A physically active 61-year-old man presents with complaints of a gradual onset of low back pain and occasional pain in the left buttock (no reports of pain in the thigh or below the knee), which he has had for the past 3 weeks. According to the patient, the increasing pain prevents participation in his hobbies and socializing with friends. The patient denies any unexplained weight loss, any night pain unrelated to movement, or any changes in bowel or bladder habits. The patient reported symptoms get worse with prolonged standing, lying prone, and walking, but improve with sitting or sidelying with his knees drawn up to his chest.
List the differential diagnosis for complaints of a gradual onset of pain in the low back in this age group.
The differential diagnosis for low back pain in this population must include osteoarthritis of the spine, lateral recess stenosis, strain or sprain, and neoplastic, vasculogenic and neurogenic causes.
List the potential reasons for the patient’s symptoms getting worse with prolonged standing, walking, and lying but better with sitting or the fetal position.
This type of history tends to indicate a mechanical source of symptoms. Prolonged standing, lying prone, and walking all involve extension of the lumbar spine/an increase in the lumbar lordosis, whereas sitting and sidelying with the knees drawn up both involve flexion of the lumbar spine and a decrease in the lumbar lordosis.
From the history, what are the indications that low back pain may be a musculoskeletal problem?
But history indicates a predictable cause and effect for the patient symptoms -- if he extends his lumbar spine the symptoms are aggravated, if he flexes his lumbar spine the symptoms get better.
Does this presentation/history warrant a Cyriax lower quarter screening examination? Why or why not?
In situations where the spine is involved, it is always worth taking the time to perform a lower quarter screening examination.
Upon observation, it was noted that the patient stood with a reduced lumbar lordosis. Because of the insidious nature of the LBP, a lumbar scan was performed with the following positive findings:
- Full and pain-free range of all lumbar movements was noted, although overpressure into full extension was painful and worsened with the addition of side bending to either side.
- No dural or nerve root signs were present, but the prone knee bending (PKB) test reproduced the LBP.
The tests and measures revealed the following:
- The application of passive bilateral knee flexion (Pheasant’s test) with the patient in prone, increased the symptoms.
- Adaptive shortening of the hip flexors, hamstrings, and rectus femoris was noted.