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Thoracic and Lumbar Spine Special Tests and Pathologies Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C.

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Presentation on theme: "Thoracic and Lumbar Spine Special Tests and Pathologies Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C."— Presentation transcript:

1 Thoracic and Lumbar Spine Special Tests and Pathologies Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C

2 Clinical Evaluation Spring Test: Spring Test: Test Positioning: Test Positioning: Subject is prone Subject is prone Examiner stands with thumbs or hypothenar eminence over the spinous process of a lumbar vertebrae Examiner stands with thumbs or hypothenar eminence over the spinous process of a lumbar vertebrae Action: Action: Apply a downward springing force through the spinous process of each vertebrae to assess anterior-posterior motion Apply a downward springing force through the spinous process of each vertebrae to assess anterior-posterior motion Positive Finding: Positive Finding: Increases or decreases in motion at one vertebrae compared to another (hypermobility or hypomobility) Increases or decreases in motion at one vertebrae compared to another (hypermobility or hypomobility)

3 Clinical Evaluation Nerve Root Impingement: Nerve Root Impingement: Narrowing of intervertebral foramen: Narrowing of intervertebral foramen: Stenosis Stenosis Facet joint degeneration Facet joint degeneration Herniated intervertebral disc Herniated intervertebral disc

4 Clinical Evaluation

5 Nerve Root Impingement Tests: Nerve Root Impingement Tests: Valsalva Test: Valsalva Test: Test Position: Test Position: Patient seated, examiner standing next to patient Patient seated, examiner standing next to patient Action: Action: Subject takes a deep breath and holds while bearing down as if having a bowel movement Subject takes a deep breath and holds while bearing down as if having a bowel movement Positive Finding: Positive Finding: Increased spinal or radicular pain due to intrathecal pressure Increased spinal or radicular pain due to intrathecal pressure May be secondary to a space-occupying lesion (i.e. herniated disc, tumor, osteophyte in lumbar canal) May be secondary to a space-occupying lesion (i.e. herniated disc, tumor, osteophyte in lumbar canal) Comments: Comments: Increase in intrathecal pressure may result in pulse, venous return, venous pressure (dizziness and/or fainting) Increase in intrathecal pressure may result in pulse, venous return, venous pressure (dizziness and/or fainting)

6 Clinical Evaluation Nerve Root Impingement Tests: Nerve Root Impingement Tests: Milgram Test: Milgram Test: Test Position: Test Position: Patient supine, examiner at feet of the patient Patient supine, examiner at feet of the patient Action: Action: Patient performs a bilateral straight leg raise to the height of 2 to 6 inches and is asked to hold the position for 30 seconds Patient performs a bilateral straight leg raise to the height of 2 to 6 inches and is asked to hold the position for 30 seconds Positive Finding: Positive Finding: Patient unable to hold position, cannot lift the leg, or has pain with test Patient unable to hold position, cannot lift the leg, or has pain with test Implications: Implications: Intrathecal or extrathecal pressure causing an intervertebral disc to place pressure on a lumbar nerve root Intrathecal or extrathecal pressure causing an intervertebral disc to place pressure on a lumbar nerve root

7 Clinical Evaluation Nerve Root Impingement Tests: Nerve Root Impingement Tests: Kernigs Test: Kernigs Test: Test Position: Test Position: Patient supine, examiner at side of patient Patient supine, examiner at side of patient Action: Action: Patient performs a unilateral active straight leg raise with the knee extended until pain occurs Patient performs a unilateral active straight leg raise with the knee extended until pain occurs After pain occurs, the patient flexes the knee After pain occurs, the patient flexes the knee Positive Finding: Positive Finding: Pain in the spine and possibly radiating into lower extremity Pain in the spine and possibly radiating into lower extremity Pain relieved when patient flexes the knee Pain relieved when patient flexes the knee Implications: Implications: Nerve root impingement secondary to bulging of the intervertebral disc or bony entrapment; irritation of dural sheath; irritation of meninges Nerve root impingement secondary to bulging of the intervertebral disc or bony entrapment; irritation of dural sheath; irritation of meninges

8 Clinical Evaluation Nerve Root Impingement Tests: Nerve Root Impingement Tests: Kernig/Brudzinski Test: Kernig/Brudzinski Test: Patient actively flexes the cervical spine (lifts the head) Patient actively flexes the cervical spine (lifts the head) Hip unilaterally flexed (no more than 90 0 ) Hip unilaterally flexed (no more than 90 0 ) Knee than flexed to no more than 90 0 Knee than flexed to no more than 90 0 (+) pain with neck and hip flexion; pain relieved when knee is flexed (+) pain with neck and hip flexion; pain relieved when knee is flexed

