Physical Exam of the Lower Spine and Lower Extremities

Written by Travis Brege with Dr. Nabil Ebraheim

The steps of any orthopedic examination will follow the pattern of inspection, palpation, range of motion, and tests of strength for the key groups of muscles applying all the appropriate provocative tests and neurovascular examinations. 

First, in the inspection of the spine, look for any visible deformities in the coronal (frontal) and sagittal (longitudinal) planes. In the coronal plane, check for scoliosis and pelvic obliquity1. In the sagittal plane, check for normal cervical lordosis, thoracic kyphosis, and lumbar lordosis2. While assessing the symmetry of the whole body, make sure to assess the skin for lesions, hairy patches, dimples, surgical scars, muscular atrophy, and anything else that may be abnormal.

Next, you want to palpate the iliac crests, posterior superior iliac spines, spinous processes, sacrum, trochanters, and ischial tuberosities. Palpate the soft tissue as well, assessing trigger points such as the gluteus muscles, piriformis, and sciatic nerve. 

Assess the patient’s movement first with their gait as certain gaits may indicate various pathologies (ie. antalgic, Trendelenburg, steppage, and staggering gaits)3. Then, check the movements of the lower spine to identify if any causes pain; for example, extension of the spine creates pain in lumbar stenosis4, while spinal flexion can create pain when a disk pathology is present5.

Now, we can assess the individual nerve roots from L2-S1 using sensory and motor testing, reflex tests, specific provocative tests, and check for Waddell Signs. 

In sensory testing, the areas that can be assessed include pain, light touch, temperature, and proprioception (awareness of the position of one’s body). Sensory testing can indicate a spinal root pathology in the presence of a dermatomal pattern of dysfunction, or it can suggest a neuropathy in the presence of a glove-and-stocking distribution of sensory dysfunction6. The specific pattern of sensory distribution in the lower extremities can be normal, impaired, or completely absent in some cases. 

In motor testing, the action of hip flexion comes largely from the iliopsoas muscle, which is innervated by the L1, L2, and L3 lumbar nerve roots. Hip abduction is completed through the L2, L3, and L4 lumbar nerve roots. Knee extension is innervated by the L2, L3, and L4 lumbar nerve roots. Dorsiflexion is largely performed via the tibialis anterior muscle which is innervated by the L4 lumbar nerve root. Extension of the hallux is mainly innervated by the L5 lumbar nerve root. Ankle plantarflexion is performed using the gastro-soleus complex whose main innervation is from the S1 sacral nerve root7. 

For reflexes, only two exist in the lower extremity that are utilized in physical examination. The Patellar Reflex which is innervated by the L4 lumbar nerve root, and the Achilles Tendon Reflex which is innervated by the S1 sacral nerve root7. 

Provocative and special tests can be used to help differentiate between musculoskeletal pathology and spinal pathology. These include the Straight Leg Raising Test for L5-S1 nerve root irritation8 and the Femoral Stretch Test for L3-L4 nerve root irritation9. Upper motor neuron lesions can be identified or ruled out utilizing the Clonus Test10 and the Babinski Test11. The Bulbocavernosus Reflex can be utilized to detect spinal shock12. The Faber (Flexion, ABduction, External Rotation) Test is a good test for assessing the sacroiliac joint, but it is NOT confirmatory13,14. Sacroiliac joint test is usually confirmed by the injection of an anesthetic with a positive response for reduction of pain15.

Waddell’s Signs are controversial, however, assessing for these signs can be included as a part of a thorough physical examination for a patient that presents with lower back pain. Waddell’s Signs include: (1) superficial tenderness, (2) non-anatomical tenderness (tenderness that exists over a wide area that goes beyond a single anatomical boundary), (3) axial loading pain on the patient’s head that elicits low back pain, (4) acetabular rotation causing low back pain, (5) distracted straight leg discrepancy, (6) regional sensory disturbances, (7) regional muscle weakness that can’t be explained on an anatomical basis, and (8) overreaction to a pain stimulus that isn’t reproduced when the same provocation is applied at a later time16.


1. Janicki JA, Alman B. Scoliosis: Review of diagnosis and treatment. Paediatr Child Health. 2007 Nov;12(9):771-6. doi: 10.1093/pch/12.9.771. PMID: 19030463; PMCID: PMC2532872. 

