Special Test for Lower Back

Question 1

Pain at an angle of 40 degress is indicative of
A. Hamstring tightness
B. Calf tightness
C. IVD pressure on sciatic nerve
D. SI Joint Pain

Answer 1

C. IVD pressure on sciatic nerve

Question 2

How do you perform the Sciatic Nerve test for Lower Limb Tension Tests and what does it mean

Answer 2

1. Sciatic Nerve - LLTT
   
   1. Perform the Straight Leg Raising Test (Test is below)
      Positive = Radicular Symptoms

How to perform:
* Patient lying supine, hip is medially rotated and adducted
* Lift involved leg upward by supporting the foot around the calcaneus (keep knee straight)
* Positive = Pain at 10-30 degrees
* Indicates = Tight Hamstrings (Ask where pain is_
* Positive = Pain at 35-70 degrees
* Indicates = IVD pressure on sciatic nerve (usually a lateral herniation)
* Positive = Pain at 70 degrees or more (Ask where pain is)
Indicates = SI joint pain

More information
1. Pain at 10-30 Degrees: Tight Hamstrings
Why pain occurs: When the leg is raised at a low angle (10-30 degrees) with the knee straight, there is a mild stretch on the hamstring muscles. If these muscles are tight, they will resist the stretch, and the patient may feel discomfort or pain in the hamstrings or the back of the thigh.
Interpretation: Pain or tightness in this range often indicates muscle tightness rather than nerve or joint involvement. However, to confirm hamstring tightness as the cause, it’s important to ask the patient to localize the pain—if it’s in the hamstring area, it’s more likely due to muscle tightness.

2. Pain at 35-70 Degrees: Intervertebral Disc (IVD) Pressure on Sciatic Nerve
   Why pain occurs: At this range, the straight leg raise test begins to stretch the sciatic nerve and other structures surrounding the lumbar spine. If there’s an issue like a herniated intervertebral disc pressing on the sciatic nerve roots, especially if the herniation is lateral, this movement increases pressure on the nerve and causes radiating pain, often described as a sharp or shooting pain down the leg.
   Interpretation: Pain between 35-70 degrees of leg elevation is typically considered a positive indication of nerve root irritation, often due to lumbar disc herniation. This range puts tension specifically on the sciatic nerve, so pain here points more toward nerve involvement than just muscle tightness.
3. Pain at 70 Degrees or More: Sacroiliac (SI) Joint Pain
   Why pain occurs: As the leg is lifted higher (70+ degrees), the hamstrings are fully stretched, and the sciatic nerve tension is maximized. However, in some cases, this movement may cause slight movement or stress in the pelvis, which can aggravate the sacroiliac (SI) joint if there’s an underlying issue there.
   Interpretation: Pain occurring only at high degrees of elevation (70+ degrees) is more likely to indicate a problem with the SI joint rather than the hamstrings or sciatic nerve. SI joint pain often feels like a deep ache or discomfort around the lower back or buttocks.

Question 3

How do you perform the Wells Leg Raising test and what does it indicate?

Answer 3

• Patient in supine while doctor raises the uninvolved leg
  
  • Positive = back and sciatic pain on the opposite side
    Indicates = Further presumptive evidence of a space (usually a medial herniation)

Question 4

What does the Bragard’s Test indicate and how do you perform it?

Answer 4

• Patient lying supine or sitting
• Doctor lifts leg off table like in SLR Test to the level of pain (This pain typically indicates tension on the sciatic nerve or associated structures.)
• Examiner then lowers the leg just below the level of pain and adds dorsiflexion of the ankle stretching the sciatic nerve (This ensures that the leg is still close to the threshold for sciatic nerve tension but not actively triggering pain. Bending the foot upwards stretches the sciatic nerve further)
  
  • Positive = pain radiating below knee
    Indicates = disc herniation, neural impingement

