Lumbar Radiculopathy Assessment: Difference between revisions

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== Introduction ==
== Introduction ==
[https://www.physio-pedia.com/Lumbar_Radiculopathy Lumbar radiculopathy] describes pain that radiates into the legs. These leg symptoms might be described by patients as sharp, shooting, shocks, numbness, and tingling. These descriptions depend on the patient's interpretation of the symptoms. <blockquote>Lumbar radiculopathy is "characterized by motor, reflex, and/or sensory changes, such as radicular pain, paresthesia, or numbness in the lower limb which may be provoked by spinal posture(s) and/or movement(s). While radiculopathy and radicular pain commonly occur together, radiculopathy can occur in the absence of pain and radicular pain can occur in the absence of radiculopathy."<ref>Thoomes E, Falla D, Cleland JA, Fernández-de-Las-Peñas C, Gallina A, de Graaf M. [https://www.tandfonline.com/doi/full/10.1080/09638288.2022.2130448 Conservative management for lumbar radiculopathy based on the stage of the disorder: a Delphi study]. Disabil Rehabil. 2023 Oct;45(21):3539-3548. </ref> </blockquote>Lumbar radiculopathy affects approximately 3-5% of the population,<ref>Vanti C, Turone L, Panizzolo A, Guccione AA, Bertozzi L, Pillastrini P. [https://archivesphysiotherapy.biomedcentral.com/articles/10.1186/s40945-021-00102-5 Vertical traction for lumbar radiculopathy: a systematic review]. Arch Physiother. 2021 Mar 15;11(1):7. </ref> and it is the most common issue that spine surgeons evaluate.<ref name=":1">Berry, J. A., Elia, C., Saini, H. S., & Miulli, D. E. (2019). A Review of Lumbar Radiculopathy, Diagnosis, and Treatment. ''Cureus'', ''11''(10), e5934. <nowiki>https://doi.org/10.7759/cureus.5934</nowiki></ref> Patients also may or may not experience back pain along with radiculopathy but roughly 12-40% of people with back pain experience radiculopathy symptoms as well.<ref name=":0">Alexander CE, Varacallo M. Lumbosacral Radiculopathy. [Updated 2023 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430837</ref>  
[https://www.physio-pedia.com/Lumbar_Radiculopathy Lumbar radiculopathy] is usually caused by compression of a lumbar nerve root, resulting in symptoms which radiate down the legs. It causes at least one of the following: decreased strength in the associated myotome, altered sensation in the dermatome or decreased reflexes.<ref name=":2">Rainey N. Lumbar Radiculopathy Assessment Course. Plus, 2023.</ref> While pain is not part of this definition, people with lumbar radiculopathy report various symptoms, including sharp, shooting pain, shocks, numbness or tingling, etc. These descriptions depend on the patient's interpretation of the symptoms. <blockquote>Lumbar radiculopathy is "characterized by motor, reflex, and/or sensory changes, such as radicular pain, paresthesia, or numbness in the lower limb which may be provoked by spinal posture(s) and/or movement(s). While radiculopathy and radicular pain commonly occur together, radiculopathy can occur in the absence of pain and radicular pain can occur in the absence of radiculopathy."<ref>Thoomes E, Falla D, Cleland JA, Fernández-de-Las-Peñas C, Gallina A, de Graaf M. [https://www.tandfonline.com/doi/full/10.1080/09638288.2022.2130448 Conservative management for lumbar radiculopathy based on the stage of the disorder: a Delphi study]. Disabil Rehabil. 2023 Oct;45(21):3539-3548. </ref> </blockquote>Lumbar radiculopathy affects approximately 3-5% of the population,<ref>Berry JA, Elia C, Saini HS, Miulli DE. A review of lumbar radiculopathy, diagnosis, and treatment. Cureus. 2019:11(10).</ref><ref>Vanti C, Turone L, Panizzolo A, Guccione AA, Bertozzi L, Pillastrini P. [https://archivesphysiotherapy.biomedcentral.com/articles/10.1186/s40945-021-00102-5 Vertical traction for lumbar radiculopathy: a systematic review]. Arch Physiother. 2021 Mar 15;11(1):7. </ref> and it is the most common issue that spine surgeons evaluate.<ref name=":1">Berry JA, Elia C, Saini HS, Miulli DE. A review of lumbar radiculopathy, diagnosis, and treatment. ''Cureus'', 2019;''11''(10):e5934.</ref> Patients may or may not experience back pain along with radiculopathy, but roughly 12-40% of people with back pain also experience radiculopathy symptoms.<ref name=":0">Alexander CE, Varacallo M. Lumbosacral Radiculopathy. [Updated 2023 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430837</ref>  


