OM FA week 5
Lower Back
At the end of this topic, the student should be able to:
Describe and perform tests for the lumbar spine.
Describe and perform the straight leg raising, the well leg straight leg raising, Hoover, Kernig and Milgram tests for the lumbar spine.
Describe and perform the Patrick (or Fabere) Test for the sacroiliac joints.
Discuss the significance of positive and negative findings for each test.
Attitude
Part Attitude Lack - under function Excess - over
function Element
Lower spine
Flexible support and strength, order, grounding, a sense of purpose in life
Unsupportive behaviour toward others and self, gloom.
Rigidity,
fickleness, lack of purpose
Lumbar Plexus
Spinal Roots
Nerves Related Structures
L2 -
L4
Femoral Skin of anterior & medial thigh Skin of medial leg & foot
Hip & knee joints (saphenous branch) Motor: to anterior thigh muscles (quadriceps and sartorius) pectineus and iliacus L2 -
L4
Obturator Motor: adductor magnus (part), longus & brevis) Gracilis, obturator externus
Sensory: skin of medial thigh hip and knee joints
L2 - L3 Lateral Femoral Cutaneous
Skin of lateral thigh
Some branches to peritoneum
L1 Iliohypogastric Skin of lower abdomen, lower back & hipAbdominal obliques and transversus Pubic region
L1 Ilioinguinal Skin of external genitalia & proximal medial thighInferior abdominal muscles L - L Genitofemoral Skin in genitals (scrotum/labia)
Sacral Plexus
Spinal Roots Nerves Related Structures
L4 – S3 Sciatic a)Tibial
Cutaneous branches: skin of posterior leg and plantar surface Motor branches: posterior muscles of thigh, leg and foot L4 – S2 b)Common
Peroneal
Cutaneous branches: skin of anterior surface of leg and foot dorsum
Motor branches: anterior (medial and lateral) muscles of leg L4 – S1 Superior
Gluteal
Motor branches: gluteus medius/minimus, TFL
L5 – S1 Inferior Gluteal
Motor branches: gluteus maximus
S1 – S3 Posterior femoral cutaneous
Cutaneous: buttock, posterior thigh, popliteal (possibly calf and heel)
Neurologic Levels L1, L2, L3
There are no individual reflexes for
L1, L2, and L3 levels, their integrity
can only be evaluated through muscle
and sensory tests.
Muscle Testing
Iliopsoas: nerves emanating from
L2, and L3
Neurologic Levels L1, L2, L3
Sensation Testing
Sensation of anterior
thigh between the
inguinal ligament and
knee joint.
Neurologic Levels L1, L2, L3
Sensation Testing
The L1 dermatome runs in
an oblique band on the
upper anterior portion of
the thigh, immediately
below the inguinal
ligament.
Note: Dermatomes relate to sensory impairment related to level of spinal cord injury, as both motor and sensory nerves run through particular lumber
segments, sensory disruption may relate to motor nerve trauma as well. A positive finding is followed by muscle testing to confirm neurologic impairment.
Neurologic Levels L1, L2, L3
Sensation Testing
L2 dermatome lies between
these two bands, on the
anterior aspect of the mid
thigh.
Neurologic Levels L1, L2, L3
Sensation Testing
L3 dermatome runs in an
oblique band on the
anterior thigh, immediately
above the knee cap.
Neurologic Levels L2, L3, L4
Neurologic Levels L4
Muscle Testing
Tibialis Anterior: L4, Deep Peroneal Nerve
Reflex Testing
Patellar Reflex is considered an L4 reflex; though it receives innervation from sources other than L4.
Sensation Testing
L4 dermatome, medial side of the leg. The crest of the tibia is the dividing line between the L4 & L5.
Tibialis Anterior Adductors
Neurologic Levels L5
Muscle Testing
Extensor Hallucis Longus: L5, Deep Peroneal Nerve
Gluteus Medius: L5, Superior Gluteal Nerve
Extensor Digitorum Longus and Brevis: L5, Deep Peroneal Nerve Reflex Testing
No easily elicited reflex. Sensation
Neurologic Levels S1
Muscle Testing
Peroneus Longus & Brevis: S1, Superficial Peroneal Nerve
Gastrocnemius-Soleus Muscles: S1, S2, Tibial Nerve
Gluteus Maximus: S1, Inferior Gluteal Nerve Reflex Testing
Achilles Tendon Reflex: To test it, put the tendon into slight stretch by dorsiflexing foot. Strike tendon to induce involuntary plantar flexion.
Sensation Testing
The S1 dermatome covers the lateral malleolus and the lateral side and plantar surface of the foot.
