1. All of the scanning exams. a. Why do we do scanning exams?

a. What is the purpose of each and every test in all of the scans?
i. Screen for serious pathology
ii. Asses status of neurological system
iii. Identify areas that need further biomechanical examination
1. AROM is the most important test. Testing Neuro-Muscular
Skeletal against gravity
2. Asses for:
a. Serious pathology (Cardinal plane no combined
motion)
i. Orthopedic pathologies
1. Fractures
2. Major muscle injuries
3. Acute joint injuries.
b. Once has been identify PIVM are performed.
c. Less serious pathologies or chronic (combined
motions, or special test performed)
AROM
Response if +
Flexion Site and behavior:
1. does the motion brings leg pain
2. Is the existing pain remains the same?
3. a normal spine at the end of lumbar flexion the lower three
segments should appear to be fixed lordosis.

Acute posterior lateral protrusion disc

History Observation Response to ROM testing
1. Felt something o back 4. Lateral shift Flexion: Limited with
2. Immediate pain and then not away from Increased leg pain
much painful side Contralateral deviation
Lumbar scan

3. Next day 5. Flattened ↑ dural stretch

 Worse back pain lumbar lordosis Sudden ↑LBP
Extension

 Appearance of leg pain If leg pain= bad

 Hurts to sit, bend, Inflammation sensitive to pressure

SideB Ipsi = ↑LBP

Contra= ↑leg pain
Rot Hard to sit
Unpredictable
 Acute posteriomedial disc protrusion
History Observation Response to ROM testing
 Similar to posterior  Ipsilateral shift Flexion Limited
 Flattened lordosis Reproduction Ipsi leg pain
Lumbar scan

Ipsi deviation
Extension Limited
↑ LBP
SB Ipsi= limited reproduces
leg pain
Contra= limited and may
produce LBP and leg pain.
Rotation Inconsistet results.

Acute Central disc Protrusion

History Observation Response to ROM testing
 Bilateral leg pain  Flatten lordosis Flexion Severely limited
 Numbness/ paraesthesia’s  No shift Reproduction LBP quickly
Lumbar scan

 Flexion or rotation Reproduction of leg pain quick

Extension Very limited
Reproduces Severe LBP
If ↑ leg pain = poor prognosis
SB Usually no pain
May be limited to muscle spasm
** Differential diagnosis **
Rotation May not be able to test in sitting
Incosistent results.
 Instability
History Observation Response to ROM testing
Previous Hx of trauma No shift Flexion WNL ROM
Long hx of LBP ↑ Lordosis or not Not painful
Double jointed (congenital) Non consistent findings. Gowers Sing
C/O giving out minimal activity Extension Acute:
May have Chiro. success.  Inability to do it
Pain ↑ with Extension SubAcute:
Hurts supine with legs straight  Can do it ↓ROM
Lumbar scan

May complaint of leg pain may  Often ↑ LBP (ante shearing

be somatic mechanism of incompetent)
Causes SDB -Typically unrestricted
-Clinically important ( rules out
extension loss) biomechanics of
lumbar facet motion.
-May reproduce pain wit Con-SB
 Contribution iliolumbar
ligament
 L5S1 Sbing coupled with
piriformis
Trauma Rotation -Sitting will tighten up TFL
Connective tissue disorders -Facets and neural arches resist
Heredity -Typically not painful except in
Eher’s Dannos severe degeneration.
 Z joint Arthritis
History Observation Response to ROM testing (if degenerative)
Flexion Not much restricted depending on
Lumbar scan

the level of injury

Extension The most painful
Restricted
Possible causes Sbing Ipsilateral restriction and pain.
-Pain is not Isolated. Rotation Ipsilateral restriction and pain.
-Capsular pattern;
EX/Rot/Sding affected side.
Radicular= if Nerve root injured

Lateral Stenosis
History Observation Response to ROM testing
-Older patients -May attempt to hold Flexion  Usually loss ROM
Lumbar scan

-LBP/leg pain ↑ activity back in flexed position  Relieves pain

-Activity in stooped position -If severe, could develop  May Gower sing/depends
-Hurts lie in supine contralateral shift etiology.
-Resemble instability found in Extension  May/may not reproduce pain
younger population. time dependent
Sbing  Ipsi Sbind if sustain ↑ leg pain
Rotation  Since is performed in sitting
pain free.

