A variety of health care professionals—family physicians, physiotherapists and chiropractors—assess and treat people with back and back-related leg pain. In addition to the four steps described here, your care provider should educate you about back pain and how best to manage your symptoms.
Step One: The clinical history
The health care professional will ask certain key questions about your symptoms.
- Where is the pain the worst?
- Is the pain constant or does it come and go?
- Do any activities and body positions make your symptoms worse or relieve your discomfort?
- How long have you been in pain?
- Where else do you feel the pain?
- What events, actions, or positions might have triggered the symptoms?
This information should provide clues to help plan treatment. (Not all back pain is caused by problems in the spine—other causes include kidney stones, urinary tract infections, and problems affecting the hip.)
The care provider may also ask whether you’re experiencing symptoms such as fever, bowel or bladder problems, weakness or numbness in the legs or elsewhere, and unexplained weight loss. These are questions intended to identify more sinister and much rarer causes of back pain.
Step Two: The physical examination
Your care provider will perform a number of tests while you’re in standing, sitting and lying down. The tests are designed to verify the information obtained from your history. These may include
- tests for movement that reproduce your typical back or leg pain.
- palpation of your back to locate tender areas
- tests for nerve irritation by lifting your leg and checking for your typical leg pain.
- assessing the strength of your leg muscles.
- tests for reflexes and sensation.
- tests for signs of nerve problems higher in your spine.
- tests of sensation in the groin and saddle area.
Step Three: To image or not to image?
Health professionals no longer routinely order X-rays and other imaging tests for people during an episode of back pain. That’s because research shows these tests are not useful and may actually make matters worse by frightening people unnecessarily. There are exceptions to this rule that may cause your care provider to recommend diagnostic imaging. Imaging may be indicated:
- if a fracture is suspected.
- if there is a significant spinal deformity
- if your back or leg pain doesn’t improve with four to six weeks of appropriate physical treatment or continues to worse.
- if there are signs of a more ominous cause for your back pain, such as a continuing fever and extreme local tenderness in your back.
- if there is the suspicion of a specific diagnosis that needs to be identified on an image.
- if surgery is indicated.
What is an X-ray?
X-rays are the oldest and most frequently used form of medical imaging. Modern X-rays use small amounts of radiation to produce images of the human body on film or a computer screen. X-ray imaging is the fastest and easiest way for a physician to view and assess the bones in your spine. It may be indicated in cases of serious trauma where a fracture is suspected.
What is a CT scan?
Computerized tomography (CT) is a series of X-ray “slices” that are interpreted by a computer able to detect slight variations invisible to the human eye. The separate layers are then reconstructed into a full picture – sometimes in 3D. These images can help diagnose specific back problems; including spinal nerve compression, herniated spinal discs, and spinal stenosis (see Three common problems that could lead to back surgery).
What is an MRI scan?
Magnetic resonance imaging (MRI) is another painless and non-invasive way to help doctors ‘see’ structures in the back. It uses a magnetic field and radio frequency pulses that influence the signals produced by hydrogen molecules in the body. These molecules are part of the body’s water so the pictures are really pictures of exactly where the water is located. That makes MRI especially useful in detecting problems with the soft tissues—for example, the soft discs between the vertebrae. It can also help doctors see the anatomy of the spinal cord and the nerves themselves. Many studies have shown that about 90% of people without any back pain or will still show a variety of ‘abnormalities’ on their MRI scans. The MRI is almost too sensitive.
Other diagnostic imaging tests
The following tests are sometimes recommended for people with specific symptoms:
- Electromyelography (EMG)
The test, which involves placing very thin needles into specific muscles, can help locate the source of symptoms, especially pain that radiates from the back down into the leg. EMG measures the electrical activity of muscles and is often performed in conjunction with ‘nerve conduction’ tests measuring activity in the nerves themselves. In some cases of leg pain, the electrical activity of the muscles or nerves is not normal and this information may be useful in making a diagnosis or planning treatment.
- Other invasive diagnostic tests
If there are good reasons to do so, your care provider may recommend other tests to locate the source of your symptoms. These include discography (a dye seen on X-ray is injected into the disc to visualize its internal structure) or selective anaesthetic injections to the nerve roots or facet joints to try and stop (and thereby identify) the source of the pain Such tests are not routine and are used only in certain circumstances, usually when back surgery is being considered.
Step Four: Creating a treatment plan
Your doctor or other health professional will share the results of your examinations and recommend treatment that he or she thinks will relieve your symptoms and help you recover as quickly as possible.
This treatment plan will likely include many of the options listed on this website (see Non-Surgical Interventions and Treatments and When Surgery is an Option).
Based on your history and the examinations your care provider should be able to give you specific advice about managing your symptoms as you recover.
If you decide to take part in ongoing treatment such as manual therapy or acupuncture, you should receive regular, repeated assessments to determine if the treatment is helping you improve.
Finally, it’s important to understand that while taking part in therapy sessions may be useful, they only represents a small portion of your day: for your back and leg symptoms to improve, you must follow instructions about staying active, balancing rest with activity, using specific pain controlling manoeuvres or medication and temporarily avoid movements and positions that trigger discomfort.