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Media Gallery

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.

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Author

Everett C Hills, MD, MS Principal Consultant, Function Focused PMR Care+, LLC

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 Association for Physician Leadership, American Congress of Rehabilitation Medicine, American Medical Association, American Society of Neurorehabilitation, Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Patrick M Foye, MD Director of Coccyx Pain Center, Professor of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Chief Editor

Stephen Kishner, MD, MHA Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans

Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Additional Contributors

J Michael Wieting, DO, MEd, FAOCPMR, FAAOE Senior Associate Dean, Professor of Physical Medicine and Rehabilitation, Professor of Osteopathic Manipulative Medicine, Lincoln Memorial University-DeBusk College of Osteopathic Medicine

J Michael Wieting, DO, MEd, FAOCPMR, FAAOE is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Osteopathic Examiners, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, Gold Humanism Honor Society, International Society for Communication Science and Medicine, Michigan Osteopathic Association, Oklahoma Osteopathic Association, Tennessee Osteopathic Medical Association

Disclosure: Nothing to disclose.

Nerve Root	Motor Examination	Functional Test
L3	Extend quadriceps	Squat down and rise
L4	Dorsiflex ankle	Walk on heels
L5	Dorsiflex great toe	Walk on heels
S1	Stand 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.

Nerve Root	Pin-Prick Sensation	Reflex
L3	Lateral thigh and medial femoral condyle	Patellar tendon reflex
L4	Medial leg and medial ankle	Patellar tendon reflex
L5	Lateral leg and dorsum of foot	Medial hamstring
S1	Sole of foot and lateral ankle	Achilles tendon reflex

Mechanical Low Back Pain Questions & Answers

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