CHAPTER 25: LUMBAR SPINE, PELVIC, AND HIP INJURIES
Chapter 25:
LUMBAR SPINE, PELVIC, AND HIP INJURIES



This is Chapter 25 from R. C. Schafer, DC, PhD, FICC's best-selling book:
“Chiropractic Management of Sports and Recreational Injuries”

Second Edition ~ Wiliams & Wilkins


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Lumbar Spine Injuries
   Initial Assessment
   Contusions andStrains
   Facet Syndromes
   Acute Lumbosacral Sprain
   Acute Lumbosacral Angle
   Lumbosacral Instability
   Basic Neurologic Aspects of Lumbar Subluxation Syndromes
   Spinal Cord Injuries
   Intervertebral Disc Syndrome
   Spondylolisthesis
   Lumbar Spondylolysis
   Subluxations, Fractures, and Dislocations

Injuries of the Pelvis
   Physiologic or Anatomic Short Leg
   Postural Patterns
   Contusions and Strains
   Sprains and Subluxations
   Fractures and Dislocations

Injuries of the Hip
   Contusions and Strains
   Trochanteric Bursitis
   Causalgia Syndrome
   Hip Sprain
   Subluxations
   Fractures and Dislocations

Chapter 25: Lumbar Spine, Pelvic, and Hip Injuries

The lumbar spine, sacrum, ilia, pubic bones, and hips work as a functional unit. Any disorder of one part immediately affects the function of the other parts. A wide assortment of muscle, tendon, ligament, bone, nerve, and vascular injuries in this area are witnessed during athletic care.


     Lumbar Spine Injuries

Low back disability, amounting to up to 25% of all athletic injuries, rapidly demotivates athletic participation. For biomechanical reasons, the incidence of injury is two times higher in taller athletes than shorter players. The mechanism of injury is usually intrinsic rather than extrinsic. The cause can often be through overbending, a steady lift, or a sudden release --all of which primarily involve the musculature. Intervertebral disc conditions are more often, but not exclusively, attributed to extrinsic blows and wrenches. An accurate and complete history is vital to offer the best management and counsel.

Initial Assessment

The first step in the examination process is knowing the mechanism of injury if possible. With this knowledge, evaluation can be rapid and accurate. A player injured on the field should never be moved until emergency assessment is completed. Once severe injury has been eliminated, transfer to a back board can be made and further evaluation conducted at the aid station.

Tenderness.   Tenderness is frequently found at the apices of spinal curves and rotations and not infrequently where one curve merges with another. Tenderness about spinous or transverse processes is usually of low intensity and suggests articular strain. Tenderness noted at the points of nerve exit from the spine and continuing in the pathway of the peripheral division of the nerves is a valuable aid in spinal analysis; however, the lack of tenderness is not a clear indication of lack of spinal dysfunction. Tenderness is a subjective symptom influenced by many individual structural, functional, and psychologic factors which often makes it an unreliable sign. Always evaluate the presence and symmetry of lower-extremity pulses.


      RANGE OF MOTION

The range of lumbar spine motion is determined by the disc's resistance to distortion, disc thickness, and the angle and size of the articular surfaces. While motion is potentially greater than that of the thoracic spine because of lack of rib restriction, facet facing and heavy ligaments check the range of motion. Most significant to movements in the lumbar spine is the fact that all movements are to some degree three dimensional; ie, when the lumbar spine bends laterally, it tends to rotate posteriorly on the side of convexity and assume a hyperlordotic tendency.

The transitional lumbosacral area of L5-S1 constitutes a rather unique "universal joint"; eg, when the sacrum rotates anterior-inferior on one side within the ilia, L5 tends to rotate in the opposite direction, thus effecting a mechanical accommodation with the lumbar spine above assuming a posterior rotation on the side of the unilateral anterior-inferiority. It also tends to assume an anteroflexion position, thus effecting the three-dimensional movements of the lumbar spine. In view of the intricacy of the lumbosacral junction, anomalies such as asymmetrical facets have a strong influence on normal movements in this area.

If lumbar active motions are normal, there is no need to test passively. A patient may be observed, however, who replaces normal lumbar motion by exaggerated hip motion, or vice versa. In such a situation, range of motion of the restricted lumbar or hip joints should be passively tested.

During flexion of the lumbar spine, the anterior longitudinal ligaments relax and the supraspinal and interspinal ligaments stretch. Flexion will not normally result in a kyphosis of the lumbar area as flexion may do in the cervical area. While a number of disorders result in decreased flexion, paraspinal muscle spasm is the first suspicion. The degree of extension is controlled by stretching of the anterior longitudinal ligament and rectus abdominis muscles, relaxation of the posterior ligaments, and integrity of the intrinsic motor muscles of the back. If spondylolisthesis exists, pain will be increased during extension.

      EVALUATING NEUROLOGIC LEVELS OF THE LOWER EXTREMITIES

A sensory and motor neurologic assessment should be made as soon as possible. Determine tonus (flaccidity, rigidity, spasticity) by passive movements. Then test voluntary power of each suspected group of muscles against resistance, and compare the force bilaterally. Test cremasteric (L1-L2), patellar (L2-L4), gluteal (L4-S1), suprapatellar, Achilles (L5-S2), plantar (S1-S2), and anal (S5-Cx1) Reflexes.   Note patellar or ankle clonus. Test coordination and sensation by gait, heel-to-knee and foot-to-buttock tests, and Romberg's station test.

      TRIGGER POINTS

Trigger points for the lumbosacral and sacroiliac articular complexes are commonly located

(1) alongside the T12 spinous process,
(2) alongside the L5 spinous process,
(3) over the greater sciatic notch through the gluteal muscles,
(4) over the crest of the ilium,
(5) over the belly of the tensor fascia lata muscle,
(6) in the ischiorectal fossa apex, and
(7) at the sciatic outlet onto the back of the thigh from under the gluteus maximus.


      DISTORTION PATTERNS

A unique feature of a spinal and pelvic distortion or subluxation is the fact that the segment or segments can be carried into the deviation of the distortion pattern much more readily than out of the gravitational pattern of the deviation. The following examples illustrate this:

(1) If there is a right structural scoliotic deviation of the lumbar area, the patient sitting straddle on a bench to fix the pelvis will find it easier to rotate the torso to the right than to the left.

(2) If an innominate in subluxation has rotated to the posterior on the right, the patient is able to raise the right knee (thus rotating the ilum posteriorly) noticeably higher than the left knee. But it is more difficult for the patient to extend the right thigh (thus rotating the ilium anteriorly) than the left thigh.

(3) If there is a left wedging of L5, L4, or L3, lateral flexion to the left is noticeably easier than lateral flexion to the right.

The transition points of the spinal curvatures (ie, the atlanto-occipital, cervicobrachial, thoracolumbar, and lumbosacral points) serve as mobile differentials about which flexion, extension, circumflexion, circumduction, and compensatory scoliotic deviations should occur. If these areas are kept mobile, the adaptive, compensatory, and ordinary motor functions of the spine are enhanced.


Contusions and Strains

Fortunately, most injuries seen will involve uncomplicated contusions and subluxations of the spinal area and adjacent free ribs that are relatively easy to manage. However, severe contusion of the lumbodorsal fascia is occasionally seen which frequently leads to an extensive painful hematoma. When severe injury does occur, the type widely varies from sport to sport. In some cases, a silent condition such as a spina bifida occulta may only be brought to light through strenuous athletic activity.

      LOAD CONSIDERATIONS

The importance of spinal loads is underscored with weight lifters, bowlers, oarsmen from lifting the shell, and even in lordotic long-distance runners. It has been estimated that when an object is held 14 inches away from the spine, the load on the lumbosacral disc is 15 times the weight lifted. Lifting a 100-lb weight at arms' length theoretically places a 1,500-lb load on the lumbosacral disc. This load, of course, must be dissipated, otherwise the L5 vertebra would crush. The load is dissipated through the paraspinal muscles and, importantly, by the abdominal cavity which acts as a hydraulic chamber absorbing and diminishing the load applied. These observations on spine loading emphasize the vulnerability of the spine to the mechanical stresses placed upon it, especially in people with poor muscle tone. Bony compression of the emerging nerve roots arises as a result of subarticular entrapment, pendicular kinking, or foraminal impingement due to posterior vertebral subluxation.

      MUSCLE SPASMS

General spasm of the spinal muscles guarding motion in the vertebral joints can be viewed by watching body attitude (eg, stiff carriage) and by efforts to bend the spine forward, backward, and to the sides. If we are familiar with the average range of motility in each direction and at different ages, this test is usually easy and rapid. Backward bending is the least satisfactory; and in doubtful cases, the patient should be prone while the examiner, standing over him, lifts the whole trunk by the feet.

      MANAGEMENT

The benefits of articular adjustments are well known within the profession. To relieve muscle spasm, heat is helpful, but cold and vapocoolant sprays have sometimes shown to be more effective. The effects of traction are often dramatic but sometimes short-lived if a herniated disc is involved. A predisposing ankle or arch weakness may be present which requires special stabilization.

Passive Stretch.   Mild passive stretch is an excellent method of reducing spasm in the long muscles, but heavy passive stretch destroys the beneficial reflexes. For example, hypertonic erector muscles of the spine can be simply relaxed by placing the patient prone on a split head-piece adjusting table and tilting the abdominal and pelvic section upward to flex the spine. The weight of the structures above and below the midpoint of the flexed spine offer a mild stretching effect, both cephally and caudally. The muscles should relax within 2-3 minutes. Thumb pressure, placed on a trigger area, is then directed towards the muscle's attachment and held for a few moments until relaxation is complete. Psoas or quadriceps spasm can be relaxed with Braggard's test by holding the straight leg for a minute or two in extension and dorsiflexing the foot.

Vapocoolant Technique in Acute Low Back Muscle Spasms.   NOTE: At one time "spray and stretch" was a popular form of treatment for Trigger Points. That form of sustained contraction of muscle is amenable to several techniques. The first, and least popular with patients is called "ischemic pressure" (NIMMO), involving deep and sustained pressure on the point. Cold and pressure receptors in the skin are inhibitory to the gamma motor neurons that appear to sustain the viscious-cycle contraction of TrPs. PIR (or post-isometric relaxation) is a slower and kinder to the patient method for disrupting sustained muscle spasm. The CFC sprays were taken off the market in the 90s, when CFCs (chloro-fouoro-carbon) were outlawed for their deleterious impact on the ozone layer.

Adjuncts.   Other methods may prove helpful. Peripheral inhibitory afferent impulses can be generated to partially close the presynaptic gate by acupressure, acupuncture, or transcutaneous nerve stimulation. Isotonic exercises are useful in improving circulation and inducing the stretch reflex when done supine to reduce exteroceptive influences on the central nervous system. An acid-base imbalance from muscle hypoxia and acidosis may be prevented by supplemental alkalinization. In chronic cases, relaxation training and biofeedback therapy are helpful.


Facet Syndromes

The subluxation of lumbar facet structures, states Howe, is a part of all lumbar dyskinesias and must be present if a motor unit is deranged. In a three-point articular arrangement, such as at each vertebral motor unit, no disrelationship can exist that does not derange two of the three articulations. Thus, determination of the integrity or subluxation of the facets in any given motor unit is important in assessing that unit's status.

      ROENTGENOLOGIC CONSIDERATIONS

Any method of spinographic interpretation which utilizes millimetric measurements from any set of preselected points is most likely to be faulty because structural asymmetry and minor anomaly is universal in all vertebrae. However, the estimation of the integrity of facet joints is a reliable method of assessing the presence of intervertebral subluxation. An evaluation of the alignment of the articular processes comprising a facet joint may be difficult from the A-P or P-A view alone when the plane of the facet facing is other than sagittal or semisaggital. In this case, oblique views of the lumbosacral area are of great value in determining facet alignment since the joint plane and articular surfaces can nearly always be visualized.

When one cannot visually identify disrelationships of the facet articular structures, Howe suggests use of Hadley's S curve. This is made by tracing a line along the undersurface of the transverse process at the superior and bringing it down the inferior articular surface. This line is joined by a line drawn upward from the base of the superior articular process of the inferior vertebrae of the lower edge of its articular surface. These lines should join to form a smooth S. If the S is broken, subluxation is present. This A-P procedure can be used on an oblique view.

      DIFFERENTIATION

To help differentiate the low back and sciatic neuralgia of a facet syndrome to that of a disc that is protruding:

  1. With the patient standing with feet moderately apart, the doctor from behind the patient firmly wraps his arms around the patient's pelvis and firms his lateral thigh against the back of the patients' pelvis. The patient is asked to bend forward. If it is a facet involvement, the patient will feel relief. If it is a disc that is stressed, symptoms will be aggravated.

  2. In facet involvement, the patient seeks to find relief by sitting with feet elevated and resting upon a stool, chair, or desk. In disc involvement, the patient keeps knees flexed and sits sideways in his chair and moves first to one side and then to the other for relief. If lumbosacral and sacroiliac pain migrates from one to the other side, it is suspected to be associated with arthritic changes.

