Orthopaedic Assessments

The Lumbar Spine

● Agenda
– Applied anatomy of the lumbar spine
● Introduction to the following joint play terms:

– Loose Packed (Resting) Position

– Closed Packed Position
● Review

● Kinematics

– Patient History
– Observation
– Examination
● Active movements

● Passive movements

● Resisted isometric (Active free, active resisted)

movements
– Special Tests
– Joint Play
 JOINT PLAY
Loose (Resting) vs. Close Packed Position
● Joint Play
– The small amount of ROM that can be
obtained by the therapist (passively)
– The “play” cannot be elicited under voluntary
control
– Joint dysfunction signifies a loss of joint play
movement

● For a joint to have full, pain-free

voluntary movement, joint play
movement is necessary.
 Loose Packed (Resting) Position

● The position in which a respective

joint is under the least amount of
stress

● The ligaments of the joint are at

their greatest laxity and passive
separation of the joint surfaces are
at their greatest
 Close Packed Position
● The position in which a respective
joint is under the greatest amount of
stress (joint surfaces are tightly
compressed)

● The ligaments of the joint are

maximally tight; joint surfaces
cannot be separated by distractive
forces
 Lumbar Spine
● Resting Position
– Midway b/w flexion & extension

● Close Packed Position

– Extension

● Capsular Pattern
– Side flexion & rotation equally limited
– Extension
Role of the lumbar spine:

● Supports the upper body

● Transmits weight of the upper

body to the pelvis and lower

limbs
● Should always be included when

examining the spine, the hip

and/or sacroiliac joints
 Applied Anatomy
● 10 (five pairs) facet joints
● Superior facets face
medially and backward
● Inferior facets face

laterally and forward

● Shape and orientation of
facets direct movement
● Rotation is minimal
● Forward flexion is greatest
Psoas major Anatomy - Muscles
–ORIGIN
•Transverse processes of L1-
5, bodies of T12-L5 and
intervertebral discs below
bodies of T12-L4
–INSERTION
•Middle surface of lesser
trochanter of femur
–ACTION
•Flexes and medially rotates
hip; acting bilaterally
increases lumbar lordosis;
unilaterally – assists in same
side lateral flexion
 Anatomy - Muscles
Iliacus
–ORIGIN
•Iliac fossa within abdomen
–INSERTION
•Lowermost surface of lesser
trochanter of femur
–ACTION
•Flexes medially rotates hip;
acting bilaterally with psoas –
flexes the trunk on the femur
 Anatomy - Muscles
Rectus abdominus
–ORIGIN
•Pubic crest and symphysis
–INSERTION
•Costal cartilages of ribs 5-7;
xiphoid process
–ACTION
•Flexes vertebral column
 Anatomy - Muscles
External obliques
–ORIGIN
External surfaces of ribs 5-
12, interdigitating with
serratus ant’r and lat dorsi
–INSERTION
•Linea alba, as inguinal
ligament, and external lip
of ant’r ½ of iliac crest
–ACTION
•Bilaterally flex vertebral
column; unilaterally lateral
flexion of column
 Anatomy - Muscles
Internal obliques
–ORIGIN
•Inguinal ligament, iliac crest
and thoracolumbar fascia
–INSERTION
•Crest of pubis (with
transversus), linea alba and
inf’r borders of ribs 10-12
–ACTION
•Flexes vertebral column
 Anatomy - Muscles
Transversus abdominus
–ORIGIN
•Inner surfaces of ribs 6-12,
thoracolumbar fascia, ant’r
¾ of iliac crest and lat’l 1/3
of inguinal lig.
–INSERTION
•Linea alba, pubic crest and
pectin pubis
–ACTION
•Visceral compression
 Anatomy - Muscles
Latissimus dorsi
–ORIGIN
•SP’s T6-12, ribs 8-12,
thoracolumbar fascia, post’r
1/3 of iliac crest; a slip from
inf’r angle of scapula
–INSERTION
•Intertubercular groove
–ACTION
•(with insertion fixed) ass’ts
in tilting pelvis anterior/
laterally. Bilaterally, assist
with spine hyperextion and
anterior pelvic tilt
 Anatomy - Muscles
Quadratus lumborum
–ORIGIN
•Iliolumbar lig, iliac crest
–INSERTION
•Inf’r border of last rib and
TP’s of L1-4
–ACTION
•Assists in ext’n, lat’l flxn and
depresses last rib.
 Anatomy - Muscles
Erector spinae (iliocostalis)
–ORIGIN
•Med’l & lat’l crest of
sacrum, SP’s of lumbar and
T11-12, iliac crest, lower 6
ribs
–INSERTION
•By tendons into 12 ribs &
dorsum of TP of 7th Csp
–ACTION
•Inc. lordosis; assists with all
spinal ext,n, lateral flxn
 Anatomy - Muscles
Erector spinae (longissimus)
–ORIGIN
•With iliocostalis lumborum,
post’r surfaces of TP’s of
lumbar vertebrae,
thoracolumbar fascial
–INSERTION
•By tendons into TP’s of Tsp
–ACTION
•Increases lordosis; assists with
all spinal extension
 Anatomy - Muscles
Transversospinalis (semispinalis)
–ORIGIN
•Thoracic TP’s
–INSERTION
•SP’s of upper 4 thoracic and
cervical SP’s 2-7
–ACTION
•Extends and laterally flexes
spine
 Anatomy - Muscles
Transversospinalis
(multifidi)
–ORIGIN
•Post’r sacral surface,
medial surface of PSIS,
TP’s of L5-C4
–INSERTION
•Spanning two to four
vertebrae, inserting into SP
of vertebra above
–ACTION
•Spinal extension
 Anatomy - Muscles
Transversospinalis
(rotatores)
–ORIGIN
•TP’s of vertebrae
–INSERTION
•Lamina of vertebra
above
–ACTION
•Rotates spine
 Kinematics
● Majority of lumbar movement occurs at
L4-5 and L5-S1
● Center of Gravity passes just anterior