9 Clinical Evaluation Nerve Root Impingement Tests: Nerve Root Impingement Tests: Unilateral Straight Leg Raise Test (Lasegue Test): Unilateral Straight Leg Raise Test (Lasegue Test): Test Position: Test Position: Patient supine, examiner standing at tested side with the distal hand around the subjects heel and proximal hand on subjects distal thigh (anterior) – maintains knee extension Patient supine, examiner standing at tested side with the distal hand around the subjects heel and proximal hand on subjects distal thigh (anterior) – maintains knee extension Action: Action: Examiner slowly raises the leg until pain/tightness noted or full ROM is obtained Examiner slowly raises the leg until pain/tightness noted or full ROM is obtained Slowly lower the leg until the pain or tightness resolves, at which point dorsiflex the ankle and have subject flex the neck Slowly lower the leg until the pain or tightness resolves, at which point dorsiflex the ankle and have subject flex the neck

10 Clinical Evaluation Straight Leg Raise Test: Straight Leg Raise Test: Positive Findings: Positive Findings: Leg and/or low back pain occurring with DF and or neck flexion is indicative of dural involvement and/or sciatic nerve irritation Leg and/or low back pain occurring with DF and or neck flexion is indicative of dural involvement and/or sciatic nerve irritation Lack of pain reproduction with DF and/or neck flexion is indicative of hamstring tightness or SI pathology Lack of pain reproduction with DF and/or neck flexion is indicative of hamstring tightness or SI pathology

11 Clinical Evaluation Nerve Root Impingement Tests: Nerve Root Impingement Tests: Well Straight Leg Raising Test: Well Straight Leg Raising Test: Can be used to differentiate between sciatic nerve irritation or a herniated intervertebral disc that is irritating the nerve root Can be used to differentiate between sciatic nerve irritation or a herniated intervertebral disc that is irritating the nerve root Test Position: Test Position: Patient supine, examiner standing at unaffected side; one hand grasps under the heel while other is placed on anterior thigh to stabilize the leg in extension Patient supine, examiner standing at unaffected side; one hand grasps under the heel while other is placed on anterior thigh to stabilize the leg in extension

12 Clinical Evaluation Well Straight Leg Raise Test: Well Straight Leg Raise Test: Action: Action: Examiner raises the leg by flexing the hip until discomfort is reported (knee kept in full extension) Examiner raises the leg by flexing the hip until discomfort is reported (knee kept in full extension) Positive Finding: Positive Finding: Pain is experienced on the side opposite that being raised Pain is experienced on the side opposite that being raised

13 Clinical Evaluation Nerve Root Impingement Tests: Nerve Root Impingement Tests: Quadrant Test: Quadrant Test: Test Position: Test Position: Patient standing with feet shoulder width apart Patient standing with feet shoulder width apart Examiner stands behind the patient, grasping the patients shoulders Examiner stands behind the patient, grasping the patients shoulders Action: Action: Patient extends the spine as far as possible, than sidebends and rotates to affected side Patient extends the spine as far as possible, than sidebends and rotates to affected side Examiner provides overpressure through the shoulders, supporting the patient as needed Examiner provides overpressure through the shoulders, supporting the patient as needed

14 Clinical Evaluation Nerve Root Impingement Tests: Nerve Root Impingement Tests: Quadrant Test: Quadrant Test: Positive Findings: Positive Findings: Reproduction of patients symptoms Reproduction of patients symptoms Implications: Implications: Radicular pain indicates compression of the intervertebral foramina that impinges on the lumbar nerve roots Radicular pain indicates compression of the intervertebral foramina that impinges on the lumbar nerve roots Local pain (not radiating) indicates facet joint pathology Local pain (not radiating) indicates facet joint pathology Symptoms isolated to the area of the PSIS may indicate SI joint dysfunction Symptoms isolated to the area of the PSIS may indicate SI joint dysfunction

