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

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

4. Clinical Evaluation

5. Clinical Evaluation Nerve Root Impingement Tests: Valsalva Test:
Test Position:
Patient seated, examiner standing next to patient
Action:
Subject takes a deep breath and holds while bearing down as if having a bowel movement
Positive Finding:
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)
Comments:
Increase in intrathecal pressure may result in ↓ pulse, ↓ venous return, ↑ venous pressure (dizziness and/or fainting)

6. Clinical Evaluation Nerve Root Impingement Tests: Milgram Test:
Test Position:
Patient supine, examiner at feet of the patient
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
Positive Finding:
Patient unable to hold position, cannot lift the leg, or has pain with test
Implications:
Intrathecal or extrathecal pressure causing an intervertebral disc to place pressure on a lumbar nerve root

7. Clinical Evaluation Nerve Root Impingement Tests: Kernig’s Test:
Test Position:
Patient supine, examiner at side of patient
Action:
Patient performs a unilateral active straight leg raise with the knee extended until pain occurs
After pain occurs, the patient flexes the knee
Positive Finding:
Pain in the spine and possibly radiating into lower extremity
Pain relieved when patient flexes the knee
Implications:
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:
Kernig/Brudzinski Test:
Patient actively flexes the cervical spine (lifts the head)
Hip unilaterally flexed (no more than 900)
Knee than flexed to no more than 900
(+) ↑ pain with neck and hip flexion; pain relieved when knee is flexed

9. Clinical Evaluation Nerve Root Impingement Tests:
Unilateral Straight Leg Raise Test (Lasegue Test):
Test Position:
Patient supine, examiner standing at tested side with the distal hand around the subject’s heel and proximal hand on subject’s distal thigh (anterior) – maintains knee extension
Action:
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

10. Clinical Evaluation Straight Leg Raise Test: 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
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:
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
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

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

13. Clinical Evaluation Nerve Root Impingement Tests: Quadrant Test:
Test Position:
Patient standing with feet shoulder width apart
Examiner stands behind the patient, grasping the patient’s shoulders
Action:
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

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

15. Clinical Evaluation Nerve Root Impingement Tests: Slump Test:
Test Position:
Patient sits over edge of table; examiner is at side of patient
Action:
(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
(3) Knee is actively extended
(4) Ankle is actively dorsiflexed
(5) Repeat on opposite side

16. Clinical Evaluation Slump Test: Positive Findings: Implications:
Sciatic pain or reproduction of other neurological symptoms
Implications:
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:
Malingering – medical and psychological terms that refers to an individual fabricating/exaggerating their level of symptoms
Financial compensation (fraud)
Avoiding work
Obtaining drugs
Attract attention or sympathy

18. Clinical Evaluation Test for Patient Malingering: Hoover Test:
Test Position:
Patient supine
Examiner at feet of patient with hands cupping the calcaneous of each leg
Action:
Patient attempts to actively straight leg raise on the involved side
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 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
Lower Quarter Neurological Screen
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

22. Clinical Evaluation Nerve Root Level Motor Testing L1 Hip flexion L2
Lower Quarter Neurological Screen
Nerve Root Level
Motor Testing L1
Hip flexion L2 L3
Knee extension L4
Dorsiflexion L5
Great toe extension S1
Plantarflexion S2 NA

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

25. Clinical Evaluation Babinkski’s Test: Test Position: athlete supine
Athletic Trainer Position:  At the foot of the athlete holding a blunt tool (reflex hammer)
Procedure:  Rub the tool up bottom of athlete’s foot starting at the calcaneus and ending at the great toe.
Positive test: Great toe extends while other toes splay.
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.

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

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

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

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

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

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

32. Clinical Evaluation Intervertebral Disc Herniation:
Extrusion of nucleus pulposus through annulus fibrosus
Impingement/pressure on nerve root below affected 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. Clinical Evaluation Lumbar Disc Degeneration: History:
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
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
Predisposing condition – history of lumbar spine trauma

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

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

38. Clinical Evaluation Intervertebral Disc Degeneration: Surgery
Spinal Fusion:
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
Technique (basics):
Small pieces of extra bone fills space between two vertebrae (pelvic bone, allograft bone)
Disc removed
Wires, rods, screws, metal cages or plates may be used

39. Clinical Evaluation

40. Clinical Evaluation
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

41. Clinical Evaluation Cauda Equina Syndrome:
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
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)
Congenital causes:
Spina bifida (abnormality in closure of spinal canal)
Tumors of the cauda equina
Acquired causes of Cauda Equina Syndrome:
Injury (spinal fractures)
Secondary to medical procedures

42. Clinical Evaluation Femoral Nerve Stretch Test:
Tests for nerve root impingement at L2, L3, L4
Test position:
Patient prone with a pillow under the abdomen; examiner at side of patient
Action:
Examiner passively extends hip while keeping knee flexed to 900
Positive test:
Pain in anterior and lateral thigh

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

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

45. Clinical Evaluation Tension Sign: Tests for sciatic nerve irritation
Test position:
Patient supine; examiner’s one hand grasps the heel while other grasps the thigh
Action:
Hip and knee flexed to 900
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:
Tenderness and reproduction of sciatica symptoms

46. Clinical Evaluation

47. Clinical Evaluation Bowstring Test: (Cram Test) Test position: Action:
Patient supine
Action:
Examiner performs a passive straight leg raise on involved side
If subjects reports radiating pain, examiner flexes the subject’s knee to approximately 200 in attempt to reduce pain
Pressure than applied to popliteal area to reproduce radicular pain
Positive finding:
Painful radicular reproduction with popliteal compression
Indicates sciatic nerve tension

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

49. Clinical Evaluation Spondylolisthesis:
Progression of spondylolysis → separation of vertebrae (superior vertebrae slides anteriorly on the one below it)
“Decapitated Scotty dog” deformity:
Head of the dog (anterior element of vertebrae) has become detached from body (posterior element)
Severity – amount of anterior displacement
Epidemiology:
Most prevalent in women and adolescents
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: History:
Onset of pain:
Insidious; pain begins as an ache, ↑ to constant pain
Characteristics:
Lumbar pain, radiating into buttocks and upper posterolateral thigh
MOI:
Repetitive stress (extension)
Predisposing conditions:
Muscular imbalances
Repetitive hyperextension activities
Inspection:
↑ lordotic curve
Altered GAIT

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

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

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

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

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

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

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

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

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

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

62. Clinical Evaluation Patrick or FABER Test: Test position: Action:
Subject supine
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
Positive test:
Involved lower extremity does not abduct below level of uninvolved side
SI pathology, iliopsoas tightness

63. Clinical Evaluation Gaenslen’s Test: Test position: Action:
Subject supine, lying close to edge of table; examiner stands at side
Action:
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
Positive finding:
Pain in SI region indicating SI joint dysfunction

64. Clinical Evaluation Long-Sitting Test: Test position: Action:
Subject supine, both hips and knees extended; examiner standing with thumbs on subject’s medial malleoli
Action:
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
Positive finding:
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

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

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