Lower Body Part 1 Flashcards
Assesses posterolateral, posteromedial, subrhizal, and postero-central disc protrusion.
Antalgia Sign
Antalgia Sign: Procedure
Observe the patient in an antalgic lean
Antalgia Sign: Pathomechanics
With unilateral nerve root entrapment from a disc protrusion that creates low back and/or leg pain/symptoms. And the patient moves into a position to stay out of pain.
Antalgia Sign: Indications
The protrusion lateral to the nerve root causes the patient to lean away from the symptoms. The patient that has a unilateral nerve root entrapment with low back and/or leg pain and the disc is medial to the nerve root; the patient will lean into the side of pain. Unilateral symptoms and they lean forward, and then the disc bulge is in front of the nerve root. Patient has bilateral pain, indicates a central disc protrusion.
Correlate with antalgic sign, only you observe the patient going from seated to standing.
Minor Sign
Minor Sign: Procedure
As the patient goes from a seated to a standing position, the examiner observes if the patient is antalgic and has difficulty arising from a seated position (such as using their hands to walk up their body while antalgic).
Minor Sign: Pathomechanics
When a patient has an antalgic lean due to a disc protrusion the patient will sit with that lean. In order to rise from a seated position and stay out of pain as they rise, they will guard themselves upon rising. In the absence of a disc lesion many other low back conditions can be painful enough to cause the patient to guard upon rising.
Minor Sign: Indications
Lean away from the side of pain=lateral disc; lean toward the side of pain=medial disc; lean forward with unilateral pain subrhizal disc; lean forward with bilateral pain central disc and in the absence of a disc lesion difficulty rising from a seated position indicates the patient’s symptoms are severe facet, lumbosacral sprain, strain.
Nachlas Test: Procedure
Patient is prone and relaxed. Doctor passively flexes the patient’s knee, approximating the heel to the same buttock
Nachlas Test: Pathomechanics
The procedure stretches the quads, which in turn pulls on the ASIS, which causes the ilium to extend. During that extension, the ilium compresses up against the sacrum. Compression of the ilium upon the sacrum can cause the sacrum to extend and therefore, extension of the lumbar spine
Nachlas Test: Indications
Production or aggravation of pain in the SI joint on the side being tested indicates SI joint pathology. Pain in the lumbopelvic spine is facet joint. This would be an arthralgia diagnosis
Assess for lumbar nerve root irritation or inflammation from stretch mechanism
Linder’s Sign
Lindner’s Sign: Procedure
Patient is seated. Could be done standing or lying down also, Doctor passively flexes the head, and chin to the chest.
Lindner’s Pathomechanics
The dura mater is attached at the foramen magnum and at the C1 arch. Flexion of the head or neck pulls the dural sac cephalid. Therefore you can pull the nerve roots in the lower spine superiorward and through the IVF’s and spinal canal, and therefore stretch the nerve roots.
Lindner’s Indications
Reproduction or aggravation of local low back pain and/or radiating pain along the course of the nerve (upper lumbar = femoral nerve, lower lumber = sciatic nerve) could indicate nerve root pathology
Assesses for pathological involvement in the SI joint structures, mainly the gluteus medius muscle or the posterior superior iliac joint capsule
Mennell’s Sign
Mennell’s Sign: Procedure
Could be done seated or prone. The examiner stands behind the patient and palpates lateral to the PSIS for symptomatology, and then medial to the PSIS for the symptomatology.
Mennell’s Sign: Pathomechanics
When palpating lateral to the PSIS you are palpating the tendon of the gluteus medius, and when palpating medial to the PSIS, you are palpating the capsule of the superior sacral iliac ligament.
Mennell’s Sign: Indications
Reproduction of symptoms lateral to the PSIS will be a gluteus medius muscle involvement, and medial will be superior sacral iliac ligament involvement
Assesses for facet joint surface pathology, nerve root encroachment by an intervertebral disc. Could also assess for muscle strain, ligament sprain
Kemp’s Test
Kemp’s Test: Procedure
(Two parts) Part I is standing. Part II is seated. If the patient has low back pain, a standing test should be done first. Part I: If the patient has unilateral problem, you will support the ipsilateral posterior ilium on the side of pain with one hand. With your other arm, grasp across the back of the patient shoulders. Then you will flex the patient forward and to the side away from testing, then extend, lateral flex and rotate toward the symptomatic side. Switch and check the other side. Part II: Seated. Perform the same procedure
Kemp’s Test: Pathomechanics
You compress the facet joints and narrow the IVF toward the side that you are testing on the standing patient. When performed seated, you load the disc, which may cause a contained disc protrusion to bulge more than it already is. When you extend and rotate to the side being tested, you will cause the disc to bulge even more.