15 Clinical Evaluation 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 side of patient Patient sits over edge of table; examiner is at side of patient Action: Action: (1) Patient slumps forward along thoracolumbar spine, rounding the shoulders while keeping cervical spine neutral (1) Patient slumps forward along thoracolumbar spine, rounding the shoulders while keeping cervical spine neutral (2) Patient flexes cervical spine; Clinician holds patient in this position (2) Patient flexes cervical spine; Clinician holds patient 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

16 Clinical Evaluation Slump Test: Slump Test: Positive Findings: Positive Findings: Sciatic pain or reproduction of other neurological symptoms Sciatic pain or reproduction of other neurological symptoms Implications: Implications: Impingement of the dural lining, spinal cord, or nerve roots Impingement of the dural lining, spinal cord, or nerve roots Note: Patient performs ACTIVE knee extension and dorsiflexion

17 Clinical Evaluation Test for Patient Malingering: Test for Patient Malingering: Malingering – medical and psychological terms that refers to an individual fabricating/exaggerating their level of symptoms Malingering – medical and psychological terms that refers to an individual fabricating/exaggerating their level of symptoms Financial compensation (fraud) Financial compensation (fraud) Avoiding work Avoiding work Obtaining drugs Obtaining drugs Attract attention or sympathy Attract attention or sympathy

18 Clinical Evaluation Test for Patient Malingering: Test for Patient Malingering: Hoover Test: Hoover Test: Test Position: Test Position: Patient supine Patient supine Examiner at feet of patient with hands cupping the calcaneous of each leg Examiner at feet of patient with hands cupping the calcaneous of each leg Action: Action: Patient attempts to actively straight leg raise on the involved side Patient attempts to actively straight leg raise on the involved side Positive Findings: Positive Findings: Patient does not attempt to lift the leg and examiner does NOT sense pressure from the uninvolved leg pressing down on the hand Patient does not attempt to lift the leg and examiner does NOT sense pressure from the uninvolved leg pressing down on the hand Patient is not attempting to perform the test Patient is not attempting to perform the test

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

20 Clinical Evaluation Nerve Root Level Sensory Testing L1 Inguinal area (just below inguinal ligament L2 Mid-thigh (medial) L3 Medial knee (just above superior pole of patella) L4 Medial aspect of lower leg, medial ankle, big toe L5 Top of foot (an/or blow head of fibula) S1 Lateral foot S2 Posterior thigh, popliteal fossa Lower Quarter Neurological Screen

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22 Clinical Evaluation Nerve Root Level Motor Testing L1 Hip flexion L2 L3 Knee extension L4Dorsiflexion L5 Great toe extension S1Plantarflexion S2NA Lower Quarter Neurological Screen

23 Clinical Evaluation Nerve Root Level Reflex Testing L4 Patellar Tendon L5 S1 Achilles Tendon S2 Lower Quarter Neurological Screen

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25 Clinical Evaluation Babinkskis Test: Babinkskis Test: Test Position: athlete supine Test Position: athlete supine Athletic Trainer Position: At the foot of the athlete holding a blunt tool (reflex hammer) Athletic Trainer Position: At the foot of the athlete holding a blunt tool (reflex hammer) Procedure: Rub the tool up bottom of athletes foot starting at the calcaneus and ending at the great toe. Procedure: Rub the tool up bottom of athletes foot starting at the calcaneus and ending at the great toe. Positive test: Great toe extends while other toes splay. Positive test: Great toe extends while other toes splay. Implications: Lesion of upper motor neurons, may be caused by trauma to the brain Implications: Lesion of upper motor neurons, may be caused by trauma to the brain Comments: This reflex occurs naturally in newborns. However, this reflex should cease quickly after birth. Comments: This reflex occurs naturally in newborns. However, this reflex should cease quickly after birth.

26 Clinical Evaluation Erector Spinae Muscle Strain: Erector Spinae Muscle Strain: Common low back pathology Common low back pathology MOI: MOI: History of heavy or repetitive lifting History of heavy or repetitive lifting Signs/Symptoms: Signs/Symptoms: Aching back Aching back Pain with passive and active flexion, resisted extension Pain with passive and active flexion, resisted extension Neurological Evaluation: Neurological Evaluation: Negative results Negative results

