Physical Exam

Thoracolumbar Spine and Back Palpation

🎬

Video coming September 2026

How to Perform

Begin by carefully palpating the area of pain or other concern. Palpate the thoracic and lumbar spinous processes, adjacent paraspinal muscles, and sacroiliac joints as clinically indicated. Compare paired structures bilaterally. Note any midline bony tenderness, palpable step-off, paraspinal tenderness or spasm, swelling, or mass.

How to Interpret

Sacroiliac Joint Pathology

Sacral sulcus tenderness, detecting block-confirmed sacroiliac joint pain

Rule in

Not helpfulDerived CI

Rule out

InconclusiveWide CI

Evidence:Limited

Spinal Malignancy

Midline bony (spinous-process) tenderness

Rule in

Minimally helpfulDerived CI

Rule out

InconclusiveWide CI

Evidence:Limited

Spondylolisthesis

Palpable step-off between adjacent spinous processes (low midline sill sign)

Rule in

HelpfulDerived CI

Rule out

Somewhat helpfulDerived CI

Evidence:Limited

References

Deyo RA, Diehl AK. Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies. J Gen Intern Med. 1988 May-Jun;3(3):230-238. doi:10.1007/BF02596337. PMID 2967893.
Berbari EF, Kanj SS, Kowalski TJ, Darouiche RO, Widmer AF, Schmitt SK, Hendershot EF, Holtom PD, Huddleston PM 3rd, Petermann GW, Osmon DR; Infectious Diseases Society of America. 2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults. Clin Infect Dis. 2015;61(6):e26-e46. PMID 26229122. doi:10.1093/cid/civ482.
Faust JS, Tsung JW. Eliciting renal tenderness by sonopalpation in diagnosing acute pyelonephritis. Crit Ultrasound J (Ultrasound J). 2017;9(1):1. doi:10.1186/s13089-016-0056-6. PMID: 28050884.
Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bogduk N. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine (Phila Pa 1976). 1996;21(22):2594-2602. PMID: 8961447.
Ahn K, Jhun HJ. New physical examination tests for lumbar spondylolisthesis and instability: low midline sill sign and interspinous gap change during lumbar flexion-extension motion. BMC Musculoskelet Disord. 2015;16:97. doi:10.1186/s12891-015-0551-0. PMID: 25896607.
Downie A, Williams CM, Henschke N, Hancock MJ, Ostelo RW, de Vet HC, Macaskill P, Irwig L, van Tulder MW, Koes BW, Maher CG. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ. 2013;347:f7095. doi:10.1136/bmj.f7095. PMID: 24335669.
Bickley LS, Szilagyi PG, Hoffman RM, Soriano RP. Bates' Guide to Physical Examination and History Taking. 13th ed. Philadelphia, PA: Wolters Kluwer; 2021.
Swartz MH. Textbook of Physical Diagnosis: History and Examination. 9th ed. Philadelphia, PA: Elsevier; 2025.

Research last updated September 10, 2026.