welcome to another Lab video Everybody we're going to be looking at a clinical examination of the lumbar spine so we're going to start with that in a standing position in order to do an inspection of that region so for our patient here Dennis we're going to do that and what I'd like to start with here is just taking a look at our posture at the pelvis area so the lumbo pelvic region are we in an anteriorly rotated position of the pelvis posteriorly rotated position and how we can tell that is really by finding a couple key landmarks so if you can hold your hands across the chest this is just so you can see a little bit better here so first I'm going to palpate the Asis here in the front of the pelvis and we're also going to palpate the PSIs in the back of the pelvis and then from that you know there's a little bit of natural tendency for most people to sit in slight anterior rotation of the pelvis about 15 20 degrees or so and so this should line up to about that much off the horizontal plane and if it's more than that then this person would be inbe excessive anterior rotation or if it's a flatter angle between the two it' be more of excessive posterior rotation all right so Dennis here is actually in a little bit of posterior rotation not significantly uh but if we had a lot of anterior rotation then we would see a posture known as lower cross syndrome so I'm actually going to move your hips for you and just kind of arch your back with me as I do this so stay up nice and tall tall chest and perfect so this is an extreme posture but if someone had very tight hip flexors um and largely anteriorly rotated pelvis structures then this would be an extreme example of our lower cross syndrome and then come back just neutral position perfect other things we want to be able to palpate in the area here is iliac crest right so from the Asis coming around the sides and then that's going to help us to palpate the PSIs as we come all the way around the back that's right where that I CR terminates before we hit into the safer okay that's one thing I like to look for another thing is just Symmetry and Alignment from the back but we'll go more into that in the grass spine so while we're in this position before um we do anything on the table I'd like to do an assessment of range of motion just in a standing position here so we're gonna go ahead and do that for standing forward flexion so Den go ahead and just reach all the way down as far as you're comfortable with for me is trying to touch your toes to the floor and if you can just hold that position you actually some straight something a little bit straighter there we go okay all right that's as far as you can go all right and where do you feel that if you feel it anywhere okay so we hit some hamstring tightness you don't feel it in your back anywhere yeah a little bit little bit okay uh in middle of back low back where you feel that middle perfect so these are questions you need to be asking your patient in order to understand where is the tightness coming from if he can't touch the floor it Le down to his toes there's some tightness somewhere where so where is that so in his case he gets a lot of rounding through this upper lumbar lower thoracic spine which is good to know he has good mobility in flexion through that region the lumare spine itself is a little bit blocked and rigid so that assume that the segmental mobility between each vertebrae is a little bit limited and with the history of hamstring strength you know back up the hamstring is going to be tight as well of course so we do have to watch out for that okay so that's our forward flexion test normal is going to be at least reaching past the malleoli of the ankles um but for some people especially our more flexible um athletes maybe some of our females would expect Toes or to the floor okay next one we're going to check extension so going put your hands on your hips for me and then just Arch all the way back as far as you're comfortable with looking up to the sky really trying to get a lot of range of motion through this back here good perfect so with this not only are we looking for Comfort or pain do you have any pain with that no okay you can go ahead and come back to neutral there lot less motion there then in flection yeah this is gonna be normal some people are going to be more prone to having easier range of motion going one way or the other okay but that was pain free so that's good to know and again not a lot of movement between L1 and L5 if you do that one more time for me we're actually G to see kind of a hinge Point developing here in the upper lumbar spine right about here it's right around maybe L1 or L2 and not a lot of movement in the lower lumbar SP okay that's good can you go and face the camera for all right next next thing we're going to look for is going to be lumbar spine side bending okay so for this one I'm G to have you st nice and Tall hands to your sides and you're just going to reach down start the right side reach down the side of your leg as far as you can but keeping your chest tall okay good and then once he gets to that point I'm gonna just put my finger where he's at to mark it okay and same thing on the other side good making sure the chest stays tall so it's purely frontal plane all right I'm Mark that you can go and return to neutral there that's pretty symmetrical within normal limits what I'm looking