Athletic Training & Sports Medicine Center

AH 325

Lumbar Spine Injuries Laboratory

Secondary Survey

History

Mechanism of injury

Direct trauma

Contusion

Spinous processes (periosteal hematoma)
Erector spinae muscles
Kidney

Fracture

Spinous process (direct blow or landing on the buttock)
Transverse process (direct blow to the side of the spinal column)
Arch fracture (rare but potentially very serious due to possible neurological involvement)
Pars interarticularis (fatigue fx in young athletes with excessive lumbar extension, 4 x mores frequent in white female gymnasts than nonathletes, strong heredity component)
Vertebral end plate (compression forces through lumbar spine, fissure or depressed fx, due to falling on backside or long sitting position)

Overstretch

Hyperflexion

supraspinous ligament sprain, tear, or avulsion of spinous process fragment (1^st)
facet joint capsular ligament (3^rd), if to the side (1^st)
posterior layer of the iliolumbar ligament at L5, S1
interspinous ligament (2^nd) & ligamentum flavum, possibly but not readily overstretched
posterior longitudinal ligament, not easily stretched because of its proximity to the fulcrum
intervertebral disc (migrates posteriorly)
anterior compression fx of T12, L1
sprain of posterior fibers of sacrococcygeal joint capsule

Hyperextension

compressed facet joints (most commonly)
periosteum of the vertebrae lamina (from the articular process)
anterior longitudinal ligament
vertebral arch fx
spinous process fx (form compressing against one another)
intervertebral disc (tensile forces anteriorly & compressive forces posteriorly)

Rotation or Lateral Flexion (with rotation, ex to right the left facet joint is impacted & right facet joint gaps)

capsular ligaments of the facet joint
intervertebral discs (most commonly at L4-5 & L5-S1 due to more motion)
excessive facet compression

subchondral bone fx
fx of the base of the base of the inferior or superior articular process
fx of the vertebral lamina

sacroiliac joint
iliolumbar ligament (with lateral flexion & flexion)

NOTE: Lateral flexion movements are always coupled with rotation.

Overcontraction (muscle strain, most frequently the erector spinae or lateral flexors)

concentric - sudden forceful violent
eccentric against to great a resistance

Overuse

Rotation

repeated rotation on fixed pelvis

gluteus medius
piriformis

small lumbar spine rotators
facet joint (cartilage breakdown, degenerative changes, osteophytes
intervertebral disc (microfailure with 3⁰ rotation/ macrofailure with 12⁰ rotation

Extension

facet joint degeneration
pars interarticularis stress fx resulting in spondylolysis to spondylolisthesis
sacroiliac joint sprain

Compression

intervertebral disc degeneration (most commonly with forward bending & compression)
vertebral end plates
facet joints

Flexion

prolonged flexion can cause low back pain, particularly with tight hamstrings, ex. Wt lifting, bicycling, hockey, paddling, speed skating

Pain

Location

Local

facet joint (synovial membrane, capsule)
posterior vertebral ligaments
intervertebral disc (may start centrally & move unilaterally)
anterior & posterior longitudinal ligaments
paravertebral muscles, tendon, fascia
dura mater or dural sleeve
nerve root
bone (periosteum & subchondral) localized centrally & to posterior buttocks & thigh

Referred Pain

visceral (kidney disorders, gynecological disorders, prostatitis, pancreatitis, small intestine disorders
vascular (abdominal aortic aneurysm, occlusion of the iliac arteries)
neural (infections of the neural tissue, arachnoiditis)
cancer (prostate, spinal metastases)
systemic disorders (rheumatoid arthritis, ankylosing spondylitis, osteoporosis, vertebral osteomyelitis)

Somatic Referred Pain - pain of musculoskeletal origin that is perceived in an area remote from the lesion site. Often diffuse, dull nature, may be projected segmentally or along dermatomes, myotomes, or sclerotomes. May be caused by confusion in CNS due to afferent messages from lower extremity traveling to neurons in CNS with afferent pain messages from the lumbar spine.

lumbar facet joints
capsules
ligaments
muscles
dura mater or dura sleeve
fascia
bone

Radicular Pain - caused by irritation of spinal nerves or nerve roots resulting in neurological signs at that level. Pain is usually a shooting quality & travels down involved limb, usually more severe in its distal distribution than at irritation site.
Myofascial Pain - tender trigger points in muscle tissue that refer pain in specific patterns
Referred, Radicular, or Myofascial Referred Pain

Buttock, posterior thigh, calf, & foot

buttocks ache that changes sides - sacroiliac arthritis
referred unilateral buttock pain - myofascial trigger points in iliocostalis lumborum, longissimus thoracis, multifidi, quadratus lumborum, & gluteus maximus
buttock pain, posterior thigh, back of knee & calf - posterolateral disc protrusion & associated nerve root irritation
lateral lumbar & buttocks region - L4-L5 & L5-S1 facet joints
alternating sciatica - early signs of ankylosing spondylitis, intermittent claudication, large disc herniation, or malignant disease
posterior thigh & calf - sacroiliac joints, intermittent claudication (on walking)
bilateral pain posterior thigh & calves - spondylolisthesis, spinal claudication, or a neoplasm
posterior thigh - myofascial trigger point in midbelly of gluteus maximus
posterior thigh, calf, sole of the foot - myofascial trigger point in midbelly of piriformis muscle
posterior knee & calf - myofascial trigger points in soleus, gastrocnemius, or popliteus muscles

Groin

with lumbar spine symptoms - pressure on 3^rd sacral nerve root
hip pathology

Anterior thigh, lower leg, & dorsum of foot

with lumbar symptoms - 2^nd or 3^rd lumbar root compression, particularly 3^rd if in anterior lower leg
anterior thigh - myofascial trigger points in iliopsoas, adductor magnus, vastus intermedius, & quadriceps femoris muscles
hip joint, psoas, adductors, quadriceps, femur, or acetabulum - 2^nd or 3^rd lumbar nerve root or possible irritation of anterior cutaneous nerve as it passes under the inguinal ligament
anterior thigh, knee, medial aspect of lower leg - myofascial trigger points in adductor longus & brevis muscles
dorsum of the foot, especially 2^nd & 3^rd toes - 5^th lumbar nerve root irritation

Lateral thigh, lateral leg, & lateral foot

lateral thigh with lumbar symptoms - irritation of 4^th or 5^th lumbar nerve root - can radiate to inner & dorsal aspect of foot
lateral thigh - myofascial trigger points in vastus lateralis & tensor fascia lata
pain & paresthesia in skin supplying lateral thigh - local injury or irritation to the lateral cutaneous nerve as it crosses inguinal ligament
lateral leg pain - pressure on peroneal nerve, trauma or prolonged compression
lateral aspect of lower leg & foot with localized pain behind lateral malleolus - myofascial trigger point in peroneal muscles
lateral border of foot & the 4^th & 5^th toes - often caused by 1^st sacral nerve root compression

Perineal (rectal, penile, scrotal, testicular, vaginal, bladder) tissue- very rare

low lumbar disc lesion compressing the 4^th sacral root
Somatic - musculoskeletal
Radicular - compression or irritation of spinal nerves or nerve roots

