Diagnostic Approach to Back Pain
Back pain is one of the most common chief complaints you'll see in primary care—and one where it's easy to wonder whether you're missing something serious or ordering testing that isn't actually necessary.
The key is having a systematic way to work through it: screen for red flags first, consider whether the pain could be coming from something other than the musculoskeletal system, perform a focused exam, and then decide whether the patient needs imaging, further evaluation, or conservative management.
In this episode, I walk through my approach to evaluating low back pain in primary care, including the history questions I ask, the red flags I don't want to miss, my focused physical exam, when I consider imaging, and how I set expectations for recovery.
2026 Update: The overall triage-based approach to low back pain in this episode is still one I use and teach today. A few points about imaging and escalation are worth clarifying:
Trauma doesn't automatically require imaging. Consider the mechanism of injury, fracture risk factors, exam findings, and clinical suspicion when deciding whether imaging is indicated.
Routine imaging isn't recommended for uncomplicated low back pain without red flags or another specific indication. When imaging is needed, the type of imaging should be based on the suspected pathology.
Suspected cauda equina syndrome requires urgent/emergent evaluation and MRI. Concerning findings include urinary retention or new urinary/fecal incontinence, saddle anesthesia, and severe or progressive lower-extremity neurologic deficits.
For a current point-of-care approach to evaluating back pain, including red flags, focused exam, imaging considerations, and next steps, see the Back Pain Cheat Sheet in the Digital NP Binder.
Listen
Watch
What I Cover in This Episode:
A triage-based approach to evaluating low back pain
History questions that help narrow the differential
Red flags for cauda equina syndrome and other serious causes of back pain
Considering non-musculoskeletal causes of back pain
What to include in a focused physical exam
Straight leg raise, FABER testing, and lower-extremity strength testing
When imaging may—or may not—be appropriate
Physical therapy and setting realistic expectations for recovery
Key Takeaways
Start by Looking for What You Can't Miss
Before assuming low back pain is musculoskeletal, screen for serious neurologic compromise, fracture, infection, malignancy, and non-musculoskeletal causes suggested by the history and presentation.
Ask Specifically About Cauda Equina Symptoms
Don't just ask whether the patient has “bowel or bladder problems.” Ask specifically about new urinary retention or incontinence, bowel dysfunction, saddle anesthesia, and new or progressive lower-extremity weakness or neurologic deficits. Suspected cauda equina syndrome requires urgent/emergent evaluation and MRI.
Remember: Back Pain Isn't Always Coming From the Back
Consider whether the presentation could reflect another process, such as pyelonephritis, abdominal or pelvic pathology, or vascular disease, based on the location, associated symptoms, and risk factors. The episode specifically makes this distinction rather than treating all back pain as mechanical.
Use the Exam to Narrow Your Differential
Your exam should be driven by what you're considering. Depending on the presentation, that may include spinal and muscular palpation, neurologic testing including strength and sensation, straight leg raise, hip assessment/FABER, abdominal exam, or other targeted examination.
Most Uncomplicated Low Back Pain Doesn't Need Immediate Imaging
Don't order an X-ray or MRI simply because a patient has back pain. Imaging should be driven by red flags, concern for specific underlying pathology, or other clinical indications.
Set Expectations for Recovery
For uncomplicated musculoskeletal low back pain, help patients understand that improvement may take time. Discuss activity, appropriate conservative management, physical therapy when indicated, follow-up, and the symptoms that should prompt earlier reassessment.
Want Low Back Pain Quick References?
The Back Pain Cheat Sheet gives you a quick, step-by-step approach to evaluating back pain—including red flags, the focused exam, imaging considerations, and next steps. Get your copy inside the Digital NP Binder.
And if you want help making sure you ask and document the important history questions during the visit, the Quick Text Library includes a customizable Low Back Pain HPI QuickText you can add to your EHR. Check out the Quick Text Library here.
