Thoracic and Lumbar Spine Special Tests and Pathologies Orthopedic Assessment III – Head, Spine,...

Thoracic and Lumbar Thoracic and Lumbar Spine Special Tests Spine Special Tests

and Pathologiesand PathologiesOrthopedic Assessment III Orthopedic Assessment III – Head, Spine, and Trunk – Head, Spine, and Trunk

with Labwith Lab

PET 5609CPET 5609C

Clinical EvaluationClinical Evaluation

Spring Test:Spring Test: Test Positioning:Test Positioning:

Subject is proneSubject is prone Examiner stands with thumbs or hypothenar Examiner stands with thumbs or hypothenar

eminence over the spinous process of a lumbar eminence over the spinous process of a lumbar vertebraevertebrae

Action:Action: Apply a downward “springing” force through the Apply a downward “springing” force through the

spinous process of each vertebrae to assess anterior-spinous process of each vertebrae to assess anterior-posterior motionposterior motion

Positive Finding:Positive Finding: Increases or decreases in motion at one vertebrae Increases or decreases in motion at one vertebrae

compared to another (hypermobility or hypomobility)compared to another (hypermobility or hypomobility)


Nerve Root Nerve Root Impingement:Impingement: Narrowing of Narrowing of

intervertebral intervertebral foramen:foramen:

StenosisStenosis Facet joint Facet joint

degenerationdegeneration Herniated Herniated

intervertebral discintervertebral disc


Clinical EvaluationClinical Evaluation Nerve Root Impingement Tests:Nerve Root Impingement Tests:

Valsalva Test:Valsalva Test: Test Position:Test Position:

Patient seated, examiner standing next to patientPatient seated, examiner standing next to patient Action:Action:

Subject takes a deep breath and holds while bearing Subject takes a deep breath and holds while bearing down as if having a bowel movementdown as if having a bowel movement

Positive Finding:Positive Finding: Increased spinal or radicular pain due to Increased spinal or radicular pain due to ↑ ↑ intrathecal intrathecal

pressurepressure May be secondary to a space-occupying lesion (i.e. May be secondary to a space-occupying lesion (i.e.

herniated disc, tumor, osteophyte in lumbar canal)herniated disc, tumor, osteophyte in lumbar canal) Comments:Comments:

Increase in intrathecal pressure may result in Increase in intrathecal pressure may result in ↓ ↓ pulse, pulse, ↓ venous return, ↑ venous pressure (dizziness and/or ↓ venous return, ↑ venous pressure (dizziness and/or fainting)fainting)


Milgram Test:Milgram Test: Test Position:Test Position:

Patient supine, examiner at feet of the patientPatient supine, examiner at feet of the patient Action:Action:

Patient performs a bilateral straight leg raise to Patient performs a bilateral straight leg raise to the height of 2 to 6 inches and is asked to hold the height of 2 to 6 inches and is asked to hold the position for 30 secondsthe position for 30 seconds

Positive Finding:Positive Finding: Patient unable to hold position, cannot lift the Patient unable to hold position, cannot lift the

leg, or has pain with testleg, or has pain with test Implications:Implications:

Intrathecal or extrathecal pressure causing an Intrathecal or extrathecal pressure causing an intervertebral disc to place pressure on a lumbar intervertebral disc to place pressure on a lumbar nerve rootnerve root


Kernig’s Test:Kernig’s Test: Test Position:Test Position:

Patient supine, examiner at side of patientPatient supine, examiner at side of patient Action:Action:

Patient performs a unilateral active straight leg Patient performs a unilateral active straight leg raise with the knee extended until pain occursraise with the knee extended until pain occurs

After pain occurs, the patient flexes the kneeAfter pain occurs, the patient flexes the knee Positive Finding:Positive Finding:

Pain in the spine and possibly radiating into Pain in the spine and possibly radiating into lower extremitylower extremity

Pain relieved when patient flexes the kneePain relieved when patient flexes the knee Implications:Implications:

Nerve root impingement secondary to bulging of Nerve root impingement secondary to bulging of the intervertebral disc or bony entrapment; the intervertebral disc or bony entrapment; irritation of dural sheath; irritation of meningesirritation of dural sheath; irritation of meninges

Clinical EvaluationClinical Evaluation Nerve Root Nerve Root

Impingement Tests:Impingement Tests: Kernig/Brudzinski Kernig/Brudzinski

Test:Test: Patient actively flexes Patient actively flexes

the cervical spine (lifts the cervical spine (lifts the head)the head)

Hip unilaterally flexed Hip unilaterally flexed (no more than 90(no more than 9000))

Knee than flexed to no Knee than flexed to no more than 90more than 9000

(+) ↑ pain with neck (+) ↑ pain with neck and hip flexion; pain and hip flexion; pain relieved when knee is relieved when knee is flexedflexed


