Dr. Singh Teaches the Exam of Low Back Pain and Hip Pain

May 13, 2014

At the last Stanford 25 session, Dr. Baldeep Singh taught the exam of low back pain and hip pain. Dr. Singh is the Clinical Chief of the Stanford Internal Medicine Clinic. Below are some take-home points for the session.

When a patient complains of lower back pain, buttock pain, hip pain, etc, the physical exam should focus on the following “zones”:

Use the “one finger rule”, i.e. use one finger to point to the pain.

Anterior Zone –
1) anterior superior iliac crest (enthesitis)
2) True “hip pain” is typically localized to the groin (i.e. OA of the hip, femoral-acetabular syndrome)

Lateral Zone – greater trochanter bursitis
Posterior Zone – SI joint disease, lumbar radiculopathy
Posterior Lateral Zone – Piriformis syndrome

More Take-home Points:

  • Ask your patient to undress every time to enhance your exam & look for scars, atrophy, erythema, or rash (i.e. Zoster), and do a thorough neurologic exam in back pain particularly focusing on L4-S1 weakness or numbness (95% of disc diease).
  • For back pain, gait may help to localize root nerve cause: Direct patient to walk across exam area and back; inability to walk on one’s toes may reflect significant S1 weakness. Inablity to walk on one’s heels may reflect significant weakness L5.
  • Use the FABER (Flesion, abduction, external rotation of leg) to elicit pain from sacroiliitis (SI joint disease).
  • Strike or percuss axially either the heels or patella to elicit hip pain response; positive pain response can suggest stress fracture.
  • Always check for saddle numbness or rectal tone on admitted patient for back pain to rule out cauda equina syndrome or myelopathy.

Write-up by Tanya Kailath, NP

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