2. Scheer JK, Tang JA, Smith JS, Acosta FL Jr, Protopsaltis TS, Blondel B, Bess S, Shaffrey CI, Deviren V, Lafage V, Schwab F, Ames CP; International Spine Study Group. Cervical spine alignment, sagittal deformity, and clinical implications: a review. J Neurosurg Spine. 2013 Aug;19(2):141-59. doi: 10.3171/2013.4.SPINE12838. Epub 2013 Jun 14. PMID: 23768023. 

3. Lim MR, Huang RC, Wu A, Girardi FP, Cammisa FP Jr. Evaluation of the elderly patient with an abnormal gait. J Am Acad Orthop Surg. 2007 Feb;15(2):107-17. doi: 10.5435/00124635-200702000-00005. PMID: 17277257.

4. Katz JN, Harris MB. Clinical practice. Lumbar spinal stenosis. N Engl J Med. 2008 Feb 21;358(8):818-25. doi: 10.1056/NEJMcp0708097. PMID: 18287604.

5. Kuai S, Liu W, Ji R, Zhou W. The Effect of Lumbar Disc Herniation on Spine Loading Characteristics during Trunk Flexion and Two Types of Picking Up Activities. J Healthc Eng. 2017;2017:6294503. doi: 10.1155/2017/6294503. Epub 2017 Jun 11. PMID: 29065628; PMCID: PMC5485332.

6. Scott K, Kothari MJ. Evaluating the patient with peripheral nervous system complaints. J Am Osteopath Assoc. 2005 Feb;105(2):71-83. doi: 10.7556/jaoa.2005.105.2.71. PMID: 15784929.

7. Basit H. Anatomy, Back, Spinal Nerve-Muscle Innervation [Internet]. StatPearls [Internet]. U.S. National Library of Medicine; 2021 [cited 2021Oct25]. Available from:

8. Capra F, Vanti C, Donati R, Tombetti S, O’Reilly C, Pillastrini P. Validity of the straight-leg raise test for patients with sciatic pain with or without lumbar pain using magnetic resonance imaging results as a reference standard. J Manipulative Physiol Ther. 2011 May;34(4):231-8. doi: 10.1016/j.jmpt.2011.04.010. Epub 2011 May 5. PMID: 21621724.

9. Suri P, Rainville J, Katz JN, Jouve C, Hartigan C, Limke J, Pena E, Li L, Swaim B, Hunter DJ. The accuracy of the physical examination for the diagnosis of midlumbar and low lumbar nerve root impingement. Spine (Phila Pa 1976). 2011 Jan 1;36(1):63-73. doi: 10.1097/BRS.0b013e3181c953cc. PMID: 20543768; PMCID: PMC2978791.

10. Zimmerman B, Hubbard JB. Clonus. 2021 Aug 12. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 30521283.

11. van Gijn J. The Babinski reflex. Postgrad Med J. 1995 Nov;71(841):645-8. doi: 10.1136/pgmj.71.841.645. PMID: 7494766; PMCID: PMC2398330.

12. Ko HY. Revisit Spinal Shock: Pattern of Reflex Evolution during Spinal Shock. Korean J Neurotrauma. 2018 Oct;14(2):47-54. doi: 10.13004/kjnt.2018.14.2.47. Epub 2018 Oct 31. PMID: 30402418; PMCID: PMC6218357.

13. Cattley P, Winyard J, Trevaskis J, Eaton S. Validity and reliability of clinical tests for the sacroiliac joint. A review of literature. Australas Chiropr Osteopathy. 2002 Nov;10(2):73-80. PMID: 17987177; PMCID: PMC2051080.

14. Nejati P, Sartaj E, Imani F, Moeineddin R, Nejati L, Safavi M. Accuracy of the Diagnostic Tests of Sacroiliac Joint Dysfunction. J Chiropr Med. 2020 Mar;19(1):28-37. doi: 10.1016/j.jcm.2019.12.002. Epub 2020 Sep 12. PMID: 33192189; PMCID: PMC7646135.

15. Jung MW, Schellhas K, Johnson B. Use of Diagnostic Injections to Evaluate Sacroiliac Joint Pain. Int J Spine Surg. 2020 Feb 10;14(Suppl 1):30-34. doi: 10.14444/6081. PMID: 32123655; PMCID: PMC7041665.

Spine Exam: Neck and Upper Extremity

 Written by Ryan Jones with Dr. Nabil Ebraheim

Neck and upper extremities spine examination or cervical spine physical examination involves assessment of vertebrae C3-T2, cranial nerve roots C4-T1, and all the muscles innervated by these nerve roots along with the muscles associated with basic neck movement. This examination follows the typical pattern of orthopedic examination of inspection, palpation, range of motion, neurological evaluation, and special tests1.


