With the patient lying down on his or her back on an examination table or exam floor, the examiner lifts the patient's leg while the knee is straight. In order to make this test more specific, the ankle can be dorsiflexed and the cervical spine flexed. To determine whether the pelvis is anteriorly or posteriorly tilted, you must bilaterally palpate the ASIS’s, PSIS’s, and pubic tubercles. The final postural assessment for lumbar spine pathologies is observing the patient’s adapted sitting posture. Observe the patient as they walk from the waiting room to the treatment area so they are not conscious of being observed. When a patient presents with a pathology, the joints above and below the area of symptoms need to be checked for referral into the affected area; this process is called clearing the joints. The thoracic spine is cleared with motions that are similar to the motions of the lumbar spine; these include flexion, extension, rotation, and lateral flexion. The SIJ can be cleared with compression and distraction techniques while the patient is lying supine. Range of motion (ROM) testing is useful in determining what the cause of a patient’s pain is.
Have the patient move into extension by sliding their hands down the back of their thighs, and then return to neutral.
Have the patient seated on a plinth or stable chair, with feet flat on the floor and arms crossed over the chest. If the patient’s comparable sign was not elicited in flexion, extension, lateral flexion, or rotation, the examiner needs to try the quadrant test.
When palpating the lumbar spine, the patient should be lying prone on a plinth, with a pillow under the lower legs for comfort.
First, feel for heat and look for visible signs of inflammation such as redness or swelling. Following palpation, perform a “sweep of 2s” on L1-L5 both centrally (on the spinous process) and unilaterally (on the facet joints). Central PAs are performed by placing the base of the hypothenar eminence directly over the spinous process with the hand perpendicular to the patient. Special tests for the lumbar spine include dermatomes, myotomes, reflexes, upper motor neuron testing, and neural tension testing. The dermatomes that are evaluated in patients with lumbar pathologies are L1-S2, for the purpose of evaluating sensory integrity.
To ensure that muscle strength is unaffected, a myotome screen of L2-S2 spinal levels should be performed. Patellar Tendon Reflex: The patellar tendon reflex assesses L2 and L3 nerve roots and should trigger a quick contraction of the quadriceps. Achilles Tendon Reflex: Testing the Achilles tendon evaluates the nerve roots of S1 and S2 which should cause a quick contraction of the plantar flexors. Upper motor neuron lesions may be suspected if a patient with lumbar pathology complains of bilateral lower extremity pain or paresthesia. Clonus: Position the patient supine on the plinth with their leg bent and hip externally rotated, resting on the examiner’s thigh. Passive neck flexion: This is the least threatening of the tension tests, and therefore should be executed first. Prone knee bend: The prone knee bend only needs to be performed when a patient experiences neurological symptoms into the anterior thigh. Slump: This is the most aggressive of the four positions, and should only be performed when no symptoms were elicited with the aforementioned tests. Check for postural deviations, look for whether the patient is leaning to one side, and note the curvatures of the spine in the sagittal and frontal planes.
In normal pelvic alignment, the ASIS and PSIS should be level horizontally, and the ASIS and pubic tubercles should be level vertically when viewed from the side. Assess for femoral ante- and retro-version, tibial rotation, recurvatum, patellar position, pes planus, and pes cavus.
When evaluating gait look for swaying, leaning, Trendelenburg, hip hiking, hip rotation, steppage gait, and any other abnormalities that may be present.
In a patient with a lumbar pathology, symptoms could be local to the back or they could refer down the leg, therefore the joints that need to be cleared will vary from case to case. The patient is seated for thoracic clearing; if the active motion does not produce pain then overpressure should be applied. Compression is performed by placing the base of the hands over the medial portions of the patient’s ASIS’s, leaning directly over the patient, and pushing the hands outward. Have the patient in supine and passively flex their hip by supporting the distal femur and lower leg with one arm and placing the other hand on the iliac crest. This can be done by applying overpressure to a maximally flexed knee, followed by overpressure on a maximally extended knee. When testing, active ROM should be completed prior to passive range or adding overpressure. If pain was not elicited, have the patient perform the motion again and provide overpressure.
If there is no pain, have the patient sidebend again and apply overpressure by placing one hand over the top of the right shoulder and the other over the side of the left shoulder. The quadrant test is a combination movement that consists of 3 separate motions: extension, side-bending, and rotation. Palpation is used to assess mobility of the vertebrae by finding the resistance points of each joint; resistance 1 (R1) is where the examiner begins to feel resistance, while R2 is the end of the range.
The “sweep of 2s” is a series of 2-3 oscillations of grade 2 posterior-anterior (PA) pressures on each of the lumbar segments.
The other hand is placed horizontally on the base hand to translate the downward force from the therapist's body.
