Handout-Lower Quarter Lumbar Spine, Sacrum, Pelvis, hip 2023.pdf

Screening Lumbar Spine, Sacrum, Pelvis and Lower Quarter PHTR‐619 Ruth Lyons Hansen, PT, DPT, PhD Board Certified Cardiopulmonary Specialist Outline • Lumbar Spine • Sacrum • Pelvis • Lower Quadrant • • • • • Buttock Hip Groin Thigh Leg Spine • Serious pathology is not common in LBP. (Jarvik 2...

Screening Lumbar Spine, Sacrum, Pelvis and Lower Quarter PHTR‐619 Ruth Lyons Hansen, PT, DPT, PhD Board Certified Cardiopulmonary Specialist Outline • Lumbar Spine • Sacrum • Pelvis • Lower Quadrant • • • • • Buttock Hip Groin Thigh Leg Spine • Serious pathology is not common in LBP. (Jarvik 2002) • Many will have one red flag • Presence or absence of red flags unrelated to a particular dx (Premkumar, 2018) • Clusters of S & S should be carefully evaluated • Focus on Dx where early dx will have impact: infection, fracture, intra abdominal pathology, cauda equina lesion Visceral Pain – Lumbar Spine • Metastatic Lesions • Kidney Disease • Prostate Disease • Testicular CA • Aortic Aneurysm • Acute Pancreatitis • Intestinal Disorders • Gynecological Disorders • PAD Clinical Decision Tool • R/O spine tumor if patient meets criteria: • • • • • age > 50 years No recent weight loss No h/o CA Is responding to conservative treatment Pain < 1 month duration • Deyo RA, Diehl AK 1988 Lumbar Radiculopathy Cluster • Dermatomal pattern • Pain with coughing, sneezing, or straining • More Pain sitting • Muscle weakness • Sensory symptoms • Paresis • + SLR Lumbar Stenosis • Radiating leg pain when standing or walking • Pain decreases or absent when sitting because pt prefers flexion • Improvement of symptoms with forward flexion • Wide based gait • Age > 50 Screening the Sacrum SI joint • History is very important • Systemic diseases that refer pain to the sacrum include • Infection (increased risk: Trauma, IV drug use, immunosuppression) • • • • Endocarditis Prostate CA or other cancers Gynecologic disorders Rheumatic diseases that target this area • Ankylosing spondylitis • Reiter’s syndrome/reactive arthritis • Psoriatic arthritis • Paget’s disease • GI (large intestine/colon) • Chron’s Disease • Vascular disorders SI Joint • SI joint pain can mimic pain referred from: • Lumbar disc herniation • Spinal stenosis • Facet joint dysfunction • Hip • R/O fracture, infection or tumor • Precipitating event. Clinical Signs of SI Problem • Back pain • Buttock pain • Thigh pain • “Sciatic like pain” • Difficulty sitting in one place • SI Joint test cluster: • + Distraction, + compression, + sacral spring, + thigh thrust, + Gaenslen test • R/o other causes Unilateral Sacroilliac (SI) Pain Pattern Other Medical Causes • Prostate CA • Other neoplasms • Gynecological causes • Metabolic bone disease Metabolic Bone Disease (causes of SI & sacral pain) • Osteoporosis – most common • Osteodystrophy • • • • Osteomalacia – reduced Ca+, soft bone Osteoporosis ‐ ↓ bone mass, porous & fragile Osteosclerosis – hardened bone Osteitis fibrosa – Ca+ in bone replaced with fibrotic scar • Paget’s Disease Paget’s Disease • A slowly progressive enlargement and deformity of multiple bones. • Acceleration of bone deposition and resorption. • Weak, spongy and deformed bones. • The most common symptom is bone pain. • Redness and warmth in affected areas • Commonly scapula and pelvis Fractures • 3 types of fractures that affect the sacrum: • Trauma‐related fractures • Insufficiency fractures • Pathologic fractures • results from bone that has been weakened by neoplasm or other diseases Tumors • Benign: • osteochondroma, osteoid osteoma, giant cell • Primary malignant tumors • Chordoma, chondrosarcoma, myeloma • Metastatic: • Breast, lung, colon, prostate, uterine, rectal/anal Giant Cell Tumor • • • • • Highly aggressive local tumor of bone Benign but unpredictable ‐ can degrade to malignant Pain in the lower back and sacrum that radiates to one or to both legs. May have swelling in the area of complaint. Other symptoms: • abdominal complaints • neurological signs and symptoms • • • • bowel and bladder sexual dysfunction weakness of the lower extremity Sensory changes GI Causes of Sacral Pain • PMH of: • • • • • Ulcerative colitis Crohn’s disease Irritable bowel syndrome Colon cancer