Spine Evaluation. Copyright 2004, Yoshiyuki Shiratori. All right reserved.

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1 Spine Evaluation 1. History Chief Complaint: A. What happened? B. Is it a sharp or dull pain? C. How long have you had the pain? D. Can you pinpoint the pain? E. Do you have any numbness or tingling? Mechanism: A. How did it happen? B. What was felt or heard? Previous History: A. Have you injured this before? 2. Observation Swelling Discoloration Posture A. Scoliosis: Lateral or S curvature of the spine B. Lordosis: Frontal curvature of the lumbar spine C. Kyphosis: Also called Gibbus deformity. Posterior curvature of the upper thoracic spine Skin markings A. Lipomata: Fatty masses appearing on the skin. B. Hair Patch: Called Faun s Beard. Sign of underlying spina bifida occulata C. Café au Lait Spots: Darkened patches of skin. Sign of underlying collagen disease of a connective tissue Gait (e.g. Lurches, Steppage) General appearance A. Muscle tone B. Scares C. Leg length (true and apparent) 3. Check the bone for fracture Proper location and palpation A. Vertebrae (spinous processes and facets) 7 Cervical vertebrae Fx and dx spinous pain, muscle spasm, bilateral sensory deficits, motor weakness, paralysis Usually caused by headfirst contact 12 Thoracic Vertebrae 5 Lumbar Vertebrae Spondylosis: Bony defect in line (stress fx of the transverse process, no slippage)

2 Spondylolisthesis: Forward slippage of one vertebrae on another Usually at L4/L5 or L5/S1 5 Sacral Vertebrae (fused) 4 Coccygeal (fused) Coccydynia: Painful coccyx Surface Landmarks on the back Vertebra Bony Landmark C2 One finger s breadth inferior to the mastoid process C6 Posterior to the cricoid cartilage C7 and T1 Prominent spinous processes in neck T2 Top of scapula T4 Base of spine of scapula T12 Lowest floating rib L4 Top of iliac crest L5 Demarcated by bilateral dimples S2 Level of PSIS (From: Sports Injury Management 2 rd Ed.) 4. Check the ligaments Supraspinal: Between each vertebrae Ligamentum nuchae Ligamentum flavum 5. Check the soft tissue and muscle tendons Scalene Sternocleidomastoid Trapezius Latissimus Dorsi Rhomboid Erector Spinae Quadratus Lumborum Internal Obliques External Obliques Rectus Abdominus 6. Compare ROM Compare bilaterally Stabilize the proper area AROM A. Lumbar Flexion Bend forward Have the athlete slide their hands down their thigh B. Lumbar Extension Place one hand on their back and ask the athlete look toward the ceiling

3 C. Trunk Lateral Bending Stabilize the iliac crest and lean to the left/right while they slide their hand down their leg D. Trunk Rotation Stabilize the iliac crest with one hand and have the athlete to look over their shoulder E. Neck Flexion Should be able to touch their chin. Watch for smoothness of motion F. Neck Extension Should be able to look at the ceiling. Watch for smoothness of motion G. Neck Lateral Bending Should be able to tilt their head about 45º H. Neck Rotation Should be able to move to the line of the shoulder Torticollis limited ROM PROM: Perform the same motion as AROM 7. Resistive ROM Stabilize the proper area Compare bilaterally, starting with the non injured ankle Performed both concentric and eccentric tests A. Trunk Flexion Athlete is supine Have the athlete do a crunches/ sit ups B. Trunk Extension Athlete is prone Stabilize the leg and have the athlete do a back extension against gravity C. Trunk Lateral Bending Athlete lays on the side Stabilize the leg and lift body up against gravity D. Trunk Rotation Stabilize at the iliac crest Pressure against the opposite posterior shoulder E. Neck Flexion Pressure against the forehead F. Neck Extension Pressure against back of the head G. Neck Lateral Bending Stabilize the opposite shoulder Pressure against the side of the head H. Neck Rotation Stabilize the opposite shoulder Pressure against the side of the head 8. Orthopedic Special Tests (Lumbar/Thoracic Spine)

4 Test for disk herniation A. Valsalva Maneuver This test assesses for a herniated disk or other intrathecal lesion in the spinal canal Position: Athlete is sitting Procedure: Have the athlete take a deep breath Bear down as if they were trying to move their bowels Blow into a closed fist Positive sign: Pain in the spinal cord by the herniation This test is also done for cervical herniation Test for neuropathy A. Straight Leg Raise Test This test assesses sciatic nerve irritation Position: Athlete is supine Hand placement: Support the foot around the calcaneus Procedure: Passively flexed the athlete s hip (knee is in full extension) until pain or discomfort is felt. Slowly lower the leg to release pain. Then dorsiflex their leg Positive sign: Dorsiflexion eliciting pain Pain with hip flexion indicates tight hamstring B. Well Straight Leg Raise Test This test is used to identify a disc herniation Position: Athlete is supine Hand placement: Support the foot around the calcaneus Procedure: Passively flex the hip as in the SLR test. Just perform on the uninvolved side Positive sign: Increased pain on the involved side C. Babinski Test This test is used to identify an upper motor neuron lesion Procedure: Using a blunt object (e.g. pen light, end of a reflex hammer), run the object on the plantar aspect of the foot, starting from the calcaneus along the lateral border to the forefoot. Positive sign: Great toe extension and flexion of digits 2-5 D. Oppenheim Test This test is used to identify an upper motor neuron lesion Procedure: Run your fingernail or an object along the crest of the athlete s tibia Positive sign: Same reaction as Babinski

