🩺 Clinical Assessment of Back Pain: What Really Happens During a Medical Evaluation of Back Pain? 

Back pain is one of the most common reasons people visit their GP or physiotherapist. In fact, it is the third most frequent symptom seen in primary care. While most cases are simple and self limiting, a small percentage may indicate something more serious, so getting the clinical assessment right is essential.
If you’ve ever wondered what actually happens during a professional back pain assessment, this guide walks you through the full process, step by step.

🔍 Why Clinical Assessment Matters: Back pain has a wide range of possible causes, from simple mechanical strain to nerve root irritation or, rarely, serious underlying disease. A structured assessment helps clinicians:
•     Identify the likely cause of pain
•     Rule out serious pathology
•     Guide appropriate treatment
•     Predict recovery and risk of chronic pain
This structured approach is known as diagnostic triage.

 🧭 Diagnostic Triage - The Foundation of Back Pain Assessment: Clinicians begin by placing patients into one of three key categories:
1. Simple Mechanical Back Pain (most common)
Pain varies with movement and posture, usually localised to the lower back, sometimes referring to the buttocks or thighs.
2. Nerve Root Pain (sciatica-type symptoms)
Pain radiates below the knee, often sharp or shooting, following a dermatomal pattern.
3. Possible Serious Pathology (red flags)
Rare, but essential to identify early; includes infection, fracture, cancer, or systemic disease.

🚩 Understanding “Flag” Systems in Back Pain
Clinicians use a colour‑coded “flag” system to identify risks and barriers to recovery:

These flags help shape both diagnosis and long‑term management.

🗣️ The Patient History: The Most Important Step
A detailed history often provides more clues than any scan or test. Clinicians ask about:
Pain characteristics
•     Location
•     Onset
•     Radiation (e.g., down the leg)
•     What makes it better or worse
Red flag symptoms
•     Unexplained weight loss
•     Fever
•     Trauma
•     Night pain
•     History of cancer
•     Neurological symptoms
Psychosocial factors
Using structured prompts (e.g., the CERTIFICATE framework), clinicians explore mood, coping strategies, work issues, and expectations.

4. 👀 Physical Examination: What the Clinician Looks For...
The physical exam is systematic and includes several components.

A. General Observation
Before the patient even sits down, the clinician notes:
•     Gait abnormalities
•     Posture (e.g., sciatic tilt, kyphosis)
•     Pain behaviours
•     Muscle spasm

B. Standing Examination
Key assessments include:
•     Identifying the exact location of pain
•     Checking for deformities (e.g., scoliosis, spondylolisthesis)
•     Schober’s test for lumbar flexibility
•     Heel and toe walking to assess nerve root strength
•     Basic neurological screening

C. Supine Examination
This part helps differentiate hip pathology, nerve root irritation, and mechanical causes.
Straight Leg Raise (SLR) Test
A classic test for nerve root irritation (e.g., disc prolapse).
Pain reproduced in the leg—not the back—within the first 30° is significant.
Neurological Testing
•     Motor strength (L2–S1)
•     Sensation (dermatomal patterns)
•     Reflexes (knee and ankle)
Crossed SLR
Pain on the opposite side suggests a large disc prolapse.

D. Prone Examination
Includes:
•     S1 strength testing
•     Femoral stretch test (L3 nerve root)
•     Ankle reflex assessment

E. Palpation
Although often nonspecific, palpation may reveal:
•     Step deformity (spondylolisthesis)
•     Localised vertebral tenderness (possible infection or fracture)
•     Widespread tenderness (possible abnormal illness behaviour)

5. 🧪 Investigations: When Are Scans or Blood Tests Needed?
Most patients do not need imaging.
Investigations are reserved for those with red flags or persistent symptoms.
Blood tests may include:
•     Full blood count
•     ESR/CRP
•     PSA (men)
•     Bone profile
•     Immunoglobulin electrophoresis
Imaging options:
•     X‑ray (suspected fracture)
•     MRI (nerve root compression, infection, tumour)
•     CT scan
•     Bone scan

6. 🧠 The Biopsychosocial Model: Looking Beyond the Spine
If pain persists beyond six weeks, clinicians assess:
•     Mood and depression
•     Fear‑avoidance beliefs
•     Work‑related stress
•     Coping strategies
Standardised tools such as the Oswestry Disability Index, Fear Avoidance Beliefs Questionnaire, and pain drawings help track progress.

🏁 Final Thoughts: A Holistic, Evidence‑Based Approach
A clinical assessment for back pain is far more than a quick physical exam. It’s a structured, evidence‑based process that considers:
•     Physical findings
•     Neurological signs
•     Psychosocial factors
•     Risk of serious disease
This comprehensive approach ensures patients receive the right diagnosis, the right treatment, and the best chance of recovery. If you're experiencing back pain, understanding this process can help you feel more informed and confident when seeking care.

Disclaimer: Please note that all spinal disorders are different. If you have any concerns about using any of the products discussed, a medical practitioner who knows your specific condition should be consulted. 

 VertiBaX Education