Physiotherapy Initial Assessment

Goals - Return to 5 km parkrun pain-free and sit at work desk for > 2 hours without discomfort.

Subjective

PC Right-sided lower back pain (LBP) with intermittent right buttock ache.

HPC

3/52 history of acute-onset right LBP triggered whilst lifting a heavy plant pot in the garden. Felt an immediate twinge at the right L4/5 level. Stiffened up significantly the following morning (NRS 7/10). Symptoms have gradually improved over the past week to a baseline ache of 3/10, though sharp catches persist on bending.

Neuro - Nil P&N, numbness, or weakness in BIL lower limbs.

Aggs - Lumbar flexion, sitting > 30 mins, putting on socks, lifting.

Eases - Walking, gentle movement, heat pack, ibuprofen.

24hr - Stiff and sore first thing in the morning for ~30 mins. Eases with movement during the day, aches by evening after prolonged desk work.

Hx injury - Left ankle lateral ligament sprain (2019), fully resolved. No previous episodes of disabling LBP.

Social Hx - Accountant. Works from home 4 days/week. Uses a non-adjustable dining chair and works directly off a laptop on the dining table without an external monitor or keyboard. Sits for ~7 hours/day.

PA - Normally runs 5 km 2x/week on road and attends a 45-min spin class 1x/week. Currently ceased both due to pain; walking dog 20 mins daily instead.

General Health

Sleep - 7 hours, good quality. Wakes 1x if turning quickly in bed, settles immediately.

Stress - Low

Smoke - No

Drink - Yes

PMH - Mild asthma (well controlled). Otherwise fit and well. Nil Hx of Ca, steroid use, or unexplained weight loss.

DH - Ibuprofen 400 mg PO TID PRN, salbutamol 100 mcg INH PRN. NKDA.

Red Flags - Nil night pain, persistent unremitting pain, sweats, fever, or feeling unwell. Nil saddle anaesthesia, bladder/bowel dysfunction, bilateral P&N, or gait disturbance.

ICE

I - Believes he has "slipped a disc" from lifting with poor technique. C - Worried that running or bending will cause permanent spinal damage. E - Wants a clear diagnosis, reassurance on safe activities, and exercises to speed up recovery.

Investigations - Nil to date.

Objective

Obs: Normal lumbar lordosis, mild antalgic shift to left on standing flexion. Palpation: Hypertonicity right lumbar paraspinal muscles. Tender over right L4/5 facet joint and QL. Active ROM Lumbar:

• Flexion: Fingertips to mid-patella, reproduces right LBP (4/10).
• Extension: 75% expected range, mild end-range stiffness.
• Side Flexion: Left 100% (pulling sensation right flank); Right 75% (local pinch right L4/5). Neuro: SLR 80 degrees BIL (hamstring tightness only). Myotomes L2-S1 5/5 BIL, dermatomes intact to light touch BIL, reflexes (patellar/Achilles) ++ symmetrical. Functional: Squat to 90 degrees knee flexion, guarded lumbar spine.

HEP:

1. Supine knee rolls
2. Pelvic tilts
3. Cat-camel stretch
4. Glute bridges

Analysis

Presentation consistent with recovering acute mechanical LBP / right lumbar facet joint sprain with secondary paraspinal muscle guarding. No radicular features or red flags. Ergonomic setup at home likely contributing to persistent low-grade symptoms. Good prognosis with reassurance, ergonomic modifications, and graded reactivation.

Plan

FU 2 weeks Rv Lumbar ROM, HEP compliance, ergonomic adjustments, and readiness for walk-run progression.