== Causes of Radiculopathy ==
== Causes of Radiculopathy ==
The primary cause of lumbar radiculopathy is compression of the nerve root.<ref>Amjad F, Mohseni-Bandpei MA, Gilani SA, Ahmad A, Hanif A. [https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-022-05196-x Effects of non-surgical decompression therapy in addition to routine physical therapy on pain, range of motion, endurance, functional disability and quality of life versus routine physical therapy alone in patients with lumbar radiculopathy; a randomized controlled trial]. BMC Musculoskelet Disord. 2022 Mar 16;23(1):255.</ref> It is commonly believed to be caused by a disc herniation or bulge pressing on the nerve but there are a number of potential causes such as<ref name=":0" />:
The primary cause of lumbar radiculopathy is compression of the nerve root.<ref>Amjad F, Mohseni-Bandpei MA, Gilani SA, Ahmad A, Hanif A. [https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-022-05196-x Effects of non-surgical decompression therapy in addition to routine physical therapy on pain, range of motion, endurance, functional disability and quality of life versus routine physical therapy alone in patients with lumbar radiculopathy; a randomized controlled trial]. BMC Musculoskelet Disord. 2022 Mar 16;23(1):255.</ref> It is commonly believed to be caused by a disc herniation or bulge pressing on the nerve, but there are a number of potential causes such as<ref name=":0" />:


* degenerative conditions: [[spondylolisthesis]], [[Lumbar Spinal Stenosis|spinal stenosis,]] [[Osteophyte|osteophytes]]
* degenerative conditions: [[spondylolisthesis]], [[Lumbar Spinal Stenosis|spinal stenosis,]] [[Osteophyte|osteophytes]]
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== Assessment for Radiculopathy ==
== Assessment for Radiculopathy ==
When patients present with radicular symptoms, it is essential to perform an assessment to ensure a proper diagnosis and treatment, and to rule out red flag symptoms. If red flag symptoms are found, it is important to refer out. Red flags include:<ref>DePalma MG. [https://journals.lww.com/jaapa/fulltext/2020/08000/red_flags_of_low_back_pain.1.aspx Red flags of low back pain]. JAAPA. 2020 Aug;33(8):8-11. </ref>
When patients present with radicular symptoms, it is essential to perform a thorough assessment to ensure appropriate management and to rule out red flags. If red flag symptoms are found, it is important to refer out. Red flags include<ref>DePalma MG. [https://journals.lww.com/jaapa/fulltext/2020/08000/red_flags_of_low_back_pain.1.aspx Red flags of low back pain]. JAAPA. 2020 Aug;33(8):8-11. </ref>:


* fever
* fever
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For more information on red flags, please see: [[An Introduction to Red Flags in Serious Pathology]].
For more information on red flags, please see: [[An Introduction to Red Flags in Serious Pathology]].


An assessment for patients with lumbar radiculopathy will typically include:
=== Body Chart ===
It is always important to fill in a body chart to determine where a patient does and does NOT have symptoms. This will give you a clearer picture of what is occurring.<ref name=":2" />
 
* Make sure you palpate where the symptoms are and aren't, so you can establish the exact location of symptoms.
* Palpate spots that patients have not told you about to check for symptoms. A patient might not think some symptoms are as important, but if you palpate them, there is a better chance that they will tell you about symptoms that may be relevant.
 
=== Objective Examination ===
The assessment for patients with lumbar radiculopathy will typically include:


* myotome testing ([[Assessing Muscle Strength#Measuring Muscle Strength|manual muscle testing (MMT)]])
* myotome testing ([[Assessing Muscle Strength#Measuring Muscle Strength|manual muscle testing (MMT)]])
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* deep tendon reflexes
* deep tendon reflexes
* neurodynamics
* neurodynamics
* repeated movements
* range of motion testing, repeated movements
* lumbar accessory mobility testing


There is research to suggest that physical tests have "poor diagnostic performance" when performed in isolation, but performance may improve when tests are used in combination.<ref>Van der Windt DA, Simons E, Riphagen II, Ammendolia C, Verhagen AP, Laslett M, et al. [https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007431.pub2/full Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain]. Cochrane Database Syst Rev. 2010 Feb 17;(2):CD007431. </ref> Keep in mind, you can utilise these tests as a test and retest measure to show improvement.  
There is research to suggest that physical tests have "poor diagnostic performance" when performed in isolation, but performance may improve when tests are used in combination.<ref>Van der Windt DA, Simons E, Riphagen II, Ammendolia C, Verhagen AP, Laslett M, et al. [https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007431.pub2/full Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain]. Cochrane Database Syst Rev. 2010 Feb 17;(2):CD007431. </ref> Please keep in mind that you can utilise these tests as a test and retest measure to show improvement.  


