Diagnosis of osteochondrosis of the lumbosacral spine

Degenerative-dystrophic changes in the intervertebral discs in osteochondrosis of the lumbosacral spine, accompanied by one or another neurological symptomatology, are almost always accompanied by disturbances in the normal statics and biomechanics of the spine, which is especially evident in the lumbosacral spine.

A clinical examination of the patient is carried out in a standing position:

• When examined from the side, the degree of change in the curvature of the lumbar region is determined (flattening of the lordosis or the presence of kyphosis);
• The results of visual observation are confirmed by palpation of the spinous processes (similar to the thoracic region);
• When examining from behind, the type of scoliosis and its degree are determined;
• The presence, degree and side of tension of the long muscles of the back and limbs are determined;
• The range of motion (active and passive) is examined;
• The presence of pain is noted upon palpation of the spinous processes and interspinous spaces, as well as pain in the paravertebral points corresponding to the interspinous spaces;
• Myofascial pain points (MPP) are identified.

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Study of the muscular system

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Muscles of the calf and foot

Movements in the joints of the foot are performed with the help of muscles that are located on the lower leg in three groups: anterior, posterior and lateral.

The posterior muscle group is 4 times stronger than the anterior one. This is explained by the fact that the foot is a lever of the 1st and 2nd kind, depending on the position and the function performed.

• At rest, the foot is a first-class lever, in which the fulcrum lies between the points of application of force and resistance;
• When rising on the toes, the foot acts as a second-class lever, in which the point of resistance lies between the points of application of force and support.

Function of the foot muscles:

• Plantar flexion of the ankle joint is produced by different muscles depending on whether the foot is loaded or not.

With the foot unloaded (the patient's initial position is lying on his stomach, with his feet lowered over the edge of the couch), plantar flexion is performed by mm. tibialis posterior, peroneus longus, and to a lesser extent by m. peroneus brevis.

ATTENTION! The gastrocnemius muscle does not contract.

• Dorsiflexion of the freely hanging foot at the ankle joint is performed by mm. tibialis anterior, peroneus tertius. Due to the fact that m. tibialis anterior supinates the foot when contracting, m. peroneus brevis contracts as a synergist to obtain isolated dorsiflexion. The long extensor of the big toe and the common long extensor of the fingers, which also participates in pronation of the foot, participate in dorsiflexion.
• Supination - turning the foot with the sole inward with simultaneous bringing the anterior part to the midplane of the body - occurs in the talocalcaneonavicular joint. In the patient's SP lying on his side, this movement is produced only by m. tibialis posterior. But if resistance is added, then other supinators also come into action (m. tibialis anterior and triceps surae simultaneously), since they must neutralize their flexion-extension action on the ankle joint and summarize supination.

ATTENTION! There is no muscle that produces isolated adduction of the foot.

• Pronation is a movement opposite to supination, characterized by the rotation of the foot with the sole outward with simultaneous abduction of the forefoot from the midplane of the body. Pronation is initiated by the peroneus brevis, which produces only the abduction of the forefoot. The peroneus longus produces the rotation of the foot outward, abduction, and plantar flexion. In addition, the common long extensor of the fingers takes part in the pronation of the foot.

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Study of the function of individual muscles

1. Extensor pollicis longus.

The function of the muscle is dorsiflexion of the 1st finger and foot.

The muscles are examined in the patient's SP lying down, the foot is at a right angle to the shin. The patient is asked to dorsiflex the big toe (the movement is performed actively with resistance to the doctor's hand). When the muscle contracts, the tendon is easily palpated above the first metatarsal bone.

2. Long extensor of the fingers.

The function of the muscle is dorsiflexion of the foot and toes (II-III-IV-V), as well as pronation of the foot.

ATTENTION! The rewarding effect is enhanced in the dorsiflexion position.

When examining the muscle strength of the long extensor of the fingers, the patient is asked to place the foot in a position of maximum dorsiflexion with straightened toes. In another case, the doctor counteracts this movement with one hand, and palpates the tendon of the muscle with the other.

3. Anterior tibialis muscle.

The main function of the muscle is dorsal

Ankle flexion and supination. The muscle also helps maintain the longitudinal arch of the foot.

To determine the functions of this muscle, the foot is placed, if possible, in a position of slight plantar flexion and abduction and the patient is asked to perform dorsal flexion with raising the inner edge of the foot, the same movement, but the doctor resists the movement with one hand, and palpates the tendon under the skin of the dorsum of the foot with the other.

