Chapter 22d
Case Study: Low Back Pain - 4

Subjective: This patient is 41 year old laborer who is currently unemployed due to chronic, diffuse LBP and right posterior thigh and calf pain. He states that his pain back and leg pains are constant and are worsened by sitting, standing or walking more than one block. He complains of numbness and weakness in his right foot and occasionally trips over his right foot when he is walking. He denies bowel or bladder problems. His symptoms began in 1985 when he fell and landed on his buttocks while he was carrying a 90 LB bag of cement on a construction job. He was diagnosed as having a "broken bone" (fractured end plate) in his spine and was placed in a rigid orthosis for 3 months. In 1987 he underwent an anterior interbody fusion of L4-5 and L5-S1. In 1991 he underwent a second spinal fusion of L3-4 to L5-S1. He has not returned to work since his initial injury in 1985. He has no other health problems, he is taking 800 mg of Motrin TID. He states that he would like to change occupations but that he has only a 7th grade education.

Objective: This patient is moderately obese and stands with an erect posture. There is a well-healed surgical incision along the midline of the mid- and lower lumbar spine. The erector spinae muscles are poorly defined as are the anterior compartment muscles of his right leg. His leg length is equal. His range of motion is as follows: lumbar FB and BB is 10%, Side bending is 20%, rotation is 5%, both hips flex to 100 degrees, SLR is 55 degrees on the left and 45 degrees on the right and is limited by hamstring tightness. Motor testing is WNL except 3-/5 strength for all L4 and L5 innervated muscles on the right. Sensory is WNL, the DIR's are WNL except for a hypoactive achilles reflex on the right. The Lasigue maneuver is negative, the SI joint provocative tests are negative. When palpating the spine the patient complains of general discomfort over all lumbar spinous processes and erector spinae muscles. Gait analysis reveals a slight "steppage gait" on the right.


Treatment Plan:

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