The neck flexion movement has also been called Hyndman's sign, Brudzinski sign, Linder sign, and the Soto-Hall test. If the examiner desires, neck flexion may be done by itself as a passive movement (passive neck flexion). Tension in the cervicothoracic junction is normal and should not be considered a production of symptoms. If lumbar, leg, or arm symptoms are produced, the neurological tissue is involved. The ankle dorsiflexion movement has also been called the Bragard's test. Pain that increases with neck flexion, ankle dorsiflexion, or both indicates stretching of the dura mater of the spinal cord or a lesion within the spinal cord (e.g., disc herniation, tumor, meningitis). Pain that does not increase with neck flexion may indicate a lesion in the hamstring area (tight hamstrings) or in the lumbosacral or sacroiliac joints. Sicard's test involves straight leg raising and then extension of the big toe instead of foot dorsiflexion. Turyn's test involves only extension of the big toe.²⁰⁰

With unilateral straight leg raising, the nerve roots, primarily the L5, S1, and S2 nerve roots (sciatic nerve), are normally completely stretched at 70°, having an excursion of approximately 2 to 6 cm (0.8 to 2.4 inches).¹⁹⁵ Pain after 70° is probably joint pain from the lumbar area (e.g., facet joints) or sacroiliac joints (Figure 9-66). However, if the examiner suspects hamstring tightness, the hamstrings must also be cleared by examination (see Chapter 11). The examiner should compare the two legs for any differences. Although the sciatic nerve roots are commonly stretched at 70° hip flexion, the ROM for straight leg raising and the stress placed on the neurological tissue vary greatly from person to person. For example, patients who are very hypermobile (e.g., gymnasts, synchronized swimmers) may not show a positive straight leg raising test until 110° to 120° of hip flexion, even in the presence of nerve root pathology. It is more important to compare left and right sides for symptoms before deciding whether a lesion is caused by stretching of the neurological tissue or arises from the joints or other soft tissues.

For patients who have difficulty lying supine, a modified straight leg raising test has been suggested.201 The patient is in a side lying position with the test leg uppermost and the hip and knee at 90°. The lumbosacral spine is in neutral but may be positioned in slight flexion or extension if this is more comfortable for the patient. The examiner then passively extends the patient's knee (Figure 9-67), noting pain, resistance, and reproduction of the patient's symptoms for a positive test. The knee position (amount of flexion remaining) on the affected side is compared with that on the good side.

The examiner should then test both legs simultaneously (bilateral straight leg raising , Figure 9-68). This test must be done with care, because the examiner is lifting the weight of both lower limbs and thereby placing a large stress on the examiner's lumbar spine. With the patient relaxed in the supine position and knees extended, the examiner lifts both of the legs by flexing the patient's hips until the patient complains of pain or tightness. Because both legs are lifted the pelvis is not stabilized (as it would be by one leg in unilateral straight leg raise), so on hip flexion the pelvis is freer to rotate, thereby decreasing the stress on the neurological tissue. If the test causes pain before 70° of hip flexion, the lesion is probably in the sacroiliac joints; if the test causes pain after 70°, the lesion is probably in the lumbar spine area.

With the unilateral straight leg raising test, 80° to 90° of hip flexion is normal. If one leg is lifted and the patient complains of pain on the opposite side, it is an indication of a space-occupying lesion (e.g., a herniated disc, inflammatory swelling). This finding of pain when the examiner is testing the opposite (good) leg may be called the well leg raising test of Fajersztajn (Figure 9-69), a prostrate leg raising test, a sciatic phenomenon, Lhermitt's test, or the crossover sign .^182,195,202 It is typically indicates a rather large intervertebral disc protrusion, usually medial to the nerve root (see Figure 9-69), and a poor prognosis for conservative treatment.^197,203 The test causes stretching of the ipsilateral as well as the contralateral nerve root, pulling laterally on the dural sac. A positive Lasègue's and crossover sign can also indicate the degree of disc injury. For example, both are limited to a greater degree if sequestration of the disc occurs.⁸⁶ If the examiner finds this test positive, careful questioning about bowel and bladder symptoms is a necessity. Many, but not all, patients with a central protrusion are candidates for surgery, especially if there are bowel and bladder symptoms.