Onset

Sudden - Immediate

In sacroiliac joint preceded by sudden twisting motion - sacroiliac sprain
Following a twist or lift that becomes worse in 2 hours or by next day, described as a snap, click, or tear

muscle strain or tear
ligament sprain or tear
facet joint subluxation or meniscal entrapment between articular facets
acute intervertebral disc protrusion

Gradual

chronic intervertebral disc degeneration with nerve root irritation
degenerative facet joint
neoplasm
spondylolysis
spondylolisthesis
systemic or local disease
repeated episodes of local pain

intervertebral disc protrusion with posterior longitudinal ligament irritation
unstable facet joint
progressing disc herniation - radicular pain beginning as backache, radiates unilaterally down one leg with no back symptoms & progress to numbness in that limb

Type

Sharp, well localized suggests superficial lesions

skin
superficial fascia (lumbodorsal fascia)
tendon (iliopsoas)
superficial muscle (superficial erector spinae)
superficial ligament (supraspinatus ligament & interspinous ligament)
bursa (greater trochanteric)
periosteum (spinous process)
muscle-periosteal junction (quadratus lumborum)
joint capsule (facet joint)

Sharp, shooting

nerve lesion probably affecting the A delta fibers (sciatic nerve)
nerve root irritation (radicular pain) with neurological changes such as dermatomal paresthesia, numbness or myotomal weakness

Dull & aching spread over diffuse area is typical of a deeper somatic pathologic condition, deep somatic pain can be associated with autonomic system responses (sweating, piloerection, pallor)

deep muscle (deep erector spinae & gluteal medius)
bone (vertebral body)

Aching

fascia (lumbodorsal fascia)
deep muscle (piriformis)
deep ligament (posterior longitudinal ligament)
chronic bursitis (iliopsoas bursitis)

Burning

skin (lesion or irritation)
peripheral nerve (neuritis)

Pins Needles, Tingling

peripheral nerves (lateral cutaneous nerve of the thigh)
dorsal nerve root (L5 nerve root pain down lateral calf)

Numbness

dorsal nerve root compression (S1 nerve root numbness under lateral malleolus)
peripheral nerve compression (obturator cutaneous nerve supply to medial thigh)

Timing of pain

Morning - suggests that rest does not help in relief or that sleeping position or the mattress is not supporting the lesion

pain & stiffness - can suggest muscular injury, ongoing infection, arthritis, ankylosing spondylitis, degenerative disease, lasting until late morning suggests ankylosing spondylitis
joint & disc problems usually are relieved by sleeping

Evening or all night

more serious pathologic condition such as bone neoplasm, local or systemic disease, very acute intervertebral disc lesion
sacroiliac joint can cause night pain when lying on side or turning over
hip joint problems or greater trochanteric bursitis can cause discomfort when lying on affected side

As the day goes on

condition aggravated by activity

disc lesions
facet joint problems
arthritis
muscular problems
sacroiliac dysfunction & pain aggravated by weight bearing

Sitting

intervertebral disc pressure is increased in sitting, especially in kyphosis vs. lordosis
fatigue & overstretching of the posterior ligaments of the lumbar spine & facet joint ligaments & capsule
spondylolisthesis may be relieved by sitting but walking or prolonged standing increases discomfort
ligamentous instability or muscular strain is triggered by changing positions
facet joint derangements cause pain on movements, relieved by recumbency
sacroiliac joint problems aggravated by sitting & arising from seated position

Aggravating activities

Prolonged sitting, lifting, stooping, or twisting aggravate intervertebral disc lesions & pre-existing facet problems
Combination of hip & spine extension or rotation that causes pain in sacroiliac joint may suggest sacroiliac joint sprain, iliac rotational displacement, sacroiliac joint hypomobility or hypermobility
Sacroiliac dysfunction causes pain on twisting, climbing stairs, sitting and rising from a chair, and on prolonged standing with weight bearing on the affected side
Excessive lordosis aggravates spondylosis & spondylolisthesis
Coughing or sneezing causes sharp pain when space in spinal canal is occupied by lesion, usually a disc lesion

Alleviating activities

Lying supine with hips & knees flexed alleviates most back problems
Sitting with a lumbar roll in lordosis may alleviate back pain
Most musculoskeletal pain alleviated by rest

Pain progression

tendon & ligament injuries, pain decreases 3 to 5 weeks after wound healing, but may last up to 6 months
Pain in muscular injuries decreases quickly in a week to 10 days
Degenerative disc problems cause ongoing pain lasting for months or years
Facet pain tends to decrease after 4 to 6 weeks if aggravating positions are avoided
Pain that gets worse quickly can be caused by a systemic infection or acute disc herniation

Severity - not a good indicator of the degree of injury, facet joint sprain may be extremely painful whereas complete disc herniation may cause only slight pain & numbness

Function

Degree of disability - usually somewhat indicative of the degree of injury. Muscle spasm of the erector spinae can affect all body movements, even walking
Disc protrusion affecting sacral nerves results in bowel or bladder problems or numbness & should be referred immediately due to the possibility of cauda equina compression, a medical emergency
Prostate cancer can cause lumbar pain so any urinary irregularities should be referred
Kidney problems may cause back or flank discomfort
Gynecological problems should be referred
Unexplained weight loss, fatigue, & night pain are symptoms of serious back pathology(neoplasm, tuberculosis) & should be referred

Sensations

Clicking -suspect facet problem
Tearing - suggests muscle injury
Numbness - sign of a nerve root irritation or injury, may result from peripheral nerve injury
Catching - sign of muscle spasm or facet joint problem
Tingling, warmth, or coldness - may be neural or circulatory problem

Previous history

Previous consultants
Findings
Treatments
Therapy
Rehabilitation
Surgeries
Successes or failures

Observation

Anterior view

Head - rotated or laterally flexed may be compensation for deformity or imbalance below (leg length)

Facial expression - chronic pain causes drawn & fatigued appearance

Shoulder level - can be due to overdevelopment of one side of body such as in baseball, may cause a functional scoliosis or may be caused by structural scoliosis or leg length discrepancy

Rib cage position - structural scoliosis may cause one side to be more prominent due to vertebral rotation

Umbilicus position - may be off center due to asymmetric abdominal development, pelvic obliquity, scoliosis, unilateral muscle spasm, nerve injury

Abdominal development - protruding abdomen & associated muscle weakness increases susceptibility to excessive lordosis

Elbow distance from trunk - if different, may indicate muscle spasm, scoliosis, or uneven unilateral development

Arm length - if appearing different lengths, may be due to drop shoulder & associated scoliosis

Anterior Superior Iliac Crests & Spines - leg-length difference, angulation of the femoral neck, or asymmetrical ilia, iliac rotation

Hip, Knee, or Low Back - if all slightly flexed, can be a sign of iliosacral dysfunction with posterior iliac rotation

Hip Anteversion or Retroversion - If femur is rotated inward, or anteversion or a posterior iliac rotation exists ¾ anteversion causes pelvis to tilt anteriorly. If bilateral, can lead to excessive lordosis. If femur is rotated outward, , retroversion or an anterior iliac rotation exists. Retroversion unilaterally can cause a leg-length difference.

Quadriceps development - quad atrophy can result from neurological problem at L2, L3, L4, or at the femoral nerve

Genu Valgum or Varum - Genu valgum associated with anteriorly rotated pelvis leading to excessive lordosis. If one knee is valgus & other is varus, leg length difference can result leading to back problems.

