LUMBAR VERTEBRAE

Axial (Overhead) Lateral (Side) View

View

1
 INTERVERTEBRAL DISC

nucleus pulposus collagen

annulus fibre
proteoglycan
flbrosus molecule

vertrebral bOdy
(bone)

lntervertebral
disc
I
vertrebral bOdy
(bone)
(9 A..J,H. f i,tf tt , IMNet!'lefllllClt
anion
lamella cation
Interstiti
al fluld
2
Anterior longitudinal Limits extension
ligament
Posterior longitudinal Limits forward
ligament flexion
Ligamentum Limits forward
flavum flexion
Supraspinous Limits forward
ligament flexion
lnterspinous ligaments Limit forward
flexion
lntertransverse ligaments Limit contralateral lateral
flexion

lliolumbar Resists anterior sliding of

ligament LS & S1
 ,, -----
------
- --- -
-Abdominal -
Rectus

-..,. -
fascia abdominus
;,.;,?,£..... Transverse
abdominus

P s o a s major
Quadrall.Js
lumborum
,¥--E x te r n a l
L3
oblique
0 Internal
Latissimus oblique
dorsi
Lateral
raphe
Anterior l a y e r }
Middle layer Thoracolumbar
Er ctor lliocostalis Posterior layer fascia
{ sp,nae Longissimus Lumbodorsal
fascia
 OBJECTIVE ASSESSMENT
ON OBSERVATION
• BODY TYPE: Endomorphic, mesomorphic,
ectomorphic
• Posture : anterior view, posterior view, lateral
view
• Gait : swing phase , stance phase
• External aids
• Attitude of body
Posture
Scoliosis (static, sciatic, idiopathic)
Lordosis (excessive, flattened)
Lordotic deviations
Flat back posture
Sway back posture
PALPATION
 WARMTH
 TENDERNESS:
• SPINOUS PROCESS
• TRANSVERSE
PROCESS
• ZYGOAPOPHYSEAL
JOINT
 ON EXAMINATION
LUMBAR FLEXION ROM:
Starting position: Landmarks for goniometric alignment (midaxillary
line at level of lowest rib, mid-axillary line) indicated by orange line
and dot.
LUMBAR EXTENSION:

LUMBAR LATERAL FLEXION:

LUMBAR ROTATION:
Resisted isometrics for abdominals
 Isometrics for Extensors
This test is designed to test the strength of iliocostalis , erector spine and
multifidus
.
• Normal (5) = With hands clasped behind the head,
extends the lumbar spine, lifting the head, chest, and
ribs from the floor (20 to 30 second hold)

Good (4) = With hands at the side, extends the lumbar

spine, lifting the head, chest, and ribs from the floor
(15 to 20 second hold)

Fair (3) = With hands at the side, extends the lumbar

spine, lifting the sternum off the floor (10 to 15 second
hold)

Poor (2) = With hands at the side, extends the lumbar

spine, lifting the head off the floor (1 to 10 second hold)

Trace (1) = Only slight contraction of the muscle with

no movement
Back Rotators/Multifidus Test. This test checks the ability of the lumbar
rotators and multifidus to stabilize the trunk during dynamic extremity
movement.

Normal (5) = Able to do contralateral arm and leg, both sides while
maintaining neutral pelvis (20 to 30 second hold)

Good (4) = Able to maintain neutral pelvis while doing single leg lift but
not able to hold neutral pelvis when doing contralateral arm and leg (20
second hold)

Fair (3) = Able to do single arm lift and maintain neutral pelvis (20 second
hold)

Poor (2) = Unable to maintain neutral pelvis while

doing single arm lift
 Special tests
Centralization. The patient either stands or lies prone depending on the intent of a loaded or unloaded assessment. Multiple directions of
repeated end-range lumbar testing are targeted. Movements may include extension, flexion, or side flexion. Movements are generally
repeated for 5–20 attempts until a definite centralization or peripheralization of symptoms occurs. Centralization of symptoms is
considered a positive finding for discogenic symptoms.

The Single-Legged Squat. The single-legged squat can be used as an indicator of lumbopelvic–hip stability. The test is functional, requires
control of the body over a single weight-bearing lower limb, and is frequently used clinically to assess hip and trunk muscular coordination
and/or control.

Loss of Extension. The patient lies in the prone position. The patient is asked to extend his or her lumbar spine while keeping the pelvis in
contact with the treatment table. A positive test for diskogenic symptoms is moderate or major loss of extension. A study by Laslett et
al.129 using visual observation found that a loss of extension in predicting symptomatic disks had a sensitivity of 27% and specificity of
87%.

Neurodynamic Mobility Testing. The slump, straight (Well) leg raise, bowstring, double straight leg raise, and prone knee flexion tests .

Milgram’s Test. Milgram’s test is as much an assessment of abdominal muscle strength as it is intrathecal irritability.With legs fully
extended, the supine patient is asked to raise both feet approximately 2 inches off the table and maintain this position for at least 10
seconds and up to 30 seconds .The inability to perform this test due to muscle weakness is not considered a positive finding within the
context of this test, but should nevertheless still be charted.
PELVIC COMPLEX
 Anatomy of pelvis
• The term "innominate" means "nameless" or
"unspecified." The pelvic bones are called
innominate bones because each pelvic bone is
actually made up of three individual bones that
fuse together during development - the ilium,
ischium, and pubis. These three bones are
originally separate but eventually join together
to form a single bone, which is referred to as
the innominate bone or os coxae.
 FORM CLOSURE
Form closure arises from the anatomical alignment of the bones of the innominate and the
sacrum, where the sacrum forms a kind of keystone between the wings of the pelvis. The SIJ
transfers large loads and its shape is adapted to this task. The articular surfaces are relatively
flat, which helps to transfer compression forces and bending movements. However, a
relatively flat joint is vulnerable to shear forces. The SIJ is protected from these forces in three
ways.