The seated patient is asked to take a breath, hold it, and then bear down as if evacuating the bowels (Figure 9-70). If pain increases, it indicates increased intrathecal pressure. The symptoms may be accentuated by having the patient first flex the hip to a position just short of that causing pain.¹⁹⁵

 Farfan Torsion Test.32,38

This nonspecific test stresses the facet joints, joint capsule, supraspinous and interspinous ligaments, neural arch, the longitudinal ligaments, and the disc. The patient lies prone. The examiner stabilizes the ribs and spine (at about T12) with one hand and places the other hand under the anterior aspect of the ilium. The examiner then pulls the ilium backward (Figure 9-71) causing the spine to be rotated on the opposite side producing torque on the opposite side. The test is said to be positive if it reproduces all or some of the patient's symptoms. The other side is tested for compression.

 H and I Stability Tests.75,92

This set of movements tests for muscle spasm and can be used to detect instability. The H and I monikers relate to the movements that occur (Figure 9-72).

 Lateral Lumbar Spine Stability Test.92

The patient is placed in side lying with the lumbar spine in neutral. The examiner places the forearm over the side of the thorax at about the L3 level as an example. The examiner then applies a downward pressure to the transverse process of L3, which produces a shear to the side on which the patient is lying for vertebra below L3 and a relative lateral shear in the opposite direction to the segments above L3 (Figure 9-73). The production of the patient's symptoms indicates a positive test.

 Passive Lumbar Extension Test.207,208

The patient lies prone and relaxed. The examiner passively lifts and extends both extremities at the same time to about 1 foot (30 cm) from the bed. While maintaining the extension, the examiner gently pulls the legs (Figure 9-74). The test is considered positive if, in the extended position, the patient complains of strong pain in the lumbar region, very heavy feeling in the low back, or it feels like the low back is “coming off” and the pain disappears when the legs are lowered to the start position. Numbness or prickling sensation are not positive signs.

The patient lies prone. With one hand, the examiner gently applies pressure to the posterior aspect of the lumbar spine. With the other hand, the examiner passively flexes the patient's knees until the heels touch the buttocks (Figure 9-75). If this hyperextension of the spine causes the patient to feel pain in the leg, the test is considered positive and indicates an unstable spinal segment.²⁰⁹

The patient lies prone with the body on the examining table and the legs over the edge resting on the floor (Figure 9-76 ). The examiner applies pressure to the posterior aspect of the lumbar spine while the patient rests in this position. The patient then lifts the legs off the floor, and the examiner again applies posterior compression to the lumbar spine. If pain is elicited in the resting position only, the test is positive, because the muscle action masks the instability.^210,211

 Specific Lumbar Spine Torsion Test.75,92

This test stresses specific levels of the lumbar spine. To do this, the specific level must be rotated and stressed. An example would be testing the integrity of left rotation on L5 S1. The patient is placed in a right side lying position with the lumbar spine in slight extension (slight lordosis). To achieve rotation and side bending, the examiner grasps the right arm and pulls it upward and forward at a 45° angle until movement is felt at the L5 spinous process. This “locks” all the vertebrae above L5. The examiner then stabilizes the L5 spinous process by holding the left shoulder back with the examiner's elbow while rotating the pelvis and sacrum forward until S1 starts to move (Figure 9-77) with the opposite hand. Minimal movement should occur, and a normal capsular tissue stretch should be felt when L5 S1 is stressed by carefully pushing the shoulder back with the elbow and rotating the pelvis forward with the other arm/hand. This test position is a common position used to manipulate the spine, so the examiner should take care not to overstress the rotation during assessment. In some cases, when doing the test, the examiner may hear a “click” or “pop.” This is the same “pop” or “click” that would be heard with a manipulation.

 Test of Anterior Lumbar Spine Instability.92

The patient is placed in side lying with the hips flexed to 70° and knees flexed. The examiner palpates the desired spinous processes (e.g., L4 to L5). By pushing the patient's knees posteriorly with the body along the line of the femur, the examiner can feel the relative movement of the L5 spinous process on L4 (Figure 9-78). Normally, there should be little or no movement. Other levels of the spine may be tested in a similar fashion. A problem with the test is that the examiner should ensure that the posterior ligaments of the spine are relatively loose or relaxed. This can be controlled by altering the amount of hip flexion. With greater hip flexion, the posterior ligaments tighten more from the bottom (sacrum) up.