Nerve Root Impingement Tests:Nerve Root Impingement Tests: Unilateral Straight Leg Raise Test Unilateral Straight Leg Raise Test

(Lasegue Test):(Lasegue Test): Test Position:Test Position:

Patient supine, examiner standing at tested Patient supine, examiner standing at tested side with the distal hand around the subject’s side with the distal hand around the subject’s heel and proximal hand on subject’s distal heel and proximal hand on subject’s distal thigh (anterior) – maintains knee extensionthigh (anterior) – maintains knee extension

Action:Action: Examiner slowly raises the leg until Examiner slowly raises the leg until

pain/tightness noted or full ROM is obtainedpain/tightness noted or full ROM is obtained Slowly lower the leg until the pain or Slowly lower the leg until the pain or

tightness resolves, at which point dorsiflex tightness resolves, at which point dorsiflex the ankle and have subject flex the neckthe ankle and have subject flex the neck

Clinical EvaluationClinical Evaluation Straight Leg Raise Straight Leg Raise

Test: Test: Positive Findings:Positive Findings:

Leg and/or low back Leg and/or low back pain occurring with pain occurring with DF and or neck DF and or neck flexion is indicative flexion is indicative of dural involvement of dural involvement and/or sciatic nerve and/or sciatic nerve irritationirritation

Lack of pain Lack of pain reproduction with DF reproduction with DF and/or neck flexion is and/or neck flexion is indicative of indicative of hamstring tightness hamstring tightness or SI pathologyor SI pathology


Nerve Root Impingement Tests:Nerve Root Impingement Tests: Well Straight Leg Raising Test:Well Straight Leg Raising Test:

Can be used to differentiate between Can be used to differentiate between sciatic nerve irritation or a herniated sciatic nerve irritation or a herniated intervertebral disc that is irritating the intervertebral disc that is irritating the nerve root nerve root

Test Position:Test Position: Patient supine, examiner standing at Patient supine, examiner standing at

unaffected side; one hand grasps under the unaffected side; one hand grasps under the heel while other is placed on anterior thigh heel while other is placed on anterior thigh to stabilize the leg in extensionto stabilize the leg in extension


Well Straight Leg Well Straight Leg Raise Test:Raise Test: Action:Action:

Examiner raises the Examiner raises the leg by flexing the leg by flexing the hip until discomfort hip until discomfort is reported (knee is reported (knee kept in full kept in full extension) extension)

Positive Finding:Positive Finding: Pain is experienced Pain is experienced

on the side opposite on the side opposite that being raisedthat being raised


Nerve Root Impingement Tests:Nerve Root Impingement Tests: Quadrant Test:Quadrant Test:

Test Position:Test Position: Patient standing with feet shoulder width Patient standing with feet shoulder width

apartapart Examiner stands behind the patient, Examiner stands behind the patient,

grasping the patient’s shouldersgrasping the patient’s shoulders Action:Action:

Patient extends the spine as far as possible, Patient extends the spine as far as possible, than sidebends and rotates to affected sidethan sidebends and rotates to affected side

Examiner provides overpressure through the Examiner provides overpressure through the shoulders, supporting the patient as neededshoulders, supporting the patient as needed


Nerve Root Impingement Tests:Nerve Root Impingement Tests: Quadrant Test:Quadrant Test:

Positive Findings:Positive Findings: Reproduction of patient’s symptomsReproduction of patient’s symptoms

Implications:Implications: Radicular pain indicates compression of the Radicular pain indicates compression of the

intervertebral foramina that impinges on the intervertebral foramina that impinges on the lumbar nerve rootslumbar nerve roots

Local pain (not radiating) indicates facet Local pain (not radiating) indicates facet joint pathologyjoint pathology

Symptoms isolated to the area of the PSIS Symptoms isolated to the area of the PSIS may indicate SI joint dysfunctionmay indicate SI joint dysfunction


Nerve Root Impingement Tests:Nerve Root Impingement Tests: Slump Test:Slump Test:

Test Position:Test Position: Patient sits over edge of table; examiner is at Patient sits over edge of table; examiner is at

side of patientside of patient Action:Action:

(1) Patient slumps forward along thoracolumbar (1) Patient slumps forward along thoracolumbar spine, rounding the shoulders while keeping spine, rounding the shoulders while keeping cervical spine neutralcervical spine neutral

(2) Patient flexes cervical spine; Clinician holds (2) Patient flexes cervical spine; Clinician holds patient in this positionpatient in this position

(3) Knee is actively extended(3) Knee is actively extended (4) Ankle is actively dorsiflexed(4) Ankle is actively dorsiflexed (5) Repeat on opposite side(5) Repeat on opposite side


Slump Test:Slump Test: Positive Findings:Positive Findings:

Sciatic pain or Sciatic pain or reproduction of reproduction of other neurological other neurological symptomssymptoms