4. Peroneus longus muscle.

The muscle performs a variety of functions:

• produces plantar flexion of the foot,
• produces pronation (lifting the outer edge of the foot),
• maintains the maximum arch of the foot.

The muscle function is determined with the leg bent at the knee joint, the foot is placed on the surface of the couch with its inner edge. The patient is asked to lift the distal part of the foot above the surface of the couch (the same movement, but the doctor resists this movement with one hand). The tension of the muscle is determined with the other hand at the head of the fibula.

ATTENTION! Tension of the tendon cannot be determined, since within the foot before the transition to the plantar surface it passes next to the tendon of the peroneus brevis muscle.

5. Peroneus brevis muscle.

The function of the muscle is to produce plantar flexion, abduction and elevation of the outer edge of the foot.

ATTENTION! The peroneus brevis is the only muscle that provides pure abduction of the foot.

To determine the function of the muscle, the patient is asked to move the foot outward (the same movement, but with resistance from the doctor). Tension of the tendon is determined behind the styloid process of the 5th metatarsal bone.

6. The triceps surae is the most powerful muscle of the lower leg. The muscle consists of 3 heads - two superficial and one deep. The two superficial heads form the gastrocnemius muscle, and the deep one forms the soleus.

This muscle is a powerful plantar flexor of the foot. Its tension keeps the body in an upright position.

To determine muscle function, the patient is offered:

• in the initial position standing, rise up on your toes;
• in the initial position, standing, sit on your toes. The doctor measures the distance (in cm) between your heels and the floor;
• in the initial position - lying on your back, the leg is bent at the hip and knee joint;
• performing plantar flexion of the foot, while the doctor resists the movement;
• the patient performs the same movement without resistance.

7. Posterior tibialis muscle.

The muscle function is to produce plantar flexion of the foot and supination. In addition, it participates in maintaining the longitudinal arch of the foot and prevents the displacement of the talus to the medial side.

The muscle function is examined with the leg bent at the hip and knee joints, the foot is placed on the surface of the couch with the outer edge. The patient is asked to lift the distal part of the foot, the doctor provides a measured resistance to the movement with one hand; with the other hand he palpates the tendon of the muscle between the inner malleolus and the tuberosity of the navicular bone (the same movement is performed without resistance).

8. Long flexor of the fingers.

The muscle produces plantar flexion of the terminal phalanges of the II-V toes and the foot, in addition, it lifts the inner edge of the foot.

The muscle function is examined with the foot at a right angle to the shin. The patient is asked to bend the fingers, the doctor resists the movement with one hand, and palpates the tendon of the muscle behind the inner ankle with the other (the same movement, but without resistance).

9. Flexor pollicis longus.

The function of the muscle is to produce plantar flexion of the first toe and raise the inner edge of the foot.

The muscle function is examined with the foot at a right angle to the shin. The patient is asked to bend the big toe, the doctor resists the movement with one hand, and palpates the tendon located behind the inner ankle with the other (the same movement, but without resistance).

Thus, having determined the function of each muscle separately, the doctor has a complete picture of the condition of the calf muscles.

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Thigh muscles

A. The following muscles participate in hip flexion:

• iliopsoas muscle;
• rectus femoris;
• sartorius;
• pectineal muscle;
• the muscle that tenses the broad fascia of the thigh.

To determine the function of the muscles involved in hip flexion, the patient is asked to bend the leg at the hip and knee joints. When performing this movement, the following examination options are possible:

• The doctor holds the patient's shin with one hand (in the lower third of the shin or by the heel)! With the other hand, he palpates the tense muscles;
• the doctor prevents the hip from flexing with one hand;
• the patient actively bends the leg at the hip and knee joints.

The anterior group of thigh muscles includes the quadriceps femoris, which has four heads:

• rectus femoris;
• broad lateral;
• wide intermediate;
• broad medial muscle.

The broad muscles of the thigh originate from the anterior, lateral and partially posterior surfaces of the femur. In the lower third of the thigh, all four heads unite into a common tendon that attaches to the tuberosity of the tibia.

The patella lies within the thickness of the tendon.

Muscle function:

• extends the leg;
• The rectus abdominis muscle flexes the thigh.

