Comparing clinical presentation and interventions for the spine, pelvis, and temporomandibular joint

Comparing clinical presentation

PTA role: Spinal and peripheral joint mobilization and manipulation - including thrust techniques - are performed exclusively by the physical therapist; APTA policy does not permit a PTA to perform or carry out these interventions. As a PTA, you deliver the interventions the PT has delegated to you (therapeutic exercise, patient education, manual traction, and similar), while monitoring the patient’s response, collecting objective data, and reporting changes to the PT - you don’t evaluate the patient or modify the plan of care. Notify the PT immediately if you see new or worsening neurological deficits, saddle anesthesia, or bowel/bladder changes (possible cauda equina signs), or signs of myelopathy such as hyperreflexia or gait disturbance; these call for immediate follow-up, not continued treatment.

Several of these conditions share opposite mechanical patterns worth contrasting directly. Use this directional preference to help differentiate look-alike back pain presentations.

Condition	Worsens with	Eases with
Spinal stenosis, facet entrapment, spondylolysis	Extension	Flexion and/or rest
Posterolateral disc herniation	Flexion	Extension (directional preference)

Manipulation and traction - contraindications and precautions: Fracture, upper cervical (odontoid) instability, spinal cord compression (myelopathy), and cauda equina signs are contraindications - don’t proceed, and notify the PT. An unstable segment, such as spondylolisthesis, is a precaution; mobilization should target the adjacent, stable segments rather than the unstable one. Acute WAD is also a precaution, since ligamentous and odontoid injury must be ruled out before any manual therapy proceeds.

Medications across these conditions: Acetaminophen or NSAIDs, corticosteroids, and muscle relaxants are commonly used across most of the conditions in this chapter. As the PTA, keep their effects on therapy in mind: analgesics and NSAIDs can mask pain during exercise, so watch for overexertion; prolonged corticosteroid use can weaken tendons, ligaments, and bone; and muscle relaxants can cause sedation and increase fall risk. See the medications, imaging, and fractures chapter for more detail.

Spinal stenosis

• Spinal or intervertebral stenosis

  • Narrowing of the spinal canal or intervertebral foramina
    • Can cause neurological or vascular dysfunction

• Symptoms

  • Back, buttock, and leg pain, usually bilateral with central canal stenosis and often one-sided with foraminal stenosis
  • 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

• Physical therapy management

  • Flexion-based exercises (e.g., posterior pelvic tilt, single/double knee-to-chest)
  • Dynamic stability for trunk and pelvis
  • Manual therapy such as joint mobilization (performed by the PT)
  • 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 the joint caused by the natural process of aging
  • Occurs due to repetitive weight bearing of facets and intervertebral joints over the 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 time
  • 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

• Physical therapy management

  • Spinal mobilization as appropriate (performed by the PT)
  • 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 the patient
  • Spasms in the back or neck muscles as a protective response to the pain.
  • Usually no neurological signs (no numbness, weakness, or reflex change); in the low back, pain may refer into the buttock or thigh but typically not below the knee

• Diagnosis

  • Clinical presentation
    • Special test - quadrant test

• Physical therapy management

  • Facet manipulation to improve mobility (performed by the PT)

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 of the spine
  • Muscle spasms
  • Pain may be constant or episodic
  • No neurological findings

• Diagnosis

  • Clinical presentation
  • CT scan
  • MRI

• Physical therapy management

  • Joint mobilization (performed by the PT)
  • 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

• Physical therapy management

  • Extension-based (directional preference) exercises such as prone press-ups; progress if symptoms centralize, stop and report to the PT if they peripheralize
  • Improve the dynamic stability of the trunk and pelvis
  • Spinal manipulation (performed by the PT)
  • 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
    • More common in the cervical spine

• Symptoms

  • Upper extremity pain, weakness, or paresthesia from nerve root compression at the level of the herniation (lower motor neuron signs)
  • Lower extremity weakness or paresthesia if the herniation also compresses the spinal cord at that level, producing signs below it (upper motor neuron signs - this pattern is called myelopathy, distinct from radicular nerve root compression)
  • Possible compression of the spinal cord, causing gait disturbance and hyperreflexia
  • In the lumbar spine, a large central herniation can compress the cauda equina (saddle anesthesia, bowel/bladder changes); stop treatment and notify the PT immediately

• Diagnosis

  • Clinical presentation
  • MRI

• Physical therapy management

  • Cervical stabilization and postural control exercises
  • 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 narrowing of the intervertebral foramina.

• 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

  • 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
  • Strengthening of spinal stabilizers, especially deep core muscles
  • Aerobic conditioning (walking, cycling)
  • Joint mobilization to improve mobility (performed by the PT)

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)
  • 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 activities and sport-specific movements

Spondylolisthesis

• Anterior slippage of one vertebra over the vertebra below it. It may be the result of spondylolysis (isthmic) or degenerative changes.

• Isthmic slips are most common at L5-S1; degenerative slips are most common at L4-L5.