to the sacral promontory

● Therefore, these two segments are
most likely to suffer breakdown and
degeneration
● Unstable, excess of motion creating low
back pain (ie. spondylolisthesis)
 Activity and Percentage Increase in Disc
Pressure (at L3)
● Coughing or straining ● 5 to 35%
● Laughing ● 40 to 50%
● Walking ● 15%
● Lateral flexion ● 25%
● Small jump ● 40%
● Forward flexion ● 150%
● Rotation ● 20%
● Lifting a 20kg wt with ● 73%
back straight and knees
bent
 Patient History
also see handout

● From the intake form, make note of the

client's:
– Age
– Occupation
– Sex

● LODRFICARA-WASPS
– (location, onset, duration, rad./ref., frequency,
intensity, character, agg., rel., assoc. s&sx, work
demands, activities, systems review, prev. inj., social
life)
 Observation
When observing your client, look for the
following four traits:

(1) Body type

● Ectomorphic, mesomorphic, endomorphic
(2) Gait
● Normal or altered? If altered, is it in the limb or is
it in compensation of a problem elsewhere
(3) Attitude
● Tense? Bored? Lethargic? Appearance? Healthy
looking?
(4) Total spinal posture (posture analysis)
Lordotic Spinal Posture

Causes of Increased Lordosis

1) Postural deformity
2) Lax (weakened) muscles (especially abdominal)
3) Heavy abdomen
4) Compensatory from a another deformity (ie.
Kyphosis)
5) Hip flexion contracture
6) Spondylolisthesis
7) Congenital problems (ie. Hips)
8) Failure of segmentation of the neural arch (ie.
 Pathological Lordosis
May observe:
● Sagging shoulders
● Medial rotation of the
legs
● Anterior head carriage
● Increased pelvic angle
(greater than 30°)
● Anterior pelvic tilt
● All in an attempt to Tight: Hip flexors, TFL,
keep the center of Erectors
gravity where it should Weak: Abdominals
be
 Swayback Deformity
Will observe:
● *Excessive arching of lumbar
spine while thoracic spine
exhibits a kyphosis
● *Increased pelvic angle
(greater than 30°)
● The spine is sharply bending
back at the lumbosacral angle
● Entire pelvis shifts anteriorly
● Hips move into extension Tight: Hip extensors, lower
(because they have shot forward) lumbar extensors, upper
● Thoracic spine flexes on the abdominals
lumbar spine to maintain center of Weak: Hip flexors, lower
gravity abdominals, lower thoracic
extensors
Flatback
● Decreased lordotic
curvature
● Decreased pelvic
inclination to
approximately
20°
● Mobile lumbar
spine
Tight: hip musculature
(except hip flexors)
Weak: erector spinae, hip
flexors
 Scoliosis
Lateral curvature of the spine

(1) Structural Scoliosis

– Primarily involves bony deformity (congenital
or acquired)
– May be progressive
– Wedge vertebra, hemivertebra, failure of
segmentation, idiopathic (genetic)
– Loss of normal flexibility
– Lateral flexion is asymmetric
– Curve persists during forward flexing (“rib
humping”)
 Scoliosis
Lateral curvature of the spine

