The Meaning of Waddell's Signs

AuthorSamuel D. Hodge, Jr./Jack E. Hubbard
ProfessionSkilled litigator, is chair of the department of legal studies at Temple University/Professor of Neurology at the University of Minnesota
The Meaning of
Waddells Signs
Samuel D. Hodge Jr., Jack E. Hubbard, and Nicole Marie Saitta
is duping.
is trickery.
Toba Beta, 2011
The worst crime
is faking it.
Kurt Cobain,
When pain ends,
gain ends too.
Robert Browning,
Beth was involved in a motor vehicle accident resulting in low back pain. An orthopedic
surgeon1 diagnosed a minor soft-tissue injury to her lower back and prescribed three
months of physical therapy. At the completion of that treatment, Beth still complained
of tremendous pain in the lumbar region that radiated down both legs. The physician
ordered an MRI of the back and electrodiagnostic testing, which were both normal. Dur-
ing a follow-up examination, the patient exclaimed that the pain had become much worse,
preventing her from engaging in any form of activity. The discomfort was so severe that
the patient complained when the doctor merely touched the skin on her back, and he
was unable to lift her leg off the table without producing radiating pain. The doctor
was puzzled by these symptoms since he could not appreciate any muscle spasms, her
neurological exam was normal, and the pain did not follow a known anatomic pathway.
Upon completion of the examination, he wrote in Beth’s chart that she was focused on
the accident and exhibited multiple Waddell’s signs. What did the doctor mean by these
comments? Is he saying that his patient is a malingerer and a fraud?
Scope of the Problem
Most people with low back pain back enjoy a good recovery, with 60 percent of those
individuals become asymptomatic within six weeks.2 The overwhelming majority of all
low back pain sufferers become pain-free within three months of the start of their symp-
toms.3 Surprisingly, only a small percentage of those with chronic symptoms incur the
bulk of the cost in treating low back pain.4 In fact, about three-quarters of these expenses
are incurred by a mere 20 percent of these individuals.5 The fact that a benign physi-
cal problem has such an important socioeconomic impact can probably be explained by
complex psychological, societal, and legal factors.6
Distinguishing between individuals who have a significant nonorganic component to
their low back pain and those who do not is challenging.7 This point is complicated by
the fact that those with chronic low back pain who do not or no longer have compensa-
tion claims pending tend to have much better treatment outcomes than those involved
in active litigation.8 It has even been suggested that 20 to 30 percent of compensation
claimants who have a legitimate injury show some degree of “lack of effort” or exag-
geration of their complaints.9 Secondary gain may also be a significant contributing fac-
tor in illness and disability.10 In this regard, several tests have been developed to detect
nonorganic causes of low back pain, and Waddell’s signs are the best known. Although

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