Lower Back Pain Case Summary

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DOI: 8/15/2016. Patient is a 65-year-old male manager who sustained injury while he was lifting a tire that was lying flat on the ground when he slipped and felt a pull in his back. Per the procedure report dated 10/14/16, the patient had a lumbar trigger point injection. Based on the medical report dated 11/16/16, the patient complains of lower back pain which is sharp, dull and achy in nature. The lower back pain radiates to bilateral side, bilateral hips and bilateral legs. Lower back pain is associated with numbness and tingling to the bilateral buttocks, bilateral legs and bilateral ankles. Lower back pain is worsened with sitting, standing, lying down, movement activities, climbing stairs, bending and lifting. Lower back pain is improved with therapy.…show more content…
Patient has been receiving physical therapy since the accident. Patient states that there is pain relief following physical therapy. Lumbar spine examination reveals tenderness upon palpation at L1-S1 levels with muscle spasm present. Trigger points with palpable taut bands were noted at bilateral paraspinal level L3-S1 with referral patterns laterally to the region in a fan-like pattern. Range of motion (ROM) is as follows: extension is 20 degrees; forward flexion is 40 degrees; rotation is 10 degrees bilaterally; and lateral flexion is 10 degrees bilaterally. Leg raised exam, Braggard 's test, Sacroiliac compression, Sacral notch tenderness and Ober 's test are positive bilaterally. Sensory examination by pinprick shows hypoesthesia at right medial foot (L4) and at left lateral foot (S1). It was noted that the IW is status post lumbar trigger point injection #2 with 75% pain relief for few weeks. Manual muscle strength testing is 5/5 normal with the exception of bilateral hip flexion and right hip abduction at

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