examination of the lumbar spine

clues

      walking / mobility aids

      external appliances

      lumbar brace

      AFO

Look

From front

      stand patient facing you

General

      manifestations of systemic disease

      face

      skin

      height and habitus

Contour

Wasting

      quadriceps

from lateral side

      turn patient side on

Deformity

      normal

      there is a thoracic kyphosis and a lumbar lordosis

      abnormal

      exaggerated

      reduced

from back

      turn patient facing away from you

Deformity

      scoliosis

      shoulder height

      scapular symmetry

      flank contour

      loin creases

      PSIS height (leg length)

      legs

      symmetry of stance

Skin

      scars

      pigmentation

      dimple or hairy patch

Contour

Swelling

      paravertebral spasm

Wasting

      buttocks

      thighs

      calves

Move

Forward flexion

      perform simultaneously

Forward flexion test

      standing with feet together and knees straight

      aiming to touch floor

      comment on

      pain

      amount (fingertips in relation to front of legs)

Schobarís 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

      from flexed position

      pain

      difficulty (hands on thighs)

      extension catch

      hyperextension

      one hand in small of back and one hand on shoulder

      amount (15o-30o)

Lateral flexion

      from midline

      one hand on hip and other hand on shoulder

      pain

      amount (15o-30o)

Rotation

      feet still and twist body

      look from above

      angle between plane of shoulders and pelvis

      amount (45o)

gait

      walk away from you

      walk towards you

      on tiptoes

      on heels

      walk beside patient to steady them

      squat

lying prone

Feel

Spine

      palpation

      down middle

      down each side

      comment on

      malalignment

      step

      defect

      percussion

      tenderness

SI joints

      palpate

      tenderness

Buttock

      tenderness

      masses

Move

Femoral stretch test

      steady pelvis with one hand

      test hip extension range first

      lift leg with knee straight (hand under knee)

      then stretch femoral nerve

      flex knee to 90 degrees

      grasp ankle with other hand and lift

      positive if reproduces leg pain

      in distribution of femoral nerve

(Ankle jerk)

      with knee flexed to 90o

on lateral side
Abductor power

      lift leg up

      palpate contraction

      grade power

SI joint

      semilateral position

      leg flexed and adducted across body

      forced adduction

lying supine
Straight leg raise

Hip ROM

      flex hip to 90o and rotate hip

      comment

      painless range of hip movement

Lasegue

      lift leg from bed with knee straight

      note when pain occurs

      at what angle of hip flexion

      note where pain is

      back or leg

      same as usual pain

      in distribution of sciatic nerve

      differentiate from tight hamstrings

Dorsiflexion (sciatic stretch)

      lower leg until pain just disappears

      forcibly dorsiflex foot and assess if pain recurs

Bowstring

      hand in popliteal fossa

      slightly flex knee

      apply pressure to medial and lateral hamstrings

      apply pressure to nerve in popliteal fossa

      comment if reproduces pain

Power

      put joint into desired position

      palpate muscle

      ask patient to maintain position against you

Hip

      hip adduction (L2,3)

      squeeze knees together

      hip abduction (L4,5,1)

      push legs apart

      hip flexion (L2,3)

      pull knee to chest

      hip extension (L4,5)

      push knee away

Knee

      knee flexion (L5,S1)

      pull heel to bottom

      knee extension (L3,4)

      hold knee straight

Foot

      ankle dorsiflexion (L4, 5)

      pull foot up

      hallux dorsiflexion (L5)

      pull big toe up

      ankle plantarflexion (S1,2)

      push foot down

      hallux plantarflexion (S1,2)

      push big toe down

      ankle inversion (L4)
hold foot in

      ankle eversion (L5,S1)

      hold foot out

Reflexes

      knee jerk (L4)

      flex knee slightly

      ankle jerk (S1)

      flex knee and ankle to 90o in midair OR

      tap on soles

      Babinski

      scratch soles

Sensation

      light touch

      L1 (groin)

      L2 (proximal lateral thigh)

      L3 (medial distal thigh and knee)

      L4 (medial calf)

      L5 (lateral calf, dorsum of foot and medial toes)

      S1 (sole and lateral toes)

      S2 (posterior calf and thigh)

      S3,4 ('bulls-eye' around perineum)

Special

circulation

      pulses

      assess proximally if foot pulses absent

cephalad

      hip joint

      ROM

Other

Ankylosing spondylitis

      wall test

      stand with back to wall

      heels, buttocks and occiput touch wall

      SI joint

      SI stress test

      chest expansion

      measure inspiratory and expiratory difference

      should be > 5 cm

Kyphosis

      forward bending test

      observe from side

      correction test

      hyperextension while prone

Leg length

      correction

      blocks and reassess curve

      sitting

      reassess curve