Osteopath Initial Consult

Initial Consultation

Practitioner: Thomas Vance, DO (MP)

Created: 14/05/2024 09:30

Last updated: 14/05/2024 10:15

Presenting Complaint

S: Localised R lower back pain (L4-S1 region) and R superior gluteal region.

Q: Constant dull ache; sharp catching pain with sudden transitional movements.

I: Current 4/10; worst 8/10 upon waking or lifting.

R: Occasional dull referral into R posterior thigh (stops above knee). Nil paraesthesia or numbness.

T: Intermittent, worse in early morning (stiffness lasts ~20 mins) and end of workday.

AGG: Prolonged sitting (> 30 mins), lumbar flexion, lifting from floor, transitioning sit-to-stand.

REL: Gentle walking, heat pack, lying supine with knees flexed, ibuprofen.

Complaint History

ONSET: 3/52

MOI: Insidious onset the morning after heavy gardening and lifting soil bags.

CHRONO: Static; initial acute spasm subsided after 4 days, but baseline ache persists.

PREV TTT: Remedial massage 1/52 ago (temporary relief for 24 hrs); seen by GP.

PREV INVEST/IMAGING: Lumbar spine X-ray (2021) showed mild L4/5 disc space narrowing; nil imaging for current episode.

Past Medical History

PREV EPS: Similar R LBP episode 2 yrs ago following long-distance drive; resolved within 1/52 with rest.

ACC/INJ: Grade 2 R ankle inversion sprain (2018); minor rear-end MVA (2015) with mild whiplash, fully resolved.

ILLNESSES: Mild asthma, essential hypertension.

MEDN: ibuprofen (Advil®) 400 mg PO PRN; salbutamol (Ventolin®) 100 mcg INH PRN; ramipril (Altace®) 5 mg PO OD.

OPERATIONS: Laparoscopic appendicectomy (2012).

LEISURE: Recreational gardening, walking dog (3 km daily), recreational swimming (1x/wk).

Goals

SHORT: Reduce baseline pain to < 2/10 and sit comfortably at work desk for > 1 hr.

INTERMED: Resume gardening and household lifting without pain flare-ups within 4/52.

LONG: Maintain spinal mobility and core strength to prevent future recurrences.

Assessment

EXAMINATION: Mild antalgic lean to L; flattened lumbar lordosis; R pelvic tilt (ASIS low on R). Lx AROM: Flexion limited to mid-shin (reproduces R lumbosacral ache), Extension 10° (sharp local catch R L4/5), L SB 25° (tightness R QL), R SB 15° (local pain). Neuro: L2-S1 myotomes, dermatomes, and DTRs intact and symmetrical B/L.

RESTRICTED: Lx extension, R side-bending, L4/5 and L5/S1 PA accessory glide, R hip internal rotation.

HT: Hypertonicity noted in B/L lumbar erector spinae (R > L), R quadratus lumborum, R gluteus medius, and R piriformis.

PALP: Tenderness over R L4/5 and L5/S1 facet joints, R iliolumbar ligament, and R PSIS.

SPECIAL TESTS: Kemps test: +ve on R for local lumbar pain. SLR: 75° R (hamstring tightness only, nil radicular pain), 80° L. Slump test: -ve B/L. Thigh thrust and Gaenslen's: -ve B/L.

Diagnosis

DX: Acute-on-chronic R L4/5 facet joint sprain with secondary myofascial hypertonicity.

WORKING DX: Mechanical low back pain (R L4/5 facetogenic dysfunction).

DDX: L4/5 posterolateral discogenic pain, R sacroiliac joint dysfunction, iliolumbar ligament sprain.

INVEST: Nil indicated at present; review need for Lx MRI if neurological deficits develop or nil improvement in 4/52.

Treatment

ST: Longitudinal and cross-fibre soft tissue massage to B/L lumbar paraspinal muscles, R QL, and R gluteal musculature.

ARTIC: Rhythmic lumbar flexion/extension and rotational mobilisation (Grades II-III) to L1-S1; R hip circumduction.

MET: Post-isometric relaxation to R QL, R iliopsoas, R piriformis, and L4/5 opening (ERSL4).

HVLA: Lx roll manipulation targeting R L4/5 gapping (audible cavitation achieved, well tolerated).

DN: Dry needling to R QL and R gluteus medius trigger points (0.30 x 50 mm needles, local twitch response elicited).

Treatment Plan

TTT FREQ & DUR: 1x/wk for 2/52, then review with aim to space to fortnightly over 4-6/52.

ADVICE: Apply heat pack 15-20 mins in evenings; take micro-breaks from sitting every 30 mins; avoid heavy lifting and sustained stooped postures in garden for next 7 days.

REHAB: Supine single knee-to-chest (3 x 30s B/L), pelvic tilts (2 x 10), cat-camel mobility (2 x 10), supine piriformis stretch (3 x 30s R). Performed 2x daily.

Further Information

Informed consent obtained prior to examination and treatment (including HVLA and DN). Patient warned of potential 24-48 hr post-treatment soreness and advised to maintain hydration. Red flag symptoms (cauda equina syndrome: saddle anaesthesia, bladder/bowel changes, progressive lower limb weakness) discussed; advised to attend ED immediately if these occur. Re-evaluated post-treatment: Lx extension improved by 50% with reduced catching pain.