Case 3

Presenting Complaint

Sally is a 53 year old receptionist. She is assisted into your office by her husband as she is struggling
with walking. She suffers sharp and shooting pain in her lower back on her left side which radiates
down the left posterior-lateral aspect of the left thigh to the left calf. The pain does not extend to
the left foot when questioned.

Onset and history of presenting complaint.

The pain commenced suddenly when making the bed that morning. She gets relief from lying down
but struggles to stand up after resting for some time. Sally has admitted that she has had a few
episodes of low back pain previously which she ignored since the pain simply disappeared - she
thought the same would happen now. She contributed the pain to long hours of sitting at work and
lack of physical activity.

Sally is overweight with a lack of muscle conditioning but says her health is generally ok. Her bowels
are a ‘bit all over the place’ although she suffers no pain in her abdomen. She loves the odd drink
every now and then and smokes 2 packets of cigarettes a week. She is happily married however
states that her husband is not well as he has been diagnosed with prostate cancer.

Her family history reveals that her grandfather passed away from bowel cancer 10 years ago. There
is high blood pressure in the family but that’s all she can recall. She mentions also that she feels
tired lately on a constant basis.

QUESTIONS

1. What further information would you seek from Sally?

Follow LODCTRRAPPA or any other pertinent questions (TIM FALS or CRIME LEGEND). Ask
more questions on her bowels ‘being all over the place’
2. Using only the information in the case history above, list the possible causes of Sally’s back
and leg pain? Explain your answer in each case
More likely to be complicated pain so:
L4,5 intervertebral disc herniation/bulge
L5,S1 spinal stenosis (dynamic lateral recess stenosis) although they haven’t done this
yet)
Piriformis entrapment
A sprain/strain in the multifidus muscle (not likely as it seems more like complicated
pain)
3. According to each differential as outlined in question 2, indicate the strength of the
following statements (from the case above) to the respective differential:
a. “She suffers sharp and shooting pain in her lower back on her left side which
radiates down the left posterior-lateral aspect of the left thigh to the left calf. The
pain does not extend to the left foot when questioned”
L4,5 intervertebral disc herniation/bulge: consistent for the distribution of radicular or
complicated pain
L5,S1 spinal stenosis (dynamic lateral recess stenosis) although they haven’t done this yet).
The more lateral the ‘compression’ the more likely it will impact the nerve root above. The
distribution and presentation makes sense although they haven’t done this condition yet.
 Piriformis entrapment. The distribution for piriformis is more posterior leg pain not posterior
lateral leg pain as with this case. Also the piriformis entrapment is more likely to be sensory
rather than painful.
A sprain/strain in the multifidus muscle (not likely as it seems more like complicated pain).
The distribution would makes sense although the pain would seem pretty severe for a
strain/sprain (possible though)

b. “She contributed the pain to long hours of sitting at work and lack of physical
activity”.
L4,5 intervertebral disc herniation/bulge
Consistent with this finding (in a flexed position sitting and out of condition)
L5,S1 spinal stenosis (dynamic lateral recess stenosis) although they haven’t done this yet)
Probably not consistent with this finding if she slouches (opening the IVF). It depends
how see sits.
Piriformis entrapment (not likely as it’s more complicated pain)
Consistent with this finding as sitting would make this condition worse.
A sprain/strain in the multifidus muscle (not likely as it seems more like complicated pain)
Consistent with this finding as slouching would put stretched the injured tissues in
the multifidus triangle.

c. “The pain commenced suddenly when making the bed that morning”
L4,5 intervertebral disc herniation/bulge
Consistent with this finding (bending, shear and torsion)
L5,S1 spinal stenosis (dynamic lateral recess stenosis) although they haven’t done this yet)
Consistent with this finding. It is possible for a lateral recess stenosis to be positive
with minor incident.
Piriformis entrapment (not likely as it’s more complicated pain)
This is not a typical aetiology for this condition but possible
A sprain/strain in the multifidus muscle (not likely as it seems more like complicated pain)
The mechanism of injury is usually more severe for this condition but possible

4. For your examination, the aim is to eliminate and confirm your differential diagnoses. From
the tests you have learnt so far, design an examination plan for this patient. Use
GORPOMNICS according to sitting, standing, supine and prone routine.

According to Standing, sitting, supine, prone routine

Gait
Observation
Active and passive range of motion
Static and motion palpation

Ortho tests (see table)

Muscle testing: not necessary
Neuro tests: Yes for lower limb SMR
Investigations: MRI, CT
Systems: Abdominal exam for bowel (Supine)
Test (only mentioned for true positives)
Squat test yes (standing)
Lumbar Kemps test (Yes for decreasing IVF)
Lumbar Vertical compression test
Yes for disc although not reliable
Slump test Yes for disc
Djerine’s triad (Valsalva, cough, sneeze) Yes for stenosis and disc
Flip or Bechterew’s test Yes for disc
Straight leg raising test (SLR) Yes for disc
Well straight leg raising test (WSLR) Yes for disc
Bilateral straight leg raising test Not necessary
Braggard’s test Yes for disc
Bonnet’s test Yes for piriformis
Bowstring’s test Yes of disc (if necessary)
Kernigs/brudzinki’s test (yes for stenosis and disc, more so Kernigs)
Milgrams test Yes for stenosis and disc
Nachlas test (prone knee bending No
Ely’s test No
Yeoman’s test No
Lumbar springing test Yes for location
Trendelenberg’s test No
Patrick Fabere test Yes (for length of pelvic stabilisers)
Sign of the Buttock For piriformis entrapment
Thomas test Check psoas anyway
Belt test or supported Adam’s No
Ober’s test No