by James J. Lehman, DC, MBA

It is common for healthcare providers to make a diagnosis of “low back pain” without identifying the actual pain generators or determining the best therapeutic approach to care.  This is possibly one of the main reasons so many back pain patients progress from acute lower back pain to chronic lower back pain, a global public health problem and  leading cause of disability all over the world.[1]

I believe that the lack of properly trained primary care providers is the reason that we now have a chronic pain epidemic complicated by an opioid addiction epidemic.[2] At the University of Bridgeport, College of Chiropractic, I have taught neuromusculoskeletal medicine with a focus on physical examination and differential diagnosis to hundreds of chiropractic students. Each of the students were required to memorize the definition of an orthopedic test, which I coined some 12 years ago based upon my experience and a paper written by Simpson and Gemmel.[3]

An orthopedic test is most often a provocative maneuver performed to reproduce the patient’s chief concern pain, in order to identify the painful tissue.

The performance of orthopedic testing with lower back pain patients should augment the differential diagnosis process and lead to appropriate, high-quality health care. Too often lower back pain patients are misdiagnosed.  Not every low back pain patient is suffering with a disc condition at the lumbo-sacral spine.  Oftentimes, when a patient complains of pain in the area of the sacro-iliac region or the posterior iliac crest, a diagnosis of mechanical low back pain is made by chiropractors and osteopaths and spinal manipulation of the lumbo-sacral spine and sacro-iliac joints is performed.

If the pain generators such as lumbar facet capsules and localized active myofascial trigger points are symptomatic expressive, due to biomechanical dysfunction at these levels of the spine, spinal manipulation is indicated and may produce a satisfactory response to care.[4] Usually, this condition is diagnosed as a lumbar facet syndrome, will respond to spinal manipulation within six to 12 treatments.[5] An osteopathic physician at the University of North Texas Health Science Center cited an article that discusses spinal manipulation dosing and efficacy.[6]

In their dose-response and efficacy trial of spinal manipulative therapy (SMT) in patients with chronic nonspecific low back pain (LBP), Haas et al. [1] concluded that 12 treatment sessions are the best dose within a 12-week end point. This was largely based on responder analysis wherein 50 percent of patients achieved at least 50 percent pain improvement with this dose of chiropractic treatment, which consisted primarily of high-velocity low-amplitude thrust techniques. In comparison with 0 sessions (control), significantly more patients responded to this 12-session regimen but not to the six- or 18-session regimens.

Yet, chiropractors and osteopaths often make the lumbar facet syndrome diagnosis and provide spinal manipulation without relief of the lower back pain.  The reason may be that the actual cause of the lower back pain originates in the lower thoracolumbar facet joints. Maigne has reported that up to 40 percent of patients with lower back pain are actually experiencing biomechanical problems at the thoracolumbar spine rather than the lumbo-sacral spine.  This misdiagnosis may lead to chronic lower back pain. He explains that the clinical diagnosis of thoracolumbar junction syndrome may be performed with palpation, skin rolling, and precise location of the pain.

Low back pain arising from the apophyseal joints of the thoracolumbar region is common and is often erroneously attributed to pathologic changes in the low back. The diagnosis is made on pure clinical grounds. Classic signs are: a positive “iliac-crest point” test, a positive skin-rolling test, localized tenderness over a certain spinous process at the thoracolumbar junction and tenderness over the involved apophyseal joint. The diagnosis is confirmed by a periapophyseal joint block using a local anesthetic. Of 350 patients seen in a back pain clinic, 40 percent were found to have pain of thoracolumbar origin. Treatment included manipulation, infiltration with corticosteroids, electrocoagulation and/or surgical denervation of the involved apophyseal joint. [7]

It has been my clinical experience that strains of the thoracolumbar paravertebral muscles with resultant myofascial trigger points and subsequent facet joint dysfunction may cause activation of the primary division of a posterior ramus of a spinal nerve (dorsal ramus of a spinal nerve). The compression or irritation may cause referred pain into one or more of the cluneal nerve distributions. Maigne described these localized and referred pain areas.

  • Unilateral lower back pain, usually in the sacroiliac region
  • Inguinal or testicular pain
  • Abdominal pain
  • Gynecological symptoms or pain
  • Pubic pain

I strongly recommend that with every patient presenting with low back pain, due to a neuromusculoskeletal condition, one must evaluate the patient’s lumbo-sacral and thoraco-lumbar spine prior to commencing manual medicine interventions. The evaluation should include a history of present illness that questions the location of the chief concern pain and secondary or tertiary locations, such as the abdomen, groin, and lower extremity.  Palpation should attempt to elicit pain over the thoracolumbar paravertebral muscles and the cluneal nerves at the posterior iliac crest in the area of the sacro-iliac joint and the superior gluteal muscles.  Palpation of the irritated branch of the cluneal nerve should reproduce the chief concern, lower back pain. The experienced examiner will note enlargement of the symptomatic expressive cluneal nerve.

When this condition is properly identified and diagnosed, spinal manipulation of the thoraco-lumbar spine will usually resolve the lower back pain. Maigne claimed that thoracolumbar junction syndrome is particularly responsive to spinal manipulative therapy, and no further treatment is required in most cases as long as it is performed adequately.[8]

Note, Maigne’s syndrome is known by a number of different names including posterior ramus syndrome, thoracolumbar junction syndrome, and dorsal ramus syndrome.



[1] Gedin F, Skeppholm M, Burström K, Sparring V, Tessma M, Zethraeus N. Effectiveness, costs and cost-effectiveness of chiropractic care and physiotherapy compared with information and advice in the treatment of non-specific chronic low back pain: study protocol for a randomised controlled trial. Trials. 2017 Dec 22; 18(1):613.

[2] A Call to Revolutionize Chronic Pain Care in America: An Opportunity in Health Care Reform. The Mayday Fund.  March 4, 2010.

[3] Simpson R. and Gemmell H. Accuracy of spinal orthopaedic tests: a systematic review. Chiropractic and Osteopathy. 2006 14:26.

[4] Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine J. 2004 May-Jun; 4(3):335-56.

[5] Mitchell Haas, Darcy Vavrek, David Peterson, Nayak Polissar, and Moni B. Neradilek, Dose. Response and Efficacy of Spinal Manipulation for Care of Chronic Low Back Pain” A Randomized Controlled Trial. Spine J. 2014 Jul 1; 14(7): 1106–1116.

[6] Licciardone JC. Short-term dosing of manual therapies for chronic low back pain. Spine J. 2014 Jun 1; 14(6):1085-6.

[7] Maigne R. Low back pain of thoracolumbar origin. Arch Phys Med Rehabil. 1980 Sep; 61(9):389-95.

[8] Soo-Ryu Kim, Min-Ji Lee, Seung-Jun Lee, Young-Sung Suh, Dae-Hyun Kim, and Ji-Hee Hong. Thoracolumbar Junction Syndrome Causing Pain around Posterior Iliac Crest: A Case Report. Korean J Fam Med. 2013 Mar; 34(2): 152–155.