for is can you reach at least to the level of the fibular head on both sides if he's reaching to the Joint line of the femoral epicondyle mobile it's going to be restricted if he can go past that fibular head that's good that's clearing range of motion but we want to see at least to the fibular Head okay so that's Sagal and frontal plane last one we're going to check is transverse plan so go and put your arms across your chest want to hold your hip still we want to make sure that we hold the hips still with trunk twisting that way we are not assessing for any lower extremity or hip range motion just lumbar spine okay have you twist all the way to your left as far as you can we're just eyeballing this here we should see approximately 60 plus degrees range that's plenty and go to your right walk that hip range motion a little bit tighter that way it looks like do you feel any pain or any difference either direction sure okay but no pain no pain just a little stiffer okay sounds good so you would note that in this case the limited forward fold or flexion range motion limited extension especially and uh between the left and right rotation limited on the right okay so that'll do it for a standing assessment of inspection and range of motion now we're going to take take a look at our posture and some palpation points on the table in our lumbar spine we have some key palpation points that we're going to talk about so working into that first one is going to be our IL that Crest this is going to be really big on orienting us in terms of geography and location of where we are at in this part of the body so we want to easily be able to palpate that iliac crest from the lateral aspect and we should be able to trace that all the way to the posterior superior iliac spine this thickening and really densification of the bone here that's a huge palpation point right there poster your superior iliac spine PSIs okay what lives in between that is going to be are sacrum okay and then as we come up we have L5 L4 3 2 and one on the spinus process of each okay and a in a patient it's not as clear as to which one's which so a good trick to find it is going to be putting your hands at the top of the iliac crest and from there thumbs are going to meet in the middle on a spinus process and that typically lines up with L4 as you see there so top of the ilc CEST rest thumbs in the middle we're going to line up with L4 in order to orient us as to which level of the spine are we at okay and if we move just codly we're at L5 if I go cranially we have L3 2 one okay easiest palpation points to the spine is those spinus processes what connects them is the interspinous ligaments those can be sprained with hyperflexion moments all right and if we move laterally so let me go here if we move laterally one finger width we are on What's called the Facet Joint as you can see right here and here or the articular pillar right so that's where the spine articulates really in flection extension with the levels above and below it right so as the spine moves flexion extension flexion extension you can see how those facet joints open and close right if you consider Facet Joint dysfunction the Clos is that compression of extension does not feel good all right so again to palpate that one finger width lateral to the spinage process we're going to be on that articular pillar you have to sink through the soft tissue of the spine in order to be there you can assess for joint play here or you can assess for pain one more finger width laterally is going to place you at the transverse process of the spine which is a bony attachment point for some of our core muscles okay so we have spinus process articular pillar transverse process one finger width every time you move out okay that's going to be our key palpation points here of the lumbar spine now let's go ahead and do it on a real patient okay so for palpation of lumbar spine we're typically going to be doing this in a prone position for our patient and the reason being for that is because uh all the structures in the spine are located posteriorly in the spine itself so we're not going to be able to Pal too many bony structures anteriorly at all just some of the muscular ones in the core so how I like to start here just to orient ourselves into the area is again finding that iliac crest on laterally and then coming around to the back and one key palpation point is going to be that PSIs so we're going to cover that again here and I'm just going to follow that ilat Crest all the way around the posterior aspect and then you'll feel it get thicker and more nodule like in the very back bilaterally before it dives into the central uh aspect of the spine which at this level is called sacrum so there's our PSIs not only is this a good point to palpate to assess for pain someone has SI joint pain this is usually a spot that's tender on that side but this is also important to look at symmetry in terms of height or level of the thumbs so once I get a good palpation on both I like to look straight down over the top and make sure that they're on a level horizontal plane if one is raised relative to the other that could indicate a pelvic rotation right so if this right side was raised up that would tend to indicate either an upslip of that half of the pelvis or potentially an anterior rotation usually that's G to be more confident okay so PSIs is