      MANAGEMENT

The associated pain, accentuated by hyperextension of the trunk, results when an inferior apophyseal facet becomes displaced upward so that it impinges on the IVF contents of the inferior vertebral notch (eg, nerve root) of the superior vertebra. Cryotherapy and other forms of pain control are advisable during the acute stage for 48 hours. Considerable relief will be achieved by placing the patient prone with a roll under the lower abdomen to flex the lumbar spine while applying manual traction techniques. This should be followed by corrective adjustments to relieve associated fixations and abnormal biomecha- nics, traction, and other physiotherapy modalities. A regimen of therapeutic exercises and shoe inserts designed to improve postural balance and lessen gait shock are helpful during recuperation.

Various neurologic and orthopedic procedures relative to lumbosacral syndromes are listed in Table 25.1.


Table 25.1.   Review of Neurologic and Orthopedic Manuevers, Reflexes, Signs, or Tests Relative to Lumbosacral Syndromes
Achilles' reflex    Ely's heel-to-buttock    Milgram's test
Adams' sign          test                    Minor's sign
Adductor reflex     Fajersztajn's test       Muscle strength grading
Anal reflex         Gaenslen's test          Nachlas' test
Babinski's          Giegel's reflex          Naffziger's test
  plantar           Gluteal reflex           Neri's bowing sign
   reflex           Goldthwait's test        Neri's test
Babinski's          Gower's sign             O'Connell's test
 sciatic sign       Hamstring reflex         Patella reflex
Barre's sign        Heel walk test           Pitres' sign
Bechterew's test    Hyperextension tests     Range of motion tests
Beery's sign        Jandrassik's maneuver    Romberg's station test
Belt test           Kemp's test              Sicard's sign
Bonnet's sign       Kernig's sign            Smith-Peterson's test
Bowstring sign      Lasegue's                Spinal percussion test
Bragard's test       differential            Toe walk test
Buckling sign        sign                    Turyn's sign
Cremasteric         Lasegue's SLR            Vanzetti's sign
 reflex              test                    Westphal's sign
Dejerine's triad    Lewin's punch            Yeoman's test
Demianoff's sign     test                    
Deyerle-May's       Light touch/              
 test                pain tests              
Double leg          Lindner's sign          
 raise test         
Duchenne's sign


You may review all these tests @:
Chapter 3: Orthopedic and Neurologic Procedures
in Schafer's “Basic Chiropractic Procedural Manual”


Acute Lumbosacral Sprain

These sprains are of frequent appearance. Heavy loads or severe blows may rupture some associated ligaments and/or subluxate the joint. Pain may be local or referred. Symptoms are usually relieved by rest and aggravated by activity. Care must be taken to differentiate from a sacroiliac or hip lesion. Localized tenderness and the various clinical tests are helpful in differentiation.

Management.   During the acute hyperemic stage, structural alignment, cold, compression support, ultrasound, and rest are indicated. After 48 hours, passive congestion may be managed by gentle passive manipulation, sinusoidal stimulation, ultrasound, and a mild range of motion exercise initiated. During consolidation, local moderate heat, moderate active exercise, motorized alternating traction, moderate range of motion manipulation, and ultrasound are beneficial. In the stage of fibroblastic activity, deep heat, deep massage, vigorous active exercise, motorized alternating traction, negative galvanism, ultrasound, and active joint manipulation speed recovery and inhibit postinjury effects. Vitamin C and manganese glycerophosphate are helpful throughout treatment to speed healing.


Acute Lumbosacral Angle

In this condition, Olsen states that the acute angulation of L5 on S1 is twofold:

(1) There is bursal involvement due to an overriding of the facets which stretches the bursa.

(2) There is a narrowing of the intervertebral foramen (IVF) causing a telescoping from the superior to the inferior of the facet joints. Radiologically, the type of bursitis cannot be defined. Orthopedically, the problem is described as the facet-pain syndrome.

Cartilage is found between all articular surfaces, and undue stress during weight bearing on the facets can cause injury to the cartilage which will progress with degenerative changes. The degeneration may cause L5 to slip forward (degenerative disc disease), portray decreased disc space (discogenic disease), or exhibit decreased space with eburnation (discopathy). Sacralization is the only time when it is normal to have a decreased disc space, unless the disc is underdeveloped (hypoplasia). Along with the facet syndrome, there may also be an increased lordosis of the lumbar spine.

The facet syndrome can occur with

(1) the anteriorly based sacrum with a normal lordosis;
(2) the anteriorly based sacrum with an accentuated lordosis;
(3) the anteriorly based sacrum with a "sway back"; or
(4) a normally based sacral angle and the "sway back" type of individual.

Evaluation is made by drawing a line through the superior border of the sacral base and through the inferior border of L5. If these lines cross within the IVF or anterior to it, this indicates a facet syndrome. Olsen recommends the use of Fergurson's angle, where the body of L3 is X'ed and a line is dropped perpendicular from the center of the vertebral body. This line normally falls over the sacral prominatory or the anterior edge of the sacrum and reveals normal lumbosacral weight bearing (Fergurson's line of gravity). The L5 disc spacing is seen normally as symmetrical with the one above, and the actual weight bearing is on the nucleus pulposus.

A persistent notochord may be seen where the disc is normal but embedded into the body of the vertebra. This is seen in a postural facet syndrome where the anterior disc space is wide at the expense of narrowed disc space posteriorly and the body of the vertebra has rocked on the nucleus. It is not pathologic. For example, a normal vertebra presents decreased disc space posteriorly with the lines crossing in the IVF. There is normal disc space anteriorly, but in order for this to happen, there is a herniation. The disc is normal, but the symmetry of the disc interspace is broken.


Lumbosacral Instability

Lumbosacral instability is a mechanical aberration of the spine which renders it more susceptible to fatigue and/or subsequent trauma by reason of the variance from the optimal structural weight-bearing capabilities. Hariman states that between 50% and 80% of the general population exhibit some degree of the factors which predispose to instability whether by reason of anomalous development of articular relationships or altered relationships due to trauma or disease consequences. It is the most common finding of lumbosacral roentgenography and often brought to light after an athletic strain.

Disturbance of the physiologic response of the spinal motor unit is the primary finding with the sequela of "stress response syndrome" which may take the form of any degree between sclerosis of a tendon to and including an ankylosing hypertrophic osteophytosis or arthrosis. Frequent trauma to the articular structures as a result of excessive joint motility results in repetitive microtrauma. The scope of involvement and the tissue response is determined by the type and severity of the instability.

Signs and Symptoms.   Unusual early fatigue is a constant symptom, and this leads to strain, sprain, and subsequent disc pathologies. Symptom susceptibility increases with the age of the individual. Postural evaluation is especially important in the physical diagnosis of the sequelae as well as to an extra-spinal causation (eg, anatomic short leg).

Roentgenographic Considerations.   Roentgen diagnosis is the only sure manner of delineating the type and severity of the underlying productive agent of the condition of instability. There is no characteristic finding except the recognition of the various anomalies and pathologies present. Care should be taken to include the entire pelvis in this determination as, for instance, a sacroiliac arthrosis may lead to instability.

Management.   This condition often requires supportive therapies such as heel lifts and/or orthopedic belts in addition to specific adjustive therapy directed toward stabilization of the motor unit. Hariman feels the prognosis is excellent with adjustive and supportive management. High doses of vitamin C with calcium and magnesium have also proved helpful in disc conditions. Efforts and counsel should be directed to minimize the production of future microtrauma. Loss of stability and compensation due to injury in the future may be expected to reproduce symptoms in an exaggerated form.

      PERTINENT PROCEDURES IN LUMBOSACRAL SYNDROMES

Giegel's (Inguinal) Reflex.   With the patient supine, the skin of the upper thigh is stimulated from the midline toward the groin. A normal response is an abdominal contraction at the upper edge of Poupart's ligament. This reflex (L1--L2) is essentially the female counterpart of the cremasteric reflex in the male.

Adductor Reflex.   With the patient supine and the thigh moderately abducted, a normal response is seen when the tendon of the adductor magnus is tapped and a contraction of the adductor muscles occurs. This reflex reaction tests the integrity of the obturator nerve and L2–L4 segments of the spinal cord, as does the patellar reflex.

Hamstring Reflex.   The patient is placed supine with the knees flexed and the thighs moderately abducted. The tendons of the semitendinosus and semimembranosus are hooked by the examiner's index finger and the finger is percussed. Normally, a palpable contraction of the hamstrings occurs. An exaggerated response indicates an upper motor neuron lesion above L4, and it may be associated with a reflex flexion of the knee (Stookey response). An absent response signifies a lower motor neuron lesion affecting the L4–S1 segments, as do absent Achilles and plantar reflexes.

Heel Walk Test.   A patient should normally be able to walk several steps on the heels with the forefoot dorsiflexed. With the exception of a localized heel disorder (eg, calcaneal spur) or contracted calf muscles, an inability to do this because of low back pain or weakness can suggest an L5 lesion.

Toe Walk Test.   Walking for several steps on the base of the toes with the heels raised will normally produce no discomfort to the patient. With the exception of a localized forefoot disorder (eg, plantar wart, neuroma) or an anterior leg syndrome (eg, shin splints), an inability to do this because of low back pain or weakness can suggest an S1–S2 lesion.

Double Leg Raise Test.   This is a two-phase test:

(1) The patient is placed supine, and a straight-leg-raising (SLR) test is performed on each limb: first on one side, and then on the other.

(2) The SLR test is then performed on both limbs simultaneously; ie, a bilateral SLR test. If pain occurs at a lower angle when both legs are raised together than when performing the monolateral SLR manuever, the test is considered positive for a lumbosacral area lesion.

O'Connell's Test.   This test is conducted similar to that of the double leg raise test except that both limbs are flexed on the trunk to an angle just below the patient's pain threshold. Then the limb on the opposite side of involvement is lowered. If this exacerbates the pain, the test is positive for sciatic neuritis.

Nachlas' Test.   The patient is placed in the prone position. The examiner flexes the knee on the thigh to a right angle, then, with pressure against the anterior surface of the ankle, the heel is slowly directed straight toward the homolateral buttock. The contralateral ilium should be stabilized by the examiner's other hand. If a sharp pain is elicited in the ipsilateral buttock or sacral area, a sacroiliac disorder should be suspected. If the pain occurs in the lower back area or is of a sciatic-like in nature, a lower lumbar disorder (especially L3–L4) is indicated. If pain occurs in the upper lumbar area, groin, or anterior thigh, quadriceps spasticity/contacture or a femoral nerve lesion should be suspected.

Gower's Maneuver.   The patient uses the hands on the thighs in progressive short steps upward to extend the trunk to the erect position when arising from a sitting or forward flexed position. This sign is positive in cases of severe muscular degeneration (eg, muscular dystrophy) of the lumbopelvic extensors or a bilateral low back disorder (eg, spondylolisthesis).

Hyperextension Tests.   These two tests help in localizing the origin of low back pain.

(1) The patient is placed prone. With one hand the doctor stabilizes the contralateral ilium, and the other hand is used to extend the patient's thigh on the hip with the knee slightly flexed. If pain radiates down the front of the thigh during this extension, inflamed L3–L4 nerve roots should be suspected if acute spasm of the quadriceps or hip pathology have been ruled out.

(2) With the patient remaining in the relaxed prone position, the examiner stabilizes the patient's lower legs and instructs the patient to attempt to extend the spine by lifting the head and shoulders as high as possible from the table by extending the elbows bilaterally. If localized pain occurs, the patient is then asked to place a finger on the focal point.

Also see Adam's sign, Bechterew's test, Beery's sign, Forestier's bowstring sign, Bragard's test, Fajersztajn's test, Goldthwait's test, Gower's manuever, Hibb's test, Kemp's test, Kernig's sign, Lasegue's SLR test, Minor's sign, Naffziger's test, Neri's bowing sign, Neri's test, and Smith-Peterson's test, and Westphal's sign.


Basic Neurologic Aspects of Lumbar Subluxation Syndromes

Disturbances of nerve function associated with subluxation syndromes manifest as abnormalities in sensory interpretations and/or motor activities. These disturbances may be through one of two primary mechanisms: direct nerve or nerve root disorders, or of a reflex nature.

      NERVE ROOT INSULTS

When direct nerve root involvement occurs on the posterior root of a specific neuromere, it manifests as an increase or decrease in awareness over the dermatome; ie, the superficial skin area supplied by this segment. Typical examples might include forminal occlusion or irritating factors exhibited clinically as hyperesthesia, particularly on the

(1) anterolateral aspects of the leg, medial foot, and great toe, when involvement occurs between L4-L5; and

(2) posterolateral aspect of the lower leg and lateral foot and toes when involvement occurs between L5-S1.

In other instances, this nerve root involvement may cause hypertonicity and the sensation of deep pain in the musculature supplied by the neuromere; for example, L4 and L5 involvements, with deep pain or cramping sensations in the buttock, posterior thigh and calf, or anterior tibial musculature. In addition, direct pressure over the nerve root or distribution may be particularly painful.

Reflexes.   Nerve root insults from subluxations may also be evident as disturbances in motor reflexes and/or muscular strength. Examples of these reflexes include the deep tendon reflexes such as seen in reduced patella and Achilles tendon reflexes when involvement occurs between L4-L5. These reflexes should also be compared bilaterally to judge whether hyporeflexia is unilateral; unilateral hyperreflexia is highly indicative of an upper motor neuron lesion.

