Spotting Back Pain Malingerers: A Pain in the Annulus

This past weekend I attended the NPACE continuing education conference in Nashville. Not only was I able to connect with old friends from my NP program, I also learned a thing or two about healthcare. One particular presentation that caught my interest discussed all things back pain. Working in the emergency department I treat a lot of patients for back pain. While most of my patients are well intentioned, presenting with legitimate back injuries, back pain is a common complaint among drug seekers.

So, how do you spot a malingering back pain patient? Back pain expert and orthopedic nurse practitioner Gregory Holm (who practices at a ski resort by the way!) reviewed Waddell’s Signs. These signs, if positive, have been historically used to indicate inorganic (read psychological or nonexistent) back pain. Could this insightful set of tests can help you spot drug seekers in your practice? Let’s do a quick review of Waddell’s Signs and discuss their accuracy. 

Waddell’s Signs

Waddell’s signs are the 1987 creation of physician Gordon Waddell. The signs were initially published in a paper entitled “A New Clinical Model for the Treatment of Low-Back Pain”. The publication was well received. While the article discussed other features of back pain, such as the effect of physical activity on outcomes, it became famous for Waddell’s list of signs that identify “magnified or inappropriate illness behavior”. Waddell’s five signs of inorganic back pain include:

  • Tenderness Tests– superficial tenderness with the slightest touch, and/or tenderness that crosses multiple anatomic structures
  • Simulation Tests– pain with axial load (when pushing on the patient’s head) and/or pain with simulated rotation (rotating the shoulders and pelvis together maintains the alignment of the back and should not be painful)
  • Distraction Tests– inconsistent results, positive tests are rechecked when the patient’s attention is distracted (ex. the examiner performs an initial straight leg raise test eliciting pain then extends the patient’s knee at another point during the visit without pain)
  • Non-Anatomic Sensory Changes– regional weakness or sensory changes that are inconsistent with dermatomal distribution (weakness that is jerky or “cog-wheeling” or give-way weakness, sensory loss in an entire extremity)
  • Overreaction– exaggerated responses out of proportion to the exam

If three of the five tests are positive, there is a high probability the patient has a non-organic cause of low back pain. While Waddell’s signs make it likely the patient’s pain is psychogenic, they can not completely exclude an organic cause of back pain. Waddell himself warns that positive tests do not necessarily indicate faking symptoms or malingering but that there may be a psychosocial issue affecting the patient’s symptoms.

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Waddell’s signs have been extensively studied, and even re-evaluated by Waddell himself. Several objections to the tests have been raised. Many researchers caution that Waddell’s signs address the problem of low back pain too narrowly. Pain is intrinsically related to fear. So, patients with organic back pain may test positive on Waddell’s scale simply out of fear that a maneuver performed by the examiner may be painful. Preconceived notions on part of the examiner have also been shown to affect the outcome of Waddell’s tests. And, while positive Waddell’s signs may detect a psychosocial cause of pain, this does not necessarily indicate malingering. It may be a result of another psychological problem such as depression.


Waddell’s signs should be used with caution. They can be a helpful indicator that non-organic causes of back pain are at play but examiners must be cautious that preconceived notions don’t color test results. The tests must be performed in a standardized, consistent manner. Waddell’s signs do not rule out physical causes of back pain so healthcare providers must evaluate patients with positive signs completely for concurrent physical findings. Ultimately, these tests are not a highly reliable method of spotting malingerers and drug seekers.

Oh yeah, what is an annulus, anyway?

If you could use an anatomy refresher, the annulus is the outer ring of the discs between the vertbrae of the spine. The annulus surrounds an inner gel-like center called the nucleus pulposus. The strong fibers that make up the annulus ensure that pressure is spread evenly across the disc. When disc degeneration or spinal injury occur, the nucleus may be forced out of the surrounding annulus putting pressure on the nerve located near the disc. This commonly causes sciatica.

The annulus weakens with age leaving us more prone to back injuries and chonic back pain. The annulus is also responsible for loss of height with age. The disc naturally shrikns in size over time resulting in shorter stature. Depressingly, more than 60 percent of individuals show evidence of degenerative disc disease on MRI after age 40.

Do you use Waddell’s signs in your practice? What indicators do you use to spot drug seekers?


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1 thought on “Spotting Back Pain Malingerers: A Pain in the Annulus”

  1. Waddell’s “theories” have fallen out of favor as a way of diagnosing different types of pain. This test is akin to using leaches….ancient practice.

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