Revision – Low back pain
Contents
Congenital (occurred prior to birth) ....................................................................................................... 4
Spina Bifida Occulta ............................................................................................................................ 4
Spondylolisthesis................................................................................................................................. 4
Facet direction anomalies, L/S anomalies .......................................................................................... 5
Scoliosis ............................................................................................................................................... 6
Klipperfeil ............................................................................................................................................ 7
Acquired - Traumatic .............................................................................................................................. 8
Muscle tear ......................................................................................................................................... 8
Ligament injury ................................................................................................................................... 8
Fractures e.g. Vertebral ...................................................................................................................... 9
Facet Dysfunction ............................................................................................................................... 9
Herniated Disc ................................................................................................................................... 10
Acquired - Infective ............................................................................................................................... 11
Osteomyelitis .................................................................................................................................... 11
Tuberculosis TB ................................................................................................................................. 11
Discitis ............................................................................................................................................... 12
Acquired - Inflammatory ....................................................................................................................... 13
Ankylosing Spondylitis ...................................................................................................................... 13
Rheumatoid disease of joints RA ...................................................................................................... 14
Acquired - Neoplastic ............................................................................................................................ 15
Bone Metastasis ................................................................................................................................ 15
Osteosarcoma, Fibrosarcoma, Chondrosarcoma ............................................................................. 15
Page 1 of 26
Revision – Low back pain
Acquired - Degenerative ....................................................................................................................... 16
Osteoarthritis, Spondylosis, Spondyloarthrosis ................................................................................ 16
Disc lesion ......................................................................................................................................... 16
Facet problems ................................................................................................................................. 17
Lumbar spine stenosis....................................................................................................................... 17
Acquired - Metabolic............................................................................................................................. 19
Osteoporosis ..................................................................................................................................... 19
Osteomalacia / Rickets...................................................................................................................... 19
Acquired - Endocrine............................................................................................................................. 21
Cushings ............................................................................................................................................ 21
Acquired - Idiopathic ............................................................................................................................. 22
Padget’s disease ................................................................................................................................ 22
Scheuermann’s disease aka Osteochondrosis or Osteochondritis ................................................... 22
Piriformis syndrome .......................................................................................................................... 23
Page 2 of 26
Revision – Low back pain
Congenital
Acquired
Spina Bifida
Traumatic
 Muscle tear
 Ligament damage
 Joint strain
 Fracture
 Disc injury
Infective
 Osteomyelitis
 TB
Inflammatory
 AS
 RA
Neoplastic
Degenerative
 OA
 Disc
Metabolic
 Osteoporosis
 Osteomalacia
Endocrine
 Cushings
Idiopathic
 Padgets
 Schermanns
Psychogenic
Visceral
Vascular
Gynae
Renal
Block vertebrae
Lumbarisation
Sacralisation
Scoliosis
Klipperfeil
Facet Anomalies
Low riding, High riding L5
Red Flags
 Unexplained weight loss
 Hxx of malignancy
 Infection
 Symptoms unrelated to movement
 Cauda Equina
Anatomy:
Page 3 of 26
Revision – Low back pain
Congenital (occurred prior to birth)
Spina Bifida Occulta
Definition
Who gets it
Signs
Symptoms
Medical Tests
Complications
What can we do
Failure to unite/develop the posterior arch leaving the spinal canal exposed reducing the attachment
site of ligaments and muscles
Estimated that 25% of LBP population
Folic acid defect in diet prior to conception and during pregnancy (folic acid is found in breakfast
cereal, baked beans, green leafy veg, peas and chickpeas, oranges)
Suspected link to LDL gene error
Taking epilepsy and bipolar medication whilst pregnant (valproate, carbamazepine, lamotrigine)
Dimple in low back
Hairy patch in low back
Pigmented area in low back
Haemangioma
Low back ache
Stiff low back
Poor gait
X-ray
Congenital neoplasm
Mid-line spur splitting the spinal canal
Tightened shortened filum terminale causing a low lying spinal cord
Spina cord can be tethered which can cause paralysis as the child grows
Poor bladder control
Carvo varus – heel inverted, increased arch, clawed toes and adducted foot
Advise on diet prior to and during pregnancy
Advise to discuss medications with the doctor prior to and during pregnancy
Avoid HVT of the low l.sp considering the possible instability in that area
Spondylolisthesis
Definition
Who gets it
Anterior movement of the vertebral body with or without Spondylolytic (a fracture of the pars
interarticularis in the lumbar spine)
Retro lythesis is a backward movement of the vertebral body
Young: spondylolytic spondylolisthesis (commonly L5/S1 with step at L4/5)
Elderly: non-spondylotytic spondylolithesis (commonly L3/4 with a step at L3/4) due to degenerative
changes
Predisposed by: congenital anomaly, bony weakness, fibrosis union only, increased lumbar lordosis,
increased functional demands, growth spurts with participation in active sports, pregnancy,
visceralptosis and a loss of abdominal tone.
Symptoms
Signs
tests you can do
Odd gait
Acute back pain eased by rest, worse on standing, agg by increased hamstring tone
Groin strains, Hamstring strains that won’t resolve
C/T pain or H/A
Wide ranging from no symptoms (incidental finding, esp. in children) to severe back & leg pain with
nerve damage esp. on hyperextension of the back. Beware of Cauda Equina syndrome
Young child 6-7 YOA – acute back pain, agg by weight bearing and eased by bed rest. Poor range of
l.sp flexion
Older child – excessive sports >24 hours per week with hard landings and falls, stress from
hyperlordotic activities
Young adult – hxx of contact sports with an injury that is failing to resolve.
Palpable step
Reduced flexion
Increased tension in hamstrings
Vibration test with tuning form to establish whether there is a #
Page 4 of 26
Revision – Low back pain
medical tests
medical treatments
(and side effects)
contraindications to
specific osteopathic
techniques
Palpate for a palpable step
X-Ray (most visible from an oblique view), looking for the scotty dog with an increased neck length
(degenerative) or a collar (fracture) at worst decapitated!
CT scan
Grading according to the amount of slippage (grade 1 <25%, 2 = 25-50% 3 = 51-75% 4 = 67-100%
etc)
Wide ranging from observation to surgical stabilization of the spine depending on the age of the
patient, type of slip and symptoms experienced.
Hyperextension, HVT, strong articulatory techniques esp. in extension can all cause further slippage
Facet direction anomalies, L/S anomalies
Sacralisation
Lumbarisation
Block vertebrae
Hemi vertebrae
A developmental anomaly where the 5th lumbar vertebra fuses with the sacral vertebra
A developmental anomaly where the 1st sacral vertebra is not fused to the rest of the sacrum. It acts
like an additional lumbar vertebra
Occur with improper segmentalisation
Wedge shaped vertebrae and can cause an angle in the spine. Most common in the mid thorax
especially T8. Can cause narrowing of the spinal canal and instability of the spine.
Possible cause is a lack of blood supply
Page 5 of 26
Revision – Low back pain
Scoliosis
Definition
Type
Congenital
Idiopathic
Can be early onset
before 10yoa or late
onset 10-18yoa
Neuromuscular
Secondary/
compensatory
Who gets it
Symptoms
Signs
Tests you can do
Medical tests
Medical treatments
(and side effects)
contraindications to
specific osteopathic
techniques
Pathology
Abnormal spinal
development
unknown
Examples
hemi vertebra
Abnormal forces acting on
the spine
Cerebral palsy
Spina bifida
Mm dystrophies
Spinal cord injuries
Glove puppet - LLD.
String puppet - Asymmetry in cranial
baseAntalgic postures-trunk will tilt
markedly
Curve develops secondary
to other process
Adolescent idiopathic scoliosis
Idiopathic-2.5% of population effected. F:M 9:1
Presents at juvenile and adolescent ages.
Increased incidence of back ache.
Can be symptomless.
Deformity. - Spinal curve, rib hump, LLD, protruding scapulae.
Idiopathic structuralInitial lateral curve with compensatory curves above/below.
Pt is side bent and rotated ipsilaterally, until centre line of weight bearing moves away from spinal
axis, the rotation is reversed to compensate; ribs are thrown back on the convex side, increasing
deformity.
Once the S/B is ipsilateral and ROT is contralateral then this is a Structural Scoliosis
Measure leg length
Check standing to seated posture.
Bony landmarks
Forward flexion –high side more apparent.
Standing x rays- show and monitor progress of curve
MRI to exclude any ass. cord abnormality.
Measurement of lateral curve-‘cob angle’ on a/p x-ray
Measurement of the rib angle- done with pt flexed at 90look at the angle of the back away from
horizontal.
In mild to moderate idiopathic curves-bracing (Milwaukee)
Congenital most neuromuscular and severe idiopathic = Surgery –harrington rods spinal fusion,
stabilisation correction
Severe thoracic curves have systemic implications to the pulmonary and cardiovascular systems.
Scoliosis association uk advised osteopathy can help with pain, we CANNOT prevent curvatures
progressing.
Page 6 of 26
Revision – Low back pain
Klipperfeil
Definition
A congenital condition where there is fusion of two or more cervical vertebrae
Who gets it
?developmental anomaly
?foetal alcohol syndrome
?vascular compromise
Symptoms
Reduced range of motion of the cervical spine
Signs
Medical Tests
Medical ttt
Contraindications
Renal anomalies
Cardiovascular anomalies
Short neck, Low hairline,
Restricted range of motion in the cervical spine
Also associated with other congenital anomalies e.g. Spengel shoulder
X-ray
Cervical instability
Cardiovascular compromise
Spinal cord stenosis
Page 7 of 26
Revision – Low back pain
Acquired - Traumatic
Muscle tear
Definition
A stretching or tearing of a muscle or tendon as a result of an overstretch
Classed as:

Grade 1 - there is very minor damage to the muscle fibres

Grade 2 - there is a partial tear of the muscle fibres

Grade 3 - there is a complete tear of the muscle fibres
Who gets it
Symptoms
Anyone from a traumatic onset
Local pain, stiffness, bruising,



Signs
Grade 1 – sore, able to continue with activity
Grade 2 – lots of pain, swelling, bruising
Grade 3 – lots of pain, swelling, bruising, no muscle function
Visible signs of damage (swelling or bruising)
Agg: Recruitment of the muscle. Stretch to the muscle. Flexion and S/B away from the damaged side.
Usually all spinal movements are affected
NAF: Passively shortening the muscle, EXT
Treatment




Rest for 48-72 hours
Ice
Compression
Elevation
Surgery if a grade 3 to repair the muscle tear
Ligament injury
Definition
A stretching or tearing of a ligament

Who gets it
Symptoms
Signs
GRADE 1 - There is damage to a few collagen fibres, producing a local inflammatory
response.

GRADE 2 - There is damage to a more extensive number of collagen fibres.

GRADE 3 - The damage to collagen fibres is such that there is a complete rupture of the
ligament.
Anyone from a traumatic onset

Grade 1 - This is characterised by pain over the affected ligament.

Grade 2 - This produces a more marked inflammatory response characterised by intense
pain and joint effusion (swelling).

