Differential diagnosis with intervention of spine, pelvis, and TMJ

Spine and pelvis differential diagnosis

• Spinal or intervertebral stenosis
  • Narrowing of spinal canal or intervertebral foremen
    • Can cause neurological or vascular dysfunction

• Symptoms
  • Bilateral back, buttocks, and leg pain
  • Pain increases with extension
  • Pain increases with walking
  • Pain decreases with flexion and/or rest
• Diagnosis
  • Clinical presentation
    • Special tests- bicycle test
  • MRI
  • CT imaging
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Corticosteroids
  • Muscle relaxants
• Physical therapy management
  • Flexion based exercises that centralize pain
  • Dynamic stability for trunk and pelvis
  • Manual therapy
  • Avoidance of extension, ipsilateral side-bending, and ipsilateral rotation

Facet joint dysfunction (two types: degenerative joint disease, facet entrapment)

• Degenerative joint disease
  • Causes bone hypertrophy, capsular fibrosis, hypermobility or hypomobility at joint caused by natural process of aging
  • Occurs due to repetitive weight bearing of facets and intervertebral joints over life-span

• Symptoms
  • Localized pain in the neck, back, or buttocks
  • Pain that worsens with certain movements, such as bending, twisting, or standing for long periods of times
  • Pain that radiates into the arms, legs, or shoulders
  • Difficulty moving the neck or back
  • Morning stiffness that improves with activity
• Diagnosis
  • Clinical presentation
    • Special test- quadrant test
  • X-ray
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Corticosteroids
  • Muscle relaxants
• Physical therapy management
  • Spinal mobilization as appropriate
  • Exercise promoting dynamic stability of trunk and pelvis

• Facet entrapment (acute locked back)
  • A condition where the small joints (facet joints) connecting vertebrae in the spine become inflamed or damaged, causing pain and potentially restricting movement

• Symptoms
  • Dull, aching pain in the back or neck, which can worsen with certain movements or activities
  • Difficulty moving the spine - flexion is most comfortable for patient
  • Spasms in the back or neck muscles as a protective response to the pain.
  • Can cause nerve irritation can cause numbness or tingling in the arms, legs, or buttocks.
• Diagnosis
  • Clinical presentation
    • Special test- quadrant test
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Corticosteroids
  • Muscle relaxants
• Physical therapy management
  • Facet manipulation to improve mobility

Disc Conditions

• Internal disc disruption
  • Internal annulus is disrupted while outside structures remain intact

• Symptoms
  • Chronic, central low back pain
  • Pain worsens with activity and loading the spine
  • Muscle spasms.
  • Pain may be constant or episodic
  • No neurological findings
• Diagnosis
  • Clinical presentation
  • CT scan
  • MRI
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Corticosteroids
  • Muscle relaxants
• Physical therapy management
  • Joint mobilization
  • Patient education on biomechanics and positions to avoid

• Posterolateral bulge/herniation
  • Overstretching or tearing of annular rings, vertebral endplate, and or ligamentous structures due to high compressive forces or repetitive trauma

• Symptoms
  • Radicular pain
  • Lower extremity weakness
  • Lower extremity paresis
• Diagnosis
  • Clinical presentation
  • MRI
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Corticosteroids
  • Muscle relaxants
• Physical therapy management
  • Improve dynamic stability of trunk and pelvis
  • Spinal manipulation
  • Manual traction
  • Positional gapping
  • Patient education on biomechanics

• Central posterior bulge herniation
  • Overstretching or tearing of annular rings, vertebral endplate, and or ligamentous structures due to high compressive forces or long term postural misalignment
    • Move common in cervical spine

• Symptoms
  • Radicular pain
  • Lower extremity weakness
  • Lower extremity paresthesia
  • Possible compression of spinal cord causing upper motor neuron lesion
• Diagnosis
  • Clinical presentation
  • MRI
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Corticosteroids
  • Muscle relaxants
• Physical therapy management
  • Improve dynamic stability of trunk and pelvis
  • Spinal manipulation
  • Manual traction
  • Positional gapping

