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Neuro Anatomy
Lumbar Spine
Spinal Nerves
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Spinal nerves emerge from dura mater as ventral (anterior) and dorsal (posterior) nerve
roots
The ventral nerve root carries motor information away from the spine
The dorsal nerve root carries sensory information from the body to the spine
The dorsal root ganglion contains the cell bodies of the sensory neurons
The dorsal root ganglion is particularly sensitive and is often the cause of radicular pain
The two nerve roots then come together as they go through intervertebral foramen
They will then split into ventral and dorsal rami to become peripheral nerves
Dorsal rami supplies posterior back muscles
Ventral rami progress into forming a plexus supplying the rest of the body
Lumbar Nerve Roots
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The lumbar nerve root is named by the vertebrae above e.g the nerve below L2 vertebrae is
L2
Lumbar Plexus
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Formed by the ventral rami of the first, second, third and part of the fourth lumbar nerves
Form within the substance of psoas major
First lumbar nerve divides into upper and lower branches
Upper branch divides into iliohypogastric and ilioinguinal nerves
Lower branch joins upper branch of second lumbar nerve to form genitofemoral nerve
Lower branch of second lumbar nerve joint third and upper part of fourth to form anterior
and posterior divisions
Anterior divisions form the obturator nerve
Posterior divisions form the femoral nerve
Obturator Nerve
From
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Anterior divisions of the lumbar plexus
Root Value
 L2,3,4
Anatomy
 Merges in the substance of psoas major descending and emerging at the medial border of
the muscle lateral to the sacrum
 Passes through the obturator canal and divides into anterior and posterior branches
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These branches continue to descend through the adductor muscle group
Muscles Supplied
 Adductor longus
 Adductor brevis
 Adductor magnus
 Gracilis
 Obturator externus
 Pectineus
Cutaneous branch
 Medial aspect of the thigh
Femoral Nerve
From
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Posterior divisions of the lumbar plexus
Root Value
 L2, 3, 4
Anatomy
 Emerges from the lateral border of psoas major running between psoas and iliacus
 Passess below the inguinal ligament
 The nerve then divides into various branches supplying the anterior lower limb
 The saphenous nerve arises approx. 3cm below the inguinal ligament and passes inferiorly
and along the medial side of the leg finishing at the first metatarsal
 The saphenous nerve can often be a source of medial knee pain during squating
Muscles Supplied
 Iliacus
 Sartorius
 Quadriceps femoris
Cutaneous Branch
 Anterior cutaneous nerve of thigh
 Saphenous nerve
Lumbosacral Plexus
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Formed by the ventral rami of the fourth lumbar to fourth sacral nerves
Lies on the posterior wall of the pelvis between piriformis and its fascia
Sciatic Nerve
From
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Anterior divisions of the lumbar plexus
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Root Value
 L4,5, S1, 2, 3
Anatomy
 Leaves the pelvis and enters gluteal region through greater sciatic foramen below piriformis
 Passes down back of thigh deep to hamstrings
 Divides into common peroneal and tibial nerve approx. 2/3 down the thigh but in some
cases can be proximal to piriformis
Muscles Supplied
 Hamstrings
 Hamstring part of adductor magnus
Peroneal Nerve
From
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Terminal branch of sciatic nerve
Root Value
 L4, 5, S1, 2
Anatomy
 Passes along the upper lateral side of the popliteal fossa
 Wraps around the neck of fibula and splits into deep peroneal nerve and superficial peroneal
nerve
 Deep peroneal and superficial peroneal nerves continue to pass down into the dorsum of
the foot
Muscles Supplied
 Peroneals
 Extensors of foot
 Tibialis anterior
Cutaneous Branch
 Lateral cutaneous nerve of the calf
 Peroneal communicating branch
Tibial Nerve
From
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Terminal branch of sciatic nerve
Root Value
 L4, 5, S1, 2, 3
Anatomy
 Passes along the upper medial side of the popliteal fossa
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Passes underneath soleus and behind the medial malleolus into the plantar aspect of the
foot
The nerve then divides into the lateral and medial plantar nerves
Muscles Supplied
 Gastrocnemius
 Soleus
 Plantaris
 Poplitieus
 Tibialis posterior
 Flexors of the foot
Cutaneous Branch
 Sural nerve
 Peroneal communicating nerve
Sural Nerve
From
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Terminal branch of sciatic nerve
Root Value
 L4, 5, S1, 2, 3
Anatomy
 Arises from tibial nerve between the two heads of gastrocnemius
 Passes down and behind the lateral malleolus and into the lateral foot
 The sural nerve only has a sensory component
Neurodynamics
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The Neurodynamic System
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Refers to the interaction of the nervous system with its surrounding structures
Made up of 3 components
o Mechanical Interface
 All the structures that surround the nervous system, i.e tendons, ligaments,
fascia, blood vessels, disc etc
o Neural Structures
 Brain, spinal cord, dura mater, nerve rootlets, nerve roots, peripheral nerves
o Innervated Tissues
 Any structure that is innervated by a nerve
 If there is a restriction or alteration in any neural structure MTrP’s can
develop in the muscles it may supply
 Sensory AND motor functions can be inhibited.
Abnormal Neurodynamic System
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Can be the result of one or a combination of the following three components
o Tension
 As the nervous system is connected at both ends it will act like a piece of
string with certain movements taking up the slack increasing the amount of
tension
o Sliding
 The nervous system will slide in relation to the mechanical interface.
