A 69-year-old man presents to his primary care physician with hip and back pain. He states this weekend he had a barbecue. When he was lifting a heavy object, he suddenly felt pain in his lower back. He describes the pain as in his buttocks but states that at times it travels down his leg. He states that it feels electrical and burning in nature. The patient has a medical history of obesity, diabetes, depression, anxiety, diverticulosis, constipation, and a surgical repair of his anterior cruciate ligament. His current medications include metformin, insulin, lisinopril, fluoxetine, and sodium docusate. His temperature is 98.6°F (37°C), blood pressure is 131/82 mmHg, pulse is 82/min, and respirations are 14/min. On physical exam, he is found to have an intact motor and sensory function in his lower extremities bilaterally. No clonus or Babinski sign is appreciated. An exam of the cranial nerves is intact bilaterally. Which of the following is most likely to help confirm the diagnosis?
Palpating the paraspinal muscles
Radiography
Straight leg raise
Flexion, abduction, and external rotation of the thigh
Straight leg raise
This patient is presenting with lower back pain that is electrical and travels down his legs after lifting an object suggesting a diagnosis of a herniated disc. The straight leg test can help confirm the diagnosis.

A herniated disc classically presents in a middle-aged or older individual who was lifting a heavy object with improper form. They will typically experience lower back pain that can be described as radicular. The pain will typically travel down the legs or "shoot down" the legs and is typically described as feeling electrical. The straight leg test on physical exam supports the diagnosis without an MRI. When the individual raises their leg, this causes compression of the spinal nerve roots leading to an exacerbation of symptoms. The most appropriate initial step in management for these patients is limiting strenuous activity, physical therapy, and NSAIDs. Patients who have chronic symptoms that have failed conservative management can undergo surgical laminectomy.

Camino and Piuzzi present the data regarding the diagnostic value of the straight leg raise test. They discuss how this test can exacerbate patients with radicular symptoms. They recommend all practitioners learn how to perform and interpret this test.

Incorrect Answers:
Answer A: Flexion, abduction, and external rotation of the thigh is referred to as the FABER test and is used to evaluate for sacroiliitis which can present with lower back pain and pain in the buttocks. This exam maneuver will cause intense pain in patients who have inflammation of the joint. Treatment is with physical therapy and NSAIDs.

Answer B: Internal rotation of the extended hip is the Freiberg test which evaluates for piriformis syndrome. Piriformis syndrome presents with lower back pain similar to a herniated disc; however, is less likely to have occurred after a single lifting episode and does not typically present with electrical pain that originates in the buttocks.

Answer C: Palpating the paraspinal muscles is a non-specific test that could further support a diagnosis of a muscle strain. It will likely not provide much information in the diagnosis of a herniated disc. Patients with muscle strain can be treated conservatively with relative rest and NSAIDs.

Answer D: Radiography is unlikely to offer information regarding this patient's herniated disc. While it can detect bony abnormalities, the detail of this imaging modality will not depict a herniated disc. An MRI is required to offer the detail necessary to make the diagnosis and is the most accurate test for a herniated disc.

Bullet Summary:
A herniated disc typically presents with pain in the lower back that radiates down the legs and is exacerbated by the straight leg raise test.