fiu - thoracic and lumbar spine special tests and pathologies
TRANSCRIPT
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Thoracic and LumbarThoracic and Lumbar
Spine Special TestsSpine Special Testsand Pathologiesand Pathologies
Orthopedic Assessment IIIOrthopedic Assessment III Head, Spine, and Trunk Head, Spine, and Trunk
with Labwith Lab
PET !"#$PET !"#$
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Clinical EvaluationClinical Evaluation
Spring Test%Spring Test% Test Positioning:Test Positioning:
Subject is proneSubject is prone
Examiner stands with thumbs or hypothenarExaminer stands with thumbs or hypothenar
eminence over the spinous process of a lumbareminence over the spinous process of a lumbarvertebraevertebrae
Action:Action:Apply a downward springing! force through theApply 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 #inding:Positive #inding:
$ncreases or decreases in motion at one vertebrae$ncreases or decreases in motion at one vertebrae
compared to another %hypermobility or hypomobility&compared to another %hypermobility or hypomobility&
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Clinical EvaluationClinical Evaluation
'erve (oot'erve (oot
$mpingement:$mpingement: 'arrowing of'arrowing of
intervertebralintervertebralforamen:foramen: StenosisStenosis
#acet joint#acet joint
degenerationdegeneration
)erniated)erniated
intervertebral discintervertebral disc
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Clinical EvaluationClinical Evaluation
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Clinical EvaluationClinical Evaluation
'erve (oot $mpingement Tests:'erve (oot $mpingement Tests: &alsal'a Test%&alsal'a Test%
Test Position:Test Position: Patient seated* examiner standing next to patientPatient seated* examiner standing next to patient
Action:Action: Subject ta+es a deep breath and holds while bearingSubject ta+es a deep breath and holds while bearing
down as if having a bowel movementdown as if having a bowel movement
Positive #inding:Positive #inding: $ncreased spinal or radicular pain due to$ncreased spinal or radicular pain due to intrathecalintrathecal
pressurepressure
,ay be secondary to a space"occupying lesion %i-e-,ay 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: $ncrease in intrathecal pressure may result in$ncrease in intrathecal pressure may result in pulse* .pulse* .venous return* / venous pressure %di00iness and1orvenous return* / venous pressure %di00iness and1orfainting&fainting&
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Clinical EvaluationClinical Evaluation
'erve (oot $mpingement Tests:'erve (oot $mpingement Tests:(ilgram Test%(ilgram 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 thePatient performs a bilateral straight leg raise to the
height of 2 to 3 inches and is as+ed to hold theheight of 2 to 3 inches and is as+ed to hold theposition for 45 secondsposition for 45 seconds
Positive #inding:Positive #inding: Patient unable to hold position* cannot lift the leg*Patient unable to hold position* cannot lift the leg*
or has pain with testor has pain with test $mplications:$mplications:
$ntrathecal or extrathecal pressure causing an$ntrathecal or extrathecal pressure causing anintervertebral disc to place pressure on a lumbarintervertebral disc to place pressure on a lumbarnerve rootnerve root
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Clinical EvaluationClinical Evaluation
'erve (oot $mpingement Tests:'erve (oot $mpingement Tests:)ernig*s Test%)ernig*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 legPatient performs a unilateral active straight leg
raise with the +nee extended until pain occursraise with the +nee extended until pain occurs After pain occurs* the patient 6exes the +neeAfter pain occurs* the patient 6exes the +nee
Positive #inding:Positive #inding: Pain in the spine and possibly radiating into lowerPain in the spine and possibly radiating into lower
extremityextremity
Pain relieved when patient 6exes the +neePain relieved when patient 6exes the +nee $mplications:$mplications:
'erve root impingement secondary to bulging of'erve root impingement secondary to bulging ofthe intervertebral disc or bony entrapment7the intervertebral disc or bony entrapment7irritation of dural sheath7 irritation of meningesirritation of dural sheath7 irritation of meninges
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Clinical EvaluationClinical Evaluation
'erve (oot'erve (oot$mpingement Tests:$mpingement Tests:)ernig+rud-inski)ernig+rud-inski
Test%Test%
Patient actively 6exesPatient actively 6exesthe cervical spine %liftsthe cervical spine %liftsthe head&the head&
)ip unilaterally 6exed)ip unilaterally 6exed%no more than 85%no more than 8555&&
9nee than 6exed to no9nee than 6exed to no
more than 85more than 8555 %& / pain with nec+%& / pain with nec+
and hip 6exion7 painand hip 6exion7 painrelieved when +nee isrelieved when +nee is6exed6exed
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Clinical EvaluationClinical Evaluation
'erve (oot $mpingement Tests:'erve (oot $mpingement Tests: .nilateral Straight Leg /aise Test.nilateral Straight Leg /aise Test
0Lasegue Test1%0Lasegue Test1%
Test Position:Test Position: Patient supine* examiner standing at testedPatient supine* examiner standing at tested
side with the distal hand around the subject;sside with the distal hand around the subject;sheel and proximal hand on subject;s distalheel and proximal hand on subject;s distalthigh %anterior& < maintains +nee extensionthigh %anterior& < maintains +nee extension
Action:Action: Examiner slowly raises the leg untilExaminer slowly raises the leg until
pain1tightness noted or full (=, is obtainedpain1tightness noted or full (=, is obtained Slowly lower the leg until the pain orSlowly lower the leg until the pain or