Central Stenosis
Scan
Lumbar

 Most compelling findings is the presence of cauda equine or cord S&S

 Patter of AROM will reflect primary causative agent.
 Possible bilateral loss sensory, motor, reflex.
 Iliolumbar ligament
Lumbar Scanning

History /Patophysiology function / History Response to ROM Testing

Attaches to L5 Sacrum Stabilizer of Flexion 
Several parts lumbrosacral junction;
Extension  Taught
 Tip of anterior inferior prevents shearing of L5
aspect of L5 TP on S1 Rotation 
 Runs laterally and splits in SBing  Becomes taught with
two bands Hx: contralateral Sbing
o Lower band: across 1. Can become
and anterior SI Jt involved with a
ligament to reach problem affecting
posterior marging of L5/S1
iliac fossa. 2. L2 innervation can
o Upper band: QL produce concurrent
attach, passes iliac somatic anterior
crest, anterior to SI thigh pain and groin
joint is continous pain.
with TFL

Lumbar stress test

Test Rationale
Compression Damage to vertebral body, end-plate or
overload Test disc will create and inflammatory reaction. a positive test and indicates damage to the
The resultant paint will be aggravated by
any intra-vertebral or intra discal
pressure. (Not done with NO trauma
patients, or three months chronic pain)
Torsion Test Torsion is resisted by annular fibers of the Reproduction of pain with 1 phase (Lower
disc and therefore, also by their
attachment to the end-plate.
Torsion is also resisted by Z-joints and
therefore also the neural arches between
them.
Test is designed for acute pathologies.
Fractured neural arch, unlike the
compression test this test may be used to
assess even very chronic pathologies due
to mechanical pain.
P/A shearing 1) First a rapid PA
Test 2) Then a slow PA
a) Reproduction of pain + soft end
feel indicates possibility of
segmental PA instability.
Response/ and results
Reproduction of the reported pain constitutes
vertebral body, end-plate disc.
*If test is negative then we can start flexion
exercises.
Thoracic and opposite innominate) then
segmental testing.
1. Unilateral positive:
a. Possibility of a fracture through
Z-joint (compression)
b. Or Traumatic arthritis
c. In chronic dysfunction a positive
result = Segmental instability
2. Bilateral positive: pain in both
directions indicates the possibility of :
a. Acute disc-end plate lesion
b. Or a fracture neural arch
Reproduction of patient’s pain with initial,
rapid PA thrust indicates:
1. Possibility of an acute segmental
dysfunction
2. Or irritable segmental dysfunction
A slow PA will reproduce more pain.
 Response/ Nerve root Peripheral Spinal cord Cauda
Test Equina
Pain Constant intense Intermittent milder Constant Intense Constant intense
Segmental Segmental Muti-segmental Multi-segmental Multi-segmental

SSeennssoorryy
Multi-segmental Match 1 peripheral N.

Paresthesia Big Small Huge Huge

Segmental Multi-segmental Multi-segmental Multi-segmental
Area Match 1-peripheral N.
Numbness Small. (overlap) Big Huge Huge
Have to look at the Distal distribution of Multi-segmental Multi-segemental
distal portion of the the peripheral area.
root problem.
(dermatome)
Key muscles affected Muscles distal to Spasticity Flaccid, fatiguing
Motor injury site that are More than 3 weakness,
innervated by the beats when Multi-segmental