Implications:Implications: Impingement of Impingement of

the dural lining, the dural lining, spinal cord, or spinal cord, or nerve rootsnerve roots

Note: Patient performs ACTIVE knee extension and dorsiflexion

Clinical EvaluationClinical Evaluation Test for Patient Test for Patient

Malingering:Malingering: Malingering – medical Malingering – medical

and psychological and psychological terms that refers to an terms that refers to an individual individual fabricating/exaggeratinfabricating/exaggerating their level of g their level of symptomssymptoms

Financial Financial compensation (fraud)compensation (fraud)

Avoiding workAvoiding work Obtaining drugsObtaining drugs Attract attention or Attract attention or

sympathysympathy

Clinical EvaluationClinical Evaluation Test for Patient Malingering:Test for Patient Malingering:

Hoover Test:Hoover Test: Test Position:Test Position:

Patient supinePatient supine Examiner at feet of patient with hands cupping Examiner at feet of patient with hands cupping

the calcaneous of each legthe calcaneous of each leg Action:Action:

Patient attempts to actively straight leg raise on Patient attempts to actively straight leg raise on the involved sidethe involved side

Positive Findings:Positive Findings: Patient does not attempt to lift the leg and Patient does not attempt to lift the leg and

examiner does NOT sense pressure from the examiner does NOT sense pressure from the uninvolved leg pressing down on the hand uninvolved leg pressing down on the hand

Patient is not attempting to perform the testPatient is not attempting to perform the test


Test Note: Examiner should be standing at feet of patient with their hands cupping the heels of each leg


Nerve Nerve Root Root LevelLevel

Sensory TestingSensory Testing

L1L1 Inguinal area (just below inguinal Inguinal area (just below inguinal ligamentligament

L2L2 Mid-thigh (medial)Mid-thigh (medial)

L3L3 Medial knee (just above superior Medial knee (just above superior pole of patella)pole of patella)

L4L4 Medial aspect of lower leg, medial Medial aspect of lower leg, medial ankle, big toeankle, big toe

L5L5 Top of foot (an/or blow head of Top of foot (an/or blow head of fibula)fibula)

S1S1 Lateral footLateral foot

S2S2 Posterior thigh, popliteal fossaPosterior thigh, popliteal fossa

Lower Quarter Neurological ScreenLower Quarter Neurological Screen


Nerve Root Nerve Root LevelLevel

Motor TestingMotor Testing

L1L1 Hip flexionHip flexion

L2L2 Hip flexionHip flexion

L3L3 Knee extensionKnee extension

L4L4 DorsiflexionDorsiflexion

L5L5 Great toe extensionGreat toe extension

S1S1 PlantarflexionPlantarflexion

S2S2 NANA



Nerve Nerve Root Root LevelLevel

Reflex Reflex TestingTesting

L4L4 Patellar Patellar TendonTendon

L5L5 Patellar Patellar TendonTendon

S1S1 Achilles Achilles TendonTendon

S2S2 Achilles Achilles TendonTendon


Clinical EvaluationClinical Evaluation Babinkski’s Test:Babinkski’s Test:

Test Position: athlete supineTest Position: athlete supine Athletic Trainer Position: At Athletic Trainer Position: At

the foot of the athlete the foot of the athlete holding a blunt tool (reflex holding a blunt tool (reflex hammer)hammer)

Procedure: Rub the tool up Procedure: Rub the tool up bottom of athlete’s foot bottom of athlete’s foot starting at the calcaneus and starting at the calcaneus and ending at the great toe.ending at the great toe.

Positive test: Great toe Positive test: Great toe extends while other toes extends while other toes splay.splay.

Implications: Lesion of Implications: Lesion of upper motor neurons, may upper motor neurons, may be caused by trauma to the be caused by trauma to the brainbrain

Comments: This reflex Comments: This reflex occurs naturally in occurs naturally in newborns. However, this newborns. However, this reflex should cease quickly reflex should cease quickly after birth.after birth.


Erector Spinae Erector Spinae Muscle Strain:Muscle Strain: Common low back Common low back

pathologypathology MOI: MOI:

History of heavy or History of heavy or repetitive liftingrepetitive lifting

Signs/Symptoms:Signs/Symptoms: Aching backAching back Pain Pain ↑ ↑ with passive and with passive and

active flexion, resisted active flexion, resisted extensionextension

Neurological Neurological Evaluation:Evaluation:

Negative resultsNegative results

Clinical EvaluationClinical Evaluation Facet Joint Dysfunction:Facet Joint Dysfunction:

Pathology of facet joints – 40% of all chronic Pathology of facet joints – 40% of all chronic low back painlow back pain

Vague signs/symptoms:Vague signs/symptoms: Often resemble other low back pathologies (i.e. Often resemble other low back pathologies (i.e.