Grade 3 - This produces intense pain, joint effusion and marked joint instability. Surgery may
be necessary to restore joint stability.
Increased ligament laxity
Muscular spasm
Agg: end of range stretch to the damaged part of the ligament
NAF: active resisted muscle test
Page 8 of 26
Revision – Low back pain
Fractures e.g. Vertebral
Definition
Who gets it
Symptoms
Signs
Tests you can do
Medical tests
Medical treatments
(and side effects)
Contraindications to
specific osteopathic
techniques
Disruption in the continuity of bone tissue
Complete = complete separation of bone e.g. Spondylytic Spondylolythesis
Incomplete = some bone fragments still intact
Stress # = Incomplete # from unusual or repetitive strain
Crush # = Collapse of a vertebra due to trauma, osteoporosis or other bone
degenerative conditions
Greenstick # = only in children. Bone is less brittle and can therefore bow without complete disruption
of the bones cortex
Simple # = Skin remains intact
Compound # = Skin is broken
Anyone
Local pain. Muscle guarding.
Stress # = pain after exx, then pain during and after exx, then continual pain and night pain
Case Hxx v important.
Crush # may cause loss in height.
Tuning fork – use large tuning fork, place over area. This will cause extreme pain in the case of a
fracture. However, false negatives can occur!
Stress # = Hopping on one leg (the affected leg) should elicit pain.
X – ray. Some #s may not show on X – ray until osteoblastic activity occurs i.e. a few days post
trauma.
NSAIDs (SE = GI problems i.e. stomach ulcers with prolonged use)
Immobilisation i.e. with a cast (SE = mm wasting and poor venous drainage)
Surgery – commonly offered with hip #s to decrease the risk of DVT’s and pulmonary embolism.
Otherwise offered when bony remodelling is required. (SE = infection)
Pain may limit ttt. Crush # indicates weakness of the vertebral body and therefore, avoid HVT.
Complications = Compartment syndrome
Necrosis i.e. Scaphoid bone
Facet Dysfunction
Facet direction in the L.sp = parasaggital enabling FLEX, EXT, S/B with limited ROT
Definition
Synovitis/haemarthrosis (acute sprain) – transient LBP, strain/nipping to the capsule causes effusion
which is relieved 2-3 days due to reduced segmental health, fibrogen deposited into the joint causing
Intracapsular adhesions
Who gets it
Stiffness
Painful entrapment
Mechanical block
Chronic facet dysfunction
Synovitis/haemarthrosis (acute sprain) –. Onset with a sudden movement, initially with sharp
localised pain. Can radiate to the buttock and iliac crest.
Painful entrapment – an acute pain, leads to postural deviation away from the painful side
immediately following injury.
Symptoms
Prolonged standing with a lordotic L.sp can stress the living bone and cause remodelling, enlargement
and realignment of the facets to reduce stress and redistribute it
Synovitis/haemarthrosis (acute sprain) - Initially sharp localised pain, Onset with a sudden
movement
Signs
Painful entrapment – an acute pain when trying to resume normal alignment. The pain may migrate
up the back 1 day later with painful muscular guarding
Synovitis/haemarthrosis (acute sprain) - Can be palpated in the c.sp
Prognosis
Painful entrapment – an acute pain with an Antalgic posture
Synovitis/haemarthrosis (acute sprain) – 2 weeks
Page 9 of 26
Revision – Low back pain
Herniated Disc
Definition
Who gets it
Extrusion of the nucleus pulposus through a tear in the annulus fibrosus.
Can cause pressure on the nerve route.
Commonly young adults (30-50 yoa) at the L/S, then L4/5, the L3/4
Vunerable to failure of the posterior ligamentous system due to the influence on the prestressing mechanisms of facet and disc.
Sustained flexion puts a distraction force on the posterior disc and failure can occur at the posterior
annulus or PLL. If repeated and sustained this can begin the process of discal degeneration. Desk
slumping, Congenital anomalies, Acquired anomalies, Trauma
High riding L5 (body in line with iliac crest)
Low riding L5 (L4 on the inter iliac line)
Sacralisation
Lumbarisation
Spina bifida
Block vertebrae
Symptoms (Can vary)
Pathophysiology
Prognosis
Signs
Tests you can do
Medical tests
Medical treatments
(and side effects)
Contraindications to
specific osteopathic
techniques
Commonly back pain with very limited mvt (inability to straighten up fully).
Pain may worsen with flexion, coughing and straining, sitting
If a nerve route is irritated symptoms of NRI or NRC will be present i.e. pain into the limb, P+N,
numbness or weakness (“I can’t pick my foot up properly, it drags along the floor”).
Onset is gradual
Occasionally symptoms of cauda equine – saddle anaesthesia, urinary retention, and faecal
incontinence.
Stress to outer tissues which lose their integrity and become stretched
Results in poor nutrition with compromised pumping mechanisms
Can cause a loss of proprioceptive function increasing the vunerability to damage
Muscles are recruited to provide the lost support which fatigue and this stress eventually reaches the
disc
Prolapse normally posteriolateral
1 – 3 months
There may be a loss of the lumbar lordosis, a protective scoliosis and mm guarding.
Flexion may relieve the leg pain
Lateral shift away from the herniation
Side bend away can relieve symptoms
SLRT with pain radiating below the knee in a lancinating line. Possible not below the knee... not
found in Grieve Chapter 6!
With NR involvement there may be reduced or absent reflexes, reduced or absent sensitivity to touch
(light/sharp), and weakness in a specific dermatome/myotome.
Neurological tests including reflexes, power, light touch, and pin prick. SLR to test neural tethering. If
crossed SLR is positive high chance of disc involvement. Quadrant tests and slump tests can be
used.
MRI will show the disc.
X-ray may show a narrowed joint space.
NSAIDs and analgesics (SE = GI upsets, constipation, stomach ulcers). Oral steroids or local epidural
injection (SE = osteoporosis, or iatrogenic Cushings if long term use).
96% recover within 6 months without surgical intervention (webmd.com). Indicators for surgery are
objective weakness and other neuro findings, limitations to daily activity, worsening leg pain for at
least 1 month despite prescribed NSAIDs and analgesics, confirmation of disc herniation by MRI.
Discectomy - surgical removal of herniated disc that presses on a nerve root or the spinal cord. –
10% have persistent symptoms post surgery, especially those with severe neuro deficit before hand.
10% have a reoccurrence some time after the surgery. There is a risk of infection. Most are
successful.
Fusion – Bone graft is used to fuse 2 or more vertebra together to completely prevent spinal mvt.
Disc may be removed and replaced – fairly old-fashioned method. SE = altered spinal mechanics,
potential for injury elsewhere from increased demand..
Discs are generally injured in flexion when lifting something heavy or via torsion injuries. Therefore it
is best to avoid reinforced flexion and rotational mvts in treatment. This means that HVT’s at the
affected segment are contraindicated.
Page 10 of 26
Revision – Low back pain
Acquired - Infective
Osteomyelitis
Definition
who gets it
Osteomyelitis is an infection of a bone usually Bacterial
e.g. Staphylococcus Aureus, MRSA
Recent #, Artificial Hip, Prosthesis, Recent Surgery,
Immune compromised i.e. AIDS, Chemo-TTT, Diabetes
(
Symptoms
Signs
OMT tests
medical tests
Medical ttt (and
S/E)
OMT and
contraindications
sensation), Steroids use, previous Osteomyelitis Hxx.




