Lumbar and SIJ Flashcards
Observation - The
Buttgripper
(SIJ)
PASSIVE: Over activity deep external rotators of the hip joint uni or bilaterally
ACTIVE
*One leg stance
*Pelvic control [trunk control; abductor
*Hip control [overactive piriformis; glut med/min
Control of pelvis/hip
*
Control of the pelvis/hip
*One leg stance: Recruitment of trunk muscles
If force closure is not in place
ant sagital rot of tested sides’s ilium CN ipsilat SIJ + longitudinal pelvic rot towards lifted leg + caudal pubic symphysis displacement
* One leg stance: Recruitment of hip muscles
If force closure is not in place –> anterior displacement/rot of femur
LX / SIJ palpation
*Position of bony landmarks,
mostly for symmetry
*Iliac crests, PSIS’s, ASIS’s, greater
trochanters i.r.t pelvis
Standing Forward
Flexion test (StFT)
establish innominate asymmetry [‘torsion’]: Try to find a pattern
*Iliac crests R L; PSIS R L; ASIS R L; PSIS ASIS R L;
Greater trochanters pelvis
*Palpate PSIS movement with trunk and leg movement
*Forward Flexion Test; Gillet Test
*Hip rotations
Posterior Pelvic Pain Provocation test [P4] /Thigh thrust
*The test is performed supine and the
patient’s hip flexed to an angle of 90
degrees on the side to be examined:
*Light manual pressure is applied to
the patient’s flexed knee along the
longitudinal axis of the femur while
the pelvis is stabilized by the
examiner’s other hand resting on the
patients contralateral ASIS
*The test is positive when the patient
feels a familiar well localized pain
deep in the gluteal area on the
provoked side
Gaenslen’s test
The patient, lying supine, flexes the hip/knee and draws it towards the chest by clasping the flexed knee with both hands. The opposite leg extends over the edge while the other leg remains flexed. The examiner uses this manoeuvre to gently stress both sacroiliac joints simultaneously.
Anterior ligament stress
- Legs slightly bend on pillows
- Transvers opening force on ASIS
- Comfortable contact
- Take up soft tissue slack
- Strong small ‘overpressure’
Posterior ligament stress
- patient in side lying
- Push down vertically
- Comfortable contact – careful avoiding ‘glut minimus pinch’
Sacral thrust
P-a sacrum
Nutation & counternutation of the sacrum
EROM P-a-p differentiation
SIJ vs lumbo-sacral pain
provocation
Stabilise sacrum in p-a direction, do a-p pressure on ASIS
EROM Longitudinal
movement SIJ vs LS
pain provocation
Stabilise sacrum in longit-ceph direction, do longit-caud
pressure innominate
Stabilise sacrum in longit-caud direction, do longit-ceph
pressure on ischial tub
ASLR (MC test)
*Assessing pelvic control strategy: Just lift 10 cm and
observe
*Lumbopelvic stabilization lacking = compensation
*rib cage draws in = EO
*Lower ribs flare out = IO
*Thoracic extension = ES
*Abdomen bulge = breath holding
*Repeat with pelvic belt. Improvement = positive test
*+ test = a need for rehab of Force Closure
ASLR (original test)
*The patient is asked to score any feeling of impairment
[‘how much effort?’] (on both sides separately) on a 6
point scale: not difficult at all = 0; minimally difficult = 1;
somewhat difficult = 2; fairly difficult = 3; very difficult =
4; unable to do = 5 Mens et al 2001 ; EBCG 2008]
*Feel under WB heel which one pushes down the
hardest to lift the other leg
*Repeat with pelvic belt. Improvement = positive test
*+ test = a need for rehab of Force Closure
SIJ *Pain Provocation tests - best evidence base
*P4 , Ant gapping, Gaenslen FABER [3 out of 4 +]
*Post gapping; EROM sagittal rotation innominate in sidelying
*PAM in prone [ EndROM tests]
SIJ - Motor Control tests medium to strong evidence base
*One leg standing
*ASLR
SIJ RX - SIJ movement treatment
Pain - sidelying
- Physiological movement’ of the SIJ
= Sagittal rotation of the
innominate [Mid ROM in sidelying] - Both legs bend – mid-ROM
- Do PSR and ASR movement
SIJ RX - maitlands
- Any of the physical examination movements