Atrophy.   Prolonged and/or severe nerve root irritation may also cause evidence of trophic changes in the tissues supplied. This may be characterized by obvious atrophy which would be rare in athletics. Such a sign is particularly objective when the circumference of an involved limb is measured at the greatest girth in the initial stage and this value is compared to measurements taken in later stages.

Kemp's Test.   While in a sitting position, the patient is supported by the examiner who reaches around the patient's shoulders and upper chest from behind. The patient is directed to lean forward to one side and then around to eventually bend obliquely backward by placing his palm on his buttock and sliding it down the back of his thigh and leg as far as possible. The maneuver is similar to that used in cervical compression. If this compression causes or aggravates a pattern of radicular pain in the thigh and leg, it is a positive sign and indicates nerve root compression. It may also indicate a strain or sprain and thus be present when the patient leans obliquely forward or at any point in motion.

Since the elderly weekend athlete is less prone to an actual herniation of a disc due to lessened elasticity involved in the aging process, other reasons for nerve root compression are usually the cause. Degenerative joint disease, exostoses, inflammatory or fibrotic residues, narrowing from disc degeneration, tumors -- all must be evaluated.

      SCIATIC IRRITATION

Although it is the largest nerve of the body and supplies through its branches all the muscles below the knee, the sciatic nerve is rarely injured by sudden trauma. It is often affected, however, by sciatic neuritis (sciatica) which is frequently due to intermittent trauma. Sciatic neuralgia or neuritis is characterized by pain of variable intensity to a maximum that is almost unbearable. The pain radiates from the sacroiliac area down the posterior thigh and even to the sole of the foot. Muscular atrophy and the characteristic limp are usually present.

Sciatic neuropathy must be differentiated from a lumbar compression radiculopathy, and this is often challenging. The latter can be considered a nerve compression syndrome. As disc herniation rarely involves several segments, neuropathy is first suspected when multiple segments are involved. When the straight-leg-raising test is made just short of pain, internal rotation of the femur increases pain and external rotation decreases pain in sciatic neuropathy but has little effect upon lumbar radiculopathies.

      CLINICAL SIGNS

Note the comparative height of the iliac crests. If chronic sciatic neuralgia is on the high iliac crest side, degenerative disc weakening with posterolateral protrusion should be suspected. If occuring on the side of the low iliac crest, one must consider the possibility of a sacroiliac slip and lumbosacral torsion as being the causative factor. There is a lessening or lack of the deep tendon reflex in sciatica (Babinski's sciatica sign). When the patient's great toe on the affected side is flexed, pain will often be experienced in the gluteal region (Turny's sign). Also in sciatica, the pelvis tends to maintain a horizontal position despite any induced degree of scoliosis (Vanzetti's sign), unlike other conditions in which scoliosis occurs where the pelvis is tilted.

Lasegue's Straight-Leg-Raising Test.   The patient lies supine with legs extended. The examiner places one hand under the heel of the affected side and the other hand is placed on the knee to prevent the knee from bending. With the limb extended, the examiner flexes the thigh on the pelvis keeping the knee straight. Normally, the patient will be able to have the limb extended to almost 90° without pain. If this maneuver is markedly limited by pain, the test is positive and suggests sciatica from lumbosacral or sacroiliac lesions, subluxation syndrome, hamstring tightness, disc lesions, spondylolisthesis adhesions, or IVF occlusion. Some examiners feel that pain at 30° indicates sacroiliac involvement; at 60°, lumbosacral disorder; 80°, L4-L5 problem. A second method of using this sign is to have the patient attempt to touch the floor with the fingers while the knees are held in extension during the standing position. Under these conditions, the knee of the affected side will be flex, the heel slightly elevate, and the body elevate more or less to the painful side. Many reports confirm that when Lasegue's sign is positive, the pupils will dilate, blood pressure will rise, and the pulse will become more rapid. These phenomena are not present in the malingerer or psychoneurotic individual.

Braggard's Test.   If Lasegue's test is positive at a given point, the leg is lowered below this point and dorsiflexion of the foot is induced. The sign is negative if pain is not increased. A positive sign is a finding in sciatic neuritis, spinal cord tumors, IVD lesions, and spinal nerve irritations. A negative sign points to muscluar involvement such as tight hamstrings. Braggard's test helps to differentiate the pain of sciatic involvement from that of sacroiliac involvement as the sacroiliac articulation is not stressed by the Braggard maneuver, nor is the lumbosacral joint.

Fajersztajn's Test.   When straight leg raising and dorsiflexion of the foot are performed on the asymptomatic side of a sciatic patient and this causes pain on the symptomatic side, there is a positive Fajersztajn's sign which is particularly indicative of a sciatic nerve root involvement such as a disc syndrome, dural root sleeve adhesions, or some other space-occupying lesion. This is sometimes called the well or cross-leg straight-leg-raising test.

Demianoff's Test.   This is a variant of Lasegue's test used in lumbago and funiculitis with the intent of differentiating between lumbago and sciatica. When the affected limb is first extended and then flexed at the hip, the corresponding half of the body becomes lowered and with it the muscle fibers fixed to the lumbosacral segment. This act, which stretches the muscles, induces sharp lumbar pain. Lasegue's sign is thus negative as pain is caused by stretching the affected muscles at the posterior portion of the pelvis rather than stretching the sciatic nerve. To accomplish with the patient supine, the pelvis is fixed by the examiner's hand firmly placed on the anterior superior iliac spine, and the other hand elevates the leg on the same side. No pain results when the leg is raised to a 80° angle. When lumbago and sciatica are coexistent, Demianoff's sign is negative on the affected side but positive on the opposite side unless the pelvis is fixed. Demianoff's sign is also negative in bilateral sciatica with lumbago. The fixation of the pelvis prevents stretching the sciatic nerve, and any undue pain experienced is usually associated with ischiotrochanteric groove adhesions. This sign has been found to be valuable in determining local lesions of muscles, upper lumbar nerve roots, and funicular sciatica.

Belt Test.   The standing male patient bends forward with the examiner holding the patient's belt at the back. If bending over without support is more painful than with support, it indicates a sacroiliac lesion. Conversely, if bending over with support is more painful than without support, it is indicative of lumbosacral or lumbar involvement.

Deyelle-May Test.   This test is often helpful in differentiating the various etiologies of sciatic pain and particularly designed to differentiate between pain from pressure on the nerve or its roots and pain due to other mechanisms in the lower back. Compression or tractional pressure on muscles, ligaments, tendons, or bursae may cause reflex pain that often mimics actual direct nerve irritation. Usually, reflex pain does not follow the pattern of a specific nerve root, is more vague, does not cause sensory disturbances in the skin, comes and goes, but may be very intense. The procedure, in the sitting position, is to instruct the patient to sit very still and brace himself in the chair with his hands. The painful leg is passively extended until it causes pain, then lowered just below this point. The leg is then held by the examiner's knees and deep palpation is applied to the sciatic nerve high in the popliteal space which has been made taut by the maneuver. Severe pain indicates definite sciatic irritation or a root compression syndrome as opposed to other causes of back and leg pain such as the stretching of strained muscles and tendons or the movements of sprained articulations.

Minor's Sign.   A patient with sciatica will arise from the seated position in a particular supporting position. If the chair has arms, both will be grasped and the trunk will be flexed forward. When arising, the elbows extend to push the trunk forward and upward, the hand on the uninvolved side will then be placed on the thigh, the other hand will be placed on the hip of the involved side, and the knee on the involved side will remain flexed to relieve the tension on the sciatic nerve. The knee on the uninvolved side is then extended to support the majority of body weight.

Buckling Sign.   With the patient supine, the examiner slowly raises the involved lower limb (flexes it on the trunk) with the unsupported knee extended. A patient with radiculitis will automatically flex the knee to relieve the tension from the sciatic nerve.

Lindner's Sign.   The patient is placed supine. A positive sign is found when conducting Brudzinski's test (progressive occiput, cervical, and upper thoracic flexion) if the patient's ipsilateral sciatic pain is reproduced or aggravated. It is indicative of lower lumbar radiculitis, as contrasted to the sharp but diffuse pain experienced in meningitis.

Sicard's Sign.   A patient with sciatic-lke symptoms is placed in the supine position. The limb on the involved side is raised with the knee extended to the point of pain, then it is lowered about 5*, and the examiner firmly dorsiflexes the large toe. Because this will increase tension forces on the sciatic nerve, pain will be reproduced in the posterior leg and/or thigh in cases of sciatic neuritis.

Lewin's Punch Test.   This test, which should be reserved for the young and muscular, is conducted with the patient in the relaxed standing position. If local pathology has been ruled out, a positive sign of lower lumbar radiculitis is seen when a sharp below to the ipsilateral buttock over the area of the belly of the piriformis elicits a sharp pain, but a similar blow to the contralateral buttock does not elicit pain.

Bonnet's Sign.   A patient with sciatica is placed supine. The examiner lifts the involved limb slightly, adducts and internally rotates the thigh while maintaining the knee extended, and then continues to flex the thigh on the trunk to patient tolerance as in a SLR test. If this maneuver exaggerates the patient's pain or the pain response is sooner than that seen in Laseque's SLR test, sciatic neuritis, psoas irritation, or a hip lesion is indicated.

Lasegue's Differential Sign.   This test is used to rule out hip disease. A patient with sciatic symptoms is placed supine. If pain is elicited on flexing the thigh on the trunk with the knee extended, but it is not produced when the thigh is flexed on the trunk with the knee relaxed (flexed), coxa pathology can be ruled out.


      MANAGEMENT

As direct trauma to the nerve is so rare, careful evaluation of lumbar, sacral, and sacroiliac subluxations and fixations must be made, as well as lower back, pelvic, and hip musculature and trigger points. Corrective osseous adjustments, muscle techniques, and reflex techniques should be applied when indicated. Local heat and corrective muscle rehabilitation speed recovery when applied in the appropriate stage. Of all nerves in the body, the sciatic is one of the slowest to regenerate. The feet, upper cervical area, thoracolumbar junction, and overall posture should be evaluated for signs of predisposing defects in biomechanics.


Spinal Cord Injuries

Any trace of sensory abnormality, objective or subjective, should immediately raise suspicion of injury to the spinal cord or cauda equina. Injuries to the lumbosacral cord or its tail occur from vertebral fractures, dislocations, or penetrating wounds in severe accidents. In other rare instances, the cord may be damaged from violent falls with trunk flexion. The T12-L1 and L5-S1 areas are the common sites of injury, especially those of crushing fractures with cord compression. Neurologic symptoms develop rapidly, but the lower the injury, the fewer roots will be involved. More common than these rare occurrences are cord tractions, concussions, and less frequent contusions.

Traction of the Spinal Cord.   A scoliotic deviation must always be attended by a commensurate vertebral body rotation to the convex side. If this does not occur, it is atypical and most likely pain producing. If the vertebral bodies were not subject to the law of rotation during bending, the spine would have to lengthen during bending and its contents (ie, cord, cauda equina, and their coverings) would be subjected to considerable stretch. Thus, in a case of scoliotic deviation in the lumbar area without body rotation towards the convex side, seek signs indicating undue tension within the vertebral canal. It should also be noted that atlanto-occipital, atlanto-axial, and coccyx disrelation with partial fixation places a degree of traction upon the cord, dura, and dural sleeves in flexion-extension and lateral bending efforts.

Concussion of the Spinal Cord.   Immediate signs are usually not manifested in mild or moderate injuries; but weeks later, lower extremity weakness and stiffness may be experienced. It takes time for the nerve fibers to degenerate. Deep reflexes become exaggerated, and originally mild sensory, bladder, and rectal disurbances progress. The picture is cloudy, often mimiking a number of cord diseases (eg, sclerosis, atrophy, syringomyelia). Life is rarely threatened, but full recovery is doubtful.

Contusions of the Spinal Cord.   Cord concussion usually complicates cord contusion. If laceration occurs, shock is rapid. Deep reflexes, sensation, and sphincter control are lost. The paralysis is flaccid. Obviously, a prognosis cannot be made until the shock is survived.

Kernig's Test.   The supine patient is asked to place both hands behind his head and forcibly flex his head toward his chest. Pain in either the neck, lower back, or down the lower extremities indicates meningeal irritation, nerve root involvement, or irritation of the dural coverings of the nerve root. A variation of this test is also attributed to Kernig: The examiner flexes the thigh at a right angle with the torso and holds it there with one hand. With the other hand, the ankle is grasped and an attempt is made to extend the leg at the knee. If pain or resistance is encountered as the leg extends, the sign is positive provided there is no joint stiffness or sacroiliac disorder. Milgram's Test.   Ask the supine patient to keep his knees straight and lift both legs off the table about 2 inches and to hold this position for as long as possible. The test stretches the anterior abdominal and iliopsoas muscles and increases intrathecal pressure. Intrathecal pressure can be ruled out if the patient can hold this position for 30 seconds without pain. If this position cannot be held or if pain is experienced during the test, a positive sign is offered indicating intrathecal pathology, herniated disc, or pressure upon the cord from some source.


Intervertebral Disc Syndrome

It is generally agreed that a true diagnosis of disc herniation with or without fragmentation of the nucleus pulposus can only be made on surgical intervention. Thus the term "intervertebral disc syndrome" is generally used when conservative diagnostic means are used exclusively. There is considerable dogmatism associated with both diagnosis and management.

