BACKACHE:

LIVE WEBINAR
COMPREHENSIVE NOTES

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Backache Webinar
Comprehensive notes
By Dr. Subodh Chaturvedi

The Fundamental Framework for Back Pain

When a patient says "Idhar dard hota hai idhar" (I have pain here and
here), we need a system. Not all back pain originates from the back;
some can be referred pain (e.g., from the kidneys). However, for
pain that is from the back, we can simplify the causes.

The "3 Kya" (What are the 3 things that cause pain?)
1. Muscles (and Ligaments)
2. Joints (Facet joints, Sacroiliac joints)
3. Nerves (Nerve roots, spinal cord)

The "3 Kyun" (What are the 3 reasons for the pain?)
1. Pressure: Something is being compressed.
2. Stretch: Something is being pulled or strained.
3. Inflammation: There is an inflammatory process.

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By combining these two simple concepts, we can create a
powerful diagnostic grid that covers most common causes
of low back pain. This is the MNJ-PSI System.

Structure Mechanism Common Causes

Muscle/Ligament Stretching Muscle strain/spasm, Ligament
sprain, Myofascial pain
Inflammation Acute muscle tear (rare in Low
Back Pain)
Nerve Pressing Herniated disc, Spinal stenosis,
Epidural abscess
Stretching Nerve root tension,
Spondylolisthesis
Inflammation Radiculitis, Post-disc herniation
inflammation
Joint Pressing Osteophyte stenosis,
Hypertrophic facet
Stretching Facet joint strain, SI joint
dysfunction
Inflammation Spondyloarthritis, Facet
arthritis, Vertebral infection

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Differentiating Muscle, Nerve, & Joint Pain Through History
Feature-Based History Taking (MNJ System)
Feature MUSCLE NERVE JOINT
(Radiculopathy)
LOCATION Paramedian (off Midline OR Localized over
to the side) dermatomal the joint
RADIATION Stops ABOVE the Goes BELOW the Does NOT
knee knee to the foot radiate
CHARACTER Aching, tight, Burning, electric, Deep, dull ache
pulling tingling
NUMBNESS NO YES - follows a NO
dermatomal pattern
WEAKNESS Generalized Specific motor Pain-limited
fatigue weakness (e.g., foot weakness only
drop)
AGGRAVATED Position Sitting, forward Weight-bearing,
BY changes, rising bending, standing,
from a chair coughing/sneezing extension
RELIEVED BY Movement helps, Standing, lying down Rest, non-weight
warmth bearing
MORNING Worse initially, Variable Worse if
loosens in 15-30 inflammatory
min (>90 min
stiffness)
NIGHT PAIN Uncomfortable Positional Severe at 3-5 AM
when turning in if inflammatory
bed

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💡 Clinical Pearl: The Classic Muscular Pain Triad
If a patient reports these three symptoms, it's very likely muscular
pain:
1. Morning stiffness that gets better with movement.
2. Pain on rising from a chair.
3. Pain on turning in bed at night.

Case Analysis Using the MNJ System

Case 1: The "Orange Monkey" - Muscle Pain
History:
• Location: Paramedian (off to the
side).
• Radiation: Stays above the knee.
• Character: Aching, tight, pulling.
• Aggravating Factors: Pain on rising
from a chair.
• Relieving Factors: Better with
walking.
• Associated Symptoms: No burning or tingling.

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Diagnosis: MUSCLE + ख च िं ाव (STRETCH)
This is a classic presentation of a muscle
strain (e.g., Iliopsoas or Quadratus
Lumborum strain).

Case 2: Monkey" - Nerve Compression

History:
• Radiation: Pain goes BELOW the knee, down to the toe.
• Character: Burning, electric, tingling sensation.
• Aggravating Factors: Worse with sitting and coughing.
• Weakness: Patient reports their "slipper falls off" when
walking. This indicates MOTOR weakness (foot drop).
Important Warning
The presence of motor involvement (weakness like foot drop) is a
significant finding and means investigation is necessary.

