Physical Examination of Back Spine

Last updated: February 8, 2026Reviewed date: February 8, 2026Reading time: 5 min read
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Article Summary

Physical examination of the back spine should be completed in all patients with low back pain. A systematic approach to the physical examination is crucial to the correct diagnosis and treatment of the patient and could significantly affect the potential outcome. A complete examination of the lumbar spine should include the following: inspection, palpation, range of motion, flexibility, muscle strength, sensory examination, reflexes, provocative maneuvers,...

Key Takeaways

  • This article explains Introduction in simple medical language.
  • This article explains Inspection in simple medical language.
  • This article explains Palpation in simple medical language.
  • This article explains Range of Motion in simple medical language.
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Definition

Physical examination of the back spine should be completed in all patients with . A systematic approach to the physical examination is crucial to the correct and treatment of the patient and could significantly affect the potential outcome. A complete examination of the should include the following: inspection, palpation, range of motion, flexibility, muscle strength, sensory examination, reflexes, provocative maneuvers, as well as an examination of gait. One must remember that the physical examination should always be used as an adjunct to a patient’s history, and together they should guide the development of a and treatment plan.

Introduction

Follows the IP-PASS examination methodology

  • Inspection
  • Palpation
  • Passive Range of Motion
  • Active Range of Motion
  • Strength & Neurovascular
  • Special Tests

Inspection

  • Skin
    • Color: , ecchymosis, white, black
    • Trophic changes (altered hair growth, sweat production)
    • Scars
  • Muscle tone: ,
  • Deformity: asymmetry, rotation,
  • Areas of emphasis for back exam
    • Evaluate for lordosis, ,
    • Leg length discrepancy
    • Overall posture

Anterior inspection – With the anterior inspection, the examiner must begin with the head. The position of the head should be symmetrical on the shoulders. The shoulders are usually equal in height; although in many people, especially overhead athletes, the dominant shoulder is slightly lower. The anterior superior iliac spine, the iliac crest, and the greater trochanter should be equal in height. The patellas should also be equal in height and face anteriorly. Examiner should identify genu valgus/varus. The medial malleoli should also be equal in height. The clinician should look for varus/valgus deformity of the forefoot and prone/supine position of the feet and note the foot arch.

Posterior inspection – Posterior observation is the most crucial aspect of inspection in patients with LBP. The symmetry of the head and shoulder height should be reexamined in this plane (Fig. 79.1). Scapular symmetry is assessed. The spine of the is normally at the T3 level. The inferior angle of the scapula is at the level of T8. The clinician should assess the symmetry of the scapula at these levels. The distance of the inferior angle of the scapula from the spine is also noteworthy. With the inspection of the spine, the clinician should search for tissue asymmetry, signs of , or erythema. The spinal column should be evaluated for signs of scoliosis. Asymmetrical paraspinal fullness is also clinically significant and should be noted. The waistlines should be equal in height. Iliac crests should be symmetrical Gluteal folds, popliteal creases, and medial malleoli should also be symmetrical bilaterally. The Achilles and the heels should be midline

Lateral inspection – With an examination of the patient in the coronal plane, alignment of the ear, the shoulder, and the peak of the iliac crest are assessed. The spine is generally in lordosis. An increased lumbar lordosis could be a sign of , weak hip extensors, or a hip flexor contracture. A flattened lumbar lordosis could be a sign of disc herniation or low .

Palpation

  • Palpate for
    • Effusion
    • Clicking
    • Snapping
    • Crepitus
    • Temperature
    • Masses
  • Areas of Emphasis
    • Midline tenderness
    • Stepoffs
    • Sacroiliac joint

Range of Motion

    • Flexion: 80 from neutral
    • Extension: 30 from neutral
  • Lumbar
    • Flexion: 40-60 from neutral
    • Extension: 20-35 from neutral
    • Rotation: 45 from neutral
    • Lateral Flexion (side bending): 25 degrees from neutral

