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52 y/o active male, LBP, knee pain, parasthesia

Patient description: T12 fracture secondary to fall downstairs 2008, healed non-surgically – residual pain twisting limiting golf. Low back pain with end range lumbar extension, yoga participant 1-3 times a week. Started cycling on January, 30 – 70 miles per week, hybrid bike 10-15 miles per session, Swimming daily during hotter seasons. Past 2 weeks decreased activity due to Spring break. Pain in the right lower hip back area has been present for years – wears inserts since January although had not been wearing inserts for several years although found that back pain diminished with inserts. Friday did couples massage, spent an hour in the hot pool, felt better- although yesterday while driving had numbness and tingling in the right leg down to the foot and had to pull over, the foot is currently swollen. The patient had weight loss from 230 down to 200 via program at a local hospital, although weight gain back to 222 lb at present. Had hypertension in 2002 was on Batablocker, which was discontinued weight loss and blood pressure stabilized at present. Currently has skin lesions being treated on the forehead. The patient is retired from the financial industry, married and has 2 children ages 2 and 6. Surgical history includes AC joint separation secondary to softball injury 1999 left side, ligament repair.

Hx: Sciatica started while on spring break last week (Friday and drove the next day to Missouri 1000 miles (5 hours seated driving Sat and Sunday) with terrible intensity. Have had it on and off for months [ pain in lower right hip/buttock area has been present while sleeping on the side], but not this bad and [in the past the pain had] subsided with ibuprofen 800 mg and yoga. [Last week the right] knee pain was also triggered from the daughter’s spring party [on Friday] as he was stationed at low children’s cookie table and he repeatedly was up and down (squats) for 2 hours. Knee pain history goes back 12 months ago when pt was working on a project at his house and walked into the pool with a load of lumber [at that point self-treated and pain diminished].  Doctor [Internist] started pt on steroids  [2 days prior to PT evaluation] and Tylenol codeine for nighttime. Pt reports he cannot bend his knee easily.

Objective: Patient reports standing at rest a constant ache in 3/10, visual inspection revealed right calf atrophy, Functional movements: AROM forward flexion pt felt stretch or pain in right ischial tuberosity area, back bending, side bending and rotation did not increase pain – prone palpation revealed no trigger points at the hip or lumbar spine and patient denied any soreness with palpation at glute med, min, max, piriformis or sacrum. Pain with palpation over the upper lumbar spinous process

Knee has to increase anterior movement ligamentous laxity right, pain posterior knee with Mcmurry lateral possible meniscus injury and/or Bakers cyst, atrophy mentioned above

Increased lordosis lumbar spine with concern for anterior slipping; Large discrepancy between sacrum and L5 in prone Lumbar spine paraspinal muscles are hypoactive- Rule out nerve root damage first via MRI, then is necessary NCV test due to prolonged muscle atrophy despite activity level- also look for stenosis

Impression and Plan: Patient educated to follow MD’s orders for an MRI, to avoid chiropractic manipulation for fear of spine damage, to avoid hyperextension of lumbar spine especially with yoga, to use ice for inflammation, and allow initiation of knee program, since knee pain is likely orthopedic and not due to the radicular symptoms.

A final thought on leaving was the patients persistent pain in his back with intermittent pain into the scrotum area, and the patient called to report a severe increase in pain upon getting into his car.

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