Motor
peripheral nerve testing SCI
Reflex Hyporeflexia Hyporeflexive Spastic or Clonus Hypo-Areflexic
Areflexic Areflexic Hypereflexia
Bowell and Bowel and
Other bladder retention bladder
incontinence
 Paraesthesia
AREA Possible cause
Total lower quadrant Might indicate central stenosis
Quadrilateral parathesia Specially aggravated by neck flexion indicates
cervical cord compression
Contra-lateral head and limb paraesthesia Cerebral stroke
Diffuse, No-segmental, Non-cerebral, Non- Multiple Sclerosis.
mechanically-irritated paraesthesia
Structure affected Manifestation of behavior.
Arterial Occlusion  Felt over a large area
 Unilateral
 Multi-segmental
 Intense pricking brought with movement
Nerve Root Compression  Felt over a large area
 Will be identifiable
 Dermatomal distribution (will be more painful
tingling sensation, longer periods of time.
 Constant tingling needles with dermatome
distribution without necessarily becoming
numb= Pressure on a NERVE ROOT
Peripheral Nerve Root Compression  Felt over a small area
 Will be identifiable (segemental)
 Peripheral distribution
 Low intensity tingling (rapidly proceeded by
numbness)
 Non painful (unless neuritis is involved) short
lived (minutes to hours) rapid progresses to
numbness
 Bilateral, constant tingling in the “glove and
sock” distribution, with or without numbness ==
Peripheral neuropathy
Dietary insufficiency  Over massive areas
o Both arms and legs.
o Even trunk.
RSD or Nerve Root Traction  Non segmental
o Segmental
o Or multisegmental
 Sliding Tension Protective
Distal tension makes pain decreased Distal tension makes pain Distal tension makes Pain increased
Description
General

Full ROM increased full ROM at joints ROM at joints limited muscle tension.
ROM limitations exist only by
pain, may have full PROM

1. c/o aches and pain at site along 1. Aches and pain 1. Altered muscle dysfunction occurs in
Symptoms

course of nerve 2. Possible paresthesia a pattern that protects a specific neural

2. Sx distance related with time
tethering
3. If not inflamed sx intermittent
4. Sx reproduction when move through
it’s full ROM
3. Impairment of sensation structure.
4. May be intermittent
5. only occur when nerve is
tensioned or has a sustain
posture that tension the
nerve

1. Hx possible interface dysfunction 1. Stretching out brings the

History

2. repetitive motion with terminal ROM patient symptoms.

3. Use it, it gets worse,
4. Rest improves

1. Confusing 1. AROM & PROM loss ROM 1. Will ↑muscular resistance to motion
findings
Physical

2. Additional tension component may when nerve under tension 2. Need test Nuero
relief pain Proximal ON= distal OFF = ↑ Sx 3. Muscular resistance
Proximal ON= Distal ON = Sx worse
ON = ON = Reduce pain Proximal OFF= Distal ON = ↑Sx.
ON= ON may ↑ Sx.
ON = OFF = may ↑ Sx
 Neruodynamic Testing of the lumbar Scan
Test:
1. Taking up the slack 0-35°
2. Assessing ability of neural tissue to glide 30°-60°
3. The remaining motion is tensioning: nerves, and articular and
myofascial elements.
If suspect hx of inflammatory process is best to start with SLR rather than
Slump T.
Response:
1. If sx are produced within the expected ROM the key is to reproduce
SLR

and decreased symptoms with Foot/Ankle (distal component) and

Head/ Neck(proximal component)
2. Test done over the other leg. If Symptoms are reproduced on
contralateral leg and reproduces LBP and/or Ipsilateral leg symptoms
== BAD PROGNOSIS == sure large disc injury.
3. If both are negative then repeat with both legs at the same time ==
Sign of central disc lesion.
4. If negative to this but positive to Slump test == disc lesion sensitive to
WB compression.
5. Sitting position: WB causes disc to protrude enough to cause
symptoms.
6. Supine position body weight relieved the protrusion is no longer
enough to produce sx.
Slump If pt c/o sounds like radicular pn but SLR didn’t reproduce sx perform the
Slump T.
Prone 1. Test nerve roots from L1-L4.
Knee a. Note commonality of L4 in both SLR and Slump test and PKB
Bending test
Passive  Consider a very sensitive test if reproduces pain in the LB or in the legs
Neck o CLASSIC MENINGITIS
Flexion

