A postural examination was performed in relaxed standing by the physical therapist, which included assessment of head position, shoulder and thoracolumbar deviations, pelvic height and rotation, lower extremity alignment, and symmetrical weight bearing.45
Postural gait assessment was conducted while watching the subject ambulate to and from the treatment area. Physical examination revealed a non‐antalgic gait, normal standing posture, and symmetrical lower extremity alignment. She presented with negative crepitus, apprehension, effusion, erythema, and ecchymosis through visual inspection of the trunk and lower quarter.
A lower quarter neurological examination was performed to screen for symptoms of spinal origin,46
which included dermatomal, myotomal, deep tendon reflex, and neurodynamic testing. Dermatomal testing was performed by accessing the L2 to S2 nerve roots through light touch and pin prink. Myotomal testing was performed by manual muscle testing the representative muscles for the L2 to S2 levels bilaterally. Deep tendon reflex testing was performed by assessing the patellar tendon (L2‐L4) and Achilles tendon (S1‐S2) reflexes. Neurodynamic testing was assessed with a passive straight‐leg raise to determine the presence of neural tension.47
Babinski and clonus testing was performed and was absent bilaterally. All components of the neurological screen were normal and did not reveal any abnormalities, nor reproduce the subject's symptoms.
The Selective Functional Movement Assessment (SFMA) was used as the primary functional screen to assess movement patterns and identify primary areas of dysfunction.48
Multi‐segmental flexion (toe touch or forward flexion), single leg stance, and overhead squat were found to be dysfunctional patterns (with multi‐segmental flexion painful) and were used as test‐retest movements in order to determine objective subject outcomes. See and for forward flexion movement dysfunction displayed at initial exam.
Multi‐segmental flexion (side view).
Multi‐segmental flexion (front view).
The overhead squat pattern demonstrated visually perceived excessive bodyweight shifting toward the left lower extremity and lack of right lower extremity weight acceptance, which may occur with a stability dysfunction. Single leg stance assessment demonstrated moderate hip and trunk compensatory corrections and instability bilaterally with greater difficulty perceived during right stance leg compared to the left, indicating a possible asymmetrical core and/or hip stability dysfunction.
Lumbar and hip active range of motion (AROM) assessment was performed and recorded using an inclinometer and standard goniometer. A goniometer was used to assess hip flexion and extension AROM and has been reported to have moderate reliability (ICC = 0.58‐0.79).49
Hip internal and external rotation was assessed using an inclinometer. An inclinometer was used to measure lumbar motions. Fritz et al41
found moderate reliability when accessing lumbar flexion and extension AROM with an inclinometer (ICC = 0.60‐0.61). Active lumbar ROM assessment revealed 65° of lumbar forward flexion (finger tips to mid‐tibia; and ); 25° of lumbar extension (finger tips to popliteal space); 34° of left lumbar side bending (finger tips to fibula head); 32° of right lumbar side bending (finger tips to fibula head); 55° of left lumbar rotation; and 55° of right lumbar rotation. Active Hip AROM assessment revealed 124° of left hip flexion; 122° of right hip flexion; 20° of left hip extension; 22° of right hip extension; 37° of left hip internal rotation; 34° of right hip internal rotation; 48° of left hip external rotation; and 50° of right external rotation. Hip abduction and adduction was visually assessed and determined to be equal bilaterally and within normal limits. Lumbar AROM assessment revealed all planes were within normal limits. Hip AROM revealed no limitations in all planes and were within normal limits. The lumbar locked rotation test (ICC = 0.87‐0.90)50
was performed and ROM was WNL bilateral. The thoracic spine involvement was eliminated as a primary source of the subject's complaint.
Manual muscle testing (MMT) of the hip musculature was performed described by Kendall,51
including hip flexion, extension, abduction, adduction, internal rotation, and external rotation. Hip MMT assessment revealed a 5/5 hip flexion bilaterally; 5/5 hip extension on left versus 4/5 on right; 5/5 hip abduction on left versus 4/5 on right; 5/5 hip adduction bilaterally; 5/5 hip internal rotation bilaterally; 5/5 hip external rotation on left versus 4/5 on right. In summary, strength assessment of the hip musculature revealed weakness in hip extension, abduction, and external rotation on the right. All other hip planes assessed using manual muscle testing was symmetrical with no functional deficits.
