Weekend 4 Case Presentation

[Taylor Blattenberger]

Please read the attached info and answer the following questions:

1) Reading only the subjective examination please list your primary hypothesis as well as your top 3 differentials

2) Does the objective information follow a familiar pattern? If so, what are your primary *’s? If not, what information is inconsistent?

3) What other objective tests would you have performed with this individual?

4) Given the patient’s current presentation, what is the role of physical therapy in this case?

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[helenrshep]

1) Hypotheses after subjective: lumbar radiculopathy (primary, L3/4), facet referral, hip pathology, disc (L3/4) referral

2) Pattern – yes, still seems to be L3/4 radiculopathy, however, it is interesting that SLR was negative

3) Possibly slump (or prone Ely’s?), quadrant testing, repeated motions (does repeated extension diminish the tingling?)

4) Given there are no significant red flags, I would feel comfortable treating him. I would address the lack of hip extension, possible nerve glide, address quad weakness (mini squat). I’d be curious to know more about what makes his symptoms peripheralize/centralize – were you able to bring them on or get them to go away with anything you did? He seems to be fitting into the “specific exercise” category (pending thoughts on centralizing/peripheralizing).

[Steven Lagasse]

1) Reading only the subjective examination please list your primary hypothesis as well as your top 3 differentials
Primary Hypothesis:
Radic L3/4

Differentials
– Facet L3/4
– Femoral Nerve Entrapment
– Extra-articular hip

2) Does the objective information follow a familiar pattern? If so, what are your primary *’s? If not, what information is inconsistent?
Appears to fit a pattern for L3/4 Radic

Primary *’s
– Quad weakness
– Decreased DTRs
– N/T in a dermatomal pattern
– Repeated Extension decreasing pain/symptoms

3) What other objective tests would you have performed with this individual?
– Slump
– Ely’s
– Hip PAM
– Maybe Quadrant

4) Given the patient’s current presentation, what is the role of physical therapy in this case?

Capitalize on the fact that he is feeling better from the steroid pack. Focus on performing movements that continue to decrease his pain/symptoms. His goals are stair climbing, and yard work that requires flexion positions. Begin incorporating activities to help with quad strength and slowly start to weave in flexion based movements once they’re not too provocative.

[awilson12]

1) Primary and top 3 differentials:
– Primary hypothesis: L4 radiculopathy
– Differential diagnosis: mid lumbar facet arthropathy, lumbar multifidus referral, peripheral nerve entrapment- femoral/saphenous

2) Doesn’t completely fit expected clinical pattern but most consistent with L3-4 radiculopathy
o Asterisks: subjective report of n/t and weakness, myotomal, dermatomal, and reflex changes in L3-4 nerve root distribution
o Inconsistent findings: no aggravation/alleviation with lumbar range of motion (with initial aggravating factors seemed more extension sensitive so would expect this to change symptoms), negative SLR

3) Lumbar quadrants, sustained and repeated motions; interested in quality of lumbar AROM screen

4) With no specific provocation during the exam, it is difficult to identify original contributing factors to LE symptoms; that being said I don’t think that PT is an inappropriate place for this patient and because of current decreased irritability can probably progress faster to return to function

[lacarroll]

1) Reading only the subjective examination please list your primary hypothesis as well as your top 3 differentials
– Primary: L3/4 Radiculopathy; other top 3: L3/4 Facet, Hip pathology, myofascial strain

2) Does the objective information follow a familiar pattern? If so, what are your primary *’s? If not, what information is inconsistent?
– Seems to follow lumbar radic pattern: symptoms down the leg, weakness, paresthesias, decreased reflexes along L3/4 pattern; I would think that SLR would have been positive

3) What other objective tests would you have performed with this individual?
– Slump, prone knee bend, swing test

4) Given the patient’s current presentation, what is the role of physical therapy in this case?
– I think that there are areas that can be improved, especially since he has such a long history of back pain. He has functional goals like stairs and getting back to his yard work, so I think that this is an opportunity for us to come in and be able to educate and teach this man to move more efficiently in order to prevent flare ups in the future.

[Taylor Blattenberger]

Thanks a lot guys! Great thoughts about neurodynamics, especially as it pertains to a possible peripheral nerve pathology. Hopefully I can shed some more light on these and other questions you might have tomorrow!

[Author]

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