By Julie Kramer & Amanda Schram
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Table of Contents
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Postural Exam[1]
Observe the patient in standing. Check for postural deviations, look for whether the patient is leaning to one side, and note the curvatures of the spine in the sagittal and frontal planes. Common postural deviations such as excessive lumbar lordosis, flat back, and sway back may be observed in patients with lumbar pathologies. Excessive lumbar lordosis is when the concave curve of the low back is greater than normal, and the pelvis is anteriorly tilted. Flat back is when the concave curve of the low back is either diminished or completely flat, and the pelvis is posteriorly tilted. Sway back is characterized by increased lordosis due to posterior positioning of the thoracic spine and the pelvis displacing anteriorly, along with a posterior pelvic tilt.
To determine whether the pelvis is anteriorly or posteriorly tilted, you must bilaterally palpate the ASIS’s, PSIS’s, and pubic tubercles. In normal pelvic alignment, the ASIS and PSIS should be level horizontally, and the ASIS and pubic tubercles should be level vertically when viewed from the side. Additionally, the ASIS’s should be viewed anteriorly for levelness from one side to the other. Observing the ASIS positioning in these two different views will help to identify a variety of alignment concerns. If one ASIS appears higher than the other, the patient may have a leg-length discrepancy, an innominate upslip, or an innominate rotation. These conditions may be related to the patient’s lower back complaints, and thus should be noted in the exam.
Leg positioning also needs to be observed while the patient is in standing. Assess for femoral ante- and retro-version, tibial rotation, recurvatum, patellar position, pes planus, and pes cavus. Lower extremity alignment may contribute to low back pain in certain cases, or could lead to lumbar malalignment.
The final postural assessment for lumbar spine pathologies is observing the patient’s adapted sitting posture. Take note of what is comfortable for them. The adapted sitting posture could be a contributing factor to the patient’s symptoms, and therefore should be discussed with the patient so they are educated on how to prevent future lumbar problems.
Gait Evaluation
Observe the patient as they walk from the waiting room to the treatment area so they are not conscious of being observed. When evaluating gait look for swaying, leaning, Trendelenburg, hip hiking, hip rotation, steppage gait, and any other abnormalities that may be present. Gait deviations can be indicative of muscle tightness, muscle weakness, limb asymmetry, and/or pain.
Clearing Joints
When a patient presents with a pathology, the joints above and below the area of symptoms need to be checked for referral into the affected area; this process is called clearing the joints. In a patient with a lumbar pathology, symptoms could be local to the back or they could refer down the leg, therefore the joints that need to be cleared will vary from case to case. Instructions for clearing the joints related to lumbar pathologies are below. If the patient’s comparable sign is not elicited during any of the following tests, then the joints are clear and the problem is most likely local to the lumbar spine. The accompanying videos will help provide further instruction for joint clearing techniques.
Thoracic Spine
The thoracic spine is cleared with motions that are similar to the motions of the lumbar spine; these include flexion, extension, rotation, and lateral flexion. The patient is seated for thoracic clearing; if the active motion does not produce pain then overpressure should be applied. The video below demonstrates thoracic range of motion testing and should be viewed for information regarding proper positioning and hand placement.
Sacroiliac Joint (SIJ)
The SIJ can be cleared with compression and distraction techniques while the patient is lying supine. Compression is performed by placing the base of the hands over the medial portions of the patient’s ASIS’s, leaning directly over the patient, and pushing the hands outward. For distraction, place the heels of the hands on the lateral portion of the ASIS’s with the fingers extending down around the ilium and provide a medially directed force with your hands.
Hip
The hip is cleared in a progressive fashion, starting with hip flexion. Have the patient in supine and passively flex their hip by supporting the distal femur and lower leg with one arm and placing the other hand on the iliac crest. Since the goal of this test is to clear just the hip, pelvic rotation needs to be avoided so symptoms are only provoked by isolated hip movements. Therefore, the fingers of the hand on the iliac crest should extend back to the PSIS in order to feel for pelvic rotation during passive hip flexion. If no symptoms are felt with flexion, the hip should be brought out of full flexion to a 90/90 angle at the hip and knee, then internally rotated by moving the lower leg laterally and maintaining the femur perpendicular to the plinth. If this is tolerated, a combined flexion with adduction movement should be used by wrapping both hands around the knee and taking the hip through the motion. If there are still no symptoms, add internal rotation to the already flexed and adducted hip. Finally, if no comparable sign has been reproduced, add joint compression to the flexed, adducted, and internally rotated hip by directing your force down through the shaft of the femur with the hands cupped over the knee. If symptoms are reproduced with any of these progressions, the testing does not need to continue any further.
