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

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