27 Clinical Evaluation Facet Joint Dysfunction: Facet Joint Dysfunction: Pathology of facet joints – 40% of all chronic low back pain Pathology of facet joints – 40% of all chronic low back pain Vague signs/symptoms: Vague signs/symptoms: Often resemble other low back pathologies (i.e. strain/spasm of paraspinal muscles, nerve root impingement, disc degeneration) Often resemble other low back pathologies (i.e. strain/spasm of paraspinal muscles, nerve root impingement, disc degeneration) Involvement: Involvement: Dislocation/sublocation of facet: Dislocation/sublocation of facet: Tends to lock the involved spinal segment (hypomobile vertebrae) Tends to lock the involved spinal segment (hypomobile vertebrae) Facet joint syndrome: (inflammation) Facet joint syndrome: (inflammation) Causes: repetitive stress through movement or loading Causes: repetitive stress through movement or loading Degeneration: (arthritis) Degeneration: (arthritis) Causes: undefined history Causes: undefined history intervertebral foramen size (nerve root impingement) intervertebral foramen size (nerve root impingement)

28 Clinical Evaluation Facet Joint Dysfunction: Facet Joint Dysfunction: History: History: Onset – insidious Onset – insidious Pain characteristics – localized Pain characteristics – localized MOI – extension, rotation, lateral bending of vertebrae MOI – extension, rotation, lateral bending of vertebrae Predisposing conditions – repeated motions of spinal extension, rotation, lateral bending Predisposing conditions – repeated motions of spinal extension, rotation, lateral bending Inspection: Inspection: Patient may assume posture that pressure on affected facets Patient may assume posture that pressure on affected facets Palpation: Palpation: Possible local muscle spasm (paravertebral muscles) Possible local muscle spasm (paravertebral muscles)

29 Clinical Evaluation Facet Joint Dysfunction: Facet Joint Dysfunction: Ligamentous Tests: Ligamentous Tests: Spring Test – pain, motion Spring Test – pain, motion Neurological Tests: Neurological Tests: Not applicable unless secondary nerve root impingement occurs Not applicable unless secondary nerve root impingement occurs Special Tests: Special Tests: Quadrant Test (+) Quadrant Test (+) Intervertebral disc lesions (-) Intervertebral disc lesions (-)

30 Clinical Evaluation Facet Joint Dysfunction: Facet Joint Dysfunction: Initial Treatment: Initial Treatment: NSAIDs NSAIDs Instruct patient to avoid postures/movements that irritate facets Instruct patient to avoid postures/movements that irritate facets Modalities – moist heat, e-stim, ice to muscle spasm Modalities – moist heat, e-stim, ice to muscle spasm Therapeutic Exercises: Therapeutic Exercises: Stretching and strengthening: Stretching and strengthening: Low back Low back Abdominals Abdominals Hip flexors, hip extensors, hamstrings Hip flexors, hip extensors, hamstrings

31 Clinical Evaluation Intervertebral Disc Lesions: Intervertebral Disc Lesions: Disc Degeneration: Disc Degeneration: Loss of water from nucleus pulposus Loss of water from nucleus pulposus cushioning ability cushioning ability stress load on annulus fibrosus stress load on annulus fibrosus Small tears occur to annulus (scar tissue formation – not as strong as normal tissue) Small tears occur to annulus (scar tissue formation – not as strong as normal tissue) Bulging of nucleus pulposus Bulging of nucleus pulposus

32 Clinical Evaluation Intervertebral Disc Herniation: Intervertebral Disc Herniation: Extrusion of nucleus pulposus through annulus fibrosus Extrusion of nucleus pulposus through annulus fibrosus Impingement/pressure on nerve root below affected disc Impingement/pressure on nerve root below affected disc Sequestrated – nuclear material breaks away from rest of disc Sequestrated – nuclear material breaks away from rest of disc

33 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)

34 Clinical Evaluation

35 Lumbar Disc Degeneration: Lumbar Disc Degeneration: History: History: Onset – insidious or may be related to single episode Onset – insidious or may be related to single episode Breakdown of disc is related to repetitive stress; Last episode – final failure an annulus fibrosus to contain nucleus pulposus Breakdown of disc is related to repetitive stress; Last episode – final failure an annulus fibrosus to contain nucleus pulposus Pain characteristics – affected vertebrae; compression of spinal nerve root leads to pain in low back, buttocks, radiating into thigh, calf, heel, foot Pain characteristics – affected vertebrae; compression of spinal nerve root leads to pain in low back, buttocks, radiating into thigh, calf, heel, foot MOI – repetitive loading of disc MOI – repetitive loading of disc Predisposing condition – history of lumbar spine trauma Predisposing condition – history of lumbar spine trauma

