Lower back and hip Assessment
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Please convert the information below into a Physiotherapy SOAP note, incorporating clinical and biomechanical analysis, and include a final section with a deep and detailed clinical and biomechanical analysis, as well as Opportunities for Improvement.
Type of assessment
Initial Evaluation
Follow Up Note
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Side
Left
Right
Bilateral
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Objective Assessment
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On examination
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ROM Lumbar spine
Flexion
Full range of motion - 40 – 60°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
Extension
Full range of motion - 20 – 35°°
Reduced range of motion
Reduce range of motion due to pain
Full range of motion with pain
Rotation Right
Full range of motion - 3 – 18°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
Rotation Left
Full range of motion - 3 – 18°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
Right Lateral Flexion
Full range of motion - 15 – 25°°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
Left lateral Flexion
Full range of motion - 15 – 25°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
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ROM Hip
Flexion
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
Extension
Full range of motion - 0–30°
Reduced range of motion
Reduce range of motion due to pain
Full range of motion with pain
Abduction
Full range of motion - 0–45°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
Adduction
Full range of motion - 0–30°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
Internal rotation
Full range of motion - 0–45°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
External rotation
Full range of motion - 0–45°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
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Muscle Power Lumbar spine
Flexion
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
Extension
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
3 – Full movement against gravity, no added resistance
4 – Full movement against gravity with moderate resistance
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
Right lateral flexion
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
3 – Full movement against gravity, no added resistance
4 – Full movement against gravity with moderate resistance
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
Left lateral flexion
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
3 – Full movement against gravity, no added resistance
4 – Full movement against gravity with moderate resistance
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
Right rotation
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
3 – Full movement against gravity, no added resistance
4 – Full movement against gravity with moderate resistance
5 – Full movement against gravity with strong resistance (normal strength)
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Muscle Power Hip
Flexion
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
Extension
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
3 – Full movement against gravity, no added resistance
4 – Full movement against gravity with moderate resistance
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
Abduction
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
3 – Full movement against gravity, no added resistance
4 – Full movement against gravity with moderate resistance
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
Adduction
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
3 – Full movement against gravity, no added resistance
4 – Full movement against gravity with moderate resistance
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
Internal rotation
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
3 – Full movement against gravity, no added resistance
4 – Full movement against gravity with moderate resistance
5 – Full movement against gravity with strong resistance (normal strength)
External rotation
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
3 – Full movement against gravity, no added resistance
4 – Full movement against gravity with moderate resistance
5 – Full movement against gravity with strong resistance (normal strength)
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Postural Deviations & Biomechanical Variations of the Lower back
Pelvic Alignment
Normal pelvic alignment
Anterior pelvic tilt (increased hip flexion, increases lumbar lordosis)
Posterior pelvic tilt (pelvis rotated backward, flattens lumbar curve)
Lateral pelvic tilt / obliquity (one iliac crest higher)
Pelvic rotation (one side of pelvis forward/backward in transverse plane)
Lumbar Curve (Sagittal Plane)
Normal lumbar lordosis
Hyperlordosis (exaggerated inward curve)
Hypolordosis / “flat back” (reduced inward curve)
Frontal Plane Deviations
No frontal deviation (normal symmetry)
Scoliosis (lateral curvature of lumbar spine)
Shifted posture (trunk lean to right / left)
Unequal lower rib height (rotation or side‑bend present)
Transverse Plane (Rotation)
Neutral transverse alignment
Lumbar rotation right (vertebral bodies rotated right)
Lumbar rotation left
Pelvis rotated relative to shoulders (torso twist)
Dynamic / Functional Variations
Normal dynamic posture
“Sway back” posture (posterior pelvic shift, thoracic hyperkyphosis)
“Flat back” posture (loss of lumbar curve with posterior pelvic tilt)
