Lower Extremity Reflex Testing: Guide for Physical Therapists [Disc Bulge, Herniation Diagnosis]

By dpope2020

September 22, 2023

achilles reflex, achilles tendon, ankle reflex, dan pope, deep tendon reflex test, deep tendon reflexes, fitness pain free, knee jerk reflex, knee jerk reflexes, knee reflex, knee reflexes, lower extremity reflex testing, lower extremity reflexes, lower limb reflexes, lumbar spine reflex tests, lumbar spine reflexes, Physical Examination (Diagnostic Test), physical therapist, physical therapy, physiotherapy, reflex test, reflex testing, reflex tests

Lower Extremity Reflex Testing: Guide for Physical Therapists [Disc Bulge, Herniation Diagnosis]

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In today's video we go over Lower Extremity Reflex Testing: Guide for Physical Therapists [Disc Bulge, Herniation Diagnosis]: 

In today's video, we dive deep into the world of reflex testing for the lower extremity, helping you to get a more accurate diagnosis in your patients with disc pathology and radicular low back pain.

Discover how to use reflex tests as a powerful tool in differentiating lumbar radiculopathy from other conditions.

We'll show you step-by-step how to assess reflexes in the patellar and Achilles tendons, helping you identify the specific level of injury. But here's the kicker...

Reflex testing isn't foolproof, and we'll explain why.  We'll delve into the sensitivity and specificity of these tests and what it means for your diagnosis. Your patients deserve the best care, and we're here to help you deliver it.

Don't forget to like, subscribe, and hit that notification bell for more valuable insights.

  • 0:00 - Intro
  • 0:09 - What is reflex testing
  • 0:25 - Problems with diagnostics
  • 0:48 - Performing reflex testing
  • 1:45 - Achilles tendon reflex testing
  • 2:30 - Conclusion 

Reflexes off the chart...

- Dan Pope DPT,OCS,CSCS

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Thank you!

Dan Pope DPT, OCS, CSCS

References: 

