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

Comparing clinical presentation

• Spinal or intervertebral stenosis

  • Narrowing of the spinal canal or intervertebral foramina
    • 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 anti-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 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

• Medical management

  • Acetaminophen or non-steroidal anti-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 the patient
  • Spasms in the back or neck muscles as a protective response to the pain.
  • 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 anti-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 of 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 anti-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 anti-inflammatory (NSAIDs)
  • Corticosteroids
  • Muscle relaxants

• Physical therapy management

  • Improve the dynamic stability of the 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
    • 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

• Diagnosis

  • Clinical presentation
  • MRI

• Medical management

  • Acetaminophen or non-steroidal anti-inflammatory (NSAIDs)
  • Corticosteroids
  • Muscle relaxants

• Physical therapy management

  • Improve the dynamic stability of the 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 for 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 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.

• 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

  • 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 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

• Medical management

  • Acetaminophen or non-steroidal anti-inflammatory (NSAIDs)
  • Corticosteroids
  • Muscle relaxants

• Physical therapy management

  • Spinal manipulation
  • Patient education on biomechanics and positions to avoid
  • Joint mobilization
  • Functional training

Scoliosis

Scoliosis is a spinal condition in which there is an abnormal curvature of the spine.

• Symptoms

  • Uneven shoulders, hips, or waist
  • One scapula is more prominent than the other
  • A visible curve in the spine
  • Back pain or discomfort
  • Head not centered over the body

• 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.

• Medical management

  • Observation: Closely monitoring the curve over time, especially in growing children.
  • Bracing: Used to stop or slow the progression of the curve in growing adolescents.
  • Surgery: Considered for severe curves or when conservative treatments fail. Common procedures include spinal fusion with rods and screws to straighten the spine and relieve nerve compression.

• Physical therapy management

  • Strengthening: Focuses on building strength in the back and core muscles to improve stability and support the spine.
  • Flexibility and range of motion: Exercises to improve flexibility, reduce muscle tenderness, and improve overall movement quality
  • Postural training: Exercises and techniques to help improve posture and alignment.
  • Pain management: May include various modalities to help manage pain, such as stretching, exercise, and yoga.
  • Functional improvement: Aims to improve the ability to perform daily activities, not to reduce the spinal curvature itself.