7. LBP

Question 1

What is the action of the piriformis muscle?

Answer 1

ER of Hip (when extended) and abduction (when hip is flexed).

Question 2

What is piriformis syndrome?

• May be associated with what?
• What special test is non-specific, but may be (+/-)?

Answer 2

• Deep ache/ LBP => butt (greater sciatic foramen) => that radiates down the posterior aspect of the thigh. Numbness and tingling in SAME pattern bc sciatic nerve is close
  
  • Worsens when sitting > 20 minutes; better when walking
• Trauma or overuse/ wallet test
• Straight leg raise test

Question 3

In Piriformis Syndrome, what may increase susceptibility of sciatic nerve entrapment?

Answer 3

How close the [piriformis m] is to the [sciatic nerve].

Question 4

What SD may be associated with Piriformis Syndrome

Answer 4

1. Ipsilateral hip ER SD
2. Sacrum is rotated anteriorly towards ipsilateral side on a contralateral oblique axis.
   
   1. R-sided pirformis syndrome => L/L sacral torsion with compensatory rotation of lower lumbar vertebra to the R.
   2. => leads to ipsilateral physiologic short leg

Question 5

How is Piriformis Syndrome diagnosed?

Answer 5

• Diagnosis of exclusion: rule out other causes with PE, XR, and/or MRI
  
  • MRI is LAST resort

Question 6

How is Piriformis Syndrome treated?

Answer 6

1. OMT
2. PT = effective for most
3. Analgesics, glucocorticoid injection or botox injections

Question 7

What physiological change do we see with piriformis syndrome?

Answer 7

Short ipsilatal leg

Question 8

Piriformis syndrome will cause a TP where?

Answer 8

2/3 of the distance between the ILA and greater trochanter.

Question 9

L/L Sacral Torsion

What will we find?

Answer 9

• R sacral sulcus = deep/ anterior
• L ILA = shallow/ posterior / inferior

Question 11

What is psoas syndrome?

• Chronic psoas spasm can cause what?

Answer 11

RLQ sharp, cramping pain that radiates to the lower back with hypertonic psoas muscle.

• Chronic => persistent strain across lumbosacral junction.

Question 12

Psoas Syndrome

• What SD may be associated?
• If crhonic

Answer 12

1. Type 2 SD of L1 and L2: flexed and rotated towards side of affected psoas; SB towards
2. L5 E (extended)
3. Chronic psoas syndrome: may have two type 1 SD (1 above and below) around the type 2 SD of L1/L2

Question 13

Psoas Syndrome TP is commonly found where?

Answer 13

Ipsilateral iliacus and contralateral pirformis

Question 14

OMT for Psoas Syndrome?

Answer 14

1. OMT directed at SD in [thoracolumbar junction and lumbosacral area].
2. Stretch hypertonic psoas m.

Question 15

Short Leg Syndrome

• Describe the pain
• Findings?
• Often have pain/SD where?
• Often associated with what disease?

Answer 15

• Dull, midline lumbosacral pain that gets worse as the day progesses due to sacral base unleveling
• Findings: sacral base unleveling; medial mallelos short after SD resolves
• SI and lumbosacral joint pain/SD
• Scoliosis

Question 16

When there is pain in the [lumbosacral area], what is the first structure to react?

Answer 16

Iliolumbar ligmant; tender where it attaches [iliac crest] or [L4/5 TP]

Question 17

Where is the Chapmans point for iliolumbar ligament?

Answer 17

Colon

Question 18

SD associated with Short Leg Syndrome

Answer 18

1. Lumbar spine is [SB away] and [rotated towards] the side with the LOWER sacral base
2. Anterior inominate rotation on side of the short leg;
3. On longer leg
   
   1. Posterior innominate rotation on side of l_ong leg._
   2. Pelvic side shift to the side of the longer leg
   3. Foot = pronated and IR

Question 19

How do you dx short leg syndrome

Answer 19

Standing postural XR and measure: iliac crests, femoral head and sacral base

Question 20

How to treat Short Leg Syndrome?

Answer 20

1. Treat SD 1st.
2. Stretch assymetric muscles
3. Heel lift therapy
4. If there is an acute change in leg length, replace full discrepancy IMMEDIATELY.

Question 21

heel lift therapy?

• Only treat if discrepency is ______.
• How much heel lift can we add?
• Final lift height

Answer 21

• Only treat if leg length discrepancy is > 5 mm
• Add a max of 1/4 heel lift in shoe; 1/4 can may be added to outside (1/2 total). You can add total 1/2 outside the shoe.
• Final lift height should be 1/2 - 3/4 of measured discrepancy, unless recent sudden cause apparent

Question 22

When performing Heel Lift Therapy, if patients condition is fragile, how much heel lift do we add? Flexible?

Answer 22

• Fragile: Start with 1/16 and add 1/16 every 2 weeks.
• Flexible: Start with 1/8 and add 1/8 every 2 weeks.