Pain and tenderness over an area of bone
A lump may develop over a bone, very tender
Redness of overlying skin
Feeling generally unwell with fever (high temperature) as the infection spreads
- Usually long bones of the leg (femur, tibia and fibula)

Redness, Swelling, Pain around the fracture site, tender lump, Pus may exit from wound over
fracture site
None
Early Stages: Blood Test/Bone Biopsy
Later Stages: X Ray/Surgery
Antibiotic TTT (within 3-5 days of the start of infection)
RED FLAG (fever, infection)
Avoid infected area (gloves) on inspection
Tuberculosis TB
Definition
Who gets it
Symptoms
Signs
Tests
Medical tests
Medical ttt
OMT
Tuberculosis (TB) is a bacterial infection (mycobacterium tuberculosis). It is spread through inhaling tiny
droplets of saliva from the coughs or sneezes of an infected person.
TB mainly affects the lungs. However, the infection can spread to many parts of the body, including the
bones (e.g. spine), organs and nervous system
TB develops slowly in the body. You may not experience any symptoms for many months or even years
after being infected.
Latent TB is where the body is able to wall off the infection
Immune compromised e.g. HIV infection
Non vaccinated
Living in an area
Poor diet & lifestyle
Diabetics
People on steroids
It is suspected that 1 in 8 adults have latent TB
persistent cough
weight loss
night sweats, fever
In skeletal TB - bone pain, curving of the affected bone or joint, loss of movement or feeling in the affected
bone or joint, weakened bone that may fracture easily
Enlarged lymph nodes
Temperature
Respiratory exam
Spinal exam
X-ray, quite difficult to diagnose
Sputum test
Preventative – BCG vaccination if a negative mantoux test
A combination of antibiotics (the Edinburgh method?)
Can cause fibrosis in the lungs
Can cause
Page 11 of 26
Revision – Low back pain
Discitis
Definition
Who gets it
Symptoms
Signs
Tests
Medical tests
Medical ttt
OMT
An infection that affects the intevetebral disc space.
Usually under 8 YOA
Post surgery
Severe Pain in low back or area of surgery
Children may be arching their back
Severe pain
May refuse to walk
MRI but X-ray and CT may indicate
Biopsy
Antibiotics
Pain medication
Brace
If developed into an abscess then this will be drained
Recommend keeping moving within pain limits to encourage fluid movement in the area
Page 12 of 26
Revision – Low back pain
Acquired - Inflammatory
Ankylosing Spondylitis
Definition
Who gets it
Pathophys
Symptoms
A chronic inflammatory condition affecting the spine and SIJs
Young adults 15-40 More Men (9:1)
Women tend to get a more peripheral joint involvement
Thought to be a genetic predisposition with HLA B27
Thought to be some environmental triggers
Inflammation occurs at enthesis,
Bone erodes
Healing with fibrous tissue
Ossification of fibrous tissue results in ankylosis
Reduced ROM
Repetitive cycle.
Stiffening worse in AM (lingers for 3 hours) and after rest. Stiff in more than one or two spinal
joints.
Symptoms improve with exx
Insidious onset of LBP and discomfort. Intermittent LBA lasts days/weeks
Early involvement of SIJ
Stiffness especially in T/L
Pain my radiate to buttock and posterior thighs, rarely below knees
Other features: Ethesitis (plantar fasciitis, Chostochondritis, Achilles tendinitis and attachment sites
at the pelvis)
Signs
Medical tests
Medical ttt
OMT
Non articular symptoms: Fever, Malaise, Iritis, Cardiac involvement, Neuro involvement, Lung
fibrosis due to t.sp fusion
Reduced L.sp lordosis
Maybe muscle spasm
Reduced mobility in all directions
Tenderness at local enthuses
Pain on sacral springing
One or more painful swollen joints
X-ray: Romanus lesion where syndesmophytes form at the insertion of the outer fibres of the
annulus, Calcification of the interspinous and supraspinous ligaments leading to a bamboo spine
Increased ESR with inflammation
HLS-B27
NSAID and Analgesia
Mobilise
Advice on EXX, Posture, Avoid prolonged activity
Page 13 of 26
Revision – Low back pain
Acquired inflammatory cont...
Rheumatoid disease of joints RA
Definition
Who gets it
Symptoms
Signs
A chronic systemic inflammatory disease of the synovial membrane leading to inflammation and
proliferation of the synovium
More Women (3:1)
Onset b/t 10 – 70 YOA with a peak b/t 30-40 YOA
It is thought there are some genetic influences and some immunological influences (bacteria.
Virus)
Genetics, Environment, Immune reaction to bacterial/virus infection
Onset is usually insidious with pain and stiffness
Joint pain worse in AM with some improvement with activity. Stiffness in AM may last for several
hours
Worse at night and can disturb sleep
Usually affects the small joints of the hands and feet: PIP, MCP and Wrist
Radial deviation of wrist, Ulna deviation of the fingers
Swan neck deformity
Boutonnieres deformity
Extra articular features: Malaise and fatigue, Fever occasionally is an early feature, Weight loss,
Sjogrens – dry eyes (white blood cells attach salivary and tear glands), Vasculitis, Pericarditis,
Lymphadenopathy, Bronchial nodules, raynalds
Warm hot joints, swollen and red
Reduced ROM and muscle waste in hands
Later signs: deformity, persistent swelling and marked muscle waste

