Back Pain

Hello all.

I've recently seen a client and would like to see what you think.

Subjectively,

27 tear old male who presented with low back pain for ~3 months.
Pain is located L3/L4 level felt centrally and lateral to the spinous process with severity 4/10. Described as an "ache" occasionally gets a "dart" with movements (cannot say specifically what mvts).

Describes pain as being worst in the morning and in the evening after working. Loosens out in the morning after shower etc and can work etc.

Cannot remember a specific incident that brought pain on. Hs never had any back trouble before. Had an op for Gilmores groin last year, no problems since. Doesnt smoke.

Had seen a chiropractor for ~6 sessions. Found some relief after first two sessions, nothing since. Imrovement that came with Rx is still present. Had seen a physio previously and was told something re sciatic nerve.... (i really dont think there is any indication).

Works in gardening.

No red flags present etc.


Objectively,

Observation- quite good static posture in standing. Slightly flat back posture if anything. Hyperactivity in low thoracic erector spinae bilaterally.

Active movement- flexion=full and painfree
ext= limited 3/4 range pain as above 5/10
lateral flexion= full and painfree bilaterally
combined mvts- ext and lateral flex (B) 6/10.

Palpation- PAIVMS Central PA T10-l5 no pain elicited, some muscle spasm l2 and l3. Pain elicited 5/10 bilaterally with PA pressure approx 3 cms lateral to L3 SP. Obvious spasm in low thoracic and upper lumbar erector spinae.

Full neuro exam- NAD

Pelvic mobility- decreased ppn re pelvic position when sitting. Problems finding a neutral position.

Sacro Iliac joint- clear. Tx spine clear. Hips clear.

I may have forgotten some things here...

It would seem that its an inflammatory type pain due to its 24 hr pattern. Im thinkin some minor tear of the disc with associated sensitisation of the disc (not nerve). More than likely has been unable to heal as client continues to work in manual labour...

Treatment focused on relieving the spasm with heat, massage. Gentle extension exs in prone within limits of pain to promote acceptance of movement. Pelvic mobility and ppn exs. Education and advice re general posture and manual handling. Started some core stability work.

He has not seen a medic yet, i have advised to get an x-ray and NSAIDS etc.

any ideas? much appreciated

Hi,

Great history - i wish more posts contained as much as you put in. Thanks!

What does "ppn" mean?

Does flexion ease his pain?

I am thinking it is a flexion control problem at L3/4. The theory goes like this...

He is able to flex pain-free. he lacks the ability to find neutral spine and so goes to the end of range of flexion at L3/4 to locate his joint in space. Therefore the joint gets used to flexion and restricted into extension there. Compensatory muscles in the L/S and T/S ES are overworking trying to hold him together.

You can go treat his discs or whatever you want - it doesn't really matter. The bottom line is that you have to stop the repetitive strain on his L/S - That is why the chiro is not working - because it is not primarily a joint stiffness problem but a motor control problem.

What are his Aggs, Eases and PPIVMs like?

Thanks

Hi roycar,
Why x-ray? No red flags present and no history of trauma. Is an x-ray really going to change the way this patient is managed? This is a classic mechanical type of low back pain with no worrying features. Encourage a return to normal activity.
The history of a groin problem and L3/4 is interesting. I agree unlikely to have anything to do with sciatic nerve. Did you test Femoral nerve?

Roycar,

i would have to agree with alo 120% on this one, that's what i thought of as well. out of curiosity with the neuro exam what did you do?, did you specifically do a prone knee bend test ( butler if ref needed ). I would be referring for scan if i was you!
C

I agree with alophysio. And I also wanted to know, like Orihc, what do you refer with a full neuro exam?

Besides checking neurodynamically the L3,L4, it would help if you checked individually the segments L2,3,4. check how it moved in type one & type 2 motions respectively, check its status in lateral flexion & rotation separately during type one motion. It would definitely throw some light on how you must tackle this case.

how do.

After your comment alo i dug out some of o'sullivans articles on motor control and had a good read. I dont really have the time for a long post but yea you were indeed on the right track. the last couple weeks we've focused on regaining lumbar segmental range and worked on pelvic and spinal positioning with appropriate local muscle control. there's been quite an improvement. i think last session he was ~60% better. no pain in the morning which was his main problem etc etc. thanks a mil

Glad to hear things are going well. The MC works really well when appropriate!