tightness resolves* at which point dorsi6extightness resolves* at which point dorsi6exthe an+le and have subject 6ex the nec+the an+le and have subject 6ex the nec+
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Clinical EvaluationClinical Evaluation
Straight Leg /aiseStraight Leg /aiseTest%Test% Positive #indings:Positive #indings:
>eg and1or low bac+>eg and1or low bac+
pain occurring withpain occurring with?# and or nec+?# and or nec+6exion is indicative6exion is indicativeof dural involvementof dural involvementand1or sciatic nerveand1or sciatic nerveirritationirritation
>ac+ of pain>ac+ of painreproduction with ?#reproduction with ?#and1or nec+ 6exion isand1or nec+ 6exion isindicative ofindicative ofhamstring tightnesshamstring tightnessor S$ pathologyor S$ pathology
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Clinical EvaluationClinical Evaluation
'erve (oot $mpingement Tests:'erve (oot $mpingement Tests: 2ell Straight Leg /aising Test%2ell Straight Leg /aising Test%
Can be used to di@erentiate betweenCan be used to di@erentiate between
sciatic nerve irritation or a herniatedsciatic nerve irritation or a herniatedintervertebral disc that is irritating theintervertebral disc that is irritating the
nerve rootnerve root
Test Position:Test Position: Patient supine* examiner standing atPatient supine* examiner standing at
una@ected side7 one hand grasps under theuna@ected side7 one hand grasps under the
heel while other is placed on anterior thighheel while other is placed on anterior thigh
to stabili0e the leg in extensionto stabili0e the leg in extension
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Clinical EvaluationClinical Evaluation
2ell Straight Leg2ell Straight Leg
/aise Test%/aise Test%Action:Action:
Examiner raises theExaminer raises the
leg by 6exing the hipleg by 6exing the hip
until discomfort isuntil discomfort is
reported %+nee +eptreported %+nee +ept
in full extension&in full extension&
Positive #inding:Positive #inding: Pain is experiencedPain is experienced
on the side oppositeon the side opposite
that being raisedthat being raised
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Clinical EvaluationClinical Evaluation
'erve (oot $mpingement Tests:'erve (oot $mpingement Tests: 3uadrant Test%3uadrant Test%
Test Position:Test Position:
Patient standing with feet shoulder widthPatient standing with feet shoulder widthapartapart
Examiner stands behind the patient* graspingExaminer stands behind the patient* grasping
the patient;s shouldersthe 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 a@ected sidethan sidebends and rotates to a@ected side
Examiner provides overpressure through theExaminer provides overpressure through the
shoulders* supporting the patient as neededshoulders* supporting the patient as needed
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Clinical EvaluationClinical Evaluation
'erve (oot $mpingement Tests:'erve (oot $mpingement Tests: 3uadrant Test%3uadrant Test%
Positive #indings:Positive #indings:
(eproduction of patient;s symptoms(eproduction of patient;s symptoms $mplications:$mplications:
(adicular pain indicates compression of the(adicular pain indicates compression of the
intervertebral foramina that impinges on theintervertebral foramina that impinges on the
lumbar nerve rootslumbar nerve roots
>ocal pain %not radiating& indicates facet joint>ocal pain %not radiating& indicates facet joint
pathologypathology
Symptoms isolated to the area of the PS$S maySymptoms isolated to the area of the PS$S may
indicate S$ joint dysfunctionindicate S$ joint dysfunction
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Clinical EvaluationClinical Evaluation
'erve (oot $mpingement Tests:'erve (oot $mpingement Tests: Slump Test%Slump Test%
Test Position:Test Position: Patient sits over edge of table7 examiner is at sidePatient sits over edge of table7 examiner is at side
of patientof patientAction:Action:
%& Patient slumps forward along thoracolumbar%& Patient slumps forward along thoracolumbarspine* rounding the shoulders while +eepingspine* rounding the shoulders while +eepingcervical spine neutralcervical spine neutral
%2& Patient 6exes cervical spine7 Clinician holds%2& Patient 6exes cervical spine7 Clinician holdspatient in this positionpatient in this position %4& 9nee is actively extended%4& 9nee is actively extended %B& An+le is actively dorsi6exed%B& An+le is actively dorsi6exed %& (epeat on opposite side%& (epeat on opposite side
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Clinical EvaluationClinical Evaluation
Slump Test%Slump Test% Positive #indings:Positive #indings:
Sciatic pain orSciatic pain or
reproduction ofreproduction of
other neurologicalother neurological
symptomssymptoms
$mplications:$mplications: $mpingement of$mpingement of
the dural lining*the dural lining*spinal cord* orspinal cord* or
nerve rootsnerve roots
4ote% Patient per5ormsA$TI&E knee e6tension and
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Clinical EvaluationClinical Evaluation
Test for PatientTest for Patient
,alingering:,alingering: ,alingering < medical,alingering < medical
and psychological termsand psychological terms
that refers to anthat refers to an
individualindividual
fabricating1exaggeratinfabricating1exaggeratin
g their level ofg their level of
symptomssymptoms #inancial compensation#inancial compensation
%fraud&%fraud&
Avoiding wor+Avoiding wor+
=btaining drugs=btaining drugs
Attract attention orAttract attention or
sympathysympathy
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Clinical EvaluationClinical Evaluation
Test for Patient ,alingering:Test for Patient ,alingering:Hoo'er Test%Hoo'er Test%
Test Position:Test Position: Patient supinePatient supine Examiner at feet of patient with hands cuppingExaminer 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 onPatient attempts to actively straight leg raise on