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Diagnosis: NERVE + COMPRESSION
This is a classic presentation of radiculopathy, likely from a
herniated disc pressing on a nerve root.

Case 3: The "Kim Jong Un Monkey" - Inflammatory

Joint Pain
History:
• Duration: Chronic (4 months).
• Time Pattern: Night pain that wakes him at 3-4 AM. Severe
morning stiffness lasting more than 90 minutes.
• Relieving Factors: Pain gets better with movement and
exercise.
• Location: Pain is in the buttocks (SI joint area).
• Other: Young age (28 years), which is a typical age for
Ankylosing Spondylitis (AS). Has a dramatic response to
NSAIDs.

Diagnosis: JOINT + सूजन (INFLAMMATION)

These are classic features of inflammatory back pain, with a strong
suspicion for Ankylosing Spondylitis.

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Clinical Examination

After a thorough history, a focused examination helps confirm your

suspicion.
1. Palpation: Gently palpate the spine and paraspinal muscles to
localize tenderness.
2. Gait: Ask the patient to walk. Look for an antalgic gait, where
the patient limps to spend less time on the painful leg.

3. Special Tests:
o Heel Walking: Tests the strength of dorsiflexors (L5 nerve
root). Inability to heel walk suggests an L5 issue.
o Toe Walking: Tests the strength of plantar flexors (S1
nerve root). Inability to toe walk suggests an S1 issue.

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 o Straight Leg Raise (SLR) Test:
▪ Positive at 30-70 degrees: Highly suggestive of Nerve
root irritation (sciatica).
▪ Pain at >70 degrees: More likely hamstring tightness
or Muscle/Joint pain.
o Faber Test (Flexion, Abduction, External Rotation): A
test for SI joint pathology. If it elicits pain in the SI joint
area, it points towards a Joint issue
Examination MUSCLE NERVE JOINT
Finding
Heel Walking Normal Weak if L5 Normal
Toe Walking Normal Weak if S1 Normal
SLR Negative (or pain Positive (30- Negative
>70°) 70°)
Faber Test Negative Negative Positive

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Putting It All Together: Clinical
Vignettes

Clinical Picture Think Mechanism

45yo, acute pain after lifting, Iliopsoas strain MUSCLE +
paramedian, aching, pain STRETCH
rising from chair, better with
walking
50yo, pain to lateral foot, S1 radiculopathy NERVE +
burning, worse sitting, can't PRESSURE
toe walk
28yo, 4 months pain, wakes Ankylosing JOINT +
at 4 AM, stiff >90 min, better Spondylitis INFLAMMATION
with exercise, buttocks pain
60yo, pain on standing >20 Spinal stenosis NERVE +
min, better with PRESSURE
sitting/leaning forward,
bilateral leg heaviness
35yo, flank pain turning in QL strain MUSCLE +
bed, no urinary symptoms STRETCH
on USG
55yo, localized back pain, Facet JOINT +
worse with extension, arthropathy PRESSURE/INFL
elderly, no radiation AMMATION

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Investigation Strategy: When and
What to Order
Direct Quote Worth Remembering
"Investigation confirms diagnosis, it doesn't make it."
The diagnosis should primarily come from your history and clinical
exam.
Golden Rule: Wait 3-4 Weeks
For simple mechanical back pain with no red flags, do not rush for
imaging. 70% of back pain is muscular and won't show on an MRI
anyway!
INVESTIGATE IMMEDIATELY IF: WAIT 3-4 WEEKS INVESTIGATE
IF: AFTER 3-4 WEEKS
IF:
Red Flags Present No red flags Failed
conservative
treatment
- Cauda equina symptoms - Acute - Non-responder
(saddle anesthesia, mechanical pain
bowel/bladder incontinence)
- Progressive weakness - You're starting a - Recurrent pain
conservative trial
- Fever + constitutional
symptoms
- Cancer history + new pain
- Age >50 + severe pain
- Significant trauma

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The Investigation Ladder (Follow the steps!)

