Patient Case

[Katie Long]

Hey guys,

For those of you who don’t know me, my name is Katie. I finished the residency in September of this year. I have a patient that I’ve been treating for the past several weeks and I am stumped and would appreciate any help or advice anyone has to offer.

Patient is a 25-year old active male who works in retail. He is a retired collegiate basketball player and still plays recreational ball several times a week.

Subjective: MOI- pt was playing basketball in March, when he went for a layup and then landed in a crouched position. While in this crouched position, another player (~6’4″, 250#) landed on top of him. He states that initially he had no back pain, but after the game he sat down for a bit and that is when he noticed his back pain. His sx have always been on his L side. He went to a chiro, who helped with the constant back pain. He still gets back pain occasionally, but now his pain is primarily posterior thigh pain that can travel down to the posterolateral knee and then up to the posterior hip and L low back. When at its absolute worst, it can travel to the lateral calf. He describes his pain as a tight, ache, burn that can occasionally be itchy. He is having a hard time stretching and lifting weights because of his pain.
AGGS: standing at work during 8-10 hour shifts, running, playing basketball, stretching his L leg out straight in sitting (slump position), sprinting, walking, bending forward
EASES: crossing L leg over R in sitting (sometimes), meds (sort of), laying down

XR: (-) for fx or other significant findings

Objective:
Gait- antalgic. decreased stride length on L, decreased stance time L

Lumbar ROM:
-flexion AROM: 20% with posterior thigh sx provocation, notable deviation into LSB and L knee flexion; PROM- worse sx, to 25% ROM
-extension AROM: 100%, no increase in sx
-LSB AROM: 60% increase in thigh sx
-RSB: 100%, no sx provocation
-L flexion quadrant: 20% most sx provocation in posterior thigh and posterolateral knee

Resisted testing:
-resisted lumbar extension in flexed position: provocation of posterior thigh and posterolateral knee sx
-eccentric HS lengthening: provocation of posterior thigh sx (no sx when tested HS strength in 90/90

Neurodynamic:
-Slump: R sided testing results in L sided increase in posterior thigh sx with full R knee extension, no change with cervical extension; L side testing results in provocation of posterior thigh sx at lacking 70 deg from full knee extension, slightly worse with cervical extension
-SLR: R side results in posterior thigh tightness on R (not his sx), no change with cervical flexion; L side results in immediate provocation of his posterior thigh sx at 30 deg hip flexion, worsened with cervical flexion

Accessory Mobility:
-CPA: hypomobile, no sx provocation through lumbar and lower thoracic
-UPA: hypomobile, no sx provocation
-UPA in prone prop with LSB: no sx provocation

Palpation:
(-) sx provocation with palpation of lumbar spine paraspinals and gluteal musculature

Special testing:
Swing test: (+) during L SL stance during R swing; (+) during L swing for decreased ROM and increased posterior thigh sx

My primary working hypothesis is that a very large component of this patient’s sx are dural in nature. Things we’ve worked on:
-R sided sciatic nerve gliders, then tensioners moving into working on L sided glider
-lumbopelvic Elvy
-hip and lumbar spine mobilizations
-throacic spine manipulation in SLR
-lumbar spine mobilization in SLR
-lumbar spine extension PPIVM in SLR
-long sit slump stretching
-supine neurodynamic tension of R LE in SLR, (B) UE in ULTT with L LE slackened (no change in sx)
-STM lumbar paraspinals
-dry needling glute med
-RDLs
-SL squats with manual cue for hip ABD
-seated flexion with dowel rod
-supine knee to chest
-figure 4 glute stretch

While we have made some improvements in ROM over the past month, He continues to report severe sx with prolonged standing at work and has been unable to return to basketball. He reports subjectively that we have made 40% improvement in his sx.

My questions for you all are this:
Am I missing something?
What other things would you want to look at?
what other interventions would you try?
Does this warrant referral back to the MD for MRI?

Any help is appreciated!! I am stumped!

[Kyle Feldman]

Hey Katie

Looks like you have thrown a ton out at this case.

Sounds like immediate pain improved with chiro, how long ago did he stop chiro and did the severe symptoms lessen?

Also I agree it sounds dural and you have done almost everything dural to treat it
.

