Waddells Sign


Waddell's signs were developed to identify psychogenic, or nonorganic, manifestations of pain in patients that may have heightened emotional effects on their conditions. In order for these signs to be significantly correlated with disability, three of the five signs should be present, Waddell et al. in 1980.4  They have been also associated with detecting malingering in patients with complaints of lower back pain.


1. Superficial and Widespread tenderness or Nonanatomic tenderness. (Skin discomfort on light palpation or tenderness crossing over non-anatomical boundaries)
2. Stimulation tests: Axial loading and Pain on simulated rotation. (eliciting pain when pressing down on the top of the patient’s head or rotating the shoulders and pelvis together should not be painful)
3. Distracted straight leg raise. (if a patient complains of pain on straight leg raise, but not if the examiner extends the knee with the patient seated at another time during the initial evaluation)

4. Non-anatomic sensory changes: Regional sensory changes and Regional weakness.(sensory loss in an entire extremity or side of the body or weakness that is nonconsistent and jerky, ie "cogwheeling")
5. Overreaction. (Exaggerated painful response to a stimulus, that is not reproduced when the same stimulus is given later)

If there are more than 3 of 5 present then there is high probability that patient has non-organic pain.


There have been questions and research that has questioned the reliability of Waddell's signs when trying to associate positive Waddell's signs with non-organinc signs and physiological signs. (Fishbain, Cole, Cutler, Lewis, Rosomoff, & Rosomoff, A structured evidence-based review on the meaning of nonorganic physical signs: Waddell signs. Pain Medicine. 4(2):141-81, 2003 Jun.)

Although Waddell's signs can detect a non-organic component to pain, they do not exclude an organic cause. A high Waddell score (>3) is indicative only of symptom magnification or possible illness behavior. Often the test has been misused (Main, Chris J. PhD; Waddell, Gordon DSc. MD. Spine. 23(21):2367-2371, November 1, 1998.). It does not signify malingering.


"Nonorganic physical signs in low-back pain". PMID 6446157