Tibial torsion - Internal tibial torsion can lead to internal femoral rotation resulting in anterior pelvis tilt & increased lordosis

Longitudinal arch - If one arch is pronated & other is supinated a functional leg length difference can result. Anatomical leg length differences can be caused by previous fracture, structural differences, malalignment, & others.

Lateral view

Forward head - shortening of suboccipital muscles, increased midcervical lordosis, resulting in subsequent thoracic spine increased kyphosis & lumbar lordosis

Excessive Thoracic Kyphosis - may be due to ankylosing spondylitis, Scheuermann disease, osteoporosis, hereditary asymmetry in pedicle length or vertebral arch height

Scheuermann disease (adolescent osteochondrosis) - Males develop this between ages 14-18 as a result of anterior disc protrusion¾ end plate of vertebra is eroded, causing a wedging of the thoracic vertebrae T10 to L1 region. Usually only slight pain, but posture is altered causing thoracic kyphosis

Excessive Lumbar Lordosis - amount of curve is determined by:

wedge shape of L5
wedge shape of the L5-S1 intervertebral disc
slope of the sacrum
surrounding musculature
stabilizing lumbar ligaments
muscle groups: abdominals, erector spinae, glutei, hamstrings, & hip flexors

NOTE: A normal curve is necessary to absorb shock, straight flat back has forces of compression or repeated loading

Postural muscle imbalances

Bad postural habits or overuse of certain muscle groups can lead to sacrum tilting forward & excessive lumbar lordosis
Muscle imbalances are usually weak abdominals, tight hip flexors (iliopsoas, rectus femoris), tight erector spinae, weak hamstrings, weak gluteals

Spot-related muscle imbalances - certain sports tend to cause imbalances through overdevelopment such as lumbar lordosis in gymnastics, etc
Other muscle imbalances in frontal plane by unilateral overuse include a tight quadratus lumborum, tensor fascia lata, & adductors or piriformis on one side, along with a weak gluteus medius on the opposite side

Structural causes

Spondylolysis - most common structural defect, in the pars interarticularis, can be congenital or repeated microtrauma, most commonly L5 over S1, sometimes L4 over L5, more common in young female gymnasts
Spondylolisthesis - forward slippage of the superior vertebra over the inferior one
Spina bifida occulta - birth defect, lack of fusion of the neural arch of one or more vertebrae posteriorly, with resulting weakness & potential problems
Variations in sacral fusion - sacralization of 5^th lumbar vertebra or lumbarization of 1^st sacral vertebra
Excessive Lumbar Lordosis - can lead to lumbar strain, disc degeneration & herniation, lumbar sprains, potential for developing spondylolysis or spondylolisthesis, facet joint degeneration, nerve root impingement problems

Knees - genu recurvatum is often seen with anterior pelvic tilt & resulting excessive lumbar lordosis, flattened lumbar curve can have posterior pelvic tilt, often accompanied by tight hamstrings, flexed knees may be caused by acute spinal derangement such as disc herniation or facet joint lesion.

Posterior view

Shoulder levels - drop shoulder may be due to overuse of one arm, may be accompanied by functional scoliosis
Scapular positions - assist in determining bilateral muscle & bony development
Spinous process alignment of spine - especially helpful in determining scoliosis, structural or functional

Functional scoliosis may be caused by:

unilateral muscle tightness, overdevelopment, or spasm
Unilateral muscle imbalances
leg length differences
disc protrusion or facet dysfunction impinging the nerve roots on one side

Paraspinal muscle development - hypertrophy or atrophy,

unilateral hypertrophy may indicate sacroiliac joint problems on that side
bilateral hypertrophy may indicate paraspinal muscle spasm, underlying spondylolisthesis, overdevelopment of spinal extensors

Waist angles - if unlevel, may indicate leg length discrepancy, lateral pelvis tilt, iliac rotation
Iliac crest - if unlevel, may indicate leg length discrepancy, lateral pelvis tilt, iliac rotation
Posterior superior iliac spines

Leg length difference - pelvis & sacral base tilt toward short leg side while lumbar spine rotates in same direction but laterally flexes in opposite direction
Ilium rotation - with posterior iliac rotation, tend to stand with hip & knee in compensatory extension on injured side, PSIS & iliac crest will be lower on involved side, but ASIS will be higher. With anterior iliac rotation, tend to stand with painful side in compensatory flexion, PSIS & iliac crest will be higher on involved side, but ASIS will be lower

Bony abnormalities - if iliac crest is low on one side but posterior spines or greater trochanter are level, the following may exist: bony abnormality of the pelvis, positional fault of the SI joint, anomaly of the femoral neck, or a slipped capital femoral epiphysis
Gluteal folds - sagging of one buttocks can be caused by an L5 or S1 nerve root impingement, hip joint conditions can also lead to gluteal atrophy, lower gluteal mass can indicate leg length difference
Hamstring development - atrophy of hamstrings & gastrocnemii may be a sign of chronic S1 or S2
Popliteal creases
Gastrocnemii development - atrophy may indicate S1 or S2 nerve root irritation
Calcaneal alignment - unilateral calcaneus valgus will cause a slight functional leg length difference, if one is in varus & other in valgus there may be significant leg length difference
Skin markings - lipoma, faun’s bears (tufts of hair) or birth marks may indicate underlying spina bifida, skin tags & café-au-lait spots can indicate tumor or collagen disease, hair patch may also indicate underlying bony defect, skin may have an "orange skin" (dimpled) appearance indicating pathology at that level

Gait - Trendelenburg gait indicates gluteus medius weakness causing body to lean toward weak side
Sitting, Standing, & Lying Postures - sitting is uncomfortable for many back problems particularly without lumbar support, particularly with disc problems, whereas acute facet joint problems are relieved by sitting or reclining. Long sitting will be uncomfortable with acute disc herniation

Palpation

Point tenderness, temperature differences, swelling, adhesions, calcium deposits, muscle spasms & tears, trigger points
Palpate paraspinal muscles during relaxation & contraction
Prone & posteriorly

Bony

Spinous processes

Springing test anterior-posterior - rigidity indicates hypomobility, springing indicates hypermobility
lateral pressure - rotational restriction indicates dysfunction at involved level, palpable step or ledge may indicate spondylolisthesis
transverse processes of lumbar vertebrae
lumbosacral junction
posterior pelvis & sacral triangle
ischial tuberosities
coccyx

Soft tissues - palpate for reactive muscle spasm, trigger points, pilomotor reflex, sudomotor reflex (increased skin perspiration), subcutaneous trophedema (thickened subcutaneous tissue) - skin rolling

Interspinous ligaments, palpate interspinous ligament and interspinous spaces during movement
Paraspinal muscles

iliocostalis lumborum
multifidus & rotatores

Thoracolumbar fascia
Quadratus lumborum - just below 12^th rib & above iliac crest
Glutei
Piriformis
Sciatic nerve with patient standing & one hip flexed palpate ischial tuberosity & palpate sciatic nerve (Hoppenfeld 242 & 246)
Hamstrings
Gastrocnemii