Tests for Lumbar & Thoracic Spine
Active Range of Motion Tests
Four single plane movements performed standing.
flexion (both sides) extension
lateral flexion
Tests for Lumbar & Thoracic Spine
Passive Range of Motion Tests
Difficult to perform because of the weight of the torso and
positioning factors.
A sitting position may be the best option.
The end-feel for all the movements of the spine when there is
no dysfunction is tissue stretch.
Lumbar & Thoracic Spine - Special Tests
Straight Leg Raising Test
Designed to reproduce back and leg pain so that its cause can be determined.
Lie supine on an examining table.
Lift the leg supporting the foot around the calcaneus, place your free hand on the anterior aspect of the knee to prevent it bending.
The extent to which the leg can be raised without discomfort or pain varies, but normally about 80 degrees.
Lumbar & Thoracic Spine - Special Tests
Straight Leg Raising Test
If painful, determine if pathology is due to sciatic nerve or hamstring tightness.
Hamstring pain involves only the posterior thigh. Sciatic pain can extend all the way down the leg. The test may elicit symptoms of other low back pain. Pain in the opposite leg (positive well leg straight leg raising test).
At the point where the patient experiences pain, lower the leg slightly, and then dorsiflex the foot to stretch the sciatic nerve and reproduce sciatic pain.
Lumbar & Thoracic Spine - Special Tests
Straight Leg Raising Test
If no pain on foot dorsiflexion, the pain probably due to tight hamstrings.
A positive reaction to the straight leg raising test and dorsiflexion manoeuvre, ask the patient to locate, as nearly as possible, the source of his pain. It may be either in the lumbar spine or anywhere along the course of the sciatic nerve.
Lumbar & Thoracic Spine - Special Tests
Well Leg Straight Leg Raising Test
Lie supine, raise the uninvolved leg. If there is back or sciatic pain on the opposite (involved) side, there is further presumptive evidence of a space occupying lesion such as a herniated disc in the lumbar area. This test is also referred to as the opposite leg, or positive cross leg straight leg raising test.
Lumbar & Thoracic Spine - Special Tests
Milgram Test
Lying supine, keeping the legs straight, raise them to a position about 5 cm.
Hold this position as long as
possible.
This manoeuvre stretches the iliopsoas muscle and anterior
abdominal muscles, and increases the intrathecal pressure.
If this position can be held for 30 seconds without pain, intrathecal pathology may be ruled out.
Lumbar & Thoracic Spine - Special Tests
A positive Milgram Test
Cannot hold the position. Cannot lift the legs at all.
Experiences pain while attempting.
May indicate:
intrathecal or extrathecal pathology (herniated disc)
Lumbar & Thoracic Spine - Special Tests
Hoover Test
This test helps to determine whether the patient is
malingering when stating that the leg cannot be raised, and
should be performed in conjunction with the Milgram test.
Lumbar & Thoracic Spine - Special Tests
As the patient tries to raise the leg, cup one hand under the calcaneus of the opposite foot.
If genuinely trying to raise the leg, they put pressure on the calcaneus of the opposite leg to gain leverage; you can feel this downward pressure on your hand.
If the patient does not bear down while attempting to raise the leg, they are probably not really trying.
Lumbar & Thoracic Spine - Special Tests
Kernig Test
Stretches the spinal cord to reproduce pain.
Lie supine with hands behind the head to forcibly flex the head onto the
chest.
The patient may complain of pain in the cervical spine, or low back or down the legs, an indication of meningeal
irritation, nerve root involvement, or irritation of the dural coverings of the
Have the patient locate the area from which the pain originates so that you can
Lumbar & Thoracic Spine - Special Tests
Patrick or Fabere Test
Detects pathology in the hip and sacroiliac joint.
Pathology of the sacroiliac joint is relatively uncommon. However, when it is found, it is usually in conjunction with either a severe and massive trauma involving the pelvis or infectious diseases, such as tuberculosis.
Lumbar & Thoracic Spine - Special Tests
Patrick or Fabere Test
Lie supine, place the foot of the involved side on the opposite knee. The hip joint is now flexed, abducted, and externally rotated. In this position, inguinal pain is a general indication that there is pathology in the hip joint or the surrounding muscles.
When the end point of flexion, abduction, and external rotation has been reached, the femur is fixed in relation to the pelvis.
To stress the sacroiliac joint, extend the range of motion by placing one hand on the flexed knee joint and the other hand on the anterior
Press down on each of these points as if you were opening the binding of a book. If the patient complains of increased pain,
