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Introduction
1. Cardiopulmonary system
2. Pulmonary system
3. Neuromuscular system
4. Pediatrics
5. Musculoskeletal system
5.1 Anatomy of musculoskeletal system
5.2 Foundation content of musculoskeletal system
5.3 Upper extremity anatomy
5.4 Special tests of upper extremity
5.5 Comparing clinical presentation and interventions for upper extremity
5.6 Lower extremity anatomy
5.7 Special tests of lower extremity
5.8 Comparing clinical presentation and interventions of lower extremity
5.9 Spine, pelvis, and temporomandibular joint anatomy
5.10 Special tests of the spine, pelvis, and temporomandibular joint
5.11 Comparing clinical presentation and interventions for the spine, pelvis, and tempromandipular joint
5.12 Other MSK conditions
5.13 Gait
5.14 Prosthetics and orthotics
5.15 Medications, imaging, and fractures
5.16 Surgical protocols
6. Other system
7. Non systems
Wrapping up
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5.11 Comparing clinical presentation and interventions for the spine, pelvis, and tempromandipular joint
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5. Musculoskeletal system
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Comparing clinical presentation and interventions for the spine, pelvis, and tempromandipular joint

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Spine and pelvis differential diagnosis

  • 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
    • Radicular pain
    • Lower extremity weakness
    • Lower extremity paresthesia
    • Possible compression of the spinal cord, causing an upper motor neuron lesion
  • 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 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, 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
      • Canadian C-spine rules
    • 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.
Scoliosis
Scoliosis

Sacroiliac joint conditions

  • Causes of dysfunction can be inflammation, degenerative changes, or abnormal movement patterns
    • Can be associated with the lumbar spine, so will need to examine both when pain is 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 anti-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 anti-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 and 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 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 strength of the hand
  • Headache
    • Ringing in the ears
    • Forward head posture
    • May have cervical spine pain
  • Diagnosis
    • Clinical presentation
    • X-ray
    • MRI
  • Medical management
    • Acetaminophen or non-steroidal anti-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

Spinal or intervertebral stenosis

  • Narrowing of spinal canal or foramina; causes neuro/vascular dysfunction
  • Symptoms: bilateral back/buttock/leg pain, worse with extension/walking, relieved by flexion/rest
  • Diagnosis: clinical presentation, bicycle test, MRI/CT
  • Management: NSAIDs, corticosteroids, muscle relaxants; PT with flexion-based exercises, trunk/pelvis stability, avoid extension

Facet joint dysfunction

  • Degenerative joint disease: facet hypertrophy, capsular fibrosis, mobility changes from aging/repetitive loading
    • Symptoms: localized/radiating pain, morning stiffness, worse with movement
    • Diagnosis: quadrant test, X-ray
    • Management: NSAIDs, corticosteroids, muscle relaxants; PT with mobilization, trunk/pelvis stability
  • Facet entrapment: acute locked back from inflamed/damaged facet joints
    • Symptoms: dull/aching pain, flexion preferred, muscle spasm, possible nerve irritation
    • Diagnosis: quadrant test
    • Management: NSAIDs, corticosteroids, muscle relaxants; PT with facet manipulation

Disc Conditions

  • Internal disc disruption: annulus disrupted, outer structures intact
    • Symptoms: chronic central low back pain, worse with activity, no neuro findings
    • Diagnosis: clinical, CT/MRI
    • Management: NSAIDs, corticosteroids, muscle relaxants; PT with joint mobilization, biomechanics education
  • Posterolateral bulge/herniation: annular/endplate/ligament injury
    • Symptoms: radicular pain, LE weakness/paresis
    • Diagnosis: clinical, MRI
    • Management: NSAIDs, corticosteroids, muscle relaxants; PT with trunk/pelvis stability, manipulation, traction, education
  • Central posterior bulge/herniation: more common cervical, compressive/postural etiology
    • Symptoms: radicular pain, LE weakness/paresthesia, possible UMN lesion
    • Diagnosis: clinical, MRI
    • Management: NSAIDs, corticosteroids, muscle relaxants; PT with trunk/pelvis stability, manipulation, traction

Spondylosis

  • Degenerative spine changes: disc desiccation, osteophytes, facet changes
  • Symptoms: gradual chronic pain/stiffness, limited ROM, possible radicular symptoms
  • Diagnosis: X-ray (disc space, osteophytes), MRI (neural compression)
  • Management: NSAIDs, muscle relaxants, corticosteroid injections, surgery if severe; PT with postural/ergonomic training, stretching, core strengthening, manual therapy

Spondylolysis

  • Stress fracture/defect in pars interarticularis, often L5, young athletes
  • Symptoms: localized low back pain, worse with extension, tight hamstrings, no neuro symptoms
  • Diagnosis: oblique X-ray (“Scotty dog”), CT/MRI
  • Management: rest/activity modification, NSAIDs, bracing, rare surgery; PT with extension avoidance, core stabilization, hamstring/hip mobility