Supine & anteriorly

Bony

Iliac crest & ASIS
Pubic tubercles

Soft tissues

Abdominals
Rectus abdominis
Iliopsoas
Adductors

Functional tests

Rule out

Hip joint test (hip flexion & medial rotation with overpressure) supine actively flex hip, then apply overpressure until pelvic motion begins, then actively internally rotate hip, then apply overpressure. Look for asymmetry, abnormal motion or pain
Laguerre test - position as in Faber test, hip externally rotated, abducted, knee flexed, gently externally rotate
Thoracic spine - look for scoliosis, thoracic kyphosis, etc. Perform thoracic spine flexion, extension, lateral flexion, rotation, and overpressure in each. Look for pain, limited range
Systemic disorders - rule out through thorough medical history & observation, may exist with any of the following:

painful back at night with joint stiffness in the morning
poor general health, especially during periods when the injury flares up
problem continually getting worse without apparent cause
problem with insidious onset
painful limb joints with lumbar discomfort
problem not responding to rest or activity

Tests in standing

Active forward flexion (40⁰ to 60⁰) incomplete straightening of lumbar lordosis in flexion may be caused by:

muscle spasm
local or generalized facet capsular restriction
degenerative disease causing sacrospinalis muscle spasm
rigidity of the entire spine present with advancing ankylosing spondylitis

Pain at the limit of range of motion may be caused by:

dura mater stretch
sciatic nerve root irritation or nerve compression
lumbodorsal muscle strain or thoracolumbar fascia strain (erector spinae, transversospinalis, intertransversarii, sacrospinalis, latissimus dorsi
a hip problem
apposition of the caudal edges of the vertebral bodies anteriorly due to osteophyte formation

Central backache at the end of the range of motion may be caused by:

posterior capsular ligaments of the facet joint
supraspinous ligaments
ligamentum flavum
interspinous ligament (rare)
posterior longitudinal ligament (rare)
superior band of the iliolumbar ligament

Unilateral pain during forward bending may cause deviation toward or away from painful side

Active forward flexion test -palpate just inferior to PSIS bilaterally during flexion to determine if one rides up higher than the other. The side that is blocked or hypomobile moves up further & forward, which means the that side is locked in anterior iliac rotation, opposite side is locked in posterior iliac rotation, or pubic or iliac subluxation (superior or inferior)
Active return from forward flexion, if difficulty in returning smoothly there may be:

disc degeneration
severe muscle spasm
posterior facet problem
lumbar spine instability
tightness or spasm in hamstrings
irritated sciatic nerve (disc herniation, piriformis syndrome)
hip joint pathologic conditions
sacroiliac dysfunction
gluteal strain or spasm

Active extension (20⁰ to 35⁰)

Minor pain at end of range of motion may indicate a posterior facet joint problem or a sacroiliac joint problem
Restrictions may be due to ankylosing spondylitis or osteophyte formation
Back bending that causes buttock or lower limb pain can be due to:

articular derangement in a lumbar facet joint
intervertebral disc herniation
articular derangement of the hip joint
sacroiliac joint sprain

Back bending that causes pain in front of thigh can occur due to 3^rd lumbar disc lesion, iliopsoas strain, or osteoarthritis of the hip

Repeated active forward bending & back bending - repeatedly bend forward & backward about 10 times to determine if the pain centralizes into the back area or if it radiates or refers distally. If the pain centralizes and does not peripheralize then it is probably mechanical pain. Peripheralization or radiation into the extremity with this test is indicative of intervertebral disc pathology. With posterior herniation, the pain usually increases with forward bending & centralizes with back bending.
Active Side Bending (Lateral flexion 15⁰ to 20⁰) Compare the fingertip distance from the fibular head. Range of motion may be limited by:

lumbosacral fascia
capsular facet ligaments
iliolumbar & iliofemoral ligaments
intertransverse ligaments
latissimus dorsi, quadratus lumborum, deep spinal muscles, lateral fibers of external & internal oblique muscles
Serious diseases in lumbar spine such as tuberculosis, ankylosing spondylosis, neoplasm, osteomyelitis
With age motion may be limited by osteophyte formation
Pain on side toward bending indicates compression of lesion is causing pain which is true with chronic lumbar disc lesions, facet joint impingement, sacroiliac sprains. Usually acute disc lesions cause lateral deviation away from involved side.
Pain on opposite side away from direction of bending can indicate lumbar joint (interspinous ligament, joint capsule) or muscle injury (quadratus lumborum, sacrospinalis, intertransverse muscles). Iliac crest contusions will be painful when leaning away from them.
Pain from overpressure is likely to be a capsular restriction

Active side bending & back bending - increases shearing forces through facet, disc, & sacroiliac joint

Pain in sacroiliac region is positive for pathology
Pain in facet joint region at end range is indicative of facet joint pathology

Tests in Sitting

Active trunk rotation (3⁰ to 18⁰) - primary limiting structure to rotation in the lumbar is the facet joints. Most rotation occurs in thoracic & cervical spine. When rotation occurs the vertebrae tilt forward slightly, opening the posterior facets & stretching the posterior lateral disc annulus. Rotation may be limited by the

supraspinous ligament
interspinous ligament
somewhat by the following muscles

opposite deep rotators
opposite internal oblique
ipsilateral external oblique
lumbofascia that is stretching on opposite side

Limitation of motion and painful range on the side opposite of rotation suggests muscle strain usually involving the obliques or lumbofascial tissue
Limitation of motion and painful range on the same side of rotation suggest facet lesion or disc protrusion.
Overpressure may help pinpoint location of pain or restriction.

Active forward bending in sitting

Long sitting - forward bending buttocks or limb pain indicates disc herniation
Short sitting - tests the sacroiliac motion, sacroiliac lesions one PSIS will move higher in sitting, but move forward in standing position. The higher one is hypomobile due to sacrum & ilium moving as one rather than independently. With iliosacral lesions, both PSIS remain level in sitting, whereas in standing one will move forward.

Tests in prone lying

Resisted hip extension with knee flexion to test weakness of the gluteus maximus, may indicate L5 nerve root problem or inferior gluteal nerve injury
Active spinal extension - pain during movement indicates lumbar facet joint irritation
Active double leg raise - weakness or pain indicates injury to back extensors, hip extensors, or hamstrings (erector spinae muscles such as sacrospinalis) (transversospinalis)

Tests in Side Lying

Active side bending or lateral flexion - hold trunk down while patient attempts to lateral flex

If thorax rotates forward, external oblique is stronger. If thorax rotates backward, internal oblique is stronger. If the back hyperextend, the quadratus lumborum & latissimus dorsi are stronger.
Sacroiliac sprains or problems may be painful with this test.

Resisted hip abduction - detects weakness in gluteus medius - superior gluteal nerve (L4, L5, S1)
Passive lumbar flexion & extension - used for palpation of spinous processes, mobility of each vertebra, degree of gapping between processes, supraspinous or interspinous ligament. Inability of a lumbar level to have gapping indicates a hypomobility dysfunction.

