Horizontal shear forces appear to be the most damaging forces for disrupting the ligamentous strapping between vertebrae. ETIOLOGIC PICTURE When sliding outward, trigger deposits in structures on the gluteal aspect of the PSIS may be noted. If pain or resistance is encountered as the leg extends, the sign is positive provided there is no hip or knee stiffness or sacroiliac disorder. Oblique views show a defect in the isthmus or pars interarticularis where the neural arch is visualized as a picture of a terrier's head. Severe, sudden muscle contraction, especially during rotation in flexion, can produce fragmented osseous tears near sites of soft-tissue origin and insertion. If the protrusion is lateral to the nerve root, the patient will lean laterally away from the side of lesion and the sciatic pain. The incidence of low back disorders of a protracted and recurring nature is much higher in those patients whose spines show evidence of development defects and anomalies. The transverse processes of the lumbar vertebrae should be palpated. In addition, rotation is coupled with tilting and vice versa. It is also for this reason that back muscles are rarely weak unless paralysis is present. With motion, the various segments of the spine can be felt to glide closer together or further apart. Regardless of the initial cause, the disc space narrows and the posterior facets compress and "telescope" as the superior segment tends to slide posteriorly upon the inferior segment of the motion unit, which tears or at least stretches the posterior aspect of the capsules. Trauma: Lumbar and Sacral Syndromes Lumbar Ligament and Muscle Fixations The range of lumbar motion is determined by the disc's resistance to distortion, its thickness (Table 12.1), and the angle and size of the articular surfaces. Lateral. In testing hyperextension, the prone patient is asked to lift his trunk upward by extending his elbows, yet keeping his lower pelvis firm against the examining table. When the examiner passively flexes the patient's neck and trunk, it is called the Soto-Hall test. ETIOLOGIC PICTURE When a sacral base is subluxated unilaterally anteroinferior and lateral so that the adjacent ilium is subluxated posteroinferior and medial, the ipsilateral PSIS on the side of inferiority will be low in the standing and sitting positions. After a long illness, for example, a patient can sit erect long before he can stand. Mechanical Pain. This is normal sacroiliac motion. Thus, when lipping of or spurs at the inferior L5 body are seen, a history of instability can be presumed. An increase in pain is a positive indication of a sacroiliac lesion if the possibility of a hip lesion has been eliminated. If the sensory fibers are impaired, distention and dribbling result because the urge to defecate or urinate has been diminished (eg, tabes dorsalis). Is the pelvis level? Tenderness will be found inferomedial to the PSIS and often at the pubic symphysis, contralateral anterior acetabulum, and fascia lata. They show that the orientation of the lumbar articulation contributes to greater shear forces on the IVDs during axial rotation. Flexion. We'll assume you're ok with this, but you can opt-out if you wish. However, if the abdominals and/or hamstrings are weak, the lordosis begins to occur at about 45° to compensate for the abnormally increased sacral angle. In addition, emotional factors must be considered. STANDING LATERAL BENDING If movement is forced, avulsion may occur leading to further degenerative changes. In distinct lordosis, however, the facets are relatively locked and lateral flexion is so restricted that the vertebrae must severely rotate (far more than the normal coupling motion) to allow lateral bending. The iliolumbar, sacroiliac, and sacrotuberous ligaments are common sites of ligamentous shortening that affect pelvic dynamics, and they appear to become involved in that order according to Grieve. Spondylogenic back pain can be subclassified as follows: Back pain and/or sciatic pain derived from changes in the aorta and vessels in the lower extremities. If Lasegue's supine test is positive at a given point, the leg is lowered below this point and dorsiflexion of the foot is induced. The normal range appears to be between 35°–55°, depending upon the reference used. Such fractures are sometimes not evident or are poorly visualized in roentgenography unless markedly displaced or angled due to overlying gas and/or soft-tissue shadows that obscure detail. To help differentiate the low back and sciatic neuralgia of a facet syndrome from that of a protruding disc, several physical clues are available. Tuberculosis is the first suspicion. In some cases, spondylolisthesis develops without spondylolysis by osseous elongation of the pars interarticularis and pedicles. The clinical state of the sacroiliac ligaments is determined by the habitual positions the articulations are required to maintain. Standing Test for Inferior Joint Motion. Because of the lax capsules, a minor sprain can produce a severe synovitis at the posterior joints. Erichsen's Pelvic Rock Test. Bertolotti' syndrome is occasionally seen, which consists of sacralization of L5 in association with sciatica and scoliosis. Similarly, ligaments tend to be located contralaterally, on the other side of the joint from the motion that they limit. DIFFERENTIAL DIAGNOSIS TIPS The precipitating cause is often through overbending, a steady lift, or a sudden release --all of which primarily involve the musculature. When lumbar and pelvic muscles