Kemp’s Test: Indications
When performed standing, aggravation or reproduction of pain being localized will be facets. Radiating pain will be a nerve root being compressed. In seated, reproduction or aggravation of low back and radiating pain indicates a disc encroaching on a nerve root.
2 tests that assess for meningeal irritation
Brudzinski Sign
Kernig Sign
Brudzinski Sign: Procedure
This sign is seen when the patient is lying supine and passive cervical flexion is performed
Brudzinski Sign: Pathomechanics
Any passive cervical flexion stretches the dura mater cephalad because of its attachment to the foramen magnum and C1 vertebral arch stretching the lumbar nerve root and the sciatic nerve
Brudzinski Sign: Indication
The sign seen in this procedure is the patient flexing their knees bilaterally to relieve the tension in the hamstring muscles and therefore sciatic nerve and the stretch on the dura
Kernig Sign: Procedure
The patient is supine and the examiner will flex one leg at a time, flexing the hip and knee to 90 degrees, and then attempting to extend the lower leg
Kernig Sign: Pathomechanics
With the hip and knee flexed the sciatic nerve is relaxed. When the lower leg is extended the sciatic nerve is stretched in turn stretching the lower lumbar nerve roots and the dura mater inferiorly
Kernig Sign: Indication
The inability to extend the lower leg due to the production of spinal symptoms indicates meningeal irritation
Assesses for sciatica, IVD lesions, vertebral exostosises, dural sleeve adhesions, muscle spasms, and vertebral subluxations. Classically assesses nerve root entrapment by a disc.
Bechterew’s Test
Bechterew’s Test: Procedure
Active straight leg raise test seated. Patient is seated. Examiner asks the patient to extend the symptomatic leg if there is a unilateral problem, then the good leg. Then have the patient raise both legs. Doctor will hold down on the thigh when the patient straightens the lower leg.
Bechterew’s Test: Pathomechanics
With the patient seated, the lumbar spine is flexed; therefore the Disc has 220-275 mm/Hg pressure. Extension of the knee actively contracts the quads, thus stretching hamstrings, sacral plexus, and L4-S1 nerve roots
Bechterew’s Test: Indications
Reproduction or aggravation of low back pain and or leg pain along the sciatic nerve distribution indicates nerve root pathology, which could be due to a disc lesion, exostosises (bone spurs), and adhesions. Generalized superficial low back pain represents muscle spasms and pathology. Tripod sign: Patient raises the symptomatic leg or bilateral legs and places arms behind them. Pain would indicate nerve root with a disc problem
To assess for having either SI joint or lumbosacral joint pathology, the test localizes the problem
Goldthwaite’s Sign
Goldthwaite’s Sign: Procedure
Patient is supine. Doctor places one hand under the lumbo sacral spine; so that the little finger is on the PSIS and the other 3 fingers are between the spinous processes of the lower lumbar spine. The doctor slowly raises the affected leg with the other hand until the symptoms are reproduced
Goldthwaite’s Sign: Pathomechanics
As the leg is raised with the knee extended, the hip joint is flexing, then the SI joint flexes, and eventually the lumbar spine flexes
Goldthwaite’s Sign: Indications
Aggravation or reproduction of the patient’s symptoms during SI joint movement (felt with pinky) indicates an SI joint lesion. If during lumbar spine movement, then it is in the lumbar spine
Assesses for a disc lesion or other SOL, similar to Valsalva’s
Milgram’s Test
Milgram’s Test: Procedure
Patient is supine. Patient is instructed to raise both of their legs until both of their heels are 6 inches off the table. Patient is to hold that position as long as possible (up to 30 seconds).
Milgram’s Test: Pathomechanics
This mechanism is flexion of the iliopsoas muscle, which is a hip flexor. This will compress the lumbar spine, which will load the discs. It also transfers all the weight of the legs onto the pelvis, which further compresses the lumbar spine. Most patients cannot do this without holding their breath and contracting their ab muscles. Holding the breath decreases the heart rate, increasing pressure of the CSF
Milgram’s Test: Indications
Reproduction or aggravation of low back pain and/or leg pain along the sciatic nerve distribution indicates nerve root entrapment by the IVD.
Assess for upper lumbar nerve root lesions for radicular symptoms that may occur along the femoral root
Ely’s Sign
Ely’s Sign: Procedure
Have patient prone and relaxed. Doctor will grasp the distal lower leg, flexing the knee to the opposite buttock
Ely’s Sign: Pathomechanics
This will stretch the quadriceps and the femoral nerve. The ilium will be externally rotated, which will also stretch the lumbar plexus.
Ely’s Sign: Indications
Aggravation or reproduction of symptoms in the low back and/or radiating to the anterior thigh, along the course of the femoral nerve indicates a nerve root lesion from stretch. If patient complains of ipsilateral joint pain could indicate SI Joint lesion
Assesses mid lumbar nerve root and femoral nerve root involvement from the stretch.
