Photo courtesy: eorthopod.com

A patient was referred to me the other day with diagnosis of low back pain.  He was a 40 year old, white male with about a 6 month history of low back pain (he pointed to the ‘small of the back’ and into the gluteal fold but was quite diffuse).  He described it as mainly stiffness and tight, but also a dull achy pain.  He only had sharp pains if he moved “a wrong way” and denies numbness, tingling, burning or any other LE symptoms.

He did not seek care for a long time as he thought it was normal due to the nature of his profession (construction worker), however, had no MOI that he is aware of; just slowly came on. He was quite bland in description of what makes symptoms worse/better and just said, “it is there pretty much all the time”.  The subjective examination was not extremely detailed (but not uncommon for a male at this age and profession).

His clinical exam showed a 25% limitation with ‘pulling’ in small of back with both forward flexion and extension of the lumbar spine.  He had symmetrical side-bending and rotation and limited ~10%.  No directional preference was found for any increased or decreased amount of pain (again, he had no referral symptoms).  DTRs were brisk and symmetrical and no myotomal weakness but trunk and hip musculature grossly rated at 4/5 on MMT scale.  No pain to provocation to major lumbosacral structures in standing.

Other clinical features included negative SLR (I normally do not do this test if no referral symptoms but did not take but a few seconds.  Main finding was hamstring tightness equally bilaterally.  However, he did have the following positive SIJ tests.

1. Thigh Thrust.

2. ASIS Distraction.

3. Sacral Thrust.

Click here to go back to a past set of posts of mine to diagnose SIJ involvement.  (+) 3 of 6 tests are indicative of a positive cluster.

What do you think about the clinical exam so far?  What are your thoughts on the cause of patient’s symptoms and how to go about treating this?  Stay tuned later in the week for part 2. 

 

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One comment

  1. This is a great clinical exercise – very relevant. A full McKenzie exam would be able to tell you if there is indeed a directional preference, reduction, abolishment, or centralization of symptoms. At a minimum this would include loading (flexion/extension) in lying. I do not see this listed in your clinical exam. I believe that Laslett has provided some data that showed adding this to your exam can increase the specificity and LR of positive SIJ tests if there is no improvement with McKenzie loading strategies (Increasing the +Liklihood Ratio from 4 to 6 or 7…dont have the study infront of me though). Using LR’s would then help improve the decision making by directly influencing you post test probability. of the condition being present or not. The treatment-based classification for low back pain may also be able to give you some clues for treatment. Paticularly stabilization vs manipulation categories – in which case you would need to know his hip IR ROM, lumbar spine stiffness to PA pressures, FABQ work subscale, SLR angle, and prone instability test before trying to classify the patient.

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