Case 1 – Back in the Bank

A 26 year old bank teller who recently moved house and does spin classes 4 days per week comes into your office looking for advice for his Low Back Pain.
History

He tells you the pain started 2 months ago. He does not note any injury, however he states that it was around the time when work picked up and he stopped being as active. He feels the pain in his lower right back, he points to the right of his lower lumbar and sacroiliac area. He states that initially it was 8-9/10 in the first week but since its been a nagging 3-4/10. He says that it’s worse when he’s at work sitting behind the counter or when he’s moving boxes from the basement of his new house upstairs. Initially he continued his spinning classes but found that afterwards his back was always worse off. He says he can’t really think of anything that has made his back better, although it’s still sore, he says it doesn’t bother him as much when walking around.
You ask about position, specifically if he notices a difference in his back pain between standing for a long time versus sitting for a long time?
He states that its usually worse after sitting. He states that its usually worse after sittingHe has registered massage therapy and taken ibuprofen 400mg q4h for 3 days with only immediate relief.

He denies any radiating symptoms going down his legs. He says occasionally he feels a tight pain in his right buttock but nothing further down his thigh. He also denies any numnbess or tingling in his lower limbs.
You ask about cauda equina symptoms:
1) Have you had any episodes where you lost control of your bowels or soiled your underwear? No.
2) Have you gone prolonged periods of time without peeing or had difficulty peeing? No.
3) Have you had any numbness or tingling in your testes? No.
4) Have you you had any numbness or tingling around your anus? No.
He has had back pain before but it only lasted a couple of weeks.
He states that the although his pain can be worse in the evening time, he does not wake up from sleep. He has noticed that he has put on about 10 pounds in the last 6 months from reduced activity level and eating out more.

Examination:
He is mildly overweight with a forward posture.  He continues to shift his position in his seat throughout the interview.   On inspection he has a loss of lordosis and on palpation increased tone in his paraspinals.   He is able to walk forward and backwards on his heels, and up and down 10+ times on his toes, while his trendelenberg was normal.   His gait was unremarkable.  Forward flexion in standing with straight legs, reproduced pain with his fingertips approaching the superior border of his patella.   When asked to extend backwards while standing the patient reports some relief.

In a seated position.  The patient’s reflexes were tested, 1+ bilateral knee and ankle jerks and downgoing babinski reflexes.  Slump testing with forward flexion of the trunk and extension of first left knee, then right knee revealed increased back pain on right side, which was relieved with reclining backwards.   Testing of L3 hip flexion v. resistance, L4 knee extension v. resistance, L5 peroneals and dorsiflexion and S1 plantar flexion:  all revealed 5/5 power bilaterally.  Sensation was also subjectively reported as normal and equal bilaterally.  Coordination was noted to be normal as well.

Lower limb neural tension tests, femoral nerve and sciatic (Straight Leg Raise) were both negative.

Sacroiliac testing (Patrick test, Gaenslen’s, Single straight knee heel land, open book, closed bood and SI joint line palpation)  were all normal

THere was no evidence of leg length discrepancy.

With isolated lumbar flexion with bilateraly forced hip flexion, his pain was once again reproduced.

His pain was reduced by having him lying prone, with pelvis flat on bed, and pushing his upper trunk into extension.

Diagnosis:

Discogenic Back Pain – although his pain may very well be arising from sensory fibres at the posterior aspect of his vertebral disc, verifying this would be very invasive and in the end not all that helpful to the patient.
Sciatica – The patient has denied having any pain symptoms beyond his buttock and his lower neural tension tests, specifically his straight leg raise were negative.
Flexion-type Low Back pain – the patient described both positions and mechanical movements which worsen his pain. These were sitting both at work as well as in racing position on a spin bike, as well as bending with boxes. These all involve forward flexion of his lumbar spine. This classification and diagnosis allows for direction of treatment.
Lumbar Spinal Stenosis – although it is possible that he could have congenital spinal stenosis, or post traumatic, he describes no similar prolonged episodes, and no injury. Lumbar spinal stenosis, is usually provoked by extension like movements of the lumbar spine and can be relieved with flexion.
Boney Metastases – Although it is always important to keep life-threatening illnesses in our minds when considering diagnoses, it is unlikely given his history of mechanically affected back pain, that this is secondary to boney mets.

Plan:

1.  Extension type exercises.
2.  Modify activities that involve prolonged periods of lumbar flexion (sitting and cycling) or repeated bending (lifting boxes).  For example, work in multiple standing breaks from sitting.  Use lumbar support when sitting, or pull self as close to work space as possible and recline.   Change cardiovascular activities from sitting or repeated bending (cycling and rowing) to extension type activities: elliptical, swimming, walking.
3.  Heat or Ice – when back is flared, it is important not to forget about conservative modalities like icing or heat for lower back to assist in relieving back pain.
4.  Chiropractic treatment in acute low back pain can be very helpful for patients and can guide the patient in extensions, stretching exercises and core strengthening.
5.  Physiotherapy can use some modalities to reduce muscle tension and guide the patient in extensions, stretching exercises and core strengthening.
6.  Medications:  Although only symptom managing, can include Tylenol, NSAIDS, muscle relaxants, and in extreme cases narcotics for severe acute low back pain.

Still having issues despite modifications and treatment: Consider pelvic tilt exercises, psoas stretches and abdominal support when doing extensions.

Dr. Neil Dilworth CCFP Dip Sport Med