Question 23

A 21 year old male comes into clinic with low back pain and left buttock pain for the past 2 weeks. He is an offensive lineman on the local college football team. He does not recall a specific injury, but states that he sustains several hits during practice and games. History reveals that for the past month he has had a change in gait. He denies any radiation of pain down the legs. Straight leg raise test is negative. During the TART exam there is a palpable “step off” in the lower lumbar spine when the patient flexes forward. Which of the following mechanisms most likely contributed to this patient’s presentation?

• A. hyperflexion injury of the spine
• B. repetitive hyperextension of the spine
• C. axial load injury to the spine
• D. rapid twisting motion of the spine

Answer 23

• B. repetitive hyperextension of the spine => Spondylolysis** and **Spondylolisthesis

Question 24

What does Spondylolysis/Spondylolisthesis cause?

Answer 24

Hyperlordosis due to repetitive hyperextension, stress, overuse or macrotrauma.

Question 25

**_Spondylolysis vs Spondylolisthesis_** ## Footnote \_\_\_\_\_\_\_\_\_\_\_\_: stress fracture in the **pars interarticularis** \_\_\_\_\_\_\_\_\_\_\_\_: stress **fracture** + **sliding** of vertebra

Answer 25

* **Spondylolysis**: stress fracture in the pars interarticularis * **Spondylolisthesis**: stress fracture plus sliding of vertebra

Question 26

Who displays symptoms in **Spondylolisthesis** and what are they, typically? Bilateral/unilateral fractures.

Answer 26

* **\> 20** ; children are often have change in gait/posture * **LBP =\> butt/posterior thigh;** **tight hamstrings** * 80% of time =\> **bilateral** fxs

Question 27

Who displays symptoms in **Spondlylolysis** and what are they, typically?

Answer 27

* Children =\> asx * **Adolescent athlete** =\> gradual onset of LBP that can radiate to butt/posterior though

Question 28

**_Spondylolysis/Spondylolisthesis_** * Pain MORE likely to **radiate** to **buttocks** or **posterior thigh.**

Answer 28

**Spondylolisthesis**

Question 29

**Spondylolysis/Spondylolisthesis** * Finding: * Common SD?

Answer 29

Finding: **step off of SP in lumbar flexion** 1. Psoas spasm/inhibition 2. Iliacus dysfunction 3. Flexed upper lumbar dysfunction 4. SI/sacral torsion 5. Inominate dysfunction

Question 30

Dx and Tx **Spondylolysis/Spondylolisthesis** with OMT?

Answer 30

* AP, lateral and oblique XR * **Indirect** & **ST**; **_no HVLA_**

Question 31

**_Spondylolysis/Spondylolisthesis_** * Focus XRCISE on: * Other treatments

Answer 31

* Focus exercise on **strengthing muscles** and **getting rid of lordosis** * Stretch hamstring, improve posture, avoid contact sports

Question 32

A 40 year old male presents to the clinic with pain in the right buttock that radiates down the posterior thigh that has been going on for one week. He has also had weakness in his right leg and has lost his balance a few times. Straight leg raise test is positive. Imaging of the lumbar spine reveals herniation of the spinal disc between L4 and L5. Protrusion of which of the following anatomical structures is most likely responsible for causing the patient’s symptoms? A. nucleus pulposus B. annulus fibrosus C. vertebral body D. vertebral endplate

Answer 32

**A. nucleus pulposus**

Question 33

What is **spinal disc herniation?**

Answer 33

**Rotational stress** causes microtrauma =\> makes disc more prone to damage =\> **sudden compressive** or **rotational** **force** can tear a weak [annulus fibrosis], **[releasing nucleus pulposis]** * **=\> sudden** onset of _LBP with bending/lifting_ and may be associated with radiculopathy (_=\> posteior thigh =\> LE weakness)_

Question 34

**_Spinal Disc Herniation_** * Most common herniation: \_\_\_\_\_\_\_\_. * Most commonly affected discs: \_\_\_\_\_\_\_\_\_\_. * Symptoms are due to: \_\_\_\_\_\_\_\_\_\_\_ * May be associated with \_\_\_\_\_\_\_ * (+) Special Test:

Answer 34

* **Posterolateral** herniation * **L4-5** and **L5-S1** * **Inflammation of the nerve root,** NOT direct pressure * **Radiculopathy** * **Straight Leg Raise Test**

Question 35

**_Spinal Disc Herniation_** * Confirmation of herniation: * Tx: * OMT:

Answer 35

* MRI * If acute: conservative treatment (rest a few days, ice, NSAIDS, steroids). * After acute phase: OMT at muscles and PT. * FPR = useful to tx radiculopathy.

Question 36

**_Spinal Disc Herniation:_** * Findings: * OMT findings: * Indications for surgery

Answer 36

* + straight leg raise and LE weakness * None * **Intractable** **pain**, **progressive**, or **moderate =\> severe neuro deficit.**

Question 37

Best tx for **radiculopathy**?