The terms protrusion, rupture, and herniation are often used to describe the pathologic grade of an IVD lesion. However, to establish a practical guideline in the management of such lesions, many physicians refer to a Grade I, II, or III disc syndrome based primarily on symptomatology.

      CLASSES

In a Grade I syndrome, the patient has intermittent pain and spasm with local tenderness. There is very little or no root compression. Paresthesia and/or radiculitis may extend to the ischium.

In a Grade II syndrome, some nerve root compression exists along with pain, sensory disturbance, and occassionally some atrophy. Paresthesia and/or radiculitis may extend to the knee.

In a Grade III syndrome, there is marked demonstrable muscle weakness, pronounced atrophy, and intractable radicular pain. Paresthesia and/or radiculitis may extend to the ankle or foot.

Beyond these three grades, we find frank herniation. In rupture, there is a complete extrusion of the nucleus through the annulus into the canal or IVF. All the above symptoms are found in herniation, and, in addition, pain is worse at night and not generally relieved by most conservative therapies.

The IVD syndrome usually has a traumatic origin and occurs more commonly between the ages of 20 and 60. There may be a history of low back complaints with evidence of organic or structural disease. Most protrusions seen in athletes occur at the L4-L5 or L5-S1 level, involving the L4, L5, or S1 roots. A unilateral sciatic pain following a specific dermatome segmentation and not remissive except by a possible position of relief is often presented. There is usually a C scoliosis away from the side of pain, splinting, and a flattening of the lumbar spine. Lasegue's, Kemp's, and Nafzigger's tests are positive. There may be diminished tendon reflexes of the involved segment and possible weakness and/or atrophy of the musculature innervated.

Lasegue's Rebound Test.   At the conclusion of a positive sign during the straight-leg-raising test, the examiner may permit the leg to drop to a pillow without warning. If this rebound test causes a marked increase in pain and muscle spasm, then a disc involvement is suspect.


      OTHER CLINICAL SIGNS

A number of helpful neurologic and orthopedic procedures have been developed to aid the diagnosis and differentiation of IVD lesions. See Table 25.2.

Bechterew's Test.   The patient in the seated position is asked to extend first one knee with the leg straight forward (parallel to the floor). If this is performed, the patient is asked to extend the other knee likewise. If this can be performed, the patient is asked to extend both limbs simultaneously. If the patient is unable to perform any of these tests because of sciatic pain or able only by leaning far backward to relieve the tension on the sciatic nerve, a lumbar disc disorder or acute lumbosacral sprain should be suspected.

Dejerine's Sign.   If sneezing, coughing, and straining at the stool (Dejerine's triad) or some other Valsalva maneuver produces or increases a severe low back or radiating sciatic pain, a positive Dejerine's sign is present. This is indicative of some disorder that is aggravated by increased intrathecal pressure (eg, IVD lesion, cord tumor, etc).

Astrom's Suspension Test.   This is a confirmatory test for sciatic neuritis and/or lumbar traction therapy. The patient is asked to step on a low stool, grasp a horizontal bar, and hang suspended for several seconds. In most cases, the traction effect produced will be sufficient enough to retract a protruding disc, separated the articular facets, open the IVFs, and, thus, relieve the patient's discomfort. A variation of this test is for the examiner to conduct a spinal percussion test while the patient is suspended.

Also see Beery's sign, Goldthwait's test, Neri's bowing sign, Lewin's supine test, Brudzinski's test, and Naffziger's test.


      ROENTGENOGRAPHIC CONSIDERATIONS

Normally, as a major adaptive change to the carrying of weight, there is a flattening of the lumbar lordosis and a mild rotation of the sacrum into a more vertical position. The maximum adaptation occurs at the lumbosacral junction with only minor adjustments at the higher levels. The L5 disc assumes a more nearly horizontal position with widening posteriorly and compression anteriorly, which results in a decrease in the downward sliding force applied at the S1 level. These reflections by Olsen go on to state that the usual manifestion of disordered function of any part of the motor unit is weakness. He quotes DeJarnette's 1967 notes that "The position of the sacral base is often compensatory to keep severe situations from becoming worse through weight bearing".

When an IVD leaves its normal anatomic position, routine radiographic examination without contrast medium may present diagnostic characteristics such as narrowing of the intervertebral space (most typical), retrolisthesis of the vertebral body superior to the herniated disc, posterior osteophytes on the side of the direction of the herniated disc or apophyseal arthrosis, and sclerosis of the vertebral plates as a result of stress on "denuded" bone (frequent). Malformations as asymmetric transitional lumbosacral vertebra and spina bifida are seen more frequently with herniated disc than in cases in which such anomalies do not exist. Scoliosis is more common in the L4-L5 disc than in the L5-S1 disc.

Three functional views should be taken in the erect position: A-P neutral and right and left maximum lateral flexion. Points to especially evaluate are asymmetry and unilateral elevation of disc spaces, limited and impaired mobility on the affected side, blocked mobility contralaterally one segment above the L5-S1 level, and slight rotation of the L4 or L5 vertebral body toward the side of collapse. Abnormal findings suggesting a fixed prolapse in these functional views include flattening of the lumbar curve, posterior shifting of one or more lumbar vertebral bodies, impaired mobility on forward flexion so that the disc space does not change as compared to the findings in the neutral position, and impaired mobility on dorsiflexion.

      MANAGEMENT

The cause of pain may vary from a mild bulge, to a severe protrusion, to frank prolapse and rupture of the IVD into the vertebral canal. While physical signs are helpful, but not conclusive, in determining the extent of damage, subjective symptoms are often misleading.

Cryotherapy and other forms of pain control are advisable during the acute stage for 48 hours. Some relief will be achieved by placing the patient prone with a small roll under the lower abdomen to flex the lumbar spine while applying manual traction techniques. This should be followed by corrective adjustments to correct attending fixations and abnormal biomechanics, traction, and other physiotherapy modalities. A regimen of therapeutic exercises to improve torso strength, a temporary lumbopelvic support, and shoe inserts designed to improve postural balance and lessen gait shock are extremely helpful during recuperation.


Table 25.2.   Review of Neurologic and Orthopedic Manuevers, Reflexes, Signs, or Tests Relative to Intervertebral Disc Syndromes
Adams' sign              Goldthwait's test       Milgram's test
Astrom's suspension      Gower's sign            Minor's sign
 test                    Hyperextension          Muscle strength grading
Babinski's sciatic        tests                  Naffziger's test
 sign                    Kemp's test             Neri's bowing sign
Bechterew's test         Kernig's sign           Range of motion tests
Beery's sign             Lasegue's rebound       Tendon reflexes
Bowstring sign            test                   Turyn's sign
Bragard's test           Lasegue's SLR test      Vanzetti's sign
Dejerine's sign          Lewin's supine test
Deyerle-May's test       Light touch/
Fajersztajn's test        pain tests


Spondylolisthesis

The anterior or posterior sliding of one vertebral body on another (spondylolisthesis) can result from either traumatic pars defects or degenerative disease of the facets. There is a separation of the pars interarticularis which allows the vertebral body to slip forward, carrying with it a portion of the neural arch. Davis points out that many authorities consider the condition as congenital, while others are of the opinion that trauma in early childhood is more often responsible. Regardless, when witnessed in an adult, the lesion dates from childhood rather than from some recent injury. Rehberger states it occurs in 4%-6% of people, but is present in about 25% of people complaining of constant backache.

      BACKGROUND

An increase in the S1 sagittal diameter in spondylolisthesis occurs during teen maturation. Displacement tends to increase before the age of 30, but this trend sharply decreases thereafter unless there is an unusual cause such as chornic fatigue coupled with an unusual prolonged posture.

Predisposing spinal instability is frequently related to a degenerated disc at the spondylolisthetic level. Quite often the lesion is asymptomatic during the first 2 decades of life. Dimpling of the skin above the level of the spondylolisthesis may be observed or extra skin folds may be seen because of the altered spinal alignment. When the condition does become symptomatic, the pain is usually recurrent and increases in severity with subsequent episodes. Low back pain often develops after insignificant injury or strain, with recurrent pain gradually increasing in intensity. Weakness, fatigue, stiffness, unilateral or bilateral sciatic pain, and extreme tenderness in the area of the spinous process of L5 are associated. Pain usually subsides in the supine position.

      ROENTGENOGRAPHIC CONSIDERATIONS

Disc tone is best analyzed through neutral, flexion, and extension views. As with spondylolysis, the most common site of spondylolisthesis is in the lower spine, but it has been reported in all areas of the lumbar spine and the cervical area. The typical situation is slippage of L5 on the sacral base (75% to 80%), but it is occasionally seen at the L4 segment.

Spondylolisthesis is graded by dividing the sacral base or the superior end plate of L5 into four equal parts when viewed in the lateral film: the Meyerding method. The part occupied by the posterior-inferior tip of the vertebra above indicates the degree of forward slip. In suspected cases where no obvious gross slippage has occurred, the Meschan method is used on the lateral projection. A line is drawn across the posterior, superior, and inferior tip of the L5 vertebral body. A second line is drawn from the posterior-superior tip of the sacrum to the posterior-inferior tip of L4. Normally, these lines should overlap or nearly so. If they are parallel or form an angular wedge at the superior, it indicates an anterior movement of L5. If the angle formed is greater than 2° or if the lines are parallel and separated more than 3 mm, a spondylolisthesis is present. To determine the degree of instability, flexion and extension studies in the lateral projection are utilized. The degree of angulation formed in flexion is subtracted from the degree of angulation formed in extension, as the maximum degree of slippage is seen during extension. The result of these two measurements offers the degree of instability present.

Oblique views show a defect in the isthmus or pars interarticularis where the neural arch is visualized as a picture of a terrier's head. The pedicle and transverse process form the head of the dog, the ears by the superior articular process, the neck by the pars interarticularis, the body by the lamina, and front legs by the inferior articular process. When the defect appears as a collar on the dog, a spondylolysis is present. If the terrier is decapitated, a spondylolisthesis is present.

Other roentgenographic findings include an unusual lumbar lordosis with increased lumbosacral angle and overriding of facets adjacent to the defect which is usually visible on the A-P view. In time, the overriding apophyseal joints show osteoarthritic changes. The amphiarthroidial joint between the vertebral bodies frequently shows narrowing, spurring, and associated osteoarthritic changes. A lumbar kyphosis is rarely seen, indicating the possibility of a herniated disc.

      MANAGEMENT

Symptoms progress from mild stiffness and low-back spasm after working or lifting in the forward flexion position to a sharp pain upon mild hyperextension of the trunk. Pain elicited by spinal percussion exhibits late, but depression of the spinous process is an early physical sign.

Cryotherapy and other forms of pain control are advisable during the acute stage (eg, 48 hours). Considerable relief will be achieved by placing the patient prone with a small roll under the lower abdomen to flex the lumbar spine while applying manual traction techniques. This should be followed by corrective adjustments to release attending fixations, improve abnormal biomechanics, and help reduce the separation. Traction and other physiotherapy modalities are helpful adjuncts. A regimen of mild stretching exercises, with emphasis on flexion, is extremely helpful during recuperation. Sole lifts or lowered heels may be necessary if the sacral angle is abnormally wide. Lifting should be prohibited until the patient is unsymptomatic for several weeks, and then initiated only with caution.


Lumbar Spondylolysis

Spondylolysis is similar to spondylolisthesis in that there is also a defect in the pars interarticularis, but there is no anterior slipping of the vertebral body. Disc narrowing and facet sclerosis are frequently associated. It is a degenerative condition of early middle life, more common to males and often associated with athletic or occupational stress. The most common site of spondylolysis is in the lower spine.

In describing spondylolysis, Davis reminds us that the term "pre-spondylolisthesis" is a misnomer as it indicates that spondylolisthesis will occur. This term is also inaccurate to describe an exaggeration of the sacral base angle. It is true that spondylolysis will contribute to spinal instability much the same as an exaggerated sacral base angle, but it is not true that spondylolisthesis will result in either condition. Degenerative arthropathy of the apophyseal joints will most likely result from the stress and strain placed upon the facets. The defective arrangement will also predispose the individual to spinal fatigue. The condition is also referred to as hypertrophic osteoarthritis, this is also a misnomer as there is no inflammatory involvement present. The appropriate nomenclature is discogenic spondylosis.

There is a high incidence of trauma and strenuous physical activity in the history of spondylolysis. Incidence in sports is particularly high in fast bowlers, affecting the contralateral side of the active arm. It is common in the obese, robust, endomorphic individual such as heavy boxers and professional wrestlers. It is not uncommon in oarsmen. A large number of college and professional football interior linemen present low-back pain with abnormalities present on radiographs. A large percentage of such cases show a degree of spondylolysis or spondylolisthesis, usually with normal neurologic signs. Because of chronic lumbar stress, weight lifting is also commonly associated with an increased incidence in spondylolysis and disc herniation at the lower lumbar area. Rarely, vertebral-body fracture is associated.