Check for any visual deformities or abnormal anatomical alignments in the coronal and sagittal plane including typical cervical lordosis and thoracic kyphosis1. Also, look for any surgical scars, skin defects like café au lait spots, or muscular atrophy2. Muscular atrophy can present as shoulder imbalance, scapular winging, or a general unilateral reduction in size of muscles of the upper extremities.


Palpate for local tenderness along the spinal axis while also looking for any asymmetry2. This includes palpations of the spinous processes and facet joints of the vertebrae along with palpation of the scapula to look for any asymmetry. Palpate the paraspinal muscles while looking for any tenderness or asymmetry. The muscles of importance include the trapezius, rhomboids, and levator scapulae muscles1,3.

Range of Motion

Range of motion for the cervical spine involves checking cervical flexion (normal = 50), extension (normal = 60), rotation (normal = 80), and lateral bending (normal = 45)2. A thorough range of motion examination should also be done for the shoulder due to the extensive nerve root innervation. Shoulder range of motion involves testing abduction (normal = 180), adduction (normal = 45), flexion (normal = 90), extension (normal = 45), internal rotation (normal = 55), and external rotation (normal = 45)4. Any abnormalities in range of motion can be indicative of muscular or neurological pathologies.

Neurological Examination

Test the motor ability and strength of the muscles associated with each cranial root for strength by grading it 0-V based on the muscle manual testing grading system2,3. Any weakness is a sign of muscular or neurological pathology. Next, test for sensory function for pain (with a paper clip) and light touch (finger) sensation at the dermatome for each cranial nerve1. Any abnormalities may be a result of neurological pathologies. Test the biceps reflex for C5, brachioradialis reflex for C6, and triceps reflex for C7 cranial nerve root abnormalities1.

Special Tests

Use the following provocative test to differentiate neck pathologies from other upper extremity:

·         Spurling’s test is indictive of acute radioculopathy2.

·         Hoffman’s test is indictive of cervical myelopathy2.

·         Lhermitte’s test is indicative of compression and myelopathy of the cervical spine2.

·         Stretch test is indicative of brachial plexus pathology.

·         Compression test is indicative of narrowing of the neural foramen, facet joint pressure, or muscle spasms from the paraspinal muscles3.

·         Observation of steppage, lateral, or wide-base gait are all indicative of myelopathy or neurological pathology2.

Remember that an MRI may be required to confidently differentiate between shoulder and neck pathologies1.


1.       Ebraheim N. Spine Exam & Upper Extremity – Everything You Need to Know – Dr. Nabil Ebraheim [Internet]. Toledo (OH): University of Toledo Medical Center, Department of Orthopedics; 2021 Aug 4 [cited 2021 Oct 23]. Available from:

2.       Moore DW. Neck & Upper Extremity Spine Exam [Internet]. Santa Barbara (CA): Santa Barbara Orthopedic Associates; 2021 June 27 [cited 2021 Oct 23]. Available from:

3.       Iyer KM. Examination of the Cervical Spine. In: Clinical Examination in Orthopedics. London: Springer; 2012. pp 97-107.

4.       Iyer KM. Examination of the Shoulder. In: Clinical Examination in Orthopedics. London: Springer; 2012. pp 9-18.

Neck Pain Causes and Treatments

Written by Katherine Esser and Dr. Nabil Ebraheim

Neck pain is a common ailment of the American population, affecting 30 to 50% of adults annually. While there are numerous etiologies of neck pain, this is a brief review of the more common causes and modes of treatment.

Firstly, radiculopathy from disc herniation. In addition to neck pain, the patient will complain of arm pain that typically follows a myotomal pattern, and sensory symptoms (like burning and tingling) that follow a specific dermatome in the hand. There may also be motor weakness of the upper extremity. This is due to compression of a nerve root either by a disc herniation or by arthritis that narrows the foramen. A neurological exam assessing motor, sensory and reflex testing should be done to determine cervical spine disc herniation. Treatment should first be non-surgical with anti-inflammatory medication, isometric exercises, physical therapy, and muscle relaxants. An MRI should be ordered if symptoms do not improve after 6–12 weeks of conservative treatment. If there is an indication for surgery, it often involves decompression and fusion of the involved disc space. 26% of patients with cervical radiculopathy require surgery.

