Thoracic and Lumbar

Spine Special Tests

and Pathologies
Orthopedic Assessment III
Head, Spine, and Trunk
with Lab
PET 5609C

Clinical Evaluation

Spring Test:

Test Positioning:

Action:

Subject is prone
Examiner stands with thumbs or hypothenar
eminence over the spinous process of a lumbar
vertebrae
Apply a downward springing force through the
spinous process of each vertebrae to assess anteriorposterior motion

Positive Finding:

Increases or decreases in motion at one vertebrae

compared to another (hypermobility or hypomobility)

Clinical Evaluation

Nerve Root
Impingement:

Narrowing of
intervertebral
foramen:

Stenosis
Facet joint
degeneration
Herniated
intervertebral disc

Clinical Evaluation

Clinical Evaluation

Nerve Root Impingement Tests:

Valsalva Test:

Test Position:

Action:

Subject takes a deep breath and holds while bearing

down as if having a bowel movement

Positive Finding:

Patient seated, examiner standing next to patient

Increased spinal or radicular pain due to intrathecal

pressure
May be secondary to a space-occupying lesion (i.e.
herniated disc, tumor, osteophyte in lumbar canal)

Comments:

Increase in intrathecal pressure may result in pulse,

venous return, venous pressure (dizziness and/or
fainting)

Clinical Evaluation

Nerve Root Impingement Tests:

Milgram Test:

Test Position:

Action:

Patient performs a bilateral straight leg raise to the

height of 2 to 6 inches and is asked to hold the
position for 30 seconds

Positive Finding:

Patient supine, examiner at feet of the patient

Patient unable to hold position, cannot lift the leg,

or has pain with test

Implications:

Intrathecal or extrathecal pressure causing an

intervertebral disc to place pressure on a lumbar
nerve root

Clinical Evaluation

Nerve Root Impingement Tests:

Kernigs Test:

Test Position:

Action:

Patient performs a unilateral active straight leg

raise with the knee extended until pain occurs
After pain occurs, the patient flexes the knee

Positive Finding:

Patient supine, examiner at side of patient

Pain in the spine and possibly radiating into lower

extremity
Pain relieved when patient flexes the knee

Implications:

Nerve root impingement secondary to bulging of

the intervertebral disc or bony entrapment;
irritation of dural sheath; irritation of meninges

Clinical Evaluation

Nerve Root
Impingement Tests:

Kernig/Brudzinski
Test:

Patient actively flexes

the cervical spine (lifts
the head)
Hip unilaterally flexed
(no more than 900)
Knee than flexed to no
more than 900
(+) pain with neck
and hip flexion; pain
relieved when knee is
flexed

Clinical Evaluation

Nerve Root Impingement Tests:

Unilateral Straight Leg Raise Test

(Lasegue Test):

Test Position:

Patient supine, examiner standing at tested

side with the distal hand around the subjects
heel and proximal hand on subjects distal
thigh (anterior) maintains knee extension

Action:

Examiner slowly raises the leg until

pain/tightness noted or full ROM is obtained
Slowly lower the leg until the pain or
tightness resolves, at which point dorsiflex
the ankle and have subject flex the neck

Clinical Evaluation

Straight Leg Raise

Test:

Positive Findings:

Leg and/or low back

pain occurring with
DF and or neck
flexion is indicative
of dural involvement
and/or sciatic nerve
irritation
Lack of pain
reproduction with DF
and/or neck flexion is
indicative of
hamstring tightness
or SI pathology

Clinical Evaluation

Nerve Root Impingement Tests:

Well Straight Leg Raising Test:

Can be used to differentiate between
sciatic nerve irritation or a herniated
intervertebral disc that is irritating the
nerve root
Test Position:

Patient supine, examiner standing at

unaffected side; one hand grasps under the
heel while other is placed on anterior thigh
to stabilize the leg in extension

Clinical Evaluation

Well Straight Leg

Raise Test:

Action:

Examiner raises the

leg by flexing the hip
until discomfort is
reported (knee kept
in full extension)

Positive Finding:

Pain is experienced
on the side opposite
that being raised

Clinical Evaluation

Nerve Root Impingement Tests:

Quadrant Test:

Test Position:

Patient standing with feet shoulder width

apart
Examiner stands behind the patient, grasping
the patients shoulders

Action:

Patient extends the spine as far as possible,

than sidebends and rotates to affected side
Examiner provides overpressure through the
shoulders, supporting the patient as needed

