How to Conduct a Physical Examination of the Patient with Chronic Pain

Part I of this series introduced the complexities of evaluating patients with chronic pain syndromes, which are among the most common conditions that present to primary care. Here in Part II, we cover useful tips when examining patients with chronic pain. Of course, we cannot cover every possible patient presentation, but the following provides a solid general outline – especially for individuals presenting with low back or musculoskeletal pain.

Pain Exam Pro Tips

In addition to carrying a reflex hammer and tuning fork, we recommend keeping a dermatome chart handy because patients presenting with radiculopathy will have characteristic patterns of pain and deficits.

Individuals with chronic pain may have heightened sensitivity, so proceed with gentle palpation and movements. Explain procedures and findings clearly to the patient and be mindful of exacerbating pain during examination.

The physical examination of a patient who has chronic pain involves several key steps to assess their condition comprehensively. From a documentation standpoint, recorded findings should include specific areas of tenderness, limitations in range of motion, sensory deficits, and any positive special tests. A more detailed/comprehensive musculoskeletal exam may be less important for a patient with an abdominal visceral pain syndrome. It is also key to keep the cardiovascular and pulmonary exam limited unless otherwise indicated. Below is a recommended structured approach.

General Evaluation

Appearance and Behaviors

Note general appearance, signs of distress, or abnormal postures or gait patterns. Observe and document excessive somnolence/narcosis that may be related to CNS depressant medications. Notable characteristics such as pallor, jaundice, and cachexia may signal an underlying malignancy.

Observe how the patient moves, including any guarding or difficulty in certain movements. Look for exaggerated behaviors that may be suggestive of Waddell’s sign, which can help to detect possible feigning of symptoms or nonorganic components to lower back pain.

Vital Signs

Assessing vital signs is crucial, particularly for tachycardia and tachypnea, which can indicate acute or heightened chronic pain.

The exam should include measuring:

blood pressure
heart rate
respiratory rate
pulse oximetry, if available
temperature, if needed

Ask the patient about use of NSAIDs, as these medications can elevate blood pressure in both normotensive and hypertensive individuals.

HEENT

Pinpoint pupils may indicate opioid use, while dilated pupils can suggest previous stroke, or psychostimulant or anticholinergic drug use. Erythematous conjunctiva can be a sign of cannabinoid or other illicit drug use.

Extremities

Symptoms of peripheral vascular disease or cyanosis should be noted if present. Edema is a known side effect of many medications including antihypertensives, NSAIDs, and gabapentinoids.

See also, how to conduct a virtual pain exam if needed.

Neurological Examination

The neurological exam is an often-overlooked component of the examination of patients with pain. There are six basic components:

Deep Tendon Reflexes: brachioradialis (C5), biceps (C6), triceps (C7), patella (L4), and Achilles (S1), graded 0 to 4+ (2 is normal). If hyperreflexia is present, clinicians may assess the Hoffmann’s reflex (flicking the distal interphalangeal [DIP] joint of the patient’s middle finger results in flexion/contraction of the index finger and adduction of the thumb), ankle clonus, Babinski, and other subtle findings such as jaw jerk. By convention, the deep tendon reflexes are graded as follows:
1. 0=no response; always abnormal
2. 1+=a slight but definitely present response; may or may not be normal
3. 2+=a brisk response; normal
4. 3+=a very brisk response; may or may not be normal
5. 4+=a tap elicits a repeating reflex (clonus); always abnormal
Sensory Function: Test light touch, thermal, or pinprick sensation, and proprioception. I typically use a cold tuning fork at the shoulders, radial, and ulnar side of the hands, as well as the thighs and inner calf (L4), top of foot (L5), and outer calf (S1). Assess allodynia (sensitivity to light tough) and hyperalgesia (exaggerated response to pain).
Motor Function: Evaluate muscle strength. I typically assess strength and symmetry at the biceps, triceps, wrist flexor/extensors, finger abduction, hip flexors, quadriceps, hamstrings, ankle, and big toe flexors/extensors.
Cerebellar Function: test coordination with finger tap, foot tap, dysdiadochokinesia (inability to perform rapid alternating movements).
Cranial Nerve Exam: Assess lateral gaze for EOM (extraocular muscle) function and nystagmus, midline tongue protrusion, symmetrical hearing to finger rub, forehead wrinkle with eyes shut tightly and wide open, and shoulder shrug strength.
Psychiatric Exam: Evaluate and document psychiatric characteristics, including the patient’s speech, mood/affect, and judgement.

Musculoskeletal Examination

Gait Assessment: Observe walking pattern and any abnormalities for patients presenting with radicular or musculoskeletal complaints.

Joint Inspection: Look for obvious joint abnormalities, spinal curvatures (lordosis, kyphosis).

Range of Motion (ROM): Assess joint flexibility and limitations, especially at patient’s area(s) of maximal pain. Pain with forward lumbar flexion may represent disc disease, while pain with hyperextension represents lumbar facet dysfunction.

Palpation: Check for tenderness, trigger points, and muscle spasm. Attempt to find the patient’s point of maximal pain intensity, which may correspond to their pain “generator.” Paravertebral muscle spasm with non-radiating tenderness to palpation between the rib margin and the iliac crest is typically how lower back pain will present. Attempt provocative maneuvers to localize pain to the lumbar facet joints (deep palpation with hyperextension and lateral rotation), sacroiliac joint over the posterior superior iliac spine(PSIS). Use the following tests: distraction, thigh thrust, FABER(Patrick’s), and Gaenslen’s maneuvers). Also assess pain over the piriformis muscle at the sciatic notch.

For individuals new onset generalized MSK pain, see additional assessment recommendations.

Special Tests

If indicated, the following may be considered. We always explain the utility to the patient in advance should they have questions or concerns.

Spurling’s test can assess for cervical radicular pain. Have the patient extend their neck and bend it toward the affected side while applying axial compression. Radiating pain down toward the upper extremity is suggestive of radiculopathy or radiculitis.
Straight leg raise test, also called the Lasegue test, assesses for lumbosacral nerve root irritation from sciatica or lumbar disc herniation.

By following these steps, you can conduct a thorough physical examination of a patient with chronic pain, addressing both physical and psychosocial aspects essential for comprehensive management.