Strength

  • Motor examination
    • Should include examination of intrinsic back muscles and lower extremities
  • Back
    • Extension: Erector Spinae Muscles, Multifidus
    • Lateral Flexion (side bending): Erector Spinae Muscles, Quadratus Lumborum
    • Rotation: Multifidus
    • Flexion: Rectus Abdominis, Internal obliques, External Obliques
  • Hip
    • Hip Flexion (L2, L3): Iliopsoas
    • Hip Adduction (L2, L3): Gracilis, Obturator Externus, Adductor Brevis, Adductor Longus and Adductor Magnus
    • Hip Extension (L5): Gluteus Maximus, Biceps Femoris, Semitendinosus, Semimembranosus, Adductor Magnus
    • Hip Abduction (L5): Gluteus Medius, Gluteus Minimus, Tensor Fasciae Latae
  • Knee
    • Knee Extension (L3, L4): Rectus Femoris, Vastus Lateralis, Vastus Medius, Vastus Intermedius
    • Knee Flexion: Biceps Femoris, Semitendinosus, Semimembranosus, Gracilis, Sartorius, Gastrocnemius, Popliteus
  • Ankle
    • Dorsiflexion (L4, L5): Tibialis Anterior
    • Plantarflexion (S1): Gastrocnemius, Soleus, Peroneal Muscles
    • Eversion (S1): Peroneal Muscles
    • Inversion (L5): Tibialis Posterior
  • Foot
    • Toe Dorsiflexion (L5): Extensor Hallucis Longus, Extensor Digitorum Longus
    • Toe Plantarflexion (S2): Flexor Hallucis Longus, Flexor Digitorum Longus

Neurovascular

Dermatomes of the lower extremity[1]
  • Sensory Nerves
    • L1: Iliac crest,
    • L2, L3: Anterior and inner thigh
    • L4: Lateral thigh, anterior knee, medial leg
    • L5: Lateral leg, dorsal foot
    • S1: Posterior Leg
    • S2: Plantar foot
    • S3, S4: Perianal
  • Dermatomes (see image)
    • Knee: L3/L4
    • : S1/S2
  • Reflexes
    • Commonly Used
      • Patellar (L3, L4)
      • Achilles (S1, S2)
    • Uncommonly Used
      • Medial Hamstring (L5, S1)
      • Lateral Hamstring (S1, S2)
      • Posterior Tibial (L4, L5)
      • Cremasteric (L1, L2)
      • Anal wink/ bulbocavernous (S2)
  • Myotomes
    • L2: Hip Adduction, Hip Flexion
    • L3: Knee Extension, Hip Adduction, Hip Flexion
    • L4: Knee Extension, Dorsiflexion
    • L5: Hip Abduction, Hip Extension, Toe Dorsiflexion, Foot Inversion, Dorsiflexion
    • S1 Foot Version, Plantarflexion
    • S2: Toe Plantar Flexion
    • S3: Bowel, function
    • S4: Bowel, bladder function
  • Vascular
    • Femoral
    • Popliteal Artery
    • Dorsalis Pedis Artery
    • Posterior Tibial Artery

Special Tests

  •  ()
    • Straight Leg Raise Test
    • Kemp Test
  • Herniated Nucleus Pulposus
    • Femoral Nerve Tension Test
    • Straight Leg Raise Test
    • Slump Test
  • Facet Joint
    • Kemp Test
    • Kemp Test
    • Straight Leg Raise Test
  • Sacroiliac Joint Pain
    • Stork Test
    • Standing Flexion Test
    • One Legged Hyperextension
    • FABER Test
    • Posterior Shear Test
    • Resisted Abduction Test
    • Sacroiliac Distraction Test
    • Sacroiliac Compression Test
    • Gaenslens Test
    • Fortins Sign
    • Cranial Shear Test
    • Sacral Thrust Test
    • Active Straight Leg Raise Test
  • Spondylolysis
    • One Legged Hyperextension
  • Spondylolisthesis
    • One Legged Hyperextension
    • Provocative Walking Test
  • Ankylosing Spondylitis
    • Schobers Test
    • FABER Test
  • Sacral Stress Fracture
    • FABER Test
    • Flamingo Test
    • Gaenslens Test
    • Squish Test
  • Cauda Equina Syndrome
    • Bulbocavernous Reflex
  • Scoliosis
    • Adams Forward Bend Test
  • Upper Motor Neuron Lesion
    • Babinski Test
  • Spinal Cord Injury, Spinal Shock
    • Bulbocavernous Reflex
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Doctor visit helper

Prepare before seeing a doctor

A simple rural-patient checklist to help you explain symptoms clearly, ask better questions, and avoid unsafe self-treatment.

Safety note: This is not a prescription or diagnosis. For severe symptoms, pregnancy danger signs, children with serious illness, chest pain, breathing difficulty, stroke-like weakness, or major injury, seek urgent care.

Which doctor may help?

Orthopedic doctor, spine specialist, neurologist, or physiotherapist depending on severity.