Knee
If symptoms are present past the gluteal fold, then it is necessary to clear the knee. This can be done by applying overpressure to a maximally flexed knee, followed by overpressure on a maximally extended knee.
Ankle
If symptoms are distal to the knee, then the ankle must be cleared. Clearing this joint requires the patient to be lying prone with the knee flexed. The examiner provides a quick flick of the ankle into dorsiflexion and plantarflexion, then finishes by turning it into inversion.
Range of Motion Testing
Range of motion (ROM) testing is useful in determining what the cause of a patient’s pain is. When testing, active ROM should be completed prior to passive range or adding overpressure. In the lumbar spine, ROM includes flexion, extension, lateral flexion, and rotation, each of which is described below and demonstrated in the video at the end of this section. Normal values for lumbar ROM are in the table below and should be observed throughout the process of assessing these movements as well.[2]
| Motion | Normal Values |
|---|---|
| Flexion | 40-60o |
| Extension | 20-25o |
| Lateral Flexion | 15-35o |
| Rotation | 5-20o |
Flexion
With the patient standing, ask the patient to move into flexion by bending forward as if trying to touch his/her feet. Then have them return to neutral. If pain was elicited with this motion, then overpressure is not needed. If the comparable sign was not reproduced, have the patient move into flexion again. Once in this position, the physical therapist should provide overpressure by placing one forearm across the sacrum/posterior pelvis, the other on the upper thoracic spine and push their arms together as if trying to “bowstring” the low back.
Extension
Have the patient move into extension by sliding their hands down the back of their thighs, and then return to neutral. If pain was not elicited, have the patient perform the motion again and provide overpressure. To do this, place your thumb and index finger on the sacrum pushing forward, place your other forearm across the patient’s upper chest and shoulders pushing backward. As you apply overpressure, make sure to position your head behind the patient’s upper back and head to lend support. When moving out of this position, be sure to assist the patient with balance and support by sliding the hand that was pushing on the sacrum up the patient’s back as they return to an upright posture.
Lateral Flexion
Have the patient lean to the right, then return to upright standing. If there is no pain, have the patient sidebend again and apply overpressure by placing one hand over the top of the right shoulder and the other over the side of the left shoulder. Overpressure is applied to the shoulders as if turning a steering wheel. When providing overpressure, one leg can be positioned on the lateral side of the patient’s left hip to prevent the hips from shifting, but this is not always necessary; this will help to isolate side flexion to the spinal segments, as well as help the patient to feel supported. Repeat these procedures for left sidebending.
Rotation
Have the patient seated on a plinth or stable chair, with feet flat on the floor and arms crossed over the chest. The patient should rotate to the right and come back to neutral. If there was no pain, have the patient go through the motion again and this time overpressure must be given at the end range. Overpressure can be given by placing one hand around the proximal humerus of each shoulder and pushing posteriorly on the right while pulling anteriorly on the left for a resultant rotary motion. Repeat these procedures for left rotation.
Lumbar Quadrant[2]
If the patient’s comparable sign was not elicited in flexion, extension, lateral flexion, or rotation, the examiner needs to try the quadrant test. The quadrant test is a combination movement that consists of 3 separate motions: extension, side-bending, and rotation. The patient may actively assist the practitioner with this test, but since it is not a common movement that is easily described, it may be easier to passively move the patient through each motion. For a left quadrant test, place one leg on the lateral side of the patient’s right leg to provide stability. With one hand on each of the patient’s shoulders, move the patient into extension. When the end of extension range has been reached, left sidebend the patient while maintaining lumbar extension. Once the patient is extended and sidebent, rotate them to the left as well, providing a little pressure at the end range. If the patient’s symptoms are reproduced at any point during this test, the test should be ended at that point and not continued any further. Repeat these steps for the right quadrant.
