Differentiation between the hip and lumbar spine 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 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).