A 44-year-old female presented with a diagnosis of left leg sciatica from her primary care physician. The patient reported the tingling-like symptoms to be in the region of her left sacroiliac joint and left buttock, with periodic numbness below her left knee and into the foot, which she noted after walking. She also reported sensations of cold and then heat along the anterolateral aspect of the left thigh during walking and periodic cramps in her right calf muscle. Her symptoms were aggravated by walking, and they were relieved by rest. She reported that the symptoms started suddenly, without trauma, 1 month prior. The patient reported having no lower extremity pain, bowel or bladder dysfunction, shortness of breath, night pain unrelated to movement, chest pain, or arm pain. No plain radiographs, magnetic resonance imaging, computerized tomography scan, bone scan, or vascular studies had been performed prior to her physical therapy evaluation. The patient had no significant past medical or surgical history.
What is your best working hypothesis for this patient?
The best working hypothesis for this patient at this stage would be left leg symptoms of a vascular and/or neurogenic origin.
- The patient demonstrated full lumbar AROM without reproduction of her symptoms.
- The patient demonstrated full lumbar PROM without reproduction of her symptoms.
- Special tests including seated compression and the standing heel-drop test were both negative.
- The patient demonstrated Normal strength (5/5) in her lower extremities with manual muscle testing.
- The patient demonstrated demonstrated normal sensation to light touch in her lower extremities.
- The SLR test, Cram's test, and the sitting slump test for nerve tension were all negative.
- The patient had a moderately diminished (grade 2/4) left dorsalis pedis pulse at rest. The right dorsalis pedis pulse at rest was normal (grade 4/4). The posterior tibialis muscle pulses were difficult to palpate on this patient and, therefore, were not graded.
- The van Gelderen bicycle test reproduced the patient's symptoms, and her legs buckled as she stepped off the bicycle after 5 minutes. Her dorsalis pedis pulse on the left side was temporarily abolished (grade 0/4).
Following the physical examination, do you think there is a neurogenic or vasculogenic cause for this patient’s symptoms?
Given the findings from the physical examination, it would appear that the cause for this patient’s symptoms is vasculogenic, more specifically intermittent vascular claudication. The lumbar spine could be ruled out as a source of the buttock or leg symptoms because the following tests were negative: AROM and PROM testing, lumbar compression, and the heel-drop test. Sciatica or nerve root lesions were ruled out as a source of the buttock or leg symptoms because the following tests were negative: strength testing of the LEs, sensation to light touch in the LEs, SLR test, sitting slump test, and Cram's test. Vascular claudication ...