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A 67 year old man presented with a complaint of intermittent low back pain that he had experienced over the last month. The patient, who described the pain as an ache, but with a gnawing quality, denied previous back problems and did not recall sustaining an injury or experiencing trauma. He also reported that sometimes the pain seemed to be associated with vague abdominal discomfort, that he had been constipated, and that his appetite had been poor. Although the patient denied having radicular signs, he mentioned that he had been unable to wear his regular shoes because they hurt his feet, and that the only footwear he could tolerate were slippers. He also reported that his feet had felt colder than usual over the last week. His medical history was significant for a myocardial infarction several years earlier, hypertension, and a 1 pack per week smoking history. The patient reported that he had not experienced any recent fever, and that apart from his back pain, he felt in good health. However, he appeared pale, his skin was warm and dry, and he seemed to be uncomfortable as he rubbed his calves frequently.

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Given this presentation, what do you think are the indications that physical therapy would benefit the patient?

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There is little if anything in this presentation that would indicate this patient would benefit from physical therapy. Despite the fact the patient has back pain, there appears to be no mechanism of injury and the description of the low back symptoms should cause concern. While intermittent low back pain would not be unusual in a 67-year-old, the gnawing quality of the pain, coupled with the rest of the history highlights the need for further investigation.

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What questions should you ask about the low back pain?

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The clinician should determine if any activities or positions have an effect on the pain. In general, sub acute and chronic musculoskeletal injuries are worsened with movement but improved with rest. In addition, questions should be asked as to whether eating or drinking has any effect on the symptoms, whether the pain is worse at any particular time of the day, and whether the patient has had similar symptoms in the past.

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What are some of the potential causes of the symptoms in the patient's feet?

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Peripheral symptoms in the feet or hands with no history of trauma or overuse are generally linked to either vascular or neurologic compromise. In patients who smoke, Raynaud's phenomenon has to be considered, although that is unlikely in this patient as he made no mention of symptoms in the hands.

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What would be your next course of action?

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Although this patient presents with no objective ...

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