Thanks for posting about this interesting patient Laura!
I saw this patient on day 1, Laura and I saw him on his second visit. I have the advantage of having his EMR up at the same time I am posting so here are a few more details:
Complaints: L SIJ (+Fortin finger test), L lateral hip (deep), L lateral leg. Pain in all 3 areas. He is’ aware’ of the L/S and L L/L region.He also has numbness, C, NV, entire L lateral thigh. No symptoms below the knee or on contralateral side. No c/o headache.
Agg factors:
Upon first getting up to stand after sitting. Walking is o.k. He hasn’t walked prolonged recently, but since the onset, if he went for a 2 mile walk, he would have delayed increase in pain.
He stopped running 2 weeks ago due to incr. pain during running. He played tennis last week and had increased pain after.
Getting in and out of the car: He has to lift his left leg (Pt. is tall and also tends to flex his cervical-lumbar spine to get into the car) due to pain.
Standing for a few minutes increases pain. He is worse first in the morning.
Ease: Lying on right side, sitting, unloading on grocery cart when shopping.
Additional Asterisks:
*Weak hip flexors on the side of the symptoms w/ myotomal testing (left), 3+/5, slightly improved on day 2.
*on day 2, numbness on the lateral thigh was increased when palpating the direction and depth of greatest restriction of soft tissue at site of the hernia repair.
*Flexion was limited on day one at less than 50% with increase of left lateral thigh numbness.
*Extension was limited to 25% w/ increase of left lateral thigh numbness
*Slump incr. thigh pain at -25 deg. knee ext on the L, no incr. w/ neck Flexion or DF
*SLR L incr. thigh pain at 55 deg, incr. w/ neck flexion and dorsiflexion.
*Femoral nerve slump test, noted by Laura above, was much more significant for reproduction of symptoms.
Hip and SIJ clearing exam = negative
Recent History (Initial Evaluation on 11/10) – He was taking the sails down on a 47 feet sailboat the weekend of Oct 2nd, due to a hurricane. This involved a lot of reaching and pulling from combined movements in extension and flexion. He also did a lot of lifting that day and noticed a gradual onset of symptoms during that day (L lumbar to L lateral thigh). He was supposed to run a 1/2 marathon on the 14th. He tried to run twice after the episode and got really severe pain in his back and L hip/thigh. Now, the past 24 hours, significantly less pain, but numbness on the outside of the L thigh. It did not keep him out of work (deskwork), but the pain awoke him, every night for the past 10 days, difficult to RTS.
Past History: 2 previous episodes, one was also since the hernia repair (’09), 18 months ago ago, onset with pulling himself out of a kayak, reaching above for a ladder at a dock into combined extension and contralateral sidebend/rotation. Both previous episodes resolved spontaneously without treatment, but with rest/decreased activity for weeks.
Previous episode, 16 years ago, worse then. He could not get off of the couch for 2 weeks. He was treated with ECI, lumbar, unknown level, and P.T., including traction. Symptoms resolved.
Findings from recent x-rays – DDD, OA of lumbar spine.
Steroid dose pack – Finished 1 week ago. He said it ‘helped marginally’.
Day 1: P/A unilateral left upper lumbar // After treatment: Slight improvement in symptom-free range of motion into extension and flexion. Gapping mobilization of upper lumbar left // decreased paraesthesia at rest, slight additional improvement in symptom-free range of motion into extension and improved lumbar range of motion into forward bend to 75% after treatment (much better improvement with gapping mobilization), increased ROM into SLR, no change in hip flexor testing. On visit 2, we needed to bring him into extension quadrant to reproduce symptoms, his improvement into flexion was maintained, he was significantly improved for the rest of the day and the night of treatment. On the second night after treatment, he awoke with significant pain/paraesthesia.
Day 2: Besides education on posture modification, we added soft tissue mobilization of the soft tissue restrictions around the hernia surgical site // decreased numbness after the soft tissue massage. We repeated the upper lumbar gapping technique.
Questions:
Meralgia Paresthetica appears to be one probable component. The lateral thigh numbness began only 24 hours prior to coming to P.T. What are the other hypotheses on the list at this point?
What do you think about the history of episode 9 years before the hernia repair?
What other details would you like to know about his past history?
Would you contact his referring physician?
If so, would you note and specific concerns or recommend any special testing at this time? Are there any questions you have for the physician?
If he returns improved in symptoms and all objective asterisks, but not resolved, what would be on your list for possible progression of treatment?
Do you think the physical therapy prognosis is good? Why?