More information:
Interpretation of Bragard’s Test:
Positive Test (Pain Radiating Below the Knee):
This typically suggests sciatic nerve irritation or compression, which may result from conditions like a disc herniation or neural impingement.
Disc Herniation: If the pain radiates below the knee, it often indicates that a lumbar disc herniation (most commonly at L4-L5 or L5-S1 levels) is pressing on the sciatic nerve roots.
Neural Impingement: Other conditions like spinal stenosis, spondylolisthesis, or piriformis syndrome can also compress the sciatic nerve, leading to similar symptoms.
Why Dorsiflexion Causes Pain in This Test:
Dorsiflexion of the ankle stretches the sciatic nerve by pulling on it from the distal end (the lower leg). If the nerve is irritated, compressed, or inflamed due to a disc herniation or other causes, this additional stretch causes pain that travels down the nerve pathway. This further confirms neural involvement as opposed to just muscular tightness.
Clinical Significance:
Bragard’s test helps differentiate between muscular pain (which might cause discomfort in the thigh but not below the knee) and neural pain due to conditions that involve the sciatic nerve or nerve roots.
A positive result strongly indicates that the patient’s pain is likely due to nerve impingement rather than isolated muscular issues, guiding the practitioner to consider treatments or imaging studies focused on nerve-related conditions.

Pain Felt Above the Knee:
Hamstring or Gluteal Muscle Tightness:

If the patient experiences pain in the thigh or buttock area, it could indicate tightness in the hamstring or gluteal muscles rather than an issue with the sciatic nerve.
In these cases, the discomfort is often muscular in nature, rather than neural. This can happen when the muscles are stretched during leg raising, and it usually doesn’t involve radiating pain below the knee.
Sciatic Nerve Irritation (Proximal Region):

Sometimes, if the sciatic nerve is irritated or compressed near its origin in the lower spine, pain may also be felt in the buttock or thigh area. However, if the pain does not radiate past the knee, it may indicate milder sciatic nerve irritation rather than a full impingement affecting the nerve roots at the lower lumbar spine.
Piriformis Syndrome:

In cases of piriformis syndrome, the sciatic nerve is compressed by the piriformis muscle in the buttock, causing pain in the gluteal region, sometimes radiating down the thigh but typically not past the knee.
Pain from piriformis syndrome tends to stay in the buttock or upper thigh, as opposed to pain from a herniated disc, which often radiates below the knee.
Lesser Sciatic Nerve Involvement:

Sometimes, an issue with the smaller nerves (like the posterior femoral cutaneous nerve) can cause pain in the upper leg without extending below the knee.
Key Takeaway:
Above-the-Knee Pain: Often indicates muscular issues (hamstring or gluteal muscles) or more localized sciatic irritation, such as piriformis syndrome.
Below-the-Knee Pain: Generally suggests more significant sciatic nerve involvement or lumbar nerve root compression, as in cases of disc herniation or neural impingement.

Question 5

What does the Valsalva test indicate and how do you perform it?

Answer 5

• Patient is seated, takes a deep breath and blows out with closed mouth (like straining at stool)
  
  • Positive = Pain in back or down the legs
    Indicates = A space occupying lesion causing an increase in intrathecal pressure

more information:
Intrathecal pressure refers to the pressure within the subarachnoid space of the spinal canal, where cerebrospinal fluid (CSF) circulates around the brain and spinal cord. This pressure is essentially the pressure of cerebrospinal fluid (CSF) in the spinal canal and is also often referred to as intracranial pressure (when measuring CSF pressure within the skull). It’s a crucial measurement because abnormal intrathecal pressure can indicate or lead to neurological issues.

Question 6

What does the Kemp’s test indicate and how do you perform it?

Answer 6

• Place patient in standing position
• Instruct the patient to slowly extend, sideband, and rotate the thorax and lumbar spine to the affected side. The idea is to have the patient run their fingertips of the hand on the affected side down the posterolateral aspect of the affected leg as far as they can go.
• This movement helps to compress the intervertebral foramen, the nerve root and the facet joints on that side
  
  • Positive: Radiating pain or other neurological signs in the affected leg (nerve involvement) or localized pain (Facet involvement)

The picture is a bit misleading. Patient is in proper position but the examiner is applying pressure to the right shoulder. This is technically called the Quadrant Test. Without applying pressure, it is the Kemp Test.*

Question 7

How do you perform the Bechterewis Test and what does it indicate?