TIER 1: Blood Tests (Screening)

• CBC + ESR/CRP: To look for infection or inflammation.
• Creatinine: To get a baseline before starting NSAIDs.
• Vit D, B12, Iron: Especially for recurrent pain (common in the
Indian context).

TIER 2: X-Ray Lumbar Spine

• Position: Must be STANDING (weight-bearing).
• Views: AP + Lateral + Flexion/Extension views (crucial to
catch instability/listhesis).
• When: For trauma, age >50, or dynamic pain.

TIER 3: MRI Lumbar Spine

• NOT on Day 1 for simple pain!
• When: If red flags, neurological signs (weakness), or failure to
respond to 4-6 weeks of conservative treatment.
• Shows: Disc issues, nerve compression, stenosis, infection.

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Investigation Pitfalls: What NOT to Do

• MRI on Day 1 for simple pain.

• Standard (supine) X-ray only. Always ask for standing +
flexion/extension views.
• Treating the MRI report, not the patient. MRI findings
often don't correlate with symptoms. Clinical correlation is
mandatory.
• Skipping blood tests. A baseline creatinine and
inflammatory markers are important.

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Treatment Protocols
Muscle Monkey: Treatment for Mechanical Back Pain
1. The Foundation (Pain & Muscle Relaxation)
o Drug: Tab. Etoshine-MR (Etoricoxib 90mg +
Thiocolchicoside 4mg)
o Dose: 1 tablet BD (twice a day) after meals.
o Duration: 5 days. Counsel the patient to complete the
course even if they feel better in 1-2 days.

2. Gastric Protection
o Drug: Cap. Pantoprazole 40mg
o Dose: 1 capsule OD (once a day) on an empty stomach
(before breakfast).
o Duration: 5 days.
o ALWAYS co-prescribe a PPI with NSAIDs!

3. Local Application (Two-Step Protocol)

o Step 1: Hot fomentation for 15 minutes, twice a day. This
opens pores and increases blood flow.
o Step 2: THEN apply Diclofenac gel. The heat improves
penetration.

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 4. Activity Guidelines
o Continue normal activities. Movement helps
recovery.
o Avoid heavy lifting for 1 week.
o NO bed rest! Bed rest makes muscles weaker.
5. Physiotherapy
o When: Start if the patient is not better in 5 days.
o Focus: Core strengthening exercises to build long-term
resilience.
o Follow-up: On Day 5.

Nerve Monkey: Radiculopathy Management Protocol

1. Phase 1: First 7-10 Days (Anti-inflammatory)
o Drug: Tab. Zerodol-SP (Aceclofenac 100mg +
Serratiopeptidase + Paracetamol)
o Dose: 1 tablet BD (after meals).
o Duration: 7-10 days.
o Gastric Protection: Cap. Pantoprazole 40mg OD for 10
days.
2. Neuropathic Pain Control
o Drug: Cap. Pregabalin 75mg (or Gabapentin 300mg if
elderly).
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 o When: Start ONLY if burning/tingling pain persists
after 3-5 days of NSAIDs.
o Dose: 1 capsule HS (at bedtime). May increase to BD after
1 week if needed.

3. Patient Counseling
o Warn about sedation/dizziness for the first 3 days of
Pregabalin/Gabapentin; it usually settles.
o Inform young females about the possibility of temporary,
reversible bloating/weight gain.

4. Activity Modification
o Avoid prolonged sitting (>30 minutes) as it increases
disc pressure.
o Take frequent breaks to stand and walk.
o Sleeping position: Semi-fowler with a pillow under the
knees to reduce nerve tension.

5. Physiotherapy
o When: After the acute pain subsides. NOT in the acute
phase.
o Focus: Core strengthening and neural mobilization
exercises.

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 6. Investigation
o MRI Lumbar Spine if there is no improvement in 4-6
weeks.
o Follow-up: Week 1, then Week 4.