Long term use of antibiotics (colitis) • Pain relieved by passing gas or having a bowel movement • Blood in the stool • always a cause for referral. Coccyodynia • Symptoms include localized pain in the tailbone/coccyx, usually aggravated by direct pressure. • Most often caused by trauma or childbirth • If persistent ask: • Were bladder, bowel or rectal symptoms present before the fall? • Cyst (Pilonidal cyst) can cause coccyx pain Pelvic Pain • Causes: • • • • • • • Musculoskeletal Neuromuscular Gynecological Infectious Vascular Cancer GI origin • Referred from the hip, sacrum, SI area or lumbar spine. • Abdominal pain, low back pain, pain in the buttocks, groin and thigh can refer to the pelvis. Neuromuscular & Musculoskeletal Causes of Pelvic Pain • Typical aggravating and relieving factors for this type of pain include the following: • • • • • Aggravated by exercise, weight bearing Aggravated by trunk/lumbar rotation Relieved by rest or stretching Pain or altered movement pattern produced by trunk and lumbar rotation Eliminated by trigger point therapy • Remember to look for contributing history, such as a fall, pregnancy, trauma and/or sexual assault. Screening for systemic causes of pelvic pain • Reproductive, colon or breast CA • Dysmenorrhea, ovarian cysts, pelvic inflammatory disease, sexually transmitted diseases • Endometriosis • Ectopic Pregnancy • Recent abortion or miscarriage • History or prolong labor; use of forceps or vacuum extraction during delivery • Multiple births • Infection • Chronic yeast/vaginal infections • Chronic bladder or urinary tract infections • Chronic irritable bowel syndrome • Pelvic/bladder surgeries • Hernias (anterior History of assault, incest or trauma • Signs of infection • Varicose veins in the lower extremities • risk factor for pelvic congestion syndrome Associated Signs and Symptoms • Discharge from the vagina or penis • Urologic signs or symptoms • Unreported abdominal pain • Painful Intercourse (Dyspareunia) • Constitutional symptoms (fever, chills, nausea, vomiting) • Missed menses or unexplained/unexpected spotting • Headache, fatigue, irritability Pelvic Pain: Gynecological Causes • Pregnancy • Ectopic pregnancy • Endometriosis • PID/STD • Prolapsed conditions (older females) • Cancer Ectopic Pregnancy • Risk factors include: • • • • • • STDs PID infertility, Previous history of EP pelvic or abdominal surgery IUD • Ectopic pregnancy is a medical emergency. S & S Ectopic Pregnancy • Unexplained vaginal bleeding (spotting), missed menses • Sudden, unexplained lower abdominal pain and pelvic cramping • especially after first missed menstrual period • usually unilateral • Pain may be mild, progressing to severe over a matter of hours to days. • Low back/shoulder pain • Hypotension and shock • tubal rupture Prolapsed Conditions • The collapse of the uterus, bladder or rectum into the vagina/vaginal wall due to poor support • There are several types of prolapse: • Uterine prolapse • Cystocele • Rectocele • Enterocele S&S • Uterine Prolapse • Lump in vaginal opening • Pelvic discomfort, backache • Abdominal cramping • Relieved by lying down • Aggravated by prolonged standing, walking, coughing, or straining • Urinary incontinence • Cystocele • Difficulty emptying bladder • Cystitis • Painful lump or bearing down sensation in the perineal area • Urinary stress incontinence • Rectocele/Enterocele • Pelvic, perineal pain and difficulty with defecation • Feeling of incomplete rectal emptying • Constipation • Painful intercourse • Aching or pressure after a bowel movement Pelvic Inflammatory Disease (PID) • Infection of the female reproductive organs. • It is a common and serious complication of some STDs (especially chlamydia & gonorrhea). • Can lead to chronic pelvic pain, infertility, abscess • All partners MUST be treated. Screening for Cancer as a Cause of Pelvic Pain • The most common in women cancers are: • Endometrial CA • Ovarian CA • Cervical CA • In the screening process the therapists reviews the following: • Do any red flags in the history or clinical presentation suggest a systemic origin of symptoms? • Are any red flags associated signs and symptoms? • What additional screening tests or questions are needed (if any)? • Do I need