 Test of Posterior Lumbar Spine Instability.92

The patient sits on the edge of the examining table. The examiner stands in front of the patient. The patient places the pronated arms with elbows bent on the anterior aspect of the examiner's shoulders. The examiner puts both hands around the patient so the fingers rest over the lumbar spine and with the heels of the hands gently pull the lumbar spine into full lordosis. To stress L5 on S1, the examiner stabilizes the sacrum with the fingers of both hands and asks the patient to push through the forearm while maintaining the lordotic posture (Figure 9-79). This produces a posterior shear of L5 on S1. Other levels of the spine may be tested in a similar fashion.

The patient stands with the examiner standing to one side. The examiner grasps the patient's pelvis with both hands and places a shoulder against the patient's lower thorax. Using the shoulder as a block, the examiner pulls the pelvis toward the examiner's body (Figure 9-80). The position is held for 10 to 15 seconds, and then the test is repeated on the opposite side.^39,184 If the patient has an evident scoliosis, the side to which the scoliosis curves should be tested first. A positive test is indicated by increased neurological symptoms on the affected side. It also indicates whether the symptoms are actually causing the scoliosis.

The patient lies supine and actively lifts both legs simultaneously off the examining table 5 to 10 cm (2 to 4 inches), holding this position for 30 seconds. The test is positive if the limbs or affected limb cannot be held for 30 seconds or if symptoms are reproduced in the affected limb.183,184 This test should always be performed with caution because of the high stress load placed on the lumbar spine.

The patient stands on one leg and extends the spine while balancing on the leg (Figure 9-81). The test is repeated with the patient standing on the opposite leg. A positive test is indicated by pain in the back and is associated with a pars interarticularis stress fracture (spondylolisthesis). If the stress fracture is unilateral, standing on the ipsilateral leg causes more pain.^212–214 If rotation is combined with extension and pain results, this indicates possible facet joint pathology on the side to which rotation occurs.

The patient stands with the examiner standing behind. The patient extends the spine while the examiner controls the movement by holding the patient's shoulders. The examiner may use his or her shoulders to hold the occiput and take the weight of the head. Overpressure is applied in extension while the patient side flexes and rotates to the side of pain. The movement is continued until the limit of range is reached or until symptoms are produced (Figure 9-82). The position causes maximum narrowing of the intervertebral foramen and stress on the facet joint to the side on which rotation occurs.²¹⁵ The test is positive if symptoms are produced.²¹⁶ Cipriano described a similar test as Kemp's test.²⁰⁰

The Schober test may be used to measure the amount of flexion occurring in the lumbar spine. A point is marked midway between the two PSISs (“dimples of the pelvis”), which is the level of S2; then, points 5 cm (2 inches) below and 10 cm (4 inches) above that level are marked. The distance between the three points is measured, the patient is asked to flex forward, and the distance is remeasured. The difference between the two measurements indicates the amount of flexion occurring in the lumbar spine. Little reported a modification of the Schober test to measure extension as well.217 After completion of the flexion movement, the patient extends the spine, and the distance between the marks is noted. Little also advocated using four marking points (one below the dimples and three above) with 10 cm (4 inches) between them.

See “Tests for Tight Hamstrings” in Chapter 11.

See “Tests for Tight Tensor Fasciae Latae” in Chapter 11.

See “Tests for Tight Rectus Femoris” in Chapter 11.

See “Tests for Tight Iliopsoas” in Chapter 11.

The patient lies supine. The patient flexes the head against resistance, coughs, or attempts to sit up with the hands resting behind the head.183,218 The sign is positive if the umbilicus does not remain in a straight line when the abdominals contract, indicating pathology in the abdominal muscles (i.e., paralysis).

 Bicycle Test of van Gelderen.225

The patient is seated on an exercise bicycle and is asked to pedal against resistance. The patient starts pedaling while leaning backward to accentuate the lumbar lordosis (Figure 9-83). If pain into the buttock and posterior thigh occurs, followed by tingling in the affected lower extremity, the first part of the test is positive. The patient is then asked to lean forward while continuing to pedal. If the pain subsides over a short period of time, the second part of the test is positive; if the patient sits upright again, the pain returns. The test determines whether the patient has neurogenic intermittent claudication.

The stoop test is performed to assess neurogenic intermittent claudication to determine whether a relation exists among neurogenic symptoms, posture, and walking.226 When the patient with neurogenic intermittent claudication walks briskly, pain ensues in the buttock and lower limb within a distance of 50 m (165 feet). To relieve the pain, the patient flexes forward. These symptoms may also be relieved when the patient is sitting and forward flexing. If flexion does not relieve the symptoms, the test is negative. Extension may also be used to bring the symptoms back.