36 Clinical Evaluation Lumbar Disc Degeneration: Lumbar Disc Degeneration: Inspection: Inspection: Slow GAIT Slow GAIT Flattened lumbar spine Flattened lumbar spine Changes in body position – guarded and painful Changes in body position – guarded and painful Sitting standing / sitting lying Sitting standing / sitting lying Changes in disc pressure Changes in disc pressure Standing position: Standing position: Lateral shift away from side of leg pain Lateral shift away from side of leg pain Palpation: Palpation: Musculature spasm Musculature spasm

37 Clinical Evaluation Lumbar Disc Degeneration: Lumbar Disc Degeneration: Functional Tests: Functional Tests: Limited ROM in all directions Limited ROM in all directions Movement in one direction may relieve or symptoms Movement in one direction may relieve or symptoms Neurological Tests: Neurological Tests: Lower quarter screen Lower quarter screen Special Tests: Special Tests: Straight leg raising, Well straight leg raising, Milgram, Sciatic and femoral nerve tension tests Straight leg raising, Well straight leg raising, Milgram, Sciatic and femoral nerve tension tests Diagnostic Tests: Diagnostic Tests: MRI MRI

38 Clinical Evaluation Intervertebral Disc Degeneration: Surgery Intervertebral Disc Degeneration: Surgery Spinal Fusion: Spinal Fusion: Welding 2 or more vertebrae together Welding 2 or more vertebrae together Cause of back pain (motion between vertebral segments) spinal fusion may be a way to prevent motion and stop the pain Cause of back pain (motion between vertebral segments) spinal fusion may be a way to prevent motion and stop the pain Technique (basics): Technique (basics): Small pieces of extra bone fills space between two vertebrae (pelvic bone, allograft bone) Small pieces of extra bone fills space between two vertebrae (pelvic bone, allograft bone) Disc removed Disc removed Wires, rods, screws, metal cages or plates may be used Wires, rods, screws, metal cages or plates may be used

39 Clinical Evaluation

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

41 Cauda Equina Syndrome: Cauda Equina Syndrome: Anatomy: spinal cord ends at the lower edge of the 1st lumbar vertebra Anatomy: spinal cord ends at the lower edge of the 1st lumbar vertebra Lumbar and sacral nerve roots form a bundle within the spinal canal below the conus medullaris Lumbar and sacral nerve roots form a bundle within the spinal canal below the conus medullaris CES – nerves within the spinal canal have been damaged; nerves supplying muscles of legs, bladder, bowel and genitals do not function properly CES – nerves within the spinal canal have been damaged; nerves supplying muscles of legs, bladder, bowel and genitals do not function properly Numbness, loss of sensation (damage usually permanent) Numbness, loss of sensation (damage usually 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

42 Clinical Evaluation Femoral Nerve Stretch Test: Femoral Nerve Stretch Test: Tests for nerve root impingement at L2, L3, L4 Tests for nerve root impingement at L2, L3, L4 Test position: Test position: Patient prone with a pillow under the abdomen; examiner at side of patient Patient prone with a pillow under the abdomen; examiner at side of patient Action: Action: Examiner passively extends hip while keeping knee flexed to 90 0 Examiner passively extends hip while keeping knee flexed to 90 0 Positive test: Positive test: Pain in anterior and lateral thigh Pain in anterior and lateral thigh

43 Clinical Evaluation Sciatica: Sciatica: General term for any inflammation involving sciatic nerve General term for any inflammation involving sciatic nerve Causes: Causes: Lumbar disc herniation Lumbar disc herniation SI joint dysfunction SI joint dysfunction Scar tissue around nerve root Scar tissue around nerve root Nerve root inflammation Nerve root inflammation Spinal stenosis Spinal stenosis Synovial cysts Synovial cysts Cancerous or noncancerous tumors Cancerous or noncancerous tumors

44 Clinical Evaluation Sciatica: Sciatica: Signs and Symptoms: Signs and Symptoms: Radiating pain Radiating pain Muscular weakness Muscular weakness Special Tests: Special Tests: Straight leg raise test Straight leg raise test Tension sign Tension sign Treatment and Rehab: Treatment and Rehab: Resolve pathology that is irritating nerve Resolve pathology that is irritating nerve Oral anti-inflammatory meds / corticosteroids Oral anti-inflammatory meds / corticosteroids Exercises for strength / ROM Exercises for strength / ROM