Spondylolisthesis

  • Anterior vertebral slippage (isthmic: pars defect, degenerative: facet/disc)
  • Symptoms: low back pain, tight hamstrings, step-off deformity, possible neuro deficits
  • Diagnosis: lateral X-ray (graded I–V), MRI (soft tissue/neural)
  • Management: NSAIDs, muscle relaxants, steroid injections, bracing, surgery if severe; PT with core strengthening, postural retraining, avoid hyperextension

Whiplash-associated disorders (WAD)

  • Cervical spine shear/tension injury; affects facets, ligaments, discs, nerves
  • Symptoms: headache, limited mobility, vertigo, hearing/TMJ issues, disequilibrium, anxiety
  • Diagnosis: clinical (Canadian C-spine rules), MRI/CT/X-ray
  • Management: NSAIDs, corticosteroids, muscle relaxants; PT with manipulation, biomechanics education, mobilization, functional training

Scoliosis

  • Abnormal spinal curvature
  • Symptoms: uneven shoulders/hips, visible curve, back pain, head off-center
  • Diagnosis: Adams forward bend, scoliometer, X-ray
  • Management: observation, bracing, surgery if severe; PT with strengthening, flexibility, postural training, pain management

Sacroiliac joint conditions

  • Dysfunction from inflammation, degeneration, abnormal movement; often coexists with lumbar issues
  • Symptoms: unilateral low back pain, radiates to buttocks/hips/thighs, worse with activity, stiffness
  • Diagnosis: clinical, SI special tests, MRI/X-ray
  • Management: NSAIDs, corticosteroids, muscle relaxants; PT with manipulation, education, mobilization, functional training

Sacral Spondylolisthesis

  • Forward slip of sacrum/L5 due to instability/trauma/degeneration
  • Symptoms: low back/sacral/hip pain, worse with extension, tight hamstrings, possible leg symptoms
  • Diagnosis: clinical, X-ray, MRI/CT
  • Management: NSAIDs, corticosteroids, muscle relaxants; PT with core stabilization, posture correction, bracing

Upslip of the Ilium

  • Ilium moves superiorly; often from trauma or muscle imbalance
  • Weak: gluteus medius/minimus, contralateral quadratus lumborum, hip adductors
  • Tight: ipsilateral quadratus lumborum, iliopsoas, hamstrings

Downslip of the Ilium

  • Ilium moves inferiorly; often from trauma or SI instability
  • Weak: ipsilateral quadratus lumborum, gluteus medius/minimus, hip abductors
  • Tight: ipsilateral hip adductors, contralateral quadratus lumborum

TMJ conditions

  • Causes: osteoarthritis, RA, myofascial pain, jaw dislocation
  • Symptoms: joint noise/locking, ROM loss, lateral deviation, headaches, ear ringing, forward head, possible cervical pain
  • Diagnosis: clinical, X-ray, MRI
  • Management: NSAIDs, corticosteroids, muscle relaxants; PT with education, mobilization, biofeedback, modalities, night splinting

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

Spine and pelvis differential diagnosis

  • 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
    • Radicular pain
    • Lower extremity weakness
    • Lower extremity paresthesia
    • Possible compression of the spinal cord, causing an upper motor neuron lesion
  • 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 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, 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
      • Canadian C-spine rules
    • 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.

Sacroiliac joint conditions

  • Causes of dysfunction can be inflammation, degenerative changes, or abnormal movement patterns
    • Can be associated with the lumbar spine, so will need to examine both when pain is 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 anti-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 anti-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 and 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 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 strength of the hand
  • Headache
    • Ringing in the ears
    • Forward head posture
    • May have cervical spine pain
  • Diagnosis
    • Clinical presentation
    • X-ray
    • MRI
  • Medical management
    • Acetaminophen or non-steroidal anti-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
Key points

Spinal or intervertebral stenosis

  • Narrowing of spinal canal or foramina; causes neuro/vascular dysfunction
  • Symptoms: bilateral back/buttock/leg pain, worse with extension/walking, relieved by flexion/rest
  • Diagnosis: clinical presentation, bicycle test, MRI/CT
  • Management: NSAIDs, corticosteroids, muscle relaxants; PT with flexion-based exercises, trunk/pelvis stability, avoid extension

Facet joint dysfunction

  • Degenerative joint disease: facet hypertrophy, capsular fibrosis, mobility changes from aging/repetitive loading
    • Symptoms: localized/radiating pain, morning stiffness, worse with movement
    • Diagnosis: quadrant test, X-ray
    • Management: NSAIDs, corticosteroids, muscle relaxants; PT with mobilization, trunk/pelvis stability
  • Facet entrapment: acute locked back from inflamed/damaged facet joints
    • Symptoms: dull/aching pain, flexion preferred, muscle spasm, possible nerve irritation
    • Diagnosis: quadrant test
    • Management: NSAIDs, corticosteroids, muscle relaxants; PT with facet manipulation