=== Myotomes ===
=== Myotomes ===
Because nerve roots are affected in lumbar radiculopathies, patients may experience a loss of strength in their lower extremities.  With manual muscle testing of the myotomes, the therapist can gain insight on the possible level of a lesion or compression of the nerve root.<ref name=":1" />  
Because nerve roots are affected in lumbar radiculopathies, patients may experience a loss of strength in their lower extremities.  With manual muscle testing of the myotomes, the therapist can gain insight into the possible level of a lesion or compression of the nerve root.<ref name=":1" />  


To test myotomes:
To test myotomes:


* instruct the patient in what you will be doing such as "I want you to lift your leg up and hold it while I press down on it"
* inform the patient about what you will be doing, such as "I want you to lift your leg up and hold it while I press down on it"
* have the patient move their lower extremity to the testing position
* have the patient move their lower extremity to the testing position
* ask them to hold while you place a gradually increasing downward force on their extremity
* ask them to hold while you place a gradually increasing downward force on their extremity
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|-
|-
|L4
|L4
|Ankle dorisiflexion
|Ankle dorsiflexion
|-
|-
|L5
|L5
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|}
|}


Remember that manual muscle testing can vary depending on the patient's and therapist's size and strength. It can be helpful to ask a patient if they felt as strong on each side after you have finished testing the myotome. A patient may test strong but tell you that one side did not feel as strong as the other.
The following video demonstrates both cervical and lumbar myotome testing. If you just want to view the lumbar myotomes, please watch from 7:22 minutes in the video.


Do keep in mind that manual muscle testing can vary depending on both the patient's and therapist's size and strength. It can be useful to ask a patient if they felt the strength in each lower extremity was the same after you have finished testing the myotome. A patient may test strong but tell you that one side did not feel as strong as the other.  
{{#ev:youtube|UodWTD_IRb8|300}}<ref>Functional Pain Management Society. Myotome testing by an expert. Available from: https://www.youtube.com/watch?v=UodWTD_IRb8 [last accessed 5/12/2023]</ref>


=== Sensation ===
=== Sensation ===
Patients may experience a change in sensation in their lower extremities with a lumbar radiculopathy. A common complaint with lumbar radiculopathy is numbness and tingling or prickling in the legs along a dermatomal pattern. Patients may also state they feel "weird" sensations in their lower extremities as well, such as tenderness, or they may state that "it doesn't feel right."  
Patients may experience a change in sensation in their lower extremities with lumbar radiculopathy. Common complaints with lumbar radiculopathy are numbness, tingling, or prickling in the legs along a dermatomal pattern. Patients may also state they feel "weird" sensations in their lower extremities, such as tenderness, or that "it doesn't feel right."  


Light touch can be assessed to determine if sensation is altered:  
Light touch can be assessed to determine if sensation is altered:  


* have the patient in the supine or seated position
* have the patient in the supine or seated position
* inform them what you will be doing - i.e. "I will be brushing along your legs in certain areas, let me know if it feels the same on both sides"
* inform them what you will be doing - i.e. "I will be brushing along your legs in certain areas; let me know if it feels the same on both sides"
* you can ask the patient to close their eyes or obscure their view so they are not biased to the testing
* you can ask the patient to close their eyes or obscure their view so they are not biased to the testing
* use your fingertips or a cotton swab to apply a light touch to a dermatome
* use your fingertips or a cotton swab to apply a light touch to a dermatome
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=== Deep Tendon Reflexes ===
=== Deep Tendon Reflexes ===
Reflexes may or may not be altered with a lumbar radiculopathy, however, it can be beneficial to assess. If the nerve root is being compromised then the patient may demonstrate diminished reflexes. For patients with a lumbar radiculopathy, the testing will be the patellar and Achille's reflexes. The testing is as follows:   
While reflexes may or may not be altered with a lumbar radiculopathy, assessing deep tendon reflexes can be beneficial. If the nerve root is compromised, the patient may demonstrate diminished reflexes. For patients with a lumbar radiculopathy, you will usually test the patellar and Achilles reflexes. The testing is as follows:   


* The patient can be either seated or lying down (prone and supine)
* the patient can be either seated or lying down (prone and supine)
* Palpate the tendon to ensure to proper identification
* palpate the tendon to ensure you are in the right place
* Make sure the patient is relaxed
* make sure the patient is relaxed
* Using a reflex hammer, perform a brisk, firm strike to the tendon.
* using a reflex hammer, perform a brisk, firm strike to the tendon
* Can repeat as necessary
* can repeat as necessary
* If a response is not found or the patient cannot relax, have the patient perform a jendrassik manoeuvre, such as clinching their jaw or trying to pull their hands apart.
* if a response is not found or the patient cannot relax, have the patient perform a Jendrassik manoeuvre, such as clenching their teeth or trying to pull their hands apart


