7. LBP Flashcards
What is the action of the piriformis muscle?
ER of Hip (when extended) and abduction (when hip is flexed).
What is piriformis syndrome?
- May be associated with what?
- What special test is non-specific, but may be (+/-)?
-
Deep ache/ LBP => butt (greater sciatic foramen) => that radiates down the posterior aspect of the thigh. Numbness and tingling in SAME pattern bc sciatic nerve is close
- Worsens when sitting > 20 minutes; better when walking
- Trauma or overuse/ wallet test
- Straight leg raise test
In Piriformis Syndrome, what may increase susceptibility of sciatic nerve entrapment?
How close the [piriformis m] is to the [sciatic nerve].
What SD may be associated with Piriformis Syndrome
- Ipsilateral hip ER SD
- Sacrum is rotated anteriorly towards ipsilateral side on a contralateral oblique axis.
- R-sided pirformis syndrome => L/L sacral torsion with compensatory rotation of lower lumbar vertebra to the R.
- => leads to ipsilateral physiologic short leg
How is Piriformis Syndrome diagnosed?
-
Diagnosis of exclusion: rule out other causes with PE, XR, and/or MRI
- MRI is LAST resort
How is Piriformis Syndrome treated?
- OMT
- PT = effective for most
- Analgesics, glucocorticoid injection or botox injections
What physiological change do we see with piriformis syndrome?
Short ipsilatal leg
Piriformis syndrome will cause a TP where?
2/3 of the distance between the ILA and greater trochanter.
L/L Sacral Torsion
What will we find?
- R sacral sulcus = deep/ anterior
- L ILA = shallow/ posterior / inferior
What is psoas syndrome?
- Chronic psoas spasm can cause what?
RLQ sharp, cramping pain that radiates to the lower back with hypertonic psoas muscle.
- Chronic => persistent strain across lumbosacral junction.
Psoas Syndrome
- What SD may be associated?
- If crhonic
- Type 2 SD of L1 and L2: flexed and rotated towards side of affected psoas; SB towards
- L5 E (extended)
- Chronic psoas syndrome: may have two type 1 SD (1 above and below) around the type 2 SD of L1/L2
Psoas Syndrome TP is commonly found where?
Ipsilateral iliacus and contralateral pirformis
OMT for Psoas Syndrome?
- OMT directed at SD in [thoracolumbar junction and lumbosacral area].
- Stretch hypertonic psoas m.
Short Leg Syndrome
- Describe the pain
- Findings?
- Often have pain/SD where?
- Often associated with what disease?
- Dull, midline lumbosacral pain that gets worse as the day progesses due to sacral base unleveling
- Findings: sacral base unleveling; medial mallelos short after SD resolves
- SI and lumbosacral joint pain/SD
- Scoliosis
When there is pain in the [lumbosacral area], what is the first structure to react?
Iliolumbar ligmant; tender where it attaches [iliac crest] or [L4/5 TP]
Where is the Chapmans point for iliolumbar ligament?
Colon
SD associated with Short Leg Syndrome
- Lumbar spine is [SB away] and [rotated towards] the side with the LOWER sacral base
- Anterior inominate rotation on side of the short leg;
-
On longer leg
- Posterior innominate rotation on side of l_ong leg._
- Pelvic side shift to the side of the longer leg
- Foot = pronated and IR
How do you dx short leg syndrome
Standing postural XR and measure: iliac crests, femoral head and sacral base
How to treat Short Leg Syndrome?
- Treat SD 1st.
- Stretch assymetric muscles
- Heel lift therapy
- If there is an acute change in leg length, replace full discrepancy IMMEDIATELY.
heel lift therapy?
- Only treat if discrepency is ______.
- How much heel lift can we add?
- Final lift height
- Only treat if leg length discrepancy is > 5 mm
- Add a max of 1/4 heel lift in shoe; 1/4 can may be added to outside (1/2 total). You can add total 1/2 outside the shoe.
- Final lift height should be 1/2 - 3/4 of measured discrepancy, unless recent sudden cause apparent
When performing Heel Lift Therapy, if patients condition is fragile, how much heel lift do we add? Flexible?