  1. Berry J A, Elia C, Saini H S, et al. (October 17, 2019) A Review of Lumbar Radiculopathy, Diagnosis, and Treatment. Cureus 11(10): e5934. doi:10.7759/cureus.5934
  2. Stynes S, Konstantinou K, Ogollah R, Hay EM, Dunn KM. Clinical diagnostic model for sciatica developed in primary care patients with low back-related leg pain. PLoS One. 2018 Apr 5;13(4):e0191852. doi: 10.1371/journal.pone.0191852. PMID: 29621243; PMCID: PMC5886387.
  3. Dydyk AM, Khan MZ, Singh P. Radicular Back Pain. [Updated 2022 Oct 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546593/
  4. Wilby MJ, Best A, Wood E, Burnside G, Bedson E, Short H, Wheatley D, Hill-McManus D, Sharma M, Clark S, Baranidharan G, Price C, Mannion R, Hutchinson PJ, Hughes DA, Marson A, Williamson PR. Surgical microdiscectomy versus transforaminal epidural steroid injection in patients with sciatica secondary to herniated lumbar disc (NERVES): a phase 3, multicentre, open-label, randomised controlled trial and economic evaluation. Lancet Rheumatol. 2021 Mar 18;3(5):e347-e356. doi: 10.1016/S2665-9913(21)00036-9. PMID: 33969319; PMCID: PMC8080892.
  5. Manchikanti L, Knezevic E, Latchaw RE, Knezevic NN, Abdi S, Sanapati MR, Staats PS, Gharibo CG, Simopoulos TT, Shah S, Abd-Elsayed A, Navani A, Kaye AD, Albers SL, Hirsch JA. Comparative Systematic Review and Meta-Analysis of Cochrane Review of Epidural Injections for Lumbar Radiculopathy or Sciatica. Pain Physician. 2022 Oct;25(7):E889-E916. PMID: 36288577.
  6. "Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021" (J Orthop Sports Phys Ther 2021;51(11):CPG1-CPG60. doi:10.2519/jospt.2021.0304). J Orthop Sports Phys Ther 2021:51(12):628. doi:10.2519/jospt.2021.9003
  7. Khorami AK, Oliveira CB, Maher CG, Bindels PJE, Machado GC, Pinto RZ, Koes BW, Chiarotto A. Recommendations for Diagnosis and Treatment of Lumbosacral Radicular Pain: A Systematic Review of Clinical Practice Guidelines. J Clin Med. 2021 Jun 3;10(11):2482. doi: 10.3390/jcm10112482. PMID: 34205193; PMCID: PMC8200038.
  8. Al Qaraghli MI, De Jesus O. Lumbar Disc Herniation. [Updated 2023 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560878/
  9. Kreiner DS, Hwang SW, Easa JE, Resnick DK, Baisden JL, Bess S, Cho CH, DePalma MJ, Dougherty P 2nd, Fernand R, Ghiselli G, Hanna AS, Lamer T, Lisi AJ, Mazanec DJ, Meagher RJ, Nucci RC, Patel RD, Sembrano JN, Sharma AK, Summers JT, Taleghani CK, Tontz WL Jr, Toton JF; North American Spine Society. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. 2014 Jan;14(1):180-91. doi: 10.1016/j.spinee.2013.08.003. Epub 2013 Nov 14. PMID: 24239490.
  10. Jesson, Toma; Runge, Nilsb; Schmid, Annina B.c,*. Physiotherapy for people with painful peripheral neuropathies: a narrative review of its efficacy and safety. PAIN Reports 5(5):p 1-e834, September/October 2020. | DOI: 10.1097/PR9.0000000000000834
  11. Mulleman D, Mammou S, Griffoul I, Watier H, Goupille P. Pathophysiology of disk-related sciatica. I.--Evidence supporting a chemical component. Joint Bone Spine. 2006 Mar;73(2):151-8. doi: 10.1016/j.jbspin.2005.03.003. Epub 2005 Jun 22. PMID: 16046173.
  12. Albrecht DS, Ahmed SU, Kettner NW, Borra RJH, Cohen-Adad J, Deng H, Houle TT, Opalacz A, Roth SA, Melo MFV, Chen L, Mao J, Hooker JM, Loggia ML, Zhang Y. Neuroinflammation of the spinal cord and nerve roots in chronic radicular pain patients. Pain. 2018 May;159(5):968-977. doi: 10.1097/j.pain.0000000000001171. PMID: 29419657; PMCID: PMC5908728.
  13. Alshami AM, Alghamdi MA, Abdelsalam MS. Effect of Neural Mobilization Exercises in Patients With Low Back-Related Leg Pain With Peripheral Nerve Sensitization: A Prospective, Controlled Trial. J Chiropr Med. 2021 Jun;20(2):59-69. doi: 10.1016/j.jcm.2021.07.001. Epub 2021 Oct 2. PMID: 34987322; PMCID: PMC8703155.
  14. Humphreys SC, Eck JC. Clinical evaluation and treatment options for herniated lumbar disc. Am Fam Physician. 1999 Feb 1;59(3):575-82, 587-8. PMID: 10029785.