the key landmark and then of course we can palate each level of the spine as we go up here starting at L5 which is going to be at the bottom but how do we know where to start there so good rule thumb is going to be this right here if you put your hands on top of the ilc crest just like so and then your thumbs meet in the middle right at that same level you're going to land on one of the spinus processes or the bony prominence that extends posteriorly into the spine and that for most people will actually land you on L4 that's a really good reference point to just get a geographical location in the spine of where you're at because you can't always see these spine pareses to count up or down so that's going to put me at L4 ilat Crest land in the middle L4 so if I want to Pate L5 I'm just going to move codly one segment and I'm going to feel for the next bony process down that's L5 L3 through one are going to be up right so I just go cranially L3 L2 L1 okay there's only five in L Bar is fine so that's pretty straightforward those are the easiest palpation points PSIs also the sacrum and spinus process 1 five now there's a couple other points that are of key interest so I'm going to go back to L4 spish process if I go one finger width just laterally to that midline which is spinal process so there we go one finger width then I'm on that level's articular pillar or Facet Joint right so this is the junction between this vertebrae and the next one down so this would be the Facet Joint of L4 L5 right here okay so you can not only assess this just palpating it for pain but you could also apply a posterior to anterior directional Force so like a joint LAX assessment and this would be a good way to assess for segmental motion at that ver vertebral level okay so that's one finger width to the side it's that Facet Joint articular pillar if I go two finger widths to the side one more then I'm on another bony prominence the last one all the way out to the side which is called the transverse process this is a key attachment point for a lot of muscles um so we're going to need to know how to palpate that as well okay if we move back to the process this is not only important just to count to which level we're at and to assess for pain but while you're doing this there a key part of your exam is to give a little anterior Force to assess for joint laxity joint play at each level of the lumbar spine and the reason being for that is because you might have some times where you feel some laxity or maybe a spring back up to your hand this should be a nice firm minimal you know minimal movement joint here L mine is pretty stable so if you feel a lot of movement or a drop off well that would be called a drop off deformity that would be a sign of potentially fracture to this part of the bone in the vertebrae or it could be a sign of a spth thesis which is a fracturing dislocation of that vertebra so if you feel a drop off step off or you feel a springiness to that segment that is an immediate red flag you're going to mark that down as a positive special test you're going to refer this patient out for Imaging and a followup uh because they might have spinal cord compression and they definitely have spinal instability okay so that's going to conclude our palpation of the lumbar spine next we're going to go through some special test for the area before moving on any further with our lumbar spine special test I want to add one more point just about the difference between referred pain and radiating pain I think a lot of times these terms can be a bit confusing and actually thrown around and uh jumbled up when medical professionals are referring to the lumbar spine region Okay so you might have heard of both terms used and if you're thinking to yourself right now what is the difference well we should actually be really clear at what is the difference because there is one so radiating pain or radicular pain or radiculopathy those are all variations of the same word is specific pain that means it is nerve related okay so if we're thinking about our lumbar spine maybe we have a discreation at l45 in this case L3 L4 you can actually see the Bulge right here on this skeleton spine this nerve root would be impinged at the lateral framan that would cause radiculopathy down the leg right so if we see that dermatomal pain sign bomal weakness any of those kinds of neurological symptoms that pain would be considered radiating pain because it is being moved from the site right if it was just localized pain it's just pain right here but if it's moving to another location from the source it from a nerve Source it's going to be radiating pain the difference between radiating pain and referred pain is just that radiating pain is always from the source of being a nerve okay nerve causes radium pain referred pain has moving pain so let's say the spine itself is painful you may feel not just local pain let's say youve set joint dysfunction right here at L3 L4 there might be pain here but there might also be pain felt in other areas like into the uh upper buttock region uh or even potentially around into the lateral hip region that's fairly common for set joint dysfunction and even for SI joint pain can refer out a lot of injuries can have referred pain that is not a new thing the key here between referred and radiating again is that radiating pain is source is from a nerve and that pain