Chapter Six

Lower and Upper Quarter Movement Impairment Examinations

Introduction

Formulating a diagnosis requires the performance of an examination and the accurate interpretation of the tests included in the examination. An examination has been designed that can be used to determine movement impairments of the lower quarter (e.g., thoracic spine, lumbar spine, hip, knee, ankle). The examination for movement impairment syndromes of the low back and hip includes the same test items, but the focus of the examination is concentrated on the painful area. A few special tests are used when assessing hip pain, and some tests can be eliminated when the focus is the lumbar spine. The advantages of this system are that it allows the therapist to determine whether (1) the low back is referring pain to the hip, (2) the pain arises from the hip joint, (3) hip dysfunction is contributing to back pain, or (4) both the hip and back are sources of pain. The test results also provide direction for the treatment. In fact, for most patients a positive finding for a test usually means that the test will become one of the patient’s exercises. On completion of the examination the therapist should be able to establish a diagnosis, which is the directional susceptibility to movement (DSM) that is causing the pain and the factors that are contributing to make this movement direction the path of least resistance.

The examination is performed with the patient standing, supine, side-lying, prone, quadruped, sitting, and standing against a wall. The charts in this chapter describe the test items in these seven positions. For each test, the segment to be examined, the normal standard for performance, the faults and criteria for the faults, the resulting impairments, and the possible DSM of the joint are identified. The listed impairments are considered as possible conditions and are not to be considered as always present with a given fault. The examination is provided in detail; however, this does not imply that all patients with low back pain will need to be examined for all the lower extremity alignment faults. A patient with hip or knee pain will need a more thorough examination of lower extremity alignment than the patient with low back pain. The details of these relationships are provided as a guide to the anatomic structures that the examiner is assessing and may need to be addressed by the treatment. Separate charts are provided for the lower and upper quarter parts of the body.

Additional check-off charts are provided that allow the therapist to check the test result and the most likely DSM. On completion of this chart, the DSM with the most positive findings should be the diagnosis. This check-off chart will also guide the therapist as to the contributing factors that are to be addressed by the treatment program and the instructions to the patient about how to modify his or her daily and sports activities. When several movement directions elicit symptoms, the therapist will also have to weigh the intensity of symptoms to select which movement direction is the most important. Only through the performance of a thorough examination and the identification of all contributing factors will the therapist be able to develop a comprehensive program that will be effective for both immediate restitution of the problem and for reducing the chance of reoccurrence.

Movement Impairments: Lower Quarter Examination

Test items, test criteria, and associated impairments

ASIS, Anterior superior iliac spine; DSM, directional susceptibility to movement; ITB, iliotibial band; MMT, manual muscle test; PIP, proximal interphalangeal; PICR, path of the instantaneous center of rotation; PSIS, posterior superior iliac spine; SLR, straight-leg raise; TFL, tensor fascia lata; TFL-ITB, tensor fascia lata–iliotibial band.

TEST	SEGMENT	FAULT
	Scoliosis	Rib hump
	Pelvis	Normal
		Anterior tilt
		Posterior tilt
		Lateral tilt
		Rotation
	Hip joint	Normal
		Flexed
		Extended
	Knees	Normal
		Hyperextended
		Flexed

TEST	SEGMENT	FAULT
		Lateral rotation
	Ankle	Longitudinal arch
Single leg stance	Normal
Other hip flexed to 70 degrees
		Lateral trunk flexion
		Hip adduction
		Pelvic rotation
		Hip rotation
Forward bending		Normal
	Lumbar	Dysfunction

TEST	SEGMENT	FAULT
		Hip dysfunction
		Ankle dysfunction
Return from forward bending		Normal
		Lumbar dysfunction
		Hip sway
Side bending		Normal
		Lumbar dysfunction
		Lumbar dysfunction

TEST	SEGMENT	FAULT
		Lumbopelvic dysfunction
	Hip muscle	Dysfunction
	Hip joint	Dysfunction
	Knee joint	Dysfunction
Supine position		Normal
	Lumbar	Dysfunction

CRITERIA	IMPAIRMENT	DSM
Maximal performance: double-leg lowering, while maintaining flat lumbar spine and posterior pelvic tilt	MMT grade 5/5
Minimal performance: maintain one hip at 90 degrees of flexion, back flat, while other lower extremity is extended and lowered to supporting surface while maintaining lumbar spine flat and pelvis in posterior pelvic tilt	MMT grade 3/5
Anterior shear on lumbar spine	Pain with hip flexion
One hip flexed to 90 degrees while other lower extremity is extended while lightly touching heel to supporting surface and able to maintain lumbar spine flat and pelvis in posterior tilt	MMT grade 2/5

TEST	SEGMENT	FAULT
	Hip	Dysfunction
	Lumbar	Neural dysfunction
Iliopsoas	Muscle performance	Normal
	Hip muscle	Dysfunction

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