Roentgenographic Considerations.   Turner describes the process as primary change in the IVD with progressive loss of turgor and elasticity contributing to softening and weakening of the disc margin. Marginal spurring, lipping, and the consequence of osteophytic formation ensues. The sacroiliac areas are not usually involved. Narrowing of one or more IVD spaces may develop when the disc space together with changes in the curvature of the spine appear narrowed. The clinical picture, associated with spondylosis deformans, is usually referred to the area of structural deformity that results in compromise of contour and diameter of the related IVF. Oblique views, along with standard A-P and lateral views, are helpful in showing defects or fractures of the pars interarticularis. Not infrequently, cephalad-angled views or tomograms are necessary.

Management of Spondylolysis and Spondylolisthesis.   Mild and moderate cases respond well to chiropractic anterior lumbar techniques. Adjunctive care includes low back traction in selected cases, positive galvanism, ultrasound, and alternating contractile currents to improve muscle tone. Immobilization using a lumbosacral support helps in the more advanced cases. Once the disorder becomes asymptomatic, corrective exercises should be recommended to maintain optimal muscle tone.

Prognosis.   Prognosis is good in firstand second-degree types with minimal neurologic symptoms. If conservative measures fail, surgical fusion and removal of the neural arch is recommended. Prognosis is good in cases of minimal separation but poor in cases of gross separation where the patient is usually left with a residual rigidity and stiffness in the lower spine.


Subluxations, Fractures, and Dislocations

Subluxations are discussed throughout this chapter, but a few general points should be made here. The apices of curvatures and rotations are logical points for spinal listings since they are frequently the location of maximum vertebral stress. Subluxations may occur at other points in curves and rotations, particularly at the beginning point of a primary defect in balance such as in the lower lumbar and upper cervical sections. Subluxations also frequently occur at the point where a primary curve merges into its compensatory curve. A posterior L3 is rare when the apex of the lumbar curve is too high or too low, but common at L4, L5, or the sacral base. When the apex of the lumbar curve is too low, a posterior subluxation will most likely be found in the upper lumbar area.

      ROENTGENOGRAPHIC CONSIDERATIONS

As in other areas of the body, x-ray views of the spine must be chosen according to the part being examined and the injury situation. And as with the cervical spine, careful evaluation must be made of the vertebral structures, the IVDs and paraspinal soft tissues. The L5-S1 and sacroiliac joints, the pelvis, and its contents deserve careful scrutiny. Acute injuries to the supporting soft tissues about a vertebra are rarely demonstrable. Their presence is suggested when the normal relations of bony structures are disturbed. However, when ligamentous lesions heal, hypertrophic spurs and sometimes bridges may develop locally on the margins of the bones affected.

The lower back and pelvis are the most common sites for avulsion-type injuries. Severe, sudden muscle contraction can produce fragmented osseous tears near sites of origin and insertion. Avulsions in the lumbar area often occur with transverse-process fragmentation at the site of psoas insertion. Although the transverse processes of the lumbar spine are quite sturdy, multiple fractures are seen in some football injuries. Lumbar transverse-process fractures are sometimes not evident or are poorly visualized in roentgenography unless markedly displaced or angulated due to overlying gas and/or soft-tissue shadows which obscure detail. Howe suggests a cleansing enema or other means of clearing over lying soft-tissue shadows whenever all bony processes are not well visualized. Transverse-process fractures are frequently asymptomatic or nearly so and lack the symptoms to encourage a most careful examination.

      Miscellaneous Pathologic Signs

Romberg's Station Test.   During this test, the examiner must stand close to the patient in the event the patient's loses balance. The patient is asked to stand in a relaxed position and to close the eyes. If this cannot be accomplished without falling or severe swaying that requires the feet to be moved to regain balance, a positive sign is established that rules out cerebellar or labyrinthine disease. A positive sign is seen in locomotor ataxis associated with marked alcoholic neuritis, spinocerebellar tract disease, and in pernicious anemia when the columns of Goll and Burdach are affected. While a patient with cerebellar or labyrinthine disease may have difficulty standing, the position is usually taken equally well with or without visual support.

Neri's Test.   The patient is placed supine with the knees extended. The examiner flexes the involved thigh on the trunk to approximately 45° while keeping the knee extended, as in a SLR test. Normally, the contralateral limb will remain fairly flat against the table. In organic hemiplegia, however, the opposite limb will flex at the knee.

Barre's Sign.   The patient is placed in the prone position with the knees passively flexed at right angles to the thigh by the examiner. If the patient cannot actively hold this position with either or both limbs, it is a positive sign of pyramidal tract disease.



     Injuries of the Pelvis

In evaluating the athletic injury, inspection and palpation offer the most significant signs. Common pelvic landmarks are the anterior superior iliac spine (ASIS), posterior superior iliac spine (PSIS), and the anterior inferior iliac spine (AIIS).


Clinical Signs

A listing of neurologic and orthopedic manuevers, reflexes, signs, and tests relative to the pelvis and sacroiliac joints is shown in Table 25.3.

Buttock Sign. A lower extremity of a supine patient is passively flexed at the hip with the knee extended as in a SLR test. If the flexion of the limb on the trunk is restricted by local or radiating buttock pain (rather than pain in the hip or lower back), it is significant of a inflammatory pelvic lesion such as ischiorectal abscess, osteomyelitis of or near the hip joint, coxa bursitis, sacroiliac septic arthritis, or an advanced pelvic neoplasm.

Also see adductor reflex, anal reflex, cremasteric reflex, Ely's heel-to- buttock test, Hibb's test, and Nachlas' test.


Table 25.3. Review of Neurologic and Orthopedic Manuevers, Reflexes, Signs, or Tests Relative to the Pelvis and Sacroiliac Joints
Disorder                       Procedures/Signs                           

Pelvic         Adductor reflex                 Ludloff's sign
Syndromes      Anal reflex                     Patella reflex
               Buttock sign                    Patrick's F-AB-ER-E test
               Cremasteric reflex              Piriformis myofascitis test
               Ely's heel-to-buttock test      Piriformis spasm test
               Hibb's test                     Pitres' sign
               Light touch/pain tests          Trendelenburg's test

Sacroiliac     Bechterew's test                Lewin's supine test
Syndromes      Belt test                       Light touch/pain tests
               Buttock sign                    Mazion's step-flex test
               Demianoff's sign                Mennell's test
               Erichsen's pelvic rock test     Minor's sign
               Gaenslen's test                 Nachlas' test
               Gillis' test                    Neri's bowing sign
               Goldthwait's test               Patella reflex
               Hibb's test                     Patrick's F-AB-ER-E test
               Hip abduction stress test       Range of motion tests
               Iliac compression test          Sacroiliac stretch test
               Laguerre's test                 Smith-Peterson's test
               Lewin-Gaenslen's test           Yeoman's test

      PHYSIOLOGIC OR ANATOMIC SHORT LEG

Upon fully extending the legs (supine position) in pelvic mechanical pathologies, the one on the side of involvement will be retracted 1/4 to 1/5 inch shorter than the one on the opposite side because the posterior innominate rotation causes the acetabulum to be carried superior and anterior: the superior position producing the retraction of the limb. However, upon bringing the extremities upward to an extended position of right angles to the body, the short leg will measure the longest because the acetabulum of the posterior innominate has been carried superior and anterior, and the anterior position now produces the added length.

Evidence of an anatomic short leg or an anteroinferior sacral subluxation, or both, also show that:

(1) If a standing patient seeks to rest his back by shifting from one foot to the other, he will come to rest himself by bearing his weight on the side on which the leg is short, the sacrum has gravitated anterior and inferior, and the innominate in compensation has rotated posterior and superior. Using the dual weight scales, the patient usually carries the most weight on the side of the short leg and anteroinferior sacrum.

(2) With the patient in the Adams position, the pelvis slants anteriorly and inferiorly. The lumbar spine gravitates into scoliotic deviation to the low sacral side, which establishes a state of reverse rotation between L5 and the sacrum.


      POSTURAL PATTERNS

Underlying physical activity is the maintenance of upright posture, which is essentially a continuous activity between the individual and gravitational forces. In just opposing gravity to achieve and maintain posture, a person consumes approximately 40% of his total energy.

Secondary spinal curves depend to a large extent on the inclination of the pelvis below, and this inclination depends greatly on the posture of the hip joints. Thus, hip muscles are strategically involved in determining pelvic inclination. In the upright position, the thighs are fixed points from which these muscles act. Contraction or shortening of the extensors (glutei, hamstrings) decrease pelvic inclination, and contraction or shortening of the flexors (iliopsoas, rectus femoris) increase inclination. Likewise, weakness of the antagonists would have the same effect. Thus, rehabilitation should be directed to relax muscles shortened by spasm or contracture (eg, abnormal reflex patterns) and strengthen counterparts weakened by inactivity or constitutional factors. This need not be a dual activity as a muscle relaxes as its antagonist contracts against resistance.

Chiropractic kinesiologic research has found in bilateral muscle checking during posture analysis that the overwhelming majority of patients presenting chronic postural defects have relative muscle weakness rather than primary muscle spasm. It appears to be this weakness that causes the contralateral muscles to contract into an apparent spasm. Therefore, the weakness is said to be primary and the spasm is secondary and thought to be the result of the prime-mover/antagonist reciprocal relationship. For example, an elevated iliac crest on the right relative to the left may be due to weakness on the right of the psoas, gluteals, and tensor fascia lata or weakness on the left of the adductors, quadratus lumborum, rectus or transverse abdominis, or the sacrospinalis muscles.


Contusions and Strains

The majority of sports-related pelvic injuries treated will be those of a musculotendinous unit. Palpation and testing muscle action against resistance will usually quickly pinpoint the site of trauma.

      HIP POINTER

This is a very common painful injury of the superior iliac crest seen in all sports. It is often difficult to heal. The easily irritated epiphysis of the iliac crest does not close until about 24 years of age and is easily injured by a shoulder, helmet, knee, or shoe blow. In addition, the picture is one of ilioinguinal and iliohypogastric nerve contusion, painful avulsion of the iliolumbar ligament from the ilium and/or sprain at its L4-L5 attachment, and crushing of the muscle bulge overlapping the crest.

Signs and Symptoms.   Symptoms often mimic fracture; ie, acute, steadily increasing pain, and severe progressing disability. On onset, a moderate injury will present tenderness below the iliac wing and at the overlapping muscle bulge but not on the crest itself, indicating a bone bruise with nerve contusion. An impact to the anterior spine may actually strip attachments along the crest. Thus, severe injury presents extreme tenderness throughout and above the crest, indicating torn attachments. The pain is agonizing, easily aggravated, and often requires hospitalization. If examination is delayed, bleeding, spasm, and swelling obscure localization of all initial diagnostic signs.

Management.   Initial management requires direct cold packs to stop the bleeding, swelling, and spasm, and careful strapping to tilt the trunk toward the ipsilateral pelvis to prevent further spasm. Disability and swelling must be monitored daily during the early stage. In minor strains with minimal swelling, cold may be discontinued after 24 hours. Active motion without heat may begin at this time. Ultrasound has been found especially helpful in resolution. Active motion with support and padding is beneficial, but heat is usually contraindicated. Activity may be resumed in 3-10 days depending upon the extent of injury. In severe strains with extensive swelling, cold must be continued for 48-72 hours. Activity may be resumed in 2-3 weeks if management is carefully controlled.


      GROIN STRAINS

These are often difficult to manage and often seen early in the season before full conditioning has occurred. They are common in hockey and from slips on muddy fields where severe hip abduction or adduction overstress might occur. A wrenching-type disability arises slowly rather than suddenly as in a quickly torn muscle.

Management.   In spite of extensive ecchymosis, there is usually immediate relief after correcting attending sacroiliac and pubic subluxations if severe avulsion has not taken place. Cold, compression, pressure by an elastic figure-8 bandage to prevent hyperextension, and rest will rapidly control the swelling. Standard physiotherapy will relieve attending muscle spasm due to the irritation from the inflammatory reaction. Carefully monitored graduated exercises must be initiated as soon as possible to avoid posttraumatic contractures which will produce recurrent disability. Return to full-scale activity can usually be expected within a week.


      SARTORIUS STRAINS AND TEARS

This often mild but persistent disability is often seen with "squatting" football linemen and occasionally in oarsmen. Discomfort is aggravated by abduction, extension, and eased after warm up.

      PIRIFORMIS DISORDERS

If the patient has deep gluteal pain, sciatic neuralgia, and walks with the foot noticeably everted on the side of involvement, involvement of the piriformis should be suspected.

Spasm Test.   To test for piriformis spasm, place the patient supine, lying on a firm flat table, grasp the patient's heels and firmly invert the feet. If one foot resists this effort and the act is attended by pain in the gluteal area, the piriformis should be suspected. Differentiation of piriformis spasm from other causes can be elicited by reproducing the pain on internal rotation of the femur when it is at a lower level than the original point of pain.

Strength Test.   To determine piriformis strength, place the patient supine, fully flex the hip, and flex the knee to a right angle. Bring the foot being tested across the opposite leg, stabilize the knee with your other hand, and apply adduction pressure to the ankle against patient resistance (thigh abduction).

Myofascitis Test.   To test for piriformis myofascitis, seat the patient on a table with hips and knees flexed. Apply resistance as the patient attempts to separate the knees. In piriformis myofascitis, pain and weakness will be noted on resisted abduction and external rotation of the thigh. Inflammation will be confirmed by rectal examination exhibiting tenderness over the lateral pelvic wall proximal to the ischial spine.