- P-a, a-p movements of the Sx, ASIS or PSIS
- Sacral nutation and counternutation
- Innominate rotation
SIJ RX - Rocabado
- Concept of restoring joint position with muscle
energy techniques - Use muscle energy to change bony position
*Muscle pulling one articular surface
*Muscles stabilising the other - Sub-max muscle contraction
- Hold 6 secs
- Repeat 6x
- 6x per day
SIJ RX - Mulligan: MWM: Pain with Lx extension
- Stabilise sacrum in p-a direction and apply a-p pressure of
innom: test LxE - Stabilise Sacrum in p-a direction and push PSIS lateral-& pa:
test LxE
SIJ RX - Passive joint mobilisation in hypo- or normal mobility
and/ or momentory pain
- Gr IV – IV+ movements: Sagital movement [P-a on sacrum, a-p on ilium]
- Transverse movement of ASIS [Ant gapping]
- Longitudinal movement caudad or cephalad
- EROM Rotation of the ilium/hemipelvis [ant or posterior]
SIJ RX - * Passive joint mobilisation for ++pain and after injury
- Supine: NZTT movements
- Sidelying: MidROM pelvic sagital rotations
Perform all Lx active movements + with over pressure (from above and below)
Perform and explain one leg stance for SIJ
*One leg stance: Recruitment of trunk
muscles
If force closure is not in place
ant sagital rot of
tested sides’s ilium CN ipsilat SIJ + longitudinal
pelvic rot towards lifted leg + caudal pubic symphysis
displacement
*One leg stance: Recruitment of hip muscles
If force closure is not in place
anterior
displacement/rot of femur
Perform lumbar manipulation to the right side (contraindications?)
- P on R side, pillow under head, hips and
knees in Flexion - P lies close enough to edge for L knee to
glide over edge of bed - T in front of P between P’s trunk and flexed
knees - P’s L shoulder is in minimal E with elbow F,
forearm resting on P’s side
STEP 1 - T localises correct level for L3/4
- T finds mid-position of the joint with F/E PPIVM
- T keeps L index finger in L3/4 interspinous space to maintain
mid-position of the joint - T or P straightens underneath R knee, keeping R hip in slight F
- T bends P L knee in F until dorsum of P’s L foot hooks behind
P’s R knee - T keeps R index or middle finger in L3/4 interspinous space
- T pushes L hand underneath P’s R shoulder and pulls P’s arm
towards ceiling until P’s L knee lifts slightly - P R hand under pillow. P R arm relaxes in abduction and
lateral rot
STEP 2 - T threads L arm through P’s elbow, L upper forearm
against P L shoulder - T chest on P’s L arm
- T’s R upper forearm behind P’s L hip
- T’s L thumb pushes down against the upper L side of the
spinous process of L3 - T middle finger pulls up against the under R side of P’s
L4 spinous process - T uses mainly forearms to simultaneously rock P’s upper
body backwards and lower body forwards in small
oscillatory movements to achieve maximum rotary stretch - T increases the pressure against spinous processes until
EOR of IVJ achieved and maintained - T executes a small, quick, sharp thrust to rotate L4 on L3
ADDITIONAL INFO
* Adjust the position so that L3/4 is neutral, take up the slack, let the P’s upper leg drop off the bed if
needed
* Roll the P over to a balance point so that the thrust will affect the pelvis and thorax equally
* Secure the thumb and finger contact
* Thrust along the joint plane by a drop/twist of the body, using the forearm against the greater
trochanter and the sternum against the ribcage as leverage
* Uses: simple mechanical low back pain, in the absence of any risk factors
FEMORAL SLUMP
Side-lying, half-foetal position, tested side
upward, lower leg in hip and knee Flexion
(held by Pt – but not fully flexed),
Cx flexion; Pt holds own head in Flexion,
Th supports upper leg under knee with arm
closest to Pt feet, other hand stabilises
pelvis,
Move Knee into F and hip into E to onset of
P1 or R1
Structural differentiation: Release head
from flex to neutral/ Cx ext.
Reapply Cx F to test the resistance to hip
extension to confirm. Tx and Lx spine must
not move.
