DD MSK

PTOR 455

A.AZIZ KHALIL
HIP AND LUMBAR
D.D
SPECIAL TEST
 Thomas Test & Modified Thomas Ely’s test
Purpose:
This test is used to rule out a hip flexion contracture
Technique:
1- the patient lying supine on the examining table. One knee is brought to the patient’s chest and held there.
Make sure the lower region of the lumbar spine remains flat on the table.
2- It is performed with the patient lying supine with the knees hanging over the edge of the table. The
unaffected leg is flexed toward the chest to stabilize the pelvis and back, and you should observe the test leg to
see if the knee extends.
The result:
In the presence of a hip flexion contracture, the extended leg will bend at the knee and the thigh will raise from
the table.
DD:
with passive knee flexion contracture secondary to iliopsoas wouldn't change the situation of hip flexion
degree, in contrary the rectus femurs contracture will lead to inc hip flexion degree
 Piriformis Flexibility Test
Purpose:
Examine piriformis flexibility.

TEST PROCEDURE:
The patient is in the supine position with their hip flexed to 60 degrees. Fully
adduct the patient’s hip followed by internal then external rotation.

The result & DD:

The normal range should be 45 degrees in either direction.

**Tightness in internal rotation is due to the superior fibers.
*Tightness in external rotation is due to tight- ness in the inferior fibers

N.B : arthrogenic restriction should be excluded before the myogenic evaluation.

 Piriformis resisted Test
Purpose:
Deep gluteal syndrome, abbreviated as DGS is defined as pain in the buttock area caused by a non-discogenic
entrapment of the sciatic nerve in the sub-gluteal space.
The structures that can be involved in sciatic nerve entrapment are not only the piriformis but also fibrous bands
containing blood vessels, gluteal muscles, hamstring muscles, the gemelli-obturator internus complex, vascular
abnormalities and space-occupying lesions. For this reason, the term “deep gluteal syndrome” instead of “piriformis
syndrome” is now preferred..

TEST PROCEDURE:
the examiner gives resistance at the flexed knee with his other hand, the patient is asked to drive their heel into
the examination table, initiating active hip abduction and external rotation.

The result & DD:

The test is positive if the patient’s familiar complaints of gluteal pain

and/or paraesthesia radiating into the posterior aspect of
the lower extremity are reproduced
Gluteal pian common causes
Sacroiliac provacation test

CLUSTER OF LASLETT

Purpose:
The Cluster of Laslett originally describes 6 provocative tests. Eventually, Laslett
proposes an algorithm comprising 4 provocative tests to identify the SI joint as the
source of pain as the other two tests didn’t have additional diagnostic value.

The result:
You can increase the specificity when the patient’s symptoms don’t centralize as
described by McKenzie.

For all tests, you are looking for the reproduction of your patient’s familiar pain. Be
aware that the thrusts are not manual therapy thrusts. As these techniques are pain
provocation techniques, be careful and start gently first. Sometimes just a single
pressure is enough.

Mark Laslett, the author of the cluster proposes a diagnostic algorithm to evaluate
the outcomes of each individual test. Overall, 2/4 is positive tests are needed to
diagnose a symptomatic SI joint. If the first two tests are positive
1- Distraction test

The patient lies supine with the legs extended. You are going to stand on the
symptomatic side and place your hands on the patient’s anterior superior iliac spines.
Then apply 3-6 moderate velocity thrusts and gradually increase pressure in a
dorsolateral direction.
2- Thigh Thrust test

our patient lies supine and you are going to stand on the asymptomatic side. Flex the
leg on the symptomatic side to 90° of hip flexion. Place one hand over the sacrum
and then apply longitudinal pressure through the patient’s femur creating a shear
force in the SI joint. Apply 3-6 higher velocity thrusts with gradually increasing
pressure
3- Compression test

Ask your patient to lie on the asymptomatic side with the hips flexed to 45° and
knees bent to 90°. You are going to position yourself behind the patient and place
your hands on the anterior rim of the ilium. They apply 3-6 vertical thrusts with
moderate velocity and gradually increasing pressure.
4- Sacral thrust test

For the sacral thrust test, your patient is going to lie in prone position. You are going
to stand next to the bench and place the palm of your hand over spinal level S2. The
direction of pressure is going to be vertically downwards. Apply 3-6 higher velocity
thrusts and gradually increase pressure
Trendelenburg’s Test