The study of the functional state of the muscle is carried out in the patient’s initial position - lying on his back:

• active movement - extension of the leg;
• movement with resistance from the doctor's hands.

ATTENTION! If there is a shortening of the posterior group of the thigh muscles, it is impossible to perform a full contraction of the quadriceps muscle. If a shortening of the muscle tensor fasciae lata is detected, dissociation of the medial part of the quadriceps muscle is observed.

B. The following are involved in hip extension:

• gluteus maximus;
• biceps femoris;
• semimembranosus muscle;
• semitendinosus muscle.

Contraction of the posterior thigh muscles occurs:

• when bending the body forward;
• hyperlordosis;
• spondylolisthesis, when the posterior edge of the pelvis rises and, consequently, the ischial tuberosity, from where these muscles originate.

As a result of compression of the fibers of the peroneal nerve (when it is still part of the sciatic nerve) by the biceps muscle, tunnel syndrome of its damage with symptoms of prolapse up to foot paresis may occur. The semitendinosus and semimembranosus muscles can play the same role. This is especially true for people whose work requires squatting or kneeling.

The functional state of the muscles is examined in the patient's initial position, lying on his stomach. When the muscles are weakened, the patient is unable to raise his leg above the horizontal level. Normally, according to I.Durianova, the patient should raise it 10-15° above the horizontal level. An isolated examination of the gluteal muscle group is performed with the leg bent at the knee joint (to prevent substitution stress in the posterior group of the thigh muscles).

The same movements can be performed with measured resistance (by the doctor’s hand).

B. The following are involved in hip adduction:

• adductor magnus;
• long and short adductor muscles;
• pectineal muscle;
• tender muscle.

The examination of the adductor muscles of the thigh is carried out with the patient in the initial position lying on his back and sitting.

1. The function of the short adductor muscles of the thigh is checked with the leg bent at the hip and knee joints.
2. It is advisable to determine the function of the long adductor muscles with the legs straight.

The test movement is performed with resistance from the doctor's hands. When attempting to bring the leg, the patient may experience pain. In these cases, it is recommended to palpate the myalgic zone. According to K. Levit (1993), the myalgic zone in cases of damage to the sacroiliac joint is located at the attachment site of the adductor muscles of the thigh, on its medial surface, and in cases of coxalgia - at the edge of the acetabulum in the area of the iliofemoral ligament.

G. The following are involved in hip abduction:

• gluteus medius muscle;
• gluteus minimus muscle.

The study is conducted with the patient in the initial position, lying on his back and sitting. The test movement is performed with the resistance of the doctor's hands.

D. The following muscles perform internal rotation of the thigh:

• anterior bundles of the gluteus medius muscle;
• anterior bundles of the gluteus minimus muscle.

The muscle examination is performed in the patient's initial position lying on his back. The test movement is performed with resistance from the doctor's hands.

E. The following muscles perform external rotation of the thigh:

• gluteus maximus;
• posterior portions of the gluteus medius and gluteus minimus;
• sartorius;
• internal and external obturator muscles;
• quadratus femoris;
• piriformis muscle.

The functional state of the muscles is examined in the patient's initial position lying on his back. The test movement is performed with the resistance of the doctor's hands.

Pelvic muscles

In the pelvic area, a distinction is made between internal and external muscles.

A. Internal muscles of the pelvis.

1. Iliopsoas muscle.

Function:

• flexes the hip and rotates it outward;
• with a fixed lower limb, tilts the pelvis and torso forward (flexion).

The functional state of the muscle is examined with the patient lying on his back:

• active movements of the legs, bent at the hip and knee joints. The same movement is performed with resistance from the doctor's hand;
• active movements - hip flexion, performed with straight legs (alternately and simultaneously). The same movement is performed with the resistance of the doctor's hand.
• active movements - with fixed lower limbs - bending the body forward. The same movement is performed with the resistance of the doctor's hands or with weights.

2. Piriformis muscle.
3. Obturator internus muscle.

Function: rotates the thigh outward.

B. External pelvic muscles.

1. Gluteus maximus muscle.

Muscle function:

• extends the hip, rotates it outward;
• with fixed limbs, extends the trunk.

To examine the function of the gluteus maximus muscle, it is necessary, from the patient’s initial position lying on his stomach:

• bend your leg at the knee joint;
• With your legs fixed, straighten your torso.

The same movements are performed with the resistance of the doctor's hands.

