Chapter 7

INSPECTION OF LUMBO-PELVIC REGION


I. THE PATIENT SHOULD BE STANDING IN UPRIGHT POSTURE

A. Inspection with the therapist behind the patient

o Bony landmark orientation:

- Most distal rib attachment = T12 level
- Iliac crest height = L3
— Base of sacrum = LS junction

o Observe the following:

- Shoulders (height, position)
- Curvature of thoracic spine (scoliosis, kyphosis, flattening)
- Curvature of lumbar spine (scoliosis, lordosis, flattening)
- Position of transverse and spinous processes (prominence, depression)
- Rib cage position (prominence, costal angle)
- Muscle development
- Iliac crest height
- PSIS level
- Greater trochanter (height, position)
- Gluteal fold (height)
- Knees (flexion, hyperextension)
- Feet (pronation, supination)

o Palpate the following:

- Scapula (vertebral border, spine, inferior angle)
- Vertebra (spinous processes, transverse processes)
- Muscle tone (paraspinals, gluteal)
- Ribs (costal angle, surface, movement)
- Sacrum (angle, position)

o Examples of deviations:

- Scoliosis
- Flattening of normal thoracic kyphosis - suspect hypomobility or hypermobility at that segment(s)
- Change in anterior-posterior position of multiple consecutive segments — suspect hypomobility or hypermobility at that segment(s)
- Rotational asymmetry (prominent transverse processes) - suspect hypomobility or hypermobility at that segment(s)
- Increased lumbar lordosis — suspect hypermobility at that segment(s), increased loading on the lumbar facets

o Examples of deviations:

- Decreased lumbar lordosis - suspect hypomobility or hypermobility at that segment(s), increased loading on the lumbar discs
- Asymmetrical iliac crest, PSIS, and/or ASIS heights
- suspect sacroiliac dysfunction, leg length difference
- Asymmetrical trochanter height- suspect leg length difference, asymmetrical hip, knee, ankle and/or foot problems

Ask the patient to bend forward.

o Observe the following:

- Pattern of movement (cranial to caudal direction)
- Quality of motion (all segments should move, excessive movement at any level)
- Rib cage position at full flexion (posterior rib prominence)

o Palpate the following:

- PSIS level and movement

o Examples of deviations:

- Omission of segmental motion - suspect hypomobility or hyperinobility at that segment(s)
- Rib cage prominence which worsens with forward flexion, suspect idiopathic structural scoliosis
- Asymmetrical PSIS height - suspect iliac dysfunction

Ask the patient to bend backward.

o Observe the following:

- Pattern of movement (cranial to caudal direction)
- Ability of motion (all segments should move, excessive movement at any level)

o Examples of deviations:

- Omission of segmental motion - suspect hypomobility or hypermobility at that segment(s)
- Excessive movement of a segment(s) — suspect hypermobility at that level
- Deviation to one side — suspect lumbar facet dysfunction

INSPECTION - Standing Forward Flexion

Standing Forward Flexion

Standing Forward Flexion (Image 2)

INSPECTION — Standing Forward Flexion

Standing Forward Flexion (Image 3)

Ask the patient to bend sideways to his right. Repeat into left sidebend.

o observe the following

- Pattern of movement (cranial to caudal direction)
- Quality of motion (all segments should move, excessive movement at any level)
- Amount of motion (compare right to left sidebend)
- Coupling characteristics (prominence of transverse processes)
- Pelvic rotation
- Weightbearing pattern

o Examples of deviations:

- Bilateral reversed coupling — suspect abnormal spinal posture
- Unilateral reversed coupling - suspect hypomobility or hypermobility at that segment(s)or scoliosis
- Decreased sidebending unilaterally - suspect sacroiliac dysfunction, lumbar facet dysfunction
- Diminished or absence of weightbearing on one side
- suspect sacroiliac dysfunction, lumbar facet dysfunction, and/or hip problem

Ask the patient to actively flex the right hip to 90 degrees. Repeat with the left hip.

o Palpate the following:

- Movement of right PSIS during right hip flexion (The right PSIS should move inferiorly)
- Movement of left PSIS during left hip flexion (The left PSIS should move inferiorly)

o Examples of deviations:

- Superior PSIS movement or absence of inferior PSIS movement — suspect sacroiliac dysfunction

B. Inspection with the therapist in front of the patient

o Observe the following:

- Shoulders (height, position)
- Rib cage position (prominence)
- ASIS (height, position)
- Knees (flexion, hyperextension)
- Feet (pronation, supination)

INSPECTION - Standing Hip Flexion

Standing Hip Flexion

Standing Hip Flexion (Image 2)

o Examples of deviations:

- Rib cage prominence

• If prominent both anteriorly and posteriorly on the same side — suspect enlargement
• If prominent on opposite sides anteriorly and posteriorly — suspect thoracic vertebral
rotation

- Shoulder position

• Bilateral rounded shoulders places CT junction and upper thoracic spine in flexion
• Unilateral rounded shoulder — suspect scoliosis or joint trauma

- Asymmetrical ASIS, iliac crest height — suspect sacroiliac dysfunction

C. Inspection with the therapist to the side of the patient

o Observe the following:

- Postural alignment (forward head posture, rounded shoulders, kyphosis, scoliosis)
- Anterior—posterior prominence of skeletal structures (rotational asymmetries)

o Examples of deviations:

- Increased thoracic kyphosis — suspect hypomobility or hypermobility at that segment(s)
- Accentuated TL junction lordosis — suspect hypermobility at that segment(s), increased loading
on lumbar facets
- Increased lumbar lordosis — suspect hypermobility at that segment(s), increased loading on lumbar
facets

II. THE PATIENT SHOULD BE SITTING IN UPRIGHT POSTURE WITH FEET SUPPORTED ON THE FLOOR AND KNEES APART

A. Inspection with the therapist behind the patient

Ask the patient to cross his arms and hold them in the horizontal position while rotating his trunk to the right. Repeat into left rotation.

o Observe the following:

- Pattern of movement (cranial to caudal direction)
- Quality of motion (all segments should move, excessive movement at any level)
- Amount of motion (compare right to left, active and passive rotation)
- Coupling characteristics

o Examples of deviations:

- Bilateral reversed coupling — suspect abnormal spinal posture
- Unilateral reversed coupling - suspect hypomobility or hypermobility or scoliosis
- Reduction of active unilateral rotation — suspect hypomobility or hypermobility
- Guarding during passive motion - suspect hypermobility
- Marked improvement in passive motion as compared to active motion — suspect muscular weakness

END FEEL:

If pushing into full passive rotation, the therapist should palpate a springy end feel.
Ask the patient to bend forward.

o observe the following:

- PSIS level

o Examples of deviations:

- Asymmetrical PSIS level — suspect sacroiliac dysfunction

INSPECTION — Sitting Forward Flexion

Sitting Forward Flexion

Sitting Forward Flexion (Image 2)

  Next: Chapter 8