Spine Evaluation
1. History
• Chief Complaint:
A. What happened?
B. Is it a sharp or dull pain?
C. How long have you had the pain?
D. Can you pinpoint the pain?
E. Do you have any numbness or tingling?
• Mechanism:
A. How did it happen?
B. What was felt or heard?
• Previous History:
A. Have you injured this before?
2. Observation
• Swelling
• Discoloration
• Posture
A. Scoliosis: Lateral or “S” curvature of the spine
B. Lordosis: Frontal curvature of the lumbar spine
C. Kyphosis: Also called “Gibbus deformity.” Posterior curvature of the upper
thoracic spine
• Skin markings
A. Lipomata: Fatty masses appearing on the skin.
B. Hair Patch: Called “Faun’s Beard.” Sign of underlying spina bifida occulata
C. Café au Lait Spots: Darkened patches of skin. Sign of underlying collagen
disease of a connective tissue
• Gait (e.g. Lurches, Steppage)
• General appearance
A. Muscle tone
B. Scares
C. Leg length (true and apparent)
3. Check the bone for fracture
• Proper location and palpation
A. Vertebrae (spinous processes and facets)
− 7 Cervical vertebrae
♦ Fx and dx⇒ spinous pain, muscle spasm, bilateral sensory deficits,
motor weakness, paralysis
♦ Usually caused by headfirst contact
− 12 Thoracic Vertebrae
− 5 Lumbar Vertebrae
♦ Spondylosis: Bony defect in line (stress fx of the transverse process,
no slippage)
Copyright © 2004, Yoshiyuki Shiratori. All right reserved.
♦ Spondylolisthesis: Forward slippage of one vertebrae on another
Usually at L4/L5 or L5/S1
− 5 Sacral Vertebrae (fused)
− 4 Coccygeal (fused)
♦ Coccydynia: Painful coccyx
Surface Landmarks on the back
Bony Landmark
One finger’s breadth inferior to the mastoid process
Posterior to the cricoid cartilage
Prominent spinous processes in neck
Top of scapula
Base of spine of scapula
Lowest floating rib
Top of iliac crest
Demarcated by bilateral dimples
Level of PSIS
(From: Sports Injury Management 2
4. Check the ligaments
• Supraspinal: Between each vertebrae
• Ligamentum nuchae
• Ligamentum flavum
Vertebra
C2
C6
C7 and T1
T2
T4
T12
L4
L5
S2
rd
Ed.)
5. Check the soft tissue and muscle tendons
• Scalene
• Sternocleidomastoid
• Trapezius
• Latissimus Dorsi
• Rhomboid
• Erector Spinae
• Quadratus Lumborum
• Internal Obliques
• External Obliques
• Rectus Abdominus
6. Compare ROM
• Compare bilaterally
• Stabilize the proper area
• AROM
A. Lumbar Flexion
− Bend forward
− Have the athlete slide their hands down their thigh
B. Lumbar Extension
− Place one hand on their back and ask the athlete look toward the ceiling
Copyright © 2004, Yoshiyuki Shiratori. All right reserved.
•
C. Trunk Lateral Bending
− Stabilize the iliac crest and lean to the left/right while they slide their hand
down their leg
D. Trunk Rotation
− Stabilize the iliac crest with one hand and have the athlete to look over
their shoulder
E. Neck Flexion
− Should be able to touch their chin. Watch for smoothness of motion
F. Neck Extension
− Should be able to look at the ceiling. Watch for smoothness of motion
G. Neck Lateral Bending
− Should be able to tilt their head about 45º
H. Neck Rotation
− Should be able to move to the line of the shoulder
− Torticollis⇒limited ROM
PROM: Perform the same motion as AROM
7. Resistive ROM
• Stabilize the proper area
• Compare bilaterally, starting with the non injured ankle
• Performed both concentric and eccentric tests
A. Trunk Flexion
− Athlete is supine
− Have the athlete do a crunches/ sit ups
B. Trunk Extension
− Athlete is prone
− Stabilize the leg and have the athlete do a back extension against gravity
C. Trunk Lateral Bending
− Athlete lays on the side
− Stabilize the leg and lift body up against gravity
D. Trunk Rotation
− Stabilize at the iliac crest
− Pressure against the opposite posterior shoulder
E. Neck Flexion
− Pressure against the forehead
F. Neck Extension
− Pressure against back of the head
G. Neck Lateral Bending
− Stabilize the opposite shoulder
− Pressure against the side of the head
H. Neck Rotation
− Stabilize the opposite shoulder
− Pressure against the side of the head
8. Orthopedic Special Tests (Lumbar/Thoracic Spine)
Copyright © 2004, Yoshiyuki Shiratori. All right reserved.