STRAIGHT LEG RAISE
TESTS Sciatic N/ Lumbo-pelvic plexus)
* Supine: Hip F with straight knee.
Structural diff: add DF for proximal
symptoms; no further diff needed for
distal symptoms – hip flexion/proximal
movement produce distal symptoms.
Sensitising movements are Hip
adduction, Hip IR/MR, Dorsilexion/
Inversion (Sural), DF/Eversion
(Tibial), PF/Inversion (Fibular/Peroneal)
SLR: SENSITISATION
TIBIAL NERVE
* DISTAL HAND HOLDS FOOT IN DF & EVERSION
PERONEAL NERVE
* DISTAL HAND GOES UNDER THE PLANTER ASPECT OF THE FOOT. FOOT HELD IN PF & INVERSION, WITH FINGERS OVER THE TOES
(HOLDING THE BABY).
* PROXIMAL HAND ON TIBIAL PLATEAU PREVENTING KNEE FLEXION AND TIBIAL IR
SURAL NERVE
* PROXIMAL HAND GOES AROUND THE MED ASPECT OF THE FOOT HOLDING THE FOOT IN DF/INVERSION
* DISTAL HAND PASSES UNDER THE LOWER LEG TO THE MED TIB & KNEE.
SLUMP
- Sitting over bed:
- Starting position: Hips and knees Flexed, back
up straight/ sacrum vertical, arms behind
back, Slump Shoulder above hips = Spinal
Flexion, add neck flexion. - For leg pain add: straighten non-symptomatic
leg, then symptomatic leg, DF can also be
added. - Structural differentiation: release Cx Flexion;
or release/reapply DF
NEURAL
PALPATION
- SCIATIC N: LATERAL FROM ISCHIAL TUBEROSITY
- TIBIAL N (POST KN MEDIAL TO LATERAL HAMSTRING TENDON (HIP F, KNEE E)
- TIBIAL N (POST/INFERIOR TO MED MALLEOLUS)
- SURAL (LATERAL FOOT, BEHIND LATERAL MALLEOLUS AND LATERAL TA)
- COMMON FIBULAR/PERONEAL N (FIBULA HEAD)
- DEEP FIBULAR/PERONEAL (FOOT = LAT TO EHL (BETWEEN 1ST AND 2ND TOE)
- SUPERFICIAL FIBULAR/PERONEAL (DORSUM OF FOOT (PF/INV) AND UP)
- FEMORAL N: ILIOPSOAS (AP’S = INDIRECT)
- FEMORAL N (MED TO ASIS JUST UNDER INGUINAL LIGAMENT)
LATERAL GLIDE WITH
PERIPHERAL NEURAL
SENSITISATION
LOCALISE JOINT AND APPLY TRANSVERSE PRESSURE TO SP
ABOVE SYMPTOMATIC LEVEL
* OSCILLATE PELVIS INTO LF X 10
* NOW PERFORM NEURAL SLIDER WITH HIP AND KNEE FLEX X5
LUMBAR
CEPHALAD GLIDE
STABILISE THORAX ANT WITH ONE HAND
* OTHER HAND USES BASE OF HAND TO CEPHALAD GLIDE THE SP
ABOVE THE PAINFUL JOINT
ILIOPSOAS length
THOMAS TEST: POSITIVE DECREASED HIP EXTENSION
* DISTAL ILIOPSOAS TP DEEP ALONG LAT WALL OF FEM TRIANGLE,
JUST ABOVE DIST ATTACHMENT TO LESSER TROCHANTER
ILIACUS TP’S INSIDE BRIM OF PELVIS BEHIND ASIS
* PRACTICAL: PROX PSOAS TP – BEND IPSILATERAL LEG, APPLY
DIGITAL PRESSURE FIRST DOWNWARD BESIDE, AND THEN
MEDIALLY BENEATH THE RECTUS ABDOMINUS MUSCLE TOWARDS
PSOAS – COMPRESSES PSOAS AGAINST LX SPINE
* TP OR SHORTNESS DUE TO MAL-ALIGNMENT, SUSTAINED POSTURE
REPETITIVE ACTIVITY,