While neural tension testing should be performed in all patients presenting with lumbar pathologies, the other special tests are only used in certain situations.

When a nerve root is irritated and it is causing numbness or tingling down the leg, the symptoms are typically the strongest in the distal-most portion of the dermatome; therefore, when checking sensation, the distal-most portion of the L1-S2 dermatomes should be tested. For patients with lumbar pathologies, the patellar and Achilles tendon reflexes must be examined. The patient should be supine with the knee bent and the leg supported under the distal thigh by the therapist. The patient remains in supine with the knee bent and hip externally rotated and supported by the examiner’s thigh. Place one hand on the posterior aspect of the calcaneus, and the other hand over the metatarsal heads on the plantar surface of the foot.
Use a pointed object, such as the handle of a reflex hammer, to run along the plantar surface of the foot from the heel, upward along the lateral aspect and across the metatarsal heads in a “C” motion.
There are four different tests that can be used when evaluating patients with lumbar pathologies: passive neck flexion, straight leg raise, prone knee bend, and slump. To begin, position the patient supine, placing your hands on the posterior aspect of the cranium over the occiput. Place one hand over the anterior thigh, just superior to the patella, with the other hand on the Achilles tendon. To complete this test, the patient should lie prone on a plinth while the examiner passively moves the leg into full knee flexion. The patient should be seated on the side of the table with hands rested at their sides and legs bent over the edge. Common postural deviations such as excessive lumbar lordosis, flat back, and sway back may be observed in patients with lumbar pathologies. Additionally, the ASIS’s should be viewed anteriorly for levelness from one side to the other. Lower extremity alignment may contribute to low back pain in certain cases, or could lead to lumbar malalignment. The adapted sitting posture could be a contributing factor to the patient’s symptoms, and therefore should be discussed with the patient so they are educated on how to prevent future lumbar problems. The video below demonstrates thoracic range of motion testing and should be viewed for information regarding proper positioning and hand placement.
For distraction, place the heels of the hands on the lateral portion of the ASIS’s with the fingers extending down around the ilium and provide a medially directed force with your hands. Since the goal of this test is to clear just the hip, pelvic rotation needs to be avoided so symptoms are only provoked by isolated hip movements. The examiner provides a quick flick of the ankle into dorsiflexion and plantarflexion, then finishes by turning it into inversion. In the lumbar spine, ROM includes flexion, extension, lateral flexion, and rotation, each of which is described below and demonstrated in the video at the end of this section.
To do this, place your thumb and index finger on the sacrum pushing forward, place your other forearm across the patient’s upper chest and shoulders pushing backward.
If there was no pain, have the patient go through the motion again and this time overpressure must be given at the end range.
The patient may actively assist the practitioner with this test, but since it is not a common movement that is easily described, it may be easier to passively move the patient through each motion. It is also used to assess for pain (P1 is where the patient begins to feel their pain) and reproduce the comparable sign. To ensure you are palpating the correct spinal levels, first palpate the PSIS and move inferior into the sulcus. Unilateral PAs are performed with the thumbs directly over the facet joints; the distal phalanx of each thumb should be “back-to-back” supporting each other for stability during the pressure.
The dermatome, myotome, and reflex testing collectively are called the neurological screen.
To conduct dermatome testing, the tip of a paper clip can be used to create the sensation, which should be a light poking of the object on the skin as if drawing a dotted line across the dermatome.
To begin, the patient should stand on the uninvolved lower extremity and perform ten heel raises. Proper technique includes using a reflex hammer to elicit the desired response and tapping the specific tendon 5-6 times.
The examiner then palpates just below the patella to locate the tendon and proceeds to tap on the midpoint. Palpate the tendon located superior to the calcaneus on the posterior aspect of the lower leg.
Patients may be hesitant to discuss bowel and bladder issues, so it is imperative that clinicians ask if they are experiencing either of these complications. Passively lift the patients leg into full hip flexion while maintaining full knee extension.
If the comparable sign of anterior thigh paresthesia is replicated, then neural tension is present.
Ask the patient to slump down into a hunched sitting posture, then add head and neck flexion so the chin is tucked into the chest. Excessive lumbar lordosis is when the concave curve of the low back is greater than normal, and the pelvis is anteriorly tilted. Observing the ASIS positioning in these two different views will help to identify a variety of alignment concerns.
If the patient’s comparable sign is not elicited during any of the following tests, then the joints are clear and the problem is most likely local to the lumbar spine. Therefore, the fingers of the hand on the iliac crest should extend back to the PSIS in order to feel for pelvic rotation during passive hip flexion. As you apply overpressure, make sure to position your head behind the patient’s upper back and head to lend support.
