CASE STUDY AND QUESTIONS: Lecture 4.

Week 3: Case 3 Sally

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?
Course: is the pain getting better/worse/staying the same?
Aggravating F’s: I know you mentioned lying down relieves the pain but is there anything that
makes it worse?
Previous management: Have you had any previous treatment for this condition?
Associated F’s: Can you think of any other associated factors that could be contributing?
Bowel habits: Have you bowel patterns changed recently? Is there blood/pain?
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
A) Left side Disc Protrusion L5/S1: Sudden onset, pain on flex and walking, laying down relieves
pain as pressure off disc. Previous ep could be that Sally has done slight tear to annulus and
continued to aggravate and now has disc protrusion. Referring pain down post/lat thing and
calf suggests nerve compression and L5/S1.

B) Left sided L5/S1 Facet pathology: Facet subluxation causes pressure on L5/S1 nerve roots
causing compression resulting in referred sharp pain in post/lat thigh and calf. Struggle with
walking and sitting up from lying position.

C) Lumbar strain/sprain: Pain in lumbar region, radiating, sudden onset, better when lying down
worse when walking and getting up as activation of muscle/lig etc.

D) Piriformis syndrome: Sharp radiating pain – irritated and compressed sciatic n. Pain on
walking, due to activation of piriformis.

E) Bowel Cancer: bowel habits ‘’all over the place,’’ grandfather passed from BC, tired
constantly, 2 packs cig a week, previous pain episodes, worsening, referred 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”
A – strong
B – strong
C – medium
D – strong
E – medium

b. “She contributed the pain to long hours of sitting at work and lack of physical activity”.
A- medium
B- medium
C- medium
D- strong
E- weak

c. “The pain commenced suddenly when making the bed that morning”

A - Strong
B - Medium
C - Strong
D - Strong
E - Weak

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
Lumbar Kemps test
Lumbar Vertical compression test

Slump test
Dejerine’s triad (Valsalva, cough, sneeze)
Flip or Bechterew’s test
Straight leg raising test (SLR)
Well straight leg raising test (WSLR)
Bilateral straight leg raising test
Braggard’s test
Bonnet’s test
Bowstring’s test
Kernig’s/Brudzinski’s test
Milgram’s test
Nachlas test (prone knee bending
Ely’s test
Yeoman’s test
Lumbar springing test
Trendelenburg’s test
Patrick Fabere test
Sign of the Buttock
Thomas test
Belt test or supported Adam’s
Ober’s test
 Questions: 3.4
The questions for this week will focus on UMNL/ LMNL and pathological reflexes.
Questions
Q1. An L5 disc pathology can lead to weakness of which muscle?
a. Peroneus longus
b. Quadriceps
c. Extensor hallicus longus
d. Gluteus maximus

Q2. Which of the following would be evident with an UMNL?

a) hyporeflexia
b) spasticity
c) flaccidity
d) fasciculations

Q3. If you detect ankle clonus in a patient, where is the location of the lesion?
a) Ankle
b) Spinothalamic tract
c) Nerve root
d) Corticospinal tract

Q4. What is tone?

Contraction of muscle fibres within a muscle

Q5. What is the difference between spasticity and rigidity?

Whereas spasticity arises as a result of damage to the corticoreticulospinal (pyramidal)

tracts, rigidity is caused by dysfunction of extrapyramidal pathways, most commonly the
basal ganglia, but also as a result of lesions of the mesencephalon and spinal cord.
Spasticity is characterized by abnormally high muscle tone, which often asymmetrically
affects antagonistic muscle groups. Rigidity differs from spasticity in that the increased tone
remains constant throughout the range of movement of the joint