Pathology
Medical
Medical ttt
OMT&
contraindications
80% hands and feet – PIP, Swan neck deformity, MCP, deformity and in 50% of these
cases there are carpal tunnel symptoms

80% Knee – joint replacement, popliteal cysts can dev and rupture

80-90% Ankle & Foot – arches flatten, nodules around Achilles, MTP can lead to hallux
valgus

60% Shoulder – sublux superiorly and rotator cuff tears

50% Elbow – lose full ext, nodules on the extensor surface

40% Cervical spine Excessive movement of C1 on C2
1. The immune system triggers an Inflammation and proliferation of synovial membrane
2. Synovium can develop a tumour like mass (pannus) which invades cartilage and bone
Lymphocytes, Macrophages and Plasma cells in the synovium. Effusion distends the joint
capsule and stretches the ligaments leading to laxity
3. Healing follows inflammation and fibrotic tissue can reduce the ROM of the joint
4. Rheumatic nodules can form in the joint, each has a central area of necrosis surrounded
by macrophages and fibrous tissue. They can also develop in subcutaneous tissue,
lungs, heart, pleura.
Symptoms present at least 6 weeks
Blood test: Elevated ESR and CRP, mild normocytic anaemia, increased WBC, RH factor +ve,
Positive antinuclear test
Synovial fluid – straw coloured and increased neutrophils present
DMARDS – disease modifying antirheumatic drugs
NSAIDS – symptomatic relief
Also tried: Corticosteroids, Gold, Antimalarials
Often Joint replacement surgery
Education, EXX Diet (fish oil supplements to reduce NSAID need)
Avoid HVT of hypermobile areas
Avoid articulatory techniques
Avoid acute areas
Page 14 of 26
Revision – Low back pain
Acquired - Neoplastic
Bone Metastasis
Definition
Who gets it
Symptoms
Signs
OMT
Common primaries spreading to bone:

Breast

Thyroid

Lung

Kidney

Prostate

Cervix

Colon

Multiple myeloma

Lymphoma
Increased chance in a patient with a Hxx of a primary cancer
Bone pain developing locally over a period of months with a progressive and
unremitting course unaffected by treatment.
Night pain
Night sweats
Sometimes no pain
Be aware that some do respond to ttt.
Lymph nodes
Tender to palpate
Vertebral fracture
No HVT
No vigorous articulation
Osteosarcoma, Fibrosarcoma, Chondrosarcoma
Definition
Sarcoma - any of a group of tumours usually arising from connective
tissue, although the term now includes some of epithelial origin; most are
malignant.
Osteosarcoma - a malignant primary neoplasm of bone composed of a
malignant connective tissue stroma with evidence of malignant osteoid,
bone, or cartilage formation; it is sub classified as osteoblastic,
chondroblastic, or fibroblastic.osteosarco´matous
Symptoms
Medical tests
Medical ttt
OMT
Pain
Lump over the bone
Fracture
Nerve pain
Fever, Chills, Night sweats
Weight loss
X-ray, CT scan, MRI, Bone scan
Surgery, Chemotherapy, Radiation
No HVT
No vigorous articulation
Page 15 of 26
Revision – Low back pain
Acquired - Degenerative
Osteoarthritis, Spondylosis, Spondyloarthrosis
Definition
Non inflammatory degenerative joint disease marked by: degeneration of the articular cartilage,
hypertrophy of bone at the margins, and changes in the synovial membrane accompanied by pain and
stiffness
Spondylosis – reduction of disc height, pain sensitive epithelia can invade the disc fissures and
increased vascularisation
Spondyloarthrosis – increased wear and tear on the facets, facet encroachment into the foramina,
osteophytes at the margins.
Spondylosis and Spondyloarthrosis can occur together and cause a flexed segment which can cause
the lordosis to rise.
Who gets it
Pathology
Symptoms
Signs
Tests
Medical tests
Medical treatments
Contraindications to
OMT
Lumbar OA tends to occur at the greatest range of movement = L3/4 (apex)
Common (up to 85% of population (often asymptomatic); F>M by 2:1 esp. in hands and knees. Risk
factors incl: age >45 YOA, wt, Hxx of trauma, infection & arthritis, post menopausal, total hysterectomy
1.Breakdown of the articular surface
2.Synovial irritation
3.Remodelling
4.Eburnation and cyst formation
5.Disorganisation
Transient pain (aching, burning) , Clicking Crepitus
Worse after activity (rel by rest) & end of day, Stiffness (short-lived);
Night pain;
Weakness due to disuse (no systemic s)
Swelling (poss. bony enlargements) & deformity; Crepitus on movement; Jt. line tenderness; Muscle
weakness & wasting; Alt wt bearing;  ROM, Synovitis
Fixed flexion test for Hip OA but principally clinical based on Hxx & examination
X-rays (blood tests are normal with OA) showing joint space narrowing, osteophytes, sub-chondral
sclerosis, sub-chondral cysts; loose bodies
Conservative (reassurance, life-style changes (wt, exx, diet); Medication (NSAIDs, corticosteroids) for
pain control, manual therapy. Surgery incl:
Debridement, Joint replacement; Joint fusion; Joint realignment, Arthroscopy
Strong techniques; HVT
Disc lesion
Definition
Who gets it
Symptoms
Cracks and fissures
Herniation
Prolapse
20-45 YOA more commonly get NRI following annulus material in the spinal canal
People with a Hxx of acute LBP and NRP
Disc injury with no NRI – LBP central, Unilateral, Bilateral. With or without referred pain into buttock,
post/lat thigh, rarely post calf.
Disc injury with NRI – LBP or Pain into buttock, thigh and calf. Possibly tingling, numbness, cold,
heavy sensation in the distal dermatome
Initially intense muscular spasm and inflammation can confuse diagnosis of the structural cause. Facets
symptoms settle within 10 days
Cauda Equina symptoms: Urinary retention, Faecal incontinence and bilateral sensory loss in the
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Onset
Daily pattern
Aggravating
factors
Relieving factors
saddle area
1. Slight twinge then pain builds over hours/overnight
2. Sudden acute pain on trivial movement often following flexion with rotation or awkward lifting
Worse on rising in AM for 1-3 hours with stiffness and pain on movement.
Difficulty flexing
Pain eases during the day but stays
Possibly difficulty laying down initially
Flexion postures: sitting, bending as it increases intra-discal pressure.
Pain increases with sitting
Valsalve aggravates leg pain
NRP pain be aggravated on standing, walking and weight bearing on side.
Pain may be relieved by moving about
Facet problems
Definition
Who gets it
Symptoms
Facet lock – no joint movement.
Intracapsular – Inflammation In the capsule. Subchondral bruising
Extracapsular – The tissues surrounding the capsule
Anyone
Particularly vulnerable are hypermobile segments due to degenerative changes
Unilateral or Bilateral pain
Referral to Buttock, thigh, calf, (shoulder, arm, Ant-Lat chest wall)
Intense pain 3-4 days which tends to resolve in 7-10 days
Pain lasting for longer may be from a degenerative facet lasting months
Agg: changing position standing from sitting, initially ache on resting and acute pain on movement.
Stiffness following sedentary position
Onset
Initially stiffness in AM which reduces after a few days
Initially rest relieves symptoms, eventually movement reduces symptoms
Facet joint strain
Commonly with a torsion injury at End or Mid range e.g. FLEX & ROT. Pain usually felt immediately but
it may increase later with inflammation
Apophysitis
Woke with a painful and stiff neck – Apophysitis (trapping a synovial fold causing pain and restriction)
Signs
Test
OMT
Facet Lock – trivial movement, reaching, flexing, pushing at mid range. No movement available
Tender to palpate the facet joint
Swelling of the joint capsule may be palpated
Quadrant tests
Intracapsular endochondral bruising – pain on opposition of the facets
Intracapsular inflammation – pain of flexion, stretching the capsule. Pain on sidebending away from the
inflamed capsule.
Apophysitis – NO HVT
Facet Lock - HVT
Lumbar spine stenosis
Definition
Pathophysiology
Narrowing of the spinal canal either

Congenital or

Secondary to Spondylosis, herniation, facet invasion or spondylolythesis, Padgets, venous
congestion

Space occupying lesion (epiconus, arachnoiditis)
If the spinal canal is < 14mm = spinal stenosis