Resources mentioned in this episode:
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Hey there, welcome to the Real World NP podcast.
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In this week's episode, I'm going to be talking to you about back pain.
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So back pain as a chief complaint in primary care is so, so common.
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So I'm going to be talking about the approach to diagnosis and the initial management steps
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and definitely covering the red flags.
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So with back pain, it is like one of the most common chief complaints in primary care.
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I really use a triage based approach, which is basically the way that I approach
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everything.
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If you've been following me for a little bit, you know it's coming.
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So whenever it comes to back pain, it's a triage based approach.
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And I have a systematic approach to seeing that patient, any patient with any chief
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complaint of basically any kind, like a symptom based visit.
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So I use an old cart acronym, onset, location, duration, characteristics, et cetera, et cetera.
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And then again, the hacked way to do this, if you're not super comfortable with all
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the differential diagnoses is to pick that ROS system that works for that, you
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know, chief complaint and asking all of the questions.
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One thing that is super helpful for common chief complaints like this that can be
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stressful to work up, especially because it's so common and patients usually want
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something that's not indicated for them, is having a quick text HPI that you
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can put in your EHR so that you can remember what questions to ask that are
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specific to back pain.
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So again, old cart ROS specific to low back pain, low back pain in
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particular. So the triage based approach is first
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questions first, is this traumatic or is it not traumatic?
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Did you have a fall? Did you have a car accident?
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What is the risk here for some sort of fracture?
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Because those patients get imaging near like that's like included if you have
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a trauma related back pain, especially if it's under four weeks.
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Again, that's the that's the first question.
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Traumatic or non-traumatic?
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The second question is how long ago did this start?
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And it says acute or chronic, acute, subacute or chronic.
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And again, I always ask this in every visit, but is it better, worse or the
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same? Right. Those are just my anchoring kind of like everyone gets that
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question. Tell me where we're at.
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Right. I just cut to the chase for the next part, which are the red flag
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questions. And so the things you're trying to elicit, number one, whenever
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it comes to back pain, are there any signs of a cauda equina syndrome?
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So do you have any numbness or tingling in your pelvic area?
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These can be tricky questions to elicit, but what you're trying to
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understand is do they have sensation of their pelvic floor area?
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Is it numb? Like when they wipe, for example, when they go to the
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bathroom, like that's one way to ask that question.
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Do you have any bowel or bladder disturbances?
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Which, again, you really have to get into that question because
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patients don't really know what that means.
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It has to do with urinary retention or incontinence, either one of those.
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Basically, like with cauda equina syndrome, you lose innervation to the
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bladder, and so it gets full and full and full until you have a sudden
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loss of continence because the bladder is over full.
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So, for example, I was a patient with not cauda equina syndrome, but
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something that really scared me into thinking that it was that.
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And they actually did a bladder scan in the ER and they were like,
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oh, no, you're actually fine.
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Like you can wait, you probably need some imaging, but you can
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wait because of that phenomena.
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But anyway, that's neither here nor there, but that's what we're
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trying to elicit with bowel or bladder dysfunction.
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The other thing that is an indicator for cauda equina is loss of
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neurologic function of the lower extremities, potentially, you know, or
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just you just want to ask that in general, if it's it may not
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necessarily be related to cauda equina, but do you have any loss
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of sensation in your lower extremities?
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Do you have any weakness?
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And again, objective and subjective weakness, because sometimes
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people have back pain and they can't lift their leg because
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it like hurts their back versus can they try to do something and
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then they can't, right?
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So those are kind of like the tricky eliciting questions you have
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to get for that history specific question.
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A couple of other red flags that you want to think about are that's
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primarily for cauda equina, saddle anesthesia, bowel or bladder
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incontinence, weakness, numbness, loss of function, et cetera.
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The other kind of general red flag you want to watch out for are
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like, what are the other things that could potentially, that
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could be felt in the back, but are not necessarily like a
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musculoskeletal back problem.