{| class="wikitable"
{| class="wikitable"
|+
|+Table 3. Lower limb reflexes
!Reflex
!Reflex
!Nerve Supply
!Nerve Supply
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|Plantarflexion
|Plantarflexion
|}   
|}   
Please watch the following video for a demonstration of reflex testing:
{{#ev:youtube|OACTm57eE5I|300}}<ref>Functional Pain Management Society. Tendon reflex testing by an expert (DTR test). Available from: https://www.youtube.com/watch?v=OACTm57eE5I [last accessed 5/12/2023]</ref>


=== Neurodynamics ===
=== Neurodynamics ===
Neurodynamic testing is looking at the sensitivity of the nerve or for a possible entrapment. The [[Straight Leg Raise Test|Straight Leg Raising]] Test (SLR) is one of the most commonly used ones along with the [[Slump Test]]. The SLR Test is also used frequently as a determination by surgeons for a surgical candidate.  The SLR and Slump Tests are used to look at the sciatic nerve (L4-S1) and the [[Femoral Nerve Tension Test|Femoral nerve test]] can be used to test the femoral nerve (L2-L4). A positive for any of the tests is a production of the patient's symptoms.
Neurodynamic testing assesses the sensitivity of the nerve and looks for a possible entrapment. The [[Straight Leg Raise Test]] (SLR) is one of the most commonly used tests, along with the [[Slump Test]]. The SLR and Slump tests assess the sciatic nerve (L4-S1). The [[Femoral Nerve Tension Test|Femoral Nerve Test]] can be used to assess the femoral nerve (L2-L4). A test is considered positive if it reproduces the patient's symptoms.


==== Straight Leg Raise Test ====
==== Straight Leg Raise Test ====
Patient is supine with both lower extremities extended. Starting with the non-painful side, the examiner passively raises the patient's leg while keeping the knee extended and the ankle in neutral. The examiner notes the non-painful side, and then repeats on the painful side A positive response is the reproduction of symptoms between 30-70 degrees of flexion.  
The patient is supine with both lower extremities extended. Starting with the non-painful side, the examiner passively raises the patient's leg while keeping the knee extended and the ankle in neutral. The examiner then repeats the test on the painful side. A positive response is the reproduction of symptoms between 30-70 degrees of flexion. Adding dorsiflexion at the end of the movement (Bragaad sign) can add further tension to the neural tissues.<ref>Pesonen J, Shacklock M, Rantanen P, Mäki J, Karttunen L, Kankaanpää M, et al. [https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-021-04159-y Extending the straight leg raise test for improved clinical evaluation of sciatica: reliability of hip internal rotation or ankle dorsiflexion]. BMC Musculoskelet Disord. 2021 Mar 24;22(1):303. </ref>
 
The following video provides a demonstration of the Straight Leg Raise Test:
 
{{#ev:youtube|bX2yMWkartg|300}}<ref>John Gibbons. Straight Leg Raise (SLR) or Lasegue test for Sciatic nerve pain (Sciatica). Available from: https://www.youtube.com/watch?v=bX2yMWkartg [last accessed 4/12/2023]</ref>


==== Slump Test ====
==== Slump Test ====
The patient is in a seated position. The patient is asked to round their spine (slouch) and bring their chin to their chest. Then the non-painful knee is extended followed by the painful side. A positive response is the reproduction of symptoms. Can also confirm symptoms by having the patient correct their posture with their head up and extend their knee which may not produce any of their leg symptoms
The patient is in a seated position. The patient is asked to bring their hands behind their back, round their spine (slouch) and bring their chin to their chest. Overpressure can be applied. The patient maximally extends their non-painful knee. They then dorsiflex their ankle. The symptom response is determined. The patient then comes out of cervical flexion, and any change in symptoms is noted. This sequence is then repeated on the painful side. This test can also be completed with both legs at the same time.<ref>Maitland GD. [https://www.sciencedirect.com/science/article/pii/S0004951414606346 The slump test: examination and treatment]. Aust J Physiother. 1985;31(6):215-9. </ref>
 
Please watch the following video if you would like to see a demonstration of the Slump Test:
 
{{#ev:youtube|L0R9fm5Swrk|300}}<ref>. The Physio Channel. Available from: https://www.youtube.com/watch?v=L0R9fm5Swrk [last accessed 4/12/2023]</ref>


