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I apologize in advance, this is kind of long.
Last week I did an eval for a 32 y/o female crossfit athlete that came into the clinic through direct access for low back pain and numbness in bilateral LE. On the body chart she marked pain in her lumbar spine and down the posterior and lateral aspects of her lower extremities with pins and needles in her feet. When I first saw the body chart, I definitely had an “oh no” moment and wanted to make sure that I ruled out cauda equina during the subjective and objective exam. Although her presentation was not what I expected based on her body chart. When we started talking she told me the pain initially started on 6/25 while she was lifting during a crossfit workout and she pushed through it. The pain got worse throughout the night and for 3 months interfered with doing ADLs and working. She was unable to pick up the laundry basket or her 3 y/o daughter due to the pain. Then she told me that the pain randomly improved significantly last Friday on 9/23 (she had all the dates memorized). I asked her if she did anything different, and she told me not really that she drank more water and tried doing a psoas release in sidelying that she saw on youtube. Since then the pain has been better, 1/10 at most, and she is able to pick up the laundry basket and her daughter without an increase in pain. She also stated that the numbness in her toes she had before she hurt her back and gets it with sitting for long durations but improves after getting up and moving around. She denied any saddle parathesia, bowel/bladder complications, and has not noticed any changes in strength in the lower extremities. She did have an MRI which found loss of disc height at L5-S1 around 4 mm and posterior disc protrusion which “slightly abuts the bilateral S1 roots without any displacement”. She also had an x-ray which she states they did not find anything.
She told me she almost didn’t come into the clinic since her pain was better. I was a little hesitant on how I wanted to do the exam after the subjective since I wanted to assess for what reproduces her pain, but I didn’t want to flare up her pain again. I think I was a bit more cautious with the exam because of that and forgot to test more functional movements for her like squats and deadlifts. I reassured her that we would look at that more at the following visit since she did ask about that. For a little more background on the objective, I did the neuro exam, her DTRs were normal, negative clonus, sensation was intact with no difference side to side, and no fatigable weakness was noted. Her SLR was negative, but she had a positive slump with reproduction of pain in her low back with slouching and looking down, but no increase when straightening either leg. What was interesting to me was that when I did palpation, she had pain with provocation testing to her lumbar spine which reproduced her pain in the low back, and palpating down the sciatic nerve pathway through bilateral lower extremities also recreated her low back pain, but did not cause pain down the leg. I was confused by this, but thought it might be due to increased sensitivity of the nerve? Or it possibly could be that her lower back was aggravated already from the exam, or both. I would be interested to hear what others think of this. She also had 4/6 (+) SIJ tests and reproduction of low back pain with flexion.
So, I think she has a few different things going on that contributed to her pain. My mind was definitely all over the place during this encounter. Based on everything, I think she likely irritated the S1 nerves when she was lifting causing the pain she marked in the body chart diagram, she might have lumbopelvic instability from having her daughter (she stated to me that she wants to work on more core exercises), and may have some nerve compression along the pathway. When doing the palpation, I did notice she had some myofascial trigger points and she does still get the numbness in bilateral toes with sitting for long durations. I did educate her on cauda equina signs and symptoms to look out for just in case her symptoms change. Overall, it was definitely a challenging encounter and I would be interested to hear what others would have done differently, or thoughts on what else could be contributing to her symptoms.
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Thanks for such a thoughtful reflection Emily! I have some thoughts for you.
It can be initially disconcerting when you see a body chart with bilateral paresthesia. That’s why having a thorough and complete neurological exam is so important! It sounds like you did such examination (both subjective and objective) and cauda equina syndrome is much less likely on your list.
It is possible to have bilateral radicular pain – I would next ask about the behavior of symptoms between the two legs. That can also help you determine is this a central problem (such as a central herniation causing bilateral nerve root compression) or a peripheral compression (such as at the posterior hip or ischial tuberosity) separately in each leg. Do they always get numb together at the same time? Is the location of paresthesia the same on each leg? It is always related to lumbar flexion positions?
The palpation to the sciatic nerve recreating LBP – I think that speaks to the mechanosensitivity to the nervous system. The connective tissue of the nervous system structures can especially become sensitive to both mechanical (eg compression) or chemical (eg inflammation) stimuli after injury. That can affect both the peripheral and central parts of the nervous system, and it can also affect the environment around the neural structures or where they innervate (which may relate to the trigger points you found).
Would she be a candidate for incorporation of a McKenzie progression or at least have that as a starting foundation for her plan of care?
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Sounds like a great start!
Keep us posted on your reassessments and further thoughts.
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