to refer or can I proceed to a planned intervention? Endometrial Ca • Usually occurs in post‐menopausal women, ages 50‐70 • S & S: • • • • Post‐menopausal bleeding Persistent irregular or heavy bleeding between periods, especially in obese ♀ Abdominal or pelvic pain with more advance disease Weight loss, fatigue with more advance disease Ovarian Ca • Risk factors: • • • • Age over 50 Family history of ovarian Nulliparity Personal history of breast, endometrial, colorectal Ca or BRCA1 or BRCA2 gene • S & S: • Bloating, a feeling of fullness, gas • Frequent or urgent urination • Nausea, indigestion, constipation, diarrhea • Menstrual disorders, pain during intercourse • Fatigue, backaches. Cervical Ca • Risk Factors: • • • • • • Early age first sexual intercourse Multiple partners (>5) h/o sexual abuse Smoking Weakened immune system HPV virus •S&S • Abnormal vaginal bleeding • Menstrual periods last longer and heavier • Bleeding after menopause • Vaginal discharge • Pelvic pain • Pain during sexual intercourse Screening for Gastrointestinal Causes of Pelvic Pain • The most common causes include: • • • • • Acute appendicitis Inflammatory bowel disease (Crohn’s disease, ulcerative colitis) Diverticulitis Irritable bowel syndrome Psoas abscess • Special Tests • • • • McBurney’s point Blumberg’s sign (rebound tenderness) Iliopsoas test Obturator Test Anterior Pelvic Pain • Most often results from any disorder that affects the hip joint • Hernias • Femoral hernias account for 20% of hernias in women (can cause lateral wall pelvic pain when the hernia strangulates) • Immediate surgical repair is indicated!!! • Inguinal hernias (likely to cause groin pain) Immediate Medical Attention and Referral • S & S point to fracture, infection or neoplasm • Suspected hernias • Blood in the stool • Refer adolescents for screening and for pap test if sexually active and presenting with pelvic pain. • If a patient doesn’t get better with PT Lower Quadrant • Buttock • Hip • Groin • Thigh • Leg Lower Quadrant Pain • Vascular conditions • Inflammatory conditions • Gastrointestinal (GI) • Kidney/Urinary Track • Gynecological • Male reproductive system • Cancer • Fracture Past Medical History • • • • Cancer Renal or urologic disease Trauma (assault/fall) Infectious/inflammatory • Crohn’s disease/ulcerative colitis • Diverticulitis • PID • Appendicitis • Reiter’s syndrome • Alcoholism • Gynecologic conditions • Recent pregnancy, childbirth or abortion • Multiparity • • • • Long term use of immunosuppressant Heart disease AIDS‐related TB Hematological disease • Sickle cell anemia • Hemophilia • Joint replacement Hip Pain Pattern • Posterior deep within the buttock • Anterior in the groin • Radiation to anterior thigh • Pain will occur with active or passive hip motions • Pain on weight bearing • Antalgic gait Referred Pain • Hip pathology may not localize pain in hip but can refer pain to low back, groin, SI and anterior thigh • Pain from LB, SI and knee can refer pain to the hip Sign of the buttock (Cyriax) • Limited trunk flexion* • to same extent as hip flexion • Limited SLR* • Passive hip flexion limited and painful • Greater than or to same extent of SLR* • Empty end feel with hip flexion • Non‐capsular pattern of hip restriction* • Painful weakness of hip extensors • Swelling in buttocks • Possible pathologies: • • • • • • • Rheumatic bursitis Osteomyelitis of femur Neoplasm Fracture of sacrum Abscess Septic Sacroiliitis Septic Bursitis Other soft tissue disorders • Femoral hernia • Bursitis • Fasciitis • Muscle impairments/imbalances • Hypertonus/hypotonus • Sprain, strain, tears • Peripheral nerve injury or entrapment • Meralgia parasthetica (Bernhardt‐Roth syndrome) • (lateral femoral cutaneous n.) Hip Arthroplasty • Start up pain followed by relief and increasing pain with longer distances may indicate component loosening. • Persistent pain that is not relieved by rest and continues through the night may be infectious. Medical Screening post hip surgery • Signs of infection • Skin temp, errythema, pain • Lab values: • Platelet levels, INR, Hg/Hct • Cardiovascular • HR, BP, RR, lung sounds, S & S • Complications of Medications Traumatic causes of hip pain • Birth trauma • Prolonged labor, delivery trauma • Assault • Stress reaction/trauma • Fulcrum test • Heel strike test • Pain on weight bearing Sciatica (old term) • Sciatica:(old terminology) • Pain in distribution of sciatic nerve without signs of radiculopathy • Radicular Pain • Pain felt in musculoskeletal system as result of nerve root compression/irritation • Radiculopathy • Nerve or nerve root irritation • Spinal involvement • Weakness, sensory changes, reflex changes • Sciatic neuropathy • Peripheral nerve lesion distal to root Risk factors systemic sciatica • Arterial insufficiency • Age, smoking, cardiac disease • Intra‐peritoneal inflammation • Total hip arthroplasty • Bacterial infection post spine surgery Oncologic Causes of Lower Quadrant Pain • Post radiation or chemotherapy – delayed effects • Primary bone cancer • Age <20, bone pain in adolescent or child • Metastasis • Breast CA, colorectal CA , prostate CA • Hodgkin’s Disease • Painless hard lymph nodes • Spinal cord tumors • Bone tumors Infectious or Inflammatory Causes of Lower Quadrant Pain • Joint pain with no cause • Current or recent skin rash • Current or recent infection • Hepatitis, mono, UTI, URI, strep, dental, Psoas Abscess • Pain in psoas fascia • May extend to hip, groin, thigh, knee • Pain in anterior hip, medial thigh or femoral triangle • Psoas spasm • Leg pulled in internal rotation (may also be flexed) • + psoas sign • Fever • Loss of appetite/GI symptoms • Palpable mass in inguinal area • +illiospoas or obturator test iIliopsoas sign McBurney’s Point GI causes of LQP • Hip or groin pain of unknown cause • History of: • PID, Crohn’s disease, ulcerative colitis, irritable bowel syndrome, diverticulitis, bowel obstruction. • Skin rash that preceded pain • GI symptoms do not coincide with joint pain and often precede it. Vascular Causes of LQP • Peripheral Vascular Disease (PVD)/Peripheral arterial Disease (PAD) • Abdominal Aortic Aneurysm • Avascular Necrosis • Deep Vein Thrombosis (DVT) Peripheral Vascular Disease • Can cause unilateral or bilateral back, hip, groin, buttock, leg pain • Intermittent claudication • Describe pain as burning, cramping or sharp • Brought on by exercise or activity relieved with rest • Known cardiovascular disease is risk factor • Bicycle test of Van Gelderen ‐ differentiate between PAD and Spinal stenosis DVT • Most common in calf but can be in other areas or extend • Dull ache in calf • + Homan’s sign (not very reliable) • Use of predictive scales is preferred – who remembers the names of the scales? • • • • • Errythema Warmth Edema Pain Other possible signs: • Fever • SOB • Dx test: Ultrasound, D dimer Avascular Osteonecrosis • Risk factors: • • • • • • • • Chronic alcohol use/abuse SLE Pancreatitis Diabetes Coagulopathies Cushing disease Gout History of hip fracture Avascular Osteonecrosis S&S • Gradual onset hip pain becomes progressive • Groin or anterior‐medial thigh pain • Pain on WB • Antalgic gait • Limited ROM (IR, Flex, ABD) • Tenderness to palpation • Hip joint stiffness • Hip dislocation Hematological causes • Sickle cell anemia • Avascular necrosis • Hemophilia • Hemarthrosis • GI bleeding Osteoporosis • Post menopausal women highest risk • Increase fall and hip fracture risk • Transient during pregnancy • Caution with sheering force through femoral head Extra‐pulmonary tuberculosis • Rare • Can cause hip or back pain • Can occur in client with HIV who also has AIDS • Presents similar to septic arthritis Urinary System • Kidney • Costo‐vertebral angle • Posterior back pain • T10‐L1 Dermatome • Ureter pain felt in groin/genital areas • Not changed by position • Systemic symptoms Liver Disease • Affects of disease can cause musculoskeletal symptoms: • • • • Ascites Distended abdomen Abdominal hernias Muscle pain Physician Referral ‐ Immediate • Painless, progressive enlargement of lymph nodes that persist or are in multiple areas • Hip or groin pain occurring simultaneously or alternately with abdominal pain • Hip or leg pain on weight bearing with positive test for stress reaction or fracture Physician Referral • Suspected loosening of hip prosthesis or infection • Sciatica accompanied by extreme motor weakness • One or more of Cyriax’s sign of the buttock • New onset of joint pain client with Crohn’s disease