Palpation[3]
When palpating the lumbar spine, the patient should be lying prone on a plinth, with a pillow under the lower legs for comfort. Palpation is used to assess mobility of the vertebrae by finding the resistance points of each joint; resistance 1 (R1) is where the examiner begins to feel resistance, while R2 is the end of the range. It is also used to assess for pain (P1 is where the patient begins to feel their pain) and reproduce the comparable sign.
First, feel for heat and look for visible signs of inflammation such as redness or swelling. Next, palpate the spinous processes and facet joints of the L1-L5 vertebrae. To ensure you are palpating the correct spinal levels, first palpate the PSIS and move inferior into the sulcus. Once this is found, move your fingers toward the spine, and you should be on the spinous process of S2. From there, move superiorly to S1 then L5. A quick assessment of whether you are on L5 is to have the patient perform an anterior pelvic tilt while you continue to palpate the spinous process. If the bony prominence disappears, you are on L5. Continue superiorly to palpate the remaining lumbar spinous processes. Finish palpation by feeling for the facet joints bilaterally. To locate the facets, go to the interspinous space between each lumbar spinous process and move laterally, approximately one finger width. Start between L5 and S1 for the L5 facet, then move superiorly to L4/L5 for the L4 facet and continue through the rest of the lumbar facet joints up to L1/L2 for the L1 facet.
Following palpation, perform a “sweep of 2s” on L1-L5 both centrally (on the spinous process) and unilaterally (on the facet joints). The “sweep of 2s” is a series of 2-3 oscillations of grade 2 posterior-anterior (PA) pressures on each of the lumbar segments. When going through the sweep of 2’s, you are looking for the patient’s comparable sign. If it is not reproduced with grade 2 pressures, move to grades 3, then 4 as tolerated. Grade 2 pressures are given as a large amplitude oscillation taking up slack in the joint and stopping just before R1 is felt. Grade 3 is also large amplitude, but pushes further in the joint range, oscillating from R1 halfway to R2. Grade 4 is a small amplitude oscillation that is performed at the end joint range to R2.
Central PAs are performed by placing the base of the hypothenar eminence directly over the spinous process with the hand perpendicular to the patient. The other hand is placed horizontally on the base hand to translate the downward force from the therapist's body. Unilateral PAs are performed with the thumbs directly over the facet joints; the distal phalanx of each thumb should be “back-to-back” supporting each other for stability during the pressure. Unilateral PAs should be performed on the unaffected side first, followed by the affected side; if both sides are painful, start with the less symptomatic side. Refer to the accompanying video for clarification on hand positioning for these two types of pressures.
Special Tests
Special tests for the lumbar spine include dermatomes, myotomes, reflexes, upper motor neuron testing, and neural tension testing. While neural tension testing should be performed in all patients presenting with lumbar pathologies, the other special tests are only used in certain situations. The dermatome, myotome, and reflex testing collectively are called the neurological screen. The objective exam only needs to include a neuro screen if the patient is complaining of symptoms below the gluteal fold of the buttock. Patients with symptoms below the gluteal fold can present with just pain down the leg, numbness and/or tingling down the leg, or a combination of these symptoms. When there are no sensory symptoms present, the dermatome test can be omitted from the neuro screen.
Dermatomes
The dermatomes that are evaluated in patients with lumbar pathologies are L1-S2, for the purpose of evaluating sensory integrity. When a nerve root is irritated and it is causing numbness or tingling down the leg, the symptoms are typically the strongest in the distal-most portion of the dermatome; therefore, when checking sensation, the distal-most portion of the L1-S2 dermatomes should be tested. To conduct dermatome testing, the tip of a paper clip can be used to create the sensation, which should be a light poking of the object on the skin as if drawing a dotted line across the dermatome. It is a good idea to allow the patient to feel the sensation on their hand prior to conducting the test so they will know what they should be feeling, and so they will know it will not hurt them. Additionally, the unaffected limb should always be tested first so the patient can compare the sensations from one limb to the other; with dermatomes, this requires testing the first area on the uninvolved side, then the same area on the involved side, then move to the second area on the good side and so on, alternating between legs. If a level is deficient, the patient will present with decreased sensation in that dermatomal pattern. If no deficiency is identified, it can be assumed that the sensory portion of the lumbar nerve roots is unaffected. Procedures for testing each of the dermatomes for L1-S2 are described below; please also reference the accompanying picture for specific locations of each segment.