strain/spasm of paraspinal muscles, nerve root strain/spasm of paraspinal muscles, nerve root impingement, disc degeneration)impingement, disc degeneration)

Involvement:Involvement: Dislocation/sublocation of facet:Dislocation/sublocation of facet:

Tends to “lock” the involved spinal segment Tends to “lock” the involved spinal segment (hypomobile vertebrae)(hypomobile vertebrae)

Facet joint syndrome: (inflammation)Facet joint syndrome: (inflammation) Causes: repetitive stress through movement or Causes: repetitive stress through movement or

loadingloading Degeneration: (arthritis)Degeneration: (arthritis)

Causes: undefined historyCauses: undefined history ↓ ↓ intervertebral foramen size (nerve root intervertebral foramen size (nerve root

impingement)impingement)


Facet Joint Dysfunction:Facet Joint Dysfunction: History:History:

Onset – insidiousOnset – insidious Pain characteristics – localizedPain characteristics – localized MOI – extension, rotation, lateral bending of MOI – extension, rotation, lateral bending of

vertebraevertebrae Predisposing conditions – repeated motions of Predisposing conditions – repeated motions of

spinal extension, rotation, lateral bendingspinal extension, rotation, lateral bending Inspection:Inspection:

Patient may assume posture that ↓ pressure on Patient may assume posture that ↓ pressure on affected facetsaffected facets

Palpation:Palpation: Possible local muscle spasm (paravertebral muscles)Possible local muscle spasm (paravertebral muscles)

Clinical EvaluationClinical Evaluation Facet Joint Facet Joint

Dysfunction:Dysfunction: Ligamentous Tests:Ligamentous Tests:

Spring Test – pain, Spring Test – pain, ↓ motion↓ motion

Neurological Tests:Neurological Tests: Not applicable Not applicable

unless secondary unless secondary nerve root nerve root impingement occursimpingement occurs

Special Tests:Special Tests: Quadrant Test (+)Quadrant Test (+) Intervertebral disc Intervertebral disc

lesions (-)lesions (-)


Facet Joint Dysfunction:Facet Joint Dysfunction: Initial Treatment:Initial Treatment:

NSAIDsNSAIDs Instruct patient to avoid Instruct patient to avoid

postures/movements that irritate facetspostures/movements that irritate facets Modalities – moist heat, e-stim, ice to ↓ Modalities – moist heat, e-stim, ice to ↓

muscle spasmmuscle spasm Therapeutic Exercises:Therapeutic Exercises:

Stretching and strengthening:Stretching and strengthening: Low backLow back AbdominalsAbdominals Hip flexors, hip extensors, hamstringsHip flexors, hip extensors, hamstrings

Clinical EvaluationClinical Evaluation Intervertebral Disc Intervertebral Disc

Lesions:Lesions: Disc Degeneration:Disc Degeneration:

Loss of water from Loss of water from nucleus pulposusnucleus pulposus

↓ ↓ cushioning abilitycushioning ability ↑ ↑ stress load on stress load on

annulus fibrosusannulus fibrosus Small tears occur to Small tears occur to

annulus (scar tissue annulus (scar tissue formation – not as formation – not as strong as normal strong as normal tissue)tissue)

Bulging of nucleus Bulging of nucleus pulposuspulposus


Intervertebral Disc Intervertebral Disc Herniation:Herniation: Extrusion of nucleus Extrusion of nucleus

pulposus through pulposus through annulus fibrosusannulus fibrosus

Impingement/Impingement/pressure on nerve pressure on nerve root below affected root below affected discdisc

Sequestrated – Sequestrated – nuclear material nuclear material breaks away from breaks away from rest of discrest of disc

MRI lumbar image:

L5/S1 disc has suffered a 9mm disc extrusion (red arrow) that is not contained by the PLL

L4/5 disc has suffered a smaller 4mm disc protrusion (green arrow) that is contained by the PLL

L3/4 (blue arrow) is completely normal and has no disc material projecting posteriorly into the epidural space

Note: L3/4 disc is white in color, which indicates it is non-degenerated (i.e., full of water and healthy proteoglycan)

Herniated discs (L4/5 & L5/S1) are "black" which indicates disc desiccation (lack of water and proteoglycan)


Clinical EvaluationClinical Evaluation Lumbar Disc Degeneration:Lumbar Disc Degeneration:

History:History: Onset – insidious or may be related to single Onset – insidious or may be related to single

episodeepisode Breakdown of disc is related to repetitive stress; Breakdown of disc is related to repetitive stress;

Last episode – final failure an annulus fibrosus to Last episode – final failure an annulus fibrosus to contain nucleus pulposuscontain nucleus pulposus

Pain characteristics – affected vertebrae; Pain characteristics – affected vertebrae; compression of spinal nerve root leads to compression of spinal nerve root leads to pain in low back, buttocks, radiating into pain in low back, buttocks, radiating into thigh, calf, heel, footthigh, calf, heel, foot