“Lordotic sway” (excess lumbar extension with anterior pelvic tilt)
“Lumbar shift” on forward bending (asymmetric flexion)
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Postural Deviations & Biomechanical Variations of the Hip
Pelvic Alignment (in relation to hip position)
Normal pelvic alignment
Anterior pelvic tilt (increased hip flexion angle)
Posterior pelvic tilt (decreased hip flexion, “flat back”)
Lateral pelvic tilt (one iliac crest higher)
Pelvic rotation (one side of pelvis anterior/posterior)
Hip Joint Position (standing posture)
Neutral hip alignment (hips level, knees straight)
Hip flexion posture (slight hip flexion bilaterally)
Hip extension posture (excessive hip hyperextension)
Hip abduction (outward shift of femur)
Hip adduction (femur angled inward, “scissoring”)
Hip internal rotation (toes turned inward)
Hip external rotation (toes turned outward)
Femoral & Acetabular Morphology Indicators
Normal femoral–acetabular relationship
Coxa vara (decreased femoral neck–shaft angle)
Coxa valga (increased femoral neck–shaft angle)
Femoral anteversion (in-toeing gait/posture)
Femoral retroversion (out-toeing gait/posture)
Acetabular anteversion (anterior hip prominence)
Acetabular retroversion (posterior hip prominence)
Lower Limb Alignment (static)
Normal frontal plane alignment (neutral Q‑angle)
Decreased Q‑angle (varus at knee, “bow‑legged”)
Increased Q‑angle (valgus at knee, “knock‑kneed”)
Tibial torsion (inward or outward twist of lower leg)
Foot pronation/supination affecting hip position
Dynamic / Functional Variations
Normal dynamic hip movement (smooth, symmetrical)
Trendelenburg sign (contralateral hip drop on stance)
Hip hike (excess elevation of one pelvis during gait)
Pelvic drop (opposite side drops excessively during stance)
Excess lumbar–hip dissociation (over‑arching back in gait)
Femoral pivot (hip pivots instead of stepping)
Compensatory Patterns (during standing or movement)
No compensations observed
Excess knee hyperextension to offload hip
Pelvic rotation to increase hip range
Trunk lean over stance leg
Contralateral vaulting (rising onto forefoot opposite side)
Hip circumduction (swinging leg out to circumvent hip pain)
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Dermatomes
C2 - Right
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Occiput / upper posterior neck
C3 - Right
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Lateral neck
C4 - Right
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Supraclavicular / top of shoulder
C5 - Right
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Deltoid
C6 - Right
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Outer aspect of the forearm and thumb
C7 - Right
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Middle finger
C8 - Right
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Little finger and medial aspect of the forearm
T1 - Right
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Medial epicondyle
C2 - Left
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Occiput / upper posterior neck
C3 - Left
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Lateral neck
C4 - Left
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Supraclavicular / top of shoulder
C5 - Left
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Deltoid
C6 - Left
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Outer aspect of the forearm and thumb
C7 - Left
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Middle finger
C8 - Left
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Little finger and medial aspect of the forearm
T1 Left
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
Medial epicondyle
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Myotomes
C1 - Right
Normal
Weak
Painful
No contraction
Fatigable
Neck flexion
C2 - Right
Normal
Weak
Painful
No contraction
Fatigable
Neck flexion (longus capitis, rectus capitis anterior)
C3 - Right
Normal
Weak
Painful
No contraction
Fatigable
Neck lateral flexion
C4 - Right
Normal
Weak
Painful
No contraction
Fatigable
Shoulder elevation (trapezius, levator scapulae)
C5 - Right
Normal
Weak
Painful
No contraction
Fatigable
Shoulder abduction / elbow flexion (deltoid, biceps)
C6 - Right
Normal
Weak
Painful
No contraction
Fatigable
Wrist extension (extensor carpi radialis group)
C7 - Right
Normal
Weak
Painful
No contraction
Fatigable
Elbow extension / wrist flexion
C8 - Right
Normal
Weak
Painful
No contraction
Fatigable
Thumb extension / finger flexion
T1 - Right
Normal
Weak
Painful
No contraction
Fatigable
Finger abduction/adduction
C1 - Left
Normal
Weak
Painful
No contraction
Fatigable
Neck flexion
C2 - Left
Normal
Weak
Painful
No contraction
Fatigable
Neck lateral flexion
C3 - Left
Normal
Weak
Painful
No contraction
Fatigable
Shoulder elevation
C4 - Left
Normal
Weak
Painful
No contraction
Fatigable
Shoulder elevation
C5 - Left
Normal
Weak
Painful
No contraction
Fatigable
Shoulder abduction / elbow flexion
C6 - Left
Normal
Weak
Painful
No contraction
Fatigable
Wrist extension
C7 - Left
Normal
Weak
Painful
No contraction
Fatigable
Elbow extension / wrist flexion
C8 - Left
Normal
Weak
Painful
No contraction
Fatigable
Thumb extension / finger flexion
T1 - Left
Normal
Weak
Painful
No contraction
Fatigable
Finger abduction/adduction
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On Palpation
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Tenderness on right side
Lumbar Paraspinal Region
Iliocostalis lumborum
Longissimus thoracis
Spinalis (thoracis)
Multifidus
Quadratus lumborum
Sacroiliac & Pelvic Region
Sacroiliac joint ligaments / PSIS sulcus
Sacrotuberous ligament (if needed)