First, the sacrum is wedge (triangular) shaped and thus is stabilized between the innominate
bones, similarly to a keystone in a Roman arch, and is kept in a state of “suspension” by the
ligaments acting upon it.
Second, in contrast to other synovial joints, the articular cartilage is not smooth but rather
irregular .
Third, a frontal dissection through the SIJ reveals cartilage covered bone extensions protruding
into the joint—the so-called “ridges” &“grooves.” They seem rather irregular, but are in fact
complementary to each other, and this unusual irregularity is very relevant as it serves to
stabilize the SIJ when compression is applied.According to Vleeming et al. (1990a), after
puberty most individuals develop a crescent-shaped ridge running the entire length of the iliac
surface with a corresponding depression on the sacral side; this complementary ridge and
groove are now believed to lock the surfaces together and increase stability of the SIJ.
If the articular surfaces of the sacrum and the innominate bones fitted together with perfect
form closure, mobility would be practically impossible. However, form closure of the SIJ is not
perfect and mobility—albeit small—is possible,and therefore stabilization during loading is
required. This is achieved by increasing compression across the joint at the moment of loading;
the anatomical structures responsible for this compression are the ligaments, muscles, and
fasciae. The mechanism of compression of the SIJ by these additional forces is what is commonly
called force closure. When the SIJ is compressed, friction of the joint increases and consequently
reinforces form closure. According to Willard et al. (2012), force closure reduces the joint’s
“neutralzone,” thereby facilitating stabilization of the SIJ.
 FORCE CLOSURE
Force closure is accomplished as follows. The first method is by
nutation of the sacrum, which is achieved either by anterior
motion of the sacral base or by posterior rotation of the
innominate bone. These two types of motion result in a tightening
of the sacrotuberous, sacrospinous, and interosseous ligaments;
this tightening assists in activating the force closure mechanism,
thereby increasing the compression of the SIJ. Counter-nutation,
on the other hand, decreases the stability of the SIJ because of the
reduced tension in the above-mentioned ligaments.
Cohen (2005) states that because the ilium and sacrum only meet
at approximately one-third of their surfaces, the associated
ligaments provide therest of the stability between these bones.
 SI DYSFUNCTION
ETIOLOGY:
Sacroiliac joint pain and dysfunction May be either
secondary to acute trauma involving sudden heavy lifting,
prolonged lifting and bending,torsional strain, fall Onto a
buttock, or rear-end motor vehicle accidents . In addition,
sacroiliac joint pain and dysfunction may occur from chronic
repetitive shear or torsional forces to the sacroiliac joint
associated with figure skating, golf, bowling, constant sitting
or lying on the affected side . It also has been described that
pain in the sacroiliac joint may be aggravated by sitting , lying
on the affected side. Weight bearing on the affected side
with standing or walking , forward flexion in the standing
position with knees fully extended .
CLINICAL MANIFESTATIONS:

Pain is usually localized over the buttock

Patients can often complain of sharp, stabbing, and/or shooting pain
which extends down the posterior thigh usually not past the knee.
Pain can frequently mimic and be misdiagnosed as radicular pain
Difficulty sitting in one place for too long due to pain
Local tenderness of the posterior aspect of the sacroiliac joint (near
the PSIS)
Pain occurs when the joint is mechanically stressed eg forward
bending
Absence of neurological deficit/nerve root tension signs
Aberrant sacroiliac movement pattern
• Patients will frequently complain of pain while sitting down, lying
on the ipsilateral side of pain, or climbing stairs
SPECIAL TESTS:
Gaenslen’s test : Pt supine with both legs
extended. The test leg is passively brought into
full knee flexion, while the opposite hip remains
in extension. Overpressure is then applied to the
flexed extremity. (Reproduction of pain)
Drop Test : Pt stands erect with heels raised on
both legs while keeping the affected side knee
extended. Pt is advised to drop the affected side
heel with a bump while bearing the whole body
weight alongside keeping the knee exteded, to
direct force cranially through the ipsilateral SIJ.
 PUBIC SYMPHYSIS DYSFUNCTION
ETIOLOGY
Diastasis
Rupture
Osteomy
Fracture
Misalignment of the pelvis
Frequently associated with pregnancy and childbirth
Increased age when bearing a child
Sports injury: caused by falling with the legs in hyper-abduction
(example: horse-riding)
• Prostatectomy
CLINICAL FEATURES:

Pain:
Burning, shooting, grinding or stabbing
Mild or prolonged
Usually relieved by rest
Radiating to the back, abdomen, groin, perineum and legs
Disappears commonly after giving birth (not in every case)
Discomfort sense onto the front of the joint
Clicking of the lower back, hip joints and sacroiliac joints when changing position
Difficulty in movements like abduction and adduction
Locomotor difficulty:
Walking
Ascending or descending stairs
Rising from a chair
Weight-bearing activities
Standing on one leg
Turning in bed
• Depression, possibly due to the discomfort
Thank you