Case Study
Low Back
Questions you need to ask this patient and what it may indicate
Help indicate the severity of his condition.
May help to determine area of concern.
Could help determine if any past injuries have returned.
Will help to determine the severity of his condition.
Will help to determine if diagnosis is neurogenic in nature. Saddle paraesthesia may indicate Cauda equina syndrome.
Will help to determine if issue is unilateral.
Will help to determine a vascular claudication diagnosis.
Will help understand how they are controlling their pain.
Will help to determine any predisposing factors.
Will help to determine any predisposing factors such as arthritic conditions.
May help determine a vascular issue causing their pain.
May cause vascular issues leading to pain in their lower limbs.
Will help to determine any aid he may need with his diagnosis (traveling, management).
Differential diagnosis – list possible causes and reasons for his pain
- Spinal canal stenosis (Ages 60+ M > F) causing burning and tingling down legs
- Vascular claudication (Ages 40 – 44, 65 – 69 M =F) causing cramping in legs
- Severe lumbar arthritis (60+ M > F) causing burning and tingling down legs
- Lx disc degeneration (Ages 60+ M > F) causing burning and tingling down legs
- Gluts, piriformis, Lumbar erector spinae strains causing pain in low back and gluts region
- Lumbar facet or Sacro iliac joint (SIJ) sprain producing pain in low back and posterior hip region
Give a list of examination procedures including any orthopaedic tests
- Lower limb neurological exam
- Lower limb peripheral vascular exam
- Straight leg raise test / Valsalva / Slump tests
- Lumbar quadrant kemps
- Sacro iliac joint (SIJ) orthopaedic tests (medial compression, thigh thrust, local sacrum compression)
Observation
- Look for any atrophy in gluts and lower limb muscles: may indicate a neurological cause
- Skin decolourisations: may indicate a vascular issue
- Swelling of lower limbs: May indicate a vascular issue or cardiac dysfunction
- Lumbar and hip: Passive / Active / resisted active range of motion tests
- Muscle palpation: Lumbar erector spinae, gluts, piriformis, hamstrings, quadriceps, gastrocnemius, soleus
- Measuring pulses in hands and feet: help detect a vascular issue
- Doppler ultrasound of lower limbs: look for blood clots and poorly functioning veins
- MRI / CT angiography of lower limbs: look for blood clots and poorly functioning veins
- Blood pressure: comparing ankles with the arms
- Walking exercise test: maximum distance patient can walk or maximum exertion without pain
Suspected working diagnosis
Suspected vascular claudication in left upper leg with associated erector spinae, gluts and piriformis strains / hypertonicity predisposed by genetics and unhealthy lifestyle
Explain the management for a diagnosis of suspected vascular claudication
Answer
A thorough explanation to the patient needs to be discussed along with a referral to his doctor. A letter to his doctor describing his symptoms and your findings will help them make an informed decision on any scans needed such as MRI or X -ray. Communication with his doctor will be important going forward.
Any significant findings on MRI or X–ray needs to be managed through his doctor and specialist. Reminding the patient that manual therapy may help with his general aches and pains in his muscles, but any issues originating from the discs or vascular system need to be addressed with a specialist.
What is the management for vascular claudication in the lower limb?
- Angioplasty – small balloon is placed and inflated in the blocked vessel allowing a healthy flow of blood
- Vascular surgery – healthy blood vessel is taken from one area to replace the blocked vessel
- GP advice on controlling any diabetes, hypertension, hyperlipidaemia, and medications
- Address any weight issues
- No smoking
- Daily walking to level of pain, increase walking if pain levels decrease
- Maintain optimal foot care (podiatrist)