Secondly, neck pain may be due to cervical myelopathy. This is the most common cause of non-traumatic spinal cord dysfunction. It is due to direct compression of the spinal cord or surrounding blood vessels, and presents in a variety of ways clinically. Indications of cervical myelopathy are an unstable and wide-based gait, clumsiness of the hands, occipital headaches, and discomfort of the neck. The pain may not be severe, but insidious, gradual, and poorly characterized. An MRI may be ordered which will show compression of the spine. Due to the slow, stepwise deterioration in cervical myelopathy, each stage may be treated differently. There is conflicting evidence regarding the conservative versus surgical approach to treatment of cervical myelopathy. The goal for surgery is cord decompression with expansion of the spinal canal, restoration of cervical lordosis, and stabilisation if the risk of cervical kyphosis is high. The evidence suggests mild cervical myelopathy should be treated conservatively with careful observation, whereas surgical intervention should be employed for moderate to severe cases.

Thirdly, neck pain may be due to a whiplash injury. This is the most common traumatic cause of neck pain. Specifically, neck hyperreflexia and neck pain after a car collision from behind. Pain may refer to the head, shoulder, or arm. There are usually no neurological deficits. The patient will have a soft tissue injury and an x-ray will show cervical lordosis due to muscle spasm. Treatment for a whiplash injury is aggressive physical therapy and mobilization.

Cervical spondylosis may also cause neck pain. This is arthritis of the spine. It is a natural degenerative process of cervical spine which will be shown on X-Ray. Degenerative changes start in the intervertebral discs with osteophyte formation and involvement of soft tissue structures. It is important to note many people over 30 years of age display similar abnormalities on imaging of the cervical spine and it may be difficult to delineate normal aging and disease. Cervical spondylosis can be diagnosed clinically based on characteristic exacerbation by neck movement. Although pain is focused in the cervical area, it is also referred to a wide area. Cervical spondylosis should be managed medically and surgery should only be done if there is instability or neurological deficit. In fact, there is evidence that suggests various exercise regiments may be more effective than usual medicinal care (analgesics, muscle relaxants) or stress management.

While there are various pathologies to include in the differential of neck pain, typically, patients with neck pain will have no injury. Pain will be in the posterior neck, tender to palpation with no radiation to the arm, no neurological deficits, and an X-Ray will show mild arthritis. Often, patients will be prescribed anti-inflammatory medication and referred to physical therapy.


1. Goode AP, Freburger J, Carey T. Prevalence, practice patterns, and evidence for chronic neck pain. Arthritis Care Res (Hoboken). 2010 Nov;62(11):1594–601. doi: 10.1002/acr.20270. Epub 2010 Jun 2. PMID: 20521306; PMCID: PMC2974793.

Ebraheim N. Neck pain causes and treatment — everything you need to know — Dr. Nabil Ebraheim [Internet]. YouTube. YouTube; 2021 [cited 2021Nov24]. Available from:

3. Wong JJ, Côté P, Quesnele JJ, Stern PJ, Mior SA. The course and prognostic factors of symptomatic cervical disc herniation with radiculopathy: a systematic review of the literature. Spine J. 2014; 14(8):1781–9.

4. Bakhsheshian J, Mehta VA, Liu JC. Current Diagnosis and Management of Cervical Spondylotic Myelopathy. Global Spine J. 2017 Sep;7(6):572–586. doi: 10.1177/2192568217699208. Epub 2017 May 31. PMID: 28894688; PMCID: PMC5582708.

5. MacDermid JC, Walton DM, Bobos P, Lomotan M, Carlesso L. A Qualitative Description of Chronic Neck Pain has Implications for Outcome Assessment and Classification. Open Orthop J. 2016 Dec 30;10:746–756. doi: 10.2174/1874325001610010746. PMID: 28217199; PMCID: PMC5301418.

6. Binder AI. Cervical spondylosis and neck pain. BMJ. 2007 Mar 10;334(7592):527–31. doi: 10.1136/bmj.39127.608299.80. PMID: 17347239; PMCID: PMC1819511.

ACL Ganglion Cyst, Meniscal Cyst, Baker Cyst — Everything You Need to Know

Written by Ali Mahmoud with Dr. Nabil Ebraheim

 There are many cysts that can occur in and around the knee joint. These types of cysts include an anterior cruciate ligament (ACL) ganglion cyst, meniscal cyst, and baker’s cyst.