To me it sounds like an annual tear with constant inflammation. I am wondering if doing constant loading and overloading into the irritation is just upsetting it more. Annual tears can take a while to heal and calm down.

It sound like he does have motions and positions that are less symptomatic. I would try to work on doing less irritating activities with strengthening emphasis.

I would also consider trying to change the loading pattern he is in while standing. If he stands for 8 hours and has a strong anterior or posterior pelvic tilt he may be irritating the tissue after 4-5 hours and causing an inflammatory response. May need to help him to work on reloading and changing positions to improve tolerance to standing.

Have you worked on graded exposure to basketball to improve his tolerance and get him back to doing something he enjoys. Maybe free throws, elbow shots, lay ups without jumping?

[Katie Long]

Hey Kyle,

Thanks for the reply. He stopped seeing the chiro several months ago. The chiro only ever helped him with his severe, constant back pain. He continues to report minimal to no back pain, his complaints now are all posterior thigh pain, which he did not have with the chiro.

He is currently taking anti-inflammatories when his sx are very bad, which help when his sx are at their worst, which could speak to the potential inflammatory process. I wonder about getting him back to his doc for a potential dose pack to address this?

Thats a good point about his loading pattern in standing. If anything, I would say that he sits in more anterior pelvic tilt than posterior. We have worked on some supine PPT activities such as bridging, squatting with PPT supine PPT. But I could definitely work on more of that, specifically in standing since that is much more functional for him and relates to his sx.

I honestly have not done any basketball specifics because I have been trying to calm things down before we build into functional (work) activities or recreational (basketball) activities. He likely would still be unable to do layups even without jumping because of the extensive stride length it requires, which is significantly symptomatic for him.

Thanks again for your input! It has given me some new things to look at when I see him next week!

[Caseylburruss]

Hi Katie,

Wondering how much you have looked into his L hip? Things that jumped out to me where the swing test, antalgic gait, axial load trauma injury while in a knee flexed position wondering what your thoughts are on that? What does his hip ROM look like? Wondering if there is a possibility of hip instability and irritation to the neural structures?

[Katie Long]

Hi Casey,

I have looked into his hip a decent amount. He denies sx with palpation of his gluteals. He has limited hip extension ROM and hip PA is limited (symptom-free). His hip flexion is WNL** with reports of thigh tightness (not his pain, unless his sx are overall increased/irritated). **As long as his knee is bent, when his knee is straight, it is symptomatic, i.e. SLR testing. Hip ER/IR is limited bilaterally (symptom-free).

Functionally, he has decreased pain during SL squat with manual cueing for increased hip ABD activation. I think the antalgic gait is directly correlated to his disliking of a terminal knee extension position during IC of gait, therefore he is decreasing his stride length.

Does this help?

Thanks so much for your reply!!

[Jennifer Boyle]

Hey Katie!
This is for sure a challenging case and I am happy you brought it up for discussion. I know your primary dx reflects something dural in nature and I have just seen Kyles post about it potentially having a lumbar component to it. What are your thoughts on bringing him into lumbar flexion and comparing his sx with this to his sx with lumbar flexion with his left leg on a stool (to allow hip and knee flexion) to put some slack back into his neural tissue? This is something I have used to determine how much of the pie is dural vs lumbar and may help you adjust treatment time delegation to each component. I think this may be one of the times you can utilize traction as a means of taking some of those loading stressors off for that tissue to have a change to heal without constant irritation. I’ll attach an article that I used for my case series presentation last year for our lumbar unit. I think he hits the inclusion criteria (pending his ODI score). I hope this helps!

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[Katie Long]

Hi Jen,

Thanks for the reply and the article! I appreciate it. Yes, I forgot to include that he does have more lumbar flexion ROM with his L LE in knee and hip flexion. I have had him working on some declined plinth flexion with his LLE slacked and he reports no provocation of his posterior thigh sx, only mild “pulling” in his low back.

After reading yours and Kyle’s posts, I definitely think I am going to try some lumbar traction with him. See if I cant get some decreased stress to the disc and maybe even some synovial fluid movement to aid in any lingering inflammatory process still occurring. Pending success with that, I will try to teach him some self-distraction for his long work shifts where he is on his feet for prolonged periods of time.

Ill keep you posted on how it goes!

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