•
Test for disk herniation
A. Valsalva Maneuver
− This test assesses for a herniated disk or other intrathecal lesion in the
spinal canal
♦ Position: Athlete is sitting
♦ Procedure: Have the athlete take a deep breath
Bear down as if they were trying to move their bowels
Blow into a closed fist
♦ Positive sign: Pain in the spinal cord by the herniation
This test is also done for cervical herniation
•
Test for neuropathy
A. Straight Leg Raise Test
− This test assesses sciatic nerve irritation
♦ Position: Athlete is supine
♦ Hand placement: Support the foot around the calcaneus
♦ Procedure: Passively flexed the athlete’s hip (knee is in full extension)
until pain or discomfort is felt. Slowly lower the leg to release pain.
Then dorsiflex their leg
♦ Positive sign: Dorsiflexion eliciting pain
Pain with hip flexion indicates tight hamstring
B. Well Straight Leg Raise Test
− This test is used to identify a disc herniation
♦ Position: Athlete is supine
♦ Hand placement: Support the foot around the calcaneus
♦ Procedure: Passively flex the hip as in the SLR test. Just perform on
the uninvolved side
♦ Positive sign: Increased pain on the involved side
C. Babinski Test
− This test is used to identify an upper motor neuron lesion
♦ Procedure: Using a blunt object (e.g. pen light, end of a reflex
hammer), run the object on the plantar aspect of the foot, starting from
the calcaneus along the lateral border to the forefoot.
♦ Positive sign: Great toe extension and flexion of digits 2-5
D. Oppenheim Test
− This test is used to identify an upper motor neuron lesion
♦ Procedure: Run your fingernail or an object along the crest of the
athlete’s tibia
♦ Positive sign: Same reaction as Babinski
Copyright © 2004, Yoshiyuki Shiratori. All right reserved.
E. Kernig- Brudzinski Test
− This test is to determine nerve root irritation, meningeal irritation, or dural
irritation. This test is a combination of two tests, Kernig’s and Brudzinski
♦ Position: Athlete is supine with their hands behind their neck and leg
extended
♦ Procedure: Have the athlete flex their neck (Kernig’s Test). Then have
them flex their hip with knee extended (Brudzinski Test). Once pain is
felt, have the athlete flex their knee
♦ Positive sign: Cervical pain disappears with knee flexion
Pain in the lower back or down the leg indicates a meningeal or
dural irritaion
F. Bowstring Test
− This test is used to identify compression or tension of the sciatic nerve
♦ Position: Athlete is supine
♦ Hand placement: Same as SLR test
♦ Procedure: Perform at SLR test until pain or discomfort is felt. Flex
the knee to relieve pain, and apply pressure at the popliteal fosssa
♦ Positive sign: Pain in the popliteal fosssa
G. Hoover Test
− This test helps to determine if the athlete is malingering (faking an injury)
when they state that they cannot raise their leg
♦ Position: Athlete is supine
♦ Hand placement: Place one hand under each heel and lift their leg
slightly off the table
♦ Procedure: Have the athlete to lift up one of their leg
♦ Negative sign: Should feel a downward pressure on the opposite heel.
If you don’t feel any pressure⇒ the person is NOT TRYING!
•
Test for vertebral defects
A. Stork Standing Test (Spondylolisthesis Test)
− This test assesses a pars fracture
♦ Position: Athlete is standing on one leg
♦ Procedure: While balancing, have the athlete extend their spine back
ward. Repeat test on the other side.
