Approach to

low back pain

Steffi Wong
• LBP: top 10 diseases and injuries - highest number of DALYs worldwide.
• All ages affected
• Prevalence 10-63 % ( = )
• In Malaysia : 12-60%
• Prevalence rate for children and adolescents is lower than adults but is rising
• Prevalence increases and peaks between the ages of 35 and 55.
• Common cause of disability, work loss, healthcare use, sickness benefits
→economic loss to the nation (loss of productivity and healthcare
expenditure)
• 80% resolves with conservative treatment (in <3 months)
• Only 5-10% may require operation

Hoy et all 2010

WHO 2010
Why low back pain
most common?

• Lumbar region bears most of

the body weight
• Most movement of spine
occurs at the lumbar region
• NOT a disease but a constellation of
symptoms
- Low back pain may present as:
1. Back pain alone
2. Back pain → groin/buttock/ posterior
upper thigh/ leg pain (sciatica @
neuropathic pain)+/- numbness and/or
muscle weakness
Low back pain is defined as pain in the
lumbosacral region, buttocks and /or thighs,
which varies with physical activity.
(level of the lowest rib down to the gluteal fold +/-radiation to leg)
Classification
• Acute (<6 weeks)
• Subacute (6-12 weeks)
• Chronic (> 12weeks)
- Typically relapsing and remitting/ character varies
*not adequate to reflect the process of chronification
Chronification:
I. increasing multidimensionality of pain
II. loss of mobility
III. restriction of function
IV. abnormal perception and mood
V. unfavorable cognitive patterns
VI. pain-related behavior
VII. on the social level : disturbances of social interaction and occupational difficulties
Evaluation
• Symptoms and accurate interpretation of the physical signs.
• Not always possible to determine the anatomic pain generator or extent
of damage in the spine just by the site of pain or tenderness elicited from
examination.
• Aim of history and physical examination :
- Serious spinal pathology (“Red Flags”) VS benign musculoskeletal pain.
+ Info on the degree of disability
+ Patient’s expectation
+ Response to treatment during subsequent follow-up visits.
• If the symptoms do not fit into any known diagnostic profile or the patient
fails to improve, then reassessment to identify factors (“Yellow Flags”*)
that may interfere with the diagnosis or recovery must be made.
History
• Age
Pain History :
• Onset, Duration, Location, Character, Quality and intensity, Radiation – Buttock, thigh, – Calf, foot (sciatica*)
• Aggravating factors
• Relieving factors
• Precipitating factors
• Dependence on rest and/or exercise
• Sleep disturbance, impaired daily activities
• Strain or Impulse pain – Sneezing, Coughing, Straining
• Spinal Claudication: Numbness including its distribution
Constitutional Symptoms: Fever, Night Sweats, weight loss,
Neurological Symptoms: Weakness, Bladder and bowel dysfunction (retention or incontinence)
Medical Illness, Social and Psychological Issues
Previous Low Back Pain (if any)
Previous Back Surgery
Work and Lifestyle History (any stress factor)
Red flags
Yellow flag sign *psychosocial factors shown to be indicative of long-term chronicity and disability

• A negative attitude that back pain is harmful or potentially severely

disabling
• Fear avoidance behavior and reduced activity levels
• An expectation that passive, rather than active, treatment will be
beneficial
• A tendency to depression, low morale, and social withdrawal
• Social or financial problems
Examination
1. Look – café-au-lait spots (? neurofibromatosis), hairy patches (? spina bifida), lordosis, list (abrupt planar
shift of the spine, above a certain point, to one side), asymmetry, tight hamstrings resulting in an abnormal
gait are considered to be a clinical feature of pars defects

List – deviation to opposite side: shoulder type PIVD

List – deviation to same side: axillary type PIVD

2. Feel – spinous process percussion tenderness (? fracture, tumor, infection), SI joint pain (? ankylosing
spondylitis), chest expansion <2.5cm (? ankylosing spondylitis), step at L5 (? spondylolisthesis), paravertebral
tenderness (tenderness anywhere from midline to midaxillary line)

Numbness or hyperesthesia over buttocks: entrapment neuropathies of superior cluneal nerves in patients
with thoracolumbar pain
3. Move – pain on bending toward
affected side, or on flexion (? Lumbar
disc disease),
pain on extension (? Facet joint or spinal
stenosis), range of motion
4. Special Tests :
a. Schober’s Test (r=0.97) : assesses the amount of lumbar flexion. Make two pen-marks, one at
10cm above the PSIS, the other 5cm below it. Upon flexion, the distance should increase >5cm.
Decreased ROM of lumbar spine suggests ankylosing spondylitis.