L1 = 23mm

L2 = 22mm

L3 = 21mm

L4 = 22mm

L5 = 23mm
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Revision – Low back pain
Acquired - Metabolic
Osteoporosis
Definition
Who gets it
Risk Factors
Symptoms
Signs
Tests you can do
Medical tests
Medical treatments (and
side effects)
Contraindications to OMT
Progressive metabolic bone disease that  bone density leading to skeletal weakness and #s with
minor trauma esp. in T.sp, L.sp, Wrist & hip
Post-menopausal women (due to lack of Oestrogen) but also 2 due to cancer, COPD, renal
failure, drugs (steroids), endocrine disease, immobilization etc
>50 YOA, Female>Male, Post menopausal, Family Hxx, Long term Glucocorticosteriod use, Race,
Hypogonadism in men, RA
Low BMI, Poor nutrition, Low calcium, Alcohol, Smoking, Low exx, immobile
Asymptomatic until #s occur in which case acute chronic back pain is common.
Common #: Hip, Vertebrae, Wrist
Eventually muscle pain. Agg by wt bearing.
Loss of height, Stooped posture
Local tenderness, dorsal Kyphosis & exaggerated CSp lordosis (due to multiple T.sp compression
#s); loss of height;
Non conclusive but checking for #s with tuning forks and local palpation
Dual energy x-ray absorptiometry (DEXA) measuring bone density T score -2.5
X-rays only show  density until 30% of bone is lost)
Medication Bisphosophonates (alendronatehen, risedronate ) to preserve bone mass reducing
Osteoblastic activity
Calcium, Calcitonin and Vit D supplements
Exx to max bone & muscle strength & minimize risk of falls;
No strong techniques that can cause #s, HVT
Osteomalacia / Rickets
Definition
Who Gets It
Risk Factors
Symptoms
Signs
Tests I can Do
Medical Tests
Medical
Treatments
Contraindications
to OMT
Calcium
metabolism
Softening of bones due to defective bone matrix mineralisation, ultimately as a result of vitamin D
deficiency
Osteomalacia: Adult form of the disease – after growth plates have closed
Rickets:Childhood form of the disease – before growth plates have closed
Primarily as a result of insufficient nutrition.
Secondary to disorders of gut e.g. celiac, pancreas, liver and kidney.
Others include people who have insufficient sunlight exposure, are pregnant,
Poor Vitamin D intake (little exposure to sunlight, housebound or hospitalised
Bone pain, esp. Lower spine, pelvis, Hips, leg bone, ribs or dental pain
Muscle weakness + fatigue possibly a waddling gait
Weak bones with increased risk of #
Compressed vertebrae / pelvic flattening / bone softening and waddling gait.
Osteomalacia: Bony deformity – vertebral bodies + skull
Rickets:
Bony deformity – bowed legs, knock knees
Hypocalcaemia – Perioral P+N, Tetany
Case history, Tuning fork to oscillate cracks in bone to generate pain. Unreliable!
Blood/Urine test: Low Vitamin D, Low Phosphosus, Low Calcium
X-ray – slight cracks may be seen in bones, Bone density scan, Bone biopsy!
Exposure to Sunlight
Diet modification to increase intake of Vitamin D, Calcium, Phosphates. Sources: cod liver oil, viosterol,
fortified foods or supplements.
Diagnosis or suspicion of Rickets or Osteomalacia is an absolute contraindication to HVT or robust
articulation.
Calcium is absorbed in the small intestine via Vitamin D dependant active ion transport. Primarily in the
duodenum dependant on Vit D, If calcium intake levels are high it can be absorbed in the Jejunum and
the Ileum passively
The kidney processes Vit D into Calcitrol which enables absorption of calcium, stimulated by parathyroid
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Revision – Low back pain
hormone
Calcitonin helps store calcium in bone (reducing it from blood)
Parathyroid hormone releases calcium from bone (increasing blood calcium levels)
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Revision – Low back pain
Acquired - Endocrine
Cushings
Definition
Who gets it
Symptoms
Signs
Cushing’s disease is a condition in which the pituitary gland releases too much
adrenocorticotropic hormone (ACTH).
A tumour or hyperplasia of the Pituitary gland
ACTH stimulates the release of Cortisol (controls carb, fat, protein metabolism and
inflammatory response)
People taking glucocorticoid drugs
Tumour that produces ACTH e.g. in pituitary
Rapid weight gain
Hyperhydrosis
Skin thinning and easy bruising
Insomnia
Amennhorea/Oligomenorrhea, infertility
Back ache
Bone pain and tenderness
Central obesity, thin limbs, Moon face, Buffalo hump, Acne
Purple strae ½ an inch wide
Hirsuitism
Decreased fertility, impotence
Mental changes: fatigue, poor mood, depression, anxiety
Medical Tests
Medical TTT
24 hour urine cortisol
Blood ACTH level
Brain MRI
Surgery to remove tumour or Radiation to the Pituitary
Removal of Adrenal Glands
Medication to control Cortisol production
OMT
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Revision – Low back pain
Acquired - Idiopathic
Padget’s disease
Definition
Who gets it?
Symptoms
Normal cycle of bone renewal and repair is disrupted, can cause bone weakening
Second most common bone disease to Osteoporosis
1-2% >55 YOA increasing to 7% >80 YOA
White British decent more widespread in the north of the country. Also in countries with high levels of
migration from the UK
Often none
Bone pain, worse at night or laying down
Hypercalcaemia: Malaise, Depression, Drowsiness, Constipation (linked to kidney stones)
Other Complications include:

# to bone

Bone deformity

Deafness

Vertigo

Headaches

Tinnitus

Neurological symptoms where the bone has reduced nerve passage

OA

Heart failure, vessels become damaged in bone and require increased effort to pump the blood
(SOB, Tired, Peripheral Oedema)

Cancer – 1 in 1000 Padget’s get sarcoma (bone pain, swelling around the affected bone, lump
on the bone)
Signs
Medical Tests
Medical TTT
X-Ray signs of increased bone remodelling
Pain relief
Bisphosphonates –reduces Osteoclastic activity, tablet taken 1* day and stand up for 30 mins to avoid
heartburn if taken orally
Calcitonin – where calcium in blood is low, injection 1* day
Physio – following #
Surgery – following # or OA changes to replace a joint
Scheuermann’s disease aka Osteochondrosis or Osteochondritis
Definition
Who gets it?
Symptoms
Signs
Effects on the
body
Adolescent osteochondritis usually in T.sp (T6 – T10).
A defect in the secondary ossification centre in the vertebral body causes an irregularity in the ossification
of the vertebral body epiphyses. Cartilaginous end-plates may be weaker than normal and damaged by
pressure from adjacent IV discs, sometimes associated with small herniations of disc material into
vertebral body (Schmorl’s nodes). With  growth and mm activity, affected vertebrae become wedgeshaped as ant bodies are subjected to greatest stress.
Adolescents (13 – 16yoa), boys>girls
Possibly due to collagen defects
Can be associated with mental and physical shocks
Active stage (1-2 years during puberty): Pain in T.sp, fatigue, after some months pain , parents may
comment that their teenager is “round shouldered” or has poor posture.
Later life: LBP from compensatory L.sp ext, pain above and below the hypomobile segment
Flexed hypomobile segment does not improve with a change in posture
Round back/round shoulders
Compensatory lumbar lordosis
Active stage: Pain agg by activity or long periods standing.
Later in life: pain from OA, pain above and below segment
Hypomobile segment leads to early degenerative change to disc through reduced tissue health results in
Spondylosis
Change in neural health in the area affected
Reduced force transmission
Can restrict rib movement, increasing upper rib breathing and increased chance of RTI
Can affect the thoracic pump affecting venous drainage from LEX
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Revision – Low back pain
Tests you can
do
Medical tests
Medical
treatments (and
side effects)
OMT
Contraindicatio
ns to OMT
Does the Hypomobile segment flexed segment improve with a change in posture?
X-ray signs:

Vertebral end plates appear irregular or fragmented

Radioluscent defects in subchondral bone (Schmorl’s nodes).

