When I see a body chart that has the low back circled as well as the posterior aspect of both legs, I quickly became concerned about the potential for serious, red flag pathology. I went into this exam with fears for the worse and was already rehearsing the conversation in my head as to how I was going to explain what UMN signs are and why she may not be fit for PT. My patient was an older woman of 61 years who had been dealing with low back and bilateral leg pain for 4 years and was able to live a relatively normal lifestyle including running for 30 min every few days, but this lifestyle involved near constant pain and discomfort on some level. She sought PT services after her pain became worse to the point where she was no longer able to keep up her running regimen as she began to experience pain around 10 minutes into the run and it became so severe that she would have to walk home clutching her low back and legs.
When I went to bring the patient back for the initial eval, I was immediately surprised by how functional the patient was; the way she popped out of her chair in the waiting room and walked back into the clinic with seemingly no issues was astonishing. There was no evidence of gait deviations, loss of balance, foot drag, etc. The patient went on to discuss how she works for “Instacart ” where she is consistently lifting heavy amounts of groceries and water bottle crates without much issue. She does endorse near constant mild to moderate pain with her job regardless of activity that steadily worsens throughout the day especially with recreational activities such as her running regimen. She described what sounds to me like neurogenic claudication, in the sense that she has bilateral symptoms that are made worse with prolonged bouts of activity. During the subjective exam, I quickly asked questions regarding urinary/bowel dysfunction and saddle anesthesia. Luckily, she was a negative for both of these questions which lessened my concern for cauda equina syndrome. Amazingly, the patient’s strength was strong with no signs of fatigable weakness. Although in hindsight, with her symptoms coming on with over a mile of running, it was unlikely that I was going to provoke her symptoms so quickly. Her sensation was intact and she was hyporeflexive bilaterally, and after discussing with her, she told me that her reflexes used to be much more reactive than they were when I assessed them telling me she was indeed hyporeflexia and not just on the lower end of normal. She was negative for all other UMN testing. She had positive slump, SLR, and prone knee bend neural testing making me question if this was actually a bilateral foraminal stenosis that was occurring instead of a claudication. The patient had only mildly limited AROM restrictions in the low back and hips with lumbar extension being the most uncomfortable and this pain remained localized to the back. Overall, I was very surprised, given the body diagram and the severity of the pain that she was initially describing to me, that she was as functional as she was. After really hearing the whole story, and performing thorough objective testing, I was able to narrow down a few objective asterisks that would help guide my differential and provide adequate treatment. The patient had a slew of questions for me as she had been to several PTs before me and was currently working with a personal trainer all of whom told she would never be able to run again. She also stated that everyone she saw never did an in depth exam the way I did and they probably made assumptions based on her symptom presentation. I encouraged her, as we control and modulate her symptoms, there is no reason to shy away from the idea of never running again and not view herself as “broken”, a term she coined several times. I think the main takeaway from this experience for both myself and my patient is that we both thought the worst of the situation and made assumptions about long term prognosis and function when we really didn’t know what was going on. I think this was a good experience in the sense that despite the presentation of high levels of pain, it does not always lead to dysfunction, especially when there are objective asterisks that are treatable. Even though she currently can’t engage in her running regimen, I think there is a good chance she will respond to conservative therapy and over time return to the activities she loves.