Practice Stations I: Imaging and Case Management Walk Throughs
Knowing the material and producing it on demand behind a closed door with a clock running are two different skills. This chapter is pure rehearsal: timed film cases and complete case management stations for the neck and head, the low back and pelvis, the extremities and the viscera, each walked through in the order you would actually perform it. Read a door card, cover the box, run the station in your head out loud, then check yourself against the reasoning.
By the end of this chapter you can
- Run a fixed film routine and state each answer as finding, location, view, impression and recommendation without wasting time.
- Turn a door card into a working differential before you knock, and plan which history questions and tests will separate the possibilities.
- Perform a complete neck and head station, including cervical radiculopathy testing, the Canadian C-spine rule and screening for cervical artery dissection.
- Separate radicular, stenotic, sacroiliac and mechanical low back presentations, and recognize cauda equina syndrome and vascular mimics.
- Work up common extremity complaints with high yield special tests and apply the Ottawa ankle and knee rules to imaging decisions.
- Recognize visceral referred pain patterns that masquerade as musculoskeletal complaints and choose the right level of urgency for referral.
- Close every station with a plain language report of findings, informed consent, a home plan, a follow up point and a concise patient note.
- Name the critical actions in each case whose omission costs the most points or puts the patient at risk.
Section 1Imaging station walk throughs
How to use these film cases
Imaging tasks on a practical exam reward two things: seeing the finding and saying it in a usable form. The second is where prepared candidates still lose points. A correct impression with no location, or a correct finding with no recommendation, is a partial answer. Practice every case below with a timer set to the official time printed in your current candidate materials, or, if you are drilling before you know it, to a short fixed window such as two minutes per film. When time is short, the order of priority is: the most important finding, then the impression, then the recommendation, then the supporting observations.
Every film answer in this section uses the same five part template:
- Finding: what you see, in descriptive terms (lucency, sclerosis, loss of height, soft tissue swelling, malalignment).
- Location: the bone or level and the side (L5 bilateral pars interarticularis; right femoral neck).
- View: the projection on which it is best seen (lateral lumbar, AP open mouth, oblique cervical).
- Impression: the single most likely diagnosis in one line, with one or two differentials if they are reasonable.
- Recommendation: further imaging or labs, referral and its urgency, and the effect on chiropractic care (proceed, modify, or do not manipulate that region).
The 90 second film routine
A routine prevents the satisfaction of search error, in which the first abnormality you find ends your look. Use the same sequence on every film, whether it is spine or extremity: read the label (age, sex, side, view, date), then ABCS: Alignment and anatomy (lines, curves, counts), Bone (density, cortical outline, trabecular pattern, each vertebra or bone in turn), Cartilage and joint spaces (disc heights, joint widths, subchondral bone, erosions), and Soft tissues (prevertebral space, psoas shadows, calcifications, the aorta, lung apices, bowel gas). Finish with the corners of the film, because a rib lesion, an apical mass or an abdominal aortic calcification often sits away from the region of interest.
| Step | What you do | What you say or write |
|---|---|---|
| 1. Orient | Read name tag, age, sex, view and side marker; hang the film correctly | "Lateral lumbar film of a 16 year old male" |
| 2. Alignment | Trace anterior and posterior vertebral body lines, spinolaminar line, George's line; count levels | "Anterior translation of L5 on S1" |
| 3. Bone | Scan each vertebra: cortex, pedicles, pars, endplates, density, trabeculae | "Lucent defect across the L5 pars" |
| 4. Cartilage | Disc heights, facet joints, SI joints, peripheral joint spaces | "L5 disc height mildly reduced" |
| 5. Soft tissue | Prevertebral space, psoas, aorta, calcifications, lung apices | "Soft tissues unremarkable" |
| 6. Answer | Commit to the impression and recommendation | "Isthmic spondylolisthesis, grade 1. Recommend flexion and extension views; modify care" |
Film cases with answers
The table below is a rapid drill set. Cover the right four columns and say the answer aloud from the description in the first column. The cases emphasize findings that change management, because that is what an examiner is looking for in the recommendation.