  15. Tawa N, Rhoda A, Diener I. Accuracy of clinical neurological examination in diagnosing lumbo-sacral radiculopathy: a systematic literature review. BMC Musculoskelet Disord. 2017 Feb 23;18(1):93. doi: 10.1186/s12891-016-1383-2. PMID: 28231784; PMCID: PMC5324296.
  16. Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27. PMID: 25430861; PMCID: PMC4464797.
  17. Brinjikji W, Diehn FE, Jarvik JG, Carr CM, Kallmes DF, Murad MH, Luetmer PH. MRI Findings of Disc Degeneration are More Prevalent in Adults with Low Back Pain than in Asymptomatic Controls: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol. 2015 Dec;36(12):2394-9. doi: 10.3174/ajnr.A4498. Epub 2015 Sep 10. PMID: 26359154; PMCID: PMC7964277.
  18. Jesson, Tom Radiculopathy, Radicular Pain and Referred Pain — What are we talking about, really? Physio Magazine UK 2018
  19. Konstantinou K, Dunn KM, Ogollah R, Lewis M, van der Windt D, Hay EM; ATLAS Study Team. Prognosis of sciatica and back-related leg pain in primary care: the ATLAS cohort. Spine J. 2018 Jun;18(6):1030-1040. doi: 10.1016/j.spinee.2017.10.071. Epub 2017 Nov 21. PMID: 29174459; PMCID: PMC5984249.
  20. Bogduk N. On the definitions and physiology of back pain, referred pain, and radicular pain. Pain. 2009 Dec 15;147(1-3):17-9. doi: 10.1016/j.pain.2009.08.020. Epub 2009 Sep 16. PMID: 19762151.
  21. Fardon DF, Williams AL, Dohring EJ, Murtagh FR, Gabriel Rothman SL, Sze GK. Lumbar disc nomenclature: version 2.0: Recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology. Spine J. 2014 Nov 1;14(11):2525-45. doi: 10.1016/j.spinee.2014.04.022. Epub 2014 Apr 24. PMID: 24768732.
  22. Adams MA, Lama P, Zehra U, Dolan P. Why do some intervertebral discs degenerate, when others (in the same spine) do not? Clin Anat. 2015 Mar;28(2):195-204. doi: 10.1002/ca.22404. Epub 2014 Apr 19. PMID: 24753325.
  23. Callaghan JP, McGill SM. Intervertebral disc herniation: studies on a porcine model exposed to highly repetitive flexion/extension motion with compressive force. Clin Biomech (Bristol, Avon). 2001 Jan;16(1):28-37. doi: 10.1016/s0268-0033(00)00063-2. PMID: 11114441.
  24. Li JQ, Kwong WH, Chan YL, Kawabata M. Comparison of In Vivo Intradiscal Pressure between Sitting and Standing in Human Lumbar Spine: A Systematic Review and Meta-Analysis. Life (Basel). 2022 Mar 20;12(3):457. doi: 10.3390/life12030457. PMID: 35330208; PMCID: PMC8950176.
  25. Saraceni N, Campbell A, Kent P, Ng L, Straker L, O'Sullivan P. Does intra-lumbar flexion during lifting differ in manual workers with and without a history of low back pain? A cross-sectional laboratory study. Ergonomics. 2022 Oct;65(10):1380-1396. doi: 10.1080/00140139.2022.2036819. Epub 2022 Apr 9. PMID: 35098885.
  26. Saraceni N, Kent P, Ng L, Campbell A, Straker L, O'Sullivan P. To Flex or Not to Flex? Is There a Relationship Between Lumbar Spine Flexion During Lifting and Low Back Pain? A Systematic Review With Meta-analysis. J Orthop Sports Phys Ther. 2020 Mar;50(3):121-130. doi: 10.2519/jospt.2020.9218. Epub 2019 Nov 28. PMID: 31775556.
  27. Saraceni N, Campbell A, Kent P, Ng L, Straker L, O'Sullivan P. Exploring lumbar and lower limb kinematics and kinetics for evidence that lifting technique is associated with LBP. PLoS One. 2021 Jul 21;16(7):e0254241. doi: 10.1371/journal.pone.0254241. PMID: 34288926; PMCID: PMC8294511.
  28. Veres SP, Robertson PA, Broom ND. The influence of torsion on disc herniation when combined with flexion. Eur Spine J. 2010 Sep;19(9):1468-78. doi: 10.1007/s00586-010-1383-0. Epub 2010 May 1. PMID: 20437184; PMCID: PMC2989279.
  29. Urban LM, MacNeil BJ. Diagnostic Accuracy of the Slump Test for Identifying Neuropathic Pain in the Lower Limb. J Orthop Sports Phys Ther. 2015 Aug;45(8):596-603. doi: 10.2519/jospt.2015.5414. Epub 2015 Jun 24. PMID: 26107044.