MOI – repetitive loading of discMOI – repetitive loading of disc Predisposing condition – history of lumbar Predisposing condition – history of lumbar

spine traumaspine trauma


Lumbar Disc Degeneration:Lumbar Disc Degeneration: Inspection:Inspection:

Slow GAITSlow GAIT Flattened lumbar spineFlattened lumbar spine Changes in body position – guarded and Changes in body position – guarded and

painfulpainful Sitting → standing / sitting → lyingSitting → standing / sitting → lying

Changes in disc pressureChanges in disc pressure Standing position:Standing position:

Lateral shift away from side of leg painLateral shift away from side of leg pain

Palpation:Palpation: Musculature spasmMusculature spasm


Lumbar Disc Degeneration:Lumbar Disc Degeneration: Functional Tests:Functional Tests:

Limited ROM in all directionsLimited ROM in all directions Movement in one direction may relieve or ↓ Movement in one direction may relieve or ↓

symptomssymptoms Neurological Tests:Neurological Tests:

Lower quarter screenLower quarter screen Special Tests:Special Tests:

Straight leg raising, Well straight leg raising, Straight leg raising, Well straight leg raising, Milgram, Sciatic and femoral nerve tension testsMilgram, Sciatic and femoral nerve tension tests

Diagnostic Tests:Diagnostic Tests: MRIMRI


Intervertebral Disc Degeneration: Intervertebral Disc Degeneration: SurgerySurgery Spinal Fusion:Spinal Fusion:

Welding 2 or more vertebrae togetherWelding 2 or more vertebrae together Cause of back pain (motion between Cause of back pain (motion between

vertebral segments) spinal fusion may be a vertebral segments) spinal fusion may be a way to prevent motion and stop the painway to prevent motion and stop the pain

Technique (basics):Technique (basics): Small pieces of extra bone fills space between Small pieces of extra bone fills space between

two vertebrae (pelvic bone, allograft bone)two vertebrae (pelvic bone, allograft bone) Disc removedDisc removed Wires, rods, screws, metal cages or plates may Wires, rods, screws, metal cages or plates may

be usedbe used


Artificial disc replacement: Disc is placed in the disc space through Artificial disc replacement: Disc is placed in the disc space through an abdominal incision; the artificial disc then maintains mobility in an abdominal incision; the artificial disc then maintains mobility in the spine and as such protects the adjacent disc from accelerated the spine and as such protects the adjacent disc from accelerated degeneration and further surgerydegeneration and further surgery


Clinical EvaluationClinical Evaluation Cauda Equina Syndrome:Cauda Equina Syndrome:

Anatomy: spinal cord ends at the lower edge of Anatomy: spinal cord ends at the lower edge of the 1st lumbar vertebra the 1st lumbar vertebra

Lumbar and sacral nerve roots form a bundle Lumbar and sacral nerve roots form a bundle within the spinal canal below the conus within the spinal canal below the conus medullarismedullaris

CES – nerves within the spinal canal have been CES – nerves within the spinal canal have been damaged; nerves supplying muscles of legs, damaged; nerves supplying muscles of legs, bladder, bowel and genitals do not function bladder, bowel and genitals do not function properlyproperly

Numbness, loss of sensation (damage usually Numbness, loss of sensation (damage usually permanent)permanent)

Congenital causes:Congenital causes: Spina bifida (abnormality in closure of spinal canal) Spina bifida (abnormality in closure of spinal canal) Tumors of the cauda equina Tumors of the cauda equina

Acquired causes of Cauda Equina Syndrome:Acquired causes of Cauda Equina Syndrome: Injury (spinal fractures) Injury (spinal fractures) Secondary to medical procedures Secondary to medical procedures

Clinical EvaluationClinical Evaluation Femoral Nerve Stretch Femoral Nerve Stretch

Test:Test: Tests for nerve root Tests for nerve root

impingement at L2, L3, L4impingement at L2, L3, L4 Test position:Test position:

Patient prone with a pillow Patient prone with a pillow under the abdomen; under the abdomen; examiner at side of patientexaminer at side of patient

Action:Action: Examiner passively extends Examiner passively extends

hip while keeping knee hip while keeping knee flexed to 90flexed to 9000

Positive test:Positive test: Pain in anterior and lateral Pain in anterior and lateral

thighthigh

Clinical EvaluationClinical Evaluation Sciatica:Sciatica:

General term for any General term for any inflammation inflammation involving sciatic nerveinvolving sciatic nerve

Causes:Causes: Lumbar disc herniationLumbar disc herniation SI joint dysfunctionSI joint dysfunction Scar tissue around Scar tissue around

nerve rootnerve root Nerve root Nerve root

inflammationinflammation Spinal stenosisSpinal stenosis Synovial cystsSynovial cysts Cancerous or Cancerous or

noncancerous tumorsnoncancerous tumors


Sciatica:Sciatica: Signs and Symptoms:Signs and Symptoms:

Radiating painRadiating pain Muscular weaknessMuscular weakness

Special Tests:Special Tests: Straight leg raise testStraight leg raise test Tension signTension sign

Treatment and Rehab:Treatment and Rehab: Resolve pathology that Resolve pathology that

is irritating nerveis irritating nerve Oral anti-inflammatory Oral anti-inflammatory

meds / corticosteroidsmeds / corticosteroids Exercises for strength / Exercises for strength /

ROMROM

Clinical EvaluationClinical Evaluation Tension Sign:Tension Sign:

Tests for sciatic nerve irritationTests for sciatic nerve irritation Test position:Test position:

Patient supine; examiner’s one hand grasps the Patient supine; examiner’s one hand grasps the heel while other grasps the thighheel while other grasps the thigh

Action:Action: Hip and knee flexed to 90Hip and knee flexed to 9000

Knee is then extended as far as possible with Knee is then extended as far as possible with the examiner palpating the tibial portion of the the examiner palpating the tibial portion of the sciatic nerve as it passes behind popliteal spacesciatic nerve as it passes behind popliteal space

Positive finding:Positive finding: Tenderness and reproduction of sciatica Tenderness and reproduction of sciatica

symptomssymptoms


Clinical EvaluationClinical Evaluation Bowstring Test: (Cram Test)Bowstring Test: (Cram Test)

Test position:Test position: Patient supinePatient supine

Action:Action: Examiner performs a passive straight leg raise on Examiner performs a passive straight leg raise on

involved sideinvolved side If subjects reports radiating pain, examiner flexes If subjects reports radiating pain, examiner flexes

the subject’s knee to approximately 20the subject’s knee to approximately 2000 in attempt in attempt to reduce painto reduce pain

Pressure than applied to popliteal area to reproduce Pressure than applied to popliteal area to reproduce radicular painradicular pain

Positive finding:Positive finding: Painful radicular reproduction with popliteal Painful radicular reproduction with popliteal

compressioncompression Indicates sciatic nerve tensionIndicates sciatic nerve tension


Spondylolysis:Spondylolysis: Defect in pars interarticularis Defect in pars interarticularis

(area between inferior and (area between inferior and superior articular facets)superior articular facets)

MOI – repetitive stressMOI – repetitive stress Unilateral or bilateral defectsUnilateral or bilateral defects Listhesis:Listhesis:

Posterior portion of the Posterior portion of the vertebrae, laminae, inferior vertebrae, laminae, inferior articular surfaces, spinous articular surfaces, spinous process separates from process separates from vertebral bodyvertebral body

““Collared Scotty dog” Collared Scotty dog” deformitydeformity

Symptoms:Symptoms: Localized mow back pain Localized mow back pain

(↑ during/after activity)(↑ during/after activity) Pain with extensionPain with extension


Spondylolisthesis:Spondylolisthesis: Progression of spondylolysis → Progression of spondylolysis →

separation of vertebrae (superior separation of vertebrae (superior vertebrae slides anteriorly on the one vertebrae slides anteriorly on the one below it)below it) ““Decapitated Scotty dog” deformity:Decapitated Scotty dog” deformity:

Head of the dog (anterior element of Head of the dog (anterior element of vertebrae) has become detached from body vertebrae) has become detached from body (posterior element)(posterior element)

Severity – amount of anterior displacementSeverity – amount of anterior displacement Epidemiology:Epidemiology:

Most prevalent in women and adolescentsMost prevalent in women and adolescents Young gymnastsYoung gymnasts

Lateral view of the lumbar spine: Bilateral break in the pars interarticularis (spondylolysis - black arrow) L5 vertebral body (red arrow) has slipped forward on the S1 vertebral body (blue arrow – spondylolisthesis)

Normal pars interarticularis - white arrow.Degree of forward slippage is equal to about 1/4 to 1/2 of the AP diameter of S1 (Grade1-Grade 2 spondylolisthesis)

Clinical EvaluationClinical Evaluation Spondylolysis and Spondylolisthesis:Spondylolysis and Spondylolisthesis:

History:History: Onset of pain:Onset of pain:

Insidious; pain begins as an ache, ↑ to constant Insidious; pain begins as an ache, ↑ to constant painpain

Characteristics:Characteristics: Lumbar pain, radiating into buttocks and upper Lumbar pain, radiating into buttocks and upper

posterolateral thighposterolateral thigh MOI:MOI:

Repetitive stress (extension)Repetitive stress (extension) Predisposing conditions:Predisposing conditions:

Muscular imbalancesMuscular imbalances Repetitive hyperextension activitiesRepetitive hyperextension activities