Answer 7

• The patient sits with a flexed neck.
• The patient is asked to extend one knee at a time.
• If no symptoms result, the patient is asked to extend both legs simultaneously.
  
  • Positive = Symptoms in the back or leg
    Indicates = Sciatic Nerve Involvement

Question 8

What does the Supported Forward Bend Test Indicate and how do you perform it?

Answer 8

• The patient is in a standing position.
• The examiner stands behind the patient and asks the patient to bend or flex forward until the lumbosacral pain is felt.
• The patient then returns to the upright position.
• The examiner again asks the patient to bend forward. The examiner, this time, supports the patient’s sacrum with his or her thigh and guides the movement by grasping both the ilium (pelvis immobilized).
• Positive: Pain Disappears
  Indicated: Sacroiliac Syndrome

More information:
The Forward Bending Support Test (also known as the Goldthwait’s test) is used to differentiate pain originating from the sacroiliac (SI) joint versus pain from the lumbar spine or other structures. Here’s an explanation of why this test might relieve pain when the examiner supports the sacrum:

SI Joint Stabilization: When the examiner supports the patient’s sacrum and pelvis during the second bend, they essentially immobilize the SI joint. If the initial pain during unsupported forward bending is due to instability or dysfunction in the SI joint, stabilizing the pelvis helps reduce movement in this joint. This stabilization can relieve pain because it prevents excessive or abnormal movement in the SI joint, which would otherwise cause irritation or stress to inflamed or dysfunctional SI joint structures.

Isolating Lumbar vs. Sacroiliac Pain: Forward bending involves both lumbar spine flexion and slight movement in the SI joint. Without stabilization, both the lumbar spine and SI joint are free to move, and pain may be felt from either region. By stabilizing the sacrum and pelvis, the movement is primarily restricted to the lumbar spine, so if pain disappears, it suggests that the SI joint was the source of pain, not the lumbar spine.

Mechanics of Pain Relief: In cases of sacroiliac syndrome, pain often results from stress or irregular motion in the joint or surrounding ligaments. Supporting the pelvis reduces the load on the SI joint structures, which can immediately alleviate discomfort caused by movements that would otherwise aggravate the joint.

Question 9

What does the Gillet’s Test or Marching test indicate and how is it performed?

Answer 9

• While the patient stands, the squatting examiner palpates the PSIS’ with one thumb and the other thumb parallel with the first thumb on the sacrum.
• The patient is then asked to stand on one leg while pulling the opposite knee up toward the chest.
• This causes the innominate bone on the same side to rotate posteriorly and the sacrum to rotate to the same side.
• The tcst is repeated with the other leg palpating the other PSIS .
  
  • Positive = If the sacroiliac joint on the side on which the knee is flexed moves minimally or up,
    Indicates = the joint is said to be Hypo-mobile, Normally, the tested PSIS moves down or inferiorly

Question 10

What muscles does the trunk rotators stretch, stretch and how do you perform it?

Answer 10

• The patient is seated on the table, with knees bent and legs hanging over the side
• Keeping the spine lengthened, the patient twists to the right as far as possible, keeping the nose in alignment with the sternum
• Reach under the patient’s right arm to place your right hand on the anterior shoulder.
• Place your left hand on the left scapula, near the inferomedial border.
• The patient relaxes and breathes in. On exhale take the patient farther in rotation.
• Hold for 30-60 seconds

Muscles stretched:
External Obliques: As the patient twists, the contralateral external oblique (opposite side of the rotation direction) is lengthened. So, if rotating to the right, the left external oblique is stretched.