The Steroid Controversy in Low Back Pain

• Clinical Bottom Line: Steroids are NOT first-line therapy for

back pain.
• ONLY Use When: For severe, acute radiculopathy with MRI-
confirmed disc herniation that has failed NSAIDs and
conservative Rx.
• NEVER Use For: Mechanical/muscular back pain or chronic
radiculopathy.
• Evidence: Benefits are modest and temporary. There is a high
adverse event rate.
• Protocol (If Using): Tab. Prednisolone/Deflazacort with a
tapering dose over 5-15 days. Be aware of side effects like
hyperglycemia, GI upset, mood changes, etc.

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Joint Monkey: Inflammatory Spondyloarthropathy Protocol
1. Primary Treatment (Anti-inflammatory)
o Drug: Tab. Etoricoxib 90mg. THIS IS THE MAIN
DRUG!
o Dose: 1 tablet OD (after meal).
o Duration: 2-4 weeks (a longer course is needed).
2. Gastric Protection
o Drug: Cap. Pantoprazole 40mg
o Dose: OD on an empty stomach.
o Duration: As long as the NSAID continues.
3. Activity
o Regular exercise is MANDATORY. Disease control
depends on it.
o Swimming is best.
o Daily stretching exercises.
o Avoid prolonged sitting.
4. Baseline Investigations
o Blood tests: HLA-B27, ESR, CRP, Complete Hemogram,
Liver & Kidney function.
o Imaging:
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 1. X-ray Pelvis (AP view) for SI joint
assessment.
2. MRI SI joints if X-ray is normal but suspicion remains
high.
5. Screen for Complications (Look beyond the spine)
o Eye exam (for uveitis).
o Skin exam (for psoriasis).
o GI history (for IBD).
6. When to Refer?
o Refer for a Rheumatology consult for long-term
management, as the patient may need biologics (Anti-TNF)
in the future.
o Follow-up: 2 weeks with reports.

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Quick Recap
• Muscle: 5-day course of NSAID+Muscle Relaxant, heat,
stay active.
• Nerve: 7-10 day course of NSAID, add Pregabalin if burning
persists.
• Joint: Longer course of NSAID, exercise is mandatory.
• ALWAYS give PPI protection with NSAIDs!
Quick Reference Guide
Drug Protocols Summary
Conditio Primary Drug Dos Add-on / Gastric Duratio
n e Neuropath Protection n
ic
Muscle Etoricoxib 1 BD - Pantoprazo 5 Days
Pain 90mg + le 40mg OD
Thiocolchicosi
de 4mg
Nerve Aceclofenac 1 BD Pregabalin Pantoprazo 7-10
Pain 100mg + 75mg HS (if le 40mg OD Days
Serratiopeptida needed)
se + PCM
Joint Etoricoxib 1 - Pantoprazo 2-4
Pain 90mg OD le 40mg OD Weeks

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Investigation Protocol Summary
When to investigate immediately (Red Flags):
• Cauda equina symptoms
(saddle anesthesia,
incontinence)
• Progressive motor
weakness
• Fever, constitutional
symptoms
• History of cancer
• Age > 50 with severe new pain
• Significant trauma

Standard Sequence (if no red flags):

1. Wait 3-4 Weeks: Trial of conservative therapy.
2. Tier 1 (Bloods): CBC, ESR/CRP, Creatinine. Vit D/B12 if
recurrent.
3. Tier 2 (X-Ray): STANDING lumbar spine with Flexion/Extension
views.
4. Tier 3 (MRI): If treatment fails, neuro signs appear, or red flags
develop.
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Clinical Pearls Collection
• Classic Muscular Pain: Pain on rising from chair, pain turning
in bed, and morning stiffness that improves with activity.
• Nerve vs. Muscle: Pain radiating BELOW the knee is the key
differentiator for nerve pain.
• Joint Pain (Inflammatory): Night pain waking the patient (3-5
AM) and morning stiffness >90 minutes are hallmarks.
• Motor Weakness: Any sign of motor weakness (like foot drop)
is an indication for investigation.
• Investigations: "Investigation confirms the diagnosis, it doesn't
make it." Rely on your clinical skills first.
• Bed Rest: Is NOT recommended for simple mechanical back
pain; it weakens muscles.