the involved sidethe involved side
Positive #indings:Positive #indings: Patient does not attempt to lift the leg andPatient does not attempt to lift the leg and
examiner does '=T sense pressure from theexaminer does '=T sense pressure from theuninvolved leg pressing down on the handuninvolved leg pressing down on the hand
Patient is not attempting to perform the testPatient is not attempting to perform the test
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Clinical EvaluationClinical Evaluation
Test 4ote% E6aminer should be standing at 5eet o5patient with their hands cupping the heels o5 each
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Clinical EvaluationClinical Evaluation
'erve'erve
(oot(oot
>evel>evel
Sensory TestingSensory Testing
>> $nguinal area %just below inguinal$nguinal area %just below inguinalligamentligament
>2>2 ,id"thigh %medial&,id"thigh %medial&
>4>4 ,edial +nee %just above superior,edial +nee %just above superiorpole of patella&pole of patella&
>B>B ,edial aspect of lower leg* medial,edial aspect of lower leg* medialan+le* big toean+le* big toe
>> Top of foot %an1or blow head ofTop of foot %an1or blow head of
Lower 3uarter 4eurological ScreenLower 3uarter 4eurological Screen
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Clinical EvaluationClinical Evaluation
'erve (oot'erve (oot
>evel>evel,otor Testing,otor Testing
>> )ip 6exion)ip 6exion
>2>2 )ip 6exion)ip 6exion
>4>4 9nee extension9nee extension
>B>B ?orsi6exion?orsi6exion>> reat toe extensionreat toe extension
SS Plantar6exionPlantar6exion
S2S2 'A'A
Lower 3uarter 4eurological ScreenLower 3uarter 4eurological Screen
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Clinical EvaluationClinical Evaluation
'erve'erve
(oot(oot>evel>evel
(e6ex(e6ex
TestingTesting
>B>B PatellarPatellarTendonTendon
>> PatellarPatellar
TendonTendon
SS AchillesAchilles
TendonTendon
S2S2 AchillesAchilles
TendonTendon
Lower 3uarter 4eurological ScreenLower 3uarter 4eurological Screen
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Clinical EvaluationClinical Evaluation
abinkski*s Test%abinkski*s Test% Test Position: athlete supineTest Position: athlete supine Athletic Trainer Position: AtAthletic Trainer Position: At
the foot of the athlete holdingthe foot of the athlete holdinga blunt tool %re6ex hammer&a blunt tool %re6ex hammer&
Procedure: (ub the tool upProcedure: (ub the tool up
bottom of athlete;s footbottom of athlete;s footstarting at the calcaneus andstarting at the calcaneus andending at the great toe-ending at the great toe-
Positive test: reat toePositive test: reat toeextends while other toesextends while other toessplay-splay-
$mplications: >esion of upper$mplications: >esion of upper
motor neurons* may bemotor neurons* may becaused by trauma to the braincaused by trauma to the brain
Comments: This re6ex occursComments: This re6ex occursnaturally in newborns-naturally in newborns-)owever* this re6ex should)owever* this re6ex shouldcease Guic+ly after birth-cease Guic+ly after birth-
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Clinical EvaluationClinical Evaluation
Erector SpinaeErector Spinae
(uscle Strain%(uscle Strain% Common low bac+Common low bac+
pathologypathology
,=$:,=$: )istory of heavy or)istory of heavy or
repetitive liftingrepetitive lifting
Signs1Symptoms:Signs1Symptoms: Aching bac+Aching bac+
PainPain with passive andwith passive andactive 6exion* resistedactive 6exion* resisted
extensionextension
'eurological Evaluation:'eurological Evaluation: 'egative results'egative results
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Clinical EvaluationClinical Evaluation
8acet 9oint :;s5unction%8acet 9oint :;s5unction% Pathology of facet joints < B5H of all chronicPathology of facet joints < B5H of all chronic
low bac+ painlow bac+ pain Iague signs1symptoms:Iague signs1symptoms:
=ften resemble other low bac+ pathologies %i-e-=ften resemble other low bac+ pathologies %i-e-strain1spasm of paraspinal muscles* nerve rootstrain1spasm of paraspinal muscles* nerve rootimpingement* disc degeneration&impingement* disc degeneration&
$nvolvement:$nvolvement: ?islocation1sublocation of facet:?islocation1sublocation of facet:
Tends to loc+! the involved spinal segmentTends to loc+! the involved spinal segment%hypomobile vertebrae&%hypomobile vertebrae&
#acet joint syndrome: %in6ammationacet joint syndrome: %in6ammation& Causes: repetitive stress through movement or loadingCauses: repetitive stress through movement or loading
?egeneration: %arthritis&?egeneration: %arthritis& Causes: undeDned historyCauses: undeDned history .. intervertebral foramen si0e %nerve root impingement&intervertebral foramen si0e %nerve root impingement&
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Clinical EvaluationClinical Evaluation
8acet 9oint :;s5unction%8acet 9oint :;s5unction% )istory:)istory:
=nset < insidious=nset < insidious
Pain characteristics < locali0edPain characteristics < locali0ed
,=$ < extension* rotation* lateral bending of,=$ < extension* rotation* lateral bending ofvertebraevertebrae
Predisposing conditions < repeated motions of spinalPredisposing conditions < repeated motions of spinal
extension* rotation* lateral bendingextension* rotation* lateral bending
$nspection:$nspection: Patient may assume posture that . pressure onPatient may assume posture that . pressure on
a@ected facetsa@ected facets
Palpation:Palpation: Possible local muscle spasm %paravertebral muscles&Possible local muscle spasm %paravertebral muscles&
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Clinical EvaluationClinical Evaluation
8acet 9oint8acet 9oint:;s5unction%:;s5unction% >igamentous Tests:>igamentous Tests:
Spring Test < pain* .Spring Test < pain* .
