Lumbar Pathologies

Muscle Strain Potentially Involved Musculature

Erector Spinae Group, Semispinalis, Quadratus Lumborum, Multifidus

Muscle Strain Mechanism of Injury

Typically acute forceful concentric action or excessive eccentric load

Muscle Strain Complaints

• Pain described as sharp

• Tenderness in affected musculature

• No neuropathy

• Feels better at rest

• Muscle spasm and/or swelling may be present 

Muscle Strain ADLs Affected

Active movements that either require contraction or passive stretch

Muscle Strain Neurologic Exam

None Affected

Muscle Strain Range of Motion

Decreased active/passive range of motion due to pain or weakness

Muscle Strain Strength 

Decreased strength and pain with active contraction

Muscle Strain Diagnosis

Manual muscle tests, important to rule out other pathologies 

Muscle Strain Treatment

Decrease pain, therapeutic exercise to restore function

Zygapophyseal/Facet Joint Sprain Structures Involved

Facet joint capsule

Zygapophyseal/Facet Joint Sprain Mechanism of Injury 

Acute or overuse

Zygapophyseal/Facet Joint Sprain Complaints

Pain located just off the midline (hips, buttocks, posterior thight)

Zygapophyseal/Facet Joint Sprain ADLs Affected

Extension movements, prolonged standing 

Zygapophyseal/Facet Joint Sprain Neurologic Exam 

None Affected

Zygapophyseal/Facet Joint Sprain Range of Motion

Pain with extension, rotation, lateral flexion, axial load 

Zygapophyseal/Facet Joint Sprain Diagnosis

Diagnostic injection therapy, imaging unreliable

Zygapophyseal/Facet Joint Sprain Special Tests

Kemps Test, Quadrant Test

Zygapophyseal/Facet Joint Sprain Treatment

NSAIDs, therapeutic exercise (flexion), spinal manipulation, traction, injection, radiofrequency ablation of medial branch

Facet Joint Syndrome/Osteoarthritis Structures Involved

Facet joint surface, joint capsule 

Facet Joint Syndrome/Osteoarthritis Mechanism of Injury

Overuse 

Facet Joint Syndrome/Osteoarthritis Complaints

• Deep ache 

• Paravertebral or posterolateral pain

• Worse in morning and improves with repetitive motion 

• Referred pain to buttocks, hip, posterior or lateral thigh 

Facet Joint Syndrome/Osteoarthritis Neurologic Exam

None Affected

Facet Joint Syndrome/Osteoarthritis Range of Motion 

Pain with extension, rotation, axial load 

Facet Joint Syndrome/Osteoarthritis Diagnosis

Imaging shows joint space narrowing, osteophyte formation, hypertrophy of the articular process, cysts, subarticular bone erosion 

Facet Joint Syndrome/Osteoarthritis Treatment

Medication, therapeutic exercise, injection, radiofrequency of medial branch, surgery 

Disc Herniation Structures Involved

Annulus fibrosis, nucleus pulposis, spinal nerve roots

Disc Herniation Mechanism of Injury

Acute of overuse

Disc Herniation Complaints

• Central low back pain (achy or sharp) 

• Radiating pain as far as foot

• Pain with transitional movements 

Disc Herniation ADLs Affected

Flexion movements, sitting (relieved by standing/lying), valsalva 

Disc Herniation Range of Motion

Decreased flexion, extension, and lateral flexion due to pain 

Disc Herniation Neurologic Exam

can have peripheral nerve weakness, paresthesia, diminished reflexes 

Disc Herniation Diagnosis

MRI, discography

Disc Herniation Special Tests

Centralization

Disc Herniation Treatment

Therapeutic exercise, steroid injection, surgery

Lumbar Stenosis Structures Involved

Central canal, lateral recess, foramen, nerve root, ligamentum flavum hypertrophy