• 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, patients 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

  • 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
    • After any spinal fusion (for any of these conditions), patients typically follow standard precautions against bending, lifting, and twisting (BLT) at the fusion site

• Physical therapy management

  • Core strengthening to stabilize the lumbar spine
  • Avoid lumbar hyperextension and heavy axial loading
  • Stretching tight muscles (especially hamstrings)
  • Joint mobilization of the adjacent, stable segments, not the unstable slipped segment (performed by the PT)

Core stabilization exercise

Core stabilization exercise appears in the plan of care for spondylolysis, spondylolisthesis, spondylosis, and nonspecific low back pain. It trains the deep trunk muscles (the transversus abdominis and multifidus) to hold the lumbar spine steady while the arms and legs move. The PTA teaches the patient to find and hold a neutral spine and progresses the exercise as the plan of care directs.

• Neutral spine is the pain-free position midway between full lumbar flexion and full extension, keeping the spine’s normal small inward curve.
• Setting the core: the abdominal drawing-in maneuver gently pulls the lower abdomen in toward the spine to activate the transversus abdominis while the patient keeps breathing normally. Abdominal bracing, stiffening all the trunk muscles together, is used for heavier loads.
• Correcting the position uses small movements of the pelvis and lower abdomen:
  • A low back sagging into excessive lordosis (pelvis tipped anteriorly) is corrected with a gentle drawing-in and a slight posterior pelvic tilt.
  • A flattened or rounded low back (pelvis tipped posteriorly) is corrected with a slight anterior pelvic tilt.
  • Cues to round the upper back or to push hard through the arms produce compensatory thoracic flexion rather than a neutral lumbar spine.
• Faults to watch for: breath holding, rounding of the upper back, tucking the pelvis so far that the low back flattens, and the low back shifting or rotating as an arm or leg moves.
• Progression: supine hook-lying (heel slides, bent-knee fall-outs) → quadruped (single arm lift, single leg extension, then opposite arm and leg together) → sitting and standing → functional and sport-specific tasks. Load is added, or support taken away, only while the patient can hold neutral.

Whiplash-associated disorders (WAD)

• Occurs in the 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 odontoid process, TMJ, spinal nerves, cranial nerves

• Symptoms

  • Headaches
  • Limited mobility
  • Vertigo
  • Hearing loss or ringing in the ears
  • Difficulty swallowing
  • TMJ dysfunction
  • Disequilibrium
  • Anxiety

• Diagnosis

  • Clinical presentation, typically with a history of a rear-end motor vehicle collision
  • MRI
  • CT scan
  • X-ray

• Physical therapy management

  • Patient education on biomechanics and positions to avoid
  • Joint mobilization (performed by the PT), once fracture and ligamentous instability (e.g., odontoid fracture) have been ruled out
  • Functional training

Scoliosis

Scoliosis is a spinal condition in which there is an abnormal curvature of the spine. Its signs, Cobb angle severity, bracing, and surgery are covered in the scoliosis, autism, and birth injuries chapter.

• Diagnosis
  • Physical exam: Adams forward-bending test to check for asymmetry.
  • Scoliometer: A device that measures trunk inclination during the forward-bending test.
  • Spinal imaging: X-rays to get a clear view of the spine’s curve.
• Physical therapy management (to improve function and posture, not to reduce the curve)
  • Strengthening of the back and core muscles, flexibility exercises, and postural training
  • Pain management: Stretching, exercise, and yoga to help manage pain.

Sacroiliac joint conditions

• Causes of dysfunction can be inflammation, degenerative changes, or abnormal movement patterns

  • Often associated with the lumbar spine - as the PTA, collect objective data from both regions when pain is reported and relay your findings to the PT

• 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
  • MRI
  • X-ray

• Physical therapy management

  • Spinal manipulation (performed by the PT)
  • Patient education on biomechanics and positions to avoid
  • Joint mobilization (performed by the PT)
  • Functional training

Upslip of the ilium (superior ilium displacement)

• The ilium on one side shifts superiorly relative to the sacrum.
• Mechanism: a fall onto the ischium, or a forceful step down from a curb or stair, is a common cause.
• Clinical findings: the iliac crest, PSIS, and ischial tuberosity sit higher on the involved side compared to the uninvolved side.
• Physical therapy management: as the PTA, you collect objective measures (landmark height, gait, pain) and report them to the PT; your delegated role includes pelvic stabilization exercise and patient education, while any correction technique is performed by the PT.

Downslip of the ilium (inferior ilium displacement)

• The ilium on one side shifts inferiorly relative to the sacrum.
• Mechanism: a traction-type injury, such as a fall or a sudden pull on the leg, is a common cause.
• Clinical findings: the iliac crest, PSIS, and ischial tuberosity sit lower on the involved side compared to the uninvolved side.
• Physical therapy management: as with an upslip, the PTA’s role is objective measurement and reporting, plus delegated stabilization exercise; the PT performs any correction technique.

TMJ conditions

• Can be due to

  • Osteoarthritis, rheumatoid arthritis
  • Myofascial pain - pain in muscles controlling TMJ
  • Dislocation of the jaw

• Symptoms

  • Joint noise when opening the mouth
  • Joint locking
  • Loss of range of motion
  • Lateral deviation during depression or elevation of the mandible
  • Decreased mandibular strength
  • Headache
  • Ringing in the ears
  • Forward head posture
  • May have cervical spine pain

• Diagnosis

  • Clinical presentation
  • X-ray
  • MRI

• Physical therapy management

  • Patient education on biomechanics and positions to avoid
  • Joint mobilization (performed by the PT)
  • Biofeedback
  • Modalities for pain and inflammation
  • Night splinting