| Film and patient | Key finding, location and view | Impression | Recommendation and effect on care |
|---|---|---|---|
| Lateral lumbar, 16 year old gymnast | Lucency across the L5 pars with anterior translation of L5 on S1 under 25 percent; best seen on lateral, pars "collar" on obliques | Isthmic spondylolisthesis, grade 1 | Flexion and extension views for instability; avoid extension loading and forceful P to A thrusts at L5; activity modification, core program; orthopedic referral if progressive or neurologic |
| Lateral cervical after a fall, 70 year old | Prevertebral soft tissue at C2 wider than about 7 mm; lucent line at the base of the dens | Odontoid fracture (type II pattern) until proven otherwise | Stop; immobilize; emergency department and CT; absolute contraindication to cervical manipulation |
| AP pelvis, 24 year old male with morning stiffness | Bilateral symmetric SI joint erosions, sclerosis and widening, best on AP and angled sacral views | Sacroiliitis, most consistent with ankylosing spondylitis | ESR, CRP and HLA-B27; rheumatology referral; extension and mobility program; no high velocity thrust to fused or osteoporotic segments |
| Lateral thoracolumbar, 74 year old woman on long term prednisone | Anterior wedging of T12 with loss of about 30 percent anterior height; diffuse osteopenia; posterior body wall intact | Osteoporotic compression fracture of T12 | DEXA and metabolic workup; MRI if pain is new, if the posterior wall is involved or if malignancy is suspected; no thrust at or near the level; refer to primary care |
| AP lumbar, 66 year old with night pain and prior breast cancer | Absent right L3 pedicle outline (the winking owl sign) | Lytic metastasis | Urgent MRI and oncology referral; absolute contraindication to manipulation of the region |
| Lateral lumbar, 72 year old male smoker | Curvilinear calcification anterior to L2 to L4 with the anterior and posterior walls more than 3 cm apart | Abdominal aortic aneurysm | Abdominal ultrasound and vascular referral; same day emergency care if pain, tenderness or hypotension; avoid lumbar thrust and side posture rotation |
| Lateral cervical flexion view, 58 year old with rheumatoid arthritis | Atlantodental interval widening from 2 mm in neutral to 6 mm in flexion | Atlantoaxial instability | Absolute contraindication to cervical manipulation; neurologic exam; urgent spine surgery referral; avoid end range flexion |
| Lateral thoracic, 68 year old male with stiff back | Flowing ossification along the anterolateral margins of at least four contiguous thoracic bodies; disc heights and SI joints preserved | DISH (diffuse idiopathic skeletal hyperostosis) | Correlate with dysphagia and metabolic risk; mobility work; avoid thrust across bridged segments, which behave like long bones and fracture with minor trauma |
| Oblique cervical, 55 year old with arm paresthesia | Uncovertebral osteophytes narrowing the right C5 to C6 intervertebral foramen; disc space narrowing at C5 to C6 on the lateral | Degenerative disc and uncovertebral arthrosis with foraminal stenosis | Correlate with C6 neurologic findings; conservative care is appropriate; avoid end range positions that close the right foramen (extension, right rotation and right lateral flexion) |
| AP shoulder, 45 year old with acute shoulder pain | Amorphous homogeneous calcification superior to the greater tuberosity | Calcific tendinitis of the supraspinatus | Conservative care, modalities and graded loading; ultrasound if needed; orthopedic referral for refractory cases |
| Frog leg lateral hips, 12 year old overweight boy with knee pain and a limp | Femoral head slipped posteromedially; a line along the superior femoral neck (Klein's line) misses the head | Slipped capital femoral epiphysis | Non weight bearing (crutches) and same day orthopedic referral; no manipulation of the hip |
| AP hip, 50 year old on corticosteroids | Subchondral crescent lucency and patchy sclerosis in the superior femoral head with preserved joint space | Avascular necrosis of the femoral head | MRI (most sensitive early); protected weight bearing; orthopedic referral |
How to word an answer under time
A clean spoken answer sounds like this: "On the lateral cervical view there is widening of the prevertebral soft tissue at C2 and a lucent line through the base of the dens. Impression: acute odontoid fracture. Recommendation: immobilize, no manipulation, and transfer to the emergency department for CT." That takes about fifteen seconds and contains every element. Avoid vague words that sound like hedging ("some changes", "possible something"). Descriptive terms are safe when you are unsure of the name: "a geographic lytic lesion with a narrow zone of transition in the proximal tibial metaphysis" earns credit even if your specific diagnosis is wrong, and the recommendation (further imaging, referral) still lands.
Reasoning: Orient first (young female, lateral lumbar). Trace the posterior body line: it steps forward at L5 to S1. Look at the pars of L5: a lucent gap crosses it. Measure: the posteroinferior corner of L5 sits within the first quarter of the S1 endplate, so this is grade 1. Write: "Finding: bilateral L5 pars defects with anterior translation of L5 on S1, lateral view. Impression: isthmic spondylolisthesis, Meyerding grade 1. Recommendation: flexion and extension views to assess instability; relative rest from hyperextension sport; core stabilization; avoid P to A thrust at L5; refer to orthopedics if neurologic signs, slip progression or high grade." Critical actions: grade the slip, comment on stability, and say how it modifies care. Missing the recommendation turns a full answer into half credit.
Every film answer has five parts (finding, location, view, impression, recommendation), and the recommendation always says whether chiropractic care proceeds, is modified or stops. A fixed ABCS routine with a final look at the corners prevents you from stopping at the first finding.
Section 2Neck and head case management walk throughs
The station spine: one sequence for every case
Case management stations differ in complaint but not in shape. Build one sequence and run it every time, so that under stress your hands and mouth follow the sequence while your mind thinks about the patient. Before the door, read the card and write (or hold in mind) three things: the top three differentials, the one red flag you must rule out for this complaint, and the two or three tests that best separate the possibilities. That ten second plan is the difference between a focused station and a scattered one.
| Step | What you do | What you say aloud |
|---|---|---|
| Door | Read the card; note age, sex, complaint, vitals, task | (silently) differentials, red flag, key tests |
| Enter | Knock, enter, wash or sanitize hands, make eye contact | "Hello, I'm Dr. ____. May I confirm your full name and date of birth?" |
| Chief complaint | Open question, then OPQRST (onset, provocation and palliation, quality, region and radiation, severity, timing) | "What brings you in today? Tell me when it started." |
| Red flag screen | Targeted questions for the region (trauma, cancer, infection, neurologic and vascular signs) | "Any fever, weight loss, night pain, numbness, weakness or trouble with your bladder?" |
| Background | Past history, medications, allergies, family and social history, review of systems | "What medications do you take, including blood thinners or steroids?" |
| Transition | Summarize and ask permission to examine; explain gowning and draping | "Let me make sure I have this right... Now I'd like to examine you. Is that all right?" |
| Exam | Vitals if not given, observation, palpation, ROM, orthopedic tests, neurologic screen, special tests | Narrate each test and its result: "Spurling's on the right reproduces arm pain: positive." |
| Findings | Plain language report of findings and working diagnosis | "What I think is happening is..." |
| Plan | Orders (imaging, labs), treatment, home care, follow up, referral; obtain consent | "Here are your options, the benefits and risks. Do you have any questions? May we proceed?" |
| Close | Thank the patient, exit, write the note if required | "I'll see you on Thursday; call me if anything changes." |
Cervical radiculopathy
Radiculopathy is a root problem, so the examination aims at a dermatome, myotome and reflex that agree. The C6 and C7 roots are most often involved because the C5 to C6 and C6 to C7 segments carry the most motion and degenerate first. Remember that cervical roots exit above the pedicle of the same numbered vertebra (the C6 root exits at C5 to C6), so a C5 to C6 disc or foraminal osteophyte affects the C6 root.