==== Femoral Nerve Test ====
==== Femoral Nerve Test ====
The patient is in the prone position with both lower extremities extended. Starting on the non-painful side, the knee is flexed to end range. Repeat on the painful side. A positive response is the reproduction of symptoms.
The patient is in prone with both lower extremities extended. The non-painful knee is passively flexed to end range. This movement is then repeated on the painful side. A positive response is the reproduction of the patient's symptoms. It is possible to add hip extension to further load the neural tissues.<ref>Butler D, Matheson J. The sensitive nervous system. Adelaide: Noigroup Publications; 2000.</ref> This test can also be performed in a side-lying position.<ref>Cunningham S. Lumbar Spine Evaluation Course. Plus, 2024.</ref>
 
The following videos show how to perform the Femoral Nerve Test in a prone position and a side-lying position:
 
<div class="row">
  <div class="col-md-6"> {{#ev:youtube|cN0uou-nZH8|250}} <div class="text-right"><ref>John Gibbons. How to test the Femoral Nerve (Lumbar Plexus L2,3,4) or reverse Lasegue's. Available from: https://www.youtube.com/watch?v=cN0uou-nZH8 [last accessed 4/12/2023]</ref></div></div>
  <div class="col-md-6"> {{#ev:youtube|nbhhewS5ZN8|250}} <div class="text-right"><ref>everydayPT. Femoral Nerve Testing (sidelying position). Available from: https://www.youtube.com/watch?v=nbhhewS5ZN8 [last accessed 3/1/2024]</ref></div></div>
</div>


=== Repeated Movement ===
=== Repeated Movement ===
The use of repeated movement testing is a hallmark of Mechanical Diagnosis and Therapy (MDT or the [[McKenzie Method|McKenzie Metho]]<nowiki/>d). The goal with utilizing repeated movement testing, is to determine if the person is able to [[Centralization|centralize]] their radicular symptoms. There is evidence that utilizing repeated movement testing can be both useful in the assessment and treatment for lumbar radiculopathy<ref>Wetzel, F. T., & Donelson, R. (2003). The role of repeated end-range/pain response assessment in the management of symptomatic lumbar discs. ''The spine journal : official journal of the North American Spine Society'', ''3''(2), 146–154. <nowiki>https://doi.org/10.1016/s1529-9430(02)00565-x</nowiki></ref>. Repeated movement testing can be useful even if a patient is only experiencing symptoms in their lower extremity<ref>osedale, R., Rastogi, R., Kidd, J., Lynch, G., Supp, G., & Robbins, S. M. (2020). A study exploring the prevalence of Extremity Pain of Spinal Source (EXPOSS). ''The Journal of manual & manipulative therapy'', ''28''(4), 222–230. <nowiki>https://doi.org/10.1080/10669817.2019.1661706</nowiki></ref>.
The use of repeated movement testing is a hallmark of Mechanical Diagnosis and Therapy (MDT or the [[McKenzie Method]]). The goal of repeated movement testing is to determine if a patient is able to [[Centralization|centralise]] their radicular symptoms. There is evidence that utilising repeated movement testing can be useful in the assessment of patients with low back and leg pain.<ref>Wetzel FT, Donelson R. The role of repeated end-range/pain response assessment in the management of symptomatic lumbar discs. The spine journal : official journal of the North American Spine Society. 2003;3(2):146–154.</ref> Repeated movement testing can be useful even if a patient is only experiencing symptoms in their lower extremity.<ref>osedale, R., Rastogi, R., Kidd, J., Lynch, G., Supp, G., & Robbins, S. M. (2020). A study exploring the prevalence of Extremity Pain of Spinal Source (EXPOSS). ''The Journal of manual & manipulative therapy'', ''28''(4), 222–230. <nowiki>https://doi.org/10.1080/10669817.2019.1661706</nowiki></ref>


Several things must be considered when performing repeated movement:
Several things must be considered when performing repeated movement:


* Direction.  Often a mistake is only performing repeated extension.
* direction: clinicians often make the mistake of only performing repeated extensions
* Loaded or unloaded. Standing is considered a loaded position of the lumbar spine whereas supine/prone is considered unloaded.
* loaded or unloaded: standing is considered a loaded position of the lumbar spine, whereas supine/prone are considered unloaded positions
* Time and/or repetition.  Another mistake that can be made is not giving enough time or the proper number of repetitions to exhaust a movement.
* time and/or repetitions: another mistake that can be made is not giving enough time or the proper number of repetitions to exhaust a movement


== Conclusion ==
== Conclusion ==
Performing these test can be not only important for diagnosing a lumbar radiculopathy but also ruling out serious pathologies and other causes of radicular symptoms not related to the spine. These measures can also be useful in demonstrating improvements over time.  
Performing these tests can help clinicians diagnose lumbar radiculopathy and rule out serious pathologies and other causes of radicular symptoms not related to the spine. These measures can also be used to demonstrate improvements over time.  