http://www.backpain-guide.com/Chapter_Fig_folders/Ch06_Path_Folder/Ch06_Images/06-4%20Radiculopathy.jpg
- L1: the paper clip should be dotted in a diagonal line along the uppermost thigh, in the groin area, moving from superior lateral to inferior medial
- L2: dot a diagonal line from superior lateral, to inferior medial along the middle of the thigh
- L3: dot a line along the medial knee
- L4: trace a dotted line along the medial ankle, just superior to the medial malleolus
- L5: make a small dotted line on the dorsum of the great toe, from the metatarsal head to the nail bed
- S1: dot a line along the lateral portion of the foot
- S2: dot small line on the medial side of the heel
Myotomes
To ensure that muscle strength is unaffected, a myotome screen of L2-S2 spinal levels should be performed. Testing S1 should be done in standing. To begin, the patient should stand on the uninvolved lower extremity and perform ten heel raises. You must observe the quality of the movement, and whether the patient loses strength throughout the repetitions. This process is repeated while standing on the involved leg. Once S1 myotome testing has been completed, instruct the patient to lie supine on the plinth to test the remaining myotomes. With each of the following, you can perform a break test, where you place the joint in the desired position and tell the patient to “hold here, don’t let me move you,” as you apply force gradually. To assess the L2 myotome, the patient resists hip flexion. Moving to L3, knee extension strength is measured. Resisted dorsiflexion tests the L4 myotome. MTP extension of the first digit assesses L5, and finally, curling the toes into flexion tests the S2 myotome. If the patient has motor nerve root involvement, they will show weakness during testing of the affected level, otherwise, the motor portions of the nerve roots can be assumed to be uninvolved with the patient's pathology. The myotome screen is demonstrated in the following video.
Reflexes[4]
Reflex testing assesses the integrity of the spinal nerve roots. For patients with lumbar pathologies, the patellar and Achilles tendon reflexes must be examined. Proper technique includes using a reflex hammer to elicit the desired response and tapping the specific tendon 5-6 times. The motor response should remain the same with each consecutive tap on the tendon. Diminishing responses could indicate early stages of nerve root involvement. The grading scale for reflexes can be viewed in the table below.
| Grade | Response |
|---|---|
| 0 | Absent |
| 1 | Diminished |
| 2 | Normal/Average |
| 3 | Exaggerated |
| 4 | Clonus, very brisk |
- Patellar Tendon Reflex: The patellar tendon reflex assesses L2 and L3 nerve roots and should trigger a quick contraction of the quadriceps. The patient should be supine with the knee bent and the leg supported under the distal thigh by the therapist. The examiner then palpates just below the patella to locate the tendon and proceeds to tap on the midpoint.
http://www.waybuilder.net/sweethaven/MedTech/Neurology/fig0212.jpg
- Achilles Tendon Reflex: Testing the Achilles tendon evaluates the nerve roots of S1 and S2 which should cause a quick contraction of the plantar flexors. The patient remains in supine with the knee bent and hip externally rotated and supported by the examiner’s thigh. Palpate the tendon located superior to the calcaneus on the posterior aspect of the lower leg. Use one hand to place the ankle into slight dorsiflexion while the other uses the reflex hammer at the desired location.
http://www.waybuilder.net/sweethaven/MedTech/Neurology/fig0213.jpg
Upper Motor Neuron Testing
Upper motor neuron lesions may be suspected if a patient with lumbar pathology complains of bilateral lower extremity pain or paresthesia. Additionally, bowel and/or bladder symptoms can be indicative of upper motor neuron damage. Patients may be hesitant to discuss bowel and bladder issues, so it is imperative that clinicians ask if they are experiencing either of these complications. Assessing for upper motor neuron lesions can be completed by testing for clonus and the Babinski sign, as described below.