* SPINAL DYSFUNCTION OR INCREASED TONE – IRRITATION OF L2, L3
AND PART OF L4 NR’S
MODIFIED THOMAS TEST
- THE PATIENT IS POSITIONED SITTING AT THE END OF AN EXAMINATION TABLE. THE PATIENT IS
THEN ASKED TO LIE DOWN WHILE BRINGING BOTH KNEES TO THEIR CHEST. THEY SHOULD THEN
PERFORM A POSTERIOR PELVIC TILT- FLAT BACK. - ONE LIMB SHOULD THEN BE LOWERED TOWARDS THE TABLE WHILE KEEPING THE OPPOSITE
TUCKED TOWARDS THEIR CHEST
PIRIFORMIS anat
- O: ANT SURFACE OF SACRUM AND
SACROTUBEROUS LIGAMENT
- O: ANT SURFACE OF SACRUM AND
- I: SUP BORDER OF GREATER TROCHANTER
OF FEMUR
- I: SUP BORDER OF GREATER TROCHANTER
- A: LAT ROT AND HIP EXT (>90 HIP FLEXION
MED ROT) GLOBAL MOBILISER
- A: LAT ROT AND HIP EXT (>90 HIP FLEXION
- N: SACRAL PLEXUS L5-S1, VENTRAL RAMI
S1-S2
- N: SACRAL PLEXUS L5-S1, VENTRAL RAMI
PIRIFORMIS MUSCLE LENGTH TEST
- SUPINE: HIP FLEXION + ADD + LR
- PT PASSIVELY FLEXES HIP TO 90⁰, THEN ADDUCTS THE HIP
TO THE END POINT RESISTANCE (KNEE RELAXED) AND
THEN PT LR THE HIP - IDEALLY - 45⁰ LR , IN PRONE
KNEE FLEXION AND HIP IR - COMPARE L TO R
PIRIFORMIS: PALPATION
- INCREASED TONE – IRRITATION OF L4, L5, S1, S2 NR’S PALPATION IF
TIGHT: DEEP PRESSURE - PALPATE THE POINT WHERE AN IMAGINARY LINE BETWEEN THE
ILIAC CREST AND THE ISCHIAL TUBEROSITY CROSSES A LINE
BETWEEN THE PSIS AND THE GREATER TROCHANTER - CAN CAUSE DECREASE IN L5/S1 REFLEX DUE TO RESTRICTION
SCIATIC NERVE MECHANICS AT MECHANICAL INTERFACE
PIRIFORMIS TREATMENT TECHNIQUES
PIN & STRETCH, WITH ADDITIONAL HOLD RELAX
* PIN THE PIRIFORMIS DOWN, CHECK ROM,
* POSSIBLY ADD STRETCH.
* ASK THE PATIENT TO PULL FOOT TOWARDS THE MIDLINE
* HOLD 10 SEC
* RELAX
* PT STRETCH LL INTO NEW ROM
QUADRATUS LUMBORUM anat
- O: ILIOLUMBAR LIG, ILIAC CREST.
OCCASIONALLY FROM UPPER BORDERS OF
TRANSVERSE PROCESSES OF L2-L5 - I: INF BORDER OF LAST RIB AND
TRANSVERSE PROCESSES OF L1-L4 - GLOBAL MOBILISER
QUADRATUS LUMBORUM length
- PT PUSHES UP SIDEWAYS AS
FAR AS POSSIBLE WITHOUT
MOVEMENT OF THE PELVIS -
MERMAID SITTING - LIMITED ROM, LACK OF
CURVATURE IN THE LX SP
AND/OR ABNORMAL
TENSION ON PALPATION (JUST
ABOVE ILIAC CREST AND LAT
TO ES) INDICATE TIGHTNESS
QUADRATUS LUMBORUM kinetic control
- BEND STAND WITH FEET SHOULDER WIDTH APART AND HANDS
TOUCHING SIDE OF HEAD AND LX FLATTENED ONTO THE WALL. - PT THEN SIDE BENDS KEEPING BACK FLAT ON THE WALL AND
WITHOUT ALLOWING PELVIS TO SHIFT LATERALLY, TILT OR ROTATE
IDEALLY: - GOOD SYMMETRY AND 35-45⁰ SF
ITB LENGTH TESTS
OBER’S TEST
* BOTTOM LEG FLEXED
NEUTRAL SPINE STABILISE
PELVIS TOP LEG
* KNEE FLEXED TO 90⁰ ABD
AND EXT TOP LEG.
