NMS 7/22/98
Lumbar orthopedic exams
-review-what do tests show
-focal site (where?), etiology (what?)
-ortho tests are designed to give you a focal Dx, but they don’t tell etiology
If pain down arm
-one test will say spine
-another test will narrow it to SOL
-a third may hint at a disc problem
-but x-ray may show VB being eaten away
-lab test may who infection
Ortho tests are not designed to reproduce subluxation complexes
Milgram’s
-merely tells you if lumbar problem or not
-why is it pos. for lumbar and not SI?
-inc. intrathecal spine dramatically (any leg lift is hard on L-spine)
-cannot have a blown disc and still be able to do Milgram’s
-ex. if radiating pain down leg but can do Milgram’s and has swollen ankles
(dibetes complications)
-Homan’s sign (like Braggard’s) for thrombophlebitis (emergency situation)
SLR
-hard on lumbar spine
-tests involved side
-don’t let pt. help you
-if pain in low back, not sciatica
SLR with external rotation
-narrows down site of problem (l-spine vs. piriformis)
Passive rotation
-can irritate bursa (there are 15 bursa in hip) as piriformis so
just assume it’s piriformis
Resisted External Rotation
-tests piriformis
True sciatica is very obvious
-pts. will be very vocal about where and what will hurt
Braggard’s
don’t
-for sciatica
Neck Flexion
-excellent dural test
WLR
-if pos. SLR and pos. WLR=medial disc (if it’s a disc)
-pt. leans into pain
Lateral disc bulge=lean away from pain
Faber-Patrick
-pt. can’t do if they have hip disease
Hoover
-for malingering
-malingering-person is conscioulsy lying and knows it
-not same as psychogenic pain
-use this when other ortho tests don’t match up consistently
-can tell if they are faking it
-pt. tried to further left bad leg
-if really trying, the good leg will push downward
-can fake out a malingerer by saying that something will likely hurt when it really
won’t
Iliac Compression
-pt. on side, bad side up
-large bursa over trochanter
-usually aseptic (due to overuse, not infection)
-so be careful where you place your hand
Heel to Buttock
-opposite of SLR
-does extension (stretches femoral nerve)
-lying on stomach aggravates L-spine
-stomach plus extension can jam facets
-Meralgia Paresthetica
-looks like femoral nerve entrapment
-but actually femoral cutaneous nerve
-often seen with PI ilium (esp. women), numbness and tingling of ant.
thigh
-bull’s eye in center of tingling that is absolutely numb
-Tx: stretching of ant. thigh, relaxation of quads, trigger point therapy
Medial Rotation of Hip
-first sign of hip disease
-hip pain is perceived deep in groin (SI pain is felt in ass)
-stretches capsule of hip
-if hip disease, pt. prefers to externally rotate the leg (walk with leg externally
rotated)
Bechterew
-good check for sciatica
-if sciatica, this cannot be negative
-to check for malingering, pretend to check ankle and slowly lift leg (if doesn’t lean
back, not sciatica)
Valsalva
-best ortho test for dura
-but can be negative for IVF encroachment-ex. spur
-the further the compressed structures are from center, the more likely you are to get
a false negative
Minor’s sign
Kemp’s sign
-useless for Dx
-good way to check for improvement
Neri Bowing
-pt. likely to slug you
Spinous percussion
-can also use edge of hammer to push in on interspinous ligament
Sample questions
1) CC burning pain in ant. thigh
+ Ely (femoral n.), Kemp (femoral n,), percussion (L-spine), valsalva (dura)
neck flexion (dura)
-SLR (not sciatic nerve)
a)L2 disc herniation
b)scleratogenous referral
c)L3 IVF encroachment
d)lumbar facet syndrome
e)meralgia paresthetica
a) would fit, not b) because can’t reproduce scleratogenous pain and it doesn’t burn, c)ruled out
by valsalva, d)facts are scleratogenous, so not this, e) meralgia is peripheral not spine
So a)is best answer
2)CC generalized LBP spasm, no trauma
+RLR, LLR, Kemp, forward flexion
-valsalva, bechterew
this problem sounds somatic
a)sciatic neuralgia-NO
b)DJD
c)lumbar sprain/strain
d)central disc
e)dural sheath irritation
b) DJD-->narrowed joints-->generalized pain
-possible
c) no trauma, so probably not sprain/strain
d)affects both sides but not a dural problem since valsalva negative
e)dural sheath (not a nerve)
-but generalized pain , not sclerotome
-dura should give sclertome pattern
Sprain/strain usually clears up in 10-14 days
DJD gets worse over time (will show up on x-ray
Answer is b)
3) CC back pain and spasm associated with left buttock and upper leg pain
+leg raises for back pain, valsalva for back pain, left kemps for back pain
forward flexion for back pain, ely
-bechterew, neck flexion, right kemps
Only the back pain was reproduced
Problem in trying to reproduce the leg pain (not typical of a neurological pain pattern)
a)L5disc syndrome
b)L4/L5 osteophytic impingement
c)facet syndrome
d)sciatica (ruled out by neg. bechterews)
e)scleratogenous
Neg. neck flexion rules out cord
Irritating dural sheath
-pos. for valsalva and leg raises (just not neck flexion), so could be a)
Valsalva may rule out b), but it’s a gray area
-also rules out c) (more likely to be disc than facet)
Could be sceratogenous also