Before reading the objective findings below, make sure you read the subjective history taking in Part 1 here of this differential diagnosis case.

Observation: Slouched posture. Decreased lumbar lordosis.

Gait: Stiff leg, wide-based gait pattern with very little knee flexion and hip extension.

Tenderness: Generalized tenderness in lower lumbar spine and SIJ with no particular one location.  This is the same in weight-bearing (standing/sitting) and non weight-bearing (prone).

Palpation: No warmth to and around the lumbar spine and pelvis.

Lumbar ROM: Painful in all directions but only limited by 25%. No particular DP. Symptoms are generalized in lumbar spine.  No peripherlization or centralization of symptoms with repeated movement exam in standing or prone.

Hip and knee ROM: Normal and unremarkable in all planes.

MMT: 4/5 hip flexion that causes low back pain.  Both knee flexion and knee extension is 4+/5 that also causes low back pain.  No myotomal weakness or remarkable findings distally.

Neurological: 

– Negative SLR and prone femoral neural tensioning test.

3+ B L4, 3+ B S1.

+ Babinski

– Hoffman sign

– Supinator sign

– 2+ B C5-C7

Based on the above information,

What are your top 3 differential diagnoses?

What type of information did you gain from the video above?

What other objective findings would you look for / test?

Would you treat, refer or treat and refer; and why?

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12 comments

  1. With a positive + Babinski I am thinking referral. Too many factors that are atypical. First given the patients age to subjectively report B neurological LE symptoms without objective reproduction is an area of concern. Her sleep habits and inability to find relief is a concern. Has she reported feeling of fatigue? Any fever? I am sure given two miscarriages there is the possibility of central sensitization.

    1. Richard,
      Thanks for responding. To answer your questions: She doesn’t particularly say she is fatigued and no fever (no other constitutional signs).
      I would think the same thing with central sensitization too, however, no symptoms after the first 2 miscarriages…
      H

  2. Harrison,
    Interesting case. My question would be were you able to affect her pain for better or worse? And by that I mean a significant change( 2-4 pt change/10). If not, then probably not mechanical. History of miscarriages, increased reflex response, weird gait pattern and inconsistent pain c/o makes me think of something visceral. Maybe,maybe some pelvic ortho thing due to pregnancy hormone response but unlikely. By the way, I have started to see more patients come in because “my insurance said I have to go to PT first before I can have a MRI.” With no idea that they could get better in therapy… just a hurdle to get over.

  3. The uterus tightens a lot after miscarriages, which can refer tension to the PF & inner unit ms, and lumbopelvic fascia, and created abdominal pain and LBP.
    But the B increased reflexes and (+) UMN signs point to a CNS problem, but (-) SLR&PKB, and inability to sleep and relieve the pain are concerning…
    I would test further the spine (e.g. accessory mobility) and SI joint (Downing, accessory mobility…)
    As a (very) young PT, I would treat the MSK symptoms and provide advice in the meantime, but I would refer back to MD ASAP.
    Very interested in knowing what you will do and what it turns out to be, thank you for sharing this case!

    1. Thanks for commenting Melanie. I would have imagined she would have more pelvic pain and/or pain with palpation to the lower quadrants, but not in this case.

      I’ll let you know how it goes 🙂

  4. So, I would treat and refer out. I need to review part one. Anyway, I have seen 2 patients lately that when I perform a patellar reflex on one side, the other side responds like in your video. Do you know why that is the case? We have Urgent Care docs next door and they have never seen it, but I have seen it twice in less than 2 months (I think they don’t perform reflexes, haha).

    1. I would think it occurs due to such an uptake in the central nervous system. I have only seen it in people who have cervical myelopathy in addition to this case.

  5. Dr. Vaughan,

    Additional Questions:
    Has she had any vision changes since August?
    Has she had any cognitive changes since August?
    Did she have any loss of balance when walking or just the altered gait pattern?
    Slump test performed? If so any Lhermitte’s sign?
    What did you grade the S1/Achilles DTR?
    Any abdominal quadrant percussion, compression/rebound symptoms?
    Response to compression/distraction?

    3+ LE DTRs & Babinski findings are consistent with a UMNL. That the UE DTRs were normal would suggest, but not guarantee, that the issue is not cervical or cortical. The left hip adduction/external rotation response to the right patellar DTR is interesting.

    Discarded initial impressions from subjective:
    While psychosocial factors related to the miscarriages can be magnifying her symptoms they wouldn’t be generating the “hard” signs. I’m tabling that initial impression.

    Continued initial impressions from subjective (in no order):
    1) Cord abutment remains viable-even without a clear DP if central centralization/LTP has occurred over the 3-4 months since onset.
    2) Neoplasm remains viable. If present, I would be more inclined to think benign & causing cord abutment.
    3) Asherman’s/Endometriosis still viable with significant scaring/intrapelvic adhesions.

    New potential impression:
    4) MS (given age, sex, race & presentation).

    Course of Action:
    Given her non-mechanical symptoms & neurological signs I would definitely refer. One could make the argument that she is already scheduled for additional medical follow-up (pending MRI and follow-up with referring physician)– so I’d consider distal DN for limbic attenuation/effect on the LHPA axis; encouraging staying active with walking/daily activity; aquatic-based exercise/activity. I not get into anything more local & specific until the MRI results came back. Same thing with pain education.

    Matt

  6. I can somehow relate to this issue since my Physical Therapist told me that the issue why I’m having a low back pain can either be centralized or peripheral cause. Just found out that I have tight hamstrings after doing some straight leg raising test which he told me the big factor why I was having that condition. After 10 sessions of rehab and home exercise program, I was able to have low intensity pain scenario.

  7. Dr Vaughan,

    Firstly this is a very interesting case. I agree with matts comments with regard to his clinical reasoning and potential differentials. With regard to MS, disconjugated eye movements with smooth pursuit testing is pathognomonic for MS so you could do this as a screening test to be able to convey something to the referring medical physician but inevitably as you know it’s not your job to confirm the medical diagnosis. For ruling cervical myelopathy, use a test cluster like you blogged about earlier this year. The hyperreflexia and UMn signs are suggestive of potential significant pathology but you have to reason that she hasn’t had any significant event since the onset of symptoms so I would assume that you can keep her if anything to teach her relaxation strategies and pain relieving activities/positions not to mention it allows you an opportunity to document advancement of symptoms and be able to convey that to the medical physician. I hope that the
    MRI is not confined to the lumbar spine as it will miss the CNS to rule out MS. My suggesting I keep her as a patient while you await the medical tests and just be in close communication with the physician regarding any significant changes in function. Nice reading this Harrison!

    -Steve Goldrick (OMT Talk)

    1. Thanks for commenting Steve and excellent points. I agree with them all. I am suspecting MS but some things aren’t just lining up. For instance, she doesn’t have any pathological changes with eye movements or cranial nerve testing and no changes in upper limb changes for upper motor neuron changes. She DOES meet some of the criteria from Cook’s CSM CPR…except for age, hoffman’s and supinator sign…

      The physician said he will go at the lumbar spine first with MRI and pending results, will refer to neuro considering the clinical exam.

      Hopefully will know more soon.
      H

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