- Clonus: Position the patient supine on the plinth with their leg bent and hip externally rotated, resting on the examiner’s thigh. Place one hand on the posterior aspect of the calcaneus, and the other hand over the metatarsal heads on the plantar surface of the foot. Provide a quick flick into dorsiflexion and sustain the end position. A positive response is plantar flexor contraction, causing repeated “beating” of the foot. 0-2 beats of the foot is a normal response.
- Babinski[4]: Position the patient supine on a plinth. Use a pointed object, such as the handle of a reflex hammer, to run along the plantar surface of the foot from the heel, upward along the lateral aspect and across the metatarsal heads in a “C” motion. A positive response is extension of the great toe and abduction of the remaining toes. A normal response to this test is the toes curling into flexion, which indicates that an upper motor neuron lesion is not present.
Neural Tension Testing[2]
These tests assess the mobility of the nervous system. There are four different tests that can be used when evaluating patients with lumbar pathologies: passive neck flexion, straight leg raise, prone knee bend, and slump.
- Passive neck flexion: This is the least threatening of the tension tests, and therefore should be executed first. To begin, position the patient supine, placing your hands on the posterior aspect of the cranium over the occiput. Next, passively move the head and neck into flexion by approximating the chin to chest. A positive result is reproduction of lower extremity neurological symptoms.
- Straight leg raise: Position the patient supine with legs extended. Place one hand over the anterior thigh, just superior to the patella, with the other hand on the Achilles tendon. Passively lift the patients leg into full hip flexion while maintaining full knee extension. If this is tolerated well, use one hand to dorsiflex the ankle. If no symptoms are present, ask the patient to lift his/her head off the table. If symptoms are reproduced by these additional movements, release the distal component to see if the symptoms subside; this will indicate whether the symptoms are resulting from neural tension or not. A negative result is no reproduction of neurological issues. If any of these progressions cause numbness or tingling into the leg, then the test is positive. If symptoms are triggered with any of the progressively added movements, discontinue the test.
http://www.longstreetclinic.com/images/straight_leg_test.jpg
- Prone knee bend: The prone knee bend only needs to be performed when a patient experiences neurological symptoms into the anterior thigh. To complete this test, the patient should lie prone on a plinth while the examiner passively moves the leg into full knee flexion. If the comparable sign of anterior thigh paresthesia is replicated, then neural tension is present.
- Slump: This is the most aggressive of the four positions, and should only be performed when no symptoms were elicited with the aforementioned tests. The patient should be seated on the side of the table with hands rested at their sides and legs bent over the edge. Ask the patient to slump down into a hunched sitting posture, then add head and neck flexion so the chin is tucked into the chest. Next, the examiner places their arm across the patients upper thoracic spine/shoulder area, with a bent elbow, so their forearm runs up the patient’s neck and their hand can be placed on the posterior aspect of the patient’s head. This is done to ensure that the patient’s slumped posture is maintained throughout the test. To add in the lower extremity, have the patient extend the uninvolved leg then dorsiflex the ankle. Return to resting and repeat on the involved leg. If extension of either leg elicits neurological symptoms, instruct the patient to hold the extended leg and dorsiflexed position as he/she extends the neck. If symptoms disappear with neck extension, then neural tension is present. Numbness or tingling can be brought on with the addition of any of the described steps. As soon as these symptoms are felt, the test should be discontinued.
http://www.physiopro.co.za/wp-content/uploads/2012/09/Neural-slump.jpg
References
1. Kendall FP, McCreary EK, Provance PG, Rodgers MM, Romani WA. Muscles Testing & Function with Posture & Pain. 5th ed. Baltimore, Maryland: Lippincott Williams and Wilkins; 2005.
2. Gulick D. Ortho Notes Clinical Examination Pocket Guide. 2nd ed. Philadelphia, PA: F.A. Davis Company; 2009.
3. Maitland GD, Edwards BC. Examination. In: Maitland GE. Maitland's Vertebral Manipulation. 7th ed. Philadelphia, PA: Elsevier Limited; 2009: 155-157.
4. Magee DJ. Orthopedic Physical Assessment. 5th ed. St. Louis, Missouri: Saunders Elsevier; 2008.
