Recently, a fellow physical therapist and friend came to me for some guidance regarding a case he was having difficulty managing. Below is a synopsis of his initial evaluation. After reading his initial evaluation, please write down a few notes or comments (positives, negatives, things you may have done differently, or further questions). Following his evaluation, I provided my response to certain questions and treatment ideas to provide further insight into his case.
Therapist Initial Evaluation (my friend):
Electric shock from the right low back to distal hamstring with a variety of different movements. Prior injection resolved S1 distribution numbness.
-Spine: normal spine curves
- Hips: narrow, symmetrical hips
- Knee/ankle: genu varum
-Tenderness and tightness into piriformis
Functional movement testing:
-Inline lunge: increased hip flexion, but movement was painfree
-Hurdle step: R lower extremity in WB- poor hip motor control
-Gait: no pelvic innom. rotation
- Squat: inc hip flexion, HS avoidance, R sided lumbar pain "catching"
- SL squat: medial collapse, 'shakiness bilat'
- SL stance: R sided LOB
- SL step down: avoided WB through R via trendelenburg
- Elbow flexion iso #8: paraspinal recruitment thoracic/lumbar, no TA activation
-Bent knee fall out: min TA activation
-Hooklying marches: mod TA activation; limited hip flexion to 105 deg because it will trigger pain
-ASLR: tight HS, no neural symptoms
-PSLR: 50% of WNL with back pain
Muscle length testing:
HS 90/90: R 145, L 155
+ Thomas B, inc sx
L Ely's + at 110 knee flexion, R WNL
+ ITB R, WNL L
Passive range of motion:
Hip 110% WNL with catch during full flexion
Overall Assessment: Pt is a 45-year old male presenting with chronic, insidious onset of low back pain with R sided, electric shock sensation down back of leg and into distal hamstring. Pt has movement impairments with hurdle step (R WB poor hip motor control), gait with minimal pelvic innominate rotation, SL squat with medial knee collapse. Additionally he had frequent R lumbar spasming reported during exam. Pt has functional limitations in running, rowing, and ADLs, sleeping.
Initial HEP prescribed: L thomas test stretch, L hip flexor Stretch, hooklying isometric marching
My Response to Evaluation:
1) From his symptom description and testing, we know he has some level of nerve irritation. I would perform a SLUMP test. If positive, neural glides could be a great treatment for symptom relief.
2) How is his hip mobility, hip IR/ER range of motion and end-feel? Commonly limited hip mobility places stress on the lumbar spine due to improper loading through the hip joints (from his SL squat and other functional movements, he appears to be offloading his right hip).
3) How is his thoracic spine mobility?
4) The patient appears to have increased hip flexion with various movements. Be sure this is not actually early/excessive lumbar flexion. (See link to a post I wrote on hip flexion vs. lumbar flexion
5) The patient appears to have poor coordination between the lumbar spine and hip joints. I would look at more basic movements, such as hand heel rocks (butt to heels in quadruped) to assess lumbopelvic disassociation and general spinal mobility.
6) How is lumbar extension? Many people lack lumbar extension due to prolonged flexion (see point 4 above) and become sensitive to that movement. Retraining lumbar extension throughout repeated loading is often beneficial for range of motion, mobility, and nerve irritation.
My Response Assessment:
Incorporate further mobility exercises for the hip and thoracic spine (likely). Stretching (as he initially prescribed) can further excite nerve symptoms and cause irritation. Additionally, I would incorporate more neural tensioning exercises for symptom management. Since the nerve is irritated, add the recumbent bike or low level total gym for nerve nutrition and proper loading through the hip. From a manual therapy perspective, I have seen good results with lateral hip mobilizations using a mobilization belt. This can improve hip mobility and reduce neural tension. Finally, basic exercises like Cat/Cow are good for emphasizing thoracic extension and are a precursor for lumbopelvic mechanics.
-Jim Heafner PT, DPT, OCS