Special tests

Neurological dysfunction tests (Neurodynamic tests)

Passive Straight Leg Raise (Laseque’s test) - key tension test for all spinal or leg symptoms that appear to involve the neural system. It stresses the following:

mobility of the dura mater & the dural sleeve of the spinal nerves for the 4^th lumbar level caudally
mobility of the 4^th & 5^th lumbar nerve roots
mobility of the 1^st & 2^nd sacral nerve roots
tension in the hamstrings due to injury or spasm
dysfunction of the hip joint & capsule
dysfunction of the lumbosacral or sacroiliac joint

Can be enhanced with additional components:

ankle dorsiflexion adds tension to the neural structures, especially along the tibial tract. Further tension may be added by everting the foot.
SLR with dorsiflexion & inversion stresses more of the sural nerve component. (Also known as Bragard's test)
SLR with plantar flexion & inversion stresses along the common peroneal nerve.
Forward bending of the cervical spine tends to stress the neural structures throughout their entirety. (Neck flexion movement is also known as Hyndman's sign, Brudzinski's sign, Lidner's sign, & Soto-Hall test.
Passive hip adduction & internal rotation stresses more of the sciatic nerve segment.
Sicard's test combines SLR & then extension of big toe instead of foot dorsiflexion.
Turyn's tests involves only extension of big toe.

Limitations of the SLR, if not caused by hamstring tightness or spasm, are usually caused by a disc lesion. The larger the disc lesion the more the SLR is limited.
At 70⁰ the neural structures (sciatic nerve & nerve roots) are fully stretched. Pain at greater ranges is probably indicative of hip, lumbosacral, or sacroiliac joint pain. If painful at greater than 700 bilaterally, it probably indicates the sacroiliac joints are involved.
Positive SLR may cause pain in leg, back, or both. Back pain is usually from central protrusions due to tension on the dura. Back & leg pain is usually from an intermediately located protrusion. Leg pain is usually from a lateral disc protrusion due to tension on the nerve roots.
A limited SLR without a disc lesion can be caused by:

any interspinous ligament damage
hip, sacroiliac, or lumbosacral joint problems
low back or posterior leg fascial restriction
malignant disease or osteomyelitis of the ilium or femur
ankylosing spondylitis
fractured sacrum
contusion or strain of the hamstring
adhesions epidurally or within the dura altering the normal nerve mobility
tumor at or above the 4^th lumbar level

Modified SLR - for patients who have difficulty lying supine, pt. is sidelying with test leg up & hip and knee at 90⁰. Lumbosacral spine is in neutral, but may be altered slightly for comfort, examiner then passively extends pt.'s knee, noting pain, resistance, and reproduction of the pt.'s symptoms for a + test. Knee position (amount of flexion remaining) on affected side is compared with that of good side.
Bilateral SLR - test both legs simultaneously, examiner lifts both legs by flexing pt.'s hips until pt. complains of pain or tightness. If pain occurs before 70⁰ , the lesion is probably in SI joint, if pain after 70⁰ , lesion is probably in lumbar spine.
Part 2 - Well leg raising test (of Fajersztajn), prostrate leg raising test, a sciatic phenomenon, Lhermitt's test, or crossover sign - pain in opposite side or on well leg test indicates a large posteromedial prolapsed disc or a centrally located protrusion. Pt. may also have bowel or bladder symptoms.

Central posterior prolapsed disc into the dura will usually cause pain during ipsilateral leg raising, contralateral leg raising, & cervical forward bending.
Medial disc herniation with nerve root irritation usually causes pain with bilateral leg raising, but cervical flexion is negative.
Lateral disc herniation with nerve root irritation usually causes pain with ipsilateral leg raising, but not contralaterally, cervical flexion may or may not be painful.

Bowstring sign - done after positive SLR to confirm nerve root lesion, Reach (+) positive SLR, flex slightly until (-), then press on common peroneal nerve in popliteal fossa (just medial to biceps femoris tendon) to elicit pain in back or down with pressure over common peroneal nerve in popliteal fossa
Prone knee bending (Nachlas) test - Patient lies prone, examiner passively flexes knee as far as possible so that heel rest against the buttock. Make sure pt.'s hip does not rotate. If flexion is limited due to knee pathology, test may be performed by passive extension of hip while knee is flexed as much as possible. Unilateral pain in lumbar area, buttock, and/or posterior thigh may indicate L2 or L3 nerve root lesion. Also stretches femoral nerve.
Femoral nerve stretch (passive) stretch in prone position - for upper lumbar, anterior thigh, or hip pain to determine involvement of femoral nerve. In prone, hold knee with one hand, stabilize pelvis with other, passively flex knee to 90⁰ & extend hip until end feel or pain limits ROM. If low back hurts, 3^rd lumbar nerve root may be irritated. May be difficult due to tight hip flexors.
Neuromeningeal Mobility test (Slump test [Maitland]) - a progressive test, continue to question & record results throughout testing, perform bilaterally

Lumbar & thoracic forward bending, hands behind back, then slump lumbar & thoracic spine, apply overpressure at shoulders
Cervical forward bending, actively flex chin to chest, apply slight overpressure to head
Knee extension, actively extend knee fully, may provide slight passive assistance to reach end range
Ankle dorsiflexion, actively dorsiflex fully, then passively maximally extend knee & dorsiflexion
Cervical back bending, release cervical flexion & actively extend head while extending knee further

Brudzinski-Kernig Test - Patient is supine with hands cupped behind head. Instruct pt. to flex head onto chest. Patient raises extended leg actively by flexing hip until pain is felt. Pt. then flexes knee, and if pain disappears it is a positive test. Pain may indicate meningeal irritation, nerve root involvement, or dural irritation. Neck flexion originally described by Brudzinski, hip flexion originally described by Kernig.
Femoral Nerve Traction test - patient lies on unaffected side with unaffected limb flexed slightly at hip & knee. Pt.'s back should be straight, not hyperextended. Pt.'s head should be slightly flexed. Examiner grasps painful extremity & extends the knee while gently extending the hip approximately 15⁰. Pt.'s knee is then flexed on the affected side which stretches the femoral nerve. Pain radiates down the anterior thigh if the test is positive. Also a traction test for the midlumbar area nerve roots (L2-L4). As with SLR, there may also be a contralateral positive test. Pain in groin & hip radiating along anterior medial thigh indicates L3 nerve root problem. Pain extending to midtibia indicates L4 nerve root problem.
Sitting Root test - modification of slump test. Pt. sits with flexed neck, knee is actively extended while the hip remains flexed at 90⁰. Increased pain indicates tension on the sciatic nerve. Used sometimes to catch the patient unaware. Patients with true sciatic pain arch backward & complain of pain into buttock, posterior thigh, & calf when the leg is straightened, indicating a positive test.
Flip Sign - Pt. sitting, examiner extends pt.'s knee & looks for symptoms. Patient is then placed supine & unilateral SLR is performed. To be positive, both tests must cause pain in sciatic distribution. If only one test is positive, examiner should suspect problems in lower lumbar spine. Combination of classic SLR & sitting root test.
Knee Flexion Test - For patient who has complained of sciatica in standing position. Pt. is asked to bend forward to touch toes. If pt. bends knee on affected side while flexing the spine, test is positive for sciatic spinal nerve root compression. If pt. is not allowed to bend knee, spinal flexion is decreased.
Gluteal Skyline Test - Pt. is relaxed prone, while examiner views buttocks from standing at pt.'s feet. Observe buttocks from eye level of buttocks to see if affected side is flattened due to atrophy. Pt. is asked to contract the gluteal muscles while examiner observes for less contraction & atrophy. If atrophy or flattening noticed, test is positive & may indicate damage to inferior gluteal nerve or pressure on the L5, S1, and/or S2 nerve roots.

