The Modified Thomas Test — A Case Study: LBP in a Youth Soccer Player (Part II)
I wrote a blog about the Modified Thomas test about a year ago—the blog aimed to identify the functional linkage between subsequent lower extremity orthopedic conditions from one evaluation. During a video for the blog, a 15-year-old soccer player demonstrated hypertonicity in the hip flexors and quadriceps. Today’s blog will discuss the repercussions of not addressing the deficits in the earlier video. You will learn how hypertonicity within the hip flexors and quadriceps ultimately results in compensation via the lumbar spine, sacroiliac joint, and iliolumbar ligament.
Case study:
A stubborn, now 16-year-old male who did not follow his father’s instructions on daily rehabilitation exercises demonstrates hypertonicity in the hip flexors and quadriceps. Pain gradually increases with playing high school soccer—3 to 4 games per week with practices in between. He started to develop left-sided sacroiliac joint pain, with peak tenderness at the iliolumbar ligament on the left. Symptoms are non-radicular, with positive SI compression and distraction tests and no other red flags.
Today’s commentary will cover:
What are the critical orthopedic tests that lead to an accurate diagnosis?
Explore a hip functional exam used to unveil the underlying cause of pain.
Learn an innovative treatment strategy to address this patient's needs and promote optimal recovery effectively.
Chiropractic Evaluation Of The Sacroiliac Joint
No single orthopedic maneuver is diagnostic for SIJD. Still, collectively, any two of the following four tests can have a very high predictive value: SI distraction, thigh thrust, SI compression, and sacral thrust. A "positive" test reproduces unilateral symptoms for each provocation maneuver near the PSIS.
The SI Distraction Test begins with a supine patient. The clinician uses straightened arms to apply a simultaneous posterior-directed force to the patient's ASIS to “spread” the anterior SI joint.
The Thigh Thrust Test is performed on a supine patient, with the hip and knee flexed to 90 degrees and the thigh only slightly adducted. The clinician places one hand beneath the patient's sacrum, and the other contacts the knee, where a downward force is applied along the shaft of the femur to create “shearing” of the SI joint. (AKA Posterior Pelvic Pain Provocation)
The SI Compression Test begins with a side-lying patient in the fetal position. The clinician applies a downward compressive force to the uppermost iliac crest.
The Sacral Thrust Test starts with the patient prone while the examiner applies an anterior pressure through the sacrum to generate a shearing force through the SI joints.
Iliolumbar ligament Tenderness can be identified through palpation as it is a superficial structure. The involvement of the iliolumbar ligament and psoas muscle significantly predicts SIJ dysfunction.
The Differential Diagnosis
SIJ provocation tests are commonly positive in discogenic patients. Discogenic pain may mimic SIJD symptoms, but the two rarely coexist. Many clinicians employ the philosophy that pain in the sacroiliac region is of lumbar origin until proven otherwise, since 90% of patients experiencing SI joint pain have symptoms referred from the lumbar spine. McKenzie assessment protocols that cause SIJ complaints to centralize point to a discogenic origin. Nerve tension signs are generally absent in SIJD.
Functional Evaluation Of The Sacroiliac Joint
Linking an orthopedic diagnosis to a functional diagnosis is essential in treating running injuries, mainly through the chiropractic orthopedic evaluation, which helps identify injuries to the sacroiliac joint and iliolumbar ligament. However, many injuries in the back, pelvis, hip, and thigh stem from functional issues within the lower extremity kinetic chain, with hip abductor weakness, lower crossed syndrome, and foot hyperpronation being common contributors. Assessments like the modified Thomas test can reveal a functional movement deficiency leading to localized lower back pain, giving you a more comprehensive and practical treatment approach.
The Thomas Test
The supine patient performs a single knee-to-chest maneuver. The clinician observes the opposite thigh to determine whether it remains flat on the table or rises. Patients with excessive hip flexor tightness will flex or lift their straightened leg. The modified Thomas test begins with the patient seated on the very edge of the table. The patient will bring one knee to their chest and then rock back. This test allows the unsupported leg to better show muscular balance by not contacting the table. (1)
RED- Positive test for hip flexor hypertonicity
GREEN- Negative Test for hip flexor hypertonicity
A positive modified Thomas test indicating hypertonicity in the hip flexors correlates with lower back pain. The lumbar spine accommodates tight pelvic muscles through lumbar hyperlordosis, exacerbated during the running motion. This condition predisposes patients to an overload of the facet and sacroiliac joints while increasing the stress on the iliolumbar ligament. This ligament often becomes the principal pain generator as the ventral band serves as a principal stabilizer of the sacroiliac joint. (1)
"These results suggest that the modified Thomas test is a reliable tool for assessing hip flexor length in clinical practice, particularly when pelvic tilt is controlled. These results have important implications for accurately testing orthopedic limitations that can contribute to low back, hip, and knee pain." (2)
Chiropractic Treatment Of Tight Hip Flexors
Perform contract-relax stretching of the hip flexors and quadriceps from the test position. This approach offers several advantages for evidence-based chiropractors:
Time-saving: Utilizing the test position can optimize efficiency by minimizing the need to switch the patient's position repeatedly during treatment.
Rapid assessment and treatment: The practitioner can swiftly assess, treat, and re-assess hypertonic muscles in seconds, ensuring a prompt and targeted intervention.
Visible progress: Patients will experience tangible and immediate results by implementing straightforward muscle stretching techniques, enhancing their perception of the treatment's effectiveness.
Bonus
Hip Flexor Hypertonicity Affects Running
Tight hip flexors can have many adverse effects on running. Here are some things to look for in your patient population to identify this potential imbalance leading to injury within your patient population.
Reduced stride length: Tight hip flexors limit the range of motion, shortening stride length while running. Runners with tight hip flexors are slower and less efficient.
Increased risk of injury: Tight hip flexors can stress other muscles and joints, increasing the risk of injuries such as runner's knee, IT band syndrome, and lower back pain.
Poor running form: Tight hip flexors can force you to overstride or to run with a forward lean, which can also increase your risk of injury commonly associated with back and knee pain.
Pain: Tight hip flexors can be painful, especially during the beginning of running or long-distance runs.
As you can see, evaluations like the Modified Thomas test can uncover key movement imbalances that contribute to lower back pain, providing a deeper understanding and a more targeted approach to treatment. However, understanding and addressing these issues is only part of the equation—delivering effective, evidence-based treatment is what truly helps patients recover and thrive. That’s where ChiroUp comes in.
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Nicodemus CL, Sikorskii A, Epstein J. Revisiting chronic low back pain: evidence that it is not non-specific. Journal of Osteopathic Medicine. 2022 Nov 29. Link
Eimiller K, Stoddard E, Janes B, Smith M, Vincek A. Reliability of Goniometric Techniques for Measuring Hip Flexor Length Using the Modified Thomas Test. International Journal of Sports Physical Therapy. 2024;19(8):997. Link