      THE SOCCER SYNDROME

In soccer, the common "scissors" kick frequently leads to instability of the sacroiliac and symphysis pubis joints. Groin pain is aggravated during full stride, jumping, and in the stretching motion of kicking with power. Also in soccer players and jockeys, a periosteal reaction may be noted at the origin of the adductor muscles (gracilis syndrome).

Roentgenographic Considerations.   When pain in the area of the symphysis pubis is the complaint, views should be taken in the weight-bearing position, first with full weight on one limb and then the other to exhibit instability. Oval or semicircular lucency and avulsion sites may be exhibited at the pubic bone near the symphysis at the origin of the gracilis muscle and the adductors longus and brevis. In addition, symphysis widening, instability, frayed corners, fluffy margins, pubic osteoporosis, and muscle attachment periosteal reactions may be seen. Stress sclerosis of the iliac portions of the sacroiliac joints are often associated in these conditions.


      OSTEITIS PUBIS

This is a rare disability seen most often in runners, competitive walkers, and football players. It is frequently chronic and episodic. The picture is one of severe groin pain sometimes radiating to the hips, groin, or abdomen that is aggravated by hip rotation, abdominal flexion, and sometimes by iliac compression. Swelling and tenderness will be noted over the symphysis pubis. A slight epiphyseal slip may be a predisposing factor. Roentgenography may reveal an eroded symphysis with joint widening, tending to calcification in later stages. Fever, dysuria, leukocytosis, and an increased sedimentation rate are inconsistent associations. Differentiation must be made from ankylosing spondylitis, adductor-origin strain, and perineal disease.

Management.   Rest, cold, diathermy, mild ultrasound, vitamin-mineral supplementation, and attention to lumbar subluxations are helpful in these often stubborn cases. Mobilization of frequently associated hip fixations is essential. Graduated return to activity must be carefully monitored to prevent recurrence of acute symptoms. If conservative measures fail, fusion of the symphysis may be advised, but postoperative results are not always good.


      GLUTEAL CONTUSIONS AND STRAINS

Contusions, especially to the ischial tuberosity and the well-developed athletic buttocks, are frequently seen. Incidence is high in hockey and field sports. Just walking may be aggravating, but pain is usually not severe. Swelling and bleeding may be extensive, but it is reduced quickly if cold is applied immediately. Recurrent bleeding is always a problem, but its likelihood is reduced if cold is continued for 3-4 days. Activity can be resumed with padding, but it is rarely adequate protection against reinjury. Full healing without reinjury will usually take place within a month.

Strain may be infrequently seen in the muscles which rotate the thigh and stabilize the hip such as the glutei, piriformis, gemilli, and quadratus femoris. Awkward slips are the typical injury mechanism, and dysfunction is extremely debilitating. Strains of the origin of the hamstring muscles, associated with lower buttock pain on exercise and ischial tenderness on forward flexion, are common among football players and sprinters. Sciatica tests will be negative. Heat, gentle passive stretching, and graduated active exercises should be incorporated into the standard strain management program.

Golfer's Strain.   An unimpeded forceful, full golf swing may injure a golfer by causing an avulsion of the ischial apophysis.

Rider's Strain.   An adductor strain is frequently suffered by horsemen, cyclists, fast bowlers, and runners. The complaint will be one of stiffness, tenderness, and pain during abduction that is high in the groin. In addition to regular strain therapy, treatment should include applying adductor tendon stretch up to patient tolerance.


Sprains and Subluxations

      SACROILIAC SPRAIN

These sprains are of frequent appearance, especially when weights are lifted. Heavy loads or severe blows may rupture some associated ligaments and subluxate the joint.

Background.   Pain may be local or referred. Symptoms are usually relieved by rest and aggravated by activity. The patient assumes the characteristic posture with a flattened lumbar area, trunk inclined away from the lesion, guarded gait, and limited spinal motions, especially spinal flexion due to hamstring tension. Jarring the spine causes a sharp localized pain in the affected joint. In some cases, abnormal mobility may be found in thigh flexion or hyperextension. Care must be taken to differentiate from a sacral base or lumbar lesion. Localized tenderness and the classic clinical tests are helpful in differentiation.

Management.   During the acute hyperemic stage, structural alignment, cold, compression support, acupressure, ultrasound, and rest are indicated. Vitamin C and manganese glycerophosphate supplementation are helpful. The stages of passive congestion, consolidation, and fibrosis are treated as in other sprains.


      SACROILIAC SUBLUXATION

This is characterized by misalignment of the sacrum in relation to the ilia independent of bilateral innominate involvement (ie, primary) or misalignment of the sacrum in relation to the ilia as a result of bilateral innominate involvement (ie, secondary). These situations point toward

(1) irritative microtrauma to the interarticular structures,
(2) induction of a vertebral motor unit subluxation and/or are contributory to chronicity of subluxations,
(3) induction of spinal curvatures and/or are contributory to the chronicity of curvatures present, and
(4) biomechanical impropriety of the pelvis in static postural accommodation and in locomotion.

If the innominate is in posterior rotation subluxation, with the patient standing supporting himself with hands on the back of a chair, he carries his thigh forward, flexes his knee and carries it upward against his abdomen (and thus rotates the innominate further posteriorly) much more readily than extending the thigh backward and thus rotating the innominate anteriorly. With the patient supine and the pelvis fixed by the examiner, the patient will find it noticeably more difficult to straight raise the leg on the side of sacroiliac subluxation. If backache is relieved when the patient goes from a standing to sitting position, such relief is indicative of a pelvic lesion rather than a lumbar condition (Berry's sign). Relief comes from hamstring relaxation.

Differentiation.   To differentiate sacroiliac from lumbosacral involvement: Have the patient supine on a firm flat table. A folded towel is placed transversely under the small of the patient's back. The doctor stabilizes the patient's pelvis by cupping his hands over the ASISs and exerting moderate pressure. The patient is instructed to raise both extremities simultaneously in a straight-leg manner. If the patient senses discomfort or an increase of discomfort in the low back or over the sacrum and gluteal area at about 25°-50° leg raise and before the small of the back wedges against the towel, sacroiliac involvement is suspected. If, on the other hand, discomfort is experienced or augmented only after the legs have been raised beyond 50° and the small of the back wedges firmly against the towel, lumbosacral involvement should be suspected. Other tests are described below.


      CLINICAL TESTS

Gaenslen's Test.   The patient is placed supine well to the side of the table with knees, thighs, and legs acutely flexed by the patient, who clasps his knees with both hands and pulls them toward his abdomen. This brings the lumbar spine firmly in contact with the table and fixes both the pelvis and lumbar spine. With the examiner standing at right angles to the patient, the patient is brought well to the side of the table and the examiner slowly hyperextends the opposite thigh by gradually increasing force by pressure of one hand on top of the knee while the examiner's other hand is on the flexed knee for support in fixing the lumbar spine and pelvis. Some examiners allow the hyperextended limb to fall from the table edge. The hyperextension of the hip exerts a rotating force on the corresponding half of the pelvis. The pull is made on the ilium through the Y ligament and the muscles attached to the anterior iliac spine. The test is positive if the thigh is hyperextended and pain is felt in the sacroiliac area or referred down the thigh, providing that the opposite sacroiliac joint is normal and the sacrum moves as a unit with the side of the pelvis opposite to that being tested. Test bilaterally. If the sign is negative, a lumbosacral lesion is suspect. This test is usually contraindicated in the elderly.

Hibb's Test.   With the patient supine, the examiner extends the patient's thigh on the affected side and rotates the hip joint internally by rotating the leg outward. Increase in pain is a positive sign of a sacroiliac or hip lesion. Erichsen's Pelvic Rock Test.   With the patient supine, the examiner places his hands on the iliac crests with his thumbs on the ASISs and forcibly compresses the pelvis toward the midline. Pain experienced in the sacroiliac joint suggests a joint lesion which may be either traumatic or infectious in origin.

Iliac Compression Test.   Place patient in side-lying position with affected side up. Examiner places his forearm over the iliac crest and leans pressure downward for about 30 seconds. A positive sign of sacroiliac inflammation or strain is seen with an increase in pain; however, absence of pain does not necessarily rule out sacroiliac involvement. It is usually contraindicated in geriatrics and pediatrics. This is a variation of Erichsen's test.

Mennell's Test.   Examiner places thumb over PSIS and exerts pressure, then slides thumb outward and then inward. The sign is positive if tenderness is increased. When sliding outward, trigger deposits in structures on the gluteal aspect of the PSIS may be noted. If when sliding inward tenderness is increased, it is indicative of sprain of the superior sacroiliac ligaments. Confirmation is positive when tenderness is increased when the examiner pulls the ASIS posterior while standing behind the patient or when the examiner pulls the PSIS forward while standing in front of the patient. This test is helpful in determining that tenderness is due to overstressed superior sacroiliac ligaments.

Yeoman's Test.   Place the patient prone. With one hand, make firm pressure over the suspected sacroiliac joint, fixing the pelvis to the table. With the other hand, flex the patient's leg on the affected side to the limit and hyperextend the thigh by lifting the knee off the examining table. If pain is increased in the sacroiliac area, it is significant of a sacroiliac lesion because of the stress on the anterior sacroiliac ligaments. Normally, no pain will be felt on this maneuver.

Goldthwait's Test.   The patient is placed supine. The examiner places one hand under the lumbar spine with each fingerpad pressed firmly against the interspinous spaces. The other hand of the examiner is used to slowly conduct a SLR test. If pain occurs or is aggravated before the lumbar processes open (0*–30°), a sacroiliac lesion should be suspected. Goldthwait felt that if pain occurred while the processes were opening at 30°–60°, a lumbosacral lesion was suggested; 60°–90°, an L1–L4 disc lesion.

Smith-Peterson's Test.   If it is possible during Goldthwait's test to raise the limb on the unaffected side to a greater level without pain than the involved side, a positive Smith-Peterson's sign is found, which confirms a sacroiliac lesion; ie, pain usually occurs at the same level for either leg when a lumbosacral lesion is present.

Sacroiliac Stretch Test.   The patient is placed supine. The examiner, standing to face the patient, crosses his arms and places a hand on the contralateral anterior-superior iliac spine and the other hand on the ipsilateral anterior-superior iliac spine. Oblique (posterolateral) pressure is then applied to spread the anterior aspects of the ilia laterally. A positive sign of sacroiliac sprain is a deep-seated pelvic pain that may radiate into the buttock or groin. While the iliac compression test is designed to stretch the posterior sacroiliac ligaments, this test stretches the ligaments on the anterior aspect of the joints.

Lewin-Gaenslen's Test.   The patient is placed in the sidelying position with the underneath lower limb flexed acutely at the hip and knee. The examiner stabilizes the uppermost hip with one hand. With the other hand, the uppermost leg is grasped near the knee and the thigh is extended on the hip. Initiated or aggravated pain suggests a sacroiliac lesion.

Hip Abduction Stress Test.   The patient is placed as in Lewin-Gaenslen's test. With the upper limb held straight and extended at the knee, the patient is instructed to attempt to abduct the upper limb while the examiner applies resistance. Pain initiated in the area of the uppermost sacroiliac joint or the hip joint suggests an inflammatory process of the respective joint.

Hibb's Test.   The patient is placed in the prone position. The examiner stabilizes the uninvolved hip, flexes the patient's knee on the involved side toward the buttock, and then slowly adducts the leg, which internally rotates the femur. Pain initiated in the hip joint indicates a hip lesion; pain rising in the sacroiliac joint, but not the hip, points to a sacroiliac lesion.

Gillis' Test.   With the patient prone and the examiner standing on the side of involvement, the examiner reaches over and stabilizes the uninvolved sacroiliac joint while the thigh on the involved side is extended at the hip. Pain initiated by this maneuver in the sacroiliac area of the involved side is a positive sign of an acute sacroiliac sprain/subluxation or sacroiliac disease.

Mazion's Step-Flex Test.   A standing patient with low back pain is asked to take a large step forward, hold this position by keeping the toes in place, and then flex the trunk forward. According to Mazion, the initiation or aggravation of the patient's complaint on the contralateral limb (the one behind) exhibits a positive sign of an unilateral subluxated ilium in relation to the sacrum (ie, sacral base anteroinferior).

Also see Bechterew's test, belt test, buttock sign, Demianoff's sign, Gaenslen's test, hyperextension tests, Lewin's supine test, Minor's sign, Nachlas' test, Neri's bowing sign, and Yeoman's test.


      PUBIC SPRAIN AND SUBLUXATION

This frequently occurring condition is often mistaken for sacroiliac slip, although sacroiliac displacement may have occured and been spontaneously reduced. Keep in mind that there is some degree of bone elasticity between the extreme A-P points of the pelvis except in the elderly. The disorder is also associated with lateral hip subluxations. In pure pubic subluxation, the only definite evidence will be found at the pubic symphysis --a fixed rotation of one innominate. The sacroiliac area will not be tender, but tenderness will be found over the painful pubis.

Management.   The displaced pubis should be corrected. This should be followed by stretching the sciatic nerve and typical sprain therapy.