b. Straight Leg Raising Test (SLRT): (sn 89-95% sp14-17%) (Kosteljanez 1988)
assesses the presence of radiculopathy – if pain is reproduced and radiates down into affected leg
when the leg is raised between 10 and 60 degrees elevation.
c. Cross SLR (sn 28%, sp90%) (van der Windt 2010): If the opposite leg produces a positive
response, it is indicative of a large herniation.
Lasegue’s test involves dorsiflexing the foot during the SLR.
Positive SLRT and Lasegue’s test indicates tension on nerve root L5 and S1.
c. Femoral nerve stretch test (sn 50-70%, sp 88-100%) (Suri 2011): detects tension in the L2–L4 nerve roots.
Patient prone, pain elicited in the anterior thigh with extension of the hip or flexion of the knee confirms a
positive RSLR test.

d. Kemp’s Test (local- facet, radiating- disc) Sp 100% (Laslett 2006), Sp 67.3% Manchikanti, 2003)

5. Complete a thorough neurological exam, including gait, ankle reflex (S1), knee reflex (L4), strength, sensation
(look for saddle anesthesia and anal sphincter tone, plus check dermatomes along lower limb).

• Radiculitis may cause both pain and neurological signs, the pain occurs in the lower limb, not in the back.

• If root inflammation also happens to involve the nerve root sleeve, back pain might also arise, but in that even
the patient will have three problems each with a different mechanism: neurological signs due to conduction
block, radicular pain due to nerve-root inflammation, and back pain due to inflammation of the dura.
NERVE ALTERED
ROOT WEAKNESS ALTERED SENSATION REFLEX
L2 Iliopsoas (Hip flexor) Anterior thigh, groin None
Anterior and lateral
L3 Quadriceps (Knee extensor) thigh Patellar
Tibialis anterior (ankle dorsiflexion; subtalar inversion)
L4 AND Limitation of femoral stretch Medial ankle and foot Patellar
Extensor hallucis longus an Extensor digitorum longus (Great-toe
dorsiflexion and other toe dorsiflexion) – Inability to heel walk Lateral calf and 1st web
L5 AND Limitation of SLRT space None
Tendo-achilles, Flexor hallucis longus, Flexor digitorum longus (Ankle
plantar flexion and plantar flexion of toes) – Inability to toe walk
AND Limitation of Bowstring/Sciatic nerve strect test (Perform SLRT;
allow patient to flex knee back until pain is relieved; apply pressure
to popliteal fossa; reproduction of pain indicates positive bowstring
S1 test) Lateral plantar foot Achilles
Wadell’s sign indicating psychological distress
(non-organic causes of pain): 3 out of 5 is significant
• Distraction testing: Inconsistent responses noted with the same test when performed in a standard fashion
and when the patient’s attention is distracted (eg, seated straight leg raising without discomfort versus
radiating pain with supine straight leg raise) SLR negative

• Overreaction: Inappropriate tenderness that is superficial or widespread

• Regional disturbances: in strength and sensation that do not correspond with dermatomal pattern

• Stimulation testing: Pain on simulated axial loading by pressing on the top of the head or simulated spine
rotation

• Tenderness: superficial and non-anatomic tenderness

 LOW BACK PAIN
(anatomical)

Non spine origin Spine origin

Visceral origin
Non spine MSK • Disc
• GIT: PUD • SI joint • Bone
• Pancreas pathology • Joint
• GUT: Stone- colicky ( Renal • Hip joint • Ligament
punch) pathology • Muscle
• Vascular ( AAA, thrombus,
embolus- X blood flow)
• Gynaecological: -
Ovarian (+/- obturator
nerve:inner thigh pain) /Pelvic
tumors
-Normal ovulation
(dysmenorrhea)
 Approach to LBP
Back pain alone Back pain + neurology

