Just Another Patient With Chronic Back Pain - Page #1
 

Author: Tyler Schmitz, DO
Editor: Idris Amin, MD
Senior Editor: Kristine Karlson MD

Patient Presentation:
A 32 year old male competitive pickleball player with no past medical history presented with a chief complaint of vague low to mid back pain.

History:
He reported his back pain started one year ago after increasing his playing time. It progressively worsened from occurring intermittently to daily. Pain was described as a dull ache that worsened after playing and was difficult to localize. It was partially relieved with high doses of NSAIDs. Assuming his pain was due to playing too much, he decreased his playing time. Recently, intractable night pain developed so he decided to seek care. Besides new onset generalized eczema, review of systems was otherwise negative. 9 months prior: L and T-spine x-rays normal; L-spine MRI showed mild bilateral facet joint capsulitis at L2-S1, and broad based disc bulging at L4-L5 with no evidence of nerve root compression; Chiropractic manipulations did not improve pain; PT improved pain initially but plateaued after 2 months.

Physical Exam:
General: Healthy appearing athletic white male in no apparent distress
Back exam:
Inspection: no deformities or masses, no rashes, no swelling, normal thoracic and lumbar curvature
Range of motion: normal thoracic and lumbar range of motion
Palpation/percussion: non-tender to palpation of thoracic and lumbar spine and paraspinal musculature, non-tender to palpation of sacroiliac joints, no pelvic obliquity
Sensation: normal sensation to light touch at lumbar dermatomes
Strength: 5/5 equal bilateral lower extremity strength
Reflexes: normal bilateral lower extremity deep tendon reflexes
Special Tests: negative bilateral straight leg raise

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NOTE: For more information, please contact the AMSSM, 4000 W. 114th Street, Suite 100, Leawood, KS 66211 (913) 327-1415.
 

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4000 W. 114th Street, Suite 100
Leawood, KS 66211
Phone: 913.327.1415


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