Lumbar Spine, Hip and SIJ Examination

Foundational Parts of Exam

o Patient history- subjective
Severity of symptoms
Nature and behavior
Does it sound nociceptive, neuropathic, not make sense?
Pain characteristics of certain tissue
Hurt worse in the morning or evening/
Hurt worse with activity that involves load or spinal position of
flexion or extension?
Rule out red flags
Cancer
Infection
Vertebral fracture
Abdominal aortic aneurysm
Cauda equina
What are the patients goals?
Measure yellow flags and impact of this condition on their life
Pain catastrophizing scale- score >30 is concerning (meaningful
change is 8 points)
Oswestry- not direct measure of yellow flags but measuring
patients perceived disability of activity participation restriction
specific to LBP
o % disability lower the # - less this condition is impacting
their life
o need to get to 50% better for meaningful change
kinesiophobia, FABQ, Depression questionnaire- directly score
yellow flags
Examination- always start with what we see
o Posture
Asymmetry- postural alignment
Tells me what they are doing in everyday activity that contributes to s/s
Loading as a theme
Anterior pelvic tilt- arent going to like compression b/c they live
there
Posterior pelvic tilt- curve reduced, live in flexion so they cant
control that
o Who might be limiting ability to get out of flexion
o With posterior pelvic tilt- likely have mobility deficits and
stiffness in hamstrings
o How do they move? Likely have weakness in spinal
extensors
o Poor postural control? Poor somatosensory?
o Are they not moving because they have difficulty with
muscle strength?
Make them move- 2 body regions
 Always start with lumbar spine and hip- don't have to screen
immediately after screening lumbar spine but it needs to be
there- regional chain interdependence
If pain is T9 and below
AROM- given on practical
PROM
o Flexion- peripheralizationtemporal summation
o Extension- limited by many things
Stretch on anterior structures
Compression of posterior structures
Joint compression
Herniated disc in the way
o Flexion is way more helpful
o SB should not provoke s/s theoretically
not a lot of stress on anterior or posterior structures
not a lot of rotation so not compressing
least aggravated position
only exception to this is a disc bulge compressing on
a nerve root or narrowing foramen pressing on nerve
if it's a lateral bulge, patient will SB away from
side of pain
if it's a medial bulge- patient will SB towards
side of pain
most helpful to identify bulge placement relationship
if have a lot of pain in SB that is not nerve
painconfusing and start to wonder if summation
issue or processing disorder (didn't point towards one
tissue)- yellow flags?
o Rotation
Most stress in L spine on facet- direct compression
Narrowing foramen some but not that much
Narrow foramen more in extension or SB or
combo of Extension and SB
Nerve pain don't get them here
If it hurts on R and rotate to L- points towards
stretching capsule
If it hurts on R and rotate to R- points towards
compression
o Neural screen- must do it
Is nervous system compromised and signs of compression?
Is nervous system irritable and contributing to pain?
must test both phenomenon requiring 2 different types of testing to
always include
How irritable? Nerve provocation tests
o Can reproduce pain but not be their pain
Clinically meaningful but not to hypothesis but gives
insight to the state of irritability of nervous system
Points to signs of processing dysfunction
 o When writing in an assessment write
with signs of neurodynamic irritability
How compromised
o Slump test- puts max tension on nervous system- will tell
you if nerve doesn't like to be stretched
o Will not always tell me if nerve is compressed
Conditions where nerve can be compressed but not
necessarily irritable to stretch
Adherent nerve root sign
Lateral stenosis
o Difference in slump and SLR is position of spine
o In thoracic spine- modified slump
o Femoral nerve- femoral slump
If only have pain in posterior thigh, then can skip
femoral slump
o Motor screen, sensory, DTR, pathological reflexes
If can tie to level of spine, then compression is in the spine
If tie it to peripheral nerve, then compression is outside the spine
DTR- can tell me about compression and irritability
Hyperreflexic- irritable
Hyporeflexic- compressed
L4- hybrid between femoral and sciatic
S1- sciatic
Sensation- lose sensory then follows motor- L5 and S1 are most
common trapped nerve
Know which muscles tie back to those
o Check mobility of the spine
Tells you where the pain is coming from
If pain is between 4 and 5 and had positive slump test- your disc is
between 4 and 5
If hypomobile at 2/3; painful wiggly at 4/5 your pain generating
segment is hypermobile segment but treat hypomobile segment to
reduce stress on hypermobile segment
Painful segment can be hyper or hypomobile
If painful segment is hypermobile- joint inflammation or disc
irritation that can be EDD (slump) or IDD (localized)- wiggle too
much
If segment is hypermobile- usually motor control problem
contributing to that
A lot of times there is a segment above or below that is stiff
Stiffness might be hamstring or disc or higher in lumbar spine
PPIVM- tells me whats stiff and whats not
PAIVM- tell me who hurts and whats stiff
One test to tell me if it moves to much it's a facet
Pure axial segmental rotation
Not pushing on TPs but trying to spin the actual segment
There should be 2 of motion-but not palpable
 Pts who are stiff at painful segment- most of the time they arent
moving enough- not enough space, overcompressed by muscle or joint
by just not having enough room
They don't like extension
o Direction- It may not open or it may not close
If joint wont close (extension) on R it is stuck in flexion and
that's where you see flexed, SB, rotation restriction
How do you find a joint that wont close?
Either there is a loss of extension or rotation
What if I am not sure if pain is coming from L4/L5 or SIJ
How do you rule our SIJ- pain provocation tests (at least 3
positive)?
Positional faults- forward flexion in sitting and palpation
Active SLR or prone knee bend with compression to see if there is
o Excessive compression
o Insufficient compression
It is possible that pain is coming from stiffness in SIJ
o How to find stiffness in SIJ
Grade 2 mob or quick flick
When doing segmental mobility testing
Almost always do a quick screen of SIJ just like
you would screen hip when pain generator is
clearly in L-spine
What would make you think hip?
Pain with squatting and hip motion- flexion and extension, or IR
and ER
o If I reproduce their pain with PROM of hip flexion, then the
hip is involved
o If I don't reproduce pain, then must bring in all hip tests but
can forget about all SIJ tests
If it hurts with IR and its groin pain and its their
groin pain- think impingement
o Intra-articular (arthritis, labral tear, facet joint synovitis due
to FAI- labral tear tests, Slam and grind joint tests (scour
circumduction), impingement tests (anterior, posterior)
o how do you rule our structural problems of the hip with
intra-articular?
Craigs test- femoral torsion
loss of IR will point you back to the hip
Extra-articular (outside hip)
o glut med tear
o piriformis syndrome- tight ER squeeze sciatic nerve-
resisted ABD with hip in ADD (stretch it then
compress it)
o iliopsoas- aggravation of hip flexor that could be involved
with labral tear
o adductor strain
o how do you tease out the muscle? by contracting it
 how do you tease out adductor vs pubic symphysis?
contract at 90, 45 (pubic shotgun) and 0 hip
flexion
if it hurts in all 3 positions its usually the
muscle