Clinical Evaluation

Nerve Root Impingement Tests:

Quadrant Test:

Positive Findings:

Reproduction of patients symptoms

Implications:

Radicular pain indicates compression of the

intervertebral foramina that impinges on the
lumbar nerve roots
Local pain (not radiating) indicates facet joint
pathology
Symptoms isolated to the area of the PSIS may
indicate SI joint dysfunction

Clinical Evaluation

Nerve Root Impingement Tests:

Slump Test:

Test Position:

Patient sits over edge of table; examiner is at side

of patient

Action:

(1) Patient slumps forward along thoracolumbar

spine, rounding the shoulders while keeping
cervical spine neutral
(2) Patient flexes cervical spine; Clinician holds
patient in this position
(3) Knee is actively extended
(4) Ankle is actively dorsiflexed
(5) Repeat on opposite side

Clinical Evaluation

Slump Test:

Positive Findings:

Sciatic pain or
reproduction of
other neurological
symptoms

Implications:

Impingement of
the dural lining,
spinal cord, or
nerve roots
Note: Patient performs
ACTIVE knee extension and

Clinical Evaluation

Test for Patient

Malingering:

Malingering medical
and psychological terms
that refers to an
individual
fabricating/exaggeratin
g their level of
symptoms

Financial compensation
(fraud)
Avoiding work
Obtaining drugs
Attract attention or
sympathy

Clinical Evaluation

Test for Patient Malingering:

Hoover Test:

Test Position:

Action:

Patient supine
Examiner at feet of patient with hands cupping
the calcaneous of each leg
Patient attempts to actively straight leg raise on
the involved side

Positive Findings:

Patient does not attempt to lift the leg and

examiner does NOT sense pressure from the
uninvolved leg pressing down on the hand
Patient is not attempting to perform the test

Clinical Evaluation

Test Note: Examiner should be standing at feet of

patient with their hands cupping the heels of each

Clinical Evaluation
Lower Quarter Neurological Screen

Nerve
Root
Level
L1
L2
L3
L4
L5

Sensory Testing

Inguinal area (just below inguinal

ligament
Mid-thigh (medial)
Medial knee (just above superior
pole of patella)
Medial aspect of lower leg, medial
ankle, big toe
Top of foot (an/or blow head of

Clinical Evaluation
Lower Quarter Neurological Screen

Nerve Root
Level
L1

Motor Testing

L2
L3

Hip flexion
Hip flexion
Knee extension

L4
L5

Dorsiflexion
Great toe extension

S1
S2

Plantarflexion
NA

Clinical Evaluation
Lower Quarter Neurological Screen

Nerve
Root
Level
L4
L5
S1
S2

Reflex
Testing
Patellar
Tendon
Patellar
Tendon
Achilles
Tendon
Achilles
Tendon

Clinical Evaluation

Babinkskis Test:

Test Position: athlete supine

Athletic Trainer Position: At
the foot of the athlete holding
a blunt tool (reflex hammer)
Procedure: Rub the tool up
bottom of athletes foot
starting at the calcaneus and
ending at the great toe.
Positive test: Great toe
extends while other toes
splay.
Implications: Lesion of upper
motor neurons, may be
caused by trauma to the brain
Comments: This reflex occurs
naturally in newborns.
However, this reflex should
cease quickly after birth.

Clinical Evaluation

Erector Spinae
Muscle Strain:

Common low back

pathology
MOI:

Signs/Symptoms:

History of heavy or
repetitive lifting
Aching back
Pain with passive and
active flexion, resisted
extension

Neurological Evaluation:

Negative results

Clinical Evaluation

Facet Joint Dysfunction:

Pathology of facet joints 40% of all chronic

low back pain
Vague signs/symptoms:

Often resemble other low back pathologies (i.e.

strain/spasm of paraspinal muscles, nerve root
impingement, disc degeneration)

Involvement:

Dislocation/sublocation of facet:

Facet joint syndrome: (inflammation)

Tends to lock the involved spinal segment

(hypomobile vertebrae)
Causes: repetitive stress through movement or loading

Degeneration: (arthritis)

Causes: undefined history

intervertebral foramen size (nerve root impingement)

Clinical Evaluation

Facet Joint Dysfunction:

History:

Inspection:

Onset insidious
Pain characteristics localized
MOI extension, rotation, lateral bending of
vertebrae
Predisposing conditions repeated motions of spinal
extension, rotation, lateral bending
Patient may assume posture that pressure on
affected facets