  30. Majlesi J, Togay H, Unalan H, Toprak S. The sensitivity and specificity of the Slump and the Straight Leg Raising tests in patients with lumbar disc herniation. J Clin Rheumatol. 2008 Apr;14(2):87-91. doi: 10.1097/RHU.0b013e31816b2f99. PMID: 18391677.
  31. Ekedahl H, Jönsson B, Annertz M, Frobell RB. Accuracy of Clinical Tests in Detecting Disk Herniation and Nerve Root Compression in Subjects With Lumbar Radicular Symptoms. Arch Phys Med Rehabil. 2018 Apr;99(4):726-735. doi: 10.1016/j.apmr.2017.11.006. Epub 2017 Dec 15. PMID: 29253501.
  32. Owen PJ, Miller CT, Mundell NL, et al. Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis. Br J Sports Med. 2020;54(21):1279-1287. doi:10.1136/bjsports-2019-100886
  33. Naqvi U, Sherman Al. Muscle Strength Grading. [Updated 2022 Aug 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK436008/
  34. Petr O, Glodny B, Brawanski K, Kerschbaumer J, Freyschlag C, Pinggera D, Rehwald R, Hartmann S, Ortler M, Thomé C. Immediate Versus Delayed Surgical Treatment of Lumbar Disc Herniation for Acute Motor Deficits: The Impact of Surgical Timing on Functional Outcome. Spine (Phila Pa 1976). 2019 Apr 1;44(7):454-463. doi: 10.1097/BRS.0000000000002295. PMID: 28658038.
  35. Stochkendahl, M.J., Kjaer, P., Hartvigsen, J. et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J 27, 60–75 (2018). https://doi.org/10.1007/s00586-017-5099-2
  36. Halliday MH, Pappas E, Hancock MJ, Clare HA, Pinto RZ, Robertson G, Ferreira PH. A Randomized Controlled Trial Comparing the McKenzie Method to Motor Control Exercises in People With Chronic Low Back Pain and a Directional Preference. J Orthop Sports Phys Ther. 2016 Jul;46(7):514-22. doi: 10.2519/jospt.2016.6379. Epub 2016 May 12. PMID: 27170524.
  37. Albert HB, Manniche C. The efficacy of systematic active conservative treatment for patients with severe sciatica: a single-blind, randomized, clinical, controlled trial. Spine 2012;37:531–42
  38. Pang JY, Tan F, Chen WW, Li CH, Dou SP, Guo JR, Zhao LY. Comparison of microendoscopic discectomy and open discectomy for single-segment lumbar disc herniation. World J Clin Cases. 2020 Jul 26;8(14):2942-2949. doi: 10.12998/wjcc.v8.i14.2942. PMID: 32775376; PMCID: PMC7385604.
  39. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs Nonoperative Treatment for Lumbar Disk Herniation: The Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial. JAMA. 2006;296(20):2441–2450. doi:10.1001/jama.296.20.2441
  40. Kögl N, Brawanski K, Girod PP, Petr O, Thomé C. Early surgery determines recovery of motor deficits in lumbar disc herniations-a prospective single-center study. Acta Neurochir (Wien). 2021 Jan;163(1):275-280. doi: 10.1007/s00701-020-04614-0. Epub 2020 Nov 4. PMID: 33145630; PMCID: PMC7778612.

Images:

  1. Intervertebral disc: Source: https://commons.wikimedia.org/wiki/File:716_Intervertebral_Disk.jpg attribution: OpenStax College, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons
  2. Herniated disc: source: https://commons.wikimedia.org/wiki/File:728_Herniated_Disk.jpg attribution: OpenStax College, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons
  3. Functional Spinal Unit: source: https://commons.wikimedia.org/wiki/File:Functional_spinal_unit_(FSU).webp attribution: Irina Nefedova, CC BY 4.0 <https://creativecommons.org/licenses/by/4.0>, via Wikimedia Commons
  4. Spinal Canal: source: https://commons.wikimedia.org/wiki/File:Spinal_canal.webp attribution:Irina Nefedova, CC BY 4.0 <https://creativecommons.org/licenses/by/4.0>, via Wikimedia Commons
  5. Dermatomes: source: https://commons.wikimedia.org/wiki/File:Dermatomes_labeled,_female_front-back_3d-shaded.svg attribution: Goran_tek-en, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons
  6. Epidural: Source: https://commons.wikimedia.org/wiki/File:Epidural_Anesthesia.png Attribution: BruceBlaus, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons Modified by Fitness Pain Free LLC