45 Clinical Evaluation Tension Sign: Tension Sign: Tests for sciatic nerve irritation Tests for sciatic nerve irritation Test position: Test position: Patient supine; examiners one hand grasps the heel while other grasps the thigh Patient supine; examiners one hand grasps the heel while other grasps the thigh Action: Action: Hip and knee flexed to 90 0 Hip and knee flexed to 90 0 Knee is then extended as far as possible with the examiner palpating the tibial portion of the sciatic nerve as it passes behind popliteal space Knee is then extended as far as possible with the examiner palpating the tibial portion of the sciatic nerve as it passes behind popliteal space Positive finding: Positive finding: Tenderness and reproduction of sciatica symptoms Tenderness and reproduction of sciatica symptoms

46 Clinical Evaluation

47 Bowstring Test: (Cram Test) Bowstring Test: (Cram Test) Test position: Test position: Patient supine Patient supine Action: Action: Examiner performs a passive straight leg raise on involved side Examiner performs a passive straight leg raise on involved side If subjects reports radiating pain, examiner flexes the subjects knee to approximately 20 0 in attempt to reduce pain If subjects reports radiating pain, examiner flexes the subjects knee to approximately 20 0 in attempt to reduce pain Pressure than applied to popliteal area to reproduce radicular pain Pressure than applied to popliteal area to reproduce radicular pain Positive finding: Positive finding: Painful radicular reproduction with popliteal compression Painful radicular reproduction with popliteal compression Indicates sciatic nerve tension Indicates sciatic nerve tension

48 Clinical Evaluation Spondylolysis: Spondylolysis: Defect in pars interarticularis (area between inferior and superior articular facets) Defect in pars interarticularis (area between inferior and superior articular facets) MOI – repetitive stress MOI – repetitive stress Unilateral or bilateral defects Unilateral or bilateral defects Listhesis: Listhesis: Posterior portion of the vertebrae, laminae, inferior articular surfaces, spinous process separates from vertebral body Posterior portion of the vertebrae, laminae, inferior articular surfaces, spinous process separates from vertebral body Collared Scotty dog deformity Collared Scotty dog deformity Symptoms: Symptoms: Localized mow back pain ( during/after activity) Localized mow back pain ( during/after activity) Pain with extension Pain with extension

49 Clinical Evaluation Spondylolisthesis: Spondylolisthesis: Progression of spondylolysis separation of vertebrae (superior vertebrae slides anteriorly on the one below it) Progression of spondylolysis separation of vertebrae (superior vertebrae slides anteriorly on the one below it) Decapitated Scotty dog deformity: Decapitated Scotty dog deformity: Head of the dog (anterior element of vertebrae) has become detached from body (posterior element) Head of the dog (anterior element of vertebrae) has become detached from body (posterior element) Severity – amount of anterior displacement Severity – amount of anterior displacement Epidemiology: Epidemiology: Most prevalent in women and adolescents Most prevalent in women and adolescents Young gymnasts Young gymnasts

50 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)

51 Clinical Evaluation Spondylolysis and Spondylolisthesis: Spondylolysis and Spondylolisthesis: History: History: Onset of pain: Onset of pain: Insidious; pain begins as an ache, to constant pain Insidious; pain begins as an ache, to constant pain Characteristics: Characteristics: Lumbar pain, radiating into buttocks and upper posterolateral thigh Lumbar pain, radiating into buttocks and upper posterolateral thigh MOI: MOI: Repetitive stress (extension) Repetitive stress (extension) Predisposing conditions: Predisposing conditions: Muscular imbalances Muscular imbalances Repetitive hyperextension activities Repetitive hyperextension activities Inspection: Inspection: lordotic curve lordotic curve Altered GAIT Altered GAIT

52 Clinical Evaluation Spondylolysis and Spondylolisthesis: Spondylolysis and Spondylolisthesis: Palpation: Palpation: Step-off deformity may be felt Step-off deformity may be felt Spasm of paraspinal muscles Spasm of paraspinal muscles Functional Tests: Functional Tests: AROM: AROM: Flexion – restricted, pain free Flexion – restricted, pain free Extension – pain Extension – pain Rotation and bending - pain Rotation and bending - pain PROM: PROM: Hip flexion – hamstring tightness Hip flexion – hamstring tightness RROM: RROM: Weakness of spinal erectors Weakness of spinal erectors