Purpose:
to determine whether pelvic stability can be maintained by the hip abductor muscles

TEST PROCEDURE
The patient stands on the test leg and raises the other leg off the ground

The result:
Normally, the pelvis should tilt upward on the non-weight-bearing side. The test
finding is abnormal if the pelvis drops on the non-weight-bearing side.
Overhead squat test
Patrick’s (Faber’s) Test- Figure Four Test

Purpose
This test is performed to assess possible dysfunction of the hip and sacroiliac joint

Technique
The patient is supine with the hip flexed, abducted, and externally rotated. The patient is
asked to place the lateral malleolus of the test leg above the knee of the extended,
unaffected leg.
The result:
The test result is positive if this maneuver causes pain for the patient.
The test may be amplified by your pressing downward on the test knee. Pain with
downward pressure indicates a sacroiliac joint problem, as the joint is compressed in this
position.
Hip OA “CLUSTER OF SUTLIVE’’
Purpose
The cluster of Sutlive is a 5-item test cluster hat can aid in the preliminary diagnosis of hip
osteoarthritis in patients who complain of unilateral hip pain
Items
1) A positive hip scour test
2) Passive hip internal rotation <= 25°
3) hip pain when squatting.
4) Active hip flexion causes lateral pain.
5) Active hip extension is painful.
The result:
3 out of 5 positive items result in a positive
hip scour test
Technique
patient lying in supine position passively flexed the hip to 90°. Move the hip towards the opposite shoulder
and apply an axial load through the femur. Assess the patient’s symptoms in the groin. Then move the hip into
internal rotation and axial compression, consequently moving it into adduction and compression
FAI

Faddir test
Purpose
This test is performed to assess possible hip impingement, FAI, and Laberal injury.

Technique
The patient is supine with the hip flexed, adducted, and internally rotated.

The result:
The test result is positive if this maneuver causes pain for the patient.
Lumbar canal stinosis

LUMBAR SPINAL STENOSIS CLUSTER “Cook Cluster”

If lumbar spinal stenosis becomes symptomatic it will often lead to neurogenic claudication.
the diagnosis should be mainly based on patient history taking, while physical examination tests have not
been found to be useful.
This means that the spinal cord or a spinal root is becoming entrapped due to the narrowing of the spinal
canal or the intervertebral foramen.
This narrowing is usually degenerative and can come from, osteophyte formation, thickening of the
ligamentum flavum, spondylarthrosis, or a disc protrusion.
The clinical prediction rule contains a cluster of 5 elements from patient-history taking and observation that
are predictive of lumbar spinal stenosis.
According to the author zero positive findings lead to a sensitivity of 96% and 4 or more positive findings lead
to a specificity of 98% for spinal lumbar stenosis
Lumbar canal stinosis

LUMBAR SPINAL STENOSIS CLUSTER “Cook Cluster”

1.Bilateral symptoms of neurological nature, so we are talking about

possible pain, impaired sensitivity, loss of muscle strength etc. in both
lower extremities
2.Leg pain more than back pain, which is common if nerve roots are
affected
3.Pain during walking or standing, which is due to the fact that the
vertebral canal, as well as the intervertebral foramen narrow in these
positions
4.Pain relief upon sitting and this has to do with the fact that we are
creating more room again in vertebral canal and intervertebral foramen
5.Age > 48y and this is due to the fact that the incidence of spinal
stenosis is rising with age and typically observed in people above 60.
TWO-STAGE TREADMILL TEST / NEUROGENIC CLAUDICATION

PURPOSE :To assesses the difference in walking distance and symptom

provocation between flat incline walking in patients who suffer from neurogenic
claudication due to lumbar spinal stenosis

TEST PROCEDURE:
patient walk on a treadmill on a level plane for 10 minutes. After a 10-minute break,
the patient is then instructed to walk on an inclined treadmill at a 15-degree plane
for 10 minutes. This incline will decrease lumbar lordosis during walking and thus
increase the cross-sectional area in the spinal canal

INDICATIONS OF A POSITIVE TEST :

positive for lumbar spinal stenosis if there is earlier onset of symptoms with level
walking or prolonged recovery time after level walking or an increased total walking
time on an inclined treadmill.
Lumbar radiculopathy

Strait leg raise test “SLR"

PURPOSE :This test is performed to stretch the sciatic nerve and its dural covering proximally.
The SLR test places a tensile stress on the sciatic nerve and exerts a caudal traction on the lumbosacral nerve roots
from L4 to S2.