Inspection:Inspection: ↑ ↑ lordotic curvelordotic curve Altered GAITAltered GAIT

Clinical EvaluationClinical Evaluation Spondylolysis and Spondylolisthesis:Spondylolysis and Spondylolisthesis:

Palpation:Palpation: Step-off deformity may be feltStep-off deformity may be felt Spasm of paraspinal musclesSpasm of paraspinal muscles

Functional Tests:Functional Tests: AROM:AROM:

Flexion – restricted, pain freeFlexion – restricted, pain free Extension – painExtension – pain Rotation and bending - painRotation and bending - pain

PROM:PROM: Hip flexion – hamstring tightnessHip flexion – hamstring tightness

RROM:RROM: Weakness of spinal erectorsWeakness of spinal erectors


Spondylolysis and Spondylolisthesis:Spondylolysis and Spondylolisthesis: Special Tests:Special Tests:

Pain with Spring testPain with Spring test SL stance test; straight leg raises may SL stance test; straight leg raises may

produce painproduce pain Neurological Exam:Neurological Exam:

Lower quarter screen (results typically Lower quarter screen (results typically negative)negative)

Comments:Comments: X-ray, CT, MRI (will differentiate between X-ray, CT, MRI (will differentiate between

spondylolysis and spondylolisthesis)spondylolysis and spondylolisthesis)


Single Leg Stance Test:Single Leg Stance Test: Test position:Test position:

Patient standing with body weight evenly Patient standing with body weight evenly distributed between the 2 feet; examiner distributed between the 2 feet; examiner stands behind pt.stands behind pt.

Action:Action: Patient lifts one leg, then places the trunk Patient lifts one leg, then places the trunk

in hyperextension; examiner may assistin hyperextension; examiner may assist Positive test:Positive test:

Pain in lumbar spine or SI areaPain in lumbar spine or SI area


Single Leg Stance Single Leg Stance Test:Test: Implication:Implication:

Shear forces are placed Shear forces are placed on pars interarticularis on pars interarticularis by iliopsoas pulling the by iliopsoas pulling the vertebrae anteriorlyvertebrae anteriorly

Comments:Comments: Unilateral fracture – Unilateral fracture –

pain when opposite leg pain when opposite leg raisedraised

Bilateral fractures – Bilateral fractures – pain with either leg pain with either leg being fracturedbeing fractured

Clinical EvaluationClinical Evaluation Sacroiliac Sacroiliac

Dysfunction:Dysfunction: History:History:

Onset:Onset: Acute or insidiousAcute or insidious

Pain characteristics:Pain characteristics: One or both SI joints; One or both SI joints;

possibly radiating pain possibly radiating pain in buttocks, groin, thighin buttocks, groin, thigh

Mechanism:Mechanism: Prolonged stressProlonged stress

Predisposing Predisposing conditions:conditions:

Postpartum women Postpartum women (relaxin levels)(relaxin levels)

Hormonal levels during Hormonal levels during menstruationmenstruation

Clinical EvaluationClinical Evaluation Sacroiliac Joint Dysfunction:Sacroiliac Joint Dysfunction:

Inspection:Inspection: Levels of iliac crests, ASIS, PSISLevels of iliac crests, ASIS, PSIS

Palpation:Palpation: Pain over SI joints and PSISPain over SI joints and PSIS

Functional tests:Functional tests: Trunk flexion (with knees extended) will cause Trunk flexion (with knees extended) will cause

movement of the sacrum on the ilia (pain)movement of the sacrum on the ilia (pain) Neurological testing:Neurological testing:

Lower quarter screenLower quarter screen Special tests:Special tests:

Long sit; SI compression and distraction; Long sit; SI compression and distraction; straight leg raising; fabre; gaenslen’s; quadrantstraight leg raising; fabre; gaenslen’s; quadrant

Clinical EvaluationClinical Evaluation Sacroiliac Joint Stress Sacroiliac Joint Stress

Test:Test: Test position:Test position:

Subject supine; examiner Subject supine; examiner stands next to subject and stands next to subject and with arms crossed, places with arms crossed, places heel of both hands on the heel of both hands on the subject’s ASISssubject’s ASISs

Action:Action: Examiner applies outward Examiner applies outward

and downward pressure with and downward pressure with the heels of both handsthe heels of both hands

Positive finding:Positive finding: Unilateral pain at SI joint or Unilateral pain at SI joint or

in gluteal/leg region is in gluteal/leg region is indicative of anterior SI indicative of anterior SI ligament sprainligament sprain



Subject side-lying; Subject side-lying; examiner stands next to examiner stands next to patient and places both patient and places both hands (one on top of the hands (one on top of the other) directly over the other) directly over the subject’s iliac crestsubject’s iliac crest