| Root | Motor test | Reflex | Sensory area |
|---|---|---|---|
| C5 | Shoulder abduction (deltoid), elbow flexion | Biceps | Lateral arm over the deltoid |
| C6 | Wrist extension, elbow flexion | Brachioradialis (and biceps) | Lateral forearm, thumb and index finger |
| C7 | Elbow extension, wrist flexion, finger extension | Triceps | Middle finger |
| C8 | Finger flexion (grip) | None reliable | Medial forearm, ring and little fingers |
| T1 | Finger abduction and adduction (interossei) | None reliable | Medial arm |
The provocative tests are best used as a cluster. Spurling's (extension, lateral flexion and rotation toward the symptomatic side with gentle axial load) is specific but not sensitive; the upper limb tension test with a median nerve bias is sensitive; distraction that relieves arm pain supports a root cause; and reduced ipsilateral cervical rotation (under about 60 degrees) adds weight. When three or four of these four are positive, cervical radiculopathy is likely; when the tension test is negative, it is much less likely. Do not perform Spurling's with a full axial load in a patient with suspected instability, fracture or myelopathy.
Always screen for myelopathy, which changes the urgency: hand clumsiness, gait imbalance, bilateral symptoms, hyperreflexia, a positive Hoffmann sign, clonus, a Babinski response or Lhermitte's sign. Progressive myelopathy needs MRI and surgical referral and is a contraindication to cervical manipulation.
Reasoning: Before entering: differentials are C6 radiculopathy, carpal tunnel syndrome (or a double crush of both), and referred pain from facet or myofascial sources; red flag is myelopathy; key tests are the C6 myotome, brachioradialis reflex, Spurling's, ULTT A and Phalen's. History: onset (lifting overhead), what aggravates it (looking up, turning right), numbness in the thumb and index finger, any hand clumsiness or gait change (none), night pain, weight loss, fever (none). Exam: cervical ROM with right rotation limited and painful; Spurling's right reproduces arm pain; distraction relieves it; ULTT A positive on the right; wrist extension 4 of 5 on the right; brachioradialis reflex 1+ on the right and 2+ on the left; decreased light touch over the right thumb; Hoffmann negative; Phalen's and carpal Tinel's negative. Say: "Your findings point to irritation of the sixth cervical nerve root on the right, most likely from a disc or a narrowed opening at C5 to C6." Plan: cervical films if indicated (age, trauma, failure to improve); conservative trial of two to four weeks with mobilization or carefully localized manipulation away from foraminal closing positions, traction, nerve glides and posture work; consent with risks including the rare risk of stroke; re-examination; MRI and referral if motor loss progresses, if myelopathic signs develop, or if there is no improvement. Critical actions: complete neuro screen, myelopathy screen, informed consent including vascular risk, and a defined re-examination point.
Neck pain after trauma: when to image
For an alert, stable patient after trauma, the Canadian C-spine rule decides whether radiography is needed (Figure 13.2). It applies to adults who are alert (GCS 15) and stable; it does not apply to children, to patients with an altered mental state, or to those with known vertebral disease. The NEXUS criteria are an alternative: no imaging if the patient has no midline cervical tenderness, no focal neurologic deficit, normal alertness, no intoxication and no painful distracting injury.
Whiplash associated disorders
Once fracture and instability have been excluded, grade the injury with the Quebec Task Force classification, because the grade drives the plan. Grade 0: no neck complaint and no signs. Grade I: neck pain, stiffness or tenderness only, with no physical signs. Grade II: neck complaint with musculoskeletal signs (reduced range of motion, point tenderness). Grade III: neck complaint with neurologic signs (reflex, motor or sensory deficit). Grade IV: fracture or dislocation. Grades I and II do best with reassurance, early return to normal activity, active exercise and short courses of manual therapy; prolonged collars and rest slow recovery. Grade III needs closer neurologic follow up and imaging if deficits progress. Grade IV is a surgical referral.
Reasoning: Apply the C-spine rule aloud. High risk factors: age under 65, a simple rear end crash is not a dangerous mechanism, no extremity paresthesias, so none. Low risk factors: simple rear end crash, ambulatory, delayed onset of neck pain, so safe to assess motion. Palpate the midline for tenderness (absent). Ask her to rotate actively: 50 degrees each way, so no radiographs are indicated by the rule. Screen for headache, dizziness, visual change and arm symptoms, and do a full upper limb neuro screen (normal). Findings: reduced and painful range of motion with paraspinal tenderness and no neurologic signs, so Whiplash Associated Disorder grade II. Plan: reassurance that most people recover, stay active, gentle range of motion exercises, soft tissue work and mobilization, manipulation only after consent and as tolerated, follow up within a week, and return precautions (new arm numbness, severe headache, dizziness or visual change means call or go to the emergency department). Document mechanism, seat position, headrest, seatbelt and airbag for the record. Critical actions: applying a decision rule before treating, neuro screen, and return precautions.
