History, Posture, Gait and Orthopedic Tests of the Spine and Pelvis

The neuromusculoskeletal examination is the core of chiropractic diagnosis, and Part II gives it the largest share of the test plan. A well taken history usually tells you what is wrong before you touch the patient; posture, gait and a short list of well chosen orthopedic tests then confirm the tissue, the level and, just as importantly, whether the patient belongs in your office at all. This chapter covers the case history, posture and gait analysis, and the orthopedic tests of the cervical, thoracic and lumbopelvic regions, with exactly how each is done, what counts as positive and what a positive result suggests.

Section 1The neuromusculoskeletal case history

Structure of the history

The history moves from the chief complaint (in the patient's words) to the history of present illness, then past medical history (prior episodes, surgeries, fractures, cancer, systemic disease), medications (anticoagulants, steroids, NSAIDs, statins, fluoroquinolones), family history (inflammatory arthritis, cancer, aneurysm), social history (occupation, activity, smoking, alcohol, drugs, stress, sleep) and a review of systems, which is where visceral and systemic disease is uncovered. The present illness is organized with a mnemonic such as OPQRST:

Mechanism of injury

The mechanism predicts the injured tissue. Combined flexion with rotation under load (lifting and twisting) stresses the posterolateral annulus and produces disc injury. Axial loading (diving, a fall onto the feet or buttocks) causes compression or burst fractures, typically at the thoracolumbar junction, and calcaneal fractures from a fall onto the feet travel with lumbar fractures. Hyperextension stresses the facet joints, pars interarticularis (spondylolysis in gymnasts and linemen) and anterior longitudinal ligament. A fall on an outstretched hand injures the wrist, elbow and shoulder. Rapid acceleration and deceleration in a motor vehicle collision causes whiplash associated disorders (WAD); important details are the direction of impact, head position (rotated heads fare worse), headrest height, seat belt use, awareness of impact and immediate versus delayed symptoms.

Pain patterns

Distinguishing pain types is the central skill of the spinal history, because each points to a different tissue and a different management path.

• Local somatic pain arises from the injured structure itself (facet capsule, disc annulus, ligament, muscle, sacroiliac joint). It is aching and fairly well localized.
• Somatic referred pain is felt at a distance from a somatic source in the same segmental supply. It is deep, dull, diffuse, hard to localize, and usually stays above the knee (or elbow). Facet, disc and sacroiliac joints all produce it. There are no neurological deficits.
• Radicular pain results from an inflamed or compressed nerve root. It is sharp, shooting, lancinating or electric, travels in a narrow band, often goes below the knee into the foot (or below the elbow into the hand), and is worse in the limb than in the back. It is often aggravated by coughing, sneezing and nerve tension tests.
• Radiculopathy is objective loss of root function: dermatomal sensory loss, myotomal weakness and a reduced reflex. Radicular pain and radiculopathy often coexist but either may occur alone.
• Myelopathy is cord compression: clumsy hands, gait disturbance, bilateral paresthesia, bowel or bladder change, and upper motor neuron signs (hyperreflexia, Hoffmann, Babinski, clonus).
• Visceral referred pain (Chapter 3) is unaffected by movement and linked to organ function.
• Nociplastic pain (central sensitization) is widespread, disproportionate pain with allodynia and hyperalgesia, typical of fibromyalgia and some chronic spinal pain.

Mechanical versus nonmechanical pain

Mechanical pain varies with posture, movement and load, is eased by certain positions or rest, and has a pattern you can reproduce on examination. Morning stiffness lasts less than about 30 minutes. Nonmechanical pain is constant, unrelieved by rest or position, often worse at night, and suggests tumor, infection, inflammatory disease or a visceral source. Inflammatory back pain, typical of axial spondyloarthritis, has its own profile: onset before age 40, insidious onset, improvement with exercise, no improvement with rest, and night pain that improves on getting up (four of these five features support the diagnosis), plus prolonged morning stiffness and alternating buttock pain.