 There can be areas where the nervous system will struggle to slide through
or between structures
o Compression
 The mechanical interface can physically compress the nervous system
Movement of the Nervous System
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Generally as a joint moves the neural structures move towards the joint distally and
proximally. This temporarily increases the slack of the nerve surrounding the joint, allowing
tension to be increased as the joint moves
The sequence of movements can affect the localization of stress
The first region to be moved or moved strongest will increase the chance of a response in
this area
Assessing Neurodynamics
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Start with standard straight leg raise
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Change the mechanical interface
o E.g ipsilateral lumbar side flexion will close the intervertebral foramen
Check neural structures sliding and tensioners
Check the innervated tissues
o Dermatome, Myotome and Deep Tendon Reflexes
o Also check anatomical muscular contraction vs muscular contraction under neural
load
Femoral Nerve Tension Test
Position
1. Client side lying- tested side upper most
2. Clients down most hip and knee flexed
3. Clients cervical spine flexed
4. Therapist standing behind client
5. Therapists stabilises hip and holds medial aspect of knee
Procedure
1. Knee flexion to 90°
2. Hip extension
3. Hip abduction to stress obturator nerve
4. Hip adduction to stress lateral femoral cutaneous nerve
Sciatic Nerve Tension Test
Position
1. Client supine
2. Therapist standing to side facing cephalad
3. Clients foot placed on therapists shoulder
Procedure
1. Knee extension
2. Hip flexion
3. Hip internal rotation
4. Hip adduction
5. Lumbar contralateral flexion
Peroneal Nerve Tension Test
Position
1. As sciatic nerve tension test
Procedure
1. As sciatic nerve tension test
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2. Ankle plantarflexion
3. Ankle inversion
Sural Nerve Tension Test
Position
1. As sciatic nerve tension test
Procedure
1. As sciatic nerve tension test
2. Ankle dorsiflexion
3. Ankle inversion
Tibial Nerve Tension Test
Position
1. As sciatic nerve tension test
Procedure
1. As sciatic nerve tension test
2. Ankle dorsiflexion
3. Ankle eversion
Slump Test- Spine, cord and meninges
Position
1. Client sat over edge of bed
2. Therapist stood to clients side
3. One hand on clients head
4. One hand on clients foot
Procedure
1. Posterior pelvic tilt
2. Cervical flexion
3. Ankle dorsiflexion
4. Knee extension
Determining The Outcome Of A Test
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Neurodynamic tests are never positive or negative
They are best describes as normal or abnormal
Abnormal results include
o Reproduction of clients familiar symptoms (pain or radiculopathy) that is altered
through structural differentiation
o Reduced OR Increased range of movement compared to normal side
o Reproduction of pain or radiculopathy in an area that they would not be expected
confirmed by structural differentiation
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Therefore when writing patient notes the following can be used
o SLR – Peroneal Nerve – Right- Abnormal- Reproduce lateral ankle pain- Decreased
with hip abduction
Structural Differentiation
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To determine whether symptoms reported during testing is due to the neurodynamic
system structural differentiation must be used
This is done in the following way
o Elicit a response using a test and hold this position
o Move a joint that is at least 2 steps away from the area of symptoms
o If this increases/decreases symptoms the neurodynamic system is the structure at
fault
o Should symptoms remain exactly the same there is a mechanical cause to the clients
symptoms during testing
Dermatome Testing
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Test the dermatome patterns of the lumbar spine bilaterally simultaneously
Abnormalities require further investigation which can be completed with sharp or blunt
testing
N.B there is considerable overlapping of dermatome patterns which often differ between
texts
Dermatome abnormalities that fail to respond to physiotherapy require investigation by a
spinal or neurological specialist
o L1: lower abdomen and groin, lumbar region between levels L2 and L4, upper, outer
aspect of the buttock
o L2: two separate areas: lower lumbar region and upper buttock, whole of the front
of the thigh
o L3: two separate areas: upper buttock, medial aspect and front of the thigh and leg
as far as the medial malleolus
o L4: lateral aspect of the thigh, front of the leg crossing to the medial aspect of the
foot, big toe only
o L5: lateral aspect of the leg, dorsum of the whole foot, first, second and third toes,
inner half of the sole of the foot
o S1: sole of the foot, lateral two toes, lower half of the posterior aspect of the leg
o S2: posterior aspect of the whole thigh and leg, plantar aspect of the heel
o S3: circular area around the anus, medial aspect of the thigh
o S4: saddle area: anus, perineum, genitals, medial upper thigh
o S5: coccygeal area
Test the myotomes of the lumbar spine bilaterally and simultaneously where possible
Maintain resistance for 5 seconds at least
Nerve root weakness will be evident after 5 seconds, peripheral nerve weakness is evident
immediately
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Myotomal weakness requires further investigation by a spinal or neurological specialist
Management
Soft Tissue Release
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While holding the limb in a position that represents the abnormal tension test perform soft
tissue release along the pathway of the peripheral nerve
Mobilisations
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The neurodynamic system can be mobilised by either ‘sliders’ or ‘tensioners’
Sliders
 Tension is never increased through the nerve
 Point A and B of a nerve will always stay the same distance from one another
 Sliders are the treatment of choice for very irritable symptoms
Tensioners
 Point A and B of a nerve will increase in distance from one another
 This can be done into resistance or symptoms, or can be completed before the onset of
symptoms
Joint Mobilisations
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Joint mobilisations can be performed during neural load
E.g Slump sitting with peroneal nerve testing while performing inferior tibio-fibular
mobilisations
Home Exercise Programme
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Clients can be instructed of self- mobilisations to complete at home
Caution-ensure correct technique of sliders and tensioners etc to avoid aggravation of
symptoms
Monitor symptom response from neurodynamic home exercise programmes as regular selfmobilisations may aggravate symptoms if done too aggressively and regularly
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