== References  ==
== References  ==

Latest revision as of 01:38, 27 February 2024

Original Editor - Matt Huey

Top Contributors - Jess Bell, Matt Huey and Wanda van Niekerk  

Introduction[edit | edit source]

Lumbar radiculopathy is usually caused by compression of a lumbar nerve root, resulting in symptoms which radiate down the legs. It causes at least one of the following: decreased strength in the associated myotome, altered sensation in the dermatome or decreased reflexes.[1] While pain is not part of this definition, people with lumbar radiculopathy report various symptoms, including sharp, shooting pain, shocks, numbness or tingling, etc. These descriptions depend on the patient's interpretation of the symptoms.

Lumbar radiculopathy is "characterized by motor, reflex, and/or sensory changes, such as radicular pain, paresthesia, or numbness in the lower limb which may be provoked by spinal posture(s) and/or movement(s). While radiculopathy and radicular pain commonly occur together, radiculopathy can occur in the absence of pain and radicular pain can occur in the absence of radiculopathy."[2]

Lumbar radiculopathy affects approximately 3-5% of the population,[3][4] and it is the most common issue that spine surgeons evaluate.[5] Patients may or may not experience back pain along with radiculopathy, but roughly 12-40% of people with back pain also experience radiculopathy symptoms.[6]

Causes of Radiculopathy[edit | edit source]

The primary cause of lumbar radiculopathy is compression of the nerve root.[7] It is commonly believed to be caused by a disc herniation or bulge pressing on the nerve, but there are a number of potential causes such as[6]:

Assessment for Radiculopathy[edit | edit source]

When patients present with radicular symptoms, it is essential to perform a thorough assessment to ensure appropriate management and to rule out red flags. If red flag symptoms are found, it is important to refer out. Red flags include[9]:

  • fever
  • unexplained weight loss
  • bowel or bladder dysfunction
  • saddle anaesthesia
  • gait ataxia
  • history of malignancy

For more information on red flags, please see: An Introduction to Red Flags in Serious Pathology.

Body Chart[edit | edit source]

It is always important to fill in a body chart to determine where a patient does and does NOT have symptoms. This will give you a clearer picture of what is occurring.[1]

  • Make sure you palpate where the symptoms are and aren't, so you can establish the exact location of symptoms.
  • Palpate spots that patients have not told you about to check for symptoms. A patient might not think some symptoms are as important, but if you palpate them, there is a better chance that they will tell you about symptoms that may be relevant.

Objective Examination[edit | edit source]

The assessment for patients with lumbar radiculopathy will typically include:

There is research to suggest that physical tests have "poor diagnostic performance" when performed in isolation, but performance may improve when tests are used in combination.[10] Please keep in mind that you can utilise these tests as a test and retest measure to show improvement.

Myotomes[edit | edit source]

Because nerve roots are affected in lumbar radiculopathies, patients may experience a loss of strength in their lower extremities. With manual muscle testing of the myotomes, the therapist can gain insight into the possible level of a lesion or compression of the nerve root.[5]

To test myotomes:

  • inform the patient about what you will be doing, such as "I want you to lift your leg up and hold it while I press down on it"
  • have the patient move their lower extremity to the testing position
  • ask them to hold while you place a gradually increasing downward force on their extremity
  • instruct the patient to hold for 3 seconds (it can help to say Hold, Hold, Hold)
  • record the patient's strength
  • repeat on the opposite side
Table 1. Nerve root and associated movement
Nerve Root Lower Extremity Movement
L2 Hip flexion
L3 Knee extension
L4 Ankle dorsiflexion
L5 Big toe extension
S1 Ankle plantarflexion
S2 Knee flexion

Remember that manual muscle testing can vary depending on the patient's and therapist's size and strength. It can be helpful to ask a patient if they felt as strong on each side after you have finished testing the myotome. A patient may test strong but tell you that one side did not feel as strong as the other.

The following video demonstrates both cervical and lumbar myotome testing. If you just want to view the lumbar myotomes, please watch from 7:22 minutes in the video.

[11]

Sensation[edit | edit source]

Patients may experience a change in sensation in their lower extremities with lumbar radiculopathy. Common complaints with lumbar radiculopathy are numbness, tingling, or prickling in the legs along a dermatomal pattern. Patients may also state they feel "weird" sensations in their lower extremities, such as tenderness, or that "it doesn't feel right."