Red flags and yellow flags

Red flags (Chapter 3) point to serious pathology: a history of cancer, unexplained weight loss, fever, immunosuppression, injection drug use, significant trauma or osteoporosis, saddle anesthesia, bladder or bowel dysfunction, progressive neurological deficit and constant night pain. Yellow flags are psychosocial factors that predict persistent pain and disability: fear avoidance beliefs (the belief that movement causes harm), catastrophizing, depression and anxiety, passive coping, expectation that only passive treatment will help, job dissatisfaction, and compensation or litigation issues. Related terms are blue flags (the worker's perception that work is harmful or unsupportive), black flags (system and contextual obstacles such as compensation rules) and orange flags (psychiatric disorder needing specialist care). The STarT Back screening tool stratifies low back pain patients into low, medium and high risk of poor outcome so that care can be matched to risk.

Outcome measures

Validated outcome measures document the baseline, track progress, justify continued care and guide discharge. Change is judged against the minimal clinically important difference (MCID), the smallest change a patient perceives as meaningful.

Section 2Posture and gait assessment

Plumb line analysis

Static posture is viewed from the side, front and back with the patient standing relaxed, barefoot, feet a comfortable distance apart, against a plumb line (a weighted string that hangs truly vertical). In the lateral view the line is aligned just anterior to the lateral malleolus, and in ideal alignment it then passes through the landmarks shown in Figure 4.2. Deviations are described by the direction the body segment lies relative to the line: a forward head, for example, places the ear anterior to the line.

In the posterior view, the line falls from the external occipital protuberance through the spinous processes and gluteal cleft and midway between the knees and the medial malleoli. Look for head tilt, unequal shoulder and scapular heights, a lateral curve, uneven waist angles (the space between the arm and trunk), unequal iliac crest, PSIS and gluteal fold heights, genu valgum or varum, and calcaneal eversion. In the anterior view, note facial and clavicular symmetry, the chest, patellar orientation (squinting patellae suggest femoral anteversion) and foot arches.

Scoliosis screening and the Adams test

Scoliosis is a lateral curvature of the spine of 10 degrees or more (Cobb method), always accompanied by vertebral rotation when structural. Adolescent idiopathic scoliosis is the most common form; small curves are equally common in boys and girls, but curves that progress are far more common in girls, and the typical pattern is a right thoracic curve. Screening signs are unequal shoulder heights, a prominent scapula, asymmetric waist angles, a trunk shifted off the pelvis (a plumb line from C7 that misses the gluteal cleft) and a rib or lumbar prominence.

In the Adams forward bend test, the standing patient bends forward from the waist with knees straight, feet together and arms hanging, palms together. The examiner looks along the back from behind (and from the front) at eye level. A rib hump (thoracic) or paravertebral prominence (lumbar) on one side is positive and indicates vertebral rotation, meaning a structural curve; the rib hump lies on the convex side of the curve. A curve that is present standing but disappears on forward bending is functional (nonstructural), caused by a leg length difference, muscle spasm, pain or habitual posture. A scoliometer measures the angle of trunk rotation; 5 to 7 degrees is the usual threshold for radiographic referral. Skeletal maturity is graded by the Risser sign (ossification of the iliac apophysis, 0 to 5); risk of progression is highest in an immature patient (Risser 0 to 1) with a larger curve.

Leg length assessment

An anatomical (structural) leg length inequality is a true difference in bone length of the femur or tibia. A functional (apparent) inequality is created by pelvic obliquity, sacroiliac dysfunction, muscle imbalance, hip contracture or foot pronation, with bones of equal length.

The most accurate measure of anatomical inequality is an upright weight bearing radiograph of the pelvis and femoral heads with the patient standing evenly, or a scanogram. Differences under about 5 mm are common and of uncertain significance.

The gait cycle

One gait cycle runs from initial contact of one foot to the next initial contact of the same foot. At normal speed, stance phase takes about 60 percent and swing phase about 40 percent. There are two periods of double support (about 10 percent each); as speed increases double support shrinks, and running replaces it with a float (flight) phase. Stance is divided into initial contact (heel strike), loading response (foot flat), midstance, terminal stance (heel off) and preswing (toe off). Swing is divided into initial swing (acceleration), midswing and terminal swing (deceleration). Normal cadence is roughly 100 to 120 steps per minute, the step width a few centimeters, and the pelvis rotates and drops slightly to minimize vertical displacement of the center of mass.

