Spine Evaluation Cont.

1. Spine Evaluation (Cont.)

2. Overview Special tests Neurological exam: DTRs Circulatory exam

3. Spine Special Tests Hoover Percussion Slump Naffziger Kernig Milgram Contralateral SLR Lasague�s sign Bowstring Pelvic rock Patrick Gaenslen�s Approximation SI rock Prone springing Femoral shear Jackson�s test Beevor�s sign Adams test Thomas test Nachlas prone knee bending Grip strength Wiggle fingers/toes Pinch/rxn to pn.

4. Hoover Place one hand under calcaneus of the patient�s uninvolved leg Asks athlete to raise opposite leg Note downward pressure exerted by the calcaneus if the athlete is actually trying to raise the involved leg Test is positive for malingering (faking) if no downward pressure is noted

5. Percussion With the patient forward flexed at the trunk, the examiner supports the patient�s chest Examiner then forcibly percusses the patient�s spine along its entire span Pain indicates positive test and may suggest possible vertebral fracture/pathology

6. Slump Sit Patient begins seated on the edge of a table with the hips in a neutral position Patient places the hands behind the back and slumps into full thoracic and lumbar flexion Patient then flexes the neck and tucks the chin to the chest Examiner then extends and supports both legs Pain at any stage of the test progression that radiates to the foot or ankle indicates a positive test and a possible disc lesion

7. Naffziger This test is not frequently used due to the potential for cranial vascular disruption Examiner begins by compressing the patient�s jugular veins for about 10 seconds Patient then asked to cough Pain indicates a positive test for disc injury

8. Kernig Patient begins in the supine position Patient instructed to place both hands behind the head and forcibly flex the neck, tucking the chin to the chest Test is positive for disc injury if pain is noted

9. Milgram Patient begins in the supine position Patient instructed to raise both heels approximately 2 inches off of the exam table and hold the position for 30 seconds , thereby increasing intrathecal pressure If patient can hold the position for 30 seconds without pain, the test is negative Test is positive for disc injury if pain is noted

10. Contralateral Straight Leg Raise Patient is instructed to raise to non-affected leg to less than or equal to 45 degrees, being certain to keep the knee fully extended Pain radiating down the involved leg is a positive sign for possible disc injury

11. Lasegue�s Sign Examiner assists the patient in raising the involved leg to the point where pain radiates all the way down the leg Leg is then lowered slightly until the pain subsides The examiner then instructs patient to forcibly dorsiflex the ankle If no increase in pain is noted, patient may then be instructed to flex the neck and tuck the chin to the chest Pain is a positive sign and may be indicative of disc injury or sciatica

12. Bowstring Test Patient is assisted in raising the involved leg until pain is noted Examiner then flexes the patient�s knee to relieve discomfort Patient then places his or her distal lower leg on the examiner�s shoulder Examiner then exerts pressure on the popliteal fossa, effectively compressing the sciatic nerve A positive test produces pain and may be indicative of disc injury or sciatic nerve involvement

13. Pelvic Rock Patient begins in supine Examiner places his or her thumbs on the patient�s ASIS and the palms on the patient�s iliac tubercles Examiner then forcibly pushes the pelvis toward and away from the mid-line of the pelvis Pain or obvious laxity indicates a positive test for sacroiliac joint instability

14. Patrick Test Patient begins in supine Hip of the involved side is externally rotated as the foot of the involved side is brought up to the opposite knee Examiner then stabilizes the hip with one hand and pushes down on the medial surface of the flexed knee, effectively forcing the hip into further external rotation A positive test results when the athlete notes pain and may indicate sacroiliac joint pathology or a tight iliotibial band

15. Gaenslen�s Test Patient is instructed to lay on the noninvolved side and pull the noninvolved knee to the chest while the examiner stabilizes the hip with one hand and forcibly extends the hip with the other Pain in the sacroiliac area indicates a positive test indicating a possible lesion to the sacroiliac joint

16. Approximation Test With the patient side lying, the examiner places one hand on the upper portion of the ilium and pushes down toward the floor Test is positive if movement produces pain May be indicative of SI joint sprain or lesion

17. Sacroiliac Rocking Test With the patient supine, the examiner flexes the patient�s knee and hip While palpating the SI joint, the examiner then adducts the patient�s hip, moving the patient�s knee toward the opposite shoulder Pain or tenderness indicates a positive test and a possible SI joint sprain or lesion

18. Prone Springing Test With the patient prone, the examiner exerts pressure on the apex of the patient�s sacrum Pain indicates possible SI joint sprain or lesion

19. Femoral Shear Test Patient begins in the supine position Examiner flexes, abducts, and laterally rotates the patient�s thigh at 45 degrees from the midline Examiner then applies an abrupt, rapid thrust along the long axis of the femur Pain on the same side indicates SI joint sprain or lesion Pain on the opposite side indicates muscular involvement

20. Jackson�s Test The patient is instructed to stand on one foot and actively extend the spine and rotate the trunk toward the support leg side Test is repeated on the opposite side Pain is a positive indication for spondylolisthesis/spondylolysis

21. Beevor�s Sign Patient is instructed to perform a � sit-up, being sure to lift the scapulae off of the exam table Movement is performed with the arms crossed and rested on the chest and the legs straight Examiner watches the umbilicus to observe its movement A positive sign will reveal movement of the umbilicus toward the strongest side, indicating muscular imbalance of the rectus abdominis

22. Adams� Test Patient is instructed to flex the trunk as if touching the toes Examiner then observes the alignment of the spine as the athlete slowly extends Significant deviation from linearity is indicative of scoliosis and/or bilateral muscle imbalances�

23. Thomas Test The patient begins in the supine position with the feet and middle portion of the lower legs extending over the edge of the table The patient is then instructed to pull one leg to the chest with the knee bent The examiner closely observes the opposite leg If opposite leg comes off table, the hip flexors are tight If the leg also externally rotates, the TFL is tight as well

24. Nachlas Prone Knee Bending The examiner passively flexes patient�s knee as far as possible Unilateral pain in the lumbar region indicates L2-L3 nerve root lesion and femoral nerve stretching Pain in the anterior thigh indicates tight quadriceps muscles

25. Grip Strength The patient is instructed to grasp examiner�s index and middle fingers of both hands and squeeze maximally The examiner should check for obvious bilateral or unilateral strength deficiencies, possibly indicating motor nerve involvement

26. Wiggle Fingers & Toes The examiner instructs the patient to quickly flex and extend the fingers and toes. Test is positive if athlete is unable to perform task and may indicate motor nerve involvement

27. Pinch & React to Pain The examiner pinches the patient at the triceps, gastrocnemius, and elsewhere to look for sensory nerve response

28. Neurological Exam: DTRs Graded 0-4+ 0 = absent 1 = hypoactive 2 = normal 3 = hyperactive s clonus 4 = hyperactive c clonus

29. DTR: Biceps (C5-C6)

30. DTR: Supinator/Brachioradialis (C5-C6)

31. DTR: Triceps (C6-C7)

32. DTR: Upper Abdominal (T8-T10)

33. DTR: Lower Abdominal (T10-T12)

34. DTR: Patella (L3-L4)

35. DTR: Achilles (S1-S2)

36. Circulatory Carotid Brachial Radial

37. Circulatory Femoral Dorsal pedal Posterior tibial