Headache stations
A headache station tests whether you can classify the headache, exclude a dangerous secondary cause, and pick a reasonable plan. Use the SNOOP screen: Systemic symptoms (fever, weight loss) or secondary risk (cancer, HIV, anticoagulation); Neurologic signs or confusion; Onset sudden (thunderclap, maximal within a minute); Older age at onset (new headache after 50); Pattern change, progression, positional headache, or headache triggered by Valsalva, exertion or sex, and papilledema or pregnancy.
| Type | Pattern | Exam clues | Station plan |
|---|---|---|---|
| Tension type | Bilateral band like pressure, mild to moderate, not worsened by routine activity, no nausea | Pericranial and cervical muscle tenderness; normal neuro exam | Manual therapy, posture, stress and sleep work, exercise |
| Migraine | Unilateral, pulsating, moderate to severe, 4 to 72 hours, worse with activity, nausea, light and sound sensitivity; aura in some | Normal neuro exam between attacks | Trigger diary, sleep and hydration routine, coordinate with primary care for medication |
| Cervicogenic | Side locked unilateral pain starting in the neck and spreading forward, provoked by neck movement or posture | Reduced rotation on the flexion rotation test (C1 to C2), upper cervical joint tenderness | Upper cervical mobilization or manipulation with consent, deep neck flexor training |
| Cluster | Severe unilateral orbital pain, 15 to 180 minutes, in bouts; tearing, nasal congestion, ptosis on that side; restlessness | Autonomic signs during attack | Refer to medical care for oxygen and specific medication |
| Giant cell arteritis | New headache over age 50, scalp tenderness, jaw claudication, visual blurring, fatigue | Tender, thickened temporal artery | Same day medical referral for ESR, CRP and steroids; vision is at risk |
| Subarachnoid hemorrhage | Thunderclap "worst headache of my life", maybe neck stiffness, vomiting, collapse | Meningismus, altered consciousness | Call emergency services |
Cervical artery dissection: the station you must not miss
Dissection of the vertebral or internal carotid artery can present first to a chiropractor as neck pain and headache, before ischemic signs appear. The risk is that a patient with an evolving dissection receives neck manipulation and the subsequent stroke is attributed to it. Ask every patient with acute neck pain and headache about new, unusual or severe pain unlike prior episodes, recent minor trauma, and the posterior circulation symptoms often remembered as the 5 Ds and 3 Ns: dizziness, diplopia, dysarthria, dysphagia, drop attacks; nystagmus, nausea, numbness (often facial or crossed). Add ataxia. Internal carotid dissection classically gives ipsilateral head, face or neck pain with a partial Horner syndrome (ptosis and miosis) and sometimes pulsatile tinnitus or a dysgeusia. Vertebrobasilar provocation tests (sustained rotation and extension) have poor accuracy and are not a safe substitute for history; a careful cranial nerve and cerebellar screen is more useful.
Reasoning: A sudden, new, unusual neck pain and headache after a trivial strain is a dissection pattern; the high blood pressure adds weight. Ask the 5 Ds and 3 Ns, visual change, facial numbness, tinnitus and taste change. She reports a brief episode of double vision and feels unsteady. Exam: cranial nerves (pupils, extraocular movements with nystagmus check, facial sensation, palate, tongue), cerebellar tests (finger to nose, heel to shin, tandem gait) and Romberg; she has mild left facial numbness and veers on tandem gait. Do not manipulate, do not perform provocative rotation tests. Say calmly: "Some of your symptoms could come from an irritated artery in the neck. That needs to be checked today with a scan at the hospital. I'm going to arrange that now." Call emergency services for transport (new neurologic signs), document the time of onset and your findings, and send a note. Critical actions: recognizing the pattern, a cranial nerve and cerebellar screen, no cervical treatment, emergency referral and clear documentation.
Neck and head stations follow one fixed sequence, but the content changes with the differential: root level testing for radiculopathy, a decision rule before imaging after trauma, SNOOP for headache, and a deliberate search for dissection signs in any new or unusual neck pain with headache. When the pattern is vascular, the station ends with an emergency referral, not an adjustment.
Section 3Low back and pelvis case management walk throughs
Triage first: the three buckets
Every low back station begins with a triage decision that the examiner wants to hear. Low back pain falls into one of three groups: nonspecific mechanical low back pain (the large majority), radicular pain or neurogenic claudication from a nerve root or spinal canal problem, and pain from serious or specific pathology (fracture, cancer, infection, cauda equina syndrome, inflammatory arthritis, aneurysm, visceral disease). The history does most of the sorting. Ask early, in plain words, about bladder and bowel function, saddle numbness, leg weakness, fever, weight loss, history of cancer, night pain unrelieved by position, steroid use, injection drug use and recent significant trauma.