Spondylosis

• Spondylosis is a degenerative condition of the spine that involves changes in the intervertebral discs and facet joints, commonly referred to as spinal osteoarthritis.
• Can be caused by degeneration of the intervertebral disc (disc desiccation), formation of osteophytes (bone spurs), or possible narrowing of the intervertebral

• Symptoms
  • Gradual onset of chronic back pain and stiffness, especially in the cervical and lumbar spine
  • Limited range of motion, especially extension and rotation
  • May be asymptomatic or cause radicular symptoms if nerve compression occurs
• Diagnosis
  • X-ray: Reduced disc space, osteophyte formation, facet joint changes
  • MRI: Assesses neural compression and disc degeneration
• Medical management
  • NSAIDs pain and inflammation
  • Muscle relaxants if muscle spasms are present
  • Corticosteroid injections (epidural or facet joint) for nerve root involvement
  • Surgical intervention (e.g., decompression or fusion) in cases of severe stenosis or myelopathy
• Physical therapy management
  • Postural education and ergonomic training
  • Stretching of tight musculature (e.g., hamstrings, hip flexors)
  • Strengthening of spinal stabilizers, especially deep core muscles
  • Manual therapy to improve mobility
  • Aerobic conditioning (walking, cycling)
  • Education on activity pacing and joint protection

Spondylolysis

• Stress fracture or defect in the pars interarticularis, the segment of bone between the superior and inferior articular processes of a vertebra.
• Often occurs due to repetitive hyperextension, particularly in young athletes
• Most commonly affects the L5 vertebra

• Symptoms
  • Localized low back pain, worsened with lumbar extension
  • Possible tight hamstrings
  • Usually no neurological symptoms
• Diagnosis
  • Oblique lumbar X-ray: Shows “Scotty dog with a collar” appearance
  • CT or MRI may confirm the presence of the defect
• Medical management
  • Activity modification (rest from extension-heavy sports)
  • NSAIDs for pain relief
  • Bracing (e.g., lumbosacral orthosis) to allow healing
  • In rare non-healing cases, surgical fixation
• Physical therapy management
  • Education: Avoid extension-based movements initially
  • Core stabilization exercises (neutral spine control)
  • Hamstring stretching and hip mobility work
  • Gradual return to sport with movement re-education
  • Emphasis on lumbar-pelvic control during dynamic a

Spondylolisthesis

• Anterior slippage of one vertebra over the vertebra below it. It may be the result of spondylolysis (isthmic) or degenerative changes.
• Types
  • Isthmic: Due to bilateral pars defects (common in younger individuals)
  • Degenerative: Due to facet joint and disc degeneration (common in older adults)

• Symptoms
  • Low back pain with or without radicular symptoms
  • Tight hamstrings and altered posture
  • Palpable step-off deformity
  • In severe cases, may present with neurological deficits
• Diagnosis
  • Lateral X-ray: Shows degree of vertebral slippage (graded I–V based on percent displacement)
  • MRI: Identifies soft tissue or neural involvement
• Medical management
  • NSAIDs, acetaminophen, or muscle relaxants for pain
  • Epidural steroid injections if radiculopathy is present
  • Bracing for pain control and stability
  • Surgical intervention (e.g., spinal fusion) in cases of high-grade slippage or neurological compromise
• Physical therapy management
  • Core strengthening to stabilize the lumbar spine
  • Postural retraining
  • Avoid lumbar hyperextension and heavy axial loading
  • Stretching tight muscles (especially hamstrings)
  • Manual therapy for adjacent segment mobility
  • Progressive return to activity under supervision
  • Education on body mechanics and functional movement patterns

Whiplash associated disorders (WAD)

• Occurs in cervical spine when excess shear and tension occur on the structures of the cervical spine
  • Structures damaged are facets/articular processes, facet joint capsule, ligaments disc, anterior/posterior muscles, fracture to odonotoid process, TMJ, spinal nerves, cranial nerves