Muscle length testing was performed by assessing the flexibility of the hamstrings, quadriceps, iliopsoas, and iliotibial band. The passive straight leg raise52
was utilized to assess hamstring flexibility and is considered positive for hamstring muscle tightness when measured <70° hip flexion.53
The passive straight leg raise was objectively measured using an inclinometer, in which Piva et al,54
showed excellent reliability when utilizing an inclinometer for hamstring flexibility (ICC = 0.91‐0.92). Passive straight leg raise measured 75° hip flexion bilaterally. The modified Thomas test, described by Bullock‐Saxton et al,55
was utilized to assess the muscle length of the quadriceps and iliopsoas, and both were deemed to be normal bilaterally. Bullock‐Saxton et al55
found excellent reliability with accessing iliopsoas muscle length (ICC = 0.98). The Ober test was utilized to assess the muscle length of the iliotibial band.56
Reese and Brandy,56
describe the reliability of the Ober test to be excellent (ICC = 0.90). No limitations were noted with lower extremity muscle length tests, including hamstrings, quadriceps, iliopsoas, and iliotibial band.
Provocative special testing was performed to access a patho‐anatomical reason for the subject's symptoms. The FABER (Flexion‐Abduction‐External Rotation), FADIR (Flexion‐Adduction‐Internal Rotation), and Log Roll tests were utilized to determine if a hip intra‐articular pathology was present. The FABER (Sn=0.89)57
, FADIR (ICC=0.87, Sp=0.43, Sn=0.75, +LR=1.32, –LR=0.58)45
, and Log Roll (ICC=0.61)58
tests were negative. Manual overpressure was added to both the FABER and FADIR end ROM to further stress the hip joint. The overpressure was intended to “scour” the joint and clear the hip joint for the presence of any intra‐articular derangement. The sacroiliac joint was screened by utilizing the distraction (k=0.69, Sp=0.81, Sn=0.60), compression (k=0.73, Sp=0.69, Sn=0.69), gaenslen (k=0.76, Sp=0.71‐0.73, Sn=0.50‐0.53), thigh thrust (k=0.88, Sp=0.69, Sn=0.88), and sacral thrust (k=0.56, Sp=0.75, Sn=0.63) tests.59,60
All sacroiliac provocation tests performed were negative. The prone instability test was performed to access lumbar segmental instability. The prone instability test (k= 0.87, ICC= 0.87)61
was positive, due to the subject experiencing painful symptoms with feet on floor that disappeared when feet were lifted off floor when a posterior to anterior (P‐A) directed force was applied to the target spinal segment.
Lumbar spinal accessory motion testing was performed in the prone position to assess joint mobility and pain reproduction by performing a P‐A directed force over the spinous process of T10 to L5 segments and judged to be either normal, hypomobile, or hypermoble. Pain provocation was positive over the L3 to L5 segments with normal pain‐free joint mobility over the remaining tested segments. Superficial to deep palpation was performed throughout the thoracolumbar and bilateral gluteal regions using flat and pincer palpatory techniques. There was tenderness to palpation present along the right gluteus maximus and gluteus medius muscles with a palpable taut band within the skeletal muscle. There was a presence of a hypersensitive tender spot within this taut band indicating suspected active MTrPs.
Motor‐Autonomic‐Sensory‐Trophic (MAST) inspection according to Gunn13
was performed to determine the likelihood of the presence of a radiculopathy. There was no observed muscle spasm or shorting present upon palpatory examination; however, taut bands were discovered in the gluteus maximum and gluteus medius muscles (as previously described). No autonomic responses were observed, such as vasomotor changes (sweating, coldness, etc.), and sensory responses were normal with no signs of supersensitivity. Lastly, no trophic changes, including dry skin, redness, trophedema, or dermatomal hair loss were present during the examination.