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So that's something like a pylonephritis, you know, do they
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have a high fever, nausea, vomiting, chills, et cetera, other
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symptoms of PILO and do they have like a sudden onset of a tearing,
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splitting pain like AAA, you know, that's really uncommon in
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primary care, but just, you know, one thing to keep in your
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mind that you can definitely feel it in the back.
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And again, do you have, is it like mid back, lower back?
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I'm specifically talking mostly about lower back in the
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situation, but you can have other visceral organ pain that
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transmits to the back.
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Like you have cholecystitis, choleothiasis, pancreatitis,
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things like that.
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And then the only other kind of red flag diagnosis that you
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kind of have to work backwards a little bit.
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It doesn't necessarily have like a hallmark symptom, but you can
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have metastatic cancer to the spine.
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So any history of cancer is really important.
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The patient's risk factors, including their age, things like
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that are important to consider.
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So there aren't necessarily again, hallmark symptoms in
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the HPI that you're getting that are related to that, but
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that's just something you want to keep in mind.
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Again, you want to think about fractures, trauma, and
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then epidural abscess can happen, especially again, what
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are your risk factors?
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Is there any IV drug use, like things like that, osteomyelitis,
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like those are like the main red flag differentials and
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symptoms to watch out for.
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So again, traumatic or non-traumatic, when was the
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onset, is this acute, subacute, or chronic?
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And then what are those red flags?
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Just asking all those red flags, again, making a quick
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text so that you don't forget, right?
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And then the next steps in terms of like the next steps
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really depend on the history, right?
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Is it something that hurts when they move?
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Is it there all the time?
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Does it come and go?
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Is it helped with medications, things like that?
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So when it comes to the physical exam, you're looking
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for, you're keeping all of those things in mind.
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So what are the, or what are the body systems that
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could be contributing to this back pain?
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Most of the time in primary care, it's musculoskeletal.
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So it's either related to bone, related to muscle.
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It could be visceral organs, right?
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It could be pylonephritis, pancreatitis, cholecystitis,
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et cetera, any of those things.
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So you want to do your physical exam.
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You want to palpate the spine.
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You want to observe the area.
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You want to do an abdominal exam.
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You want to palpate the muscles.
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One of the things that I found a little bit tricky to learn when I was a
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newer clinician was about muscle spasm and what it feels like muscle spasm
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and what does not, is there any point tenderness on the spine itself?
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And then the other tests, and again, you want to look at the skin,
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like all that other stuff, CVA testing, if you're concerned about
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like a pylonephritis, if they have concordant symptoms, et cetera.
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And then the other thing you want to test are specific
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to musculoskeletal back pain.
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So you want to do that straight leg test, straight leg raise test.
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And you're trying to see, is it pain in the back, pain down the leg,
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numbness or tingling down the leg, and at what degree of flexion
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that you're bringing the leg up as they're laying down.
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If they're capable of doing that, if they're in too much pain,
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then, you know, you do your best.
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The other thing to assess when they're laying flat
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is the Faber test, that Patrick's test.
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It's, I think it's fader and faber.
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I always say those wrong, but anyway, you're assessing for the hips, right?
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So it's, it could be the spine or it could be referred pain
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from hip related etiologies.
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And so that's, I can link to that down below this video, but it's faber.
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So it's that figure four test.
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You probably learned about that in school.
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Anyway, you can look at that down below.
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And then always doing strength testing.
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So I use the back of, again, these are little pearls, but I
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use the back of my hand, because this is a more, hand to the body
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is a much more intimate touch than the back of the hand to the body.
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And so I just prefer to do that any time I'm assessing a patient,
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unless it's really important that I'm using the front of my hand
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and the front of my fingers.
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So especially if I'm assessing their leg strength, I'm putting
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the back of my hand onto their leg and they're lifting up,
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they're pushing down, they're kicking out, their dorsal flexing.
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Is that right?
