Integrated Low Back Examination

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Integrated Low Back Examination

William Thomas, DO, VCOM PPC/OMM

Internal Medicine, Pediatrics and Sports Medicine October 2015

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Objectives

• Utilize history and physical exam to

create differential diagnosis for

musculoskeletal low back pain

• Identify indications for imaging

• Identify contraindications to osteopathic

manipulative treatment (OMT)

• Utilize osteopathic structural exam for

diagnosis of musculoskeletal low back

pain

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Additional Resources

• Casazza, BA. “Diagnosis and

treatment of acute low back pain.” Am Fam Physician; 2012; 85: 343-350

• Kinkade, S. “Evaluation and

treatment of acute low back pain.” Am Fam Physician; 2007; 75:

1181-8

• Bates’ Guide to Physical

Examination and History Taking, Chapter 16, “Spine”

Chila, Chapter 40, pp.542-574

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Functional Anatomy

• Remember the low

back and pelvis

serves as a force

transfer link between

the torso and lower

extremities

• Remember keys to dx

include referred pain

patterns, trigger

points, spinal

reflexes, and

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Don’t forget Red Flags

• Risk for Fracture

• Risk for Malignancy

• Cauda equina symptoms

• Not improving after several weeks • Hx of IV drug abuse

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Other conditions that warrant

consideration: Imbalance

• Short Leg Syndrome

• Dead Butt Syndrome

• Piriformis Syndrome

• Psoas Syndrome

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Orthopedic Exam

Facet/Spondy Tests • Single-legged hyperextension • Standing Kemp’s • Seated Kemp’s Stenosis Tests • Pheasant’s Lumbar vs Sacrum • Yeoman’s Test Discogenic Tests

• Straight Leg Raise/Crossed • Braggard’s

• Lasegue’s (bent-knee)

Discogenic Tests (cont) • Bonnet’s (piriformis) Hip and Pelvis Tests • Thomas (modified)

• FABERE

• FADIR • FAIR

• Gluteus firing pattern testing Malingering Tests

• Hoover

• Simulated Rotation • Axial load

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Proposed Office Exam

• Patient Standing

– Inspection/Postural Exam – Functional arch exam

– Gait Evaluation (shoes off) – General ROM

– Standing Flexion Test – Standing Kemp’s

– Hip Drop test

– Single-Legged Hyperextension Test – Simulated Rotation of trunk/pelvis

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Proposed Office Exam

• Patient Seated

– Neurologic testing • Sensation • DTRs – Pulses – Seated Kemp’s – Axial Compression

– Osteopathic Screen (spine, ribs) – Muscle strength testing

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Proposed Office Exam

• Patient Supine

– Osteopathic screen (pelvis, extremity, leg lengths)

– SLR/crossed SLR

– Braggard’s test (if SLR +) – Lasegue’s Test

– Bonnet’s Test (if SLR +) – FAIR

– Hoover’s Sign – Hip Exam

• ROM

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Proposed Office Exam

• Patient Prone

– Pheasant’s – Hibb’s test – Yaoman’s test

– Gluteus firing (dead butt) – Palpate

• Gluteus • Piriformis • SIJ

– Osteopathic screen (sacrum, and any other spine not done seated)

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Inspection

• Inspect the skeleton and extremities and

compare sides for the following:

– Gait

– Alignment

– Contour and symmetry of body parts – Gross deformity

– Tenderness

• Inspect muscles and compare contralateral sides for the following:

– Size and symmetry – Tone

– Temperature – Swelling

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ROM

•Posture

•Gait

•Stabilize

pelvis when

testing

Lumbar

ROM

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• Palpate bones, joints, and surrounding

muscles for the following:

– Tissue texture changes

– Tenderness

– Swelling

– Fluctuation(effusion)

– Crepitus

– Resistance to pressure

Palpation

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Gait Cycle….Osteopathic Phases

• Right heel strike

– Right innominate rotates posterior – Left rotates anterior

– Anterior sacrum rotates left – Superior sacrum level

– Spine rotates left

• Midstance

– Right leg straight

– Innominate rotates anteriorly – Sacrum rotated right, SB left

– Lumbar spine rotated left, SB right

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Functional Testing

Standing Flexion Test Seated Flexion Test

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Hip Drop Test

• Screens for the ability of the lumbar region to sidebend away from the side of the hip drop

• Physician hands on patient’s iliac crests

• Patient is told to “bend one knee without lifting his/her heel off the floor” and allowing the hip to drop downward, then bend the other knee

– The hip that drops the least is the positive side, showing a restriction in lumbar side bending toward the side of the weight bearing leg (opposite the bent knee)

– Negative (Normal)  Smooth curve away from side of hip drop – Positive Test (Abnormal)  Plane of iliac crest drops <20

– Test is named for the bent leg side (+ left hip drop test indicates restricted right lumbar side bending)