| Red flag | Concern | Next step |
|---|---|---|
| Urinary retention or overflow incontinence, saddle anesthesia, bilateral leg symptoms, reduced anal tone | Cauda equina syndrome | Emergency department now for MRI and surgical opinion |
| History of cancer, age over 50, unexplained weight loss, night pain, failure to improve in a month | Metastasis or myeloma | Films and labs promptly; MRI; medical referral |
| Fever, injection drug use, recent infection or spinal procedure, immunosuppression | Vertebral osteomyelitis, discitis, epidural abscess | Same day medical referral; emergency if neurologic signs |
| Older age, osteoporosis, long term steroids, minor fall | Compression fracture | Radiographs; no thrust at the level |
| Under 45, insidious onset, morning stiffness over 30 minutes, better with exercise, night pain in the second half of the night, alternating buttock pain | Axial spondyloarthritis | ESR, CRP, HLA-B27, SI imaging, rheumatology referral |
| Older male smoker with deep, throbbing back or abdominal pain, pulsatile mass | Abdominal aortic aneurysm | Ultrasound and vascular referral; emergency if severe pain or hypotension |
| Progressive or severe motor deficit (foot drop) | Severe root compression | Urgent MRI and surgical referral |
Lumbar radiculopathy and the level of the lesion
Lumbar roots exit below the pedicle of the same numbered vertebra. A typical posterolateral disc herniation at L4 to L5 spares the L4 root (which has already exited higher in the foramen) and compresses the traversing L5 root. A far lateral (foraminal or extraforaminal) herniation at the same level compresses the exiting L4 root instead. A central herniation can compress several roots or the cauda equina (Figure 13.3). Saying this mechanism aloud lets you match a neurologic picture to a disc level.
| Root | Motor (functional test) | Reflex | Sensory area |
|---|---|---|---|
| L4 | Knee extension, ankle dorsiflexion with inversion (tibialis anterior); squat and rise | Patellar | Medial leg and medial malleolus |
| L5 | Great toe extension (extensor hallucis longus), hip abduction; heel walking | None reliable (medial hamstring) | Lateral leg, dorsum of foot, first web space |
| S1 | Ankle plantar flexion and eversion; toe walking or repeated single leg heel raises | Achilles | Lateral foot, sole and little toe |
The straight leg raise (SLR) is sensitive for an L5 or S1 root under tension from a disc; pain must reproduce leg symptoms below the knee, typically between about 30 and 70 degrees. A crossed SLR (raising the well leg reproduces pain in the symptomatic leg) is specific and suggests a large herniation. The slump test is a sensitive alternative. The femoral nerve stretch test (prone knee bend) targets L2 to L4 roots. Centralization of pain during repeated movement testing (symptoms retreating toward the spine) predicts a good prognosis with conservative care.
Reasoning: Differentials: S1 radiculopathy from an L5 to S1 disc, piriformis or other deep gluteal pain, SI joint pain with referral. Red flag to exclude: cauda equina. Ask about bladder (normal stream, no retention), saddle numbness (none), the other leg (no symptoms), cough and sneeze aggravation (yes), sitting tolerance (poor). Exam: antalgic lean, flexion limited by leg pain, SLR on the left reproduces calf and foot pain at 40 degrees, crossed SLR negative, toe walking weak on the left with only 6 single leg heel raises compared with 15 on the right, Achilles reflex 1+ left and 2+ right, reduced light touch on the lateral left foot. State the diagnosis: "left S1 radiculopathy, most likely from an L5 to S1 disc herniation, without signs of cauda equina." Imaging: MRI is not needed now without red flags or severe or progressive deficit; reserve it for failure of 4 to 6 weeks of care or for surgical planning. Plan: explain the favorable natural history, directional preference exercises if centralization occurs, side posture or flexion distraction with consent, avoid prolonged sitting, modified duty, and re-examine in two weeks. Give explicit safety netting: "If you have trouble passing urine, numbness around your seat area, or weakness in both legs, go to the emergency department immediately." Critical actions: cauda equina questions, a complete L4, L5 and S1 screen, and the safety net instruction.
Stenosis and the vascular mimic
An older patient with leg pain on walking may have neurogenic claudication from lumbar spinal stenosis or vascular claudication from peripheral arterial disease, and the station tests whether you can separate them in a few minutes.
| Feature | Neurogenic (stenosis) | Vascular (arterial disease) |
|---|---|---|
| Relief | Sitting or bending forward; standing still does not help | Standing still for a few minutes |
| Posture | Better leaning on a shopping cart; worse walking downhill (extension) | Posture does not matter; worse uphill (more work) |
| Cycling | Usually tolerated (flexed posture) | Provokes symptoms |
| Pulses and skin | Normal pulses | Reduced pedal pulses, shiny hairless skin, cool foot, slow capillary refill |
| Test | MRI shows canal narrowing; neuro signs may be minimal at rest | Ankle brachial index under 0.9 |
| Station plan | Flexion based exercise, flexion distraction, walking program, refer if neurologic decline | Refer to primary care or vascular; urgent if rest pain, ulcers or a cold, pale limb |
Reasoning: Both kinds of claudication are possible, and with his risk factors you cannot assume a spinal cause. Ask what makes it stop: he must sit and bend forward; standing still does not help; he can walk farther leaning on a grocery cart; he rides an exercise bike without trouble. Then examine both systems: lumbar extension reproduces thigh symptoms; dorsalis pedis and posterior tibial pulses are palpable and symmetric; capillary refill is normal. Neuro: Achilles reflexes reduced bilaterally (common with age and diabetes), mild vibration loss in the toes (consider diabetic neuropathy). Assessment: neurogenic claudication from lumbar spinal stenosis is most likely; peripheral arterial disease and diabetic neuropathy remain in the differential. Plan: lumbar films (degenerative changes, spondylolisthesis), ankle brachial index to document vascular status given his risk profile, flexion based care, walking program in a flexed posture, coordination with his primary care provider about diabetes, and smoking cessation advice. Critical actions: the pulse exam, explicitly naming the vascular differential, and screening for cauda equina symptoms.