Adjustment.   Place the patient in the lateral recumbent position, with the involved side up. If the pubis on the involved side is low, adjust as you would an anterior ilium or posterior ischium with an ischial contact. If the involved pubis is high, adjust as you would a posterior ilium or anterior ischium with an ilia contact. Direct contact on the pubic area is avoided because of the hypersensitivity of the area.


      COCCYX SPRAIN AND SUBLUXATION

An irritating displacement is frequently overlooked. It is more common among women than men. The typical coccyx lies in the same curved plane as the sacrum when viewed during inspection. Slight displacements are never obvious on x-ray films. The direction of displacement is usually anterior, but it is rarely seen posterior. The cause is usually a fall in the sitting position. Ligamentous tears may be associated with subluxation and/or fracture. If a gluteus maximus is unilaterally weak, the coccyx will deviate contralaterally. Coccygodynia may be from mild to severe, and urogenital, rectal, sciatic-like complaints, and general nervousness may be associated. In traumatic situations, pain and local levator ani spasm may be pronounced and often episodic. Local tenderness is consistently present.

Keep in mind that the terminal of the spinal cord is attached to the cornua of the coccyx. As the segment moves anteriorly, the apex of the sacrum acts as a fulcrum. As the cornua rotates backward and downward, traction is made on the spinal cord. Thus, symptoms from the resulting cord tension need not be confined to the pelvic region alone (eg, occipital headaches, torticollis).

Adjustment.   While many techniques can be described, the best method is the direct method with the index finger in the rectum and the thumb on the base of the coccyx. This adjustment can be done immediately after digital examination. If the patient has difficulty in relaxing the sphincter, have him perform Valsalva's maneuver. Take care not to injure the impar ganglion of the delicate rectal wall. Gentle steady pressure is made in the direction opposite to displacement for several seconds, relaxed for several seconds, and then reapplied. This cycle should continue for about three to six times. Pressure is all that is needed. A distinct thrust may break a partial ankylosis and cause more trouble than the condition itself. However, it sometimes helps to give light thrusts simultaneously on the apex of the sacrum with your free hand. After correction, evaluate integrity of coccygeus muscles.

If upper lumbars or lower dorsals are also involved, do not adjust until after the coccygeal adjustment as the sympathetic stimulation will tend to activate probably spastic anal muscles. However, L5 or the sacrum can be adjusted for the parasympathetic supply from these areas tend to relax anal muscles.


Fractures and Dislocations

Note pelvic symmetry, deformity, and carefully palpate for bony crepitus about the ischium, rami, and hip areas. Rolling injuries are usually at fault in pelvic ring fractures such as seen in horseback riding accidents, ski falls against a hard surface, cycling and automobile accidents. Vascular, bladder, and perineal injuries are commonly associated.

      AVULSIONS IN SPORTS

Stress and avulsion fractures are far from uncommon, but the most typical injuries are associated with muscle, tendon, fascia, and cartilage injuries of the lower extremity. The most common sites of avulsion fractures in one 2-year study occurred at the ischial tuberosity at the hamstring origin, the ASIS at the sartorius origin, and the AIIS at the origin of the rectus femoris muscle. Incidence is highest in track and field sports. In sprinters, sudden severe pain in the area of the hip or buttock may be traced to an avulsion of the hamstring attachments at the ischial tuberosity. Roentgenography may indicate large crescent-shaped bone masses near the injured ischium. Most musculotendinous injuries in sprinters occur during the stride phase or at the transition point between stride to maximum finishing speed.

      FRACTURES

While pelvic fractures are not common, they should never be taken lightly as they are reported to be the second most common cause of traumatic death --second only to head injuries. Pelvic fractures often cause severe internal bleeding difficult to halt even on surgery. Shock is present in 40% of the cases. The patient with pelvic fracture, unable to stand or walk, complains of pain in the pelvic region or back and, if the bladder or kidney is injured, passes blood in the urine. A pelvic girth injury is suggested by severe low back pain (especially in retroperitoneal bleeding), severe pain with compression of the iliac crests, and pubic tenderness.

Pelvic fractures, usually due to violent injuries, are frequently multiple and result in severe deformity. The most common areas involved are those about the sacroiliac joints and the symphysis pubis. In fact, a fracture or dislocation of the pubis is frequently associated with separation of a sacroiliac joint or the neighboring sacrum or ilium.

Roentgenographic Considerations.   Fractures of the ilium are visible as sharply defined lines of diminished density that are possibly stellate. Colon or rectal gas may mimic or obscure a pelvic fracture, but as these shadows are not constant, they can be ruled out on future examination. Another source of error are the blood-vessel grooves in the ilium, but their branching character and bilaterality help in identification. In examining the young, keep in mind that the pelvic epiphyses are among the last to unite: open until 20-25 years of age.

Emergency Procedure:   Apply firm supporting bandages around the pelvis. Hold the legs together by a figure-8 bandage wound around the feet and ankles. Also secure the thighs with a bandage. A splint should be provided from armpit to foot. In pelvic fracture, there is often an urgent desire to urinate. If possible, this should be avoided to prevent possible extravasation from a ruptured urethra which would lead to perineal cellulitis.


      PELVIC FALLS

After pelvic injury, all related structures should be carefully evaluated. Direct buttock falls upon a hard surface (eg, ice or roller skating, skateboarding) often result in sacral fractures, dislocation of the coccyx, and lumbar subluxation. After pelvic or leg injury, hip dislocation is sometimes missed.

Howe points out that after falls or trauma to the back, particularly where the blow is applied to the bottom of the pelvis with force traveling up the spinal column, compression fractures of vertebral bodies frequently result. The most often missed of these occur at the T12-L1 junction, but they may possibly extend as high as T10. The reason they are often missed is that the pain is usually referred to the lumbosacral area, and there may be no spasm or even tenderness in the fracture area. If the x-ray beam is centered at the location of pain, the view may not extend high enough to include the lower thoracic area. A compression fracture is frequently not evident until several days later when deformity becomes more pronounced.

      PUBIC STRESS FRACTURES

On rare occasions, the adductor muscle attachment area at the inferior pubic ramus may be the site of a stress factor. This usually occurs from a fall or a sudden foul-line stop while delivering a bowling ball in an unbalanced position. Avulsion of the inferior pubic ramus and rupture of the adductor longus' origin may be associated, as well as laceration to scrotal vessels.



     Injuries of the Hip

Carefully palpate bony and soft tissues, and evaluate active and, if necessary, passive ranges of motion. Trendelenburg's Hip Test. A patient suspected of hip involvement stands on one foot, on the side of involvement, and raises the other foot and leg in hip and knee flexion. If the hip and its muscles are normal, the iliac crest and sacral dimple will be slightly low on the standing side and high on the legelevated side. But, if there is hip joint involvement and muscle weakness, the iliac crest and sacral dimple will be markedly high on the standing side and low on the side the leg is elevated. A positive sign indicates the gluteus medius muscle on the supported side is either weak or nonfunctioning. The gait will exhibit a characteristic lurch to counteract the imbalance caused by the descended hip.


Table 25.4. Review of Neurologic and Orthopedic Manuevers, Reflexes, Signs, or Tests Relative to the Hip Area
Adams' sign           Gauvain's sign           Muscle strength grading 
Allis' hip sign       Hennequin's sign         Ober's test 
Allis' knee sign      Hibb's test              Patrick's F-AB-ER-E test 
Anvil test            Hyperextension tests     Piriformis myofascitis 
Brudzinski's sign     Laguerre's test           test
Buttock sign          Langoria's sign          Piriformis spasm test
Ely's heel-to-        Leg length tests         Range of motion tests
 buttock              Light touch/             Thomas' test
Ely's sign             pain tests              Trendelenburg's test
                      Ludloff's sign


Contusions and Strains

      GENERAL MUSCLE SPASM

Limitations of motion due to muscular spasm are seen with special frequency in joint disease and spinal dysarthrias, but may occur in almost any form of joint trouble, particularly the larger joints. In the hip joint, two forms of spasm are important:

(1) that which is due to irritation of the psoas alone, and

(2) that in which all muscles moving the joint are more or less contracted. General spasm of the hip muscles is tested via Patrick's test.

Patrick's F-AB-ER-E Test.   This test is of particular value in that it indicates hip joint pathology. The patient lies supine, and the examiner grasps the ankle and the flexed knee. The thigh is flexed (F), abducted (AB), externally rotated (ER), and extended (E). Pain in the hip during the maneuvers, particularly on abduction and external rotation, is a positive sign of coxa pathology.

Management.   To relieve muscle spasm, heat is helpful, but cold and vapocoolant sprays have often shown to be more effective. Mild passive stretch is an excellent method of reducing spasm in the long muscles, but heavy passive stretch destroys the beneficial Reflexes.   Quadriceps spasm can usually be relaxed by passive hip and knee flexion. Peripheral inhibitory afferent impulses can be generated to partially close the presynaptic gate by acupressure, acupuncture, or transcutaneous nerve stimulation.


      ILIOPSOAS SPASM

In pure psoas spasm, the thigh is usually somewhat flexed on the trunk, though this may be concealed by forward bending of the trunk. Very slight degrees of psoas spasm may be appreciable only when, with the patient lying prone, the examiner attempts hyperextension. In pure psoas spasm, other motions of the hip (rotation, adduction, abduction, and flexion) are not impeded. Keep in mind that in the normal erect posture only about 12% of the weight of the abdominal organs is borne by the suspensory ligaments; the majority of weight is supported by the inclined psoas and contained thereon by the abdominal wall.

Standard Tests.   To test iliopsoas integrity, the seated patient is asked is raise each knee by hip flexion against resistance of the examiner's hand placed on the distal anterior thigh. Then test in the supine position. The ability to flex the thigh in the supine position but not in the seated position indicates an iliopsoas lesion. To further test, raise the leg to be tested of the supine patient to about 45°, keeping the knee extended. The patient is asked to resist a downward and slightly lateral pressure when the examiner exerts pressure against the lower anteromedial leg.

Ely's Test.   To support iliopsoas spasm suspicions, place the patient prone with toes hanging over the edge of the table, legs relaxed. One or the other heel is approximated to the opposite buttock. After flexion of the knee, pain in the hip will make it impossible to carry out the test if there is any irritation of the psoas muscle or its sheath. The buttock will tend to rise on the involved side. However, a positive Ely's sign can be an indication of a lumbar lesion or a contracture of the tensor fascia lata.

Thomas' Test.   This is a test to determine excessive iliopsoas tension. Have the supine patient hold one flexed knee against his abdomen with his hands while the other limb is allowed to fully extend. The patient's lumbar spine should normally flatten. If the extended limb does not extend fully or if the patient rocks his chest forward or arches his back, a fixed flexion contracture of the hip is indicated, as from a shortened iliopsoas muscle. Test bilaterally. The normal range of hip flexion is 120°.

Palpation.   Iliopsoas hypertonicity can be confirmed by tension and pain during deep palpation of the abdomen below the umbilicus and lateral to the linea alba.


      PERTHE'S DISEASE

This is a state of osteochondrosis of the femoral capital epiphysis. The picture is one of ischemic necrosis followed by reconstitution, seen in children usually before the age of 10. It is more common in boys and usually is unilateral. There is an insidious limp, especially when fatigued, with some hip abduction limitation. Leg shortening is witnessed only in the late stages. Physical signs may be negative, while roentgenography is indicative; ie, increased epiphyseal density, wide joint space, dense femoral head fragments, followed by metaphyseal area cavitation and a fragmented epiphysis. During spontaneous resolution, bone texture normalizes, the shortened femoral neck widens, and the femoral head tends to mushroom. This cycle takes about 3 years to accomplish.


Trochanteric Bursitis

Uncommon contusions directly on the prominent greater trochanter undoubtedly result in a varying degree of bursitis that has a picture similar to that of the olecranon bursa. This bursa separates the gluteal attachments and the iliotibial band. Injury may also be the result of overuse. Incidence is higher in females than males. The area will be warm, swollen, and tender. In stubborn cases, aspiration may be necessary. Care must be taken to seek signs of fracture such as crepitus and bony tenderness before swelling occurs. Situations of chronic bursitis are sometimes related to a mobile "snapping" tensor fascia lata tendon. This seems to be more common to the ectomorphic long-distance runner. Cold, support, rest, and later deep heat will usually resolve the situation without resorting to referral for steroids.


Causalgia Syndrome

This is a reflex sympathetic dystrophy characterized by pain, paresthesia, swelling, trigger points, burning feelings, heat or cold, redness or pallor. It consists chiefly of sympathetic phenomena following severe trauma involving one or more limbs and is often followed by organic changes such as bone atrophy and mottling resulting from persistently recurring nutrient artery spasms as well as skin and muscle atrophy. Joint immobility with or without pain, scleroderma, and contracture may occur. The syndrome is a vasomotor and sympathetic disorder wherein trophic disturbance in which any thermic, tactile, sensory, or even psychic stimulus may result in an explosive attack. It may involve either or both the lower or upper extremities.


Hip Sprain

The hip articulation is situated deeply beneath heavy muscles, fat, and fascia which protect the joint but often obscure physical signs. Fortunately, injury is rare in well-supervised sports.

Background.   In the young, sprains of this joint frequently injure the upper femoral epiphysis; in adults, trauma more frequently causes injury to the muscles about the joint than to the hip joint itself.

