History
Obtain the following key information:
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The mechanism of injury, with an exact description of the event leading to the pain
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The exact localization and duration of the pain
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Any pain radiation
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Movements that aggravate or minimize the pain
Typical symptoms are pain and spasm that are localized over the posterior lumbar spinal muscle bellies lateral to the spinous process or at the insertion of the muscle at the iliac crest.
If the injury is confined to a sprain or strain injury, then structural deformities, a generalized midback pain indicating disc involvement, and neurologic symptoms should be absent.
(See also the Medscape Reference articles Lumbar Disk Problems in the Athlete [in the Sports Medicine section], Lumbar (Intervertebral) Disk Disorders [in the Emergency Medicine section], Lumbar Degenerative Disk Disease [in the Physical Medicine and Rehabilitation section], and Lumbar Disc Disease [in the Neurosurgery section].)
Range of motion (ROM), particularly in flexion, is usually painful and decreased.
Any neurologic compromise, (eg, numbness in the lower extremity, motor weakness) or any urinary or fecal incontinence syndrome indicates the possible presence of disc prolapse, nerve root impingement, or spinal canal stenosis. [14]
(See also the Medscape Reference articles Urinary Incontinence [in the Emergency Medicine section], Fecal Incontinence [in the Obstetrics/Gynecology section], Nerve Entrapment Syndromes of the Lower Extremity [in the Orthopedic Surgery section], Spinal Stenosis [in the Neurosurgery section], and Spinal Stenosis and Neurogenic Claudication [in the Physical Medicine and Rehabilitation section].)
Physical Examination
With the patient in a standing position, evaluate for obvious deformities, changes in alignment, or difficulties in achieving changes in position or full ROM. Evaluation of these signs may provide clues to muscle spasm(s) and activities that worsen the patient's pain.
Palpation of painful area: Palpation, performed with the patient in a prone position, helps to reveal the area and the size of muscle spasm(s) and the location of any point tenderness, if present. A point-specific midline back pain between the spinous processes indicates a ligamentous injury or lumbar interspinous bursitis ("kissing spines").
Neurologic examination: Evaluation of the lower extremities should include a motor examination, a sensory evaluation, and reflex testing at the knees and ankles. The straight-leg raising test helps to evaluate disc involvement, sciatica, or a neurologic deficit. A positive Patrick test points to a sacroiliac joint inflammation, but this test should be negative in lumbosacral sprains and strains. (See also the Medscape Reference article Sacroiliac Joint Injury.)