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Warning Checklist
☐ Ask about bowel/bladder control in every back pain patient
(Rule out Cauda Equina).
☐ Check for progressive weakness (e.g., foot drop) (Red Flag).
☐ Always co-prescribe a PPI with NSAIDs.
☐ Do not order an MRI on Day 1 for uncomplicated back pain.
☐ Always order STANDING X-rays with flexion/extension views to
check for instability.
☐ Do not use steroids for simple mechanical/muscular back
pain.

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QUICK REFERENCE TABLES
TABLE 1: STRUCTURE DIFFERENTIATION
History Features
Feature MUSCLE/LIGAMENT NERVE JOINT

LOCATION Paramedian (off to Midline OR Localized over

side) dermatomal joint

RADIATION Stops ABOVE knee Goes BELOW Does NOT radiate

knee to foot

CHARACTER Aching, tight, pulling Burning, Deep, dull ache

electric,
tingling

NUMBNESS NO YES - NO
dermatomal
pattern

WEAKNESS Generalized fatigue Specific Pain-limited only

motor
weakness

AGGRAVATED Position changes, Sitting, Weight-bearing,

BY rising from chair forward bend, standing,
coughing extension

RELIEVED BY Movement helps, Standing, Rest, non-weight

warmth lying down bearing

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 Feature MUSCLE/LIGAMENT NERVE JOINT

MORNING Worse initially, Variable Worse if

PATTERN loosens in 15-30 min inflammatory,
better if
mechanical

NIGHT PAIN Uncomfortable Positional Severe at 3-5 AM if

turning, not severe inflammatory

Examination Features
Test/Sign MUSCLE/LIGAMENT NERVE JOINT

SLR NEGATIVE (70-90 POSITIVE at 30-70 NEGATIVE

degrees) degrees

SLR with No change Pain increases No change

Dorsiflex (Bragard +ve)

Slump Test Negative Strongly positive Negative

Palpation Ropey, tight Usually normal Tenderness

muscles, trigger paraspinals over joint
points

Prone Hip POSITIVE for Negative Negative

Extension Iliopsoas strain

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 Test/Sign MUSCLE/LIGAMENT NERVE JOINT

FABER Test May be +ve if Negative POSITIVE if SI

piriformis joint

Extension + Minimal pain Negative POSITIVE if

Rotation facet joint

Motor Normal power (5/5) Specific weakness Normal (pain-

Testing (4/5 or less) limited)

Sensory Normal Dermatomal Normal

Testing sensory loss

Reflexes Normal Diminished/absent Normal

at level

Heel Walking Normal Weak if L5 Normal

Toe Walking Normal Weak if S1 Normal

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TABLE 2: MECHANISM DIFFERENTIATION
History Features
Feature PRESSURE STRETCH INFLAMMATION

ONSET Gradual onset Sudden onset Insidious onset over

over days after injury weeks/months

DURATION Acute to Acute (hours to Chronic (>3 months)

subacute days)
(days-weeks)

TIME Worse with Worse initially, Worst early morning (3-

PATTERN prolonged improves with 5 AM)
positions movement

DIURNAL End of day Morning worse Morning stiffness >30

VARIATION worse for 15-30 min min (often >1 hour)

NIGHT PAIN Positional Uncomfortable, Severe, unrelenting,

(can find improves with wakes from sleep
comfort) position
change

MOVEMENT Specific Movement Movement improves,

movements initially hurts, rest worsens
worsen then loosens

REST Helps (unless Initial rest Rest makes worse (gel

nerve uncomfortable, phenomenon)
compressed) then helps

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 Feature PRESSURE STRETCH INFLAMMATION

TRIGGER Repetitive Specific No clear trigger

activity, poor injury/strain
posture event

QUALITY Constant, Aching, tight, Deep, boring,

may be band-like persistent
throbbing

NSAID Moderate Good response DRAMATIC response

RESPONSE response

AGE Usually 40-60 Any age Young (<40) if

years (common 25- inflammatory
45)