travels along the path of the nerve referred pain is pain that moves or travels but the sources from any other body tissue other than a nerve that's the big differentiator it could be from a joint like a facet joint or a hip joint or an SI joint or even from a disc it could be from a muscle or a tendon in some rare cases uh but the key here is that referred pain is not caused by nerve moving the pain elsewhere it's caused by the structure itself that is not a nerve so in this case a Facet Joint causing pain felt in another location and in the Facet Joint often times feel that pain in the posterior hipic region if it's not just a localized pain okay so that's our key differences between referred and radiating pain when we're talking about our neurological testing in lumbar spine if we're talking about discretion with radiating pain we need to be very specific to that because that would indicate nerve path pain going down the leg if we said lumbar discreation with referred pain that would tell me that the nerve root at that level is unaffected maybe there's some referred pain into the hip but that's just from the disc itself there's no neural involvement okay so important caveat just to think about and consider as you guys are writing your assessment statements and also just evaluating how our patients's pain really feels and what might it be coming from all right thanks for listening we'll move on okay so for the first few special tests in the lumbar spine region we're going to do what's called neural tension testing and this is typically done what we can do this as either for the sciatic nerve or also for neurot tension for many nerve root injuries say discernation set joint dysfunction stenosis of the nerve root and the lumbar spine especially laterally if it's compressed at any point either the nerve root potentially U Down The Chain in the sciatic nerve itself like Pur foris the hamstring that any of these nerve tension tests may come back as positive because it's bound up it's compressed at some point and that compression it's going to cause symptoms down the line of the nerve okay so we're trying to reproduce those symptoms by tensioning the nerve itself okay I'm gonna show you guys just from this side of the table on denon's left leg here big disclaimer though I would definitely be on the side of the table that I'm that I'm testing this is just for the the sake of video here okay so first one I'm going to show you guys which is the most common one it's called straight leg rce test okay this is active straight leg rise test excuse me aslr so with this what I'm going to have you do is just keep your leg straight so the knee is going to be extended and you're just going to raise it up as high as you can and then just hold it there for a second okay so unable to keep it fully straight probably a sign either of hamstring tightness or static nerve tension uh and tell you what do you feel at the top here do you have any pain any tightness just tightness okay and where do you feel your tightness hamstring right here hamstring okay now no numbness tingling burning nothing like that just okay all right so you can go and bring it back down so in that case that would be a negative because yes there was some tightness but it was not nerve tension symptoms that were're looking for so that is not a hamstring special test that is looking for nerve tension so since there's no numbness tingling zingers any of nervy symptoms that he may have had with low back pain that's a negative there okay another test that we like to do right after that is going to be following it up with what we call a Vern or a binski sign and if you combine them it's K binski G so it's very similar this is going to be passive so I'm going to raise it up for you okay this would be the curring side right and it's to say I'm going to expect the same thing when I get here hamstring is going to be tight or in the case of a positive test reproduction of their sciatic nerve symptoms we to that point little bit more okay okay now once we get to that point now the difference between aslr and kigs is one that's passive and then two is the next step so kernig is a mean test and it's gonna say okay in order to confirm that it is nerve tension and not hamstring tightness I'm going to put the nerve on more tension and see if that worsens the symptoms so how I could do that there's a couple of ways but classic one I'm gonna have you bring your chin to your chest so just bring your head up does that intensify this at all good okay you can relax so that would be a negative uh because it is just hamstring tight there so in the case of static nerve tension that is going to increase tension of the spinal cord by bringing the head forward which would then increase tension in cic nerve uh from a superior aspect okay so in a case of CA that would actually worsen the symptoms in the leg here this can also be done just by providing dorsy flexion to the foot that is also going to add more length and tension to that sciatic nerve running through the posterior leg without changing the length of the hamstring at all right so that's the big thing here we're not goinging the hamstring link we're just altering the nerve tension link okay so that's the king sign positive when you add tension and it uh basically reproduces more of their symptoms and the bitki sign is the opposite this is the nice test