SIJ RISK GROUP

1. Ankylosis Spondylitis == usually starts c/o pain in the SIJ. (late teens)
2. Hypermobility Syndrome ==
a. Ehler’s Danloss Syndrome
b. Marfan’s syndrome
c. Generalized hypermoblity (womens)
3. Pregnancy
4. Specific trauma
5. Chronic loss of hip motion
6. Chronic LBP problem
Key Muscles Associated with Assessing Nerve Root Function
Upper limbs nerve root key muscle alternative
C4 diaphragm levator scapulae
C5 supraspinatus infraspinatus
C6 biceps extensors of wrist
C7 triceps flexors of wrist
C8 extensor pollicis longus opponens pollicis
T1 medial two palmar
interossei
Lower limbs nerve root key muscle alternative
L2 psoas major
L3 quadriceps hip adductors
L4 tibialis anterior may affect quadricps
L5 extensor hallucis longus hip abduction
L5 & S1 peroneals EDL
S1 hamstrings, gastrocnemius FHL, FDL
S2 gluteus maximus hamstrings, FDL, FHL

Dermatomes

Although it is well accepted that there is not one absolutely correct dermatome chart, for testing
purposes, we need to all be thinking the same thing. So for testing purposes, please use this
dermatome chart.

Cervical

C1-2: Scalp. Central portion of anterior and posterior neck side of head, upper half of ear, cheek and
upper lip.
C3: Entire neck. Lower mandible, chin, and lower half of the ear.

C4: Top of shoulder, front of chest including pectoral region, and lower half of neck.

C5: Shoulder, front of the arm, and forearm to base of thumb.

C6: Lateral arm and forearm, thumb, and index finger.

C7: Back of the arm and forearm, INDEX, LONG, and RING finger; primary supply of tip of middle finger

C8: Inner, medial forearm, inner half of the hand, LONG, RING, and LITTLE fingers.
T1: Inner side of forearm as far as the wrist

T2: A ‘Y’ shaped area stretching from the inner conovle of the humerus at the elbow, up to the arm and
dividing into two areas reaching to the sternum anteriorly and the vertebral border of the scapula
posteriorly.

T3: Area on front of chest and patch in axilla.

T4

T5 >Around trunk to level of nipple.

T6

T7-9: Around trunk to lower costal margin

T9

T10 >Around trunk to lower costal margin

T11

T12: Probably to groin and area between iliac crest and greater trochanter.

L1: Lower abdomen and groin: skin at L2-4, and upper and outer aspect of buttock.
L2: Lower lumbar and upper buttock: medial thigh.
L3: Upper buttock: anterior and slightly medial aspect of thigh , knee and leg to medial malleolus.

L4: Outer thigh and leg crossing to the medial border of the ankle and foot including the BIG TOE.
L5: Outer aspect of the leg, the top of the foot, the FIRST, SECOND, and THIRD TOES, inner half of the SOLE of the
foot.

S1: The lower half of the posterior aspect of the leg and ankle, the outer half of the SOLE of the foot and the LAST
TWO TOES.

S2. Back of the thigh and leg, back of the heel and the planter aspect of the heel. Some books show S2 as not
going to the heel saying that S1 does the entire heel.
S3: Area around the anus, strip following the inguinal ligament, and inner thigh to the knee.