Action:Action: Apply downward pressureApply downward pressure

Positive finding:Positive finding: Increased pain indicative Increased pain indicative

of SI pathology (possible of SI pathology (possible involvement of posterior involvement of posterior SI ligament)SI ligament)



Subject lying supine; Subject lying supine; examiner places both examiner places both hands on lateral aspect hands on lateral aspect of subject’s iliac crestsof subject’s iliac crests

Action:Action: Apply inward and Apply inward and

downward pressuredownward pressure Positive finding:Positive finding:

Increased pain indicative Increased pain indicative of SI pathology (possibly of SI pathology (possibly involving posterior SI involving posterior SI ligaments)ligaments)


Sacroiliac Joint Stress Test:Sacroiliac Joint Stress Test: Test position:Test position:

Subject lying prone; examiner places Subject lying prone; examiner places both hands (one on top of the other) both hands (one on top of the other) over subject’s sacrumover subject’s sacrum

Action:Action: Apply downward pressure on sacrumApply downward pressure on sacrum

Positive finding:Positive finding: Increased pain indicative of SI Increased pain indicative of SI

pathologypathology

Clinical EvaluationClinical Evaluation Patrick or FABER Test:Patrick or FABER Test:

Test position:Test position: Subject supineSubject supine

Action:Action: Examiner passively flexes, Examiner passively flexes,

abducts, and externally abducts, and externally rotates the involved leg rotates the involved leg until the foot rests on the until the foot rests on the top of the knee of top of the knee of uninvolved lower extremity; uninvolved lower extremity; examiner slowly abducts examiner slowly abducts the involved lower the involved lower extremity towards the tableextremity towards the table

Positive test:Positive test: Involved lower extremity Involved lower extremity

does not abduct below level does not abduct below level of uninvolved sideof uninvolved side

SI pathology, iliopsoas SI pathology, iliopsoas tightnesstightness

Clinical EvaluationClinical Evaluation Gaenslen’s Test:Gaenslen’s Test:

Test position:Test position: Subject supine, lying close Subject supine, lying close

to edge of table; examiner to edge of table; examiner stands at sidestands at side

Action:Action: Slide patient to edge of Slide patient to edge of

table; patient pulls far table; patient pulls far knee up to the chest; near knee up to the chest; near leg allowed to hang over leg allowed to hang over edge of tableedge of table

Examiner applies Examiner applies downward pressure on downward pressure on near leg, forcing it into near leg, forcing it into hyperextensionhyperextension

Positive finding:Positive finding: Pain in SI region Pain in SI region

indicating SI joint indicating SI joint dysfunctiondysfunction

Clinical EvaluationClinical Evaluation Long-Sitting Test:Long-Sitting Test:

Test position:Test position: Subject supine, both hips and knees extended; Subject supine, both hips and knees extended;

examiner standing with thumbs on subject’s medial examiner standing with thumbs on subject’s medial malleolimalleoli

Action:Action: Examiner passively flexes both hips and knees and Examiner passively flexes both hips and knees and

then fully extends and compares position of medial then fully extends and compares position of medial malleoli relative to eachothermalleoli relative to eachother

Subject slowly assumes the long-sitting position and Subject slowly assumes the long-sitting position and malleolar position is re-assessedmalleolar position is re-assessed

Positive finding:Positive finding: Leg appears longer in supine but shorter in long-Leg appears longer in supine but shorter in long-

sitting is indicative of an ipsilateral anteriorly rotated sitting is indicative of an ipsilateral anteriorly rotated iliumilium

Leg appears shorter in supine but longer in long-Leg appears shorter in supine but longer in long-sitting is indicative of an ipsilateral posteriorly sitting is indicative of an ipsilateral posteriorly rotated iliumrotated ilium

On-Field EvaluationOn-Field Evaluation

History:History: Location of pain:Location of pain:

Localized in vertebral column – disc rupture, Localized in vertebral column – disc rupture, sprain, facet pathologysprain, facet pathology

Radiating pain into extremities – spinal nerve Radiating pain into extremities – spinal nerve root pathologyroot pathology

Pain parallel to vertebral column – muscle spasmPain parallel to vertebral column – muscle spasm Peripheral symptoms:Peripheral symptoms:

Nerve root impingementNerve root impingement MOI:MOI:

Rotational forces, hyperextension, repetitive Rotational forces, hyperextension, repetitive stressstress

On-Field EvaluationOn-Field Evaluation Inspection:Inspection:

Position of athlete:Position of athlete: Supine – if spinal cord involvement suspected, Supine – if spinal cord involvement suspected,

manage accordingly (spine board)manage accordingly (spine board) PosturePosture Willingness to moveWillingness to move

Neurological tests:Neurological tests: SensorySensory Motor testsMotor tests

Palpation:Palpation: Bony palpationBony palpation ParaspinalsParaspinals

Date post:	30-Mar-2015
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