Ganglion cysts contain yellow viscous fluid surrounded by a thin capsule, and are considered rare when associated with the ACL (1). Theorized pathogenesis of an ACL ganglion cyst includes synovial tissue herniation, post-traumatic mucoid degeneration mediated by local release of hyaluronic acid, ectopic synovial tissue theory, and displacement of synovial fluid during embryogenesis. These cysts are often discovered during knee MRI or knee arthroscopy while evaluating symptoms of knee pain or limited knee motion. There are no defining symptoms of ACL ganglion cysts, but they should be suspected in patients with knee pain or limited range of motion in their knees. MRI’s are the gold standard for diagnosing ACL ganglion cysts, with the diagnostic criteria being a fluid signal in the substance of the ligament with two of the following three criteria: 1) mass effect on ACL fibers, 2) lobulated margins, and 3) ACL fluid disproportionate to the joint. The treatment of choice for an ACL ganglion cyst is an arthroscopic decompression with debridement of the cyst for instant relief of pain, range of motion improvement, and return to physical activities. In cases where arthroscopic decompression is not available, aspiration under CT or ultrasound have shown excellent results in treating these cysts. These cysts do not recur after resection (2).

Meniscal cysts are believed to occur when the meniscal fibrocartilage tears, allowing synovial fluid to extrude through the meniscal tear and become encysted. Meniscal cysts can be classified into 3 subtypes: parameniscal, intrameniscal, and synovial. Parameniscal cysts appear on MRI as a loculated fluid-intensity lesion with a clear connection to the adjacent meniscus (4). Intrameniscal cysts appear as an abnormally increasing signal within an enlarged meniscus. Synovial meniscal cysts are cystic outpouchings of the joint capsule that are not associated with trauma. They are frequently asymptomatic, and are found incidentally on MRIs performed to assess for other knee pathologies. Symptomatic meniscal cysts can be treated with arthroscopic resection and repair of the causative meniscal tear (3).

Baker’s cyst (popliteal cyst) is the most common cyst in the knee (3). These are fluid-filled lesions arising in the popliteal fossa as an enlargement of the gastrocnemio-semimembranosus bursa. These cysts can expand into the spaces between muscle and knee capsule. Rarely, they can extend into nearby muscles such as the vastus medialis muscle and the head of the gastrocnemius muscle (6). Complications of a Baker’s cyst include rupture, hemorrhage and infection. Most Baker’s cysts are asymptomatic, but larger ones may cause nerve entrapment, compress nearby veins, or limit knee range of motion (3). Cysts that rupture can cause symptoms similar to phlebitis (5). They can be visualized on MRI along with any associated pathology that is causing the cyst, such as arthritis or meniscal tear. They can be treated conservatively with rest, ice, and anti-inflammatory medications. They can also be treated with aspirations, steroid injections or surgical excisions. If an intra-articular pathology is present that is causing the cyst, then treatment with arthroscopy and debridement of the pathology is recommended to prevent recurrence of the Baker’s cyst.


1.       Plotkin B, Agarwal VK, Varma R. Ganglion Cyst of the Anterior Cruciate Ligament. Radiology Case Reports. 2009;4(3):1-4.

2.       Vaishya R, Esin Issa A, Agarwal AK, Vijay V. Anterior Cruciate Ligament Ganglion Cyst and Mucoid Degeneration: A Review. Cureus. 2017 Sep 13;9(9):e1682. doi: 10.7759/cureus.1682. PMID: 29152439; PMCID: PMC5679775.

3.       Telischak NA, Wu JS, Eisenberg RL. Cysts and cystic-appearing lesions of the knee: A pictorial essay. Indian J Radiol Imaging. 2014 Apr;24(2):182-91. doi: 10.4103/0971-3026.134413. PMID: 25024531; PMCID: PMC4094974.

4.       Crowell MS, Westrick RB, Fogarty BT. Cysts of the lateral meniscus. Int J Sports Phys Ther. 2013 Jun;8(3):340-8. PMID: 23772349; PMCID: PMC3679639.

5.       Handy JR. Popliteal cysts in adults: a review. Semin Arthritis Rheum. 2001 Oct;31(2):108-18. doi: 10.1053/sarh.2001.27659. PMID: 11590580.

6.       Li TY. The Sonographic Spectrum of Baker Cysts. Journal of Diagnostic Medical Sonography. 2017 Sep 9;34(1):38-48. doi: 10.1177/8756479317733750.