Section 3Orthopedic examination of the cervical spine

Before you test: trauma screening and observation

After trauma, decide whether the neck needs imaging before it is moved. The Canadian C spine rule (for alert, stable adults) first asks about high risk factors: age 65 or older, a dangerous mechanism (fall from 1 m or five stairs, axial load to the head, high speed or rollover collision, ejection, bicycle collision) or paresthesias in the extremities. Any one means radiography (or CT). If none is present, low risk factors (simple rear end collision, sitting in the emergency department, ambulatory at any time, delayed onset of neck pain, no midline tenderness) allow safe assessment of motion; if the patient can actively rotate 45 degrees left and right, no imaging is needed. The NEXUS criteria clear the neck clinically when there is no posterior midline tenderness, no intoxication, normal alertness, no focal neurological deficit and no painful distracting injury.

Observe head carriage, guarding, torticollis and skin; palpate bony landmarks (C2 spinous is the first palpable midline bump below the occiput, C7 the most prominent, and C6 moves anteriorly under the finger on extension while C7 does not), facets, muscles, the supraclavicular fossa (cervical rib, nodes) and the carotid pulses.

Range of motion

Active motion is tested first, then passive, then resisted. In the Cyriax approach, pain on active and passive motion in the same direction implicates inert tissue (joint, capsule, ligament), while pain on resisted isometric contraction implicates contractile tissue (muscle, tendon). The O'Donoghue maneuver applies this directly: pain on resisted motion suggests strain, and pain on passive motion suggests sprain.

In the lower cervical spine, lateral flexion and rotation are coupled to the same side because of the 45 degree orientation of the facet joints. Loss of rotation to one side of more than about 10 degrees is an objective, trackable finding; the cervical flexion rotation test (rotation measured in full flexion, which isolates C1 to C2) is restricted in cervicogenic headache.

Foraminal and nerve root tests

The cervical intervertebral foramen narrows with extension, ipsilateral lateral flexion and ipsilateral rotation and opens with flexion, contralateral bending and traction. Compression tests therefore reproduce radicular symptoms when a root is already crowded by a disc herniation or uncovertebral and facet osteophytes, and distraction relieves them (Figure 4.3).

No single cervical test is decisive. A clinical prediction cluster for cervical radiculopathy combines a positive ULTT 1, ipsilateral rotation under 60 degrees, relief with distraction and a positive Spurling: three of four positive makes radiculopathy likely, and all four makes it very likely. Confirm with the neurological exam (dermatomes, myotomes and reflexes, covered in Chapter 6) and look for upper motor neuron signs (Hoffmann, Babinski, hyperreflexia, gait change) that turn a radicular picture into myelopathy.

Vertebral artery and cervical artery screening

Traditional premanipulative screening tests place the neck in sustained rotation and extension to stretch the vertebral artery, watching for dizziness, nystagmus, visual disturbance, nausea or other brainstem signs.

The evidence is clear that these provocative tests have poor sensitivity and cannot predict which patients will suffer a cervical artery dissection or stroke. A negative test does not clear a patient for manipulation. Current consensus emphasizes the history: recognizing the patient who may already have a dissection in progress. Vertebral artery dissection classically produces sudden, unusual occipital or upper neck pain and headache, followed by brainstem signs (the 5 Ds and 3 Ns: dizziness, diplopia, dysarthria, dysphagia, drop attacks, nausea, nystagmus, numbness, plus ataxia). Internal carotid dissection produces anterolateral neck, face or eye pain with an ipsilateral Horner syndrome, pulsatile tinnitus or a transient ischemic attack. A positive screening test or such a history means no cervical manipulation and immediate referral.

Section 4Orthopedic examination of the thoracic spine and ribs

Inspection, motion and the ribs

The thoracic spine is the stiffest spinal region because the ribs, sternum and nearly coronal facets limit flexion and extension, while rotation is relatively free. Commonly taught thoracic ranges are about 20 to 45 degrees of flexion, 25 to 45 degrees of extension, 20 to 40 degrees of lateral flexion and 35 to 50 degrees of rotation, usually measured with the lumbar spine included as thoracolumbar motion. Inspect for kyphosis (a smooth round back, a sharp angular gibbus from a collapsed vertebra, or the wedged vertebrae of Scheuermann disease), scoliosis (Adams test, Section 2), scapular position and chest shape (pectus excavatum, pectus carinatum, barrel chest).

The upper ribs move in a pump handle fashion (increasing the anteroposterior diameter), the lower ribs in a bucket handle fashion (increasing the transverse diameter), and ribs 11 and 12 in a caliper motion. Thoracic pain must always be weighed against visceral sources: heart, aorta, esophagus, lungs and pleura, gallbladder, pancreas and kidney (Chapter 3), as well as herpes zoster before the rash appears.