Sacroiliac joint and pelvic presentations
Sacroiliac joint pain is typically unilateral, below L5, centered over the posterior superior iliac spine (the Fortin finger test points within about a finger's width of the PSIS), and aggravated by rolling in bed, climbing stairs and standing on one leg. No single test is reliable. Use the pain provocation cluster: distraction, thigh thrust, compression, sacral thrust and Gaenslen's. Three or more positive of the five (or two of the first four) makes the SI joint the likely source, provided that a discogenic source has been made less likely (no centralization on repeated movements). In pregnancy and postpartum, pelvic girdle pain is common; avoid prone positioning late in pregnancy, use side lying or pregnancy pillows and low force methods, and screen for preeclampsia (headache, visual change, high blood pressure, swelling) and preterm labor.
Reasoning: Differentials: right SI joint dysfunction, lumbar facet or disc pain, and less likely inflammatory sacroiliitis. Screen: no leg numbness or weakness, no bladder change, no fever, morning stiffness under 15 minutes, no night waking. Exam: she points to the right PSIS; lumbar repeated movements do not change or centralize the pain; neuro screen normal; SLR negative; distraction, thigh thrust and compression reproduce her pain on the right, sacral thrust and Gaenslen's are positive; Patrick's (FABER) reproduces posterior pelvic pain on the right. Four of five positive with no centralization: right SI joint pain. Plan: explain the diagnosis, obtain consent, side posture SI adjustment or drop table methods, a sacroiliac belt for short term support, gluteal and transverse abdominal strengthening, lifting mechanics with her baby, and re-examination in three weeks. Ask whether she is breastfeeding and about postpartum mood if the station allows; refer to primary care if mood concerns emerge. Critical actions: use the cluster, exclude discogenic pain and red flags, and make the home plan practical for a new parent.
Low back stations reward early triage into mechanical, radicular and serious pathology. Match a dermatome, myotome and reflex to a root and then to a disc level, separate neurogenic from vascular claudication with posture and pulses, use a test cluster for the SI joint, and always end with cauda equina safety netting.
Section 4Extremity case management walk throughs
Extremity stations in outline
Extremity stations use the same sequence with three additions: always clear the joint above and below (and the spinal segments that refer to the region), always compare with the uninjured side, and always check neurovascular status distal to an injury. After trauma, apply a decision rule before you load the joint: the Ottawa ankle and knee rules exist precisely so that you can decide on films at the bedside.
| Complaint | Most useful tests | What a positive result suggests |
|---|---|---|
| Shoulder pain with overhead use | Painful arc (about 60 to 120 degrees), Hawkins-Kennedy, Neer, resisted external rotation | Subacromial pain (impingement) cluster when the three are positive |
| Shoulder weakness after a fall, over 60 | Drop arm, external rotation lag sign, empty can strength | Full thickness rotator cuff tear; ultrasound or MRI and orthopedic referral |
| Stiff painful shoulder, 50s, diabetes | Loss of passive external rotation more than other directions | Adhesive capsulitis |
| Lateral elbow pain | Cozen's (resisted wrist extension), Mill's (passive stretch), pain free grip | Lateral elbow tendinopathy (extensor carpi radialis brevis) |
| Hand numbness at night | Phalen's, carpal Tinel's, carpal compression, thenar strength and bulk | Carpal tunnel syndrome; screen C6 and C7 for double crush |
| Wrist pain after a fall on an outstretched hand | Anatomic snuffbox and scaphoid tubercle tenderness, axial thumb load | Scaphoid fracture until proven otherwise |
| Groin pain, older adult | Loss of internal rotation and flexion, FADIR, gait | Hip osteoarthritis; groin pain with limited IR is the hip until proven otherwise |
| Knee giving way after a pivot | Lachman (most sensitive), pivot shift (most specific), anterior drawer | Anterior cruciate ligament tear |
| Knee locking or catching | Joint line tenderness, McMurray, Thessaly | Meniscal tear |
| Inversion ankle injury | Ottawa rules, anterior drawer, talar tilt, squeeze and external rotation tests | ATFL, then CFL sprain; positive squeeze suggests a high (syndesmotic) sprain |
Reasoning: Look for swelling and bruising, then apply the Ottawa rules aloud before stress tests: posterior edge and tip of the lateral malleolus nontender, medial malleolus nontender, fifth metatarsal base nontender, navicular nontender, and she took four steps (limping counts as weight bearing) at the time and now. Say: "Ottawa negative; no radiographs indicated." Then grade the sprain: tenderness over the anterior talofibular ligament, anterior drawer mildly lax compared with the left, talar tilt symmetric, squeeze and external rotation tests negative (no syndesmotic injury), and the peroneal tendons and distal pulses intact. Assessment: grade I to II lateral ankle sprain of the ATFL. Plan: protection, elevation, compression, early protected weight bearing, range of motion, then balance and proprioception training to prevent recurrence; mobilization of the talocrural joint and cuboid as tolerated with consent; brace for return to sport; re-examine in one week and order films if bony tenderness appears or she cannot bear weight. Critical actions: decision rule before testing, side to side comparison and the neurovascular check.