Myotome testing

Heel & toe walking - difficulty in heel walking indicates L4 problem, difficulty in toe walking indicates S1 problem
Resisted plantar flexion (in standing) - 10 to 20 repetitions of heel raises, fatiguing leg indicates S1 problem
Resisted knee extension (in standing) - 10 to 20 one legged ½ squats, weakness differences indicate L3,
Resisted hip flexion - in supine lying, indicates L2 which is rare, rule out other problems
Resisted knee extension (lying) - lie supine with knee flexed 90⁰, resist knee extension to determine L3 problem
Resisted dorsiflexion & inversion - weakness of tibialis anterior indicates 4^th lumbar nerve root problem
Resisted hallux extension - weakness in extensor hallucis longus & brevis indicate of L5 nerve root
Resisted eversion - If weak 5^th lumbar (in combination with hallux extension weakness) or 1^st sacral (in combination with plantar flexion & foot eversion)
Resisted knee flexion - tests L1, S1, & S2, but mainly S1
Resisted hallux flexion - test primarily S2, Disc herniation at L5 to S1 can cause S1 & S2 weakness
Resisted foot intrinsics - primarily tests S3, all foot intrinsics are innervated S2 & S3
Urogenital region - question regarding perineum/genitals & weakness of bladder/rectum, indicates perineal branch of the pudendal nerve (S2, S3, & S4)

Dermatome testing

L1 - lower abdomen & groin, lumbar region from 2^nd to 4^th vertebrae, upper & outer aspect of buttocks
L2 - lower lumbar region, upper buttock, anterior aspect of thigh (not medially)
L3 - medial aspect of the thigh to the knee, anterior aspect of the lower 1/3 of the thigh to just below the patella
L4 - medial aspect of the lower leg & foot, inner border of the foot, great toe
L5 - lateral border of the leg, anterior surface of the lower leg, 2^nd, 3^rd, & 4^th toes
S1 - posterior aspect of the lower ¼ of the leg, posterior aspect of the foot, including the heel, lateral border of the foot & sole
S2 - posterior central strip of the of the leg from below the gluteal fold to the ¾ of the way down the leg
S3 - central gluteal fold
S4 - saddle shaped area, including anus, perineum, scrotum & penis, labium & vagina

Reflexes, Check each of the following

Knee or Patellar reflex (Hoppenfeld 251) test 8 to 10 times for fatigability - L2, L3, L4, primarily L4
Ankle or Achilles reflex (Hoppenfeld 253) push in to slight dorsiflexion - S1 test for L5-S1 level
Babinski reflex (Hoppenfeld 256) run sharp instrument across plantar surface of foot, (-) when toes flex & adduct, (+) when great toe extends when other toes flex & splay

Lower limb girth measurements - quad atrophy may be due to rare L3 level problem, hamstring atrophy may be caused by L5 or S1 disc herniation, gastrocnemii atrophy can be caused by L5 or S1 disc herniation.
Intrathecal pressure tests

Naffziger's test - Patient lies supine while examiner gently compresses jugular veins for approximately 10 seconds. Pt.'s face flushes, and pt. is asked to cough. If coughing causes pain in low back, the spinal theca (covering around the spinal cord) is being compressed, leading to an increase in intrathecal pressure.
Valsalva maneuver - Seated patient is asked to take a breath, hold it, & then bear down as if evacuating the bowels. If pain increases and/or radiates it indicates intrathecal pressure, which is pressure around spinal cord, which may be due to herniated disc, tumor, or osteophyte in spinal cord space

Joint Dysfunction Tests

Schober Test - Used to measure amount of flexion occurring in lumbar spine. Mark point midway between the two PSIS (level of S2), then mark points 5cm below & 10cm above that level. Measure distance between 3 points, then ask pt. to flex & remeasure. The distance between the 2 measurements indicates amount of flexion occurring. May also be used to determine amount of extension.
Yeoman's Test - Pt. lies prone & passive while examiner stabilizes pelvis & extends each of pt.'s hips in turn with knees extended. Then repeat extension of each hip in turn with knees flexed. Pain in lumbar pain during both parts of test is + for joint dysfunction.
Milgram's Test - Pt. lies supine & simultaneously actively lifts both legs off table 2-4 inches, holding position for 30 seconds. + if pt. cannot hold for 30 seconds or if symptoms are reproduced in affected limb. Perform with caution due to stress load on lumbar spine.
McKenzie's Side Glide Test - Pt. stands with examiner at one side. Examiner grasps pt.'s pelvis with both hands & places a shoulder against pt.'s lower thorax. Using shoulder as a block, examiner pulls the pelvis toward examiner's body & holds position for 10-15 seconds. Repeat to opposite side. + test indicated by increased symptoms on affected side. If scoliosis is present, test side to which scoliosis curves first. Indicates whether symptoms are causing scoliosis.
One-Leg (Standing Stork) Lumbar Extension Test - Pt. stands on leg & extends spine while balancing on leg. Repeat with pt. standing on opposite side. + test indicated by pain in back & is associated with pars interarticularis stress fx (spondylolisthesis). If fx is unilateral, standing on ipsilateral leg causes more pain. If rotation is combined with extension & pain results, it indicates possible facet joint pathology on side to which rotation occurs.
Pheasant Test - Pt. lies prone. Examiner gently applies pressure with one hand to posterior aspect of lumbar spine and uses other hand to passively flex the pt.'s knees until the heels touch the buttocks. Test is + if pain is produced by hyperextension of spine indicating an unstable segment.
Segmental Instability Test - Pt. lies prone with body on table and legs over the edge resting on the floor. Examiner applies pressure to posterior aspect of lumbar spine while pt. rests in this position. Pt. then lifts legs off the floor and examiner again applies posterior compression to lumbar spine. If pain is elicited in resting position only, test is positive, because muscle action masks the instability.
Treadmill Test for Instability - Pt. is asked to walk on treadmill beginning at 0.6 mph & gradually accelerating to 1.8 mph for up to 10 minutes or so until symptoms are produced (low back pain, pain into lower extremities, intermittent claudication). Treadmill is level & symptom production is considered positive test.
Quandrant Test - Examiner stands behind standing pt. Pt. extends spine while examiner controls the movement by holding the pt.'s shoulders. Examiner may use their shoulders to hold the occiput to unload the weight of the head. Overpressure is applied in extension while pt. side flexes & rotates to the side of pain. Movement is continued until range limit is reached or until symptoms are produced. This position causes maximum narrowing of the intervertebral foramen & stress on the facet joint to the side which rotation occurs. Positive if symptoms are produced.