Palpation:

Possible local muscle spasm (paravertebral muscles)

Clinical Evaluation

Facet Joint
Dysfunction:

Ligamentous Tests:

Neurological Tests:

Spring Test pain,

motion
Not applicable
unless secondary
nerve root
impingement occurs

Special Tests:

Quadrant Test (+)

Intervertebral disc
lesions (-)

Clinical Evaluation

Facet Joint Dysfunction:

Initial Treatment:
NSAIDs
Instruct patient to avoid
postures/movements that irritate facets
Modalities moist heat, e-stim, ice to
muscle spasm
Therapeutic Exercises:

Stretching and strengthening:

Low back
Abdominals
Hip flexors, hip extensors, hamstrings

Clinical Evaluation

Intervertebral Disc
Lesions:

Disc Degeneration:

Loss of water from

nucleus pulposus

stress load on
annulus fibrosus

cushioning ability

Small tears occur to

annulus (scar tissue
formation not as
strong as normal
tissue)

Bulging of nucleus
pulposus

Clinical Evaluation

Intervertebral Disc
Herniation:

Extrusion of
nucleus pulposus
through annulus
fibrosus

Impingement/pressur
e on nerve root below
affected disc

Sequestrated
nuclear material
breaks away from
rest of disc

MRI lumbar image:

L5/S1 disc has suffered a
9mm disc extrusion (red
arrow) that is not contained by
the PLL
L4/5 disc has suffered a
smaller 4mm disc protrusion
(green arrow) that is
contained by the PLL
L3/4 (blue arrow) is
completely normal and has no
disc material projecting
posteriorly into the epidural
space
Note: L3/4 disc is white in
color, which indicates it is
non-degenerated (i.e., full of
water and healthy
proteoglycan)
Herniated discs (L4/5 & L5/S1)
are "black" which indicates

Clinical Evaluation

Clinical Evaluation

Lumbar Disc Degeneration:

History:

Onset insidious or may be related to single

episode

Breakdown of disc is related to repetitive stress; Last

episode final failure an annulus fibrosus to contain
nucleus pulposus

Pain characteristics affected vertebrae;

compression of spinal nerve root leads to pain
in low back, buttocks, radiating into thigh,
calf, heel, foot
MOI repetitive loading of disc
Predisposing condition history of lumbar
spine trauma

Clinical Evaluation

Lumbar Disc Degeneration:

Inspection:
Slow GAIT
Flattened lumbar spine
Changes in body position guarded and
painful

Standing position:

Sitting standing / sitting lying

Changes in disc pressure
Lateral shift away from side of leg pain

Palpation:

Musculature spasm

Clinical Evaluation

Lumbar Disc Degeneration:

Functional Tests:

Neurological Tests:

Lower quarter screen

Special Tests:

Limited ROM in all directions

Movement in one direction may relieve or
symptoms

Straight leg raising, Well straight leg raising,

Milgram, Sciatic and femoral nerve tension tests

Diagnostic Tests:

MRI

Clinical Evaluation

Intervertebral Disc Degeneration:

Surgery

Spinal Fusion:
Welding 2 or more vertebrae together
Cause of back pain (motion between
vertebral segments) spinal fusion may be a
way to prevent motion and stop the pain
Technique (basics):

Small pieces of extra bone fills space between two

vertebrae (pelvic bone, allograft bone)
Disc removed
Wires, rods, screws, metal cages or plates may be
used

Clinical Evaluation

Clinical Evaluation

Artificial disc replacement: Disc is placed in the disc space through

an abdominal incision; the artificial disc then maintains mobility in
the spine and as such protects the adjacent disc from accelerated
degeneration and further surgery

Clinical Evaluation

Cauda Equina Syndrome:

Anatomy: spinal cord ends at the lower edge of

the 1st lumbar vertebra

Lumbar and sacral nerve roots form a bundle

within the spinal canal below the conus medullaris

CES nerves within the spinal canal have been

damaged; nerves supplying muscles of legs,
bladder, bowel and genitals do not function
properly

Congenital causes:

Numbness, loss of sensation (damage usually

permanent)

Spina bifida (abnormality in closure of spinal canal)

Tumors of the cauda equina

Acquired causes of Cauda Equina Syndrome:

Injury (spinal fractures)

Secondary to medical procedures

Clinical Evaluation

Femoral Nerve Stretch

Test:

Tests for nerve root

impingement at L2, L3, L4
Test position:

Action:

Patient prone with a pillow

under the abdomen;
examiner at side of patient
Examiner passively extends
hip while keeping knee
flexed to 900

Positive test:

Pain in anterior and lateral

thigh

Clinical Evaluation

Sciatica:

General term for any

inflammation involving
sciatic nerve
Causes:

Lumbar disc herniation

SI joint dysfunction
Scar tissue around nerve
root
Nerve root inflammation
Spinal stenosis
Synovial cysts
Cancerous or
noncancerous tumors

Clinical Evaluation

Sciatica:

Signs and Symptoms:

Special Tests:

Radiating pain
Muscular weakness
Straight leg raise test
Tension sign

Treatment and Rehab:

Resolve pathology that

is irritating nerve
Oral anti-inflammatory
meds / corticosteroids
Exercises for strength /
ROM

Clinical Evaluation

Tension Sign:

Tests for sciatic nerve irritation

Test position:

Action:

Patient supine; examiners one hand grasps the

heel while other grasps the thigh
Hip and knee flexed to 900
Knee is then extended as far as possible with the
examiner palpating the tibial portion of the
sciatic nerve as it passes behind popliteal space

Positive finding:

Tenderness and reproduction of sciatica

symptoms

Clinical Evaluation

Clinical Evaluation

Bowstring Test: (Cram Test)

Test position:

Action:

Patient supine
Examiner performs a passive straight leg raise on
involved side
If subjects reports radiating pain, examiner flexes the
subjects knee to approximately 20 0 in attempt to
reduce pain
Pressure than applied to popliteal area to reproduce
radicular pain

Positive finding:

Painful radicular reproduction with popliteal

compression

Indicates sciatic nerve tension

Clinical Evaluation

Spondylolysis:

Defect in pars interarticularis

(area between inferior and
superior articular facets)
MOI repetitive stress

Unilateral or bilateral defects

Listhesis:

Posterior portion of the

vertebrae, laminae, inferior
articular surfaces, spinous
process separates from
vertebral body
Collared Scotty dog deformity
Symptoms:
Localized mow back pain (
during/after activity)
Pain with extension

Clinical Evaluation

Spondylolisthesis:

Progression of spondylolysis
separation of vertebrae (superior
vertebrae slides anteriorly on the one
below it)

Decapitated Scotty dog deformity:

Head of the dog (anterior element of vertebrae)

has become detached from body (posterior
element)
Severity amount of anterior displacement

Epidemiology:

Most prevalent in women and adolescents

Young gymnasts

Lateral view of the

lumbar spine: Bilateral
break in the pars
interarticularis
(spondylolysis - black
arrow)
L5 vertebral body (red
arrow) has slipped
forward on the S1
vertebral body (blue
arrow
spondylolisthesis)
Normal pars
interarticularis - white
arrow.
Degree of forward
slippage is equal to
about 1/4 to 1/2 of the
AP diameter of S1
(Grade1-Grade 2
spondylolisthesis)

Clinical Evaluation

Spondylolysis and Spondylolisthesis:

History:

Onset of pain:

Characteristics:

Repetitive stress (extension)

Predisposing conditions:

Lumbar pain, radiating into buttocks and upper

posterolateral thigh

MOI:

Insidious; pain begins as an ache, to constant

pain

Muscular imbalances
Repetitive hyperextension activities

Inspection:

lordotic curve
Altered GAIT

Clinical Evaluation

Spondylolysis and Spondylolisthesis:

Palpation:

Step-off deformity may be felt

Spasm of paraspinal muscles

Functional Tests:

AROM:

PROM:

Flexion restricted, pain free

Extension pain
Rotation and bending - pain
Hip flexion hamstring tightness

RROM:

Weakness of spinal erectors

Clinical Evaluation

Spondylolysis and Spondylolisthesis:

Special Tests:
Pain with Spring test
SL stance test; straight leg raises may
produce pain

Neurological Exam:

Lower quarter screen (results typically

negative)

Comments:

X-ray, CT, MRI (will differentiate between

spondylolysis and spondylolisthesis)

Clinical Evaluation

Single Leg Stance Test:

Test position:

Action:

Patient standing with body weight evenly

distributed between the 2 feet; examiner
stands behind pt.
Patient lifts one leg, then places the trunk
in hyperextension; examiner may assist

Positive test:

Pain in lumbar spine or SI area

Clinical Evaluation

Single Leg Stance

Test:

Implication:

Shear forces are placed

on pars interarticularis
by iliopsoas pulling the
vertebrae anteriorly

Comments:

Unilateral fracture
pain when opposite leg
raised
Bilateral fractures
pain with either leg
being fractured

Clinical Evaluation

Sacroiliac Dysfunction:

History:

Onset:

Pain characteristics:

One or both SI joints;

possibly radiating pain
in buttocks, groin, thigh

Mechanism:

Acute or insidious

Prolonged stress

Predisposing conditions:

Postpartum women
(relaxin levels)
Hormonal levels during
menstruation

Clinical Evaluation

Sacroiliac Joint Dysfunction:

Inspection:

Palpation:

Trunk flexion (with knees extended) will cause

movement of the sacrum on the ilia (pain)

Neurological testing:

Pain over SI joints and PSIS

Functional tests:

Levels of iliac crests, ASIS, PSIS

Lower quarter screen

Special tests:

Long sit; SI compression and distraction;

straight leg raising; fabre; gaenslens; quadrant

Clinical Evaluation

Sacroiliac Joint Stress

Test:

Test position:

Action:

Subject supine; examiner

stands next to subject and
with arms crossed, places
heel of both hands on the
subjects ASISs
Examiner applies outward
and downward pressure with
the heels of both hands

Positive finding:

Unilateral pain at SI joint or

in gluteal/leg region is
indicative of anterior SI
ligament sprain

Clinical Evaluation

Sacroiliac Joint Stress

Test:

Test position:

Action:

Subject side-lying;
examiner stands next to
patient and places both
hands (one on top of the
other) directly over the
subjects iliac crest
Apply downward pressure

Positive finding:

Increased pain indicative

of SI pathology (possible
involvement of posterior SI
ligament)

Clinical Evaluation

Sacroiliac Joint Stress

Test:

Test position:

Action:

Subject lying supine;

examiner places both
hands on lateral aspect
of subjects iliac crests
Apply inward and
downward pressure

Positive finding:

Increased pain indicative

of SI pathology (possibly
involving posterior SI
ligaments)

Clinical Evaluation

Sacroiliac Joint Stress Test:

Test position:

Action:

Subject lying prone; examiner places

both hands (one on top of the other)
over subjects sacrum
Apply downward pressure on sacrum

Positive finding:

Increased pain indicative of SI pathology

Clinical Evaluation

Patrick or FABER Test:

Test position:

Action:

Subject supine
Examiner passively flexes,
abducts, and externally
rotates the involved leg until
the foot rests on the top of
the knee of uninvolved lower
extremity; examiner slowly
abducts the involved lower
extremity towards the table

Positive test:

Involved lower extremity

does not abduct below level
of uninvolved side

SI pathology, iliopsoas
tightness

Clinical Evaluation

Gaenslens Test:

Test position:

Action:

Subject supine, lying close

to edge of table; examiner
stands at side
Slide patient to edge of
table; patient pulls far knee
up to the chest; near leg
allowed to hang over edge
of table
Examiner applies downward
pressure on near leg,
forcing it into
hyperextension

Positive finding:

Pain in SI region indicating

SI joint dysfunction

Clinical Evaluation

Long-Sitting Test:

Test position:

Action:

Subject supine, both hips and knees extended; examiner

standing with thumbs on subjects medial malleoli
Examiner passively flexes both hips and knees and then
fully extends and compares position of medial malleoli
relative to eachother
Subject slowly assumes the long-sitting position and
malleolar position is re-assessed

Positive finding:

Leg appears longer in supine but shorter in long-sitting

is indicative of an ipsilateral anteriorly rotated ilium
Leg appears shorter in supine but longer in long-sitting
is indicative of an ipsilateral posteriorly rotated ilium

On-Field Evaluation

History:

Location of pain:

Peripheral symptoms:

Localized in vertebral column disc rupture,

sprain, facet pathology
Radiating pain into extremities spinal nerve root
pathology
Pain parallel to vertebral column muscle spasm
Nerve root impingement

MOI:

Rotational forces, hyperextension, repetitive stress

On-Field Evaluation

Inspection:

Position of athlete:

Posture
Willingness to move

Neurological tests:

Supine if spinal cord involvement suspected,

manage accordingly (spine board)

Sensory
Motor tests

Palpation:

Bony palpation
Paraspinals