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 pain-free and full-range 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 non-weight-bearing
hip and knee. The sacral dimple on the non-weight-bearing 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 end-feel between both sides.
The test is repeated for (oblique) hip flexion towards the contralateral
shoulder and (transverse) hip flexion towards the contralateral hip.
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 non-affected 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 non-affected 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 (Panjabi 1992). It is essential for painfree normal activity (Jull et al. 1993) and should always
be assessed.
Palpation
Soft-tissue 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 (Maitland 2001).
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