Reasoning: Differentials: carpal tunnel syndrome, C6 or C7 radiculopathy, double crush, pronator syndrome, and systemic contributors (diabetes, hypothyroidism, pregnancy, rheumatoid arthritis). History: night symptoms and the flick sign favor carpal tunnel; ask about neck pain and arm pain above the wrist, diabetes and thyroid history. Exam: cervical screen (Spurling's and ULTT, reflexes) negative; Phalen's reproduces symptoms at 30 seconds; carpal compression positive; reduced two point discrimination on the index finger; thenar bulk normal; abductor pollicis brevis strength 5 of 5. Assessment: right carpal tunnel syndrome without motor loss. Plan: night splint with the wrist in neutral, tendon and nerve gliding exercises, ergonomic review (wrist position at the keyboard), soft tissue and carpal mobilization with consent, and re-examine in four weeks. Refer for nerve conduction studies and a hand surgery opinion if there is thenar atrophy, weakness, constant numbness or no improvement. Suggest a glucose and thyroid check with her primary care provider if not recently done. Critical actions: clear the neck, test thenar motor function, and set objective referral triggers.
Pediatric and adolescent traps
Children and adolescents bring their own extremity red flags. A limping child with knee pain may have hip disease: slipped capital femoral epiphysis in an overweight adolescent (loss of internal rotation, obligatory external rotation with hip flexion), Legg-Calvé-Perthes disease in a child of about 4 to 8, transient synovitis after a viral illness, or septic arthritis (fever, refusal to bear weight, raised inflammatory markers), which is an emergency. Persistent night bone pain or a firm mass near the knee in a teenager raises concern for osteosarcoma or Ewing sarcoma.
Reasoning: Knee pain with a limp in an overweight adolescent is SCFE until proven otherwise, because the obturator nerve refers hip pain to the knee. Examine the knee (normal) and then the hip: as you flex the left hip it rolls into external rotation, and internal rotation is markedly reduced. Do not perform forceful hip or knee testing. Say: "The knee is fine, but the hip joint needs an X-ray today, including a frog leg lateral view. Until then he should not put weight on that leg." Order AP and frog leg lateral pelvis films, provide crutches, and make a same day orthopedic referral. Explain to the parent why the hip is involved and that early treatment prevents further slipping. Critical actions: examine the hip in knee pain, non weight bearing, same day referral, no manipulation.
Extremity stations reward a decision rule before loading an injured joint, comparison with the other side, a distal neurovascular check and a look at the joint above and below. Know the most sensitive and most specific test for each common lesion, and recognize the fracture and pediatric hip traps that need immobilization or same day referral.
Section 5Visceral and red flag case management walk throughs
When the back pain is not the back
Viscera share spinal cord segments with the body wall, so visceral pain is felt in the dermatomes and myotomes of the same segments (Figure 13.5). The clues that a "musculoskeletal" complaint is visceral are consistent: pain that is not changed by movement or position, pain linked to eating, breathing, urination, exertion or the menstrual cycle, systemic signs (fever, sweating, pallor, weight loss), abnormal vital signs, and an examination that fails to reproduce the pain. If the musculoskeletal exam cannot provoke the complaint, say so aloud and widen the differential.
| Condition | How it presents to a chiropractor | Discriminating clues | Urgency |
|---|---|---|---|
| Acute coronary syndrome | Upper back, left shoulder, arm or jaw pain | Exertional or at rest, sweating, dyspnea, nausea; atypical in women, older adults and diabetics | Call emergency services now |
| Ruptured or expanding aortic aneurysm or dissection | Sudden severe back or abdominal pain | Tearing quality, pulse or BP difference between arms, hypotension, pulsatile mass | Call emergency services now |
| Pulmonary embolism | Thoracic or chest wall pain | Pleuritic pain, dyspnea, tachycardia, recent surgery, travel, calf swelling, estrogen use | Emergency |
| Kidney stone | Flank pain that radiates to the groin | Colicky, cannot get comfortable, hematuria | Same day medical care |
| Pyelonephritis | Flank pain | Fever, dysuria, costovertebral angle tenderness | Same day medical care |
| Cholecystitis | Right scapular or mid back pain | After fatty meals, RUQ tenderness, Murphy's sign, fever | Same day |
| Pancreatic cancer | Gnawing mid back pain | Weight loss, painless jaundice, new diabetes, worse lying flat | Prompt medical referral |
| Ectopic pregnancy | Low back, pelvic or shoulder tip pain | Missed period, vaginal bleeding, dizziness, reproductive age | Emergency |
| Pancoast tumor | Shoulder and medial arm pain (C8 to T1) | Smoker, Horner syndrome, hand intrinsic weakness, weight loss | Prompt referral and imaging |
| Prostate cancer metastasis | Low back or pelvic pain in an older man | Night pain, urinary symptoms, weight loss | Prompt referral; PSA and imaging |
Three levels of referral
Say the level of urgency explicitly, because the examiner scores it. Emergency: call emergency services and stay with the patient (chest pain with cardiac features, stroke signs, suspected aortic catastrophe, cauda equina with retention, severe dyspnea). Urgent or same day: direct referral with a phone call and a written note (giant cell arteritis, suspected infection, new progressive neurologic deficit, suspected fracture, SCFE). Routine: written referral and coordinated care (stable suspected tumor work up already arranged, chronic medical issues, mental health support). In every case document what you found, what you told the patient, to whom you referred and when.
Reasoning: The vitals and the door card have already told you the answer: exertional onset, sweating, tachycardia and tachypnea point to acute coronary syndrome. Keep the history short and targeted: chest pressure (some tightness), arm or jaw pain (left arm heavy), nausea (yes), cardiac history and risk factors (smoker, high cholesterol). Do not perform a full musculoskeletal exam and do not treat. Say: "Your symptoms could be coming from your heart. I am calling an ambulance now, and I'll stay with you." Call emergency services, keep him seated and calm, loosen tight clothing, monitor pulse and breathing, and be ready to begin CPR and use an AED if he becomes unresponsive; aspirin is given by emergency responders or on their instruction unless allergic. Document the time of onset, vitals and actions. Critical actions: recognizing the pattern from the door card, stopping the musculoskeletal workup, emergency activation, and staying with the patient.