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Examination Features

Feature PRESSURE STRETCH INFLAMMATION

MUSCLE May be present Prominent, Minimal

SPASM (secondary) palpable,
asymmetric

TRIGGER Absent Present, Absent

POINTS reproducible

ROM Painful in Painful at end- Globally reduced, stiff

specific range
direction

NEURO Present if nerve Absent Absent

SIGNS compressed

SLR if Nerve Positive at low Negative Negative

angle

Facet Positive if facet Negative Positive if facet

Provocation OA arthritis

SI Joint Tests Negative Negative Positive if sacroiliitis

TENDERNESS Point Diffuse Joint line tenderness

tenderness muscle
over tenderness
compressed
area

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TABLE 3: SPECIFIC CLINICAL SCENARIOS
Clinical Picture Think Matrix Cell

45yo, acute pain after Iliopsoas MUSCLE + STRETCH

lifting, paramedian, aching, strain
pain rising from chair, better
with walking

50yo, pain to lateral foot, S1 NERVE + PRESSURE

burning, worse sitting, radiculopathy
coughing hurts, can't toe
walk

28yo, 4 months pain, wakes Ankylosing JOINT + INFLAMMATION

at 4 AM, stiff 90 min, better Spondylitis
with exercise, buttocks pain

60yo, pain on standing >20 Spinal NERVE + PRESSURE

min, better sitting/leaning stenosis
forward, bilateral leg
heaviness

35yo, flank pain turning in QL strain MUSCLE + STRETCH

bed, no urinary symptoms
on USG

55yo, localized back pain, Facet JOINT +

worse with extension, arthropathy PRESSURE/INFLAMMATION
elderly, no radiation

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TABLE 4: CLINICAL REASONING GUIDE
Use this during history to build diagnostic thinking

Patient Says Your Thinking Process

Pain goes to ankle If muscle, would stop above knee. Goes

to ankle = NERVE

Burning, tingling feeling If muscle, would be aching. Burning =

NERVE pain

Worse when I wake up, better If mechanical, rest would help. Better
after moving with movement = INFLAMMATION

Pain when getting up from If disc, sitting worse. Rising movement =

chair MUSCLE (Iliopsoas)

Can't do toe walking If muscle weakness, all movements

weak. Specific toe walking = NERVE (S1)

Wakes me at 3 AM every night If muscle/disc, position change helps.

Unrelenting night pain = INFLAMMATION
or red flag

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TABLE 5: CRITICAL 'NEVER MISS' FEATURES
Feature Meaning Urgency

Bilateral leg NOT muscle, NOT simple EMERGENCY

symptoms disc - Think Cauda
equina

Saddle anesthesia Cauda equina until EMERGENCY

proven otherwise

Progressive motor Nerve under increasing URGENT MRI

weakness pressure

Fever + back pain Infection until proven URGENT

otherwise

Night pain Inflammation OR red flag Investigate

(unrelenting) (cancer/infection)

Age >50 + new Consider: Cancer, Higher suspicion

onset fracture, stenosis

Pain BELOW knee Radiculopathy, NOT Different management

simple back pain

Morning stiffness Inflammatory arthritis Rheumatology workup

>1 hour

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SUMMARY: THE 3×3 MATRIX CHEAT SHEET

STRUCTURE Recognition (30 seconds):

MUSCLE = Paramedian + Stops above knee + Aching + Normal neuro
NERVE = Below knee + Burning/tingling + Positive SLR + Motor/sensory loss
JOINT = Localized + No radiation + Joint tenderness + Normal neuro

MECHANISM Recognition (30 seconds):

PRESSURE = Specific position worse + Gradual onset + May have neuro
signs
STRETCH = Acute injury + Movement initially hurts + Tight muscles + Trigger
points
INFLAMMATION = Night pain + Morning stiffness >30 min + Better with
movement + Chronic

TREATMENT Follows Automatically:

• MUSCLE + STRETCH → Muscle Relaxant + NSAID
• NERVE + PRESSURE → NSAID + Gabapentin (± Steroid if acute severe)
• JOINT + INFLAMMATION → NSAID (mainstay) + Refer rheumatology

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