(2) Non-Structural Scoliosis

– No bony deformity
– Not progressive
– Segmental limitation
– Lateral flexion usually symmetric
– Disappears on forward flexion
 Lumbar Spine
Examination & Assessment

(1) ROM – Active, Passive, Resisted

(2) Special Tests

(3) Palpation
✗ Not covered in this class
 Lumbar Spine – Active ROM
●
Forward flexion (40 to 60°)
●
Extension (20 to 30°)
●
Lateral flexion (L&R) (15 to 20°)
●
Rotation (L&R) (3 to 18°)

● Performed standing
● Be on the lookout for limitation of movement
● May apply passive overpressure, but only if
ROM is full and pain free – be careful!
● If repetitive motion or combined movements
have been reported in the history as causing
symptoms, these movements should be
performed as well, but only after the patient
has completed the basic movements

● With forward flexion, look to see that the

movement is occurring in the lumbar spine
and not in the hips or thoracic spine
 Lumbar Spine – Passive ROM
● Forward flexion (tissue stretch)
● Extension (tissue stretch)
● Lateral flexion (L&R) (tissue stretch)
● Rotation (L&R) (tissue stretch)

● Difficult to perform because of the weight of the body,

therefore:
● DO NOT PERFORM WHILE CLIENT IS WEIGHT-
BEARING (STANDING)
● Safer to check the end feel of the individual vertebrae
during the assessment of joint play movements
● Refer to joint play later in lecture
Lumbar Spine – Resisted Isometric
● Patient is seated
● Contraction must be resisted and isometric
so that no movement occurs
● “Don't let me move you.”
● For female therapists, required to buffer your
contact with the client through a pillow

● Forward flexion
● Extension
● Lateral flexion (left and right)
● Rotation (left and right)
 Special Tests

● Tests for Neurological Dysfunction

– Slump test
– Straight leg raise test
– Bragard's Test
– Soto-Hall Test
– Valsalva

● Tests for Joint Dysfunction

– Pheasant test
General Rules to apply:
● Always perform bilaterally when
possible
● Always perform the unaffected side

first
● Must have proper therapist

positioning and hand placement;

proper client positioning
● Client safety must be ensured
 Special Tests – Neurological Dysfunction
SLUMP TEST
(aka. Sitting Dural Stretch)

● Series of steps performed sequentially

● Only progress to the next step if no positive
was elicited
● Perform test:
● Start with non-affected side, then repeat on
affected side, then repeat with both sides
simultaneously

● POSITIVE FINDING:
– Reproduction of the symptoms
 SLUMP TEST-(aka. Sitting Dural Stretch)
1) Client seated at the edge of table with their hands behind
their back
2) Ask client to “slump” the back into flexion
3) Therapist supports client's chin in the neutral position (no
head or neck flexion)
4) Therapist applies gentle overpressure across shoulders
5) Ask client to bring their “chin to chest”
6) Therapist again applies overpressure by placing hand over
the head
7) With the other hand, therapist dorsiflexes client's foot
maximally
8) Client is asked to actively straighten the knee as much as
possible
9) If unable to extend knee, release overpressure to neck
SLUMP TEST - (aka. Sitting Dural Stretch)
 Special Tests – Neurological Dysfunction
STRAIGHT LEG RAISE
1) Client supine; client completely passive
2) Therapist medially rotates hip with some
adduction; knee extended
3) Keeping the knee straight, therapist flexes the
hip until the client complains of pain or
tightness in the back or posterior leg

● POSITIVE FINDING:
– Pain; reproduction of symptoms
● INDICATION OF:
– Dural, cord and/or nerve root impingement
 Special Tests – Neurological Dysfunction
STRAIGHT LEG RAISE
Caution:
-A positive SLR need not imply neurological
dysfunction.
-Must rule out:
(1) Hamstring injury
(2) Lumbar facet injury
(3) Sacroiliac injury
 Modification to SLR Test

● If for any reason you cannot perform a SLR

with the client supine, you can instead
conduct the test in the side-lying position

(1) Client side lying with hip and knee

flexed to 90°
(2) Passively extend the knee
 Special Tests – Neurological Dysfunction
BRAGARD'S TEST
● Same procedure as for SLR except the addition
of the following:
– At the degree of hip flexion that elicits a
positive finding, therapist gently lowers the
leg until the symptoms disappear
– Therapist then maximally dorsiflexes the foot