Light touch can be assessed to determine if sensation is altered:

  • have the patient in the supine or seated position
  • inform them what you will be doing - i.e. "I will be brushing along your legs in certain areas; let me know if it feels the same on both sides"
  • you can ask the patient to close their eyes or obscure their view so they are not biased to the testing
  • use your fingertips or a cotton swab to apply a light touch to a dermatome
  • test each side and compare if it feels the same
  • to ensure consistency, use the same dermatomal map with each patient
Table 2. Lower extremity dermatomes
Dermatome Area
L1 Greater trochanter
L2 Front of thigh to knee
L3 Anterior thigh and knee, medial lower leg
L4 Lateral thigh, medial leg, dorsum of foot, big toe
L5 Posterior and lateral thigh, lateral aspect of leg, dorsum of foot, medial half of bottom of foot, toes 1-3
S1 Posterior thigh

Deep Tendon Reflexes[edit | edit source]

While reflexes may or may not be altered with a lumbar radiculopathy, assessing deep tendon reflexes can be beneficial. If the nerve root is compromised, the patient may demonstrate diminished reflexes. For patients with a lumbar radiculopathy, you will usually test the patellar and Achilles reflexes. The testing is as follows:

  • the patient can be either seated or lying down (prone and supine)
  • palpate the tendon to ensure you are in the right place
  • make sure the patient is relaxed
  • using a reflex hammer, perform a brisk, firm strike to the tendon
  • can repeat as necessary
  • if a response is not found or the patient cannot relax, have the patient perform a Jendrassik manoeuvre, such as clenching their teeth or trying to pull their hands apart
Table 3. Lower limb reflexes
Reflex Nerve Supply Segmental Innervation Area to test Expected Response
Patellar Femoral nerve L2-L4 Patella tendon Leg extension
Achilles Tibial nerve S1-2 Achilles tendon Plantarflexion

Please watch the following video for a demonstration of reflex testing:

[12]

Neurodynamics[edit | edit source]

Neurodynamic testing assesses the sensitivity of the nerve and looks for a possible entrapment. The Straight Leg Raise Test (SLR) is one of the most commonly used tests, along with the Slump Test. The SLR and Slump tests assess the sciatic nerve (L4-S1). The Femoral Nerve Test can be used to assess the femoral nerve (L2-L4). A test is considered positive if it reproduces the patient's symptoms.

Straight Leg Raise Test[edit | edit source]

The patient is supine with both lower extremities extended. Starting with the non-painful side, the examiner passively raises the patient's leg while keeping the knee extended and the ankle in neutral. The examiner then repeats the test on the painful side. A positive response is the reproduction of symptoms between 30-70 degrees of flexion. Adding dorsiflexion at the end of the movement (Bragaad sign) can add further tension to the neural tissues.[13]

The following video provides a demonstration of the Straight Leg Raise Test:

[14]

Slump Test[edit | edit source]

The patient is in a seated position. The patient is asked to bring their hands behind their back, round their spine (slouch) and bring their chin to their chest. Overpressure can be applied. The patient maximally extends their non-painful knee. They then dorsiflex their ankle. The symptom response is determined. The patient then comes out of cervical flexion, and any change in symptoms is noted. This sequence is then repeated on the painful side. This test can also be completed with both legs at the same time.[15]

Please watch the following video if you would like to see a demonstration of the Slump Test:

[16]

Femoral Nerve Test[edit | edit source]

The patient is in prone with both lower extremities extended. The non-painful knee is passively flexed to end range. This movement is then repeated on the painful side. A positive response is the reproduction of the patient's symptoms. It is possible to add hip extension to further load the neural tissues.[17] This test can also be performed in a side-lying position.[18]

The following videos show how to perform the Femoral Nerve Test in a prone position and a side-lying position:

Repeated Movement[edit | edit source]

The use of repeated movement testing is a hallmark of Mechanical Diagnosis and Therapy (MDT or the McKenzie Method). The goal of repeated movement testing is to determine if a patient is able to centralise their radicular symptoms. There is evidence that utilising repeated movement testing can be useful in the assessment of patients with low back and leg pain.[21] Repeated movement testing can be useful even if a patient is only experiencing symptoms in their lower extremity.[22]

Several things must be considered when performing repeated movement:

  • direction: clinicians often make the mistake of only performing repeated extensions
  • loaded or unloaded: standing is considered a loaded position of the lumbar spine, whereas supine/prone are considered unloaded positions
  • time and/or repetitions: another mistake that can be made is not giving enough time or the proper number of repetitions to exhaust a movement

Conclusion[edit | edit source]

Performing these tests can help clinicians diagnose lumbar radiculopathy and rule out serious pathologies and other causes of radicular symptoms not related to the spine. These measures can also be used to demonstrate improvements over time.

