Differentiation between Lumbar spine and Hip as a source of Symptoms

  


Differentiation between the hip and lumbar spine as a source of symptoms:

The hip joint may give rise to pain in the buttock or groin. In order to differentiate between pain arising as a result of spinal or hip pathology it is important that the therapist discounts the hip joint as a possible source of symptoms. With the patient supine, full flexion, medial and lateral rotation is performed actively and passively at the hip joint. These are the movements commonly painful or restricted by degenerative joint conditions such as osteoarthritis. If these movements are pain­free and full­range then it is unlikely that the hip is a source of symptoms. Compare both sides.

 


Assessing the sacroiliac joint

 Sitting flexion (Piedello’s sign)

 The seated patient is asked to flex forwards. The physiotherapist palpates the sacral dimples bilaterally. Both sacral dimples should move equally in a cephalad direction (i.e. towards the head). (This tests the movement of the sacrum on the ilium.) Excessive rising of one side indicates hypomobility at that sacroiliac joint.

Standing flexion (stork test)

 With the patient standing, the physiotherapist locates the sacral dimples (level of S2) and places the other hand centrally at the sacrum. The patient is instructed to stand on one leg while flexing the non­weight­bearing hip and knee. The sacral dimple on the non­weight­bearing side should appear to move caudally (towards the floor) by approximately 1 cm as the ilium rotates posteriorly. Hypomobility is observed if the dimple does not move distally in relation to the sacrum.

 


Compression tests

Posterior ligaments

These test the integrity of the posterior sacroiliac ligaments. The patient lies supine and the hip is passively flexed towards the ipsilateral shoulder A downward thrust is applied along the line of the femur. Observe for pain response, clunk and difference in end­feel between both sides. The test is repeated for (oblique) hip flexion towards the contralateral shoulder and (transverse) hip flexion towards the contralateral hip.

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Anterior ligaments

  Faber test

 Flexion plus abduction plus external rotation (the ‘Faber’ test) tests the integrity of the anterior sacroiliac ligaments. The test is also described as the ‘four test’ because of the position of the patient’s limb, a combination of flexion, abduction and external rotation. The physiotherapist pushes the leg downward, just proximal to the knee joint while stabilising the opposite hip with the other hand. A normal finding would be to lower the leg to the level of the opposite leg. Observe for pain response or limitation of movement.

Neurological testing Compression or traction of spinal nerve roots by disc

 trespass and/or osteophytes may give rise to referred

 pain, paraesthesia and anaesthesia, and also give positive neurological signs. Neurological signs should be carefully monitored as deterioration may indicate worsening pathology.

 


Dermatomes

 A dermatome is an area of skin supplied by a particular spinal nerve. Dermatomes may exhibit sensory changes for light touch and pin prick. Test each dermatome individually, on the unaffected and then the affected side.

Myotomes

 A myotome is a muscle supplied by a particular nerve root level. These are assessed by performing isometric resisted tests of the myotomes L1–S1 in middle range, held for approximately three seconds. Test the unaffected side, then the affected: LI–L2 for the hip flexors , L3–L4 for knee extensors , L4 for foot dorsiflexors and invertors, L5 for extension of the big toe, S1 for plantar flexion  and knee flexion, S2 for knee flexion and toe standing, and S3–S4 for muscles of the pelvic floor and the bladder.


Reflexes

• Test the non­affected first then affected side. Note: dull reflexes may indicate lower motor neurone dysfunction. Brisk reflexes may indicate an upper motor neurone dysfunction.

 • L3 corresponds to the quadriceps. The patient sits with the knee flexed and the therapist hits the patellar tendon just below the patella.

 • S1 corresponds to the plantarflexors. Dorsiflex the ankle and strike the Achilles tendon. Observe and feel for plantar flexion at the ankle

 

Adverse mechanical tension

 Passive neck flexion

 The patient is supine. The physiotherapist flexes the patient’s neck passively. Observe for any low back pain response, which may suggest disc pathology.


Straight leg raise (SLR)

 This is also known as Lasegue’s test. The patient is supine. The physiotherapist lifts the patient’s leg while maintaining extension of the knee. An abnormal finding is back pain or sciatic pain. The sciatic nerve is on full stretch at approximately 70 degrees of flexion, so a positive sign of sciatic nerve involvement occurs before this point (Palmer and Epler 1998). Any pain response and range of movement is noted and comparison made with the other side. Factors such as hip adduction and medial rotation further sensitise the sciatic nerve; dorsiflexion of the ankle will sensitise the tibial portion of the sciatic nerve; plantar flexion and inversion will sensitise the peroneal portion of the nerve.

Prone knee bend (femoral nerve stretch)

 The patient lies prone and the physiotherapist flexes the person’s knee and then extends the hip. Pain in the back or distribution of the femoral nerve indicates femoral nerve irritation or reduced mobility. Comparison is made with the other side.


Slump test

 This tests the mobility of the dura mater. The patient sits with thighs fully supported with hands clasped behind the back. The patient is instructed to slump the shoulders towards the groin . The physiotherapist applies gentle overpressure to this trunk flexion. The patient adds cervical flexion, which is maintained by the therapist. The patient then performs unilateral active knee extension and active ankle dorsiflexion. The physiotherapist should not force the movement. The non­affected side should be assessed first. Any symptoms are noted at the particular part in range. If the dura mater is tethered, symptoms will increase as each component is added to the slump test. The patient is instructed to extend the head – a reduction in symptoms on cervical extension is a positive finding, indicating abnormal neurodynamics.

Testing for lumbopelvic stability

 Stability of the lumbar spine is necessary to protect the lumbopelvic region from the everyday demands of posture and load changes. It is essential for painfree normal activity (Jull et al. 1993) and should always be assessed. With the patient in crook lying with the hips at 45 degrees flexion, he/she is instructed to maintain a neutral spine (it may be useful to tell the patient to maintain such a lordosis that an army of ants could just crawl through!). The person then performs an abdominal in­drawing by contracting the transversus abdominis muscle while attempting to maintain the spine in neutral. To challenge the transversus abdominis and multifidus stabilising muscles (and consequently the spinal position), the patient adds the leg load by alternately lifting the heels from the floor and sliding out the leg while maintaining a neutral spine position. The maintenance of a neutral spine posture can be assessed by using a biofeedback device. An inability to maintain the spine in neutral will result in the lumbar spine extending as the leg is lifted. The intra­abdominal pressure mechanism is controlled primarily by the diaphragm and transversus abdominis which provides a stiffening effect on the lumbar spine (Hodges and Richardson 1997).

Palpation Soft­tissue thickening over the articular pillar at one or more spinal levels is a common finding in cases of degenerative disease of the lumbar spine, as is hard bony thickening and prominence over the apophyseal joints. Note any general tightness or localised thickening of muscular tissue or ligamentous tissue. In general, the older the softtissue changes, the tougher they are; the more recent, the softer they are. However, a thickened or stiff area is not necessarily painful or the source of a patient’s symptoms.

 

Accessory spinal movements

 The physiotherapist applies central posteroanterior

 pressures on the spinous processes and unilateral (onesided) pressure over the articular pillar, noting areas of hyper­ and hypomobility. Record any pain experienced by the patient and the corresponding spinal level.

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