1. science
2. medicine
3. surgery

Thoracic and Lumbar Spine
Special Tests and
Pathologies
Orthopedic Assessment III – Head,
Spine, and Trunk with Lab
PET 5609C
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
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)
Clinical Evaluation

Nerve Root
Impingement:

Narrowing of
intervertebral foramen:



Stenosis
Facet joint degeneration
Herniated intervertebral
disc
Clinical Evaluation
Clinical Evaluation

Nerve Root Impingement Tests:

Valsalva Test:

Test Position:


Action:


Subject takes a deep breath and holds while bearing down as if
having a bowel movement
Positive Finding:



Patient seated, examiner standing next to patient
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)
Clinical Evaluation

Nerve Root Impingement Tests:

Milgram Test:

Test Position:


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 supine, examiner at feet of the patient
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
Clinical Evaluation

Nerve Root Impingement Tests:

Kernig’s Test:

Test Position:


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:



Patient supine, examiner at side of patient
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
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
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
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
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
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
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
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
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
Clinical Evaluation

Slump Test:

Positive Findings:


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
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
Clinical Evaluation

Test for Patient Malingering:

Hoover Test:

Test Position:



Action:


Patient supine
Examiner at feet of patient with hands cupping the calcaneous of
each leg
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
Clinical Evaluation
Test Note: Examiner should be standing at feet of patient with their
hands cupping the heels of each leg
Clinical Evaluation
Lower Quarter Neurological Screen
Nerve Root Sensory Testing
Level
L1
Inguinal area (just below inguinal ligament
L2
Mid-thigh (medial)
L3
L4
L5
Medial knee (just above superior pole of patella)
Medial aspect of lower leg, medial ankle, big toe
Top of foot (an/or blow head of fibula)
S1
S2
Lateral foot
Posterior thigh, popliteal fossa
Clinical Evaluation
Lower Quarter Neurological Screen
Nerve Root Level Motor Testing
L1
Hip flexion
L2
Hip flexion
L3
Knee extension
L4
Dorsiflexion
L5
Great toe extension
S1
Plantarflexion
S2
NA
Clinical Evaluation
Lower Quarter Neurological Screen
Nerve Root
Level
Reflex Testing
L4
Patellar Tendon
L5
Patellar Tendon
S1
Achilles Tendon
S2
Achilles Tendon
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.
Clinical Evaluation

Erector Spinae Muscle
Strain:


Common low back pathology
MOI:


Signs/Symptoms:



History of heavy or repetitive
lifting
Aching back
Pain ↑ with passive and
active flexion, resisted
extension
Neurological Evaluation:

Negative results
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:


Facet joint syndrome: (inflammation)


Tends to “lock” the involved spinal segment (hypomobile
vertebrae)
Causes: repetitive stress through movement or loading
Degeneration: (arthritis)


Causes: undefined history
↓ intervertebral foramen size (nerve root impingement)
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
Patient may assume posture that ↓ pressure on affected facets
Palpation:

Possible local muscle spasm (paravertebral muscles)
Clinical Evaluation

Facet Joint
Dysfunction:

Ligamentous Tests:


Neurological Tests:


Spring Test – pain, ↓
motion
Not applicable unless
secondary nerve root
impingement occurs
Special Tests:


Quadrant Test (+)
Intervertebral disc
lesions (-)
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
Clinical Evaluation

Intervertebral Disc
Lesions:

Disc Degeneration:

Loss of water from nucleus
pulposus


↑ stress load on annulus
fibrosus


↓ cushioning ability
Small tears occur to
annulus (scar tissue
formation – not as strong
as normal tissue)
Bulging of nucleus
pulposus
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
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)
Clinical Evaluation
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

Clinical Evaluation

Lumbar Disc Degeneration:

Inspection:
Slow GAIT
 Flattened lumbar spine
 Changes in body position – guarded and painful



Standing position:


Sitting → standing / sitting → lying
 Changes in disc pressure
Lateral shift away from side of leg pain
Palpation:

Musculature spasm
Clinical Evaluation

Lumbar Disc Degeneration:

Functional Tests:



Neurological Tests:


Lower quarter screen
Special Tests:


Limited ROM in all directions
Movement in one direction may relieve or ↓ symptoms
Straight leg raising, Well straight leg raising, Milgram, Sciatic
and femoral nerve tension tests
Diagnostic Tests:

MRI
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
Clinical Evaluation
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
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


Congenital causes:



Numbness, loss of sensation (damage usually permanent)
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
Clinical Evaluation

Femoral Nerve Stretch Test:


Tests for nerve root
impingement at L2, L3, L4
Test position:


Action:


Patient prone with a pillow under
the abdomen; examiner at side of
patient
Examiner passively extends hip
while keeping knee flexed to 900
Positive test:

Pain in anterior and lateral thigh
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
Clinical Evaluation

Sciatica:

Signs and Symptoms:



Special Tests:



Radiating pain
Muscular weakness
Straight leg raise test
Tension sign
Treatment and Rehab:



Resolve pathology that is
irritating nerve
Oral anti-inflammatory meds /
corticosteroids
Exercises for strength / ROM
Clinical Evaluation

Tension Sign:


Tests for sciatic nerve irritation
Test position:


Action:



Patient supine; examiner’s one hand grasps the heel while other
grasps the thigh
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
Clinical Evaluation
Clinical Evaluation

Bowstring Test: (Cram Test)

Test position:


Action:




Patient supine
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
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
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
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 (Grade1Grade 2 spondylolisthesis)
Clinical Evaluation

Spondylolysis and Spondylolisthesis:

History:

Onset of pain:


Characteristics:


Repetitive stress (extension)
Predisposing conditions:



Lumbar pain, radiating into buttocks and upper posterolateral
thigh
MOI:


Insidious; pain begins as an ache, ↑ to constant pain
Muscular imbalances
Repetitive hyperextension activities
Inspection:


↑ lordotic curve
Altered GAIT
Clinical Evaluation

Spondylolysis and Spondylolisthesis:

Palpation:



Step-off deformity may be felt
Spasm of paraspinal muscles
Functional Tests:

AROM:




PROM:


Flexion – restricted, pain free
Extension – pain
Rotation and bending - pain
Hip flexion – hamstring tightness
RROM:

Weakness of spinal erectors
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)
Clinical Evaluation

Single Leg Stance Test:

Test position:


Action:


Patient standing with body weight evenly distributed
between the 2 feet; examiner stands behind pt.
Patient lifts one leg, then places the trunk in
hyperextension; examiner may assist
Positive test:

Pain in lumbar spine or SI area
Clinical Evaluation

Single Leg Stance Test:

Implication:


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
Clinical Evaluation

Sacroiliac Dysfunction:

History:

Onset:


Pain characteristics:


One or both SI joints; possibly
radiating pain in buttocks,
groin, thigh
Mechanism:


Acute or insidious
Prolonged stress
Predisposing conditions:


Postpartum women (relaxin
levels)
Hormonal levels during
menstruation
Clinical Evaluation

Sacroiliac Joint Dysfunction:

Inspection:


Palpation:


Trunk flexion (with knees extended) will cause movement of the
sacrum on the ilia (pain)
Neurological testing:


Pain over SI joints and PSIS
Functional tests:


Levels of iliac crests, ASIS, PSIS
Lower quarter screen
Special tests:

Long sit; SI compression and distraction; straight leg raising;
fabre; gaenslen’s; quadrant
Clinical Evaluation

Sacroiliac Joint Stress Test:

Test position:


Action:


Subject supine; examiner stands
next to subject and with arms
crossed, places heel of both
hands on the subject’s ASISs
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
Clinical Evaluation

Sacroiliac Joint Stress Test:

Test position:


Action:


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
Apply downward pressure
Positive finding:

Increased pain indicative of SI
pathology (possible involvement
of posterior SI ligament)
Clinical Evaluation

Sacroiliac Joint Stress Test:

Test position:


Action:


Subject lying supine; examiner
places both hands on lateral
aspect of subject’s iliac crests
Apply inward and downward
pressure
Positive finding:

Increased pain indicative of SI
pathology (possibly involving
posterior SI ligaments)
Clinical Evaluation

Sacroiliac Joint Stress Test:

Test position:


Action:


Subject lying prone; examiner places both hands
(one on top of the other) over subject’s sacrum
Apply downward pressure on sacrum
Positive finding:

Increased pain indicative of SI pathology
Clinical Evaluation

Patrick or FABER Test:

Test position:


Action:


Subject supine
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
Clinical Evaluation

Gaenslen’s Test:

Test position:


Action:



Subject supine, lying close to
edge of table; examiner stands at
side
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
Clinical Evaluation

Long-Sitting Test:

Test position:


Action:



Subject supine, both hips and knees extended; examiner
standing with thumbs on subject’s medial malleoli
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
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
Nerve root impingement
MOI:

Rotational forces, hyperextension, repetitive stress
On-Field Evaluation

Inspection:

Position of athlete:




Posture
Willingness to move
Neurological tests:



Supine – if spinal cord involvement suspected, manage
accordingly (spine board)
Sensory
Motor tests
Palpation:


Bony palpation
Paraspinals