you're gonna slack in that nerve and say does that really any of the tightness yes okay perfect so if you had the stic nerve tension there and that relieved some of it that's good to know that' be a positive brazinsky sign you should definitely do this one last right because if you're going to uh instigate symptoms then you want to the right afterwards okay so we just covered aslr cing and brinsky sign of course with every special test we want to compare to both sides usually starting with the healthy or uninjured side first and then going to the injured side just for sake of time I'm just going to show you off one side uh and the last test I'm going to show you in this Supine position or sorry two more uh the first one's going to be the well straight leg R test and what that is is it's very similar to the active straight leg race test but let's say for denti in here the left leg is injured then we're going to do the straight leg on the well side so I'm actually going to do it on the right leg okay and it's the same thing I'm just going to have you bring your right leg up as far as you're comfortable with don't to push it here and let's say that causes symptom reproduction of his left sided sciatica that would be a positive sign for a well straight leg race test that would tell us maybe one of two things relax there one thing is that maybe the intensity of this sciatica and that nerve tension is so high that just increasing that tension by moving this leg up and stretching the duramater from this side if that increases tension over here that is really high s that's good to know number two is another possibility is you could have more of a centrally located discernation in the spine and therefore it can be affected easily from either extremity okay so that would be an example of a well straight leg raise that would also indicate side of nerve tension on the contralateral the last one I'm going to show you is called The Sign of the buttock and what that is is basically to differentiate between neurot tension in the leg and just generalized hip pain right so if you think about these tests so far we have a lot of moving Parts we're moving through the hip we're moving through the knee we've manipulated the foot we've manipulated the neck there's a lot of moving Parts here and so with that we're moving through other things besides just sciatic nerve so let's say someone has a generalized hip pathology maybe a laboral tear hip flexor strain something like that impingement all these are going to be false positives because they're going to cause pain okay so the sign of the buck is to do this we're going to take away any tension on the static nerve by bending the knee and I'm going to take him into passive Max hip flexion okay does that cause anything in your hip at all good if that causes hip pain or if that causes pain down the leg then we're gonna say okay that's not sciatic nerve pain at all if it's just isolated hip pain with isol said hip flexion then that is not nerve related that's probably an intraarticular hit pathology so same so think laboral tear impingement anything along those lines and then this would probably cause you to start to shift years of your evaluation because maybe we shouldn't be checking out the lumbar spine we should probably be checking out the hip or both right okay so that is the side of the buck basically to just say that the hip is not involved all the symptoms that we just found were truly from the stic nerve last thing I want to note here uh is just important to think about when you do any of these tests especially the active straight gra I'm going to do it on this like actually there's a couple things to look for just in terms of the range and when your patient feels their symptoms so Dennis in here you felt his symptoms very high up okay in the first zero to 30 or 35 degrees if your patient feels symptoms there it is actually typically not for sciatic nerve tension because there's barely any tension developed in the system at that point so if it hurts that early on 0 to 30 or 35 it's actually more indicative of Si pain okay so aclr can be more for SI pain at this range 35 to about 70 so these mid ranges a positive in here would be indicative of sciatic nerve tension if your patient doesn't feel any tightness or symptoms until after 70 75 degrees that's probably just hamstring inflexibility which is exactly what we saw here and on his right leg he actually has a recent hamstring string it's still somewhat active so go ahead and just keep that knee straight and just activ bring up as high as you're comfortable with and we'll see how high you can get there you go call that about 70 75 degrees any pain in there or just tight this is tight okay real quick does that worsen anything no it feels good that feels good all right so that's not nerve tension that's just hamstring tightness right we manipulated the length of the nerve no change but it's a good stretch right so it's definitely not sciatica or nerve radiculopathy and you started to feel symptoms in this high end range which is for hamstring right so hamstring at the top nerve in the middle and then at the very bottom we're looking for as okay uh go ahead and flip over on your stomach for me the next test we're going to do is for femoral nerve tension and it's called the fal nerve tension test whereas all the rest that we've done are going to be used for