Lumbar Stenosis Mechanism of Injury

Overuse, degenerative

Lumbar Stenosis Complaints

• Radiculopathy to buttocks, knee, foot, or groin

• Heaviness of weakness of lower extremities 

• Often bilateral or asymmetric but can be unilateral 

Lumbar Stenosis ADLs Affected

Pain with walking and standing

Lumbar Stenosis Range of Motion

Extension increases pain, flexion decreases pain 

Lumbar Stenosis Neurologic Exam

Dermatome, myotome, and reflexes can all be affected

Lumbar Stenosis Diagnosis

Imaging to measure foraminal space

Lumbar Stenosis Treatment

Therapeutic exercise, pain medication, injection, decompressive laminectomy

Lumbar Spondylosis

Nonspecific term for degenerative of the discs and/or bony structures

Lumbar Spondylosis Structures Involved

Vertebral bodies, facet joints, and/or discs

Lumbar Spondylosis Mechanism of Injury 

Overuse

Lumbar Spondylosis Complaints

Low back pain, leg pain

Lumbar Spondylosis ADLs Affected

Pain worsens with walking or standing, alleviated by sitting or supine

Lumbar Spondylosis Neurologic Exam

Dermatomes, myotomes, strength, and reflexes could all be affected

Lumbar Spondylosis Diagnosis

Xray, MRI, CT

Lumbar Spondylosis Treatment

Ice, heat, NSAIDs, therapeutic exercise, injection, surgery

Schmorls Nodes Structures Involved

Vertebral end plate, vertebral body, nucleus pulposis 

Schmorls Nodes Mechanism of Injury

Axial loading or chronic degeneration

Schmorls Nodes Complaints

Most asymptomatic but can cause low back pain

Schmorls Nodes Neurologic Exam

None Affected

Schmorls Nodes Diagnosis

MRI

Schmorls Nodes Treatment

Conservative, fusion, can resolve spontaneously

Degenerative Disc Disease

After age 40 most people experience some degree of disc degeneration although not always pathologic 

Degenerative Disc Disease Structures Involved

Nucleus puplosis, annulus, vertebral end plates

Degenerative Disc Disease Characterized By

Decreased disc space, loss of fluid, annular tears

Degenerative Disc Disease Mechanism of Injury

Overuse

Degenerative Disc Disease Complaints

Low back pain and/or radiculopathy

Degenerative Disc Disease ADLs Affected

Flexion movements

Degenerative Disc Disease Neurologic Exam

May or may not have findings

Degenerative Disc Disease Diagnosis

MRI

Degenerative Disc Disease Treatment

NSAIDs, therapeutic exercise, fusion, disc replacement

Piriformis Syndrome Also Known As

Deep Gluteal Syndrome

Piriformis Syndrome Structures Involved

Piriformis, Sciatic Nerve

Piriformis Syndrome Mechanism of Injury

Direct trauma, overuse, insidious onset

Piriformis Syndrome Complaints

Low back pain, radiating pain into buttocks/posterior thigh, tenderness in gluteal region 

Piriformis Syndrome ADLs Affected

Pain with prolonged sitting or walking, firing external rotators

Piriformis Syndrome Range of Motion

Passive tightness, reproduce symptoms with active contraction

Piriformis Syndrome Neurologic Exam

Not likely to see deficits unless it’s a chronic issue

Piriformis Syndrome Diagnosis

Rule out disc herniation, stenosis, and facet issues, MRI

Piriformis Syndrome Treatment

Therapeutic exercise, glute release, dry needling, NSAIDs, injection

Spondylolysis 

Stress fracture with no translation

Spondylolisthesis

Stress fracture that allows anterior translation of vertebral body

Spondylolysis and Spondylolisthesis Structures Involved

Pars interarticularis 

Spondylolysis and Spondylolisthesis Mechanism of Injury

• Repetitive extension and rotation 

• Tend to have hyperlordosis

• Insidious onset

Spondylolysis and Spondylolisthesis Complaints

Pain with extension (especially single leg)

Spondylolysis and Spondylolisthesis ADLs Affected 

Extension movements

Spondylolysis and Spondylolisthesis Range of Motion

Extension may be limited due to pain, flexion may be limited due to tight hamstrings 

Spondylolysis and Spondylolisthesis Neurologic Exam

None Affected

Spondylolysis and Spondylolisthesis Diagnosis

Pinpoint tenderness, step off, one legged hyperextension test, xray with oblique view 

Spondylolisthesis Classification

By amount of slippage anteriorly (Grade I-V)

Spondylolysis and Spondylolisthesis Treatment 

Rest, bracing, therapeutic exercise, posterolateral fusion if conservative 

Anterior Column of Spine

Anterior Longitudinal Ligament, Anterior half of vertebral bodies 

Middle Column of Spine

Posterior half of vertebral bodies and posterior longitudinal ligament

Posterior Column of Spine

Pedicles, laminae, spinous processes, facet joints, supraspinous/interspinous/intertransverse ligaments, ligamentum flavum

Compression Fractures

Traumatic, atraumatic, pathologic

Burst Fracture

Anterior and Middle column

Wedge Fracture

Anterior Column

Chance Fracture

Middle and posterior column, entirely through the bone 

Structures Involved in Fractures

Vertebral Body

Fracture Mechanism of Injury

Trauma, axial overload, rapid flexion, extreme rotation, shear

Fracture Complaints

Pain, loss of function

Fracture Neurologic Exam

Motor, sensory, and reflexes can all suffer deficits

Fracture Range of Motion

Should not be performed if suspected fracture

Fracture Diagnosis

Xray, CT

Fracture Treatment

Most managed conservatively, thoracic lumbar sacral orthosis, therapeutic exercise, surgery if unstable

Coccyx Fracture/Dislocation Structures Involved

Coccygeal Segments