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They're flexing their feet, whatever word I'm supposed to use there.
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The pointing and flexing of the feet, all of those things.
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And you're assessing that from a level of one to five.
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Most of the time in primary care, this is a chronic musculoskeletal chief complaint.
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However, you're doing your due diligence to look at all the other things.
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The main reasons to get imaging is if you're suspecting something
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like osteoarthritis, any sort of, you know, risk for cancer.
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Do they, we want to look if there's any lesions on the
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spine itself with an x-ray, or if they've had trauma.
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However, the next thing to consider is if they have any of those
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symptoms of caudioquina, definitely number one, get a
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supervisor involved.
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They probably need an MRI or if they have neurologic deficits of any kind,
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potentially like plus or minus, like take that with a grain of salt.
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But I think that's like, if that's, this is like an entry point,
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pearl of practice is that I see a lot of new grads who follow an algorithm
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and they go one, two, three, four.
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And that's great because algorithms are beautiful.
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And also just being cautious about the tests that we're ordering when and why.
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So take that all with a grain of salt.
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And I definitely recommend, if you're thinking, Hey, I might need an MRI,
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pause, ask somebody, do a little bit more reading and see if it's justified.
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Right?
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Cause I think I'm just trying to give like a high level here and I don't
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want you to be like, Oh, let's tell me to order an MRI.
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So like, let's leave it at that.
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But anyway, the most important thing to remember about x-rays is that you
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need to have a clinical suspicion, trauma, osteoarthritis, worried about a
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lesion of some kind, because most people, we did the, we did a research
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thing about this in grad school.
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I imagine you've done something similar, but those are very low yield tests
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for patients who have musculoskeletal muscle spasms, for example.
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But most patients who come in want an x-ray, but that is very low yield.
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For patients that you are suspecting is a musculoskeletal etiology based
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on your exam in your history, those can take between four to six weeks to get better.
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I always recommend patients seek physical therapy pending there are no red flags
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or other differential etiology potentials in an outside category from
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musculoskeletal because they can do their assessment a lot more sophisticated
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than I can, as well as give treatment recommendations for that patient to
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either do with them in physical therapy or at home.
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And the main thing, definitely, definitely, definitely watch the
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interview I did with the physical therapist.
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If you have not already, um, it is gives just so much wisdom
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about physical therapy itself.
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But one of the kind of like main pearls of that interview is that
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it is our job to set the patients up for success with their expectations
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of seeing physical therapy and their recovery time.
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Personally, when I had that back injury that brought me into the ER,
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it took at least nine weeks, nine to 12 weeks to feel the acute
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phase getting better, despite all the medications, despite the physical therapy.
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It took a long time and the prolonged recovery has taken a lot longer.
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So I just like one little pearl to take away for those musculoskeletal
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back pain people is the setting of expectations and also advising
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them with the red flags that you've already asked about,
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because if it gets worse, they know to come back.
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But that's the moral of the story with low back pain approach
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to assessment, diagnosis and kind of like first steps.
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So that's our episode for today.
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If you haven't grabbed the ultimate resource guide for the new NP,
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head over to realworldnp.com slash guide.
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You'll get these episodes and trace your inbox every week
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with notes from me, patient stories and bonuses.
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I really just don't share anywhere else.
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Thank you so very much for watching.
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Hang in there and I'll see you soon.
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That's our episode for today.
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Thank you so much for listening.
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Make sure you subscribe, leave a review and tell all your NP friends.
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So together we can help as many nurse practitioners as possible,
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give the best care to their patients.
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If you haven't gotten your copy of the ultimate resource guide
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for the new NP, head over to realworldnp.com slash guide.
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00:12:50.530 --> 00:12:53.830
You'll get these episodes sent straight to your inbox every week
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00:12:53.830 --> 00:12:57.350
with notes from me, patient stories and extra bonuses.
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I really just don't share anywhere else.
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Thank you so much again for listening.
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Take care and talk soon.
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