the sciatic nerve and also for uh uh nerve root radiculopathy as well but usually in our patients with low back pain we're GNA have more sciatic nerve dysfunction because that it feeds in more to the lumbar sacr plexus whereas floral nerve comes from the upper lumbar Roots so think L2 to L4 um and if we're working in that area then we might actually start to see symptoms more going down into the front of the thigh or weakness in the hip flexors maybe the quads that's indicative more of femoral nerve dysfunction or compression as opposed to sciatic so we have one test that we can use in order to T that nerve and maybe confirm those suspicions that the femoral nerve is involved just like the satic nerve we're just going to put it on full stretch so we think about our anatomy it runs through the front of the hip and the thigh okay so as a result I'm going to put you here in a little bit of knee flexion to put the quad on stretch and then I'm going to raise him into hip extension to put the anterior hip on stretch so this is kind of like doing a h Rec fem quad stretch for a t test but in a prone position okay any pain there in the hip or the front of the thigh or just maybe a little stretch yeah so stretch is going to be normal especially in your patient uh maybe with tight quads or hip flexures but the key differentiator here is not to look for muscle stretching but you're really looking for reproduction of nerve symptoms so numbness burning tingling you know any electrical kind of Sensations going down the front of the leg that would indicate a positive there and that would tell you get the fal nerve is involved okay so we have two more special tests here in a sitting position before we go into standing these are also going to be for neural tension this is a common theme here and these two are going to be called the B Sala test and the slump sit test okay we'll start with the B Salva test it's really easy it's a good one to do maybe if a family member gives you a call and you can't get your hands on on somebody for an eal or just a quick easy one to add to the mix so I'm going to have you do is actually just make a fist and put it right in front of your mouth almost as if you're like blowing up a balloon so bear down with your with your core and your abdomen but don't actually blow out right so just bearing down creating a little bit of intraabdominal pressure get perfect that's all you have to do just hold it for a couple of seconds by creating that intraabdominal intraabdominal pressure your relax uh you are then also increasing the pressure within the spinal cord itself so the intal pressure and the presence of nerve root compression let's say to discernation uh or really anything along those lines increasing pressure around a compressed nerve will further aggravate it so if just doing that by itself worsens or reproduces any sciatic symptoms going down the leg that's a positive Bala test for neural tension okay last one in the sitting position is going to be our slump sit test this is very similar to our supine ones and it's also very commonly done uh slump and active straight leg raise are probably your two most common tests out of this whole bunch so we're going to test his left leg here and for slump sit test it's going to be a tensioner of the sciatic nerve so we need to put it on stretch okay so first things first I'm gonna have you slouch so give me really bad posture like you not supposed to do so just hold that by being in this position you're already rounding and therefore lengthening the spinal cord so we're pre-positioning the nerves down the leg into a little bit of stretch now I'm going to have you a hold back go take this leg and just kick your foot straight out and hold that does that reproduce any tightness pain anything like no numbness or perfect if it did reproduce any numbness braing tingling especially down the back of the leg into the foot or even the toes that would be a positive for neural tension on this left side okay and same thing that we did before I can confirm by bringing your foot up so go ahead and bring your toes towards your face okay that would increase neural tension symptoms and then if you kick that away that would decrease neur attention symptoms so you can do a little bit of manipulation with it to increase your confidence of that test okay and of course we would compare it to the other side as well but in this case you don't have any L back thing so this is just demonstration okay last couple I'm G to have you stand up for me right here just facing that way we're going to do two tests here and we're shifting years so nerve injuries can also happen through extension based injuries like spies or Facet Joint dysfunction and so we have two tests that we're going to do right now for those extension based injuries the first one we're going to do is called the quadrant test all right so for actually I'm gonna have stand this yeah perfect okay so with this F quadrant test we're looking for pain reproduction in the Facet Joint region of the lumbar spine so just lateral to the spish process okay SP process just lateral what I'm GNA have you do do is go ahead and just take your right hand and reach as far as you can down uh back behind your right there we go perfect and then even twist a little bit more okay so what we're recreating in this position is a extension motion and also rotation and side Bend