5 E. Kernig- Brudzinski Test This test is to determine nerve root irritation, meningeal irritation, or dural irritation. This test is a combination of two tests, Kernig s and Brudzinski Position: Athlete is supine with their hands behind their neck and leg extended Procedure: Have the athlete flex their neck (Kernig s Test). Then have them flex their hip with knee extended (Brudzinski Test). Once pain is felt, have the athlete flex their knee Positive sign: Cervical pain disappears with knee flexion Pain in the lower back or down the leg indicates a meningeal or dural irritaion F. Bowstring Test This test is used to identify compression or tension of the sciatic nerve Position: Athlete is supine Hand placement: Same as SLR test Procedure: Perform at SLR test until pain or discomfort is felt. Flex the knee to relieve pain, and apply pressure at the popliteal fosssa Positive sign: Pain in the popliteal fosssa G. Hoover Test This test helps to determine if the athlete is malingering (faking an injury) when they state that they cannot raise their leg Position: Athlete is supine Hand placement: Place one hand under each heel and lift their leg slightly off the table Procedure: Have the athlete to lift up one of their leg Negative sign: Should feel a downward pressure on the opposite heel. If you don t feel any pressure the person is NOT TRYING! Test for vertebral defects A. Stork Standing Test (Spondylolisthesis Test) This test assesses a pars fracture Position: Athlete is standing on one leg Procedure: While balancing, have the athlete extend their spine back ward. Repeat test on the other side. Positive sign: Pain in the back If the pain is felt on one leg, the fracture might be unilateral Test for joint instability A. Spring Test This test determines if the pain is from the SI joint Position: Athlete is prone with rolled towel underneath the ASIS Hand placement: Place one hand over the apex of the sacrum, and the other hand on top of the other

6 Procedure: Apply downward pressure Positive sign: Increase pain Perform other SI test if it is positive 9. Orthopedic Special Test (Cervical Spine) Test for nerve root compression A. Cervical Compression Test This test is used to differentiate a nerve root compression and a soft tissue injury Position: Athlete is sitting with the neck in a neutral position Hand placement: Both hands on top of the athlete s head Procedure: Apply downward pressure Positive sign: Pain refers down the arm B. Spurling s Test Same as compression test. Usually done after the compression test is negative Position: Athlete is sitting, with their neck in extension and rotation to the involved side Hand placement: Same as compression test Procedure: Apply downward pressure Positive sign: Pain refers down the arm If the pain in the neck is without radiation soft tissue pain C. Cervical Distraction Test This test will confirm suspicion of a nerve root compression Position: Athlete is sitting Hand placement: One hand at the base of the skull and the other hand under the chin Procedure: Apply gradual upward force Positive sign: Symptoms subside D. Shoulder Depression Test This test determines a brachial plexus stretch Position: Athlete is sitting Hand placement: One hand stabilizes the shoulder, while the other hand is placed on the side of the head on the involved side Procedure: Passively lateral bend the neck to the uninvolved side Positive sign: Elicit pain or other symptoms Test for brachial plexus neuropathy A. Brachial Plexus Tension Test This test assesses upper limb tension Position: Athlete is seated Procedure: Hold the elbow for stabilization

7 (1) Have the athlete abducts the arm with the elbow extended, stopping just short of the onset of the symptoms (2) Externally rotate the shoulder just short of symptoms (3) Flex their elbow so that the hands lie behind the head Positive sign: Recreating the pain, numbness, or tingling along the arm B. Tinel s Sign (brachial plexus) This test assesses the pathology of the brachial plexus Position: Athlete is sitting with neck in slight flexion Procedure: Tap the transverse process Positive sign: Reproduction of the symptoms Test neurovascular dysfunction A. Vertebral Artery Test This test assesses the compression of the vertebral artery Position: Athlete is supine or sitting. If supine, have the athlete s head at the edge of the table Procedure: Passively move the athlete s head in extension, lateral bending, and rotation to the involved side Positive sign: Dizziness (nystagmus), lateral movement of the eye Neurological Tests A. Reflexes Biceps Brachii Tendon Reflex Brachioradialis Tendon Reflex Triceps Tendon Reflex (** We will cover these reflexes on Shoulder or elbow eval) Achilles Tendon Reflex Patellar Tendon Reflex Hamstring Tendon Reflex B. Dermatomes (For Brachial Plexus)

8 (For Lumbar Plexus) (From: Assessment of Athletic Injury) C. Myotomes Lower extremity look at foot and ankle eval Upper extremity we will cover it in shoulder or elbow eval

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