2. Gluteus medius muscle.

Muscle function:

• abducts the hip;
• the anterior bundles rotate the thigh inward;
• The posterior bundles rotate the thigh outward.

3. Gluteus minimus.

The function of the muscle is similar to that of the gluteus medius.

The functional state of the gluteus medius and gluteus minimus is examined with the patient lying on his side. The patient is asked to move his straight leg to the side. The normal angle of the leg to the side is 45°. The movement can be performed with the resistance of the doctor's hands.

ATTENTION! If, when abducting a straight leg, the foot rotates outward, this indicates tension in the muscle fibers of the gluteus medius and minimus.

4. Tensor fasciae latae muscle.

Function - tenses the broad fascia.

5. Quadratus femoris.

Function - rotates the thigh outward.

6. External obturator muscle.

Function - rotates the hip outward. Another component of the vertebral syndrome is the reflex tension of the paravertebral muscles, aimed at limiting movements in the affected segment of the spine.

The contracture is clearly visible during a simple examination, it is often asymmetrical and more pronounced on the affected side. With spinal movements, especially when trying to flex the torso, the muscle contracture increases and becomes more noticeable.

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Examination of paravertebral muscles

A. Superficial paravertebral muscles:

• in the patient's initial position while standing. If the erector spinae muscle is affected, he can bend his torso only a few degrees.

CAUTION! In this position, palpation of the corresponding muscles is ineffective due to postural muscle tension and the protective engagement of healthy muscles.

• For better muscle relaxation, the patient should be placed on his side with his legs drawn up to his chest. This position facilitates more effective palpation of the muscle.

B. Deep paravertebral muscles:

• in the initial position while standing, the patient cannot freely perform torso bends to the sides, rotation and extension of the torso;
• when flexing the body, a depression or flattening may be detected between the spinous processes;
• damage to the multifidus muscles or rotator muscles is accompanied by pain in the area of the adjacent spinous processes.

ATTENTION! The direction of palpation is towards the body of the vertebra, where the greatest pain is localized.

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Methodology for examining abdominal muscles

Abdominal TPs usually develop in muscles that are subject to acute or chronic overstretching, or in muscles that are in the area of pain referred from internal organs.

ATTENTION! Tension of the abdominal muscles allows you to distinguish myofascial pain from visceral pain.

Long test:

• patient's initial position - lying on the back, legs straight;
• the patient lifts his straight legs from the couch; the doctor palpates the tense muscles. If the pain does not increase with this movement, then this indicates its muscular origin; if the pain decreases, then one can judge its visceral genesis.

Examination of the rectus abdominis muscles:

• patient's initial position - lying on his back, legs bent at the knees and hip joints, hands behind his head; on command the patient should sit up slowly, without jerking;
• On command from the doctor, the patient slowly straightens his legs, lifts his head and shoulders and holds them for 5-7 seconds.

Examination of the internal and external oblique abdominal muscles:

• patient's initial position - lying on his back, legs bent at the knees and hip joints, hands behind his head;
• On the doctor's command, the patient slowly lifts the torso (to an angle of 45°) and rotates it slightly (30°). The functioning of the oblique abdominal muscles on the affected and healthy sides is compared (J. Durianova).

Range of motion testing

A. Study of active movements:

• Forward bending in patients is usually limited - the back remains flat, does not take the form of an arc, and the bend itself is achieved by flexion in the hip joints and, to a small extent, by the thoracic spine.

ATTENTION! For some patients, forward bending of the body is only possible by 5-10° and further attempts cause increased pain.

• Backward tilt is limited in 90% of patients (compensatory and protective role of flattening of lordosis and kyphosis) - the more the lordosis is straightened, the lesser the degree of backward extension.

ATTENTION! During the functional block, patients try to extend their thoracic and even cervical spine, bending their legs at the knee joints, which outwardly creates the illusion of this movement.

• Lateral tilts are most often limited and depend on:

A) type of scoliotic spinal alignment. Typical is the picture of a sharp or even complete block of movements in the direction of the convexity of the curvature with satisfactory preservation of movements in the opposite direction.

ATTENTION! This mechanism depends entirely on the relationship of the root to the disc herniation, since any movement towards the convexity of the scoliosis leads to increased tension on the root.

B) functional block of the PDS (L3 _- L4) - a limited range of motion is achieved by the overlying segments of the spine.

