KIN 191AAdvanced Assessment of Lower Extremity Injuries

THE THORACIC AND LUMBAR SPINEEVALUATION

INTRODUCTION

• HISTORY• INSPECTION• PALPATION• ROM TESTS• STRESS/STREE TESTS• NEUROGIC TEST• VASCULAR TEST

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HISTORY

• Location of pain• Onset of pain• Mechanism of injury• Consistency of pain• Prior history• Aggravating/alleviating factors• Activity changes

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Location of Pain

• Often difficult to isolate specific location of pain with low back injuries/conditions

• Radiating pain indicative of nerve root irritation– Must have perspective on myotome/dermatome

patterns for evaluation– Regarding peripheral nerves, must have

perspective on nerve root level origin

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Onset of Pain

• Acute, traumatic onset of symptoms, while possible, is not a typical presentation of low back pain symptoms

• May be able to isolate one incident with onset of symptoms, but typically that incident is representative of accumulative stresses over time which reach their “breaking” point

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Mechanism of Injury

• Direct trauma may indicate spinal fracture/s and/or internal organ injury

• Hyperextension activities (gymnastics, FB lineman, etc.) predispose to pars interarticularis injuries

• Multiple compression and shear forces depending upon activities engaged in

• Often difficult to isolate specific MOI

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Consistency of Pain

• Constant pain– If unable to affect pain with position change,

associated with inflammation from injury (acute or chronic) – swelling from facet sprain or pars interarticularis fracture

• Intermittent pain– If symptoms impacted (alleviated or aggravated)

with spine position, associated with mechanical injury – compression/stretching of nerve root

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Prior History

• Must question regarding previous history of low back injury/pain

• Structural or degenerative changes may predispose to symptoms

• Scar tissue may irritate tissues causing symptoms

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Aggravating/Alleviating Factors

• What makes it better? …worse?

• Posture/s– Prolonged sitting, etc. with activities

• Activities– May have postural component with performance

of activities

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Activity Changes

• As with many lower extremity injuries/conditions, must be mindful of changes in– Intensity of workouts– Duration of workouts– Training surface– Footwear– Sleeping arrangements

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INSPECTION

• Posture/Curvatures– Standing, sitting, with activities (e.g. – lifting)– Lateral shift away from pain/nerve root

impingement– Frontal curvature – scoliosis (see slide 14)– Sagittal curvature – excessive/absent lordosis

• Muscular appearance– Evaluate for spasm/atrophy – often readily visible

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• Gait• Skin markings– Café-au-lait spots (neurofibramatosis), Faun’s

beard (spina bifida)– Neurofibromatosis• Increased cell growth of neutral tissues; normally a

benign condition; pain possible secondary to pressure on the local nerves

– Spina bifida occulta• Incomplete closure of the spinal vertebrae

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Postures/Curvatures

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Scoliosis

• Forward flexion test– Posterior view of the spinal column while the

patient flexes the spine; note the presence of hump over the spine, suggesting scoliosis

– If functional, “hump” disappears– If structural, “hump” present

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PALPATION(Thoracic Spine)

1. Spinous processes2. Supraspinous ligament3. Costovertebral

junction4. Trapezius5. Paravertebral muscles6. Scapular muscles

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PALPATION(Lumbar Spine)

1. Spinous processes2. Step-off deformity3. Paravertebral muscles

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PALPATION(Sacrum & Pelvis)

1. Median sacral crest2. Iliac crest3. PSIS4. Gluteals5. Ischial tuberocity6. Greater trochanter7. Pubic symphysis

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RANGE OF MOTION TESTS

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AROM

• Flexion– Measure with distance from finger tips to floor– Affected by hamstring/calf/paraspinal tightness

• Extension• Lateral flexion/bending– Measure finger tips to floor or at level on LE

• Rotation– Best done in sitting to stabilize pelvis/LE– Should be bilaterally equal

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PROM

• Flexion– Bring knees to chest in supine position

• Extension– Prone position and “press-up” with pelvis on table

• Lateral flexion/bending– Often referred to as side gliding – often eliminated

• Rotation– Knees/hips flexed and rotate pelvis with shoulders on

table

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RROM

• Flexion– Stabilize pelvis, resistance to sternum with “crunch”

• Extension– Stabilize low back, resistance near scapula to “reverse

crunch”

• Lateral flexion/bending – typically not assessed• Rotation– Stabilize opposite ASIS, resistance to opposite shoulder for

“curl crunch”

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SPECIAL TESTS

• Ligamentous testing– Spring test for facet mobility/irritation

• Tests for nerve root impingement– Valsalva maneuver– Milgram test– Kernig test– Straight leg raise and well straight leg raise tests– Quadrant test– Slump test

• Test for malingering– Hoover test

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Spring Test

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Increased Intrathecal Pressure

• Increased pressure may compress intervertebral disc forcing nucleus pulposus out causing nerve root irritation/impingement – radiating pain

• Valsalva Maneuver– Seated, simulated bowel movement – hold breath

• Milgram Test– Supine, SLR to a few inches and hold

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Valsalva Test

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Milgram Test

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Kernig’s Test/Brudzinski’s Test

• Evaluative for nerve root impingement from disc bulge or herniation

• Supine, perform unilateral SLR with knee extended until pain occurs

• Flex knee at pain and symptoms should subside

• Brudzinski’s test – modification with cervical flexion to further stretch neural elements

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Kernig’s test / Brudzinski’s test

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SLR and Well SLR Tests• Evaluative for nerve root impingement,

typically discogenic in nature• SLR test– Supine, flex hip (SLR) on affected side to pain with

knee extended, back off a little, DF ankle, if symptoms reoccur, + test

• Well SLR test– SLR of opposite (uninvolved) leg, test + if pain felt

on opposite side

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Straight Leg Raise test

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Well Straight Leg Raise test

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Quadrant Test

• Often performed, not often named as such• Standing, patient extends then laterally bends

and rotates to affected side• If radiating pain, indicative of nerve root

irritation or impingement• If local pain with no radiating symptoms,

indicative of facet irritation/sprain

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Quadrant TestQuadrant Test

Slump Test

• Evaluative for nerve root, dural sheath or spinal cord irritation/inflammation

• Seated, cervical flexion and thoracic “slump” followed by knee extension and ankle dorsiflexion

• Pain and/or radiating symptoms are + test – due to neural element lengthening/stretch

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Slump Test

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Hoover Test

• Evaluative for malingering patient• Supine, clinician holding both heels, patient

instructed to perform active SLR on involved side

• Pressure should be noted in opposite heel by clinician – attempt to stabilize for movement

• Absence of pressure or inability to do SLR is + for malingering

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Hoover TestHoover Test