The high prevalence of back pain continues in spite of many available treatments, without any single treatment being a panacea. In routine clinical practice there has been a tendency for clinical examinations to become more cursory, largely influenced by increasing demands of time and arguably an overreliance on technology. The purpose of this discussion is to assist clinicians in the development of more specific problem focused examinations that can enhance the differential diagnosis of specific pain generators, and therefore lead to more patient centered specific treatments with the goal of enhancing clinical outcomes. Attention will be given to considering all aspects of the examination, including physical assessment as well as imaging studies, and the ability to rationalize when pathologies seen on imaging studies may or may not be clinically significant. The importance of considering how failed treatments influence the differential diagnosis will also be discussed.