Mechanical Inflammatory
Referred pain
pain pain

- Night pain • AAA

▪Musculo-
- Rest pain Pancreatitis
ligamentous
▪Facetogenic
▪Discogenic
▪Instability
Musculoligamentous: Lumbar strain
• Non radiating LBP associated with mechanical stress (beyond muscle/
ligamentous limit)
• Injury usually when lumbar spine mechanically disadvantage position
(rotated/fully flexed)
• Age 20-50
• Point of tenderness
• Risk factor:
✓repetitive or heavy lifting,
✓prolonged abnormal position of the trunk (rotated, flexed, hyperextended),
✓ poor body mechanics or ergonomics,
✓ core weakness, tight/weak hip girdle musculature (e.g., hamstrings, hip flexors)
Pathophysiology
• Indirect trauma (excessive stretching/tension)→ muscle fiber tearing
• Overuse→ muscle fatigue
• Muscle fatigue→ muscle spasm
• Injury→ prolonged bedrest→Deconditioned paraspinal muscles→
decreases muscle mass& power→ recurrent/risk of injury
History Physical examination
Symptoms: pain worse with movement , better with Standing- postural shift
rest Lumbar ROM limited d/t pain
(always rule out red flags & psychosocial factors- Tender paraspinal muscles or quadratus lumborum
predictors of poor outcome) SLR- provoke axial pain ( no radicular pain)
Dx of exclusion Neurological normal
Ix: Rx: - symptomatic
Lab- not indicated (unless r./o infection or Acute- pain reduction (analgesics NSAIDS, muscle
inflammatory arthritis) relaxants), control of excessive inflammation and
Imaging- Not indicated in no redflags cases spasm, and prevention of deconditioning. (no
Except- osteoporosis, steroid, high trauma, extreme prolonged bed rest)
age
*to avoid unnecessary interventions Subacute
High risk: CT/ MRI progression to normal activity (aerobic conditioning,
incorporation of postural correction and flexibility
exercises)→ progression to normal physical activity,
including sport-specific exercise.
Discogenic pain
• Worse with flexion, relieved with
extension
1. Degenerative disc disease

2. Annular tear
Degenerative disc disease
• 3 stages: (Kirkaldy Willis 1982)
1. Temporary dysfunction (degen changes as early as 20 y.o)
2. Unstable phase (loosening annulus fibrosis)- pain
3. Stabilization (fibrosis* post struct+ osteophytes)- pain+ decrease motion
(*little blood supply)
Factors cause discs to degenerate:
• Drying out of the disc with age.
• Tears in the outer portion of the disc due to daily activities and sports.
• Injury.
- nervous system around the disc is affected by disc
degeneration→+stimulate the nociceptors in the anulus fibrosus
→nociceptive pain (discogenic pain)
History Physical examination
>50 y.o L4/5 (men: 69.1%, women: 75.8%) Tender palpation
(Teraguchi (2014) Reduce motion
Symptoms: SLR neg
Axial LBP, worse sitting /bending/lifting/twisting Neurological normal
+/- radiate buttock/ thigh
+/- muscle weakness (damage nerve root)

Relieve: Frequent change position, lying down

Ix: Rx: - symptomatic****
Lab- not indicated • Physical therapy (heat/cold, SMT, TENS, PRF0
Xray AP lateral (Standing)- narrow space • Exercises: unloaded movement facilitation
CT: no value exercises of McKenzie, core, Hip ext,flx,
MRI: Increased disc signal on T2-weighted images sacrospinais strengthening, core stabilisation
(dehydration of the lumbar discs) exercises
Provocative discography (locate pain) *before fusion • Analgesics NSAIDS
• Injections corticosteroids
(Hasz 2012) • Surgery- disc replacement, spinal fusion

(Beattie 2008, Iade 2007)

 Annular tear
History Physical examination
Localized pain - unrevealing
*Radicular symptoms secondary to irritation of the
passing nerve root

(L4 L5, L5 S1)

Ix: Rx: - symptomatic***

Lab- not indicated • Analgesics NSAIDS
Xray no value • Surgery- if disc protrude cause neurology
CT myelogram : nerve root or cord compression from
a disc protrusion. (can’t identify the edema of an
annulus fibrosus tear or fissure)
MRI: T2 sequence, the annular fissure is hyperintense
(bright) *normally hypointense or dark) due to the
relative increase in water content at the fissure

Tenny (2020)
Facetogenic pain
• More pain in extension, side bending, twisting
• Facet joint synovitis or arthrosis, capsular stretch, impinged nerve by
osteophytes
• +/- disability, radiculopathy, and neurologic deficits
• Lumbar Kemp’s test (local pain)
• MRI: facet degeneration
• Analgesics (NSAIDS)
• Surgery: decomp(laminectomy, facetomy, +fusion)
• Facet injection/radiofreq denervation medial branch nerves