Muscle imbalance tests & Dysfunction Tests

Beevor's Sign - Pt. lies supine & flexes head against resistance, coughs, or attempts to sit up with hands resting behind head. + test results if umbilicus does not remain in straight line when abdominals contract, indicating pathology in abdominals such as paralysis.
Long sitting toe touching - look laterally for abnormal contours of

upper & lower back - should occur evenly from lumbar to cervical spine, extra curving of upper back & flat lower indicates muscle spasm or shortened lower back muscles
pelvis - if pelvis is rotated forward or hamstrings over stretched could add to lower back pathology
Knees - flexed knees indicate tight hamstrings or flexed to take stretch off sciatic nerve
Ankles - plantar flexed ankle indicate gastrocnemius tightness

Evaluate hamstring tightness by extending one leg with hip flexed 90⁰ while other hip remains extended on table, (Booher 344)
Hip flexor tightness (Thomas test) supine with knees over end of table, passively flex hip & knee. If contralateral hip flexes without knee extension that iliopsoas is tight. If knee extends and/or hip flexes rectus femoris is tight. If hip abducts, tensor fascia lata is tight.
Abdominal strength (curl up) - inability indicates weak abdominals

Test for Intermittent Claudication

Stoop Test - assesses neurogenic intermittent claudication to determine whether a relation exists among neurogenic symptoms, posture, and walking. When the pt. with intermittent claudication walks briskly, pain ensues in buttocks & lower limb within 165 ft. To relieve the pain, the pt. flexes forward. May also be relieved when pt. is sitting & forward flexing. If flexion does not relieve symptoms, test is (-). Extension may also elicit return of symptoms.
Bicycle Test of van Gelderen - Pt. is seated on exercise bicycle & asked to pedal against resistance while leaning backwards to accentuate the lumbar lordosis. If pain into buttocks & posterior occurs, followed by tingling into affected lower extremity, first part of test is +. Then ask pt. to lean forward & pedal. If pain subsides over short period of time, 2^nd part of test is +, if pt. sits upright again, the pain returns.

Test for Malingering

Hoover Test - Pt. lies supine with legs remaining relaxed on table while examiner places one hand under each calcaneus. Pt. is asked to lift one leg off the table, keeping the knees straight. If pt. does not lift the leg or examiner does not feel pressure under the opposite heel, the pt. is not trying or malingering. Compare two sides for differences.
Burns Test - Pt. is asked to kneel on a chair & then bend forward to touch the floor with their fingers. + for malingering if pt. is unable to perform test or pt. overbalances.

Trunk Range of motion

Measure trunk flexion from C7 to S1 in standing then flexion, (Booher 342)
Measure trunk rotation - point & rotate to furthest spot on wall behind, compare bilaterally

Sacroiliac tests

Active Stress Tests

Kinetic test, one legged standing, begin standing evenly, palpate & locate PIIS & PSIS, then stand on one leg, flex opposite knee to chest. Non weight bearing side PSIS should move down (posterior ilium rotation). As foot moves down, the PSIS should move back up. If hypomobile, PSIS will move upward rather than down.

Passive Movements

Ipsilateral Prone Kinetic Test - assesses inability of ilium to flex & to rotate laterally or posteriorly. Pt. lies prone, examiner places one thumb on the PSIS & other thumb parallel to it on the sacrum. Then ask pt. to actively extend the leg on the same side. Normally, the PSIS should move superiorly & laterally. If its doesn't hypomobility with posterior rotated ilium (outflare) is indicated.
Passive Extension & Medial Rotation of Ilium on Sacrum - Pt. sidelying with test side up, examiner places one hand over ASIS & other hand over PSIS so that the fingers palpate the posterior ilium & sacrum. Examiner then pulls the ilium forward with the ASIS hand & pushes the posterior ilium forward with the other hand while feeling the relative movement of the ilium on the sacrum. Repeat test for other side for comparison. If affected side moves less hypomobility with posterior rotated ilium (outflare) is indicated.
Passive Flexion & Lateral Rotation of Ilium on Sacrum - Pt. sidelying with test side up, examiner places one hand over ASIS & other hand over PSIS so that the fingers palpate the posterior ilium & sacrum. Examiner then pushes the ilium backward with the ASIS hand & pulls the posterior ilium backward with the other hand while feeling the relative movement of the ilium on the sacrum. Repeat test for other side for comparison. If affected side moves less hypomobility with anterior rotated ilium (inflare) is indicated.

NOTE: If both the Passive Extension & Medial Rotation of Ilium on Sacrum & Passive Flexion & Lateral Rotation of Ilium on Sacrum are positive, then an upslip of the ilium relative to the sacrum has occurred.

Passive Lateral Rotation of Hip - Pt. lies supine, examiner flexes hip & knee to 90⁰ & then externally rotates hip. Normally, this movement stresses SI joint on test side.
Pelvic rocking test (Hoppenfeld 261) supine, place palms on both ASIS & push toward each other. If SI injured may be painful & injured side motion may be increased or decreased.
Gapping test (Transverse Anterior Stress) - supine, cross hands over pelvis against ASIS, then push down & out, positive if causes unilateral sacroiliac or posterior leg pain, indicating sprain of anterior SI ligaments.
Prone Gapping (Hibb's) Test - Stresses posterior SI ligaments. Pt must be free of hip pathology & have full ROM in hips. Pt. prone, examiner stabilizes pelvis with their chest. Pt.'s knee is flexed to 90⁰ or > & hip is internally rotated maximally. While achieving end of internal rotation, examiner palpates on same side. Repeat test on other side for comparison of opening & quality of movement.
Approximation (Transverse Posterior Stress) Test - Pt. is sidelying with examiner's hands over upper part of iliac crest, pressing toward floor to cause forward pressure on sacrum. An increased feeling of pressure in SI joints indicates a possible SI lesion or sprain of posterior SI ligaments, or both.
Squish Test - Pt. supine, examiner places both hands on pt.'s ASISs & iliac crests and pushes down & in at 45⁰ angle to test posterior SI ligaments. Pain indicates + test.
Sacroiliac Rocking (Knee to Shoulder) (sacrotuberous ligament stress) Test - Pt. supine, examiner flexes pt.'s knee & hip fully, then adducts hip. SI joint is rocked by flexion & adduction of pt.'s hip. Move knee toward contralateral shoulder. Possibly internally rotate hip to maximize stress on SI joint. Simultaneously, palpate sacrotuberous ligament. Pain in SI joint indicates + test. If a longitudinal force is applied through the hip in a slow, steady manner (15-20 seconds) in an oblique & lateral direction, further stress is applied to sacrotuberous ligament. Palpate to compare slight normal movement.
Sacral Apex Pressure (Prone Springing) Test - Pt. lies prone with examiner using base of hand at the apex of the pt.'s sacrum to push down, causing shear of the sacrum on the ilium. May indicate a SI joint problem if pain produced over joint. The test causes a rotational shift of the SI joints.
Torsion Stress Test - Pt. lies prone while examiner palpates spinous process of L5, with one thumb holding it stable. Examiner uses other hand, placed around opposite anterior ilium & lifts it up (pulling posteriorly). This rotational movement stresses the lumbosacral junction, iliolumbar ligament, anterior sacroiliac ligament, & the SI joint.
Femoral Shear Test - Pt. lies supine. Examiner slightly flexes, abducts, & laterally rotates the pt.'s thigh at approximately 45⁰ from the midline, then applies a graded force through the long axis of the femur, which causes an anterior to posterior shear stress to the SI on the same side.
Superoinferior Symphysis Pubic Stress Test - Pt. lies supine. Examiner places heel of one hand over the superior pubic ramus of one bone & the heel of the other hand over the inferior pubic ramus of the other bone. Examiner then squeezes hands together, applying a shearing force to the symphysis pubis. Pain in the symphysis pubis indicates a (+) test

