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Mechanical Low Back Pain

Physician's Findings and Referral

Larry Lumbar, a 47-year old feed truck driver, came to the family physician's office complaining of a low back pain. He described the pain as a "dull ache and sometimes feels pain down the back of his right leg."

He considers himself in good health, but upon questioning states that he has had occasional back pain and stiffness "for years," usually brought on by heavy lifting.

On this occasion, the pain began when he lifted a 50-pound feed sack, pivoted to his right and bent down to drop the sack onto a dolly. He noticed immediate discomfort in his low back which progressed to stiffness and pain over 24 hours. When questioned, he states that he also has some pain, numbness and tingling in the back of his right thigh. He didn't sleep well last night and took the day off work today.

He states that he has had no bowel or bladder problems and has no weakness of the leg.

Further history-taking shows that the patient is married and has two adult children. He has insurance through his workplace which covers hospitalization, but no outpatient procedures or office visits. He wonders if worker's compensation will pay for his medical bills (this injury).

No one in this family has problems with his or her back.

He has sought care from time to time for back pain and occasional respiratory infections. He has never been hospitalized and takes no medication.

A physical examination shows that his blood pressure is 126/82, pulse is 80, weight is 243 pounds, and he is 5'11" tall. No abdominal bruits.

A regional exam of his back and a neurologic exam demonstrate the following: he is able to walk normally, but he does get onto the exam table with a great deal of caution. There is a broad band of discomfort in the low back, somewhat more on the right than on the left. There is no point tenderness over the spine or the SI joints.

He is able to walk on his heels and toes without difficulty, and he can do a single squat and rise without evidence of muscle weakness. The knee and ankle jerks (reflexes) are normal and symmetric. The toes are downgoing in response to stroking the plantar footpad. He is able to recognize the touch of your reflex hammer symmetrically on the medial, dorsal, and lateral aspects of the foot. Straight leg raising shows that he can raise his leg to about 75 degrees on the left with only minor stiffness in this back. However, at about 60 degrees of straight leg raising on the right he complains of pain in his back, shooting down the right leg.

It was decided not to perform any specific laboratory tests.

Referral

The patient's condition was reviewed, alternative possibilities were discussed, warning signs pointing to when he should call or come back immediately were also discussed, and, lastly, the patient was referred to a physical therapist for further evaluation and treatment.