Reasoning: Fever plus postprandial right scapular pain in a middle aged woman suggests cholecystitis. Ask about fatty meals, nausea, vomiting, dark urine, pale stools and yellow eyes. Examine the thoracic spine: movement and palpation do not change the pain. Examine the abdomen with consent and draping: right upper quadrant tenderness and inspiratory arrest on palpation under the right costal margin (Murphy's sign). Say: "Your back is not the source; your gallbladder may be inflamed. You need to be seen at an urgent care or emergency department today for blood tests and an ultrasound." Document and send a referral note. Critical actions: noticing the fever, examining the abdomen when the spine fails to reproduce the pain, and same day referral.
Visceral and red flag stations test whether you notice that the pain is not mechanical: it is unchanged by movement, linked to organ function, and accompanied by abnormal vitals or systemic signs. Know the referral map, name the level of urgency (emergency, same day or routine), and in an emergency stop the workup, activate help and stay with the patient.
The chapter in one breath
- State every film answer as finding, location, view, impression and recommendation, and say whether care proceeds, is modified or stops.
- A fixed ABCS routine plus a look at the film corners prevents satisfaction of search.
- Before the door, plan three differentials, one red flag and the two or three tests that separate them.
- Cervical roots exit above their pedicle; match C5 to C8 myotome, reflex and dermatome, and screen every arm complaint for myelopathy.
- Apply the Canadian C-spine rule before treating a post-trauma neck; grade whiplash with the Quebec Task Force scale.
- New, unusual neck pain and headache with the 5 Ds and 3 Ns or Horner signs means suspected dissection: no manipulation and emergency referral.
- A posterolateral L4 to L5 disc hits the traversing L5 root; a far lateral one hits the exiting L4 root.
- Ask cauda equina questions in every low back station and repeat them as the safety net.
- Separate neurogenic from vascular claudication by posture, cycling tolerance and pulses; use a five test cluster for the SI joint.
- Use the Ottawa ankle and knee rules before loading an injured joint, and look one joint up when the examined joint is normal.
- Pain unchanged by movement, linked to organ function, or with abnormal vitals is visceral until proven otherwise.
- Always state the referral level: emergency, same day or routine, and document it.
Words worth knowing
| Term | What it means |
|---|---|
| Door card | The written information posted outside a station: patient details, complaint, vital signs and the task to perform. |
| Critical action | A station item whose omission can fail the station regardless of other performance, usually a safety item. |
| ABCS | A film routine: alignment, bone, cartilage and joint spaces, soft tissues. |
| Meyerding grade | Grading of spondylolisthesis by the percentage slip of one vertebra on the one below, in quarters. |
| Pars interarticularis | The bony bridge between the superior and inferior articular processes; its defect is spondylolysis. |
| Winking owl sign | Loss of one pedicle outline on an AP spine film, a classic sign of lytic metastasis. |
| Prevertebral soft tissue | The space in front of the cervical bodies; widening (over about 7 mm at C2) suggests hemorrhage or edema from injury. |
| Atlantodental interval | The gap between the anterior arch of C1 and the dens; widening in an adult indicates transverse ligament failure. |
| Radiculopathy | Dysfunction of a nerve root producing pain, sensory loss, weakness or reflex change in its distribution. |
| Myelopathy | Spinal cord dysfunction, with upper motor neuron signs such as hyperreflexia, Hoffmann sign and gait disturbance. |
| Spurling's test | Cervical extension, side bending and rotation toward the painful side with light compression to reproduce radicular pain. |
| Canadian C-spine rule | A decision rule for alert, stable adult trauma patients that identifies who needs cervical imaging. |
| Quebec Task Force grades | Classification of whiplash associated disorders from grade 0 (no complaint) to grade IV (fracture or dislocation). |
| SNOOP | A mnemonic for headache red flags: systemic signs, neurologic signs, sudden onset, older onset, pattern change or positional triggers. |
| Cervical artery dissection | A tear in the wall of a vertebral or internal carotid artery that can cause neck pain, headache and stroke. |
| Horner syndrome | Ptosis, miosis and sometimes reduced sweating from disruption of the sympathetic pathway to the face. |
| Traversing root | The nerve root passing a disc level on its way to exit one level lower; the usual target of a posterolateral herniation. |
| Cauda equina syndrome | Compression of multiple lumbosacral roots causing saddle anesthesia, bladder or bowel dysfunction and leg weakness; a surgical emergency. |
| Neurogenic claudication | Leg pain with walking from spinal stenosis, relieved by sitting or flexing forward. |
| Ankle brachial index | Ratio of ankle to arm systolic pressure; under 0.9 indicates peripheral arterial disease. |
| Ottawa rules | Bedside criteria for deciding when ankle, foot or knee injuries need radiographs. |
| Slipped capital femoral epiphysis | Posteromedial slipping of the femoral head through the growth plate in adolescents; can present as knee pain. |
| Referred visceral pain | Pain from an organ felt in the body wall supplied by the same spinal segments. |
| Kehr's sign | Shoulder tip pain from diaphragm irritation by blood or fluid, classically from a ruptured spleen. |
| Safety netting | Explicit instructions telling a patient which new symptoms require urgent care and where to go. |