to the right side so if you think about what that does to this right sided set joint is it is essentially maximally closed or compressed and if you have faid dysfunction the one thing that it's not going to respond well to is compression so adding extension that's compression right side Bend is more compression so this position is going to be highly provocative and reproduce that pain especially on that lower right side of his back now if I want to attach the left side of the set joint let's do the same thing to the left perfect that's would be a left-sided quadrant test right so quadrant we're just going back and left that's how you do it right there some people will also do it good and cross your hands over your chest and just lean back and down to the right some people will also do it this way as well this is just provider preference um maybe just whichever one your patient responding to queuing better okay last one we're going to do here that was for set D dysfunction okay last one is going to be called the stor stand test uh this one requires a little bit of balance so scoot forward just a little bit so you can put a hand on the table uh I'm gonna have you raise let's do your right leg just raise that up just like so on hi if you can balance stay now holding that position I'm GNA have you just arch your back so just going into what extension you have which is not much that's okay so just hold that position for you can you can look for but just AR if you want your eyes okay so what are we looking for here same thing this is going to load the left side of the spy and so that's going to put even more load through the left U the set joints because we're going into extension moment in the lumbar spine but we're also really floing through this Left sided SI joint we're creating a Shear right anterior relative rotation of this part of the pelvis posterior on this side so we're com pressing this SI joint by having all of this weight on that one side you're getting full weight bearing through that SI joint and these facet joints so this test is actually testing for two things and it's primarily testing for SI joint pain but if you have pain reproduction at the facet joints then that would be indicative of Facet Joint dysfunction okay and that will conclude our special testing of the lumbar spine I just want to note that unlike some of our other body parts when we're doing these special tests not all of them are indicative of the exact uh body structure so when we're doing say a slump or active straight leg raise it's just telling us nerve tension it's not necessarily telling us discernation at what level left right center right uh we can infer that through the rest of our diagnostic process these nerve tension tests tell us that there's nerve tension right it doesn't necessarily tell us where tension or compression is happening these two tests we did showed is giving us a little bit more specificity onto the exact pathology into the facet joint or potentially the SI joint okay that'll wrap us up for that we're just going to finish with a lower quarter screen but that's all for the special test all right so last thing we're going to do here for the lumbar spine examination is a lower quarter screen I know you guys have already gone over this in lower extremity so we're not going to get too in depth here we're just going to review it quickly so that you get a refresher on it because you definitely have to know that as we examine through the Lumar spot okay so the lower quarter screen is going to differ from our neurot tension test in that it's going to actually hone in on which uh spinal level is involved okay if you have a positive slumps that just tells you that there's nerve tension the sciatic nerve is involved or there's nerve tension in the posterior room somewhere right if you have any issues in the lower quarter screen that's going to more finally T tell you is it L1 L2 L3 L4 L5 S1 or S2 any of those options okay three components dermatomes for sensation biomes for strength and reflexes uh for deep tend reflexes you have to assess all three components of the lower quarter screen every time you can't just pick and choose one component or the other let's say your your patient tells you they have some numbness in their legs means okay you can't just do the dermatomes and move on you still have to check for the myotomes and the reflexes because some of these symptoms they might be unaware of uh and this is how you find them right they're not going to be able to say everything so we're going to run through it I'm going to do everything um for dermatomes first so for check your sensation actually have you close your eyes and to start this we're going to start with L2 in the upper thigh and it's going to be light touch you could also check it with pin prick with vibration there's multiple modes of uh sensation that you can assess for but most commonly is light touch especially in our athletic training population so I'm going to do your left side right side and so do you feel that good you feel that and are they the same on both sides yeah good that was L2 you feel that feel that and are they perfect L3 real quick something to note if you guys are in a busy athletic training room and you're talking and your tension's over over here and you're moving your body while you're doing this be careful because if you're asking them is this equal