Back pain with knee

[scir]

I saw a patient a few days ago and I cannot get close to the problem although she tells me she is much better after my treatment I cannot fully understand the problem.
She is 47 year old woman working in child care
she presented with lower back pain on left side laterally to the spine at around L2-L3 level. She also presented with knee pain and pins and needles and numbness in her left knee. The two pain always came together and at the same time. The knee pain is worse than back pain.

Subjectively there was not specific pattern during the day or with activity
the pain is described as an strong ache 8/10. and has been lasting 3 weeks and is constant.
There were no redflag appart from occasional night pain that responded to painkillers and anti-inflammatories.

Objectively
general observation: her Left hip was lower than right in standing but with no leg length discrepencies and noticeable scoliosis.
Active range of movement: she had no movement restriction in her spine or knee.
PAIVM revealed generral stiffness in Lx but did not reproduce pain
Hip was clear
Knee clear
Piedalu test for sacro-illiac joint was positive on Left.
Slump test and prone neural tension test were negative
Normal myotome
Dermatomal deficit on L in L3 distribution
palpation: Area of tightness (like trigger point) around one inch laterally of spine at L3 level deep to erector spinae, her pain in the knee shot up when papated that area.

I gave her gentle massage in this area and some rotation stretches in supine
as well as MET for L hip

She initially felt worse but phone me saying she was much better the next day.

I cannot see the connection between the area of tenderness, lack of movement restriction or agravating pain and the knee pain

Anybody has any ideas

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[ramywhite]

I think we need to know her diagnosis first. Refer her to neurophysicin to diagnose her then you can handle the causes. But until then, you can correct her posture by treating muscle spasm with massage and moist heat;I think that is why she feels better after first session.
But what is "Piedalu test"? Did you mean "Gaenslen's Test"? Please inform me.

[arkesh_physio]

Did u check PAIVMs in all Grades??
What about the H/o Pain Onset(sudden or gradual)
What r the agg & easing factors??

[alophysio]

Hi,

Localised muscle spasm = pt stuck in a pain cycle - you broke the cycle with massage and rotation mobilisations (neurophysiological effects) - patient feels better.

What is there to understand - you did everything right as far as i can tell !

The area L3 is related to the knee therefore is consistent with the presentation.

The reason she was sore initially may be because you broke the adhesions / cause some local damage but essentially changed how things were so she began to feel better.

As we say in australia... "on-ya" which is short for "good on you".

[wutti]

hi, i agree with the post above. sounds all that you are on the track. so continue your treatment and start functional strengthening as soon as the pain is gone.
cheers

[asha]

How's the patient? Is she through with the pain? or she status quo?

[scir]

Hi Folks
thanks for your replies.
Ramywhite I think piedalu is also called gillet test and looks at relative movement of illiac on sacrum during hip flexion functional movements

I though I give you a patient update
Patient felt better for 2 weeks, further massage and some stretching relieved the back pain and the knee pain and increased her general lumber and hip mobility.
During a third appointment she experienced immediate burning pain in the knee during lumbar extension in prone.
So that rung a Spondylolisthesis bell for me and I have sent her for x-ray before continuing treatment

I agree that there is an element of cycle of pain. All the muscle hypertension and pain + lack of mobility could well have been a guarding mechanism that we have decreased hence allowing for the root cause to come through.
I'll keep you posted

[asha]

If the patient experienced burning at the knee during extension, the spine is restricted in extension at probably at L3-4 segment or throught out from L1-5. What did the radiographs say?

[anishkop]

The pain obviously shows all signs of a neurological origin. Do not go into extension patterns in low lumbar areas as it will only crunch up the nerve and make symptoms worse. Try ease off the pain first then progress towards improving her core stability by multifidus and Transversus Abdominis facilitation.
also try the 90-90 position of hip knee flexion for immediate relief of pain. Spondylolisthesis should have a traumatic cause or if the patient is old and osteoporotic then you can start suspecting it.