflex ankleWalk on heels
L5Dorsiflex great toeWalk on heels
S1Stand on toes*Walk on toes (plantarflex ankle)
*When testing the S1 innervated gastrocnemius muscle, the ability to stand on the toes once represents fair (3/5) strength. The patient must stand on his or her toes 5 times in a row to be rated normal (5/5) strength. Note that this approach should allow the physician to detect weakness at a much milder stage than if gastrocnemius strength were assessed only by using the examiner's hand to apply resistance to ankle plantar flexion.
Table 2. Dermatomal Sensory and Reflex Testing
Nerve RootPin-Prick SensationReflex
L3Lateral thigh and medial femoral condylePatellar tendon reflex
L4Medial leg and medial anklePatellar tendon reflex
L5Lateral leg and dorsum of footMedial hamstring
S1Sole of foot and lateral ankleAchilles tendon reflex
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