(Alexander 2020)
Instability
• Disruption of spinal unit
• Spondylolisthesis
• Spondylolysis
• Trivial fall → Osteoporotic fracture
• Trauma history → Fracture
Spondylolysis
• Prevalence 5% in gen public (Hu 2008)
• >40 y.o
Spondylolisthesis
• forward slippage of one vertebra on lower vertebrae
• Elderly common (as early 40 y.o), (DEGEN)
• children and adolescents , sports (hyperextension) of the
lumbar spine—such as gymnastics, football, and weight-
lifting.
• L4/5 common
• Sx back pain, relieve rest& sitting, +/- neurogenic claudication buttock
leg when upright walking (Unilateral/bilateral)

• Examination:
- Apart from local tenderness
If nerve pinched,
-L4, weak quads, fail heel walk, decrease plantar reflex
-L5 weak dorsiflexion ankle, EHL, Glut med,
hamstring tightness
Imaging:
• XRAY: weight bearing lumbar AP, lateral neutral, lateral flexion, lateral
extension
- slip evident on lateral xray
• MRI (persistent leg pain that has failed nonoperative modalities)
- evaluate impingement of neural elements
- T2 weighted sagittal and axial images -compression of neurologic
elements
• CT- identify bony pathology
• CT myelogram MRI is contraindicated (pacemaker)
Rx
• physical therapy and NSAIDS+ activity modification
• epidural steroid injections

Surgery:
• lumbar decompression with instrumented fusion, +/- interbody
Inflammatory pain – night pain and rest pain
• Constitutional symptoms → Malignancy
• Immunosuppressed / Recent major infection → Infection
RED FLAGS!
Ankylosing spondylitis

Systemic chronic autoimmune spondyloarthropathy characterized by

HLA-B27 histocompatability complex positive (90%)
• RF negative (seronegative)
• primarily affect axial spine
• targets sacroiliac joints, spinal apophyseal joints, symphysis pubis
• 4:1 male:female
• affects ~0.2% of Caucasian population
• usually presents in 3rd decade of life→ later neck & upper thoracic
• juvenile form <16-years-old includes enthesitis
• lumbosacral pain and stiffness (morning
worse)
• Sciatica (piriformis spasm)
• loss of horizontal gaze
• shortness of breath(costovertebral jt)
Examination:
- Limited chest wall expansion
- decreased spine motion (Schober test)
- kyphotic spine deformity
- Hip flexion contracture
- sacroiliac provocative tests
 LOW BACK PAIN
Back pain alone Back pain + neurology

+ systemic involvement Radiculopathy pain

Mechanical Inflammatory
Referred pain
pain pain • Malignancy (1’/2’)- 2’
spread to epidural • Herniated disc
- Night pain • AAA (neuropathic) • Spinal stenosis
▪Musculo-
- Rest pain • Pancreatitis • Cauda Equina • Facet joint arthropathy
ligamentous
▪Facetogenic • Compression Fracture • DDD
▪Discogenic • Infection
▪Instability
Radiation of pain (Radiculopathy)
•Pain radiating down a leg may suggest nerve impingement:
- One leg: Disc herniation
- Both legs: Cauda equina syndrome, Cord compression
• Disc herniation: Younger patients
• Osteophyte: Older patients
•Pain radiating to groin: Abdominal aortic aneurysm, renal calculi
• Pain in the buttock or proximal thigh (unlikely to be radicular pain but
rather a somatic referred pain stemming from lumbar zygoapophyseal
joints)
• Somatic pain can also be referred below the knee and even into the foot.
 Herniated disc
History Physical examination
Localized pain - SLR (sn 89-95% sp14-17%)
+Radicular symptoms secondary to irritation of the - Cross SLR (sn 28%, sp 90%)
passing nerve root - Bowstring sign (sp 92%, Sn41%)
+/- cauda equina - Nafziger test (cough impulse )
Male: female ( 3:1), 20-50 y.o - Trendenlenburg gait
- Weakness based on the level affected
(L4 L5, L5 S1 common) - Irregular reflexes
Ix: Rx: - symptomatic
Lab- not indicated • Analgesics NSAIDS+ PT
Xray no value ( degen, loss disc height loss lordosis • Surgery- ( laminotomy, discectomy if disc
CT myelogram : nerve root or cord compression from protrude cause neurology
a disc protrusion. (can’t identify the edema of an
annulus fibrosus tear or fissure)
MRI: T2 sequence, the annular fissure is hyperintense
(bright) *normally hypointense or dark) due to the
relative increase in water content at the fissure

