Low back pain with lateral shift

[Termy]

I have a patient who started getting lumbar back pain radiating to the left ventral thigh (not below the knee) after being out in the woods a few weeks back looking for mushrooms. She started feeling the pain when she was on her way back to the car, so she doesn't feel like it happened all of a sudden when bending forward or anything like that.

She has a distinct lateral shift to the right when she's standing. She also prefers leaning to the right when sitting (25 years as a busdriver, leaning to the right while steering with her left hand). I've been using mostly the McKenzie method here.

Extensions in standing, lying or just lying on her elbows in a static position results in an increase/peripherisation of her radiating pain. A moderate movement restriction in extension.

Flexion in standing x 20 produces no symptoms at all, and no movement restriction (she can reach her toes) and she prefers sitting in a cross legged position or any other position with a slightly flexed posture. No centralisation of pain, although slightly unclear. She says the pain is always there in one form or another although at times it's more of a "sensation" than regular pain.

Side gliding to the right produces no symptoms. Side gliding to the left is almost impossible because it provokes a lot of back pain as well as increased radicular pain. Because of that, she can't correct her lateral shift and neither can I.

Reduced sensation on her ventral thigh (L2/L3 area). Patellar reflexes are lively. SLR negative. Femoral nerve stretch test positive.

Not really sure what the best way to proceed is... I can't seem to find a proper way to centralise her symptoms. I haven't used the McKenzie-method for that long so I'm not that experienced with it. Could this be classified as irreducible symptoms? Could it even be a hernia? She hasn't had any MRI or anything yet. I've met her twice now and she has been doing some of her own exercises in between (she had a posterior derangement on her right side a few years back), like lying on her back and activating transversus abdominus and so on.

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[JayPhysio]

How old is this patient. I assume 50-60 years. Sounds like a possible foraminal stenosis of the upper lumbar segments. May need to send this off for imaging before you proceed further.

[Termy]

She's in her late 40's. 2 weeks ago during her last visit she was a lot better though. Hardly any lateral shift, and all she's been doing are those exercises I mentioned, plus some sort of attempt at correcting the lateral shift by lying supine with her hips flexed. I forgot to mention (and forgot to properly check that initially) that she had some leg length discrepancy as well. In retrospect I'm not sure how much of it was a "true" lateral shift (although some of it certainly was). Either way she's considerably better, and in a couple of weeks I'll see if she's continued to improve.

[physiobob]

Great to hear she is on the mend. it does sound like a posterolateral derrangement. a static position that increase the symptoms would have indicated that there was a block. The ext. in standing would have been to much load to make a reduction. a static supine extension then needs to be moved into a repeated extension in lying to mobilize the segment, perhaps with some simultaneous PA mobs to assist. You cold have started in the shift to reduce the discomfort and is movement improved slowly bring her back to midline. etc etc etc. If that was all to much then some way of tractioning her while passivley extending might have been an option. A lot of possible treatment techniques would depend on the iritability at the time and sometimes extension to soon is to much to take and you need give the client techniques to reduce any associated spasm to being with. This might include pain skiilers. Then get in there

[Termy]

Update. I met the patient last week again. She was almost, but not quite pain free. On a VAS pain scale she had 1, whereas she had 7-8 at our first meeting. I did try the supine extensions and varities of that one earlier on but she just got more radiating pain to her leg... tried a prone version as well with gradual movement from her shifted position to the midline. Anyway... she said she mostly did the exercises she started doing on her own to begin with, such as supine "leg-twists" for some lumbar mobility.. some stationary biking apparently felt good also. Maybe she would have spontaneously improved even without exercises.

[BridgetOH]

Shift correction in side-lying (vs. prone) can also be effective. I have the patient spend anywhere from 30 seconds--> 3-5 minutes in each position, with the goal being centralization of symptoms. First, I respect their shift with 1-2 pillow placement under upper body, which is then reduced to 0-1 pillows, until pt. is in sidelying without any pillows. I then have them log roll to a prone position, then on to prone + extension. This can be a useful progression in my experience!