Author: Joshua Go, DO
Co Author #1: Kevin Gray MD, CAQSM
Co Author #2: Margaret Gibson, MD, FAMSSM
Senior Editor: Justin Mark Young, MD
Editor: Diego Riveros, MD

Patient Presentation:
46-year-old female with past medical history of morbid obesity, well-controlled diabetes, sleep apnea, and HIV on ART presented to Osteopathic Manipulative Therapy clinic for low back pain.

History:
She endorsed a ground level fall during a Super Bowl watch party three months prior to presentation. Since the fall she had been having worsening low back pain. Provoking factors include prolonged sitting, stooping, and bending. She also noted right shoulder pain which is chronic, and unrelated to the fall. She denied bowel and bladder incontinence, loss of consciousness prior to fall, hypoglycemia, or history of seizures. She endorsed numbness and tingling down the low back, with some down the posterior portion of the right leg. She endorsed an inability to sit without pain.

Physical Exam:
Height: 157.5 cm. Weight: 100 kg. BMI 40.3 . Patient was afebrile and normotensive.

Back exam: Inspection showed no visible scoliosis, skin lesion, or rash. Tenderness to palpation midline along the lumbar spinous processes and the right sacral tuberosity. 4/5 Muscle strength in hip flexion, knee flexion, knee extension, ankle dorsiflexion, ankle plantar flexion, great toe flexion and extension.

No saddle anesthesia. Decreased sensation to light touch of the lateral lower leg, dorsolateral foot, first dorsal webspace, and plantar foot. Negative Hoffman's and finger jerks bilaterally. Down-going Babinski bilaterally. 2 beats of pedal clonus bilaterally.

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