42 y/o male presented with 4 week history of unrelenting low back pain with associated left sided posterior leg pain that extends distally to the ankle.
He explains that he was playing squash when he felt a twinge in the lower back. He has no prior episodes of low back pain or radicular pain.
There are no positions that relieves his low back pain or radicular pain.
He explains his symptoms are worse with coughing and sneezing.
He had a course of physiotherapy – 2x/week for the first 3 weeks, that involved heat and massage. He mentions the therapy helped the radicular pain initially but came back with a vengeance during the third week of treatment.
He has been using Endone and Lyrica to manage his symptoms and get him through the work day.
He finds it difficult getting out of bed, rolling over in bed, dressing oneself, and sitting in a vehicle.
He also mentions he has difficulty with going to the bathroom to pass a bowel movement, he is not sleeping properly because – difficult to find a comfortable position, he has difficulty cleaning the house and cleaning oneself in the shower.
Postural Analysis; towering to the right.
Gait; limping and unable to ambulate greater than 5m without needing to stop and rest with his hands on his knees.
Standing lumbar range of motion; flexion = 5 – 10 deg. extension = 0 deg. Left lateral flexion = 0 deg. Right lateral flexion = 10 deg. Left rotation = 0 deg. Right rotation = 0 deg.
Standing lumbar kemps; Left = severe positive. Right = mild positive.
Patellar Reflex; Left = 2. Right = 2.
Achilles Reflex; Left 0. Right = 2.
Motor Power; weakness with left plantar flexion (3/5).
Sensory; diminished soft/sharp differentiation along the lateral left foot.
Slump; Left = radicular pain and back pain. Right = no abnormalities detected.
Straight leg raise; Left = 25 deg. before limited by back pain and radicular pain. R = 65 deg before limited by hamistright tightness.
Vascular Testing; Hautant’s/Maigne’s (Seated) & VBI (Supine); No abnormalities detected.
Education & Advice.
MRI Referral (after the initial consultation)
Seated lumbar facet joint distraction mobilisations
T12/L1/L2 tractional adjustments
Left L5/S1 side posture tractional adjustments
Kinesiology taping techniques
Supine lumbar decompression techniques
Supine lumbar rotation mobilisation techniques
Glute and hamstring activation exercises
Core stability exercises
After 1 consultation, the patient reported an improvement for 4 hours, then the pain returned.
MRI highlighted a L5/S1 severe disc herniation with associated nerve root encroachment.
Suggested he needed to be reviewed by a lumbar orthopedic surgeon. Surgeon was not happy to move forward until a longer conservative treatment approach was trialed.
After 3 consultations by the end of week 2, the patient reports he has been able to walk for 20 min several times a day and he is sleeping better.
After 8 consultations by the end of week 4, the patient reported minimal back pain and minor radicular pain into the glute only.
After 15 consultations by the end of week 12, the patient reported unrestricted mobility and continues to have no pain with any movement. His achilles reflex and plantar flexion motor power have returned to normal.
After 25 consultations by the end of week 36, the patient continues to have no low back pain or radicular pain and has a maintenance/check-up appointment every 12 weeks.
He has returned to playing unrestricted tennis and squash.