• Symptoms
  • Heachaches
  • Limited mobility
  • Vertigo
  • Hearing loss or ringing in the ears
  • Difficulty swallowing
  • TMJ dysfunction
  • Disequilibrium
  • Anxiety
• Diagnosis
  • Clinical presentation
    • Canadian c-spine rues
  • MRI
  • CT scan
  • X-ray
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Corticosteroids
  • Muscle relaxants
• Physical therapy management
  • Spinal manipulation
  • Patient education on biomechanics and positions to avoid
  • Joint mobilization
  • Functional training

Sacroiliac joint conditions

• Causes of dysfunction can be inflammation, degenerative changes, or abnormal movement patterns
  • Can be associated with lumbar spine so will need to examine both when pain reported

• Symptoms
  • Lower back pain, often on one side
  • Pain that radiates to the buttocks, hips, or thighs
  • Pain that worsens with activities such as sitting, standing, or walking
  • Stiffness in the lower back or hips, especially after sitting for long periods
• Diagnosis
  • Clinical presentation
  • Special test- SI gapping, SI compression, Gaenslens test
  • MRI
  • X-ray
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Corticosteroids
  • Muscle relaxants
• Physical therapy management
  • Spinal manipulation
  • Patient education on biomechanics and positions to avoid
  • Joint mobilization
  • Functional training

Sacral Spondylolisthesis

• Forward slippage of the sacrum or L5 over the sacrum due to instability such as trauma, stress fractures, or degenerative changes

• Symptoms:
  • Low back pain (worse with extension).
  • Sacral/hip pain.
  • Tight hamstrings.
  • Possible nerve compression leading to leg pain or weakness.
• Diagnosis:
  • Clinical presentation
  • X-ray
  • MRI
  • CT scan
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Corticosteroids
  • Muscle relaxants
• Treatment
  • Core stabilization exercises.
  • Physical therapy for posture correction.
  • Bracing for mild cases

Upslip of the Ilium (Superior Ilium Displacement)

• The ilium on one side moves superiorly relative to the sacrum.
• Common causes:
  • Trauma (e.g., stepping off a curb forcefully, falling on one side), muscle imbalances.
• Impaired (Weak/Lengthened) Muscles:
  • Gluteus medius & gluteus minimus (difficulty stabilizing the pelvis).
  • Quadratus lumborum (opposite side) (overstretched and weak).
  • Hip adductors (on the affected side, often lengthened).
• Tight/Overactive Muscles:
  • Quadratus lumborum (same side) (shortened, pulling the ilium superiorly).
  • Iliopsoas (on the affected side, can contribute to pelvic asymmetry).
  • Hamstrings (may compensate for instability).

Downslip of the Ilium (Inferior Ilium Displacement)

• The ilium on one side moves inferiorly relative to the sacrum.
• Common causes:
  • High-impact trauma, instability in the sacroiliac (SI) joint.
• Impaired (Weak/Lengthened) Muscles:
  • Quadratus lumborum (same side) (overstretched and weak).
  • **Gluteus medius & gluteus minimus **(lack of pelvic stability).
  • Hip abductors (due to altered pelvis positioning).
• Tight/Overactive Muscles:
  • Hip adductors (same side) (contracting to stabilize the pelvis).
  • Quadratus lumborum (opposite side) (may tighten in compensation).

TMJ conditions

• Can be due to
  • Osteoarthritis, rheumatoid arthritis
  • Myofascial pain- pain in muscles controlling TMJ
  • Dislocation of jaw

• Symptoms
  • Joint noise when opening mouth
  • Joint locking
  • Loss of range of motion
  • Lateral deviation during depression or elevation of mandibile
  • Decreased strength of mandible
  • Headache
  • Ringing in ears
  • Forward head posture
  • Can have cervical spine pain
• Diagnosis
  • Clinical presentation
  • X-ray
  • MRI
• Medical management
  • Acetaminophen or non-steroidal inflammatory (NSAIDs)
  • Corticosteroids
  • Muscle relaxants
• Physical therapy management
  • Patient education on biomechanics and positions to avoid
  • Joint mobilization
  • Biofeedback
  • Modalities for pain and inflammation
  • Night splinting