When providing overpressure, one leg can be positioned on the lateral side of the patient’s left hip to prevent the hips from shifting, but this is not always necessary; this will help to isolate side flexion to the spinal segments, as well as help the patient to feel supported.
Overpressure can be given by placing one hand around the proximal humerus of each shoulder and pushing posteriorly on the right while pulling anteriorly on the left for a resultant rotary motion.

For a left quadrant test, place one leg on the lateral side of the patient’s right leg to provide stability.
Once this is found, move your fingers toward the spine, and you should be on the spinous process of S2. Unilateral PAs should be performed on the unaffected side first, followed by the affected side; if both sides are painful, start with the less symptomatic side. The objective exam only needs to include a neuro screen if the patient is complaining of symptoms below the gluteal fold of the buttock.
It is a good idea to allow the patient to feel the sensation on their hand prior to conducting the test so they will know what they should be feeling, and so they will know it will not hurt them. You must observe the quality of the movement, and whether the patient loses strength throughout the repetitions. Use one hand to place the ankle into slight dorsiflexion while the other uses the reflex hammer at the desired location. Assessing for upper motor neuron lesions can be completed by testing for clonus and the Babinski sign, as described below. A normal response to this test is the toes curling into flexion, which indicates that an upper motor neuron lesion is not present. Flat back is when the concave curve of the low back is either diminished or completely flat, and the pelvis is posteriorly tilted. If one ASIS appears higher than the other, the patient may have a leg-length discrepancy, an innominate upslip, or an innominate rotation. The accompanying videos will help provide further instruction for joint clearing techniques.
When moving out of this position, be sure to assist the patient with balance and support by sliding the hand that was pushing on the sacrum up the patient’s back as they return to an upright posture. Grade 2 pressures are given as a large amplitude oscillation taking up slack in the joint and stopping just before R1 is felt. Refer to the accompanying video for clarification on hand positioning for these two types of pressures. Additionally, the unaffected limb should always be tested first so the patient can compare the sensations from one limb to the other; with dermatomes, this requires testing the first area on the uninvolved side, then the same area on the involved side, then move to the second area on the good side and so on, alternating between legs. This is done to ensure that the patient’s slumped posture is maintained throughout the test. Sway back is characterized by increased lordosis due to posterior positioning of the thoracic spine and the pelvis displacing anteriorly, along with a posterior pelvic tilt. These conditions may be related to the patient’s lower back complaints, and thus should be noted in the exam. If this is tolerated, a combined flexion with adduction movement should be used by wrapping both hands around the knee and taking the hip through the motion. When the end of extension range has been reached, left sidebend the patient while maintaining lumbar extension. A quick assessment of whether you are on L5 is to have the patient perform an anterior pelvic tilt while you continue to palpate the spinous process.
Grade 3 is also large amplitude, but pushes further in the joint range, oscillating from R1 halfway to R2. When there are no sensory symptoms present, the dermatome test can be omitted from the neuro screen. If a level is deficient, the patient will present with decreased sensation in that dermatomal pattern. Once S1 myotome testing has been completed, instruct the patient to lie supine on the plinth to test the remaining myotomes. If symptoms are reproduced by these additional movements, release the distal component to see if the symptoms subside; this will indicate whether the symptoms are resulting from neural tension or not.
To add in the lower extremity, have the patient extend the uninvolved leg then dorsiflex the ankle.
If there are still no symptoms, add internal rotation to the already flexed and adducted hip. Once the patient is extended and sidebent, rotate them to the left as well, providing a little pressure at the end range. If no deficiency is identified, it can be assumed that the sensory portion of the lumbar nerve roots is unaffected. With each of the following, you can perform a break test, where you place the joint in the desired position and tell the patient to “hold here, don’t let me move you,” as you apply force gradually. Finally, if no comparable sign has been reproduced, add joint compression to the flexed, adducted, and internally rotated hip by directing your force down through the shaft of the femur with the hands cupped over the knee. If the patient’s symptoms are reproduced at any point during this test, the test should be ended at that point and not continued any further. Procedures for testing each of the dermatomes for L1-S2 are described below; please also reference the accompanying picture for specific locations of each segment. If any of these progressions cause numbness or tingling into the leg, then the test is positive.
If symptoms are reproduced with any of these progressions, the testing does not need to continue any further.
If symptoms are triggered with any of the progressively added movements, discontinue the test.
To locate the facets, go to the interspinous space between each lumbar spinous process and move laterally, approximately one finger width.
MTP extension of the first digit assesses L5, and finally, curling the toes into flexion tests the S2 myotome.
If the patient has motor nerve root involvement, they will show weakness during testing of the affected level, otherwise, the motor portions of the nerve roots can be assumed to be uninvolved with the patient's pathology.

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