TEST PROCEDURE:
The test is performed by asking the patient to lie supine .With the patient’s knee extended, take the patient’s foot
by the heel and elevate the entire leg 35–70 degrees from the examining table. As the leg is raised beyond
approximately 70 degrees, the sciatic nerve is being completely stretched and causes stress on the lumbar spine.

The examiner flexes the patient’s hip until the patient complains of pain or tightness in the back or back of the leg.
The examiner then slowly and carefully lowers the leg back slightly (extends it) until the patient feels no pain or
tightness.
The examiner passively dorsiflexes the patient’s foot or asks the patient to actively flex the neck so that the chin
is on the chest; or, the two actions may be done simultaneously. Most commonly, foot dorsiflexion is done first.
Lumbar radiculopathy

Strait leg raise test “SLR"

INDICATIONS OF A POSITIVE TEST :

-“Back pain only” patients who have a disc prolapse have smaller, more central prolapses.

-If the pain is primarily in the leg, the pathological condition causing the pressure on neurological tissues is
more likely to be laterally located.

- If the patient complains of pain down the opposite leg, this is called a positive crossed response on the
straight-leg-raising test and is very significant for a herniated disc.

- The patient may also complain of pain in the posterior part of the thigh, which is due to tightness of the
hamstrings.
Heel- toe walk test
PURPOSE :To assess for L5 or S1 root motor involvement.

TEST PROCEDURE:
the patient is asked to walk on heel then toe several steps, no
matter if patient used any assistive aid.

INDICATIONS OF A POSITIVE TEST :

a positive test, the patient’s struggling to maintain heel or
toe raised during walking
Mckinzie method

McKenzie directional preference "Centralization , Peripheralization

DEFINITION

The clinical phenomenon where using a specific direction of repeated movement or a sustained
positions results in an improvement in either symptoms or mechanical presentation

TEST PROCEDURE:

the patient follow one of each direction either flexion or extension basically, in which pain
symptoms centralized rather than peripheralized.
Lumbar radiculopathy

Femoral Nerve Stretch Test

•PURPOSE :This test is useful in determining whether the patient has a herniated disc in
•the L2–L4 region

TEST PROCEDURE:
•he patient is lying on the side, with the test side up. The test can also be performed with the patient lying prone.
Support the patient’s lower extremity with your arm, cradling the knee and leg. The test leg is extended at the hip
and flexed at the knee.

INDICATIONS OF A POSITIVE TEST :

If this maneuver causes increased pain or paresthesia in the anterior medial part of the thigh or medial part of
the leg
You can determine whether the pain is caused by tight rectus femoris or of neurogenic origin by releasing
some of the knee flexion and then extending the hip. If the pain increases with hip extension, it is neurogenic in
origin
 THE SLUMP TEST
•PURPOSE :a very provocative dural test that poses maximal stress on the dura. If you suspect a severe disc
prolapse or extrusion with radicular pain.

TEST PROCEDURE:
1.The patient is then asked to fold the hands behind the back and slump into lumbar and thoracic flexion
while maintaining the head erect.
2.Then gently apply over-pressure over the shoulders with one arm and ask the patient to bring the chin to
the chest.
3.Add over-pressure to this triple flexion position with the hand and ask the patient to actively extend the
knee on the affected sides while maintaining this position active test or a passive test.
4.Add passive dorsiflexion

INDICATIONS OF A POSITIVE TEST :

The slump test is positive if familiar neurological symptoms are reproduced. Some discomfort like tension
over the hamstrings with restriction in knee extension or tension over thoracic spine levels T8/T9 are non-
pathological symptoms not indicative of a positive test
Lumbar instability

PRONE INSTABILITY TEST

•PURPOSE :to detect lumbar spine instability .

TEST PROCEDURE:
1. you ask the patient to lie prone with his legs hanging off the bench, but with contact with the ground.
Then you are applying PA pressure to different segments of the lumbar spine, and you are trying to provoke
pain.
2. If pain is provoked, you ask the patient to lift his legs off the ground, and you apply PA pressure again.

INDICATIONS OF A POSITIVE TEST :

If the patient’s pain is reduced by actively bringing the legs off the ground, this means that the patient is
able to actively stabilize his spine, which is a positive test.