References[edit | edit source]

  1. 1.0 1.1 Rainey N. Lumbar Radiculopathy Assessment Course. Plus, 2023.
  2. Thoomes E, Falla D, Cleland JA, Fernández-de-Las-Peñas C, Gallina A, de Graaf M. Conservative management for lumbar radiculopathy based on the stage of the disorder: a Delphi study. Disabil Rehabil. 2023 Oct;45(21):3539-3548.
  3. Berry JA, Elia C, Saini HS, Miulli DE. A review of lumbar radiculopathy, diagnosis, and treatment. Cureus. 2019:11(10).
  4. Vanti C, Turone L, Panizzolo A, Guccione AA, Bertozzi L, Pillastrini P. Vertical traction for lumbar radiculopathy: a systematic review. Arch Physiother. 2021 Mar 15;11(1):7.
  5. 5.0 5.1 Berry JA, Elia C, Saini HS, Miulli DE. A review of lumbar radiculopathy, diagnosis, and treatment. Cureus, 2019;11(10):e5934.
  6. 6.0 6.1 Alexander CE, Varacallo M. Lumbosacral Radiculopathy. [Updated 2023 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430837
  7. Amjad F, Mohseni-Bandpei MA, Gilani SA, Ahmad A, Hanif A. Effects of non-surgical decompression therapy in addition to routine physical therapy on pain, range of motion, endurance, functional disability and quality of life versus routine physical therapy alone in patients with lumbar radiculopathy; a randomized controlled trial. BMC Musculoskelet Disord. 2022 Mar 16;23(1):255.
  8. Berthelot JM, Douane F, Ploteau S, Le Goff B, Darrieutort-Laffite C. Venous congestion as a central mechanism of radiculopathies. Joint Bone Spine. 2022 Mar;89(2):105291.
  9. DePalma MG. Red flags of low back pain. JAAPA. 2020 Aug;33(8):8-11.
  10. Van der Windt DA, Simons E, Riphagen II, Ammendolia C, Verhagen AP, Laslett M, et al. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. Cochrane Database Syst Rev. 2010 Feb 17;(2):CD007431.
  11. Functional Pain Management Society. Myotome testing by an expert. Available from: https://www.youtube.com/watch?v=UodWTD_IRb8 [last accessed 5/12/2023]
  12. Functional Pain Management Society. Tendon reflex testing by an expert (DTR test). Available from: https://www.youtube.com/watch?v=OACTm57eE5I [last accessed 5/12/2023]
  13. Pesonen J, Shacklock M, Rantanen P, Mäki J, Karttunen L, Kankaanpää M, et al. Extending the straight leg raise test for improved clinical evaluation of sciatica: reliability of hip internal rotation or ankle dorsiflexion. BMC Musculoskelet Disord. 2021 Mar 24;22(1):303.
  14. John Gibbons. Straight Leg Raise (SLR) or Lasegue test for Sciatic nerve pain (Sciatica). Available from: https://www.youtube.com/watch?v=bX2yMWkartg [last accessed 4/12/2023]
  15. Maitland GD. The slump test: examination and treatment. Aust J Physiother. 1985;31(6):215-9.
  16. . The Physio Channel. Available from: https://www.youtube.com/watch?v=L0R9fm5Swrk [last accessed 4/12/2023]
  17. Butler D, Matheson J. The sensitive nervous system. Adelaide: Noigroup Publications; 2000.
  18. Cunningham S. Lumbar Spine Evaluation Course. Plus, 2024.
  19. John Gibbons. How to test the Femoral Nerve (Lumbar Plexus L2,3,4) or reverse Lasegue's. Available from: https://www.youtube.com/watch?v=cN0uou-nZH8 [last accessed 4/12/2023]
  20. everydayPT. Femoral Nerve Testing (sidelying position). Available from: https://www.youtube.com/watch?v=nbhhewS5ZN8 [last accessed 3/1/2024]
  21. Wetzel FT, Donelson R. The role of repeated end-range/pain response assessment in the management of symptomatic lumbar discs. The spine journal : official journal of the North American Spine Society. 2003;3(2):146–154.
  22. osedale, R., Rastogi, R., Kidd, J., Lynch, G., Supp, G., & Robbins, S. M. (2020). A study exploring the prevalence of Extremity Pain of Spinal Source (EXPOSS). The Journal of manual & manipulative therapy, 28(4), 222–230. https://doi.org/10.1080/10669817.2019.1661706