What to tell the doctor

  • Mark pain area and whether pain travels to leg.
  • Write numbness, weakness, bladder/bowel problem, fever, injury, or night pain if present.
  • Bring previous X-ray/MRI and medicine list.

Questions to ask

  • Is this muscle pain, disc problem, nerve pressure, arthritis, infection, or another cause?
  • Do I need X-ray or MRI now?
  • Which activities should I avoid and which exercises are safe?
  • When can I return to work?

Tests to discuss

  • Spine and neurological examination
  • Straight leg raise or similar nerve tension tests
  • X-ray if trauma/deformity/chronic pain is suspected
  • MRI if leg weakness, sciatica, or red flags are present

Avoid these mistakes

  • Avoid heavy lifting, long bed rest, and untrained spinal manipulation.
  • Avoid NSAIDs if ulcer, kidney disease, blood thinner use, pregnancy, or allergy unless doctor says safe.

Medicine safety and first-aid guide

This section is for patient education only. It does not replace a doctor, pharmacist, or emergency care.

Safe first steps

  • Avoid heavy lifting, sudden bending, and prolonged bed rest.
  • Use comfortable posture and gentle movement as tolerated.
  • Discuss physiotherapy, X-ray, or MRI only when clinically needed.

OTC medicine safety

  • For mild back pain, pain-relief medicine may be discussed with a doctor or pharmacist.
  • Avoid repeated painkiller use if you have kidney disease, stomach ulcer, uncontrolled blood pressure, or are taking blood thinners.

Avoid these mistakes

  • Do not start antibiotics without a proper medical decision.
  • Do not use steroid tablets or injections casually for quick relief.
  • Do not delay emergency care because of home remedies.

Get urgent help if

  • Back pain with leg weakness, numbness around private area, loss of urine/stool control, fever, cancer history, or major injury needs urgent care.
Medicine names, dose, and timing must be decided by a qualified clinician or pharmacist after checking age, pregnancy, allergy, other diseases, and current medicines.

For rural patients and family caregivers

Patient health record and symptom diary

Write your symptoms, medicines already taken, test results, and questions before visiting a doctor. This note stays on your device unless you print or copy it.

Doctor to discuss: Orthopedic / spine specialist, physical medicine doctor, or qualified clinician
Tests to discuss with doctor
  • Neurological examination for leg power, sensation, reflexes, and straight leg raise
  • X-ray only if injury, deformity, long-lasting pain, or doctor suspects bone problem
  • MRI discussion if severe nerve symptoms, weakness, bladder/bowel problem, or persistent symptoms
Questions to ask
  • What is the most likely cause of my symptoms?
  • Which warning signs mean I should go to emergency care?
  • Which tests are really needed now?
  • Which medicines are safe for my age, pregnancy status, allergy, kidney/liver/stomach condition, and current medicines?
  • Is physiotherapy, posture correction, or activity modification needed?

Emergency warning signs such as chest pain, severe breathing difficulty, sudden weakness, confusion, severe dehydration, major injury, or loss of bladder/bowel control need urgent medical care. Do not wait for online information.

Safe pathway to proper treatment

Care roadmap for: Physical Examination of Back Spine

Use this simple roadmap to understand the next safe steps. It is educational and does not replace examination by a doctor.

Go to emergency care if you notice:
  • Severe or rapidly worsening symptoms
  • Breathing difficulty, chest pain, fainting, confusion, severe weakness, major injury, or severe dehydration
Doctor / service to discuss: Qualified healthcare provider; specialist depends on symptoms and examination.
  1. Step 1

    Check danger signs first

    If danger signs are present, seek emergency care and do not wait for online information.

  2. Step 2

    Record the symptom story

    Write when symptoms started, severity, medicines already taken, allergies, pregnancy status, and test results.

  3. Step 3

    Visit a qualified clinician

    A doctor, nurse, or qualified healthcare provider can examine you and decide which tests or treatment are needed.

  4. Step 4

    Do only useful tests

    Do tests after clinical assessment. Avoid unnecessary tests, random antibiotics, or repeated medicines without diagnosis.

  5. Step 5

    Follow up and return early if worse

    If symptoms worsen, new warning signs appear, or treatment is not helping, return for review quickly.

Rural patient practical tips
  • Take a written symptom diary and all previous prescriptions/test reports.
  • Do not hide medicines already taken, even herbal or over-the-counter medicines.
  • Ask which warning signs mean urgent referral to hospital.

This roadmap is for education. A real diagnosis and treatment plan requires history, examination, and clinical judgment.