 Treadmill Test.227,228

This test may also be used to determine if the patient has intermittent claudication. Two trials are conducted—one at 1.2 mph and one at the patient's preferred walking speed. The patient walks upright (no leaning forward or holding hand rails is allowed) on the treadmill for 15 minutes or until the onset of severe symptoms (symptoms that would make patient stop walking in usual life situations). Time to first symptoms, total ambulatory time, and precipitating symptoms are recorded.

The patient is asked to kneel on a chair and then bend forward to touch the floor with the fingers (Figure 9-84). The test is positive for malingering if the patient is unable to perform the test or the patient overbalances.¹⁸⁴

The patient lies supine. The examiner places one hand under each calcaneus while the patient's legs remain relaxed on the examining table (Figure 9-85).^229–231 The patient is then asked to lift one leg off the table, keeping the knees straight, as for active straight leg raising. If the patient does not lift the leg or the examiner does not feel pressure under the opposite heel, the patient is probably not really trying or may be a malingerer. If the lifted limb is weaker, however, pressure under the normal heel increases, because of the increased effort to lift the weak leg. The two sides are compared for differences.

The patient lies supine,148 and the examiner performs a passive unilateral straight leg raising test. If there is unilateral restriction, the examiner then flexes the knee to see whether hip flexion increases. If the problem is in the lumbar spine or hamstrings, hip flexion increases when the knee is flexed. This finding indicates a negative sign of the buttock test. If hip flexion does not increase when the knee is flexed, it is a positive sign of the buttock test and indicates pathology in the buttock behind the hip joint, such as a bursitis, tumor, or abscess.²³² The patient should also exhibit a noncapsular pattern of the hip.

This syndrome involves compression of the L5 nerve root as it passes under the iliolumbar ligament in the iliolumbar canal (Figure 9-91). The usual cause of compression is trauma (inflammation), osteophytes, or a tumor. Symptoms are primarily sensory (L5 dermatome) and pain. There is minimal or no effect on the L5 myotome.²³⁷

The examiner uses both thumbs to palpate the symphysis pubis. Standing at the patient's side, the examiner pushes both thumbs down onto the symphysis pubis so that the thumbs rest on the superior aspect of the pubic bones (see Figure 10-15). In this way, one can ensure that the two pubic bones are level. The symphysis pubis and pubic bones may also be carefully palpated for any tenderness (e.g., osteitis pubis).

If the examiner returns to the spinous process of L5 and moves caudally, the fingers will be resting on the sacrum. Like the lumbar spine, the sacrum has spinous processes, but they are much harder to distinguish because there are no interposing soft-tissue spaces between them. The S2 spinous process is at the level of a line joining the two PSISs (“posterior dimples”). Moving distally, the examiner's fingers may palpate the sacral hiatus, which is the caudal portion of the sacral canal. It has an inverted U shape and lies approximately 5 cm (2 inches) above the tip of the coccyx. The two bony prominences on each side of the hiatus are called the sacral cornua (see Figure 10-67). As the examiner's fingers move farther distally, they eventually rest on the posterior aspect of the coccyx. Proper palpation of the coccyx requires a rectal examination using a surgical rubber glove (Figure 9-95). The index finger is lubricated and inserted into the anus while the patient's sphincter muscles are relaxed. The finger is inserted as far as possible and then rotated so that the pulpy surface rests against the anterior surface of the coccyx. The examiner then places the thumb of the same hand against the posterior aspect of the sacrum. In this way, the coccyx can be moved back and forth. Any major tenderness (e.g., coccyodynia) should be noted.

With this view (Figure 9-96), the examiner should note the following:

With this view (Figure 9-106), the examiner should note the following:

With the oblique view (Figure 9-110), the examiner should look for any evidence of spondylolisthesis (sometimes referred to as a “Scottie dog decapitated”) or spondylolysis (sometimes referred to as a “Scottie dog with a collar;” Figure 9-111).

In some cases, motion views may be used to demonstrate abnormal spinal motion or structural abnormalities. These are usually lateral views showing flexion and extension to demonstrate instability or spondylolisthesis (Figure 9-112), but they may also include anteroposterior views with side bending.^166,262,263