NEUTRAL HIP ROTATION
* DROP LEG TO TABLE
MODIFIED OBER’S TEST
* LESS STRAIN MEDIALLY ON KNEE, LESS TENSION
ON PATELLA, LESS INTERFERENCE OF A TIGHT RF
* STABILISE PELVIS AND KEEP LATERAL TRUNK IN
CONTACT WITH TABLE
* NEUTRAL HIP ROT HIP EXT IN LINE WITH TRUNK
ALLOW LEG TO DROP TO TABLE
ERECTOR SPINAE anat
- ILIOCOSTALIS (LAT) N: L1-L3
- O: ANT SURFACE OF BROAD TENDON ATTACHED TO
MEDIAL CREST OF SACRUM, SPINOUS PROCESSES
T11-L5, POST PART OF MEDIAL LIP OF ILIAC CREST,
SUPRASPINOUS LIGAMENT, LAT CREST OF SACRUM - I: INF BORDERS OF ANGLES OF LOWER 6/7 RIBS
- LONGISSIMUS (INTERMEDIATE) N: C1-S1
- SPINALIS (MED) N: T2-L3
- GLOBAL MOBILISER
E/S: MOBILITY
- SITTING – NON-NEURAL SLUMP
- SIT AND FLEX SPINE BY ALLOWING SHOULDERS TO
SLUMP TOWARDS PELVIS BENCHMARK: EVEN
FLEXION THROUGHOUT THE TX AND LX SP WITH
20⁰ LUMBAR FLEXION - HOME STRETCH - PEDAL STRETCH
lumbar bony landmarks
- L3 → OPPOSITE THE BELLY BUTTON
- L4-L5 INTERSPACE →LEVEL WITH THE ILIAC CRESTS
- L5 → SLIDE FINGERTIPS ALONG THE FUSED SPINES OF THE SACRUM, & THEN ONTO THE L5 SPINOUS
PROCESS. IT IS DEEP, SMALL & HAS A BLUNTED BONY POINT
general palpation
- TEMPERATURE & SWEATING
- SOFT TISSUE CHANGE
- SUPERFICIAL TISSUE
- SOFT TISSUE SURROUNDING THE FACET JOINTS
- NEW SOFT OR OLD HARD TISSUE CHANGES
- SUPRASPINOUS LIGAMENTS USING THE FINGER TIPS
- ALIGNMENT OF VERTEBRA & ANOMALIES
- GENERAL MOBILITY OF THE SPINE FOR HYPO- OR HYPER MOBILITY PPIVMS, PAIVMS
MAITLAND AX
- GRADES I –V (DIFFERENT TREATMENT GOALS) & RHYTHM OF
MOVEMENT - BODY PLANE : PA & AP DIRECTIONS FOR ACCESSORY
MOVEMENTS
LONGITUDINAL MOVEMENT,
FOLLOW BODY PLANE (PERPENDICULAR) BUT
CAN BE CAUDAD/CEPHALAD OR
MEDIAL/LATERAL ORIENTATION
PASSIVE PHYSIOLOGICAL MOVEMENTS - TREATMENT PROGRESSIONS: START IN ‘LOOSE PACKED’ POSITION,
PROGRESS TO EROM POSITIONS OR ‘CLOSE PACKED
PALPATION
PPIVMS
TO DETECT ABNORMALITIES IN RANGE ON INDIVIDUAL LEVELS
* F/E DOUBLE LEG
* F/E SINGLE LEG
P.A VERTEBRAL PRESSURE HANDLING SKILLS:
* THUMBS FOR GENTLE GRADES
* LAT HAND/ PISIFORM FOR STRONGER GRADES (CENTRAL PA)
* MOBILISE AT RIGHT ANGLES TO THE BODY
* L5 LESS MOVEMENT
* USE WITH CENTRAL PAIN OR SPASM OF BOTH SIDES
* PAIN AND SPASM SHOULD NOT BE PROVOKED
CENTRAL PAIN WITH PA:
* SUPERFICIAL OR DEEP?
