Waddell’s Sign


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Waddell’s Signs: Consisting of 5 types of physical signs:

Tenderness: Tenderness is usually localized to a particular skeletal or neuromuscular structure. Nonorganic tenderness is related to the following.

  • Non-anatomic – deep tenderness felt over a wide area, not localized to one structure, often extending to the thoracic spine, sacrum or pelvis.
  • Superficial – skin is tender to a light pinch over a wide area of lumbar skin. Be aware of areas relating to nerve impingement.

Simulation: Gives the patient the impression that a certain test is being carried out when it is not. If pain is reported, a nonorganic influence is suggested.

  • Axial loading – low back pain is reported on vertical loading over the standing patient’s skull by the examiner’s hands. Neck pain is common and should be discounted.
  • Rotation – back pain is reported when shoulders and pelvis are passively rotated in the same plane as the patient stands relaxed with the feet together. In the presence of nerve root irritation, leg pain may be reproduced and should be discounted.

Distraction: a positive physical finding is demonstrated in the routine manner, then performed with the patient’s attention distracted. The distraction should be nonpainful, nonemotional and nonsurprising. Findings present only at formal examination and disappear at other times may be nonorganic.

  • Straight leg raising – patients with nonorganic components will show marked improvement on straight leg raising with distraction compared with formal testing. There are several variations based on sitting, known as the ‘flip test’.

Regional: involve a widespread region of neighbouring parts such as the leg below the knee, the entire leg, or a quarter or half of the body. It does not correspond with accepted neuroanatomy.

  • Weakness – demonstrated in formal testing by a cogwheel ‘giving way’ of muscle groups that cannot be explained on a localized neurological basis.
  • Sensory – disturbances including diminished sensation to light touch, pinprick, and sometimes other modalities fitting a ‘stocking’ rather than dermatological pattern. ‘Giving way’ and sensory changes often occur in the same area with possible associated nonanatomic tenderness.

Overreaction: during examination in the form of exaggerated verbalization, facial expression, muscle tension or tremor, sweating, or collapsing. Any individual sign counts as a positive sign for that type, a finding of three or more of the five types is clinically significant. Isolated positive signs are ignored (Waddell et al. 1980).


Welcome Students of the ESP!!!


Welcome to our website about the assessment of the lumbar spine. First, we will provide you with a little tutorial on how to use the website. Then, you are invited to participate in a quiz to test your current knowledge.

The website

The goal of the website is to guide students during the assessment of certain lumbar spine conditions. Therefore, we advise you to first take a look at the anatomy of the lower back to understand the conditions and gain sufficient knowledge on the subject.

The examination page talks about the general examination of the low back, including general patient historyobservation as well as active and passive range of motion (ROM) and neurological testing.  This page insures you get the general knowledge you will need to assess a patient with low back problems.

Next to a-specific low back pain and malingering, the website includes lumbar spinal stenosis (LSS), disc herniation, lower crossed syndrome, lumbar instability and scoliosis as low back pathologies. All these conditions are described and subdivided into the different examination parts: patient history, assessment and treatment. The first two subcategories tell you what you should look for/what you might find in a patient with that specific pathology; questions you should ask, what tests to do and what the findings might be. Also in the assessment parts, different assessment tests will be mentioned. When clicking on the test, a link will forward you to the video of the test. The video will show how to perform the test with explanations. The treatment part is only a treatment suggestion and should only be taken as an orientation.

The flowchart is meant to be an orientation how to assess a patient entering with low back pain.

Once you studied Magee, other lecture content and our website, you can go to the exam page to test your knowledge in a final quiz.

When you read over all these parts and you are wondering where this information comes from or you doubt certain choices we made, please feel free and take a look at our thesis.

ReferencesAs you can see from the image, all the references we used are included in the text and linked to the original article or their abstracts. When you go over the references, you can see that the mouse indicator become a “little hand” and the text is underlined. Just click on the authors name to open the original text in a new tab. 

Have fun!!!

The quiz

Take the Quiz!

The quiz is meant to test your knowledge. In case you fail the quiz, we strongly advise you to take your Magee and study Chapter 9 before exploring the website.

All pictures and movies on this website, apart from the anatomical pictures, were created by the editors/authors of this website and belong to the ESP, Hogeschool van Amsterdam.