become fibrotic, a search should be made for other areas within the lower extremity such as in the hip flexors and the gastrocnemius (eg, the "high heel" syndrome). An accurate and complete history is vital to arrive at an accurate diagnosis and offer the best management and counsel. Any movement or distortion of the lumbar spine affects the pelvis, and any movement or distortion of the pelvis affects the lumbar spine. PERTINENT ASSOCIATED COMPLAINTS AND FINDINGS: DIFFERENTIAL DIAGNOSIS TIPS (b) Psychogenic magnification of pain; emotionally-based exaggeration of pain produced by a pathologic disorder resulting in inappropriate disability. A comprehensive postural evaluation of the lumbar and sacral areas should include a comparative analysis of the physical signs of the full spine as found in the standing, sitting, Adams, prone, and supine positions, both with and without the use of a plumb line, grid, or other instrumentation. A small disc protrusion should be reduced by segmental extension, thus extension should relieve pain. A loss of tissue elasticity and other signs of repeated trauma or degeneration are common during middle age. When viewed from the posterior, a clinical triangle can be drawn between the high points of the iliac crest and the sacral apex. These ligaments have a tendency toward considerable shortening. Facet Angle Variations An understanding of Lovett's principles and the basic types of lumbar scolioses offers insight into distortion analysis. BASIC INVESTIGATIVE APPROACH Trunk rotation is rarely inhibited as this takes place primarily in the thoracic spine. As with the muscles, it is also helpful to know the ligaments of the lumbar spine and pelvis to be able to effectively stretch the client. (4) rotational overstress at the knee to widen the base of support, leading to chronic sprain. It has been a popular belief that damage to the facet joint is always secondary to disc failure. An absent or diminished response indicates a lesion of the corticospinal tract or a lesion of the femoral or genitofemoral nerves. ), Note: Thoracolumbar Fascia and Abdominal Aponeurosis, In addition to the fibrous fascial ligaments and joint capsules of the lumbosacral and sacroiliac region, further stabilization is provided by the thoracolumbar fascia posteriorly and the abdominal aponeurosis anteriorly. Sprains Some state that the side of fixation is always the major, while others say that the side of hypermobility is always the major because the joint is normally hypomobile. When a weight is lifted, the arms and trunk can be considered a long anterior lever that is counteracted by the extremely short lever extending from the disc nucleus (fulcrum) to the spinous process. The test is positive if the thigh is hyperextended and pain is felt in the sacroiliac area or referred down the thigh, providing that the opposite sacroiliac joint is normal and the sacrum moves as a unit with the side of the pelvis opposite to that being tested. The examiner flexes the thigh at a right angle with the torso and holds it there with one hand. Normally, these two lines should overlap or nearly so. Or, conversely, the PSIS will move posterior and inferior. Whenever a vertebral motion segment is in a state of prolonged distortion, the involved connective tissues histologically adapt to their biomechanical requirements. To test A-P mion during extension, the same contacts are taken and the patient is asked to arch the back posteriorly. If a load is being lifted, the vast majority of the force is upon the posterior lumbar ligaments until about 60° when the back muscles become active and the abdominals serve to smooth the action. Cineroentgenography shows that this is true only when the sacroiliac and pubic articulations are completely fixated in all directions of movement. In addition, rotation is coupled with tilting and vice versa. If a posterior disc protrusion or an irritated nerve root is involved, the patient will invariably assume an antalgic position. This latter point is an excellent method of gathering accurate clues of biomechanical faults. The major nerves of the lumbosacral plexus and their function are given in Table 12.4. While lumbar motion is potentially greater than that of the thoracic spine because of the lack of rib restriction, the angle of facet facing and the heavy ligaments check the range of rotary motion. ROENTGENOGRAPHIC CONSIDERATIONS See Table 12.6. In this distortion, the characteristics are an unleveling of spinal support due to anomaly, trauma, or pathology where the structural unleveling of the spine above tends to portray a normal compensatory response if the motion units are functional. The patient is placed on his side with the affected side up. DISTORTION SIGNS No pain results when the leg is raised to an 80° angle. Thus, postural distortions of the lumbar area with a muscular etiology should never be considered apart from the pelvis. The major muscles involved are the rectus abdominis, external and internal obliques, erector spinae, semispinalis thoracis, latissimus dorsi, deep posterior spinal muscles, quadratus lumborum, and psoas. Because the spine is never completely static, even during sleep, proprioceptive activity and its neuromuscular responses are continuous throughout life. Inhibited motion at some point within the normal range of sacroiliac movement is compensated by hypermobility at adjacent segments such as the lumbosacral, pubic, and proximal femur articulations. Care must be taken to differentiate these sprains from a