Look
Walking / mobility aids
Lumbar brace
AFO / shoes
Front
Wasting - quadriceps
Manifestations of systematic disease
LLD
Side
Normal
- there is a thoracic kyphosis and a lumbar lordosis
Abnormal
- exaggerated
- reduced
Back
Scoliosis
Scars
Signs spinal dysraphism
Wasting - buttocks / thighs / calves
Tenderness
- vertebral level
- sacro-iliac joints
ROM
Forward flexion test
- standing with feet together & knees straight
- aiming to touch floor with hands on legs
Comment on
- pain
- level reached (fingertips in relation to front of legs)
- normal unrolling of the lumbar spine
Schobar's test
- thumb on LS junction
- line joining dimples of Venus
- reconfirms level pelvis
- index finger 10 cm above
- width of hand
- amount of increased separation of fingers on spine
- should be at least 50%
Extension
- one hand in small of back and one hand on shoulder
- normal 15-30°
Lateral flexion
- one hand on hip and other hand on shoulder
- normal 15-30°
Rotation
- feet still & twist body
- look from above
- angle between plane of shoulders and pelvis
- amount 45°
Gait
Tiptoes (L5 / S1)
Heels (L4)
Squat / single leg squat (L3)
Supine
Hip ROM
- flex hip to 90° and rotate hip
- comment painless range of hip movement
SLR
- patient lifts leg actively from bed with knee straight
- at what angle of hip flexion is pain reproduced
- pain must be in distribution of sciatic nerve / below knee
- differentiate from hamstring pain
Lasegue
- lower leg until pain just disappears
- forcibly dorsiflex foot and assess if pain recurs
Neurological Exam
Tone
- normal, increased or decreased
- clonus ankle (normal < 2 beats)
- clonus patella
Power
L2 - hip flexion / pull knee to chest
L3 - knee extension / hold knee straight
L4 - ankle dorsiflexion / T anterior / pull foot up
L5 - hallux dorsiflexion / FHL / pull big toe up
S1 - ankle plantarfiexion / push foot down
MRC Muscle Power Grading
0 - no movement
1 - flicker only
2 - movement with gravity eliminated
3 - movement against gravity
4 - movement against resistance
5 - normal movement
Reflexes
Knee jerk (L4)
Ankle jerk (S1)
Babinski - scratch soles
Sensation - light touch
LI - groin
L2 - thigh
L3 - knee
L4 - medial malleolus
L5 - bunion / dorsum foot
S1 - sole / lateral foot
S2 - posterior calf
S3,4 - 'bulls-eye' around perineum
Lateral Side
Femoral stretch test
- flex knee to 90o
- extend hip
- positive if reproduces leg pain in distribution of femoral nerve
Abductor power (L5)
- lift leg up
- palpate contraction
- grade power
SI joint
- semilateral position
- leg flexed and adducted across body
- forced adduction
- reproduce pain
Special
Ankylosing spondylitis
- wall test
- stand with back to wall
- heels, buttocks and occiput touch wall normal
Kyphosis
- forward bending test
- hyperextension while prone
Waddell's Signs (DR TOS)
- distracted SLR
- rotation causes pain
- tenderness non anatomical
- overreaction
- superficial tenderness