The Lumbar Spine:

Assessment &
Treatment
Orthopedic Physical Assessment – Magee

Rehabilitation techniques for sports medicine

and athletic training - Prentice
Please sign in:
Teken asb in:
• Listen for the password
• Luister vir die wagwoord
Assessment - content

Applied Anatomy
Patient History
Observation
Examination
 Applied
anatomy –
HIP
Hip applied anatomy - Labrum
• Helps deepen & stabilize the joint
• Horseshoe-shaped fibrocartilaginous - Runs around perimeter of
acetabulum
• Holds femoral head in acetabulum @ end ROM = stabilizes hip
• Increases articular surface area & volume of acetabulum
• Provides proprioceptive feedback for dynamic stability
• Creates a seal of central compartment = intra-articular hip joint
• Seal resists distraction of femoral head
• Allows femoral head to “float” on surface of cartilage (protects
cartilage)
• Resists fluid flow by regulating synovial fluid = enhances nutrition of
articular cartilage
• Providing smooth gliding surface
• Acts as shock absorber
• 2ndary role in hip stabilization during lateral rotation & also
preventing anterior translation
• Labrum = avascular except @ margins
Center-edge angle & anteversion
Origins (red) & Insertions
(blue)
Origins (red) & Insertions
(blue)
• Ligaments:
• Iliofemoral ligament (Y ligament of Bigelow) =
strongest ligament in body
• Ischiofemoral ligament (weakest of the 3
ligaments)
• Pubufemoral ligament
• 4th (ligamentum teres – “ligament of the head”)
Muscles of the hip/thigh
Muscles of the hip: Their
actions & nerve root
derivations
Muscles of the hip: Their
actions & nerve root
derivations
 Pt history – lumbar spine specific:
1. Pt age?
• Different conditions @ diff ages
2. Trauma involved? What mechanism of injury?
3. What are the details of the present pain / other
symptoms?
4. Is the condition improving? Worsening? Staying the
same?
5. Does any activity ease the pain or make it worse?
6. Are there any movements that the pt feels weak /
abnormal?
7. What is their usual activity or pastime?
8. Any past medical &/or surgical history, such as
developmental disorders, systemic illnesses,
metabolic / inflammatory disorders?
 1. Posture
Observation 2. Symmetry – skinfolds
& weight bearing
3. Balance
4. Equal & symmetric
limb posititions
5. Shortening of leg –
spinal scoliosis:
functional / structural
6. Color & texture of skin
7. Scars/sinuses
8. Gait
9. Kinetic chain
 Active Movements
Passive Movements
Resisted Isometric Movements
Peripheral Joint Scanning Examination

Examinat Myotomes
Functional Assessment
ion Special Tests
Reflexes & Cutaneous Distribution
Joint Play Movements
Palpation
Diagnostic Imaging
 Active
movemen
ts
• Looking for ROM
• Willingness to move
• If mechanical at least one of the
movements will be painful
• Watch for painful arc
Active Movements: Flx (110-120°)
Active movements: Ext
Passive movements
 • Performed supine &
isometric
• “Don’t let me move you”

1. Can pt actively position

the pelvis in neutral?
2. Can pt hold the neutral
position statically while
doing hip movements?
3. Can pt control dynamic
movement of the pelvis
when doing hip

Resisted isometric movements?

movements
Resistance testing:
Endurance tests
A. Flexion
B. Extension
C. Add (knee straight)
D. Add (knee bent)
E. Abd (knee straight)
F. Abd (knee bent)
Resistance testing:
Endurance tests
G. Medial rotation
H. Lateral rotation
I. Knee flexion
J. Knee extension
 Functional
Assessment
Functional Assessment
Functional Assessment
 Tests for Hip Pathology

Tests for Rotational deformities

Tests for impingement

Special Tests for Labral lesions

tests Tests for Femoral neck Fractures

Pediatric tests for hip pathology

Tests for leg lengths

Tests for muscle tightness or pathology

Tests for hip • Craig’s test – femoral anteversion
pathology • Hip scour test
• Patrick’s test
 • Craig’s test – femoral anteversion
Tests for hip
pathology • Hip scour (grind) test
• Patrick’s test

• Also the flexion-adduction test / quadrant / scouring test

• Stresses/compresses femoral neck against acetabulum / pinched
adductor longus, pectineus, ilopsoas sartorius, TFL
• Pt in supine
• Ex: flex & adducts pt hip so that hip faces pt opposite shoulder &
resistance to movement is felt
• Slight resistance (compressive force) is maintained in arc of movement
• As movement is performed – Ex looks for any irregularity in the
movement, (bumps) pain or apprehension
• Motion also causes impingement of femoral neck against acetabular rim
(FAI)
• Pinches adductor longus, pectineus, iliopsoas, sartorius & TFL depending
on ROM
• Perform test with care!
 • Craig’s test – femoral anteversion
Tests for hip • Hip scour (grind) test
pathology
• Patrick’s test