Laquere's Test.   With the patient supine, the thigh and knee are flexed and the thigh is abducted and rotated outward. This forces the head of the femur against the anterior portion of the coxa capsule. Increased groin pain and spasm are positive signs of a lesion of the hip joint, iliopsoas muscle spasm, or a sacroiliac lesion. It differentiates from a lumbosacral disorder.

Signs and Symptoms.   Motion is restricted and pain is often referred to the medial aspect of the knee. A limp is invariably present. Use Laquere's, Ely's, Patrick's F-AB-ER-E, and Ober's tests to support your diagnosis. Thomas' sign is positive in hip contracture; Trendelenburg's sign in hip dislocation; and Allis' knee sign in hip fracture. In hip sprain, the mechanism is usually a twisting or wrenching motion. Occasionally, a stubborn case will show pus on aspiration.

Management:   When symptoms of joint involvement are present, functional rest is indicated until signs of irritation disappear. Treat as any joint sprain depending upon the stage in progress. Strapping should be provided as well as crutches during the acute stage. The patient should be carefully monitored for a month or longer.



Subluxations

      FIXATIONS

A lateral fixation of the hip joint is not an uncommon finding. On the involved side, internal rotation will be restricted and the psoas muscle will test weak.

Strength Test.   Weakness in the psoas can be tested by having the supine patient lift the extended limb to 45°, externally rotate the foot, and have the patient resist the doctor's attempt to move the patient's foot laterally and towards the floor. The examiner should stand at the foot of the table so that his nonactive hand can stabilize the patient's contralateral pelvis.

Adjustment.   Place the patient supine with the involved hip and knee flexed so that the foot rests flat upon the table without strain. Stand at the foot of the table, facing the patient. Interlock your fingers over the patient's flexed knee, and lean forward so that your sternum is almost above the knee. With your medial forearm, press the patient's leg laterally to internally rotate the femur about 25°. While holding this pressure, make a gentle thrust through the longitudinal axis of the femur. Check if the fixation has been freed by evaluating bilateral internal rotation of the hip and psoas strength.


      INTERNALLY ROTATED FEMUR

This subluxation is commonly associated with anterior pelvic tilting, external tibia rotation, and subtalar pronation. A degree of genu valgum and hip pain are presented.

Adjustment.   Place the patient supine with flexed knees so that his buttocks are near the end of the table. Stand medially, facing perpendicular to the thigh of the involved hip. Contact the medial mid-shaft aspect of the thigh, while your stabilizing hand grasps the patient's calf. Externally rotate the femur, apply traction with your stabilizing hand, and make a gentle thrust with your contact hand, directed towards further external rotation. Follow by checking the integrity of the gluteus maximus, piriformis, quadratus femoris, obturators, psoas, iliacus, gemellus, and posterior fibers of the gluteus medius.


      EXTERNALLY ROTATED FEMUR

This subluxation is related to internal tibia rotation and subtalar pronation. A degree of genu varum and hip pain are exhibited.

Adjustment.   Place the patient supine. Stand lateral to the patient on the side of involvement, facing obliquely medial. Take contact on the superolateral aspect of the femur at mid-shaft with your cephalad hand, while your stabilizing hand is wrapped over the patient's leg so that your palm supports the patient's upper calf. Internally rotate the femur, apply caudal traction with your stabilizing hand, and make a gentle thrust with your contact hand that is directed towards further internal rotation. Follow by checking the integrity of the tensor fascia lata, gluteus minimus, adductor brevis, and anterior fibers of the gluteus medius.


      SUPERIOR FEMUR SUBLUXATION

This situation is usually seen when nagging hip pain complicates low back pain. A degree of fixed internal or external rotation is often involved.

Adjustment.   Place the patient supine. Stand at the foot of the table, facing the patient, and grasp the lower leg of the involved limb just above the ankle. Stabilize the patient's contralateral foot against your knee. Apply traction, and make a gentle pull that takes into consideration any internal or external rotation involved.


      ANTERIORLY SUBLUXATED FEMUR

This is a lesser degree of an anterior (obturator) dislocation. The cause is usually a severe fall or being forced backward against an obstacle or tackler. On the involved side, the patient exhibits hip pain and an externally rotated limb that is lengthened. The head of the femur lies near the obturator foramen.

Adjustment.   Place the patient supine. Stand at the foot of the table, near the side of involvement, facing the patient. With your lateral hand, grasp the patient's posterior-distal leg just above the ankle. With your medial hand, reach across the patient's foot and grasp his heel. Both hands will be on the lateral aspect of the patient's ankle area. Apply gentle traction and medial rotation to the limb. Adduct the patient's involved limb across his other leg, maintaining careful control. Constant traction, medial rotation, and adduction should reseat the displaced femoral head.


      POSTERIORLY SUBLUXATED FEMUR

When the femur is subluxated backward, the patient has difficulty in extending his thigh. Measurement indicates limb shortening. The mechanism of injury is usually a fall, long jump, or severe upper-thigh tackle from the anterior.

Adjustment.   Place the patient supine. Stand on the side of involvement, facing medially, and centered at the patient's flexed knee. Bring the patient's knee laterally so that it is firm against your upper abdomen. With your cephalad hand, stabilize the patient's contralateral ilium. With your caudad contact hand, grasp the patient's ankle from the anterior. With your body weight, apply abduction to the flexed knee, while simultaneously applying superior pressure with your contact hand to increase hip flexion and carrying the patient's lower leg medially. This hip flexion, abduction, and external rotation should reseat the displaced femoral head.


      SCIATIC DISPLACEMENT

This is a chronic postural disorder associated with pelvic tilt where weight balance is decidedly unilateral on the involved side. Acute trauma is rarely involved, but it may be in the patient's history. The patient presents hip pain, internal limb rotation, and a shortened limb. The head of the femur is found near the lesser sciatic notch.

Adjustment.   Place the patient supine. This maneuver is essentially the opposite of adjusting an anteriorly subluxated femur. Stand at the foot of the table near the side of involvement. Face the patient. With your lateral hand, grasp the patient's posterodistal leg just above the ankle. With your medial hand, reach across the patient's foot and grasp his heel. Both hands will be on the lateral aspect of the patient's ankle area. Apply gentle traction and lateral rotation to the limb. Abduct the patient's involved limb. Constant traction, lateral rotation, and abduction should reseat the displaced femoral head.



Fractures and Dislocations

Any type of hip pain encourages careful physical and roentgenographic evaluation of the soft tissues on the lateral and medial aspects of the hip. A hip dislocation with or without fracture should be considered a major injury and referred immediately without attempts of reduction. Roentgenographs will never indicate all soft-tissue damage present. Severe pain on motion is typical in both hip dislocations and fractures.

Allis' Knee Sign.   With the patient supine, knees flexed, and soles of feet flat on table, the examiner observes heights of knees superiorly from the foot of the table. If one knee is lower than the other, it is indicative of a unilateral hip dislocation or severe coxa disorder.

Langoria's Sign.   Relaxation of the extensor muscles of the thigh is an indication of intracapsular fracture of the femur.

Hennequin's Sign.   The patient is placed supine with the knees extended. A positive sign is found if deep palpation just inferior to Poupart's ligament and lateral to the large inguinal vessels produces deep tenderness, pain, and crepitation --signs of femoral neck fracture.

Anvil Test.   If a fracture of the leg or femur is suspected, the patient is placed supine and the examiner grasps the ankle of the involved side in one hand and strikes the patient's heel with the fist of the other hand, sending a shock wave up the extremity. The result may be localized pain that will help to locate the site of fracture or pathologic focus.

Gauvain's Sign.   With the patient in the sidelying position, the examiner stabilizes the patient's uppermost iliac crest with the heel of the hand and the fingerpads are fixed against the patient's lower abdomen. With the patient's uppermost knee extended, the examiner grasps the patient's upper ankle with the other hand, moderately abducts the limb, and firmly rotates it internally and externally. With the patient's knee locked in extension, these rotary manuevers will affect the entire limb, as far superiorly as the head of the femur. A positive sign is seen when a strong abdominal contraction occurs, indicating a somatosomatic reflex spasm that is usually attributed to hip pathology (eg, coxa tuberculosis).

Also see buttock sign, Ely's heel-to-buttock test, Hyperextension tests, Hibb's test, Ober's test, Nachlas' test, and Patrick's F-AB-ER-E test.


      ROENTGENOGRAPHIC CONSIDERATIONS

The most common hip injuries viewed are dislocations and fractures, both of which may lead to avascular necrosis of the femoral head. Femur fracture occurring above the intertrochanteric line are within the joint capsule. They heal, as a rule, without the formation of visible callus.

Shenton's line is frequently disturbed in hip fracture. A gracefully arching line is drawn connecting the inferior margin of the superior pubic ramus with the medial margin of the neck of the femur. With minimal hip displacement, normal landmarks will be altered when compared bilaterally.

Prognosis.   The possibility of nonunion and of absorption of the femur neck must be kept in mind when forming a prognosis in hip fracture. The vitality of the femur head can be inferred from its density; ie, a viable head becomes decalcified to the same degree as surrounding bone. If it is dead, density will be equal to or greater than that of healthy bone.

Impactions.   Following an impaction injury, it is often difficult to locate a fracture of the margin of the head of the femur, It is shown by slight contour changes and unusual densities. Comparative views, oblique and stereoscopic views, tomography, or arthrography are frequently necessary to identify small fracture fragments.

Avulsions.   The trochanteric areas should be checked for possible injury of the gluteal insertion at the greater trochanter or avulsion of the iliopsoas insertion at the lesser trochanter. Any type of hip pain encourages careful evaluation of the soft-tissue structures in the area of the obturator internus.

Epiphyseal Slippage.   It is common for athletes in later years to exhibit degenerative disease of the hip, suggesting evidence of an old slipped capital femoral epiphysis. Even in minimal slip of this epiphysis, a chronic "tilt deformity" may result which exhibits the femoral head sitting eccentrically on the neck in a drooped or tipped position. When swelling and ecchymosis appear at the base of Scarpa's triangle and the patient is unable to raise the thigh while in the sitting position, traumatic separation at the epiphysis of the lesser trochanter is indicated (Ludloff's sign).

Evidence is clear that there is an association of certain forms of degenerative hip disease, often with osteophytic flanges on the femoral head, secondary to a rearranged femoral-acetabular articulation. Thus, recognition during the early years is most helpful. Slippage of the femoral capital epiphysis often occurs 1-2 years earlier in females because the most rapid growth in that area comes earlier.

      NECROSIS OF THE FEMUR HEAD

Recognize the possibility of post-ischemic changes in the head of the femur during roentgenography of a hip or pelvic fracture. Subcondral collapse, related sclerosis, and irregularity on the weight-bearing anterolateral and superior femoral head are characteristic of ischemic necrosis. Aseptic necrosis may result from hip dislocation without fracture. Hip necrosis is best shown in the "frog-leg" abduction, lateral, and partially flexed-hip A-P views.

Care should be taken not to confuse a radiodense femoral head with that of necrosis. After bone or vascular injury, bone ischemia may exist without roentgenographic evidence. Most of the density noted on films following bony ischemia is attributed to the reparative sclerosis of new bone laid upon the necrotic trabeculae (ie, creeping substitution). In addition to this, the relative increased density can be contributed by osteoporosis in the nonischemic zone or by a situation of minute trabecular collapse which attentuate the x-ray beam.

      FRACTURES OF THE PROXIMAL FEMUR

Femoral neck fractures are rare in the young; usually a degree of osteoporosis is predisposing. However, in contact athletics, a stress fracture of the femoral neck may become a complete fracture following later torsional stress. In anterior dislocations, a shear fracture of the superior aspect of the femoral head is usually associated. The limb will usually be externally rotated without leg shortening. In posterior dislocations, the inferior aspect of the head may be fractured. Severe trauma may result in comminuted femoral head fractures. Relaxation of the fascia between the crest of the ilium and the greater trochanter is a sign of fracture of the neck of the femur (Allis' Hip Sign).

      DISLOCATIONS

Posterior Dislocations.   The most common luxation is posterior dislocation of the femoral head, exhibiting thigh adduction and internal rotation at the hip and leg shortening on the affected side. When dislocation takes place, the head of the femur may be driven into the posterior or central acetabulum creating acetabular comminution fragments. But posterior displacement may also be seen without fracture, with a single major posterior acetabular fragment, or with femoral head fracture. The cause is usually a force against the flexed knee with the hip in flexion and slight adduction. Complications include sciatic nerve stretching causing foot drop and numbness of the lateral calf.

Anterior Dislocations.   Anterior dislocation is relatively rare because Bigelow's ligament offers considerable protection. The limb will be externally rotated, abducted, without leg shortening. Obturator, iliac, and pubic displacement may be seen, as well as those associated with femoral head fractures. In athletics, these usually occur from a blow to the back while squatting, a fall where forced abduction occurs (eg, vaulting), or forced abduction of the extended hip.

Central Dislocations.   These may be seen with displacement towards the inner wall only, with partial dome fractures or with central displacement with comminution of the dome. This type of dislocation-fracture commonly results from a severe force to the lateral trochanter and pelvis directed through the femoral head (eg, baseball slide). Occasionally, they are produced by a force on the long axis of the femur when the hip is adbucted.

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