Answer 37

**FPR**

Question 38

A 57 year old female presents to the emergency department for low back pain that radiates down her bilateral posterior thighs to the level of the knee. She states that 13 hours ago she was helping to move a couch when something “tweaked wrong” in her back. She has not urinated or had a bowel movement since this event. Which of the following is most likely to be found on physical exam? * A. positive Thomas test * B. decreased temperature sensation in the left lower extremity * C. decreased pinprick sensation in perineum * D. L2 F Rr Sr

Answer 38

* **C. decreased pinprick sensation in perineum**

Question 39

**_Cauda Equina Syndrome_** * What is it?

Answer 39

* **Spinal nerve root compression** caused by a [massive disk protrusion, fracture or ABNL mass]. * =\> **LBP** that radiates down her **bilateral posterior thighs =\>** **knee =\>** results in **bowel and bladder dysfunction** and **saddle anesthesia** (sensory loss in perineum) * Also: radicular pain, paresthesias

Question 40

If you suspect a patient has **Cauda Equina Syndrome,** what do you do? Imp OMT findings?

Answer 40

* **_Medical emergency_** –emergent decompression **within 48 hrs** or **permanent neurological damage** * **None**

Question 41

A 62 year old F presents to the outpatient clinic with low back pain. She states that the pain has been _intermittent_ over the past several months, usually lasting for several weeks before going away for some time. It seems to get _worse when bending over and sitting down_, and l_ying down makes it bette_r. She walks her dog daily and seems to think that the _pain does not bother her as much during this activity_. She _denies radiation_ of pain down her legs. Which of the following is the most likely explanation for the patient’s symptoms? * A. anterior slippage of vertebral body * B. “wear and tear” of intervertebral discs * C. microfractures from chronic axial compression * D. herniation of intervertebral disc

Answer 41

* **B. “wear and tear” of intervertebral discs** = Degenerative disc disease

Question 42

What is **Degenerative disc disease?**

Answer 42

Natural part of aging that causes **_Intermittant, non-specific_** LBP and NO radiation down legs. * **Worse** = bending over and sitting. * **Better** = laying down and does not bother with actvity.

Question 43

**_Degenerative Disc Disease_** * ___ spine is **most often affected** d/t mobility and weight-bearing responsibilities. * Dx: * Treatment?

Answer 43

* **Lumbar spine** * **XR:** however**, poor correlation** w XR and pain * OMT, PT, NSAIDS/acetominophen

Question 44

By **age 49,** 60% of ___ and 80% of ___ have osteophytes and other changes =\> indicative of degeneration

Answer 44

**60% =.\> Women** **80% =\> Men**

Question 45

A **52 year old** male presents to the family medicine clinic with l**ow back pain**. This has been **going on for several months**. He states that the pain is **worse** when he is _standing_ for long periods of time or _walking up stairs,_ with occasional symptoms of numbness and tingling in his posterior thighs. The pain is **better** by **sitting down** or **leaning over**, such as on a grocery cart. What is the most likely underlying mechanism causing his symptoms? * A. chronic type 1 lumbar somatic dysfunction * B. chronic extended posture of lumbar spine * C. narrowing of the intervertebral space * D. narrowing of the spinal canal

Answer 45

**D. narrowing of the spinal canal = Spinal stenosis**

Question 46

What is **Spinal Stenosis?**

Answer 46

Narrowing of the spinal canal that causes **LBP** and **radiculopathy** * **Worse** = _standing_ upright or _walking_ for long time * **Better** = _sitting_, l_aying down_ or _leaning over_

Question 47

What causes **spinal stenosis?**

Answer 47

1. **Herniated** or **bulging disc** 2. **Abnormal mass** 3. **Osteophytes** (bone spurs) from osteoarthritis 4. **Scar tissue f**rom previous surgery

Question 48

What type of **spinal stenosis** =\> **neurogenic claudication**: central stenosis or lateral stenosis?

Answer 48

**Central stenosis**

Question 49

**_Spinal Stenosis_** * **Dx** * **Treatment**

Answer 49

* Dx = **MRI** * TX: OMT helped 50% of pts, PT, aspirin/NSAIDS * if severe =\> surgery

Question 50

**HVLA** CI to OMT in **LBP**

Answer 50

1. LBP due to [vertebral tumor or cancer metastasis to spine] 2. Hx of osteoporosis 3. Acute phase of RA affecting lumbar spine 4. Acute lumbar disc herniation (relative CI)

Question 51

CI for OMT for **compression fracture**

Answer 51

* **Most direct tx** (except **direct MFR)**

Question 52

Which causes of LBP will you see a **+ straight leg raise test?**

Answer 52

1. **Spinal disc herniation** 2. **Piriformis syndrome (can be +/-)**