* DOES PAIN SPREAD
* MARK REPRODUCTION OF PAIN WITH *
PAIVMS
- CENTRAL PA
- UNILATERAL PA
- LUMBAR ROTATION, PG. 372 – 376
- LOCALISED ROTATION MOBILIZATION PG
396 - 398
lower and upper
lumbar rotations
Patient with painful side up
Gr I hand on bed, Gr II hand on abdomen
Gr III one knee bent, knee off bed.
Thoracic rotation, with counter pressure
Gr IV, top leg off bed
LOCALISED ROTATION: ROTATION TO THE RIGHT
- PATIENT LIES ON THE RIGHT SIDE
- PPIVM THE CHOSEN JOINT TO THE MIDPOINT
- FLEX TOP LEG TO TUCK FOOT BEHIND EXTENDED BOTTOM LEG
- ROTATE THE THORAX PASSIVELY
- PATIENTS FOREARM RESTS ON THEIR SIDE
- PT FOREARMS RESTING ON PATIENT SHOULDER AND HIP
- OSCILLATE ROTATION BETWEEN PT THUMB AND MIDDLE FINGERS
mulligan self LX snag
see picture on slide
- use fist and other hand, push up
LX FLEXION SNAG IN SITTING
STARTING POSITION PATIENT:
* SIT ON A PLINTH, LEGS OVER THE SIDE
* BELT AROUND THE P ABDOMEN JUST BELOW THE ASIS
STARTING POSITION THERAPIST:
* T STAND BEHIND THE P, BELT BELOW THE T HIPS
* ULNAR BORDER OF THE R HAND, HEEL OF HAND OR THUMB PLACED INFERIOR TO THE SPINOUS PROCESS OF THE
VERTEBRA ABOVE THE SYMPTOMATIC SPINAL LEVEL
* L HAND ON THE PLINTH FOR STABILITY’
* P FLEXES THE LX TO P1, & EXTENDS A LITTLE
* T APPLIES A GLIDING FORCE WITH R HAND UP ALONG THE FACET TREATMENT
PLANE AS P FLEXES AGAIN (ONLY ONCE)
* IF YOU ON THE RIGHT LEVEL P WILL FLEX PAINLESSLY TO NEW ROM
* THIS MEANS THIS TREATMENT CAN BE USED
* REMEMBER TO MAINTAIN (SUSTAIN) YOUR GLIDE A FEW SECONDS
* MAINTAIN THE GLIDE UNTIL THE PATIENT IS BACK IN NEUTRAL VARIATION
* L4 & ABOVE: UNILATERAL GLIDE, USE ULNAR BORDER
* L5/S1: THUMBS REINFORCED ON L5
* IF NOT EFFECTIVE, CHANGE LEVEL OR DO UNILATERAL OR USE DIFFERENT
TECHNIQUE
* TREAT A/A IN STANDING IF APPROPRIATE (OR 4 POINT KNEELING)
* ACUTE DISC LESION: MAY ADD TAPE ‘X’ TO MAINTAIN NEUTRAL E
MCKENZIE EXTENSION EXS
- PRONE LIE, HANDS UNDER THE SHOULDERS, REPEATED E, RAISE ONLY UPPER
BODY, PELVIS REMAINS RELAXED, LX SAGS, MAY ADD EXHALAôON FOR ↑ E, - REPEAT 10 X
- PRONE LIE: ADD O/P WITH HEEL OF HAND ON TRANSVERSE PROCESSES,
- T ARMS PERPENDICULAR TO SPINE, SUSTAIN AS P DOES REPEATED E
- MAINTAIN THE LORDOSIS FROM LYING TO STANDING
- REPEATED E IN STANDING
- FINALLY INTRODUCE F, AND ‘SANDWICH’ E, F, E
SIJ: Supine: Neutral zone translation tests A-P
SIJ: Prone: PA and longitudinal movement of the sacrum differentiating SIJ from L5/S1 movement
(Maitland peripheral book p 404 – 405)
SIJ: Prone: Sacral nutation and counter-nutation - Maitland Vert. Manip p 404 -406
SIJ: Side-lying: Innominate Anterior and posterior rotation
- Mid ROM (Maitland Vert. Manip p 404 – 406)
- End ROM (Petty)