Disc Conditions

  • Internal disc disruption: annulus disrupted, outer structures intact
    • Symptoms: chronic central low back pain, worse with activity, no neuro findings
    • Diagnosis: clinical, CT/MRI
    • Management: NSAIDs, corticosteroids, muscle relaxants; PT with joint mobilization, biomechanics education
  • Posterolateral bulge/herniation: annular/endplate/ligament injury
    • Symptoms: radicular pain, LE weakness/paresis
    • Diagnosis: clinical, MRI
    • Management: NSAIDs, corticosteroids, muscle relaxants; PT with trunk/pelvis stability, manipulation, traction, education
  • Central posterior bulge/herniation: more common cervical, compressive/postural etiology
    • Symptoms: radicular pain, LE weakness/paresthesia, possible UMN lesion
    • Diagnosis: clinical, MRI
    • Management: NSAIDs, corticosteroids, muscle relaxants; PT with trunk/pelvis stability, manipulation, traction

Spondylosis

  • Degenerative spine changes: disc desiccation, osteophytes, facet changes
  • Symptoms: gradual chronic pain/stiffness, limited ROM, possible radicular symptoms
  • Diagnosis: X-ray (disc space, osteophytes), MRI (neural compression)
  • Management: NSAIDs, muscle relaxants, corticosteroid injections, surgery if severe; PT with postural/ergonomic training, stretching, core strengthening, manual therapy

Spondylolysis

  • Stress fracture/defect in pars interarticularis, often L5, young athletes
  • Symptoms: localized low back pain, worse with extension, tight hamstrings, no neuro symptoms
  • Diagnosis: oblique X-ray (“Scotty dog”), CT/MRI
  • Management: rest/activity modification, NSAIDs, bracing, rare surgery; PT with extension avoidance, core stabilization, hamstring/hip mobility

Spondylolisthesis

  • Anterior vertebral slippage (isthmic: pars defect, degenerative: facet/disc)
  • Symptoms: low back pain, tight hamstrings, step-off deformity, possible neuro deficits
  • Diagnosis: lateral X-ray (graded I–V), MRI (soft tissue/neural)
  • Management: NSAIDs, muscle relaxants, steroid injections, bracing, surgery if severe; PT with core strengthening, postural retraining, avoid hyperextension

Whiplash-associated disorders (WAD)

  • Cervical spine shear/tension injury; affects facets, ligaments, discs, nerves
  • Symptoms: headache, limited mobility, vertigo, hearing/TMJ issues, disequilibrium, anxiety
  • Diagnosis: clinical (Canadian C-spine rules), MRI/CT/X-ray
  • Management: NSAIDs, corticosteroids, muscle relaxants; PT with manipulation, biomechanics education, mobilization, functional training

Scoliosis

  • Abnormal spinal curvature
  • Symptoms: uneven shoulders/hips, visible curve, back pain, head off-center
  • Diagnosis: Adams forward bend, scoliometer, X-ray
  • Management: observation, bracing, surgery if severe; PT with strengthening, flexibility, postural training, pain management

Sacroiliac joint conditions

  • Dysfunction from inflammation, degeneration, abnormal movement; often coexists with lumbar issues
  • Symptoms: unilateral low back pain, radiates to buttocks/hips/thighs, worse with activity, stiffness
  • Diagnosis: clinical, SI special tests, MRI/X-ray
  • Management: NSAIDs, corticosteroids, muscle relaxants; PT with manipulation, education, mobilization, functional training

Sacral Spondylolisthesis

  • Forward slip of sacrum/L5 due to instability/trauma/degeneration
  • Symptoms: low back/sacral/hip pain, worse with extension, tight hamstrings, possible leg symptoms
  • Diagnosis: clinical, X-ray, MRI/CT
  • Management: NSAIDs, corticosteroids, muscle relaxants; PT with core stabilization, posture correction, bracing

Upslip of the Ilium

  • Ilium moves superiorly; often from trauma or muscle imbalance
  • Weak: gluteus medius/minimus, contralateral quadratus lumborum, hip adductors
  • Tight: ipsilateral quadratus lumborum, iliopsoas, hamstrings

Downslip of the Ilium

  • Ilium moves inferiorly; often from trauma or SI instability
  • Weak: ipsilateral quadratus lumborum, gluteus medius/minimus, hip abductors
  • Tight: ipsilateral hip adductors, contralateral quadratus lumborum

TMJ conditions

  • Causes: osteoarthritis, RA, myofascial pain, jaw dislocation
  • Symptoms: joint noise/locking, ROM loss, lateral deviation, headaches, ear ringing, forward head, possible cervical pain
  • Diagnosis: clinical, X-ray, MRI
  • Management: NSAIDs, corticosteroids, muscle relaxants; PT with education, mobilization, biofeedback, modalities, night splinting