- Fragile: Start with 1/16 and add 1/16 every 2 weeks.
- Flexible: Start with 1/8 and add 1/8 every 2 weeks.
A 21 year old male comes into clinic with low back pain and left buttock pain for the past 2 weeks. He is an offensive lineman on the local college football team. He does not recall a specific injury, but states that he sustains several hits during practice and games. History reveals that for the past month he has had a change in gait. He denies any radiation of pain down the legs. Straight leg raise test is negative. During the TART exam there is a palpable “step off” in the lower lumbar spine when the patient flexes forward. Which of the following mechanisms most likely contributed to this patient’s presentation?
- A. hyperflexion injury of the spine
- B. repetitive hyperextension of the spine
- C. axial load injury to the spine
- D. rapid twisting motion of the spine
- B. repetitive hyperextension of the spine => Spondylolysis** and **Spondylolisthesis
What does Spondylolysis/Spondylolisthesis cause?
Hyperlordosis due to repetitive hyperextension, stress, overuse or macrotrauma.
Spondylolysis vs Spondylolisthesis
____________: stress fracture in the pars interarticularis
____________: stress fracture + sliding of vertebra
- Spondylolysis: stress fracture in the pars interarticularis
- Spondylolisthesis: stress fracture plus sliding of vertebra
Who displays symptoms in Spondylolisthesis and what are they, typically?
Bilateral/unilateral fractures.
-
> 20 ; children are often have change in gait/posture
- LBP => butt/posterior thigh; tight hamstrings
- 80% of time => bilateral fxs
Who displays symptoms in Spondlylolysis and what are they, typically?
- Children => asx
- Adolescent athlete => gradual onset of LBP that can radiate to butt/posterior though
Spondylolysis/Spondylolisthesis
- Pain MORE likely to radiate to buttocks or posterior thigh.
Spondylolisthesis
Spondylolysis/Spondylolisthesis
- Finding:
- Common SD?
Finding: step off of SP in lumbar flexion
- Psoas spasm/inhibition
- Iliacus dysfunction
- Flexed upper lumbar dysfunction
- SI/sacral torsion
- Inominate dysfunction
Dx and Tx Spondylolysis/Spondylolisthesis with OMT?
- AP, lateral and oblique XR
- Indirect & ST; no HVLA
Spondylolysis/Spondylolisthesis
- Focus XRCISE on:
- Other treatments
- Focus exercise on strengthing muscles and getting rid of lordosis
- Stretch hamstring, improve posture, avoid contact sports
A 40 year old male presents to the clinic with pain in the right buttock that radiates down the posterior thigh that has been going on for one week. He has also had weakness in his right leg and has lost his balance a few times. Straight leg raise test is positive. Imaging of the lumbar spine reveals herniation of the spinal disc between L4 and L5. Protrusion of which of the following anatomical structures is most likely responsible for causing the patient’s symptoms?
A. nucleus pulposus
B. annulus fibrosus
C. vertebral body
D. vertebral endplate
A. nucleus pulposus
What is spinal disc herniation?
Rotational stress causes microtrauma => makes disc more prone to damage => sudden compressive or rotational force can tear a weak [annulus fibrosis], [releasing nucleus pulposis]
- => sudden onset of LBP with bending/lifting and may be associated with radiculopathy (=> posteior thigh => LE weakness)
Spinal Disc Herniation
- Most common herniation: ________.
- Most commonly affected discs: __________.
- Symptoms are due to: ___________
- May be associated with _______
- (+) Special Test:
- Posterolateral herniation
- L4-5 and L5-S1
- Inflammation of the nerve root, NOT direct pressure
- Radiculopathy
- Straight Leg Raise Test
Spinal Disc Herniation
- Confirmation of herniation:
- Tx:
- OMT:
- MRI
- If acute: conservative treatment (rest a few days, ice, NSAIDS, steroids).
- After acute phase: OMT at muscles and PT.
- FPR = useful to tx radiculopathy.