● POSITIVE FINDING:
– Pain; reproduction of symptoms
● INDICATION OF:
– Dural, cord and/or nerve root impingement
 Special Tests – Neurological Dysfunction
SOTO-HALL TEST
● Same procedure as for SLR except the addition
of the following:
– At the degree of hip flexion that elicits a
positive finding, therapist gently lowers the
leg until the symptoms disappear
– Client flexes chin to chest (actively or
passively)
● POSITIVE FINDING:
– Pain; reproduction of symptoms
● INDICATION OF:
– Dural, cord and/or nerve root impingement
 Special Tests – Neurological Dysfunction
VALSALVA

1) Client seated
2) Ask client to take a deep
breath in, hold it, and then
bear down

● POSITIVE FINDING:
– Pain; reproduction of
symptoms
● INDICATION OF:
 Special Tests – Joint Dysfunction
PHEASANT TEST

1) Client prone
2) With one hand, the therapist applies gentle
pressure to posterior aspect of lumbar spine
3) With the other hand, the examiner passively
flexes the patient's knees until the heels touch the
buttocks

● POSITIVE FINDING:
– Pain
● INDICATION OF:
– Unstable spinal segment; facet jamming
Test shown above is Ely's test. Pheasant's is exactly the same except
gently pressure is applied to the lumbar spine with one hand.
 Special Tests – Joint Dysfunction
QUADRANT TEST
1) Client stands with therapist behind
2) Client extends spine; therapist supports
3) Therapist applies overpressure while client
side flexes and rotates to side
4) Continued until limit of range is reached or
symptoms are produced

● POSITIVE FINDING:
– Pain; reproduction of symptoms
● INDICATION OF:
– Facet joint stress; maximum narrowing of IVF
 JOINT PLAY MOVEMENTS

● USED TO DETERMINE END

FEEL OF JOINT MOVEMENT
● Replaces passive movements
● Note any decreased ROM, pain,
or differences in end feel
Joint play movements of the lumbar spine:
● Flexion
● Extension
● Side flexion
● PA central vertebral pressure (spinous
process)
● PA unilateral vertebral pressure (lamina
or transverse process)
● Transverse vertebral pressure (spinous
process)
FLEXION

● Client side lying; therapist standing in front

● Therapist flexes both hips toward the chest
with the knees bent
● Palpating between SPs, passively flex and
release client's hips (use body weight to
create movement)
➢ Feeling for a “gapping” between the
spinous processes
➢ Excessive gapping: hypermobile
➢ Decreased gapping: hypomobile
Extension

● Client side lying; therapist standing in front

● Therapist extends both hips with the
knees bent (use body weight)
● Palpate between spinous processes
➢ Feeling for a “closing” of the space
Side Flexion

● Client side lying

● Therapist grasps client's uppermost leg
and rotates upward
● Will cause side flexion in the lumbar
spine
● Must rule out hip pathology in advance

● Palpate SPs for lateral flexion

PA Central Vertebral Pressure

● Client prone; move from L5 to L1

● Bilateral contact with thumbs on SP and
fingers spread laterally
● Apply downward pressure – Vertebrae
is being pushed anteriorly
● Apply pressure slowly and cautiously
Unilateral Central Vertebral Pressure

● Client prone; move from L5 to L1

● Bilateral contact with thumbs on lamina or
TVP
● Apply downward pressure – Vertebrae is
being pushed anteriorly
● Apply pressure slowly and cautiously
● Feel for “springing”
● May repeat more than once
● Perform bilaterally
Transverse Vertebral Pressure

● Client prone; move from L5 to L1

● Bilateral contact with thumbs on side of SP
● Apply lateral pressure
●First from one side, then the other
● Apply pressure slowly and cautiously
● Feel for “springing”
● May repeat more than once
● Perform bilaterally
 Length & Strength Testing
Muscles Testing and Function
Kendall, McCreary & Provance
➔ Abdominal Strength

➔ Back Strength

➔ Hip Extensor Strength

➔ Oblique Trunk Flexor Strength

 Length & Strength Testing
Muscles Testing and Function
Kendall, McCreary & Provance

Abdominal Strength
●Supine; bilateral SLR

●Back held flat: Strong

●Back hyperextends:

Weak
 Length & Strength Testing
Muscles Testing and Function
Kendall, McCreary & Provance

Back & Hip Extensor Strength

●Prone; Extend spine

●Hands behind head; legs

stabilized
●If can raise trunk into extension:

Strong
●If cannot extend at all or can

only hyperextend at the lumbar

spine: Weak
 Length & Strength Testing
Muscles Testing and Function
Kendall, McCreary & Provance

Oblique Trunk Flexor Strength

●Supine

●Stabilize legs (held straight)

●Client clasps hands and is put

into position of trunk rotation and

flexion and is told to hold pos'n