Femoral Nerve Traction Test
Femoral Nerve Traction Test: Procedure
Patient is lying on their side. Affected side up and stabilize the patient on the table with down leg slightly flexed. Examiner will take the affected leg and with the knee flexed to 90 degrees you extend the hip
Femoral Nerve Traction Test: Pathomechanics
Knee flexed stretches the quads and the femoral nerve. With the hip extended, stretch is applied to the iliopsoas and therefore the lumbar plexus and nerve roots.
Femoral Nerve Traction Test: Indications
Aggravation or reproduction of low back nerve root symptoms and/or radiating symptoms into the anterior thigh indicates nerve root pathology. General anterior thigh symptoms are probably the quads. Linear anterior thigh symptoms along the course of the femoral nerve would be femoral nerve
Can assess for SOL entrapping the nerve root, can also assess for sacral iliac joint lesions, or mechanical lumbo-sacral involvement, also checks for hip joint lesions and hamstring and sciatic nerve lesions
Straight Leg Raising Test
SLR Test: Procedure
Patient is supine with legs extended and relaxed. Place one hand under the patient’s heel, the other hand on the anterior part of the knee. The hand on the knee helps to keep the knee extended. Doctor passively flexes the hip by raising the leg to 90 degrees if possible.
SLR Test: Pathomechanics
Flexion of the hip with the knee extended stretches the calf and hamstring muscle, sciatic nerve and between 35-70 degrees of leg rise and it stretches the sacral plexus and the nerve roots through the IVF. From 0-30 degrees is running the hip joint through flexion and also some of the SI joint through flexion. 70-90 degrees will flex the lumbar spine and stretch the ligaments.
SLR Test: Indications
Aggravation or reproduction of local nerve root symptoms and/or radiating symptoms from the low back along the sciatic nerve indicates nerve root lesion from a lateral disc entrapment (if it relieves the N.R. symptoms may indicate a medial disc entrapment). Usually occur between 35-70 degrees of leg raise. Reproduction of low back symptoms will be more low back problems above 70-90 degrees (ligament). 0-30 reproduction will be muscle pathology, hip or SI lesion
Rules out knee and hip as a problem in a SLR Test
Lasegue Test AKA Lasegue sign
Lasegue Test: Procedure
With the patient supine and following the SLR test, take the relax symptomatic leg and flex the hip and knee to 90 degrees simultaneously, if there is no symptoms extend the leg by extending the knee
Lasegue Test: Pathomechanics
Flexing the knee and hip at the same time in a patient with back and leg symptoms with the SLR, keeps the extensor muscles and the sciatic nerve and therefore the nerve roots relaxed while moving the knee and hip joints through motion. Extending the knee at the end of the test stretches the sciatica nerve and then the nerve roots
Lasegue Test: Indications
If patient’s symptoms are produced with knee extension nerve root or sciatic nerve involvement is noted. Lateral disc entrapment will be aggravated medial disc may be relieved.
Braggard’s Test: Procedure Test
Following the SLR Test, @ the degree of leg raise where symptoms are reproduced. Lower the leg until the symptoms are relieved or go away, and sharply dorsiflex the foot.
Braggard’s Test: Pathomechanics
Eases the stretch of the hamstring, sciatic nerve, nerve roots when lowering the leg and then re-stretches this tissue when dorsiflexing the foot.
Braggard’s Test: Indications
Confirms nerve root, sciatic nerve lesion from stretch seen in a SLR test, also hamstring.
Straight leg raise of the unaffected leg
Fajersztajn’s Sign AKA Well Leg Raise
Fajersztajn’s Sign: Procedure
Same as straight leg test on the well leg
Fajersztajn’s Sign: Pathomechanics
Same as straight leg test
Fajersztajn’s Sign: Indications
Aggravation of symptoms on the contralateral side indicates a neural lesion, usually a nerve entrapment from a medial disc. If you relieve the symptoms it may be because of a lateral disc
Assesses for lumbar nerve root pathology also
Bowstring Test
Bowstring Test: Procedure
Patient is supine. Leg is relaxed. Doctor will flex the leg just as in the SLR until symptoms are reproduced and then lower the leg to relieve the symptoms, and then place the patient’s heel on the doctor’s shoulder. Doctor will then place their thumbs on the medial and lateral hamstring tendons and exert inward pressure
Bowstring Test: Pathomechanics
This will stretch the hamstring muscle, sciatic nerve, and sacral plexus, L5-S1 N.R.
Bowstring Test: Indications
Aggravation or reproduction of low back symptoms and/or radiating symptoms along the sciatic nerve indicates nerve root irritation from stretch