Tenny (2020)
Non specific back pain
• Most common cause
• Usually poorly localized, not related to posture or work.
• Long periods of being very well, with occasional episodes of vague,
poorly defined pain.
• Maybe better with massage, acupuncture or chiropractic treatment.
• No serious spinal pathology.
+ Episodes of pain free periods
 Discogenic Facetogenic Stenosis Neuroforaminal Myofascial

Test SLR Lumbar Kemp’s Non-specific SLR Non specific-

Cross SLR test Cross SLR muscle spasm
Femoral stretch Motor/sensory, reflexes
Children and adolescent
• Back pain (uncommon) to emergency department
- causes of back pain trauma (25%), muscle strain (24%), sickle cell
crisis (13%), idiopathic cause (13 %), UTI(5%), viral syndrome (4%).
• Common pathology: spondylolisthesis, herniated disc, scoliosis, and
spondylolysis.
• Tumors –night time pain, constant pain, and symptoms lasting less
than three months.
• Back pain -referred pain from a medical illness such as pyelonephritis
or sickle cell crisis
 SIJ PATHOLOGY
NON SPINE ORIGIN
HIP PATHOLOGY
MSK PAIN
PSOAS PATHOLOGY
 SI Joint pathology (Saunders 2018)
• 30% non specific LBP
• H/O trauma/repetitive microtrauma
• Localized / referred pain
• Worse loading (sit,stand,run walk stairs, turn in bed)
• Pseudosciatica
Dx by provocation test + injection& confirm by imaging
Clinical examination:
-Inspect standing AP, lateral
Cluster of Laslett (3/5) Sp 91% sn 78% vs cluster Van der Wuff
- Distraction test (sn 60%, sp 81%) (Laslett 2005)
- Thigh thrust (sn >60%, sp <60%) (Stuber 2007)
- Compression test (sn 7%, sp 90%) (Werner 2013)
- Sacral thrust (sn >60%, sp >60%) (Stuber 2007)
• Stork test (Sn 43%, Sp 68%) (Dreyfuss 1996)
• Active SLR (sn 100%, sp 94%) (Mens 1993)
• Palpation along dorsal sacro-iliac ligament (sn 90%, sp 15%) (Dreyfuss 1996)
Other tests
• Patrick’s test (sn <35%, sp >90%) (Werner2013)

• Gaenslen’s test (sn <35%, sp >90%) (Werner2013)

Ix (Saunders 2018)
• Plain X-ray, CT scan, MRI, Nuclear imaging - no info on mechanical fx
• SPECT-CT - provides specific imaging patterns that match the clinical
diagnosis of SIJ instability (failure of optimal load transfer)
- Increased uptake in upper SIJ
- Uptake in posterior soft tissues
- Uptake at ligamentous insertion on ilium (loss dumbbell)
- Sclerosis of jt

127 53
Quantitative
Adductor enthesopathy

Osteitis pubis
• Manual therapy for optimal alignment and muscle positioning
- Dry Needling /Acupuncture to assist with muscle hypertonicity
• Maximise muscular control (TA & Glutes)
• Trial bracing (for ligamentous instability)
• Steroid/Prolotherapy/ PRP injection.
• Surgical fixation
• specialised physical therapy and re-institution of the optimal muscle
function- 78% (Cusi, Saunders, Hungerford, Wisby-Roth 2008)
• The remaining 21.8% will improve with injection therapies
(prolotherapy :PRP superior to Glucose (Saunders et al 2018 in J
Prolotherapy)
Hip Pathologies
• Hip OA/ labral pathology
• Resolution of back pain after the management of hip disease in
patients undergoing THA or arthroscopic hip surgery, such as that for
the management of a labral tear. Ben-Galim P(2007)

• Xray- bone/ late jt disease

• MRI- intraarticular
• patients with hip flexion contracture=false-positive femoral nerve stretch
test.
• Positive provocative tests indicate hip pathology :
1. FADIR test %, (Sn99%, Sp25%)- (hip impingement tests) - labral tear or FAI
2. FABER test (Sn81%, Sp25%)- intra-articular hip lesions, iliopsoas pain, or SI
disease (sn <35%, sp >90%) (SI pain)
3. Stinchfield resisted hip flexion test (sp32%, sn 77%) : hip flexed (>30-45 deg)-
intra articular pain (Maslowski 2010)

