History

SPINE
1. Pain: location (leg versus back), radiation, timing, duration, quality, aggravating,
relieving, change with cough/sneeze
2. Other: stiffness, deformity, numbness, weakness, bladder problems, bowel problems,
scoliosis (duration, progress, pain, neurologic signs, growth, menarche, family
history, treatment, previous XR)
3. Function: walking, limp, supports, distance, stairs, socks, toes, transportation
4. Past history: treatment, injury, surgery, similar episodes

Exam (Standing)

1. Look: shoes, sticks, spine, scars, waist, hair, deformity (scoliosis, kyphosis, lordosis),
scoliosis (balance, shoulders, rib prominence, loin creases)
2. Feel: LLD, Trendelenburg sign, pelvic obliquity(structural Scoliosis), steps

 Movement:  CERVICAL SPINE

Forward flexion Normal : 75 to 90 degrees

Extension Normal : 45 degrees

Right lateral flexion Normal : 45 to 60 degrees

Left lateral flexion Normal : 45 to 60 degrees

Rotation to right Normal : 75 degrees

Rotation to left Normal : 75 degrees

Thoracic and lumbar spine

Forward flexion (Schober’s test) Normal : 90 degrees

Extension Normal : 30 degrees

Lateral flexion to left and right Normal : 30 to 45 degrees

Rotation to left and right Normal : 45 degrees

Schobeer’s Test: The examiner makes a mark approximately at the level of L5 . The examiner then
places one finger ~5 cm below this mark, and another, second, finger, ~10 cm above this mark. The
patient is asked to touch his/her toes. By doing so, the distance between the two fingers of the
examiner increases. However, a restriction in the lumbar flexion of the patient reduces this increase;
if the distance increases less than 5 cm], then there is an indication that the flexion of the lower back
is limited.

Exam (Supine)

1. Look: asymmetry, wasting, deformity, scars, atrophy

2. Feel: pulses
3. Movement: Assess hip/knee mobility if you haven't already.

Straight leg raise (SLR): keep the knee extended and passively flex the hip by lifting
the heel off the examination couch and estimate the angle of elevation (normally 80 -
90o). If restricted by pain radiating from back to BELOW the knee (i.e. back, buttock,
thigh and calf), there is evidence of sciatic nerve root irritation. Tension on the sciatic
nerve can be increased by dorsiflexion of the ankle, causing increase in pain.

Lasegue's test: Tension is then removed by flexing the knee, often allowing the hip to
be fully flexed. If when the knee is extended from this flexed hip/knee position, the
pain is reproduced, Lasegue's test is positive.

Bowstringing's test: With hip flexed to 90o, extend the knee as far as the patient
tolerates. Pressure applied to the hamstrings (possibly pulling on the peroneal nerve)
with the thumb will immediately cause pain if there is nerve root irritation.

NOTE: If the pain on SLR is felt in the contralateral limb (cross-leg pain or cross-
sciatic tension), there may be a central disc prolapse, with risk of cauda equina
syndrom

4. Neurovascular: sensation, power, tone, coordination, abdominal reflex, tendon

reflex, anal reflex
5. Sacroiliac joint, hip & knee
Exam (Side)

Femoral stretch test. You will lie face down on the exam table with your legs extended. Your doctor
will raise one leg toward the ceiling and then bend your knee. If this test produces pain that travels
(radiates) toward the front of the thigh, it is likely that one of the nerve roots located high in the

lumbar region (lower back) is irritated

Gluteus medius test This procedure evaluates the strength of the gluteus medius muscle on the
stance side. Stand behind the patient and observe the dimples overlying the posterior superior iliac
spines. Normally, when the patient bears weight evenly on both legs, these dimples appear level.
Then ask the patient to stand on one leg. If he stands erect, the gluteus medius muscle on the stance
side should contract as soon as the opposite leg leaves the ground, and should elevate the pelvis on
the unsupported side. This elevation indicates that the gluteus medius muscle on the supported side
is functioning properly (negative Trendelenburg sign). If the pelvis on the unsupported side remains
in position or actually drops, the gluteus medius on the stance side is either weak or non-functioning
(positive Trendelenburg sign).

NAFFSIGER’s SIGN and LHERMITTE’s TEST in DAAS

Exam (Prone)

1. Look: bony tenderness, steps, soft tissue

2. Feel: glutei
3. Movement: hip internal and external rotation and extension
4. Power

MEASUREMENT OF LOWER LIMBS IS ESSENTIAL TO RULE OUT THE CAUSE

OF SCOLIOSIS FROM BEING A LIMB LENGTH DISCRIPANCY

Waddel (3/5)

1. Tenderness: superficial or non anatomic

2. Simulation tests: axial load & pelvic rotation
3. Distraction tests: SLR seated
4. Regional disturbance
5. Over reaction
Any individual sign counts as a positive sign for that category. 3 or more of the 5 categories
is clinically significant Waddell's signs may indicate non-organic or
psychological component to chronic low back pain
1. Superficial / non-anatomical tenderness: Lightly pinch the skin on a wide area of lumbar skin
(pinch test). If this causes pain, test is positive.

2. Axial loading: Using the flat of his/her hands, the examiner vertically loads the patient's skull. If
this causes pain, the test is positive. Similarly, simultaneous ipsilateral rotation of shoulders and
pelvis (i.e. log-roll) in the same plane should NOT cause pain.

3. Distraction: If the examiner elicits severe pain on SLR, but the patient is able to comfortably sit
forward with legs extended on examination couch, the test is positive.

4. Regional disturbances: Test is positive in presence of non-anatomical motor or sensory deficits

(e.g. normal heel-toe walk, but cog-wheel foot weakness).

5. Over-reaction: Test is positive if muscle spasm, tremor or collapse occur during examination

REFER 227 in DAAS to rule out SACROILIAC JOINT PATHOLOGIES!!

 KNEE
History
Pain:where,radiation,type,when,nocte,aggrevating,relevieving,how long,stairs,start up
other:locking,swell,giveway,stiffness,deformity
function:walking,limp,support,squat,kneel,stairs,toes,socks
past history:treatment,injury,surgery,sim episodes

Exam (Standing)

look:shoes,sticks,spine,back,side,front,scars,swelling,deformity,wasting,redness
feel:LLD (Trendel)
move; gait,single leg stance,hop,squat

Trendelenburg Test (Hardcastle & Nade, 1985)

Examiner stands behind patient to observe angle of pelvis
Patient asked to raise from the floor the side not being tested

hip should be at 0 - 30o flexion

support weight bearing side only
stance side usually elevated if normal
Positive test if non stance side cannot be elevated or position cannot be maintained for 30 sec
Once balanced the patient is asked to raise the non stance side of the pelvis as high as possible,
support may be given on the stance side
If leans too far over weight bearing side correct so that the vertebral prominences between the
shoulders are over the centre of the hip joint and weight bearing foot
If elevation of the pelvis is not maximal or maintained also positive test indicating abnormal hip
mechanics
Gluteus Medius is affected!!

Exam
look:swelling,wasting,deformity,fixed flexion deformity
feel:pulses, patellar tape, effusion & synovium ( X-fluct , bulge),temperature,posterior whole knee
systematically
move:crepitation,passive extension,active extension,active flexion,passive flexion
ligs:
varus/valgus testing
Lachman,anterior draw,Slocum test,Flexion-rotation-drawer test,Pivot shift test,Jerk test,Merv Cross
Lacmann,posterior draw,push back,90/90+dynamic reverse pivot shift(Jakob),ext rot.
recurvatum(Hughston)
menisci:McMurray(flex,abd,e.r.>ext.,add,i.r.),Steinman