LBP from Simon Liu

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X.L was a 28 yo guy presented to CPC with LBP. He has a history of back injury 3 month ago. He was moving furniture at home with another guy. When he tried to lift a washing machine with his friend, he felt something “pulled” in his lower back. Since then he had dull aches (2-3/10) in L his lower back near L5/S1, L buttock and his L lateral leg. He saw a GP days after the injury and was given voltaren rub which doesn’t help too much (he refused oral analgesia from the GP). Now his L leg pain has resolved but his L lower back and buttock pain were 3/10 constant dull ache. Walking, sitting still and standing for more than 30 minutes makes his pain worse(4/10, take 20 min to reduce back to 3/10 if he moves or rest). Lifting his foot off the floor either side increases his pain to 4/10).

On Palpatoin: Tender in L L5/S1, SIJ and L buttock (mid point of piriformis).

Fx test: lifting foot off floor (putting pants on): R=4/10, L=3+/10 sharp

AROM: Mainly restricted in Lx extension (30 R1, 40 º P1)

Combined mvt: pain 4/10 sharp L flexion + extension

Special tests for SIJ:

Tortion tests negative, destraction/compression negative, posterior shear test negative,
ASLR: L positive 2/10 dull, R positive 3/10 dull pain in the L lower back (improve with compression on R side, otherwise no change with any added technique) and buttock, obs: poor initiation of R ASLR.

Hip: reduced piriformis length on both sides. Positive quadrant test on both side and negative fabers test.

PPIVAM in L4/5 and L5/S1 area: reduced fl’x in L4/5 and ext’n in L5/S1
PAIVM: reduced PA glide on L5/S1, reduced L unilateral glide on L5/S1 with pain.

Dx: L4/5 closing pattern
Classification: mechanical
Stage: chronic

First treatment for him was a GIII L unilateral glide on L4/5 for 30 second then 1 min since patient improve his pain score by 1 in Fx tests( however, during treatment, patient was complaining pain in lateral side of his lower leg). Home ex was heat pack 5 minutes for every 2 hours.

Second treatment: patient was due back in 2 days and c/o walking was more aggravating (reduced onset time) and the dull ache in lateral side of his left leg had come back since last treatment. Fx tests and ASLR are still same as before the first treatment. STM and H/R for piriformis on both side was given, improvment in piriformis length was noted, a GIII PA glide on L5/S1 for 30 second and then progress to GIV for 30 second. Pain score from ASLR was improve by 1 in both sides. Fx test has improve by 2 in pain score. HEP is active extension in Lumbar spine in standing (2-3 times, 5-10 reps) and piriformis stretch.

Now my question is based on these findings, can anyone come up with a different diagnosis and what other tests do you think needs to be done? I am treating this guys signs and symptoms at the moment which appears to be OK but I dont have a good understanding of the mechanism of injury and the pathology developed, I will progress my PA glide in next treatment section with him but any suggestion for treatment?

Please discuss away, thanks

Simon