2.  The exam is where you have a chance to
narrow down your differential
 So what is your differential for Low Back pain?

3.  Lumbar Spondylosis
 Lumbar Spondylolisthesis
 Lumbar Radiculopathy
 Muscle Strain
 Sacroiliitis
 Scaroiliac dysfunction
 Spinal Stenosis
 Spinal tumor
 Cauda Equina
 Glut max tendinosis
 Greater trochanteric bursitis
 Hip OA
 Myositis ossificans

4.  Gait: able to heel and toe walk, gait intact
 ROM: limited AROM of the L spine in all planes
 Motor: 4/5 b/l hip extension and abduction 5/5 strength in the
bilateral lower extremities including
HF,KE, KF,AD, EHL, PF, inversion, eversion
 Sensation: intact to light touch in all dermatomes tested from L2-
S1 bilaterally
 Reflexes: 2+ b/l patella and Achilles, plantar response down
going, proprioception intact
 Palpation: Diffusely tender over lumbar paraspinals -TTP over
the b/l greater trochanters and bilateral SI joint
 Tone: normal in the b/l LEs
 Lymph: no lymphadenopathy at groin or popliteal fossa
 Provacative tests: - SLR, seated root (slump test), Kemp, FABER
testing, FADIR testing, Ely's test to 0 degrees, Ober's negative
bilaterally

5.  Gait Eval
 Look at feet, ankle, and knees
 Heel strike, lat foot, then cross over medially to
big toe off
 Look at shoe wear
 What is trendelenberg ?

6.  Trendelenberg
 Marilyn Monroe
 Weak Glut med
 Hip Abductor
 Sup gluteal N
 L4/L5 S1

7.  Controversial if should do this, can worsen
pain
 Flexion 90 degrees
 Extension 30 degrees
 Lat Bending 30 degrees

8.  Muscle Grading
 5 full strength and full range
 4 less than full strength, full range
 3 against gravity full range
 2 gravity eliminated, full range
 1 twitch
 0 nothing

9.  HE; one of the core muscles
 Range 0-30
 Glut max
 Hamstrings
 How isolate hamstring? Does it matter?
 Glut max prime mover (inf gluteal nerve L5,
S1, S2)
 What is the most common herniation?

10.  HF
 Range 0-125
 Iliopsoas (iliopsoas nerve L2,L3) prime hip
flexor
 Rectus femoris, sartorius (fem nerve L2,L3,L4)

11.  KE
 Range degrees
 Quads (Rectus femoris, vastus lateralis, vastus
intermedius, vastus medialis oblique) femoral
nerve L2/L3/L4

12.  KF
 Range 0-135
 Need greater than 90 degrees to stand up out of
chair
 Hamstrings:
 Semimembranosus (sciatic, tibial portion
L4/L5/S1/S2
 Semitendinosus (sciatic, tibail portion L4/L5/S1/S2
 Biceps Femoris(Long head (sciatic, tibial portion
L5/S1/S2, SHORT head common fibular portion
L4/L5/S1/S2

13.  AD
 Range 0-20
 Tibialis anterior, deep peroneal nerve
L4/L5/S1

14.  EHL does toe extension
 Deep fibular nerve L4/L5/S1

15.  PF
 Range 0-50
 Muscles Gastroc/Soleus primarily S1

16.  Inversion
 Tibialis posterior, tibial nerve L4/L5/S1
 More subtle than AD

17.  Eversion
 Peroneus longus and brevis, superficial fibular
nerve L4/L5/S1

18.  Patient with AD weakness and HE weakness,
where is the lesion?

19.  Dermatomes
 Useful to differential muscle weakness vs nerve
involvement vs myopathy

21.  Lumbar paraspinals
 Consistent with muscle sprain and facet issues

22.  Greater Trochanter
 Bursitis versus gluteus medius tendinosis

23.  SI joint
 SI joint or gluts

24.  What is tone?
 What is spasticity?

25.  What do you rule out here?
 What maneuver’s can you double up on
 Check pop fossa during SLR
 Check groin during FABER

26.  SLR/Seated Root
 Positive from 30 to 70 degrees

27.  Kemp/facet loading

28.  FABER: Flexion/Abduction, External Rotation
 Opp SI joint, or hip pain

29.  Ober’s
 Check’s TFL tightness
 Press on TFL to find tender points which also
signifies tightness
 Found a lot in runners
 Changes running mechanics

30.  FADIR
 Flexion, ADduction, Internal Rotaion

31.  ELY’S test, tests quad tightness
 Causes pelvic tilt
 Putting more stress on facets

32.  Fellows now pair up