S4: Saddle area, anus, perineum, scrotum, and penis. Vagina and labium, and inner most thigh.
 UPPER QUADRANT
SENSORY INNERVATION
AREA SEGMENTAL PERIPHERAL
Ear and over jaw C2 Greater auricular
Lateral neck C3 Transverse cutaneous
Upper traps to skin over upper chest C4 Supra-clavicular
Lateral arm C5 Upper-Axillary
Lower- Radial
Posterior Arm C5 Radial
Posterior-lateral hand C6 Radial
Over 1st interosseous
Posterior forearm C7 Radial
Lateral forearm C6 Musculo-Cutaneous
Antero-lateral hand including 3 ½ digits and finger tips C6 Median
Lateral palm and palmar surface of middle 3 ½ digits C7 Median
Anterior and posterior lateral hand including med 2 digits C8 Ulnar
Medial arm T1 Medial cutaneous of arm
Medial forearm C8 Medial cutaneous of f-arm
Axilla (arm pit) T2 Costo-brachial (APR T2)
 Upper Quadrant MOTOR
Anterior C/V flexors C1+2 APR
Diaphragm C3+4 Phrenic
Levator Scap C3+4 Dorsal Scapular
Supraspinatus and Infraspinatus C5 Suprascapular
Deltoid C5 Axillary
Biceps (long head) Brachialis, Coraco-brachialis C6 Musculocutaneous
Supinator C6 Radial
Brachioradialis C6 Radial
Wriste extensors C6 Radial
Triceps (long head) C7 Radial
Extensor pollicis longus and Abductor pollicis longus C8 Radial
Flexor Carpi Ulnaris C8 Ulnar
3rd and 4th interrossei T1 Ulnar

LOWER QUADRANT
SENSORY INNVERVATION
AREA SEGMENTAL PERIPHERAL
Upper medial thigh L2 Obturator
Lower medial thigh and medial knee L3 Medial femoral cutaneous (femoral)
Anterior thigh L3 Intermediate femoral cut (Femoral)
Lateral thigh L4 predom Lateral cutaneous (plexus)
Posterior thigh S2 Posterior cutaneous (plexus)
Medial knee and calf L3 Saphanous ( Femoral )
Medial side of foot up to but not including hallux L4 Saphenous (Femoral)
Anterior and lateral calf L4+5 Superficial Peroneal (Common P.)
Hallux L4 Superfical Peroneal (Common P. )
Dorsum of foot and Middle 3 toes L5 Superfical Peroneal (Common P.)
Web space between halluz and 2nd toe L4 (?L5) Deep Peroneal (Common P.)
Posterior lateral calf S1 Sural (Tibial)
Lateral foot and 5th toe S1 Sural (Tibial)
Medial sole over 1st MTP joint L4 Medial plantar calcaneal (Tibial)
Medial sole excluding 1st MTP joint L5 Medial plantar calcaneal (Tibial)
Lateral sole S1 Lateral Plantar Calcaneal
Heel S2 Tibial.
 LOWER QUADRANT
MOTOR INNVERVATION
AREA SEGMENTAL PERIPHERAL
Psoas L2 APR L2,L3+L4
Iliacus L2 Femoral
Quadriceps L3 Femoral
Adductors L3 Obturator
Tibialis Anterior L4 Deep Peroneal (Common P.)
Extensor Hallucis L5 Deep Peroneal (Common P.)
Evertors L5+S1 Superficial Peroneal (Common P.
Ankle Plantarflexors S1 Tibial
Hamstrings S1+S2 Sciatic
Hip abductors L5 Superior Gluteal
Gluteus Maximus S2 Inferior Gluteal

Mid range testing Best indicator of muscle stain

Shortened Position Muscle will contract mechanically in disadvantage firing
from 60-80%
Resistance Testing

Best indicator for Neural Conductivity.

Lengthened position Best indicator of
Connective tissue in the
fascia of the muscle,
contractile lesion.
1 degree more than likely
pain will be given by the
fascia
2 degree: just put those
muscle fibers in this
position will give patients
pain.
3 Degree: Complete
rupture.

Strong Painful Moderate/ Severe grade II, muscle tendon

4-5/5 Fracture Pain ↑ compression
Multiple planes of joint pain
Pain ↑ vibration
Total splinting of motion
Weak Painless Grade II mm tear
3+↓/5 Fatiguing weak Motor palsy