The ED clinician must be able to distinguish between true pathologic back pain and nonorganic back pain.

Waddell’s signs are physical exam findings that can aid in making this important distinction and can be remembered by the acronym “DORST” (Distraction, Over-reaction, Regional disturbances, Simulation tests and Tenderness).

Superficial, non-anatomic, or variable tenderness during the physical exam suggests a non-organic cause.

The clinician may also simulate back pain through provocative maneuvers such as axial loading of the head or passive rotation of the shoulders and pelvis in the same plane. Neither maneuver should elicit low back pain.

There may be a discrepancy between the symptoms reported during the supine and sitting straight leg raise (SLR). The seated version of the test, sometimes termed the distracted SLR, can be performed while distracting the patient or appearing to focus on the knee. Further, radicular pain elicited at a leg elevation of less than 30° degrees is suspicious because the nerve root and surrounding dura do not move in the neural foramen until an elevation of more than 30° degrees is reached.

Sensory and motor findings suggestive of a nonorganic cause include stocking, glove or non-dermatomal sensory loss or weakness that can be characterized as “give-way,” jerky or cogwheel.

Finally, gross overreaction is suggested by the exaggerated, inconsistent painful responses to a stimulus.

Waddell’s signs, especially if three or more are present, correlate with malingering and functional complaints (physical findings without anatomic cause). When combined with shoulder motion and neck motion producing lower back pain, Waddell’s signs predict a decreased probability of the individual returning to work.

That said, Waddell’s signs should never be used independently because they lack the sensitivity and specificity to rule out true organic pathology. Further, our focus should be on evaluating for medical emergencies. Malingering and psychosocial causes of pain are diagnosis of exclusion.