motionmotion 'eurological Tests:'eurological Tests:
'ot applicable'ot applicableunless secondaryunless secondarynerve rootnerve rootimpingement occursimpingement occurs
Special Tests:Special Tests: Juadrant Test %&Juadrant Test %& $ntervertebral disc$ntervertebral disc
lesions %"&lesions %"&
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Clinical EvaluationClinical Evaluation
8acet 9oint :;s5unction%8acet 9oint :;s5unction% $nitial Treatment:$nitial Treatment:
'SA$?s'SA$?s
$nstruct patient to avoid$nstruct patient to avoidpostures1movements that irritate facetspostures1movements that irritate facets
,odalities < moist heat* e"stim* ice to .,odalities < moist heat* e"stim* ice to .muscle spasmmuscle spasm
Therapeutic Exercises:Therapeutic Exercises: Stretching and strengthening:Stretching and strengthening: >ow bac+>ow bac+AbdominalsAbdominals )ip 6exors* hip extensors* hamstrings)ip 6exors* hip extensors* hamstrings
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Clinical EvaluationClinical Evaluation
Inter'ertebral :iscInter'ertebral :iscLesions%Lesions%:isc :egeneration%:isc :egeneration%
>oss of water from>oss of water from
nucleus pulposusnucleus pulposus .. cushioning abilitycushioning ability
// stress load onstress load onannulus Dbrosusannulus Dbrosus Small tears occur toSmall tears occur to
annulus %scar tissueannulus %scar tissue
formation < not asformation < not asstrong as normalstrong as normaltissue&tissue&
Kulging of nucleusKulging of nucleuspulposuspulposus
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Clinical EvaluationClinical Evaluation
Inter'ertebral :iscInter'ertebral :isc
Herniation%Herniation% Extrusion ofExtrusion of
nucleus pulposusnucleus pulposus
through annulusthrough annulusDbrosusDbrosus $mpingement1pressur$mpingement1pressur
e on nerve root belowe on nerve root below
a@ected disca@ected disc
SeGuestrated
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(/I lumbar image%
L+S< disc has su=ered a
#mm disc e6trusion 0redarrow1 that is not contained b;the PLL
L>+ disc has su=ered asmaller >mm disc protrusion0green arrow1 that is
contained b; the PLL
L?+> 0blue arrow1 iscompletel; normal and has nodisc material pro@ectingposteriorl; into the epiduralspace
4ote% L?+> disc is white incolor, which indicates it isnondegenerated 0iBeB, 5ull o5water and health;proteogl;can1
Herniated discs0L>+ C L+S
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Clinical EvaluationClinical Evaluation
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Clinical EvaluationClinical Evaluation
Lumbar :isc :egeneration%Lumbar :isc :egeneration% )istory:)istory:
=nset < insidious or may be related to single=nset < insidious or may be related to singleepisodeepisode Krea+down of disc is related to repetitive stress7 >astKrea+down of disc is related to repetitive stress7 >ast
episode < Dnal failure an annulus Dbrosus to containepisode < Dnal failure an annulus Dbrosus to containnucleus pulposusnucleus pulposus
Pain characteristics < a@ected vertebrae7Pain characteristics < a@ected vertebrae7compression of spinal nerve root leads to paincompression of spinal nerve root leads to painin low bac+* buttoc+s* radiating into thigh*in low bac+* buttoc+s* radiating into thigh*
calf* heel* footcalf* heel* foot ,=$ < repetitive loading of disc,=$ < repetitive loading of disc Predisposing condition < history of lumbarPredisposing condition < history of lumbar
spine traumaspine trauma
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Clinical EvaluationClinical Evaluation
Lumbar :isc :egeneration%Lumbar :isc :egeneration% $nspection:$nspection:
Slow A$TSlow A$T
#lattened lumbar spine#lattened lumbar spine Changes in body position < guarded andChanges in body position < guarded andpainfulpainful Sitting L standing 1 sitting L lyingSitting L standing 1 sitting L lying
Changes in disc pressureChanges in disc pressure
Standing position:Standing position: >ateral shift away from side of leg pain>ateral shift away from side of leg pain
Palpation:Palpation: ,usculature spasm,usculature spasm
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Clinical EvaluationClinical Evaluation
Lumbar :isc :egeneration%Lumbar :isc :egeneration% #unctional Tests:#unctional Tests:
>imited (=, in all directions>imited (=, in all directions
,ovement in one direction may relieve or .,ovement in one direction may relieve or .
