Author: Sherilyn DeStefano, MD
Co Author #1: Jason Lippman, MD
Co Author #2: Theodore Paisley, MD
Senior Editor: Mandeep Ghuman, MD, FAMSSM
Editor: Bernadette Pendergraph, MD

Patient Presentation:
A 55-year-old active female initially presented to a family medicine resident clinic with three months of central low back pain that progressively prevented her from running and cycling.

History:
At that time, the exam, x-rays and history pointed toward a mechanical source of low back pain. She initially improved with nonsteroidal anti-inflammatory drugs and physical therapy and was able to return to cycling. However, four months later, she returned to the clinic with significantly worsened symptoms. She reported continuous pain down the back and lateral side of her right leg that woke her up at night and affected her balance and ability to ambulate. She had completely given up cycling and running. The pain even impacted her ability to do office work, and she was disheartened thinking that she would have to deal with this pain long-term. She did not report any bowel or bladder incontinence.

Physical Exam:
Visualization: She had no scars, bruising, or erythema.
Range of motion: She had limited, painful lumbar flexion and extension.
Palpation: She had tenderness at her lumbar facets and lumbar paraspinals bilaterally. She had tenderness at her right superior gluteus maximus but non-tender at the spinous processes.
Strength: She had 5/5 lower extremity strength with pain on the right-sided resisted motions.
Sensation: Light touch was intact in the L2 through S1 dermatomes bilaterally.
Reflexes: Patellar and Achilles reflexes were 2+ bilaterally.
Provocative Testing: A right-sided seated Slump test and straight leg raise were positive in the S1/S2 distribution.

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