• rotational movements are not significantly affected and are reduced by 5-15° (rotation of the torso with fixed legs by 90° is considered normal).

B. Study of passive movements.

The anatomical features of the structure of the intervertebral joints predetermine the relatively high mobility of this section in the sagittal plane, significantly less in the frontal plane and insignificant (with the exception of the lumbosacral joint) in the horizontal plane.

Side bends:

• patient's initial position - lying on his side with his legs bent at a right angle (at the knees and hip joints);
• The doctor, grasping the patient's legs in the ankle area with his hands, lifts his legs and pelvis, while performing a passive lateral tilt in the lumbar segments.

Extension:

• patient's initial position - lying on the side with bent legs;
• With one hand, the doctor slowly and smoothly straightens the patient's legs, controlling this movement in each segment with the index finger of the other hand, located between the spinous processes.

Flexion:

• patient's initial position - lying on the side, legs bent;
• Using his knee, the doctor slowly and smoothly bends the patient's torso, controlling the movement in each segment with his hands located on the spine.

Rotation:

• patient's initial position - sitting or lying down;
• The doctor places the fingers of his hand on 2-3 spinous processes of adjacent vertebrae, moving sequentially in the cranial direction.

ATTENTION! Since rotation in segments L4-5 is insignificant, only the study of the displacement of the spinous process of L5 in relation to S1 has diagnostic value.

Direct palpation of pelvic girdle formations is possible in relatively limited areas. The bony base of the pelvis is located deep in the thickness of soft tissues and in some cases is inaccessible to direct palpation. As a result, direct palpation of the pelvis in most cases makes it possible to only partially identify the localization of the lesion. Lesions of deep-lying parts of the pelvis are determined by the following methodological techniques:

1. symptom of transverse concentric compression of the pelvis. The doctor places his hands on the lateral surfaces of the patient's pelvis (s.p. - lying on his back), fixing the iliac crests and then compresses the pelvis in the transverse direction. Pain occurs in the affected area.
2. symptom of transverse eccentric compression of the pelvis:

• patient's initial position - lying on his back;
• the doctor, grasping the iliac crests (near the anterior superior iliac spines), attempts to "unfold" (spread apart) the edges of the pelvis, pulling the anterior sections of the crests away from the midline of the body. When damaged, pain occurs.

3. the symptom of vertical pressure of the doctor's hands in the direction from the ischial tuberosity (2) to the iliac crest (I) supplements the data on the localization of deep-seated lesions of the pelvic bones.

In case of displacement of the pelvic girdle axis due to diseases of the spine, lower limbs, joint deformation, etc., it is recommended to determine the magnitude of the displacement of the pelvic wings by the distance of the anterior superior iliac spines from the midline of the body (possibly by the distance from the end of the xiphoid process of the sternum) to the anterior superior pelvic spines in front and from the spinous process of one of the vertebrae to the posterior superior spines (in case of dislocations, subluxations of the ilium in the sacroiliac joint).

ATTENTION! In cases of damage to the sacroiliac joint, when performing differentiated techniques, any movements in the lumbar spine that can imitate the appearance of mobility in the joint and, as a consequence, the occurrence of pain should be avoided.

These techniques include the following:

1. V.V. Kernig's maneuver. The patient is in the initial position lying on his back. The doctor places one hand under his back in the area of the lower lumbar vertebrae. With this hand it is necessary to palpate the spinous processes of the L5 and S1 vertebrae. With the other hand the doctor, grasping the patient's straight leg, slowly bends it at the hip joint. In order to determine which of the joints is affected - the sacroiliac or the lumbosacral, it is important to accurately determine the time of pain onset. If the pain appears before the onset of movements of the lumbar vertebrae (they are felt by the doctor's hand placed under the patient's back), then this indicates a disease of the sacroiliac joint; if the pain appears from the moment of the onset of movements of the spine, then this indicates a disease of the lumbosacral joint.

ATTENTION! When performing the procedure, remember that movement occurs first in the sacroiliac joint. The examination is performed on both sides.

The occurrence of pain in patients during this technique is explained by minor movements in the sacroiliac-lumbar joints, which occur due to the traction of the muscles attached to the ischial tuberosity (mm. biceps femoris, semitendinosus et semimembranosus).