♦ Positive sign: Pain in the back
If the pain is felt on one leg, the fracture might be unilateral
•
Test for joint instability
A. Spring Test
− This test determines if the pain is from the SI joint
♦ Position: Athlete is prone with rolled towel underneath the ASIS
♦ Hand placement: Place one hand over the apex of the sacrum, and the
other hand on top of the other
Copyright © 2004, Yoshiyuki Shiratori. All right reserved.
♦ Procedure: Apply downward pressure
♦ Positive sign: Increase pain
Perform other SI test if it is positive
9. Orthopedic Special Test (Cervical Spine)
• Test for nerve root compression
A. Cervical Compression Test
− This test is used to differentiate a nerve root compression and a soft tissue
injury
♦ Position: Athlete is sitting with the neck in a neutral position
♦ Hand placement: Both hands on top of the athlete’s head
♦ Procedure: Apply downward pressure
♦ Positive sign: Pain refers down the arm
B. Spurling’s Test
− Same as compression test. Usually done after the compression test is
negative
♦ Position: Athlete is sitting, with their neck in extension and rotation to
the involved side
♦ Hand placement: Same as compression test
♦ Procedure: Apply downward pressure
♦ Positive sign: Pain refers down the arm
If the pain in the neck is without radiation⇒ soft tissue pain
C. Cervical Distraction Test
− This test will confirm suspicion of a nerve root compression
♦ Position: Athlete is sitting
♦ Hand placement: One hand at the base of the skull and the other hand
under the chin
♦ Procedure: Apply gradual upward force
♦ Positive sign: Symptoms subside
D. Shoulder Depression Test
− This test determines a brachial plexus stretch
♦ Position: Athlete is sitting
♦ Hand placement: One hand stabilizes the shoulder, while the other
hand is placed on the side of the head on the involved side
♦ Procedure: Passively lateral bend the neck to the uninvolved side
♦ Positive sign: Elicit pain or other symptoms
•
Test for brachial plexus neuropathy
A. Brachial Plexus Tension Test
− This test assesses upper limb tension
♦ Position: Athlete is seated
♦ Procedure: Hold the elbow for stabilization
Copyright © 2004, Yoshiyuki Shiratori. All right reserved.
(1) Have the athlete abducts the arm with the elbow extended,
stopping just short of the onset of the symptoms
(2) Externally rotate the shoulder just short of symptoms
(3) Flex their elbow so that the hands lie behind the head
♦ Positive sign: Recreating the pain, numbness, or tingling along the arm
B. Tinel’s Sign (brachial plexus)
− This test assesses the pathology of the brachial plexus
♦ Position: Athlete is sitting with neck in slight flexion
♦ Procedure: Tap the transverse process
♦ Positive sign: Reproduction of the symptoms
•
Test neurovascular dysfunction
A. Vertebral Artery Test
− This test assesses the compression of the vertebral artery
♦ Position: Athlete is supine or sitting. If supine, have the athlete’s head
at the edge of the table
♦ Procedure: Passively move the athlete’s head in extension, lateral
bending, and rotation to the involved side
♦ Positive sign: Dizziness (nystagmus), lateral movement of the eye
•
Neurological Tests
A. Reflexes
− Biceps Brachii Tendon Reflex
− Brachioradialis Tendon Reflex
− Triceps Tendon Reflex
♦ (** We will cover these reflexes on Shoulder or elbow eval)
− Achilles Tendon Reflex
− Patellar Tendon Reflex
− Hamstring Tendon Reflex
B. Dermatomes
(For Brachial Plexus)
Copyright © 2004, Yoshiyuki Shiratori. All right reserved.
(For Lumbar Plexus)
(From: Assessment of Athletic Injury)
C. Myotomes
− Lower extremity⇒ look at foot and ankle eval
− Upper extremity⇒ we will cover it in shoulder or elbow eval
Copyright © 2004, Yoshiyuki Shiratori. All right reserved.