4. Log roll test :

- clicking or popping (acetabular labral tear)
- increased total ROM compared to contralateral side (ligament or capsular
laxity)
 Psoas Pathology
• groin and thigh pain +/- back pain
• weakness on hip flexion
• Causes :psoas abscess, hematoma, malpositioned devices (ie, pedicle
screw), and the transpsoas approach for lumbar fusion.
• History: difficulty in standing up from a chair or pain with full hip extension
• Physical examination : pain with resisted hip flexion and a positive Thomas
test

• MRI with contrast and laboratory tests (eg, ESR, CRP, FBC-to r/o abscess)
• CT is - to assess for malpositioned devices (spine screw)
 LBP< ant LBP= or < referred
LBP< local pain LBP<< referred pain
pain
hip/within hip Or LBP>> referred pain
References
• Balague F, Troussier B & Salminen JJ. Non-specific low back pain in children and adolescents: risk factors. Eur Spine J, 1999, 8: 429–438.
• Andersson GBJ. The Epidemiology of Spinal Disorders. In Frymoyer JW (ed.) The Adult Spine: Principles and Practice. Philadelphia, Lippincott-Raven, 1997, pp. 93–141.
• Manchikanti L, Pampati V, Fellows B, Baha A. The inability of the clinical picture to characterize pain from facet joints. Pain Physician. 2000;3:158–66.
• Laslett M, McDonald B, Aprill C, Tropp H, Oberg B. Clinical predictors of screening lumbar zygapophyseal joint blocks: development of clinical prediction rules. Spine J. 2006;6:370–9.
• Kirkaldy-Willis WH, Farfan HF (1982) Instability of the lumbar spine. Clin Orthop Relat Res (165):110–123
• Teraguchi, M., Yoshimura, N., Hashizume, H., Muraki, S., Yamada, H., Minamide, A., ... & Takiguchi, N. (2014). Prevalence and distribution of intervertebral disc degeneration over the entire spine in a
population-based cohort: the Wakayama Spine Study. Osteoarthritis and cartilage, 22(1), 104-110.
• Hasz, M. W. (2012). Diagnostic testing for degenerative disc disease. Advances in orthopedics, 2012.
• Beattie P. Current understanding of lumbar intervertebral disc degeneration: a review with emphasis upon etiology, pathophysiology, and lumbar magnetic resonance imaging findings. fckLRJOSPT 2008; 38(6):329-340
• lade SC, Keating JL: Unloaded movement facilitation exercise compared to no exercise or alternative therapy on outcomes for people with nonspecific chronic low back pain: a systematic review. J Manipulative Physiol
Ther 2007;30:301–11
• Hu SS, Tribus CB, Diab M, Ghanayem AJ. Spondylolisthesis and spondylolysis. J Bone Joint Surg Am. 2008;90(3):656–671.
• Feldman DS, Hedden DM, Wright JG. The use of bone scan to investigate back pain in children and adolescents. J Pediatr Orthop. 2000;20:790–5.
• Combs JA, Caskey PM. Back pain in children and adolescents: a retrospective review of 648 patients. South Med J. 1997;90:789–92.
• Khoury NJ, Hourani MH, Arabi MM, Abi-Fakher F, Haddad MC. Imaging of back pain in children and adolescents. Curr Probl Diagn Radiol. 2006;35:224–44.
• Roger E, Letts M. Sickle cell disease of the spine in children. Can J Surg. 1999;42:289–92.
• Selbst SM, Lavelle JM, Soyupak SK, Markowitz RI. Back pain in children who present to the emergency department. Clin Pediatr. 1999;38:401–6.
• Laslett, Mark. (2008). Evidence-Based Diagnosis and Treatment of the Painful Sacroiliac Joint. The Journal of manual & manipulative therapy. 16. 142-52. 10.1179/jmt.2008.16.3.142.
• Saunders, J., Cusi, M., & Van der Wall, H. (2018). What's Old Is New Again: The Sacroiliac Joint as a Cause of Lateralizing Low Back Pain. Tomography, 4(2), 72.
• Ben-Galim P, Ben-Galim T, Rand N, et al: Hip-spine syndrome: The effect of total hip replacement surgery on low back pain in severe osteoarthritis of the hip. Spine (Phila Pa 1976) 2007;32(19):2099-2102.
• Maslowski, E., Sullivan, W., Forster Harwood, J., Gonzalez, P., Kaufman, M., Vidal, A., & Akuthota, V. (2010). The diagnostic validity of hip provocation maneuvers to detect intra-articular hip pathology. PM & R : the
journal of injury, function, and rehabilitation, 2(3), 174–181.