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From: PHYSIO - for physiotherapists in education and practice
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Sent: Monday, January 08, 2001 2:48 PM
To: [log in to unmask]
Subject: Athlete with Back Pain
A coaching colleague of mine has posed the following questions and is eager
to obtain some more professional comments.
Dr Mel C Siff
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<One of my teenaged athletes who has been having chronic lower back pain was
recently evaluated by a physical therapist. He did the knee jerk and ankle
jerk reflex tests, and told her that, based on these tests, the nerves
surrounding L5 disc were not affected.
In one of Cailliet's books, he says, "The knee jerk and ankle jerk reflexes
are routinely tested to determine the integrity of nerve roots L3-L4 and S1.
There is no reflex to test L5, as the muscles innervated by this root have
no
specific tendon."
This lass was having balance problems (always tripping over her feet) and
her
left middle three would often go numb. (In the past the doctor called it
"restless leg syndrome" and not to worry about it.) Cailliet says "The
ability to pick one's toes up and clear the floor while walking so one does
not scuff one's foot in walking is a function of L5."
My question is, has there been a change in the extend of the effectiveness
of
the reflex tests since Cailliet's books have been published? Or should my
athlete seek out another therapist?
*** No change. Knee jerk is L4, Ankle jerk is S1. Rather than reflexes,
MMT is of benefit if there is sufficient weakness. Heel walking (the
inability in this case, where the foot slaps or there is no ability to raise
the foot) is used to test L5 myotomes. Muscle testing of the extensor
hallis is a good L5 muscle as is hip abduction in sidelying (Tensor Fascia
Lata). Someone is misunderstanding something somewhere, but the anatomy is
still the same. Some people test the lateral hamstring for an L5 reflex,
but this is difficult to reproduce and I have never seen any support in the
literature for this being indicative of L5.
Also, she had problem rising from a squat (and this is figure skater), but
in
an X-ray taken a year ago there was no problem with L3-L4. Calliet states,
"The L3-L4 nerves go to the thigh muscles. These thigh muscles extend
(straighten) the knee and permit a person to do a bend at the knees, do a
deep knee bend, rise from a sitting position, climb or descend stairs, and
do
squats. These muscles permit the patient to walk, run, jump, and so forth
by
virtue of the fact that they control the muscles that perform these
activities." Also, "By virtue of their specific distribution, if these
nerves (L2, L3, and L4) are irritated, they will cause weakness of the thigh
muscles. This weakness will make it difficult to do a deep knee bend, go up
and down stairs, or get in and out of a chair.
So, my second question is, is it possible that the X-ray is not a good way
to
determine irritation in the discs? Or could the doctor simply had misread
the
X-ray?
***X-ray would only show a fracture, or a slippage of the vertebra
(spondylolythesis) and some disease processes (ostoemyelitis for example).
An x-ray may also show a disc collapse, but in this age good, it is not a
good test because the discs are large (relative to older folks) and it takes
a large herniation to be "interpolated" from an x-ray. An MRI would be good
for many other reasons in this age group--given her pronounced symptoms with
balance and numbness, at some point awful diseases such as multiple
sclerosis or space occupying tumors need to be ruled out. Probably rather
than a PT at this point, a neurologist would be useful to rule out the awful
stuff. Unfortunately, once doctors rule out awful stuff, thy neglect to
treat the musculoskeletal stuff and they tend to not refer to PT.
Any insight would be appreciated. >
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Dr Mel C Siff
Denver, USA
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