Internal Obliques: The ipsilateral internal oblique (same side of the rotation direction) is stretched. For a right twist, the right internal oblique is lengthened.

Rectus Abdominis: The rotation puts a slight stretch on the rectus abdominis, particularly if the spine is kept lengthened, as this muscle helps stabilize the torso during the twist.

Transversus Abdominis: This deep muscle isn’t directly stretched by rotation but is activated to stabilize the trunk during the movement. It may not lengthen significantly but helps hold the posture.

Multifidus: This muscle group supports controlled rotation. The multifidus fibers are lengthened as the spine rotates, especially in the lumbar region.

Erector Spinae: The erector spinae muscles on the side opposite the twist (contralateral side) are stretched as the spine rotates and extends slightly.

Latissimus Dorsi: The latissimus dorsi on the side of the twist can be stretched if the shoulder and arm positions contribute to lengthening the muscle. The stretch will be greater if the patient keeps their arm stabilized on the opposite side of the body.

Rotatores and Semispinalis: These small muscles, which assist with fine-tuning rotation, will also be stretched as the spine rotates, particularly in the thoracic and lumbar regions.

Question 11

How do you perform the Quadratus Lumborum Stretch?

Answer 11

• The patient is lying on the left side, with the back at the edge of the table and the right leg hyperextended and hanging over the edge of the table.
• The left leg is bent and as close to his chest as possible.
• The patient reaches his right arm up over the head.
• Stand behind the patient, cross your arms and place your left hand against the right iliac crest; your right hand is spread wide and placed on the lateral aspect of the rib cage
• Ask the patient to relax take and take a deep breath. On exhale bring the patients foot closer to the floor increasing the QL stretch
  Hold for 30-60 seconds

Question 12

how to perform the assisted Latissimus Dorsi stretch

Answer 12

• The patient is prone on the table, arms outstretched and externally rotated
• Using a stable front-to-back lunge stance, grasp the patients’s arms or wrists securely.
• The patients takes a deep breath and on exhale, take the arms farther forward toward the ceiling, and externally rotate the arms more.
  Hold for 30- 60 seconds

Question 13

Self stretch for lower trunk flexor

Answer 13

• Lie facedown on the floor.
• Place both hands palms down; fingers point forward by each hip.
• Slowly arch the back, contracting the buttocks.
  Continue arching the back and lift your head and chest off the floor

MUSCLES STRETCHED
* Most-stretched muscle: Rectus abdominis, external/internal oblique
* Lesser-stretched muscles: Quadratus lumborum, psoas major,
iliacus, rotatores, intertransversarii

Question 14

Self stretch for Seated Lower Trunk Extensor

Answer 14

• Sit upright in a chair with legs separated.
• Slowly round the upper back and begin to lean forward.
• Continue to bend at the waist and lower the head and abdomen between the legs and below the thighs

MUSCLES STRETCHED
Most-stretched muscle: Iliocostalis lumborum, multifidus
Lesser-stretched muscles: Interspinales, rotatores, spinalis thoracis

Question 15

Self stretch reclining lower trunk extensor

Answer 15

• Lie on the back with the legs extended.
• Flex the knees and hips, bringing the knees up over the chest.
• Cross the feet at the ankles and separate the knees so that they are at least shoulder-width apart.
• Grasp the thighs at the inside of the knees and pull the legs down to the chest

MUSCLES STRETCHED
Most-stretched muscle: Iliocostalis lumborum, multifidus
Lesser-stretched muscles: Interspinales, rotatores, splnalis thoracis

Question 16

How to perform a self seated Lumbar Lateral Flexor

Answer 16

• Sit upright in a chair.
• Interlock the hands behind the head, with the elbows in a straight line
• across the shoulders.
• While keeping both elbows back and in a straight line, laterally flex the waist, and move the right elbow toward the right hip

MUSCLES STRETCHED
Most-stretched muscle: Left external oblique, left internal oblique, left rotators
Lesser-stretched muscles: Left intertransversarii, left multifidus, left quadratus lumborum