symptomssymptoms 'eurological Tests:'eurological Tests:
>ower Guarter screen>ower Guarter screen
Special Tests:Special Tests:
Straight leg raising* Mell straight leg raising*Straight leg raising* Mell straight leg raising*,ilgram* Sciatic and femoral nerve tension tests,ilgram* Sciatic and femoral nerve tension tests
?iagnostic Tests:?iagnostic Tests: ,($,($
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Clinical EvaluationClinical Evaluation
Inter'ertebral :isc :egeneration%Inter'ertebral :isc :egeneration%Surger;Surger; Spinal 8usion%Spinal 8usion%
Melding 2 or more vertebrae togetherMelding 2 or more vertebrae together Cause of bac+ pain %motion betweenCause of bac+ pain %motion betweenvertebral segments& spinal fusion may be avertebral segments& spinal fusion may be away to prevent motion and stop the painway to prevent motion and stop the pain TechniGue %basics&:TechniGue %basics&:
Small pieces of extra bone Dlls space between twoSmall pieces of extra bone Dlls space between twovertebrae %pelvic bone* allograft bone&vertebrae %pelvic bone* allograft bone& ?isc removed?isc removedMires* rods* screws* metal cages or plates may beMires* rods* screws* metal cages or plates may be
usedused
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Clinical EvaluationClinical Evaluation
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Articial disc replacement% :isc is placed in the disc space throughArticial disc replacement% :isc is placed in the disc space through
an abdominal incisionF the articial disc then maintains mobilit; inan abdominal incisionF the articial disc then maintains mobilit; in
the spine and as such protects the ad@acent disc 5rom acceleratedthe spine and as such protects the ad@acent disc 5rom accelerateddegeneration and 5urther surger;degeneration and 5urther surger;
Clinical EvaluationClinical Evaluation
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Clinical EvaluationClinical Evaluation
$auda EGuina S;ndrome%$auda EGuina S;ndrome% Anatomy: spinal cord ends at the lower edge ofAnatomy: spinal cord ends at the lower edge of
the st lumbar vertebrathe st lumbar vertebra >umbar and sacral nerve roots form a bundle>umbar and sacral nerve roots form a bundlewithin the spinal canal below the conus medullariswithin the spinal canal below the conus medullaris
CES < nerves within the spinal canal have beenCES < nerves within the spinal canal have beendamaged7 nerves supplying muscles of legs*damaged7 nerves supplying muscles of legs*bladder* bowel and genitals do not functionbladder* bowel and genitals do not functionproperlyproperly
'umbness* loss of sensation %damage usually'umbness* loss of sensation %damage usuallypermanent&permanent&
Congenital causes:Congenital causes: Spina biDda %abnormality in closure of spinal canal&Spina biDda %abnormality in closure of spinal canal& Tumors of the cauda eGuinaTumors of the cauda eGuina
AcGuired causes of Cauda EGuina Syndrome:AcGuired causes of Cauda EGuina Syndrome: $njury %spinal fractures&$njury %spinal fractures& Secondary to medical proceduresSecondary to medical procedures
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Clinical EvaluationClinical Evaluation
8emoral 4er'e Stretch8emoral 4er'e Stretch
Test%Test% Tests for nerve rootTests for nerve root
impingement at >2* >4* >Bimpingement at >2* >4* >B
Test position:Test position: Patient prone with a pillowPatient prone with a pillow
under the abdomen7under the abdomen7
examiner at side of patientexaminer at side of patient
Action:Action: Examiner passively extendsExaminer passively extends
hip while +eeping +neehip while +eeping +nee
6exed to 856exed to 8555
Positive test:Positive test: Pain in anterior and lateralPain in anterior and lateral
thighthigh
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Clinical EvaluationClinical Evaluation
Sciatica%Sciatica% eneral term for anyeneral term for any
in6ammation involvingin6ammation involvingsciatic nervesciatic nerve
Causes:Causes: >umbar disc herniation>umbar disc herniation S$ joint dysfunctionS$ joint dysfunction Scar tissue around nerveScar tissue around nerve
rootroot
'erve root in6ammation'erve root in6ammation Spinal stenosisSpinal stenosis Synovial cystsSynovial cysts Cancerous orCancerous or
noncancerous tumorsnoncancerous tumors
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Clinical EvaluationClinical Evaluation
Sciatica%Sciatica% Signs and Symptoms:Signs and Symptoms:
(adiating pain(adiating pain
,uscular wea+ness,uscular wea+ness
Special Tests:Special Tests: Straight leg raise testStraight leg raise test
Tension signTension sign
Treatment and (ehab:Treatment and (ehab: (esolve pathology that(esolve pathology that
is irritating nerveis irritating nerve =ral anti"in6ammatory=ral anti"in6ammatory
meds 1 corticosteroidsmeds 1 corticosteroids
Exercises for strength 1Exercises for strength 1
(=,(=,
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Clinical EvaluationClinical Evaluation
Tension Sign%Tension Sign% Tests for sciatic nerve irritationTests for sciatic nerve irritation Test position:Test position:
Patient supine7 examiner;s one hand grasps thePatient supine7 examiner;s one hand grasps the
heel while other grasps the thighheel while other grasps the thighAction:Action:
)ip and +nee 6exed to 85)ip and +nee 6exed to 8555
9nee is then extended as far as possible with the9nee is then extended as far as possible with theexaminer palpating the tibial portion of theexaminer palpating the tibial portion of the
sciatic nerve as it passes behind popliteal spacesciatic nerve as it passes behind popliteal space Positive Dnding:Positive Dnding:
Tenderness and reproduction of sciaticaTenderness and reproduction of sciaticasymptomssymptoms
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Clinical EvaluationClinical Evaluation
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Clinical EvaluationClinical Evaluation
owstring Test% 0$ram Test1owstring Test% 0$ram Test1 Test position:Test position:
Patient supinePatient supine
Action:Action:
Examiner performs a passive straight leg raise onExaminer performs a passive straight leg raise oninvolved sideinvolved side $f subjects reports radiating pain* examiner 6exes the$f subjects reports radiating pain* examiner 6exes the
subject;s +nee to approximately 25subject;s +nee to approximately 2555in attempt toin attempt toreduce painreduce pain
Pressure than applied to popliteal area to reproducePressure than applied to popliteal area to reproduce
radicular painradicular pain Positive Dnding:Positive Dnding:
Painful radicular reproduction with poplitealPainful radicular reproduction with poplitealcompressioncompression $ndicates sciatic nerve tension$ndicates sciatic nerve tension
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Clinical EvaluationClinical Evaluation
Spond;lol;sis%Spond;lol;sis% ?efect in pars interarticularis?efect in pars interarticularis
%area between inferior and%area between inferior and
superior articular facets&superior articular facets&
,=$ < repetitive stress,=$ < repetitive stress Nnilateral or bilateral defectsNnilateral or bilateral defects
>isthesis:>isthesis: Posterior portion of thePosterior portion of the
vertebrae* laminae* inferiorvertebrae* laminae* inferior
articular surfaces* spinousarticular surfaces* spinous
process separates fromprocess separates fromvertebral bodyvertebral body
Collared Scotty dog! deformityCollared Scotty dog! deformity
Symptoms:Symptoms:
>ocali0ed mow bac+ pain %/>ocali0ed mow bac+ pain %/
during1after activity&during1after activity&
Pain with extensionPain with extension
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Clinical EvaluationClinical Evaluation
Spond;lolisthesis%Spond;lolisthesis% Progression of spondylolysis LProgression of spondylolysis L
separation of vertebrae %superiorseparation of vertebrae %superiorvertebrae slides anteriorly on the onevertebrae slides anteriorly on the onebelow it&below it& ?ecapitated Scotty dog! deformity:?ecapitated Scotty dog! deformity:
)ead of the dog %anterior element of vertebrae&)ead of the dog %anterior element of vertebrae&has become detached from body %posteriorhas become detached from body %posteriorelement&element&
Severity < amount of anterior displacementSeverity < amount of anterior displacement Epidemiology:Epidemiology:
,ost prevalent in women and adolescents,ost prevalent in women and adolescentsOoung gymnastsOoung gymnasts
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Lateral 'iew o5 thelumbar spine% ilateral
break in the parsinterarticularis0spond;lol;sis blackarrow1L 'ertebral bod; 0redarrow1 has slipped
5orward on the S
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Clinical EvaluationClinical Evaluation
Spond;lol;sis and Spond;lolisthesis%Spond;lol;sis and Spond;lolisthesis% )istory:)istory:
=nset of pain:=nset of pain: $nsidious7 pain begins as an ache* / to constant$nsidious7 pain begins as an ache* / to constant
painpain Characteristics:Characteristics:
>umbar pain* radiating into buttoc+s and upper>umbar pain* radiating into buttoc+s and upperposterolateral thighposterolateral thigh
,=$:,=$: (epetitive stress %extension&(epetitive stress %extension&
Predisposing conditions:Predisposing conditions: ,uscular imbalances,uscular imbalances (epetitive hyperextension activities(epetitive hyperextension activities
$nspection:$nspection: // lordotic curvelordotic curveAltered A$TAltered A$T
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Clinical EvaluationClinical Evaluation
Spond;lol;sis and Spond;lolisthesis%Spond;lol;sis and Spond;lolisthesis% Palpation:Palpation:
Step"o@ deformity may be feltStep"o@ deformity may be felt Spasm of paraspinal musclesSpasm of paraspinal muscles
#unctional Tests:#unctional Tests:A(=,:A(=,:
#lexion < restricted* pain free#lexion < restricted* pain free Extension < painExtension < pain (otation and bending " pain(otation and bending " pain
P(=,:P(=,: )ip 6exion < hamstring tightness)ip 6exion < hamstring tightness
((=,:((=,: Mea+ness of spinal erectorsMea+ness of spinal erectors
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Clinical EvaluationClinical Evaluation
Spond;lol;sis and Spond;lolisthesis%Spond;lol;sis and Spond;lolisthesis% Special Tests:Special Tests:
Pain with Spring testPain with Spring test
S> stance test7 straight leg raises mayS> stance test7 straight leg raises mayproduce painproduce pain
'eurological Exam:'eurological Exam: >ower Guarter screen %results typically>ower Guarter screen %results typically
