Now let's talk about the provocative maneuvers for evaluating the lumbar spine. In evaluating the lumbar spine, we wanted to be able to differentiate between a facet syndrome, a radiculopathy, a myofascial condition, which we checked for with our palpation, and a radiculopathy. We begin our lumbar spine evaluation by having the patient in the seated position. We start with a sitting straight leg raise.
We have the patient raise the leg up to 90 degrees. We would look for the patient’s response through this maneuver. If they reach back in a painful posture, we worry about that we may be dealing with a disc injury. If they reach back with a painful posture, and put their hands back like this for protection, and tell us that they have shooting pain or pain under the leg, we worry about a discopathy causing a radiculopathy or compression of the nerve root.
If the patient gives us no painful response with raising the leg up, I’m going to gently accordion the patient. If this does not bother their back, or cause any shooting pain into the leg, or increased pain in the leg, I’m thinking that we’re not dealing with a disc or a nerve root problem, but more likely, a myofascial or joint problem. We’re going to do the same with the opposite leg. Raise it up with a sitting straight leg and see whether we’re getting symptoms. Now, we’re going to chart what these symptoms are.
If we can get the leg up to 90 degrees with no symptoms, that’s a negative straight leg on the right at 90 degrees. If we can get it up to 80 degrees with no symptoms, then we’re going to chart a sitting straight leg at 80 degrees without symptoms. When we have the leg up in this position, one more check for radiculopathy is dorsiflexion of the foot. So we’re going to take the foot and dorsiflex it, and wait for the patient to respond.
If this causes shooting lancing pain into the leg or increased pain into the leg, that's called a positive root tension sign and we’re concerned about a radiculopathy or other neurological lesion. In addition to our root tension sign, we discussed in video 2 the motor grading of the foot and the reflexes of the lower extremity, as well as sensation to light touch of the dermatomes and lower extremity, and pin. That part of the examination that we described in video 2 will also be performed with the patient in the sitting position. After doing the sitting exam, we’re going to do the supine examination. Have the patient lie down, face up for us.
And now we’re going to do the straight leg raise or Lasegue’s. We raise ... Relax the leg. We raise the leg up as far as it will go or when the patient gives us signs or tells us that they’re experiencing pain. Now in this case, the leg goes to 90 degrees.
I want you to remember that the leg went to 90 degrees when they were in the sitting position too. In straight leg raise and sitting straight leg raise, these two tests should be very similar. When I get the leg up, if the patient responds that they’re experiencing pain, I want to ask them where their pain is. If they say it’s underneath the leg, I’m concerned about a tight hamstring. If it shoots into the leg, I’m concerned about a radiculopathy.
If its pain isolated in the back, I may worry about a facet syndrome or a myofascial lumbar paravertebral problem, or possibly a disc. Now I’m going to do it for both sides. So I’m going to raise the leg up and I’m going to chart in the record where the leg went, how far that is and whether there were symptoms. In this case, I’ve got straight leg raise or SLR is negative at 90 degrees because there are no symptoms. Now remember, in doing the straight leg raise, we’re looking for shooting lancing pain under the leg, which would indicate a neurological condition.
If we have pain in the back, we may be dealing with tight hamstrings. If we have pain in the lumbar region, we may be dealing with a facet syndrome or a lumbar paravertebral myofascial condition. In addition to doing the straight leg raise, we also can do root tension sign by dorsiflexing the foot, and seeing if the patient had shooting lancing pain into the leg. The next test we want to do while the patient is supine is Faber Patrick, which is evaluating for hip lesion.
Now, we take the ankle and cross it to the knee, and have the patient drop this knee down. And we hold the ASIS and apply gentle downward pressure over the knee, and ask the patient if they’re having any pain. If they are, we want to know where. Now this is critical in our differential diagnosis. If the patient is having pain in the anterior lower quadrant region, that’s a sign of a problem with the hip. If the patient is having pain in the side of the buttock, we may be dealing with a bursitis, or a myofascial condition.
If they're reporting pain in their low back region, we may be dealing with a myofascial problem or a facet syndrome. And next, we want to evaluate for piriformis syndrome and do a piriformis stretch test. We extend the hip 90 degrees, reflex the knee 90 degrees, and we internally rotate the ankle, and have the patient press against our arm. Will you push out against my arm? Relax.
Now if that causes pain in the buttock, we may be dealing with a piriformis syndrome or a myofascial injury to the piriformis, and should evaluate that condition with palpation. Now we’re going to have the patient go prone. So will you go face down for me please, Deb? Okay? In the prone evaluation, we want to differentiate between a nerve injury of the upper lumbar spine, a sacroiliac problem, a facet problem.
We start by doing the femoral stretch test. We have the patient’s knee flexed at 90 degrees. And we raise the hip up. This puts stretching maneuver on the femoral nerve, which is L2, L3, and L4. And if this causes shooting lancing pain into the anterior thigh, we’re dealing with a femoral nerve injury, which may be a disc or radiculopathy in the upper lumbar region. If this does not bother the patient, the next thing we’re looking for is sacroiliac. So we’re going to isolate the area over the sacrum and we’re going to lift the leg up a little further, which is putting pressure on the sacroiliac joint.
If this causes pain, it’s a provocative test for the SI lesion. And finally, we’re going to put the hand over the lumbar area at approximately L102 and lift the leg up even further. Now if this produces back pain, we are jamming the facets, and this is indicative of a facet syndrome or an injury to the posture motor unit of one of the lumbar segments. To identify the exact same segment, palpation would be quite helpful. So in summary, what we have done with the prone evaluation is we’ve checked for a femoral nerve injury or a discopathy of the upper lumbar segments.
We’ve checked for sacroiliac lesion by doing a provocative maneuver or the SI. And we’ve checked for a facet lesion by doing provocative maneuver of the posterior facets. Now, if the patient had pain on the provocative testing where we hold the sacrum and raise the leg in the prone position, we want to look for the motion of the SI joint.
And that’s done by having the patient stand. Will you stand for me, please? And face this way? And we’re going to palpate the posterior superior iliac spine and the second sacral tubercle. And with palpating this, we’re going to ask the patient to raise their left leg by bending their knee as high as you can. And we’re going to look for the thumb movement over the PSIS. Drop it down for me.
Now watch the thumb movement as the patient raises the leg. Go ahead raise the leg for me, Deb. See how it goes down in relationship to the right one.
Now, do it again for me, Deb. If it goes up in relationship to the thumb over the sacrum, we have a fixated sacroiliac joint. Down again please, Deb. Move it up now again. If it goes down, we have normal motion of the sacroiliac.
So this will help in our motion palpation of a lesion of the sacroiliac joint.
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