53 Clinical Evaluation Spondylolysis and Spondylolisthesis: Spondylolysis and Spondylolisthesis: Special Tests: Special Tests: Pain with Spring test Pain with Spring test SL stance test; straight leg raises may produce pain SL stance test; straight leg raises may produce pain Neurological Exam: Neurological Exam: Lower quarter screen (results typically negative) Lower quarter screen (results typically negative) Comments: Comments: X-ray, CT, MRI (will differentiate between spondylolysis and spondylolisthesis) X-ray, CT, MRI (will differentiate between spondylolysis and spondylolisthesis)

54 Clinical Evaluation Single Leg Stance Test: Single Leg Stance Test: Test position: Test position: Patient standing with body weight evenly distributed between the 2 feet; examiner stands behind pt. Patient standing with body weight evenly distributed between the 2 feet; examiner stands behind pt. Action: Action: Patient lifts one leg, then places the trunk in hyperextension; examiner may assist Patient lifts one leg, then places the trunk in hyperextension; examiner may assist Positive test: Positive test: Pain in lumbar spine or SI area Pain in lumbar spine or SI area

55 Clinical Evaluation Single Leg Stance Test: Single Leg Stance Test: Implication: Implication: Shear forces are placed on pars interarticularis by iliopsoas pulling the vertebrae anteriorly Shear forces are placed on pars interarticularis by iliopsoas pulling the vertebrae anteriorly Comments: Comments: Unilateral fracture – pain when opposite leg raised Unilateral fracture – pain when opposite leg raised Bilateral fractures – pain with either leg being fractured Bilateral fractures – pain with either leg being fractured

56 Clinical Evaluation Sacroiliac Dysfunction: Sacroiliac Dysfunction: History: History: Onset: Onset: Acute or insidious Acute or insidious Pain characteristics: Pain characteristics: One or both SI joints; possibly radiating pain in buttocks, groin, thigh One or both SI joints; possibly radiating pain in buttocks, groin, thigh Mechanism: Mechanism: Prolonged stress Prolonged stress Predisposing conditions: Predisposing conditions: Postpartum women (relaxin levels) Postpartum women (relaxin levels) Hormonal levels during menstruation Hormonal levels during menstruation

57 Clinical Evaluation Sacroiliac Joint Dysfunction: Sacroiliac Joint Dysfunction: Inspection: Inspection: Levels of iliac crests, ASIS, PSIS Levels of iliac crests, ASIS, PSIS Palpation: Palpation: Pain over SI joints and PSIS Pain over SI joints and PSIS Functional tests: Functional tests: Trunk flexion (with knees extended) will cause movement of the sacrum on the ilia (pain) Trunk flexion (with knees extended) will cause movement of the sacrum on the ilia (pain) Neurological testing: Neurological testing: Lower quarter screen Lower quarter screen Special tests: Special tests: Long sit; SI compression and distraction; straight leg raising; fabre; gaenslens; quadrant Long sit; SI compression and distraction; straight leg raising; fabre; gaenslens; quadrant

58 Clinical Evaluation Sacroiliac Joint Stress Test: Sacroiliac Joint Stress Test: Test position: Test position: Subject supine; examiner stands next to subject and with arms crossed, places heel of both hands on the subjects ASISs Subject supine; examiner stands next to subject and with arms crossed, places heel of both hands on the subjects ASISs Action: Action: Examiner applies outward and downward pressure with the heels of both hands Examiner applies outward and downward pressure with the heels of both hands Positive finding: Positive finding: Unilateral pain at SI joint or in gluteal/leg region is indicative of anterior SI ligament sprain Unilateral pain at SI joint or in gluteal/leg region is indicative of anterior SI ligament sprain

59 Clinical Evaluation Sacroiliac Joint Stress Test: Sacroiliac Joint Stress Test: Test position: Test position: Subject side-lying; examiner stands next to patient and places both hands (one on top of the other) directly over the subjects iliac crest Subject side-lying; examiner stands next to patient and places both hands (one on top of the other) directly over the subjects iliac crest Action: Action: Apply downward pressure Apply downward pressure Positive finding: Positive finding: Increased pain indicative of SI pathology (possible involvement of posterior SI ligament) Increased pain indicative of SI pathology (possible involvement of posterior SI ligament)