sacroiliac, hip, rectal, or pelvic lesion. The primary points of reference in visual analysis are trochanter level (marked); sacral level; iliac crest level; direction of pelvic rotation; direction of lumbar, thoracic, and cervical scoliosis; shoulder girdle level and its direction of rotation; and occipital tilt. Hypertonicity tends to subluxate the ilium superiorly and to pull the 12th rib and the lumbar transverse processes posteroinferior. SUMMARY OF DYNAMIC SACROILIAC PALPATION TECHNIQUES This leads to tunnel vision because many disorders, both spinal and extraspinal, may simulate disc disease. Spinal Stenosis Thus, excessive traction forces can create considerable stress, dural leaks, etc. In contrast to quadratus lumborum fixation, stiffening of this muscle leads to sciatica on the concave side of the lumbar scoliosis. The possibility of a spinous process being asymmetrical, deviated to the right or left, without the body of the vertebra being involved should always be kept in mind. Before concluding this part of the examination, the examiner should test the effects of repetitive side bending Before concluding this part of the examination, the examiner should test the effects of repetitive loading in recumbent extension. In the upright position, the greater the lordosis, the greater the compressive forces upon the posterior elements of the vertebral segments and the greater the shearing forces on the discs. Deformity Bilateral or unilateral fixation of a posterior motion unit, causing restricted forward flexion. The iliopsoas muscle is one of the primary hip flexors. Intermittent pain, relieved by a position change. At times, the cause is readily apparent. If the motor fibers to these sphincters are impaired, incontinency is the result. Click here for an article on the ligaments of the cervical spine. In all cases, the patient should be alerted that jugular pressure may result in vertigo. Because of chronic lumbar overstress, heavy lifting is commonly associated with an increased incidence in spondylolysis and disc herniation at the lower lumbar area. If this maneuver is markedly limited by pain, the test is positive and suggests sciatica from a disc lesion, lumbosacral or sacroiliac lesion, subluxation syndrome, tight hamstring, spondylolisthetic adhesion, IVF occlusion, or a similar disorder. (2) induction of a vertebral motion unit subluxation and/or contributions to the chronicity of subluxations, LIGAMENT FIXATIONS Usually intermittent discomfort, but sometimes episodes of pain extend over many hours. As the sacroiliac lesion is usually painless, diagnosis must be made by laboratory, roentgenographic, and thermographic evidence when the classical signs of infection arise. After severe trauma, Helfet/Gruebel Lee describe the vertebral degenerative process as follows: compression injury fractures the end plates which leads to disc and posterior joint changes. Increased pain during hyperextension suggests a rotational subluxation. The question arises: What makes this normally strong and slightly movable joint displace? (3) Do the spinous processes line up straight during forward flexion and extension from flexion? McKenzie's studies indicated that "almost all low back pain is aggravated and perpetuated, if not caused, by poor sitting postures in both sedentary and manual workers." In the upright position, the greater the lordosis, the greater the compressive forces upon the posterior elements of the vertebral segments and the greater the shearing forces on the discs. Extension. If involved in either local or reflex hypertonicity, the posterior lumbar articulations on the side of fixation are forced open in an abnormal arc. Ankylosing spondylitis closely resembles spinal rheumatoid arthritis. Fractures This A-P mobility can be palpated by putting one thumb on the PSIS and the other thumb on the corresponding part of the sacrum. This allows the sacrum to move inferior, anterior, and medial, coupled with the anteroinferior angulation of the sacral base. In conditions where the paravertebral musculature is weakened, we may see a lateral curvature of the spinal column with no appreciable rotation of the vertebra. Before concluding this part of the examination, the examiner should test the effects of repetitive loading in flexion. If laceration occurs, shock is rapid. A posterior L3 is rare when the apex of the lumbar curve is too high or too low, but posteriority is common at L4, L5, or the sacral base. A loss of tissue elasticity and other signs of repeated trauma or degeneration are common during middle age. Fixation at this level produces added stress above and below leading to extension of the degenerative arthritis and spinal stenosis. Sciatic neuralgia or neuritis is characterized by pain of variable intensity to a maximum that is almost unbearable. As the patient curves his trunk laterally, the lumbar spine should curve smoothly, the sacrum will normally tilt towards the side of the concavity, but the PSISs should remain relatively level even though there is some bilaterally reciprocal iliac rotation. Sciatic neuropathy must be differentiated from a lumbar impingement radiculopathy, and this is often challenging. ETIOLOGIC PICTURE In this position, body weight (plus loading) pulls the sacrum anterior, while taut pelvic extensors pull the ilia posterior. This area includes the vast majority of structures that are most commonly involved in low back pain syndrome. Normally, no pain should be felt on this maneuver. The common factors altering the diameters of