and you're putting more pressure in one side than the other they're going to tell you it's not equal and that might actually flag your exam so you need to be very technical as you do this to make sure you're actually providing the correct amount of pressure as you go okay so that's L2 and three let's keep going so L4 can you feel that inside of the shin feel that good and are they equal yeah good L5 is that big toe you feel that you feel that and are they equal good L5 is good S1 lateral posterior shin or ankle sorry can you feel that good can you feel that y are they equal good last one that's twoa poster Cal that that are they good okay you can open your eyes so he's checked out all of his dermatomes are intact fully um fully sensory capable if there was any issues I would note that as either hypo or hyper sensient it's important to know which moving on to myotomes this is a strength component we have a different movement for each level uh each final level so L1 and two are going to be the same that's going to be HP flection I'm just gonna have you hike your knee up into my hand so just March it up yeah yeah there you go and just hold that there it's kind of funky one but just hold that now I like to actually hold these for a good four or five seconds an m a myone is not the same as mmt a lot of times we think it is but what happens if you have neurological injury and that signal supplying the motor is inadequate or diminished but a lot of people will be able to hold that for a second or two and then it'll really stop producing strength so you have to hold that for a good four or five seconds to really assess is this motor signal really intact or just a quick burst of energy and then quickly fatigued so that's L1 and two uh for L3 we going to go ahead and have you just kick out your leg so extending through the knee good and then go ahead and hold so we're checking knee extension for L3 good I'm G hold you here L4 is going to be dorsy flexion so going bring your whole foot up to your face that hold there's our L4 holding for a few seconds L5 is the big toe so I'm just going to get one finger there go and extend that big toe all the way up good that's L5 S1 is planter flexion so you're going to push your foot down and gas p good holding for a few seconds and then the last one is knee flexion so this is going to be you pulling underneath the taable so let me pull my hand under good and all these check out of course I'm comparing both sides and there's a good um easy way to remember what motion goes where right because there's multiple different strengths that we're assessing I like to think of this as riding a bike so if you think about what motions you need to ride a bike first thing you're going to do to ride a bike is usually LIF lift your knee up as you're pedaling that's L1 and two then you're going to extend the knee out as you come up and around that's L3 foot's going to have to come up toes going to have to come up up four five and then you're going to start bring that pedal bag under you so you're going to pump it with your foot that's one and your leg that's two so if you just think riding the bike that motion you're going to remember the myotomes every time last part here is going to be for the Deep tendon reflexes the dtrs we're going to use a reflex hammer and we have two we have Pell tendon and we have a killes tendon so we're going to assess tell Tenon first we're just going to give the light tab on there and for Denon here not reactive but some people just need a little bit of a distraction in order to see that so you might just choose to do this so go hold your hands like so and Pull Apart okay a little bit more of a reaction there that might wear off on the second one now he really sees it coming go and read the time for me on that clock right there that's it Perfect all right so I grade his left side here two plus which is normal and his right side here was a little hypo reflexive we'll give that a one plus so two plus is normal one plus is hypo zero is absent if there's no reflex at all that's a red flag referral three plus would be hyper reflexive so if it's really Twitchy and bouncy maybe it's not a ticklish thing that's also caused for referral okay so that teller tant reflex is good for L3 four and five and our Achilles Tenon reflex is good for S1 and S2 dermatomes for this one we're just going to go right at the base of the Achilles Tenon right above the cenus just like so there's that twitch that's a two plus same thing on this side there's that twitch two plus now key note with this in order to get it it's an easy one if you just remember this I like to support his foot and lift it gravity is going to be pulling him into a planer Flex position so if I just go right for it he's got no motion left to go and I can't feel it so if I hold him up like this now he can actually go into plan reflection with the twitch and I can feel it not just relying on my eyes my touch okay so that's going to wrap us up that's the whole lower quarter screen we did dermatomes bioton and dtrs all the way through we had no abnormal findings here so that's a clean one um but if you did you would definitely need to document that and refer that patient to Orthopedic Specialist neurologist right away all right thank you for your time everybody and we'll see you for the next live video thank you sir of course all done done with that one