Just a thought based on previous experience. As I mentioned during the conference call in my experience heel drop test usually leads to pain reproduction in irritable patients. The fact that this patient is on immunosuppressants I would suggest having discitis (infection of the disc) on your radar. Certainly rare, but I have had 2 cases before with insidious onset of LBP presenting like a disc pathology that wound up having discitis. Highly irritable with a positive heel drop. Neither of which were showing signs of systemic infection at the initial evaluation and neither had any directional preference (if i remember right).
AJ, thanks for posting. It certainly wasn’t on my radar but definitely makes sense. I think for my patient in particular, he had a MOI (albeit a rather innocuous one) and overall was not very irritable. The heel drop is not something I was really using before this fall so in my limited experience I’ve seen both irritable and non-irritable patients with positive tests, with the magnitude of their response correlating with their overall subj/obj irritability.
I’ll keep an eye on this gentlemen going forward and certainly will consider something like discitis in the future.