the IVFs are the disrelation of facet subluxation; the changes in the normal static curves of the spine; the presence of induced abnormal curves of the spine; degenerative thinning, bulging, or extrusion of the related IVD; swelling and sclerosing of the capsular ligaments and the interbody articulation; and marginal proliferations of the vertebral bodies and articulations. At the same time, the examiner should note the maximum range of motion and the production, increase, or reduction of pain and its distribution. In distinct lordosis, however, the facets are relatively locked and lateral flexion is so restricted that the vertebrae must severely rotate (far more than the normal coupling motion) to allow lateral bending. The picture is cloudy, often mimicking a number of cord diseases (eg, sclerosis, atrophy, syringomyelia). (3) the higher the intradisc pressure. This leads to tunnel vision because many disorders, both spinal and extraspinal, may simulate disc disease. Reflex pain does not usually follow the pattern of a specific nerve root. Rotation left. Body weight during development wedges the sacrum between the innominates because of their peculiar laterally inclined planes. Horizontal shear forces appear to be the most damaging forces for disrupting the ligamentous strapping between vertebrae. The comparative height of the iliac crests should be noted. This hardening is usually followed by hypertrophy or exostosis. General spasm of the spinal muscles guarding motion in the vertebral joints can be tested by watching the body attitude (eg, stiff, military carriage) and by efforts to bend the spine forward, backward, and to the sides. However, any mechanical force that will stress or deform receptors, with or without overt damage, or any irritating chemical of sufficient concentration will depolarize unmyelinated fibers and enhance afferent activity. (2) the direction of excessive rotary forces to the lumbar spine, leading to disc failure; The precipitating cause is usually a by-product of trauma, spondylosis, or poor posture. Thus, this type of fixation can be secondary to failure of the lower thoracic and lumbar muscles to elongate. Partial restriction of passive movement in one or more planes. Lumbar IVD pressure is higher during sitting than in the standing posture because intradisc pressure increases with the tendency toward lumbar kyphosis. This lateral deviation will disappear when the patient assumes different positions. Many acute spinal pains with a history of overexertion are muscular in origin. PELVIC CONSIDERATIONS Sensory Changes. A 1/4–1/2-inch excursion should be felt as the ischium moves anterosuperior and lateral on the sacrum. This is often due to hypermobile ilia and hips adapting to lumbar fixation. Thus, any alteration in normal dynamics such as a unilateral fixation must manifest biomechanic effects both above and below. Hibb's Test. The supine patient is asked to grasp the flexed knees, pull them toward the abdomen, and flex the neck forward in an attempt to touch the forehead between the knees. However, an entrapped fragment or protrusion would not be benefited and may be aggravated. With the patient in the lateral recumbent position, deep gluteal palpation will reveal taut cords. The coupled lateral bending and rotation of the lumbar spine during forward flexion: (1) protects the axial length of the lumbar spine and its contents from excessive tension; and It also tends to assume an anteroflexed position, thus producing the three-dimensional movements of the lumbar spine. In treating the fragile elderly, the cardinal concerns in both diagnosis and therapy are arteriosclerosis, demineralization, and diminished collagen. Pertinent Associated Complaints and Findings. This is especially true of the rectus abdominis. A contralateral segmental fixation or a laterally displaced nucleus pulposus would have the same effect. Severe, sudden muscle contraction, especially during rotation in flexion, can produce fragmented osseous tears near sites of soft-tissue origin and insertion. The main function of the longitudinal ligaments is to restrict abnormal motion. DISTORTION SIGNS The multiplicity of causative and effected ailments is almost endless. Near the end of spinal flexion, the sacral base slightly follows L5 anteroinferior as the sacral apex pivots posterosuperior. The muscles of the lower back help stabilize, rotate, flex, and extend the … RECUMBENT HYPERFLEXION The sacroiliac tissues on the side of lateral flexion should relax while those on the side of the convexity should tighten. For example, if a trunk extensor (located posteriorly) is tight, it restricts motion of the trunk anteriorly into flexion. Extension. Weakness leads to visceroptosis which in turn tends to produce lumbopelvic sagging and compensatory thoracic hyperflexion. Several biomechanical influences are expressed in idiopathic scoliosis when viewed in the Adams position. Once the coupled restrictions are normalized, the unstable joints will slowly tighten to meet their natural requirements. The common cause of facet syndrome is not a weak back but a weak abdomen. Internal within the joint is the ligamentum teres that connects the head of the femur to the acetabulum and limits axial distraction (traction) of the joint (see Fig. BASIC INVESTIGATIVE APPROACH BASIC INVESTIGATIVE APPROACH This A-P mobility can be palpated by putting one thumb on the PSIS and the other thumb on the corresponding part of the sacrum. The cremasteric reflex exhibits the integrity of the L2 nerve.