Initial Work Injury Physiotherapy Assessment

HOPC

• 34yo male presented with acute R sided LBP following a lifting injury at work on 12/05/2026. Felt a sudden 'twinge' in the R lumbar region while lifting a 22 kg crate from floor to waist height. Reviewed by GP on 13/05/2026; prescribed ibuprofen 400 mg PO TDS and paracetamol (Panadol®) 1,000 mg PO QID PRN. No radicular Sx, P&N, or numbness. Cauda equina screen negative.
• Aggs: Lx flexion, lifting > 5 kg, sitting > 30 mins, transitioning from sit to stand. Eases: Heat pack, walking short distances, supine lying with knees flexed, analgesia.
• 24-hour pattern: Stiff and sore on waking (NPRS 5/10), eases within 30 mins of gentle movement. Aches by late afternoon (NPRS 6/10). Sleep undisturbed once comfortable in R side-lying with pillow between knees.

Radiology

• Lumbar Spine X-ray (13/05/2026): Normal vertebral alignment and disc heights preserved. No acute fracture or pars defect.

Past Medical History

• Mild asthma, managed with salbutamol (Ventolin®) 100 mcg INH PRN. Previous L ankle sprain in 2021, fully resolved.
• NKDA.

Employment

• Warehouse Storeperson
• Westralia Logistics (Transport and Warehousing)
• Regular hours: 38 hrs/wk (07:00 to 15:06, Mon-Fri)
• Duties: Manual handling and palletising stock (up to 25 kg), operating a forklift, scanning inventory, prolonged standing and walking on concrete floors.
• Current work capacity certificate: Fit for restricted return to work from 13/05/2026 to 27/05/2026. Lifting max 5 kg from waist to chest height only. Avoid repetitive bending and twisting. Alternate sitting/standing every 30 mins. No forklift operation.
• Case Manager: Sarah Jenkins (WorkCover WA - Giovenco Insurance, Claim #WC2026-88412)
• On modified hours: No, continuing regular 38 hrs/wk.
• On modified duties: Yes. Currently assigned to dispatch office performing administrative inventory control, barcode label printing, and light packing (< 5 kg) at an elevated bench.
• Return to work plan in place: Stage 1 RTW plan active (14/05/2026 to 27/05/2026), coordinated with workplace RTW coordinator (Mark Evans) to maintain full hours on light duties with gradual upgrading of lifting capacity following physiotherapy review.

Social History

• Lives in a single-storey house with wife and 4yo son. Non-smoker, social ETOH (2-3 standard drinks on weekends). Normally plays social touch rugby weekly and walks the dog daily.

Goals

• Short-term (2 weeks): Reduce baseline pain to ≤ 2/10 NPRS, sit comfortably for 60 mins, and upgrade lifting capacity to 10 kg to resume forklift operation.
• Long-term (6 weeks): Return to full pre-injury work duties (lifting up to 25 kg) and return to social touch rugby pain-free.

Objective

• Observation: Slight antalgic gait with reduced trunk rotation. Flattened lumbar lordosis in standing. No visible bruising or swelling.
• Lumbar AROM: Flexion to mid-shin (reproduces R LBP 6/10, guarded movement); Extension 15° (R LBP 4/10 at end of range); R lateral flexion to fibular head (R LBP 4/10); L lateral flexion to knee joint line (tightness R flank, 2/10).
• Neurological/Neurodynamic: Slump test negative bilaterally. Straight Leg Raise (SLR) to 80° bilaterally, hamstring tightness only. Lower limb myotomes, dermatomes, and reflexes intact and symmetrical.
• Palpation: Hypertonicity and tenderness over R lumbar erector spinae and R quadratus lumborum. Central and unilateral PAIVMs: Hypomobile and painful (5/10) at R L4/5 facet joint and L4 central PA.
• Functional: Squat limited to 1/2 depth due to apprehension and R lumbar tightness. Sit-to-stand performed with hands pushing off thighs.

Treatment

• Education: Reassured regarding the benign nature of acute mechanical LBP and the absence of structural damage on X-ray. Advised on pacing strategies at work, ergonomic posture, and the importance of staying active within pain limits.
• Manual Therapy: Soft tissue massage and myofascial release to R lumbar erector spinae and QL (10 mins). Grade II-III R unilateral PA mobilisations at L4/5 (3 x 60 secs), improving AROM flexion to distal third of tibia.
• Active Therapy: Practised pain-free pelvic tilts, supine lumbar rotations, and hip-hinge patterning with dowel rod to offload lumbar spine during lifting tasks.
• Home Exercise Programme (HEP):
  1. Supine knee rolls: 10 reps, 3 sets, 3x/day.
  2. Posterior pelvic tilts in crook lying: 10 reps (5 sec hold), 3 sets, 3x/day.
  3. Cat-camel stretch: 10 reps, 2 sets, 2x/day.
  4. Hip hinge drill (unloaded): 10 reps, 3 sets, 2x/day.

Assessment

• Acute R L4/5 facet joint sprain with associated secondary R lumbar paraspinal muscle spasm.
• Differential diagnosis: Lumbar discogenic pain (L4/5).
• Baseline assessment completed today; immediate intra-session improvement in lumbar flexion AROM and reduced guarding following manual therapy and movement retraining.
• Mild movement apprehension (kinesiophobia) regarding lumbar flexion and lifting.

Plan

• Manage acute pain and muscle spasm, restore full pain-free lumbar AROM, and progress functional lifting mechanics to facilitate a graded upgrade in work duties.
• Review in 4 days (19/05/2026 at 09:00 AWST).
• Reassess lumbar AROM and functional squat, repeat manual therapy to R L4/5 and paraspinals, review HEP compliance, and introduce loaded deadlift/lifting drills (2-5 kg) and core stability exercises (e.g., bird-dog).
• Patient scheduled for GP review on 26/05/2026 for WorkCover certificate update.
• Complete and submit Initial WorkCover Physiotherapy Report to GP (Dr Alan Grant) and Case Manager (Sarah Jenkins) by 16/05/2026.