Semispinalis capitis
Semispinalis cervicis
Cervical multifidus
Levator scapulae
Upper trapezius
Gluteal Region
Gluteus maximus
Gluteus medius
Gluteus minimus
Piriformis
Obturator internus & gemelli
Superior & inferior gemellus
Lateral Hip / Pelvic-Femoral Interface
Tensor fasciae latae
Iliotibial band tract (distal palpation near greater trochanter)
Anterior Hip / Femoral Region
Iliopsoas complex (iliacus & psoas major)
Rectus femoris (proximal tendon near AIIS)
Sartorius (along ASIS to pes anserinus)
Medial Thigh / Adductor Region
Adductor longus
Adductor brevis & magnus
Gracilis (pes anserinus)
Posterior Thigh / Hamstring Origins
Biceps femoris (long head)
Semitendinosus
Semimembranosus
Ischial tuberosity bursae
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Tenderness on left side
Lumbar Paraspinal Region
Iliocostalis lumborum
Longissimus thoracis
Spinalis (thoracis)
Multifidus
Quadratus lumborum
Sacroiliac & Pelvic Region
Sacroiliac joint ligaments / PSIS sulcus
Sacrotuberous ligament (if needed)
Semispinalis capitis
Semispinalis cervicis
Cervical multifidus
Levator scapulae
Upper trapezius
Gluteal Region
Gluteus maximus
Gluteus medius
Gluteus minimus
Piriformis
Obturator internus & gemelli
Superior & inferior gemellus
Lateral Hip / Pelvic-Femoral Interface
Tensor fasciae latae
Iliotibial band tract (distal palpation near greater trochanter)
Anterior Hip / Femoral Region
Iliopsoas complex (iliacus & psoas major)
Rectus femoris (proximal tendon near AIIS)
Sartorius (along ASIS to pes anserinus)
Medial Thigh / Adductor Region
Adductor longus
Adductor brevis & magnus
Gracilis (pes anserinus)
Posterior Thigh / Hamstring Origins
Biceps femoris (long head)
Semitendinosus
Semimembranosus
Ischial tuberosity bursae
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Special Test
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Hip and lower back
SLR Test
Negative
Postive
Bowstring Test
Positive
Cross leg SLR
Negative
Positive
Femoral stress test - Assesses irritation of the upper lumbar nerve roots (L2–L4). With the patient lying prone, the examiner flexes the knee and extends the hip. Pain in the anterior thigh suggests femoral nerve or upper lumbar root involvement.
Negative
Positive
Kemp’s test - Used to identify lumbar facet joint irritation or nerve root compression. The patient extends, rotates, and side bends the trunk while standing or sitting. Local back pain suggests facet involvement, while radiating leg pain indicates nerve root compression.
Negative
Positive
Gaslens test - Evaluates sacroiliac (SI) joint dysfunction. The patient lies near the table edge, one leg hanging off while the other is flexed toward the chest. Downward pressure on both legs produces pain in the SI joint if the test is positive.
Negative
Positive
Tigh thrust test
Negative
Positive
Compression Test
Negative
Positive
Distraction Test
Negative
Positive
Occiput to wall test - The patient stands with their heels and back against a wall, trying to touch the back of the head (occiput) to the wall while keeping the chin level. Normally, the occiput easily touches the wall. If the head cannot touch without bending the neck backward or lifting the heels, it indicates increased thoracic kyphosis or spinal stiffness.
Negative
Positive
Faber Test - Assesses pathology in the hip or SI joint. The patient’s hip is flexed, abducted, and externally rotated so the ankle rests on the opposite knee. Downward pressure on the knee and opposite hip causes pain in the hip or SI area when positive.
Negative
Positive
FADIR Test - Used to detect femoroacetabular impingement or anterior hip pathology. The examiner flexes the hip to 90°, then adducts and internally rotates it. Groin pain during the maneuver indicates possible impingement or labral tear.
Negative
Positive
FAIR Test - Screens for piriformis syndrome due to sciatic nerve compression. With the patient side-lying, the examiner flexes, adducts, and internally rotates the hip. Pain or tingling in the buttock or down the leg suggests piriformis muscle involvement.
Negative
Positive
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Assessment
Diagnosis
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Plan
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Treatment given
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Myofascial Trigger Point release on right side
Lumbar Paraspinal Region
Iliocostalis lumborum
Longissimus thoracis
Spinalis (thoracis)
Multifidus
Quadratus lumborum
Sacroiliac & Pelvic Region
Sacroiliac joint ligaments / PSIS sulcus
Sacrotuberous ligament (if needed)
Semispinalis capitis
Semispinalis cervicis
Cervical multifidus
Levator scapulae
Upper trapezius
Gluteal Region
Gluteus maximus
Gluteus medius
Gluteus minimus
Piriformis
Obturator internus & gemelli
Superior & inferior gemellus
Lateral Hip / Pelvic-Femoral Interface
Tensor fasciae latae
Iliotibial band tract (distal palpation near greater trochanter)
Anterior Hip / Femoral Region
Iliopsoas complex (iliacus & psoas major)
Rectus femoris (proximal tendon near AIIS)
Sartorius (along ASIS to pes anserinus)
Medial Thigh / Adductor Region
Adductor longus
Adductor brevis & magnus
Gracilis (pes anserinus)
Posterior Thigh / Hamstring Origins
Biceps femoris (long head)
Semitendinosus
Semimembranosus
Ischial tuberosity bursae
Taping
Advised on do's and don'ts
Core musacle strengthening
Lower limb strengtehening
Lower limb stretching videos shared
Lower limb stretching taught
Follow up
After 1 week
After 2 weeks
After 1 month
Patient Discharged
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