PREFERRED PRACTICE PATTERNS
4C: Impaired muscle performance1
4E: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation
A 34-year-old woman 12 weeks s/p C-section presents with complaints of low back pain. The patient has two children with less than 18 months between deliveries, first was a C-section due to larger gestational size followed by a repeat C-section. Her weight gain with each pregnancy was approximately 40 lbs. No episodes of urinary incontinence reported since delivery. She is experiencing pain during childcare activities, especially lifting, bending, and prolonged sitting.
Pain is described as a constant dull ache across the center of the low back with no radicular symptoms or sensory involvement. Pain is increased when lifting or carrying her oldest child and when bending or leaning forward while bathing or changing a diaper. She reports intermittent pain when breastfeeding in a sitting position for more than 15 minutes. Increased lumbar lordosis is noted with forward head and rounded shoulders posture. A palpable diastasis of approximately 3 cm is noted just superior to umbilicus, and there is tenderness to palpation over the lumbar paraspinals. Prone instability test is positive and Thomas test is positive bilaterally. Lumbar AROM is WFL, but painful after 50% of flexion and after 75% of extension. Hip ROM is WNL. Hip flexion and extension strength are 4/5, and transverse abdominis and multifidus strength are diminished.
Visible abdominal signs. (A) Diastasis recti. This is abnormal separation of the abdominal rectus muscles. It is frequently not detected when the patient is supine unless the patient’s head is raised from the pillow so that the abdominal muscles are tensed. (B) Abdominal profiles. Careful inspection from the side may give the first clue to abnormality, directing attention to a specific region and prompting search for more signs. (From LeBlond RF, DeGowin RL, Brown DD. DeGowin’s Diagnostic Examination. 9th ed. www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)
Diastasis recti visible in the midepigastrium with Valsalva maneuver. The edges of the rectus abdominis muscle, rigid with voluntary contraction, are palpable along the entire length of the bulging area. This should not be mistaken for a ventral hernia. (From Brunicardi FC, Andersen D, Billiar T, et al. Schwartz’s Principles of Surgery. 9th ed. http://www.accessmedicine.com. ...