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- 50 y.o., unemployed
- L (L4/5) pain - Pain can radiate to buttock - Onset 3 weeks ago after sleeping on sofa - MRI in 2007 showed "degeneration at L4/5" |
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- Sharp pain, 10/10
- Episodic throughout day - Stiff in the morning taking 30 minutes to ease |
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AF: walking, standing for long periods of time, twisting, sit to stand is most painful
RF: heat (sauna & steam room), stretching, ibuprofen AA: difficulty sleeping (wakes up on turning, only getting approx. 5hrs / night) |
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Extra
- Has asthma (Fostair inhaler) - Bilateral knee meniscal surgery after injury playing tennis (still having physio, was doing cryotherapy) - Maternal: hypertension, asthma, osteoporosis - Paternal: kidney disease, IHD (ischemic heart disease) - Allergic to penicillin |
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General observations
- Hypokyphotic Cx spine - Hyperlordotic Lx spine - Hyperextended knees - R shoulder higher than L - Hypotonic glutes - Slight antalgia to R - Poor proprioception |
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ROM
- AROM Lx: RLF & RR reproduced L sided LBP @ end range; flexion limited @ 90° due to pain - PROM Lx: full & pain free - Hip ROM: R int. rot. reproduced L LBP (otherwise full & pain free) |
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- FFD: 31cm (better flexion than during AROM testing)
- SLR: L reproduced pain @ 50°, R tight hams. @ 70° - L leg: longer prone & supine - L SIJ: stiff on springing but no pain |
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Myofascial
- Tight ES bilaterally in Lx - L QL tight & TTP, R QL tight - TTP in adductors bilaterally, quads bilaterally - Hip flexors TTP - Tight glut. med. L |
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Functional
- Abdominal dead bug <30s w/ recruitment of accessory muscles - Iliopsoas & glut. max. strength reduced bilaterally - Quad length test reduced on R & caused LBP |
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Clinical tests
- Braggards & Rural NTT: on L reproduced back pain - Bonnets, Bowstrings & all other LL NTT: -ve - Fabere's, Kemp's, Thomas, Single-leg hyperextension: -ve - Gaeslen's & McKenzie glide:** on L caused L LBP |
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Working diagnosis
- Mechanical LBP complicated by L4/5 disc degeneration |
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Hx
- Mechanical triage - 10/10 pain w/ night pain potentially concerning (not red flag specifically ) - MRI findings of disc degeneration at L4/5 10 y. ago ↑ disc involvement (doesn't mean it's the cause) |
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Disc involvement suggestions
- Antalgia (position/movement to alleviate pain) - SLR on the L being reduced & causing LBP - Braggards & Rural NTT on the L reproducing the LBP |
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Lx radiculopathy:
- Should be differential based on buttock pain, antalgia & nerve tension signs (however wouldn't be working Dx) - Monitor pt for any neurological deteriorations |
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Ddx for LBP with buttock pain
- Lx radiculopathy: numbness, weakness, tingling, spasms, reduced ROM, atrophy, postive SLR test - Sciatica entrapment: pain, numbness, tingling, or weakness in buttock, leg, or foot - Lumbar disc herniation: LBP that radiates into buttock, leg, or foot - Spinal stenosis: LBP that radiates into buttock, leg, or foot, & numbness, tingling, or weakness - SI joint dysfunction: LBP that radiates into the buttock, hip or thigh - Piriformis syndrome: LBP that radiates into buttock, hip, or leg - Osteoarthritis: LBP, stiffness, reduced ROM, pain in buttock & hip - Ankylosing spondylitis: LBP, stiffness that radiates into buttock & hip |
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Red flags for back pain (+/- radiculopathy)
- Hx of cancer: persistent BP that worsens over time - Trauma: may indicate a fracture or other injury (e.g. fall or car accident) - Age: people over 50 can have signs of spinal stenosis, degenerative disc disease, other related spine changes - Fever &/or chills: may indicate infection (e.g. osteomyelitis or UTI) - Progressive neurological symptoms: BP w/ radiculopathy w/ progressive weakness, numbness, or tingling in legs/feet may indicate nerve damage/compression (prompt medical attention) - Loss of bladder/bowel control: medical emergency & requires immediate medical attention - Severe night pain: may indicate more serious condition (tumour/infection) - Hx of IV drug use or injection: may indicate spinal infection or other more serious conditions - No improvement after 4 weeks of conservative care |
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Guidelines & evidence for manual therapy in treatment of acute & subacute LBP
- Don't offer traction or acupuncture - Manual therapy (spinal manipulation, mobilisation, soft tissue) ONLY WITH exercise |
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Types of disc disease
⏺ Herniated disc: - Inner portion of disc protrudes through outer layer & can compress nearby nerve - Sx & Ssx: Pain, numbness & tingling, muscle weakness, radiating pain, changes in reflexes ⏺ DDD: - IVD breakdown over time - Sx & Ssx: Back pain, neck pain, pain that worsens w/ activity, neurological symptoms (in this case sciatica) ⏺ Discitis: - (aka. IVD infection) relatively rare condition, but can cause significant pain & discomfort - Sx & Ssx: Back pain, spinal tenderness, limited mobility, fever, spinal deformity or instability, neurological symptoms |
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