Case
- 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" |
- Sharp pain, 10/10
- Episodic throughout day
- Stiff in the morning taking 30 minutes to ease |
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) |
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 |
Physical Examination Findingscal
General observations
- Hypokyphotic Cx spine
- Hyperlordotic Lx spine
- Hyperextended knees
- R shoulder higher than L
- Hypotonic glutes
- Slight antalgia to R
- Poor proprioception |
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) |
- 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 |
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 |
Functional
- Abdominal dead bug <30s w/ recruitment of accessory muscles
- Iliopsoas & glut. max. strength reduced bilaterally
- Quad length test reduced on R & caused LBP |
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 |
Discussion
Working diagnosis
- Mechanical LBP complicated by L4/5 disc degeneration |
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) |
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 |
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 |
Learning outcomes
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 |
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 |
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 |
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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