2. The technique of applying pressure to the pubic symphysis. The patient's initial position is lying on his back. When performing this technique, movement may occur in the sacroiliac joint and, as a response, pain may occur on the affected side.
3. Leg hyperextension maneuver. The symptom is based on pain in the sacroiliac joint caused by passive movement in the joint being examined. It is tested on both sides. The patient is placed on the edge of the table so that the leg on the side of the joint being examined hangs freely. The other leg is bent with the help of the patient's arms and pulled up to the abdomen in order to fix the pelvis. The doctor carefully hyperextends the freely hanging thigh, gradually increasing his effort. Hyperextension leads to a rotational movement in the sacroiliac joint due to the traction of the iliofemoral ligament and muscles attached to the anterior (superior and inferior) iliac spines. As a result of the movements, local radiating pain occurs in the joint being examined.
4. Campbell's Symptom. The patient sits on a chair. When the sacroiliac joint is affected, the pelvis remains fixed and pain does not occur when the torso is bent forward. When the torso is straightened, pain occurs in the area of the affected joint.
5. Knee-heel test (hip abduction technique). The patient's initial position is lying on his back, the pelvis is fixed by the doctor's hand. Extreme abduction of the thigh, bent at the hip and knee joints and rotated outward (the heel touches the thigh of the straightened other leg), causes pain in the sacroiliac joint of the same name and limits the range of motion of the thigh. In this case, the distance (in cm) between the knee and the couch should be measured and the result should be compared with the results of studies conducted on the other side. Normally, the knee of the bent leg should lie on the surface of the couch.

This symptom tests flexion (flexio), abduction (abductio), external rotation (rotatio) and extension (extensio). It is also called Faber's sign, after the initial letters of each movement. In later editions, this symptom was called Patrick's phenomenon.

The following are indicative tests for examining the sacroiliac joint, based on the occurrence of pain in the joint during certain movements:

• the appearance of pain when the patient sits down quickly (Larrey's test);
• the appearance of pain when standing up on a chair, first with the healthy leg, then with the sore leg, and when lowering the sore leg, then with the healthy leg, from the chair (Ferguson test);
• the appearance of pain when positioned - one leg is placed on the other; the patient sits on a chair (Soobraze test);
• pain when pressing with the hand on the median sacral crest; patient position - lying on the stomach (Volkman-Ernesen test);
• pain when turning the thigh inward with the leg bent at the knee joint; patient position - lying on the back (Bonnet test);
• pain in the area of the sacroiliac joint caused by irritation of the nerve roots of the lumbar region can be differentiated by the Steindler test; injection of a novocaine solution into the most painful area in the lumbar spine does not relieve pain in the area of the sacroiliac joint.

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Static violations

A. Flattening of the lumbar lordosis is one of the compensatory mechanisms that ensures a reduction in the volume of the herniated disc, which in turn reduces compression on the posterior longitudinal ligament and the adjacent root.

ATTENTION! A change in statics in the form of flattening or disappearance of the lumbar lordosis in osteochondrosis of the spine is a protective position of the torso.

B. Lumbar kyphosis. The protective mechanism of fixed kyphosis consists of stretching the posterior fibrous semiring, which has lost its elasticity and resilience.

ATTENTION! In the kyphosis state of the lumbar spine, the prolapse of fragments of the fibrous ring together with the nucleus pulposus into the lumen of the spinal canal decreases, which leads to a decrease or cessation of neurological disorders for a certain time.

B. Hyperlordosis occurs as a protective and compensatory reaction of the body in response to a forward shift of the body’s center of gravity (for example, during pregnancy, obesity, flexion contracture of the hip joint, etc.).

With hyperlordosis, the diameter of the intervertebral opening decreases, pressure on the posterior sections of the intervertebral disc increases, overstretching of the anterior longitudinal ligament occurs, compression of the interspinous ligaments between the converging spinous processes, and overstretching of the capsules of the intervertebral joints. Extension is difficult, since it contributes to a decrease in the intravertebral space.

G. Scoliotic positioning of the spine is caused by a reflex reaction of the muscular system, which ensures that the spine is given a position that facilitates the displacement of the root from the maximum size of the hernial disc protrusion to the side (to the right or to the left), thereby reducing the degree of tension of the root and limiting the flow of pain impulses.

ATTENTION! The side of scoliosis will depend on the location of the hernia (lateral or paramedian), its size, the mobility of the root, as well as on the structural features of the spinal canal and the nature of the reserve spaces.