• Pt supine
• Ex places foot of pt’s leg on on top of knee of opposite leg
• Ex slowly lowers the knee of the test leg toward table
• Position displaces anterosuperior part of femora head junction to 12
o’clock position of acetabular rim
• If application of downward pressure on knee = lateral pain,
superolateral & lateral FAI are suggested
• Groin pain = iliopsoas pathology / psoas impingement against femoral
head / anterior capsule involvement
• Posterolateral pain = ischiotrochanteric impingement (especially w
increased anteversion)
• Negative test = test knee falling to table / at least parallel w table
• Positive = pain provocation
Tests for Rotational deformities
Anteroposterior impingement test
“Gear stick” sign
Lateral rim impingement test Tests for Impingement
Squat test
 Anterior labral tear test Tests for Labral lesions

• Also the FADDIR or Fitzgerald's test

• Used for anterosuperior impingement syndrome, anterior labral tears & ioliopsoas tendinitis
• Pt is supine
• Ex takes hip into full flexion, lateral rotation & full abduction as starting position.
• Ex then extends hip combined w medial rotation & adduction
• Positive test = production of pain / reproduction of pt’s symptoms w/ without a click / apprehension
• Test places greatest strain on anterolateral labrum
 Posterior labral tear test Tests for Labral lesions

• Used for labral tear, ant hip instability / posteroinferior impingement

• Pt is supine
• Ex takes hip into full flexion, adduction & medial rotation as starting position.
• Ex then takes hip into extension w abduction & lateral rotations as the ending position.
• Positive test = production of pain / reproduction of pt’s symptoms w/ without a click / apprehension
Tests for
Femoral neck
stress fractures

Fulcrum test
Heel-strike test
Pediatric
tests for hip
pathology
Ortolani’s sign & Barlow’s test
 Straight leg raise
(Lasegue’s) test Tests for leg length

• Weber-Barstow maneuver
Tests for leg
length
Hamstring contracture test
Abduction / Adduction contracture
test
Adductor squeeze test
Tests for muscle tightness
Bent-knee stretch test for proximal
hamstrings
or pathology
 Hip lag sign
Lateral step-down meneuver Tests for muscle tightness
(pelvis drop test)
Heel contra-lateral knee or pathology
Noble’s compression test
Piriformis (FAIR) test
Tests for muscle tightness
Ober’s test or pathology
 Thomas test
Trendelenburg sign
Tests for muscle tightness
Kendall or pathology
 Straight leg raise Tests for neurological
(Lasegue’s) test
symptoms

• Pt lies supine, hip med rotated & adducted to

neutral, knee extended
• Examiner flx hip until pt complains of tightness to
back of leg / pain in back
• If pain = back = likely a disc herniation
• If pain in leg – pathology causing pressure on neuro
tissues = more lateral
• Examiner ext leg till no symptoms
• Pt flex neck – chin on chest or examiner dorsiflex
pt’s foot – provocative/sensitizing test for neuro
tissue
 Prone knee bending test
Tests for Rotational
deformities
• Pt in prone
• Examiner passively flx knee as far as possible – pts heel
rest against the buttock
• At same time ensure pt hip does not rotate
• If examiner = unable to flx knee past 90 because of
pathological condition in knee – do test w passive hip ext,
while flx knee as much as possible
• Unilateral neuro pain in lumbar/buttock/posterior thigh /
ant thigh = L2/L3 nerve root

• Also neural stretch of femoral nerve

• Pain in ant thigh = tight Quads / stretching of femoral
nerve
Tests for
neurological
symptoms
Straight leg raise
(Lasegue’s) test
Tests for neurological symptoms
Straight leg raise (Lasegue’s) test
Reflexes &
cutaneous
distribution
 Palpation:

Anterior aspect:
• Iliac crest
• Greater trochanter
• Anterosuperior iliac spine
• Inguinal ligament
• Femoral triangle
• Hip joint
• Sympysis pubis
 Palpation:

Posterior:
• Iliac crest
• PSIS
• Ischial tuberosity
• Greater trochanter
• Sacroiliac
• Lumbosacral
• Sacrococcygeal joints
Diagnostic
imaging
• Plain film radiography
 1
• Femoroacetabular impingement (FAI)

2
• Acetabular labral tear

Rehabilitati 3
• Femoral neck stress fracture

on 4
• Trochanteric bursitis

techniques 5
• Post-ACL reconstruction surgery
for lumbar 6
• PCL rupture
spine 7
• Medial meniscus injury
injuries 8
• “Jumper’ knee”

9
• Osteochondritis dissecans (OCD)

10
• Patellofemoral syndrome
Pathomechanics
• Summarize the Pathomechanics & Injury mechanism for your injury
Assessment plan
• Write out your assessment plan – what you will do during the evaluation
Rehabilitation
Work in
• Provide complete rehab program w the various ex plus
your
progressions/regressions
groups:
• Warm-up
• Stretches
• Rehabilitation
• Functional / proprioception exercises