negative&negative&
Comments:Comments: "ray* CT* ,($ %will di@erentiate between"ray* CT* ,($ %will di@erentiate between
spondylolysis and spondylolisthesis&spondylolysis and spondylolisthesis&
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Clinical EvaluationClinical Evaluation
Single Leg Stance Test%Single Leg Stance Test% Test position:Test position:
Patient standing with body weight evenlyPatient standing with body weight evenly
distributed between the 2 feet7 examinerdistributed between the 2 feet7 examinerstands behind pt-stands behind pt-
Action:Action: Patient lifts one leg* then places the trun+Patient lifts one leg* then places the trun+
in hyperextension7 examiner may assistin hyperextension7 examiner may assist Positive test:Positive test:
Pain in lumbar spine or S$ areaPain in lumbar spine or S$ area
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Clinical EvaluationClinical Evaluation
Single Leg StanceSingle Leg Stance
Test%Test% $mplication:$mplication:
Shear forces are placedShear forces are placed
on pars interarticularison pars interarticularisby iliopsoas pulling theby iliopsoas pulling the
vertebrae anteriorlyvertebrae anteriorly
Comments:Comments: Nnilateral fracture
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Sacroiliac :;s5unction%Sacroiliac :;s5unction% )istory:)istory:
=nset:=nset: Acute or insidiousAcute or insidious
Pain characteristics:Pain characteristics: =ne or both S$ joints7=ne or both S$ joints7
possibly radiating painpossibly radiating painin buttoc+s* groin* thighin buttoc+s* groin* thigh
,echanism:,echanism: Prolonged stressProlonged stress
Predisposing conditions:Predisposing conditions: Postpartum womenPostpartum women
%relaxin levels&%relaxin levels& )ormonal levels during)ormonal levels during
menstruationmenstruation
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Sacroiliac 9oint :;s5unction%Sacroiliac 9oint :;s5unction% $nspection:$nspection:
>evels of iliac crests* AS$S* PS$S>evels of iliac crests* AS$S* PS$S Palpation:Palpation:
Pain over S$ joints and PS$SPain over S$ joints and PS$S #unctional tests:#unctional tests:
Trun+ 6exion %with +nees extended& will causeTrun+ 6exion %with +nees extended& will causemovement of the sacrum on the ilia %pain&movement of the sacrum on the ilia %pain&
'eurological testing:'eurological testing:
>ower Guarter screen>ower Guarter screen Special tests:Special tests:
>ong sit7 S$ compression and distraction7>ong sit7 S$ compression and distraction7straight leg raising7 fabre7 gaenslen;s7 Guadrantstraight leg raising7 fabre7 gaenslen;s7 Guadrant
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Clinical EvaluationClinical Evaluation
Sacroiliac 9oint StressSacroiliac 9oint Stress
Test%Test% Test position:Test position:
Subject supine7 examinerSubject supine7 examiner
stands next to subject andstands next to subject and
with arms crossed* placeswith arms crossed* placesheel of both hands on theheel of both hands on the
subject;s AS$Sssubject;s AS$Ss
Action:Action: Examiner applies outwardExaminer applies outward
and downward pressure withand downward pressure with
the heels of both handsthe heels of both hands Positive Dnding:Positive Dnding:
Nnilateral pain at S$ joint orNnilateral pain at S$ joint or
in gluteal1leg region isin gluteal1leg region is
indicative of anterior S$indicative of anterior S$
ligament sprainligament sprain
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Sacroiliac 9oint StressSacroiliac 9oint Stress
Test%Test% Test position:Test position:
Subject side"lying7Subject side"lying7
examiner stands next toexaminer stands next to
patient and places bothpatient and places both
hands %one on top of thehands %one on top of the
other& directly over theother& directly over the
subject;s iliac crestsubject;s iliac crest
Action:Action:
Apply downward pressureApply downward pressure Positive Dnding:Positive Dnding:
$ncreased pain indicative$ncreased pain indicative
of S$ pathology %possibleof S$ pathology %possible
involvement of posterior S$involvement of posterior S$
ligament&ligament&
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Sacroiliac 9oint StressSacroiliac 9oint Stress
Test%Test% Test position:Test position:
Subject lying supine7Subject lying supine7
examiner places bothexaminer places bothhands on lateral aspecthands on lateral aspect
of subject;s iliac crestsof subject;s iliac crests
Action:Action:Apply inward andApply inward and
downward pressuredownward pressure
Positive Dnding:Positive Dnding: $ncreased pain indicative$ncreased pain indicative
of S$ pathology %possiblyof S$ pathology %possibly
involving posterior S$involving posterior S$
ligaments&ligaments&
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Sacroiliac 9oint Stress Test%Sacroiliac 9oint Stress Test% Test position:Test position:
Subject lying prone7 examiner placesSubject lying prone7 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 Dnding:Positive Dnding: $ncreased pain indicative of S$ pathology$ncreased pain indicative of S$ pathology