Sacroiliac Joint Involvement Tests

Piedallu's Sign - Pt. sits on a hard, flat surface to keep the hamstrings, etc from affecting pelvic flexion symmetry & to increase the stability of the ilia. This tests the sacrum on the ilia. Examiner palpates the PSISs and compares their heights. If one PSIS, usually the painful one, is lower than the other, the pt. is asked to forward flex while sitting. If the lower PSIS becomes the higher one on forward flexion, test is positive for that side. Because the affected joint does not move properly & is hypomobile, it goes from a low to a high position, indicating abnormality in the torsion movement at the SI joint.
Flamingo Test or Maneuver - Pt. is asked to stand on one leg, which should cause the sacrum to shift forward & distally with forward rotation. Ilium moves in opposite direction. On the non-weightbearing side the opposite occurs but stressed less than the weightbearing side. Pain in the symphysis pubis or SI joint indicates a + test for the painful structure. Have pt. hop on one leg to increase the stress.
Hip flexion & adduction test - Supine with knee flexed, opposite leg straight, flex & adduct leg to stress Si joint on that side. May also be painful due to hip joint or S1 nerve root problem.
Gaenslen’s Sign (Hoppenfeld 261) - supine, bilateral hip flexion followed by unilateral hip extension (make sure table edge allows for hyperextension) to rotate ipsilateral SI joint forward & posteriorly on contralateral side, causes pain if SI joint is dysfunctional or possible hip joint pathology, or an L4 nerve root lesion.
Sacroiliac joint test (sidelying Gaenslen’s test) non-painful side down & locked in to hip & knee flexion by the pt., uppermost hip is extended to its limit with knee extended to apply rotary stress to upper ilium on sacrum. Painful if SI is dysfunctional or possible hip joint pathology, or an L4 nerve root lesion.
Mazion's Pelvic Maneuver - Pt. stands in straddle position with unaffected side forward so that the feet are 2 to 3 ft apart. Pt. bends forward, trying to touch the floor, until the heel of the back leg lifts off the floor. If painful in lower trunk on affected side, it is considered a + test for unilateral forward displacement of ilium relative to sacrum.
Laguere's Sign - Pt. lies supine. To test affected side, the examiner flexes, abducts, and externally rotates affected hip with overpressure at end range. Examiner must stabilize pelvis on opposite side by holding down the opposite ASIS. Pain in the affected SI indicates positive test. Compare sides.
Gillet's (Sacral Fixation) Test - Pt. stands while examiner palpates PSISs. Pt. is asked to stand on one leg while pulling the opposite knee up toward the chest. Repeat with the other leg. If the SI joint on the side which the knee is flexed moves minimally or up, the joint is hypomobile, or blocked, indicating a + test. On the normal side, the PSIS moved down or inferiorly. Similar to test performed during hip flexion in active movement.
Goldthwait's Test - Pt. lies supine. Examiner places one hand under lumbar spine so that each finger is in an interspinous space (L5-S1, L4-L5, L3-L4, & L2-L3). Examiner uses the other hand to perform SLR. If pain elicited before movement occurs at interspaces, the problem is in the SI joint. Pain during interspace movement indicates lumbar spine problem. SLR test may be positive & elicit pain referral along course of sciatic nerve if there is neurological involvement.
Yeoman's Test - Pt. lies prone and examiner flexes the pt.'s knee to 90⁰ and extends the hip. Pain localized to the SI joint indicates anterior SI ligament pathology. Lumbar pain indicates lumbar involvement and anterior thigh paresthesia indicates femoral nerve stretch.
Patrick’s or Faber (Fabere) test, (Hoppenfeld 262) Flexion/Abduction/External Rotation, supine with one leg straight, take other into abduction & external rotation, heel is placed on knee of straight leg. (-) if flexed knee drops to parallel to opposite leg. (+) when flexed knee is unable to fall into full abduction. May indicate hip joint pathology, SI joint dysfunction, iliopsoas or adductor muscle injury dependent upon location of pain
Supine to Sit (Long Sitting) Test - Pt. lies supine with legs straight. Examiner makes sure that medial malleoli are level and asks pt. to sit up. Examiner observes whether one leg moves proximally farther than the other. If one moves up farther, there is a functional leg length difference resulting from pelvic dysfunction caused by pelvic torsion or rotation.
Sit up test for Iliosacral dysfunction - supine with body straight & legs symmetric, actively flex knees, lifts pelvis off table about 4", then drop pelvis to table. Passively extend knees & lower legs one at a time to table. Legs are then rolled medially & released. Palpate & observe level of medial malleoli, then athlete sits up & malleoli are rechecked. If one SI joint is hypomobile & blocked in posterior rotation, the sacrum & ilium will move together as unit, making the leg appear longer when sitting up compared to it appearing shorter in supine. If one SI joint is in anterior rotation that leg may appear longer or same length when supine, but get shorter when sitting up.

Anterior iliac rotation

ASIS in inferior, anterior, and medial to opposite ASIS
PSIS is superior & anterior on that side
medial sulcus (formed by ilium overlapping the sacrum) is shallow
anterior iliac crest is inferior on the same side as the dysfunction
posterior iliac crest is superior
posterior tubercle on that side may be lower
ischial tuberosity is superior

Posterior iliac rotation

ASIS in superior, posterior, and lateral to opposite ASIS
PSIS is inferior & posterior
medial sulcus is deeper
anterior iliac crest is superior on the same side as the dysfunction
posterior iliac crest is inferior
posterior tubercle on that side may be higher
ischial tuberosity is inferior

Ankylosing spondylitis test - measure chest girth at expiration & maximum inspiration to get at least a 1" difference. (+) is chest expansion ability decreases
Leg length measurement tests –

Leg Length Test (True leg-length) (anatomic) - backward rotation (Nutation) of the ilium on the sacrum results in a decrease in leg length on the affected side as does anterior rotation (contranutation) of the ilium on the contralateral side. If the iliac bone on one side is lower, the leg on that side is usually longer. Pt. lies supine, flexes knees, raise pelvis about 3" & drop to table. Extend knees & make sure pt.'s lower limbs are perpendicular to the line joining the ASISs. Use a flexible tape measure to measure the distance from the ASIS to the medial or lateral malleoli. Compare to the other side. 1/2 to 1" difference is considered normal, but may be pathological. Flex knees 90⁰ with feet together & flat on table to observe if discrepancy is within femur or tibia.
Anatomic leg-length discrepancy - measure from ASIS to floor & from PSIS to floor bilaterally. May be caused by:

poliomyelitis of lower limb
fracture of femur or tibia
bone growth problems of lower limb

Functional leg-length discrepancy - Pt. stands relaxed while examiner palpates ASISs & PSISs, noting asymmetry. Pt. is then placed in correct stance (subtalar neutral, knees fully extended & toes facing straight ahead) and the ASISs & PSISs are palpated, with examiner noting whether the asymmetry has been corrected. If corrected by positioning the limb, the leg is normal length, but abnormal joint mechanics are producing a functional leg length difference. If asymmetry corrected by positioning, test is positive for functional leg length discrepancy. If ASIS is lower & PSIS is higher on same side, a functional leg-length discrepancy exists. May be caused by:

one pronated foot and/or one supinated foot
muscle spasm in one hip
hip capsule tightness
adductor muscle spasm on one side
more genu valgus on one side
femoral anteversion on one side ( if combined with pronated foot)

Circulatory tests - check femoral, popliteal, posterior tibial, & dorsalis pedis pulses to determine if deficient.

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