Ne utr al + le ft hip dr op - ri ght hip dr op

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Lumbar-Posterior Elements

• Single Legged Hyperextension test

– Pt standing on one leg & begins with extension of spine

– Pt then rotates & side bends to the ipsilateral side as the standing leg – Reproduction of pain indicates

posterolateral spine as region of pain

• Early symptoms suggest:

– Possible stenosis – Possible lumbar disk

• Late (or end range) symptoms suggest:

– Pars Fracture – Facet Syndrome

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Lumbar-Posterior Elements

• Standing/Seated Kemp’s Test – Like a Spurling’s test for the

lumbar region

– Actively or passively

– Extend, rotate and side bend

spine until symptoms reproduced – Early pain suggests disc etiology – Later pain suggests facet

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Lumbar – Discogenic

• Straight Leg Raise Test

– Passively flex hip

– (+) if reproduces radicular symptoms

• Braggard Test

– If SLR (+) then…

• Lower leg to reduce symptoms • Dorsiflex foot

• (+) if reproduces radicular symptoms

• Lasegue’s Test

– Flex hip to 900_{and flex knee}

– Passively extend knee

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Lumbar – Stenosis

• Pheasant’s Test

– Like Phalen’s test for the low back – Flex knees & compress lumbars to

extend lumbar spine and reduce A-P diameter of canal

• May need to hold for up to 60 sec

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Lumbar vs. Sacral Problems

• Yeoman’s Test

– Pt prone

– Extend hip (with or without bent knee) while

monitoring at L-S joint

– Reproduction of pain could be L-S, SIJ, or hip

– Can use progressively less extension & monitor each joint as to when pain starts in order to further localize

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Lumbar – Malingering

• Simulated Rotation

– Spine in neutral

– Rotate pelvis side to side – Should not reproduce

radicular symptoms – (+) test if reproduces

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Lumbar – Malingering

• Axial Compression – Press downward on head to add “compressive” force to spine – (+) if reproduces

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Lumbar – Malingering

• Hoover

– Place hands on b/l heels

– Pt actively flex hip with knee extended

– Should feel downward force through heel on opposite leg – (+) if do not feel down force

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Netter based on Keegan and Garrett 1948

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Neuro Exam

• Motor = muscles

responsible for foot dorsiflexion

• DTR = patellar reflex

• Sensory = medial aspect of leg and foot

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Neuro Exam

• Motor = extension of

extensor hallucis longus m. against resistance

– “Walk on heels” • No reflex**

• Sensory = lateral side of leg and dorsum of foot

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Neuro Exam

• Motor = muscles responsible

for plantarflexion

– “Walk on your toes” • DTR = achilles reflex

• Sensory = lateral malleolus and lateral aspect and

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Pulses

• Posterior Tibial Artery

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Osteopathic Screen

(above)

• Thoracic Spine

• Ribs

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Osteopathic Screen

(below)

• Pelvis

• Leg lengths

• Extremity

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• Hip flexion

– Psoas (L2-4)

• Hip adduction

– Adductors (L2-4)

• Hip abduction

– Gluteus medius and minimus (L4-5, S1)

• Hip extension – Gluteus maximus (S1) • Knee extension – Quadriceps (L2-4) • Knee flexion – Hamstrings (L4-5, S1-2) • Ankle dorsiflexion – Tibialis anterior (L4-5) • Ankle plantarflexion

– Gastrocnemius and soleus (S1)

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Specific Hip & Pelvis Exams

• Thomas Test (modified)

– Tests for:

• Iliopsoas tightness • Rectus femoris • Tensor fascia lata • Iliotibial band

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Piriformis

• Bonnet’s Test

– For Piriformis Syndrome

• Mimicker of discogenic pain – Straight Leg Raise

• If +, then…

• Lower leg to relieve symptoms & forcefully IR hip

• (+) if reproduces symptoms in ipsilateral leg

• FAIR test

– Flexion, adduction, internal rotation – (+) if reproduces symptoms in

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Specific Hip & Pelvis Exams

• FABER(E)

– Flexion, ABduction, ER, Extension

– Pain reproduced before the SI joint is engaged (groin pain) indicates pain is in the acetabulum / femoral joint

– Pain after the SI joint is engaged (back pain) indicates SI as source of pain

• FADIR

– Flexion, Adduction, Internal Rotation – Reproduction of pain symptoms suggests

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Abnormal Gluteus Firing

• Test hip extension firing pattern – 1) Hamstring – 2) Gluteus – 3) Contralateral Quadratus Lumborum – 4) Ipsilateral Quadratus Lumborum

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“Dead-Butt Syndrome”

• Treatment in the following order:

• Address any tight anterior hip capsule component • Stretch iliopsoas

• Gluteus muscle retraining

– Prone position bring toes up on table – Straighten knee

– Tighten gluteus muscles

– Maintaining gluteus contraction, extend leg – Extend toes and hold for 3-5 secs

– Then slowly return leg to table – LAST, relax gluteus muscles

• After retraining the gluteus, continue to work on Core strength too

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“Dead-Butt Syndrome”

Diagnosis _Treatment Figure 1 1 2 4 3

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