KIN 3135
Musculoskeletal Injuries 2:
The Assessment and Treatment of Spinal
Injuries and Special Patient Populations
Paolo Sanzo DSc (cand),MSc, BScPT, FCAMT, CAFCI
Orthopedic Manual Physiotherapist
Adjunct Professor
School of Kinesiology, Lakehead University
Assistant Professor
Northern Ontario School of Medicine
The Lower Quadrant
Scan
1. Introduction
2. Evaluation Midterm Examination
30%
Group Presentation
30%
Final Examination
40%
3. Labs
4. Required readings
Pages 286-307
The Lower Quadrant Scan:
A scanning examination
is used to determine if we
are dealing with a lower
quadrant problem or a
spinal injury
Components of the Lower
Quadrant Scan
Subjective Examination
Establish the kind of disorder involved and
the reason for the referral
Is the patient coming in for:
Pain
Stiffness
Weakness
Post trauma
Instability
Loss of function
Following surgery
History of present injury
Mechanism of injury
Area of symptoms
Behaviour of symptoms
Aggravating factors
Easing factors
Past medical history
Special Questions:
General health
Medications
Investigations
Spinal cord signs
Cauda equina signs
Changes in pain with coughing
Effects of bowel and bladder on pain and
changes in function
Spinal Cord Signs:
Cauda Equina Signs:
Objective Examination
Inspection:
Look at the
architectural design
anteriorly, posteriorly
and laterally
Active Range of Motion of the
Lumbar Spine:
Assess the quantity and quality of flexion,
extension, side flexion and rotation of the
lumbar spine
Passive Range of Motion of the
Lumbar Spine With
Overpressure:
Assess the same movements passively and
add overpressure assessing the end feel
End Feel:
Different sensations are imparted to the hand
at the extremes of range. This sensation is
defined as the end feel
Types of End Feels:
Bone to Bone End Feel
An abrupt halt to the movement when two
hard surfaces meet
Spasm End Feel
A sudden stop or the sensation of a vibrant
twang to passive movement
Often accompanied by pain
A protective mechanism that the body uses to
prevent further injury
Capsular End Feel
Sensation like a thick piece of leather is being
stretched
Springy Block End Feel
A rebound sensation is felt
Indicates intra articular displacement or internal
derangement
Soft Tissue Approximation End
Feel
Joint cannot be pushed any further because
one part of the body hits against another
Empty End Feel
Movement causes considerable pain before
the extreme of the range is reached
Indicates a very serious pathology, acute
bursitis or a symptom magnifier
Sacroiliac Joint Kinetic Test:
Patient stands on one leg and flexes the opposite hip
to 90 degrees while the examiner places one thumb
on the PSIS and the other thumb on the spinous
process of S2
Palpate and note any movement of the sacroiliac
joint and the ability of the patient to transfer load
from the lumbar spine to the pelvis and hip
Sacroiliac Joint Kinetic Test
Squat:
Quick clearing test for the lower extremities
If pain is reproduced then the problematic
peripheral joint may need to be assessed as per
the peripheral joint assessment
Deep Tendon Reflexes:
Test for fatigue and fading
Test 5-10 times
Knee jerk reflex (L3-4)
Achilles tendon reflex (S1-2)
Dermatomes:
An area of skin
supplied by
a single nerve root
Test for altered
nerve conduction
by assessing pain,
temperature or
light touch over
the area of skin
Myotomes:
A muscle or group of muscles that is
predominantly supplied by a single spinal
nerve
Test for fatigue and altered nerve conduction
by testing the strength and endurance of the
myotomes
L1-2
L3
L4
L5
S1
S2
Clonus:
The rhythmic and rapid alternating
contraction and relaxation of a muscle brought
on by sudden passive tendon stretching
Tested by rapidly extending the wrist,
dorsiflexing the ankle or shearing the patella
cranially
+ve test suggests an upper motor neuron lesion
Babinski:
The skin of the sole of the foot is slowly
stroked along the lateral border of the heel
forward
+ve test occurs with
extension of D1 and
fanning of the other toes
Indicates a disorder of
the motor pathways of
the brain and spinal cord
Dural Testing:
Straight Leg Raise
Passively raise the
patient’s leg noting
the onset of pain and
symptoms
The straight leg raise assesses the integrity of
the dura of the sciatic nerve and its various
branches
Femoral Nerve Stretch
Passively flex the
patient’s knee
noting the onset of
pain and symptoms
Also known as the
Prone Knee Bend
The femoral nerve stretch
assesses the integrity
of the dura of the femoral
nerve and its various
branches
Biases the upper
lumbosacral plexus
(L2-L4)
Sacroiliac Joint Stress Test:
Anterior Sacroiliac Ligament
Stress Test
Push the medial aspect of the ASIS laterally
noting any pain or laxity
Indicative of the anterior sacroiliac ligament
sprain
Anterior Sacroiliac Ligament
Stress Test
Posterior Sacroiliac Ligament
Stress Test
Push the lateral aspect of the iliums medially
noting any pain or laxity
Indicative of a posterior sacroiliac ligament
sprain and potential sacroiliac joint
involvement
Posterior Sacroiliac Joint
Ligament Stress Test
Accessory Movements of the
Lumbar Spine:
Joint mobilization techniques used to identify
the level of involvement in the lumbar spine
Special Tests:
Any other special tests that the examiner feels
are required may be performed at this time
Analysis:
Based upon the subjective and objective
findings a diagnosis and a problem list is
made
Example:
25 year old male complaining of low back
pain and posterolateral hip pain and
numbness with radiation into the right
hamstring region secondary to a lumbar
spine disc derangement
Plan:
A treatment plan is then made to address each of the
problems identified in the problem list
Example:
Problem List:
1. Increased low back and
left leg pain and numbness
2. Decreased ROM of the
lumbar spine
3. Weakness of the L3
myotome on the left
Treatment:
1. Moist heat and TENS
to the lumbar spine
2. Stretching program the
in the gym
3. Strengthening program
in the gym