Spinal Disc Herniation:
- Findings:
- OMT findings:
- Indications for surgery
- straight leg raise and LE weakness
- None
- Intractable pain, progressive, or moderate => severe neuro deficit.
Best tx for radiculopathy?
FPR
A 57 year old female presents to the emergency department for low back pain that radiates down her bilateral posterior thighs to the level of the knee. She states that 13 hours ago she was helping to move a couch when something “tweaked wrong” in her back. She has not urinated or had a bowel movement since this event. Which of the following is most likely to be found on physical exam?
- A. positive Thomas test
- B. decreased temperature sensation in the left lower extremity
- C. decreased pinprick sensation in perineum
- D. L2 F Rr Sr
- C. decreased pinprick sensation in perineum
Cauda Equina Syndrome
- What is it?
-
Spinal nerve root compression caused by a [massive disk protrusion, fracture or ABNL mass].
- => LBP that radiates down her bilateral posterior thighs => knee => results in bowel and bladder dysfunction and saddle anesthesia (sensory loss in perineum)
- Also: radicular pain, paresthesias
If you suspect a patient has Cauda Equina Syndrome, what do you do?
Imp OMT findings?
- Medical emergency –emergent decompression within 48 hrs or permanent neurological damage
- None
A 62 year old F presents to the outpatient clinic with low back pain. She states that the pain has been intermittent over the past several months, usually lasting for several weeks before going away for some time. It seems to get worse when bending over and sitting down, and l_ying down makes it bette_r. She walks her dog daily and seems to think that the pain does not bother her as much during this activity. She denies radiation of pain down her legs. Which of the following is the most likely explanation for the patient’s symptoms?
- A. anterior slippage of vertebral body
- B. “wear and tear” of intervertebral discs
- C. microfractures from chronic axial compression
- D. herniation of intervertebral disc
- B. “wear and tear” of intervertebral discs = Degenerative disc disease
What is Degenerative disc disease?
Natural part of aging that causes Intermittant, non-specific LBP and NO radiation down legs.
- Worse = bending over and sitting.
- Better = laying down and does not bother with actvity.
Degenerative Disc Disease
- ___ spine is most often affected d/t mobility and weight-bearing responsibilities.
- Dx:
- Treatment?
- Lumbar spine
- XR: however, poor correlation w XR and pain
- OMT, PT, NSAIDS/acetominophen
By age 49, 60% of ___ and 80% of ___ have osteophytes and other changes => indicative of degeneration
60% =.> Women
80% => Men
A 52 year old male presents to the family medicine clinic with low back pain. This has been going on for several months. He states that the pain is worse when he is standing for long periods of time or walking up stairs, with occasional symptoms of numbness and tingling in his posterior thighs. The pain is better by sitting down or leaning over, such as on a grocery cart. What is the most likely underlying mechanism causing his symptoms?
- A. chronic type 1 lumbar somatic dysfunction
- B. chronic extended posture of lumbar spine
- C. narrowing of the intervertebral space
- D. narrowing of the spinal canal
D. narrowing of the spinal canal = Spinal stenosis
What is Spinal Stenosis?
Narrowing of the spinal canal that causes LBP and radiculopathy
- Worse = standing upright or walking for long time
- Better = sitting, l_aying down_ or leaning over
What causes spinal stenosis?
- Herniated or bulging disc
- Abnormal mass
- Osteophytes (bone spurs) from osteoarthritis
- Scar tissue from previous surgery
What type of spinal stenosis => neurogenic claudication: central stenosis or lateral stenosis?
Central stenosis
Spinal Stenosis
- Dx
- Treatment
- Dx = MRI
- TX: OMT helped 50% of pts, PT, aspirin/NSAIDS
- if severe => surgery
HVLA CI to OMT in LBP
- LBP due to [vertebral tumor or cancer metastasis to spine]
- Hx of osteoporosis
- Acute phase of RA affecting lumbar spine
- Acute lumbar disc herniation (relative CI)
CI for OMT for compression fracture
- Most direct tx (except direct MFR)
Which causes of LBP will you see a + straight leg raise test?
- Spinal disc herniation
- Piriformis syndrome (can be +/-)