Bodies become wedge-shaped

Claw osteophytes

Detached epiphyseal ring
<40o: Back-strengthening exercises and postural training
40 – 60o: Brace to T.sp Kyphosis
>60o: Fusion using a hook-rod system
Work to improve ROM of hypomobile segment
Look at rib, diaphragm movement
Advise at the hyper vascular stage during puberty to modify activities avoiding high impact
Avoid extreme flexion
Be aware of possibility of anterior spurs on vertebral bodies
Piriformis syndrome
Definition
Who gets it
Symptoms
Signs
Tests
TTT
Sciatic neuritis (L5-S3)due to Piriformis contracture or spasm leading to mechanical or chemical
infiltration of the nociceptors of the nevi nevorum of the epineurium causing pain and
paraesthesia in the sciatic nerve distribution.
Anatomic anomaly - In 75% of people the sciatic and posterior cutaneous nerve pass beneath
Piriformis. In 5% of people the sciatic nerve or branches of it (common peroneal, tibial) pass
through Piriformis
Injury to gleutei
Biomechanical overuse (LLD)
Tight external rotators
Can cause minot low back ache
Aggrevated by neck flexion and SLRT
SLRT +ve
Hibb’s +ve which stretches piriformis
Massage
Mobilise with MET
Look at the pelvis and LLD
Stretching exx
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Revision – Low back pain
Acquired - Psychogenic
o
Psychosomatic
Acquired - Visceral
o
o
o
o
IBS
Crohns
Peptic ulcer
Carcinoma GIT
Acquired - Vascular
o
o
AAA
Dissecting
Acquired – Renal conditions
o
o
o
Calculus
Carcinoma
Inflammatory disease
Acquired – Gynaecological conditions
o
o
o
o
PID
Endometriosis
Neoplasm
Batsons Plexus can influence LBP before or after periods
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Revision – Low back pain
Pain
Nociceptor stimulation:
Nociceptors are found in all tissues of the body which a nerve supply (Skin, Muscle,
Ligaments, Fascia, Tendons, Joint capsules, Synovium, Outer disc, Dura, Blood vessels,
Viscera)
Nociceptors sample the environment to report disturbance from normal: Chemical irritation,
Mechanical deformation, Temperature changes
Information enters the dorsal horn and is transmitted to higher centres where it may be
modulated
Central neurogenic
Peripheral neurogenic
Pain referral patterns
Pain felt other than at the source of pain. No actual damage to the region of pain. Results
from central processing of pain sensation. Extent of referral is proportional to the intensity of
the stimulation. Referred pain usually presents with local pain. Non dermatomal pattern and
can vary in a subject from moment to moment. Usually aggravated by movement of the
inflamed tissue, not movement at the location of referral

Nerve root pain – Motor loss of muscles supplied by the nerve, Sensation loss in a
dermatomal pattern
NRI – Leg pain
NRC - objective neurological signs, sensory loss, muscle power loss. More serious!
NRP –
o
o
o
o
o
o
unpleasant,
More intense in the limb than spine,
in a nerve root distribution, tingling in a dermatome
Pain exacerbated by movement
Unpleasant tingling, numbness
Shooting lancinating pain in a line into the leg
Causes:
o Disc commonly <40 YOA
o Facet joint capsule bulging
o Intra-neural e.g. Neurofibroma or Cancer. Gradual onset of symptoms

Somatic referred pain:
o
Structures that refer away from the spine: Disc, Ligaments, Facet Capsule,
SI Capsule, Muscle, Fascia, Nerve Root.
o
C2/3 (occasionally C3/4) referred up the back of the Occiput, can spread over
the head to the forehead with more intense stimulation. (Bogduk & Marsland)
C3/4 back of neck. (Bogduk & Marsland)
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Revision – Low back pain
o
C5/6 and C6/7 refers down into thorax and across the shoulder. (Bogduk &
Marsland)
o
Thoracic joints referred pain 1 joint inferior and lateral to the location, ½
vertebral height of segment superior. Unilateral pain that did not cross the
posterior axillary line. (Dreyfuss et al)
o
o
o
o
o
L1/2 Intracapsular lateral flank and around the iliac crest. (McCall)
L1/2 pericapsular lateral flank and into the groin
L4/5 Intracapsular glutei and L1 dermatome
L4/5 pericapsular glutei and into lateral thigh
Sacroiliac Intracapsular refers pain over the SI joint line and into the groin,
possibly posterior thigh and calf with more symptomatic people.
Discs can refer into the leg and below the knee
o

Viscero somatic (not usually agg by movement
o
o
o
o
o
o
o
o
o
Stomach – pain can refer to L1/L2 rarely without epigastric pain. Starts 1-3
hours after meals (duodenal ulcer)
Kidney – T12-L1 cost vertebral angle. Radiates around the flank towards the
umbilicus. Usually dull and constant
Gallbladder – commonly felt in the epigastrium and may ref to the mid or
lower thoracic region. Can refer to the right shoulder tip
Pancreas – pain refers to L1
Uterus – low back ach – vague
Prostrate – low back and external genitalia. Cancer is unlikely to directly
cause LBP. Metastasis can cause a secondary in the spine causing low back
pain
Lungs
Aorta – aneurysm (weakening of the wall) can present as leg pain on walking
up hill relieved by stopping.
 LBP from direct pressure on vertebral bodies and surrounding
structures.
 Abdominal pain dull and steady unrelated to meals or activity.
Epigastric discomfort which may radiate to the buttocks and thighs
Colon – can refer pain to the back. Pain may start in the abdomen a radiate to
the back. Pain may be relieved by passing a stool
Can be associated with other symptoms

Emotional Somatic
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