http://images.google.com/imgres?imgurl=http://www.usbjd.org/projects/images/NATA-topnav_r2_c2.gif&imgrefurl=http://www.usbjd.org/projects/project_op.cfm%3FdirID%3D116&h=242&w=275&sz=38&hl=en&start=4&um=1&tbnid=pnRrYbfdvlTFnM:&tbnh=100&tbnw=114&prev=/images%3Fq%3DNational%2BAthletic%2BTrainers%2BAssociation%26svnum%3D10%26um%3D1%26hl%3Den%26rls%3DHPIB,HPIB:2005-17,HPIB:enhttp://images.google.com/imgres?imgurl=http://www.usbjd.org/projects/images/NATA-topnav_r2_c2.gif&imgrefurl=http://www.usbjd.org/projects/project_op.cfm%3FdirID%3D116&h=242&w=275&sz=38&hl=en&start=4&um=1&tbnid=pnRrYbfdvlTFnM:&tbnh=100&tbnw=114&prev=/images%3Fq%3DNational%2BAthletic%2BTrainers%2BAssociation%26svnum%3D10%26um%3D1%26hl%3Den%26rls%3DHPIB,HPIB:2005-17,HPIB:en -
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Patrick or 8AE/ Test%Patrick or 8AE/ Test% Test position:Test position:
Subject supineSubject supine
Action:Action: Examiner passively 6exes*Examiner passively 6exes*
abducts* and externallyabducts* and externallyrotates the involved leg untilrotates the involved leg untilthe foot rests on the top ofthe foot rests on the top ofthe +nee of uninvolved lowerthe +nee of uninvolved lowerextremity7 examiner slowlyextremity7 examiner slowlyabducts the involved lowerabducts the involved lowerextremity towards the tableextremity towards the table
Positive test:Positive test: $nvolved lower extremity$nvolved lower extremity
does not abduct below leveldoes not abduct below levelof uninvolved sideof uninvolved side
S$ pathology* iliopsoasS$ pathology* iliopsoastightnesstightness
http://images.google.com/imgres?imgurl=http://www.usbjd.org/projects/images/NATA-topnav_r2_c2.gif&imgrefurl=http://www.usbjd.org/projects/project_op.cfm%3FdirID%3D116&h=242&w=275&sz=38&hl=en&start=4&um=1&tbnid=pnRrYbfdvlTFnM:&tbnh=100&tbnw=114&prev=/images%3Fq%3DNational%2BAthletic%2BTrainers%2BAssociation%26svnum%3D10%26um%3D1%26hl%3Den%26rls%3DHPIB,HPIB:2005-17,HPIB:enhttp://images.google.com/imgres?imgurl=http://www.usbjd.org/projects/images/NATA-topnav_r2_c2.gif&imgrefurl=http://www.usbjd.org/projects/project_op.cfm%3FdirID%3D116&h=242&w=275&sz=38&hl=en&start=4&um=1&tbnid=pnRrYbfdvlTFnM:&tbnh=100&tbnw=114&prev=/images%3Fq%3DNational%2BAthletic%2BTrainers%2BAssociation%26svnum%3D10%26um%3D1%26hl%3Den%26rls%3DHPIB,HPIB:2005-17,HPIB:en -
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aenslen*s Test%aenslen*s Test% Test position:Test position:
Subject supine* lying closeSubject supine* lying closeto edge of table7 examinerto edge of table7 examinerstands at sidestands at side
Action:Action: Slide patient to edge ofSlide patient to edge of
table7 patient pulls far +neetable7 patient pulls far +neeup to the chest7 near legup to the chest7 near legallowed to hang over edgeallowed to hang over edgeof tableof table
Examiner applies downwardExaminer applies downward
pressure on near leg*pressure on near leg*forcing it intoforcing it intohyperextensionhyperextension
Positive Dnding:Positive Dnding: Pain in S$ region indicatingPain in S$ region indicating
S$ joint dysfunctionS$ joint dysfunction
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Clinical EvaluationClinical Evaluation
LongSitting Test%LongSitting Test% Test position:Test position:
Subject supine* both hips and +nees extended7 examinerSubject supine* both hips and +nees extended7 examinerstanding with thumbs on subject;s medial malleolistanding with thumbs on subject;s medial malleoli
Action:Action:
Examiner passively 6exes both hips and +nees and thenExaminer passively 6exes both hips and +nees and thenfully extends and compares position of medial malleolifully extends and compares position of medial malleolirelative to eachotherrelative to eachother
Subject slowly assumes the long"sitting position andSubject slowly assumes the long"sitting position andmalleolar position is re"assessedmalleolar position is re"assessed
Positive Dnding:Positive Dnding: >eg appears longer in supine but shorter in long"sitting>eg appears longer in supine but shorter in long"sitting
is indicative of an ipsilateral anteriorly rotated iliumis indicative of an ipsilateral anteriorly rotated ilium >eg appears shorter in supine but longer in long"sitting>eg appears shorter in supine but longer in long"sitting
is indicative of an ipsilateral posteriorly rotated iliumis indicative of an ipsilateral posteriorly rotated ilium
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=n"#ield Evaluation=n"#ield Evaluation
)istory:)istory: >ocation of pain:>ocation of pain:
>ocali0ed in vertebral column < disc rupture*>ocali0ed in vertebral column < disc rupture*
sprain* facet pathologysprain* facet pathology
(adiating pain into extremities < spinal nerve root(adiating pain into extremities < spinal nerve rootpathologypathology
Pain parallel to vertebral column < muscle spasmPain parallel to vertebral column < muscle spasm
Peripheral symptoms:Peripheral symptoms: 'erve root impingement'erve root impingement
,=$:,=$: (otational forces* hyperextension* repetitive stress(otational forces* hyperextension* repetitive stress
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=n"#ield Evaluation=n"#ield Evaluation
$nspection:$nspection: 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&
PosturePostureMillingness to moveMillingness to move 'eurological tests:'eurological tests:
SensorySensory ,otor tests,otor tests
Palpation:Palpation: Kony palpationKony palpation ParaspinalsParaspinals