60 Clinical Evaluation Sacroiliac Joint Stress Test: Sacroiliac Joint Stress Test: Test position: Test position: Subject lying supine; examiner places both hands on lateral aspect of subjects iliac crests Subject lying supine; examiner places both hands on lateral aspect of subjects iliac crests Action: Action: Apply inward and downward pressure Apply inward and downward pressure Positive finding: Positive finding: Increased pain indicative of SI pathology (possibly involving posterior SI ligaments) Increased pain indicative of SI pathology (possibly involving posterior SI ligaments)

61 Clinical Evaluation Sacroiliac Joint Stress Test: Sacroiliac Joint Stress Test: Test position: Test position: Subject lying prone; examiner places both hands (one on top of the other) over subjects sacrum Subject lying prone; examiner places both hands (one on top of the other) over subjects sacrum Action: Action: Apply downward pressure on sacrum Apply downward pressure on sacrum Positive finding: Positive finding: Increased pain indicative of SI pathology Increased pain indicative of SI pathology

62 Clinical Evaluation Patrick or FABER Test: Patrick or FABER Test: Test position: Test position: Subject supine Subject supine Action: Action: Examiner passively flexes, abducts, and externally rotates the involved leg until the foot rests on the top of the knee of uninvolved lower extremity; examiner slowly abducts the involved lower extremity towards the table Examiner passively flexes, abducts, and externally rotates the involved leg until the foot rests on the top of the knee of uninvolved lower extremity; examiner slowly abducts the involved lower extremity towards the table Positive test: Positive test: Involved lower extremity does not abduct below level of uninvolved side Involved lower extremity does not abduct below level of uninvolved side SI pathology, iliopsoas tightness SI pathology, iliopsoas tightness

63 Clinical Evaluation Gaenslens Test: Gaenslens Test: Test position: Test position: Subject supine, lying close to edge of table; examiner stands at side Subject supine, lying close to edge of table; examiner stands at side Action: Action: Slide patient to edge of table; patient pulls far knee up to the chest; near leg allowed to hang over edge of table Slide patient to edge of table; patient pulls far knee up to the chest; near leg allowed to hang over edge of table Examiner applies downward pressure on near leg, forcing it into hyperextension Examiner applies downward pressure on near leg, forcing it into hyperextension Positive finding: Positive finding: Pain in SI region indicating SI joint dysfunction Pain in SI region indicating SI joint dysfunction

64 Clinical Evaluation Long-Sitting Test: Long-Sitting Test: Test position: Test position: Subject supine, both hips and knees extended; examiner standing with thumbs on subjects medial malleoli Subject supine, both hips and knees extended; examiner standing with thumbs on subjects medial malleoli Action: Action: Examiner passively flexes both hips and knees and then fully extends and compares position of medial malleoli relative to eachother Examiner passively flexes both hips and knees and then fully extends and compares position of medial malleoli relative to eachother Subject slowly assumes the long-sitting position and malleolar position is re-assessed Subject slowly assumes the long-sitting position and malleolar position is re-assessed Positive finding: Positive finding: Leg appears longer in supine but shorter in long-sitting is indicative of an ipsilateral anteriorly rotated ilium Leg appears longer in supine but shorter in long-sitting is indicative of an ipsilateral anteriorly rotated ilium Leg appears shorter in supine but longer in long-sitting is indicative of an ipsilateral posteriorly rotated ilium Leg appears shorter in supine but longer in long-sitting is indicative of an ipsilateral posteriorly rotated ilium

65 On-Field Evaluation History: History: Location of pain: Location of pain: Localized in vertebral column – disc rupture, sprain, facet pathology Localized in vertebral column – disc rupture, sprain, facet pathology Radiating pain into extremities – spinal nerve root pathology Radiating pain into extremities – spinal nerve root pathology Pain parallel to vertebral column – muscle spasm Pain parallel to vertebral column – muscle spasm Peripheral symptoms: Peripheral symptoms: Nerve root impingement Nerve root impingement MOI: MOI: Rotational forces, hyperextension, repetitive stress Rotational forces, hyperextension, repetitive stress

66 On-Field Evaluation Inspection: Inspection: Position of athlete: Position of athlete: Supine – if spinal cord involvement suspected, manage accordingly (spine board) Supine – if spinal cord involvement suspected, manage accordingly (spine board) Posture Posture Willingness to move Willingness to move Neurological tests: Neurological tests: Sensory Sensory Motor tests Motor tests Palpation: Palpation: Bony palpation Bony palpation Paraspinals Paraspinals


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