Thoracic and rib tests

The direction of umbilical movement in Beevor sign follows the stronger muscle: with weak lower abdominals the intact upper fibers pull the umbilicus toward the head. Abdominal superficial reflexes (T8 to T12) complement it, and their asymmetric loss in a child with scoliosis suggests a syrinx.

Thoracic outlet syndrome

The thoracic outlet is the passage from the root of the neck to the axilla through which the brachial plexus, subclavian artery and subclavian vein travel. There are three sites of potential compression (Figure 4.4): the interscalene triangle (anterior scalene in front, middle scalene behind, first rib below; the plexus and artery pass through it, the vein passes in front of the anterior scalene), the costoclavicular space (between the clavicle and first rib) and the subcoracoid (pectoralis minor) space beneath the pectoralis minor tendon at the coracoid. Contributing factors include a cervical rib or long C7 transverse process, scalene hypertrophy or fibrous bands, a healed clavicle fracture, drooping shoulders and repetitive overhead work.

More than 90 percent of cases are neurogenic, usually affecting the lower trunk (C8 and T1): aching in the neck, shoulder and medial arm, paresthesia in the ulnar forearm and fourth and fifth fingers, worse with overhead activity and carrying, and, in long standing cases, wasting of the thenar eminence (Gilliatt Sumner hand). Arterial TOS causes coldness, pallor, claudication of the arm and emboli; venous TOS causes swelling, cyanosis and heaviness, and effort thrombosis of the subclavian vein (Paget Schroetter syndrome) after vigorous arm use is an urgent referral.

Pulse obliteration during these positions also occurs in many people without symptoms, so a pulse change alone has poor specificity. The meaningful finding is reproduction of the patient's own symptoms, ideally on more than one test, combined with a compatible history and a neurological exam that excludes C8 radiculopathy and ulnar neuropathy at the elbow. A chest or cervical film may show a cervical rib or apical lung lesion; a Pancoast tumor of the lung apex can mimic TOS with shoulder and ulnar arm pain plus Horner syndrome.

Section 5Orthopedic examination of the lumbar spine and pelvis

Lumbar motion

Commonly taught lumbar ranges are about 40 to 60 degrees of flexion, 20 to 35 degrees of extension, 15 to 25 degrees of lateral flexion and only 3 to 18 degrees of rotation, because the sagittally oriented facets block twisting. Watch the quality of motion: a painful arc, deviation to one side during flexion (a lateral shift away from a posterolateral disc protrusion), reversal of lumbopelvic rhythm when returning from flexion, and a flat segment that does not open on flexion. The modified Schöber test marks the lumbosacral junction (the level of the dimples of Venus) and points 10 cm above and 5 cm below; the 15 cm span should lengthen by at least about 5 cm on full flexion, and less than that supports ankylosing spondylitis or other causes of restricted lumbar flexion.

Nerve tension tests

Straight leg raising pulls the sciatic nerve and the L4 to S1 roots caudally through their foramina. The first 30 degrees or so takes up slack with little root movement; between about 30 and 70 degrees the roots move and are placed under tension; beyond 70 degrees most of the strain falls on the lumbar joints, the sacroiliac joint and the hamstrings (Figure 4.5).

Pressure, facet and space occupying lesion tests

Sacroiliac, hip and soft tissue tests

Single sacroiliac tests are unreliable. The best supported approach is a cluster of provocation tests: distraction (gapping of the anterior joint by pressing the ASISs apart), compression (side lying downward pressure on the iliac crest), thigh thrust (posterior shear through the femur with the hip flexed 90 degrees), sacral thrust (prone, pressure on the sacrum) and Gaenslen. Three or more positive tests out of five, together with pain below L5 and no centralization during repeated movements, make the sacroiliac joint a likely pain source.

Nonorganic signs: Hoover and Waddell

Some findings indicate that pain behavior is not explained by structural disease alone. They must be interpreted carefully: they identify illness behavior and psychosocial distress that need to be addressed, not proof that the patient is lying, and they can coexist with genuine pathology.

Three or more of the five Waddell categories is considered significant. A positive score predicts poorer outcomes and calls for attention to yellow flags and, often, a multidisciplinary approach; it does not by itself justify ending care or a conclusion of malingering.

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