• In homolateral scoliosis, the root is displaced laterally and is often tightly pressed against the inner surface of the yellow ligament. The localization of the hernia is paramedian.
• In heterolateral scoliosis, the opposite relationship is observed - the disc herniation is located more laterally, and the root tends to shift medially.

In addition to static disorders, patients also experience significant impairment of the biomechanics of the spine, mainly due to the mobility of the lumbar region.

• Forward bending of the torso is usually limited, the back remains flat, does not take the form of an arc, as is normal, and the bending itself is carried out by bending in the hip joints and to a small extent by the thoracic spine. In some patients, forward bending of the torso is possible only by 5-10, and further attempts cause a sharp increase in pain. Only patients with formed kyphosis of the lumbar spine can usually bend forward to the full extent.
• The backward tilt of the body is most often limited by the more the lordosis is straightened, the less is the degree of backward extension. The complete absence of movements of the lumbar spine in one direction or another is called a "block". When the lumbar spine is blocked backward, patients try to perform extension at the expense of the thoracic and even cervical spine, bending their legs at the knee joints, which externally creates the illusion of this movement.
• Usually, the range of body movements to the sides is impaired, which depends on the type of scoliosis. A typical picture is a sharp limitation or even a complete block of movements in the direction of the convexity of the scoliosis with satisfactory preservation of movements in the opposite direction. This mechanism depends on the relationship of the root to the disc herniation, since any movement in the direction of the convexity of the scoliosis leads to increased tension of the root. Along with this, it is often necessary to observe a blockade of movements in the lumbar region in both directions, while III-V, and sometimes II lumbar vertebrae are completely excluded from movements. The limited range of movements is carried out due to the overlying segments of the spine. In some patients, a blockade of all types of movement in the lumbar region occurs, which is caused by a reflex contraction of all muscle groups that immobilize the affected section of the spine in the most advantageous position.
• Rotational movements of the spine are not significantly affected and are reduced by 5-15° (rotation of the torso with fixed legs by 90° is considered normal).

Lumbosacral junction and pelvis The bones of the pelvic girdle are connected to each other in front by the pubic semi-joint, and behind they form the sacroiliac joints with the sacrum. As a result, the pelvis is formed.

The sacroiliac joint is formed by the auricular surfaces of the sacrum and ilium and is a flat joint. The joint capsule is reinforced by strong short ligaments in front and behind. The sacroiliac interosseous ligament, stretched between the iliac tuberosity and the sacral tuberosity, plays a major role in strengthening the joint.

The pubic symphysis (pubic symphysis) is formed by the pubic (pubic) bones, which are firmly fused with the fibrocartilaginous interpubic disc located between them. There is a slit-like cavity in the thickness of the disc. The pubic symphysis is strengthened from above by the superior pubic ligament, and from below by the arcuate pubic ligament.

The pelvis is normally a closed ring with slightly mobile links. The position and tilt of the pelvis depend on the position of the lumbar spine, the condition of the hip joints and abdominal muscles, as well as the muscles that lock the lower opening of the pelvis. There is a direct relationship between the pelvis and the position of the lower limbs. With congenital dislocation, coxitis, ankylosis, contracture in the hip joint, the position of the pelvis changes noticeably. Mutually mobile parts of the pelvis are the iliac bones and sacrum on one side, and the pubic bone on the other. Between the ilium and the sacrum there is an articulation (art. sacroiliaса), which imperceptibly complements the movement in the sacroiliac articulation and in the hip joint.

For a vertical position of the body in space, the pelvis must be positioned strictly horizontally. With an asymmetrical position of the pelvis, the normal functioning of the vestibulocerebellar, striopallidal and antigravity systems of the human body is hampered.

Changes in the spinal column (scoliotic alignment) lead to postural defects and incorrect leg placement. These distorted biomechanical effects are transmitted through the pelvic joints, which can be a source of pseudo-radicular pain radiating to the groin area, buttock, shin, and posterolateral surface of the thigh. According to Klevit (1993), pain from the sacroiliac joint never radiates along the midline of the body. This is an important distinguishing feature of pain in the sacroiliac joint.

During a visual inspection, you should pay attention to:

• possible distortion of the sacral Michaelis rhombus;
• asymmetry of the gluteal folds;
• possible downward displacement of one buttock;
• asymmetry of the pelvic girdle line.

Palpation is mandatory:

• iliac crest;
• spinous processes;
• coccyx.

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