Clinical Case #1: James

(1)

Princeton Spine & Joint Center, Princeton, NJ, USA

James is an 84-year-old retired ironworker. He is referred by his primary care provider. James has a 10-year history of intermittent lower back pain that he says sometimes refers into the bilateral buttocks. The pain has been slowly getting worse in the last 2 years and finally he told his primary care doctor about it because the pain has been preventing him from going for walks, which is something he loves to do. He can walk about a block before the pain starts to get bad, and at a block and a half, James feels that he has to sit down because of the pain. The pain is much worse with standing and often he has no pain with sitting.

James’ back feels very stiff in the morning, but he does some gentle stretching in the morning and that serves to get his back feeling looser and ready to start the day. He rates the pain while sitting as a 1/10 on VAS. He rates the pain as 8/10 on VAS after walking a block and says that the pain will get to a 10/10 if he continues to push it with walking. James says that one time he walked “too far” and ended up having to sit on the side of the road until the pain passed so that he could walk back home.

James takes Tylenol for his pain and says that it used to help but it does not anymore. He sometimes takes Aleve and finds it helps a little more than the Tylenol used to but he doesn’t like taking medications. He has not done any physical therapy for the pain and has not had any other treatments, including no acupuncture or chiropractic care. He has had no imaging studies of his lower back.

In general, other than his back pain, James is in good medical health. He has high cholesterol and hypertension but these are managed well with medications. He has no history of cancer. James does some stretching in the morning for exercise. He has been doing the same stretches for about 20 years. He learned the stretches from his cousin who is a personal trainer. Besides his morning stretches, James does not exercise regularly but he does enjoy walking. It is his inability to walk due to the pain that has driven James to seek help for his lower back pain. James denies any radiating leg pain and denies any numbness, tingling, burning, or weakness in the legs.

Physical Examination

On physical examination, James is 5′10 in., 185 lb. His gait is non-antalgic. He walks slightly stooped forward and has some mild thoracic kyphosis. He has full, pain-free lumbar trunk flexion but is restricted in lumbar extension and has pain with bilateral oblique lumbar extension.

James has good muscle tone and 5/5 strength in the lower extremities. He has a negative straight leg raise bilaterally, 2+ reflexes in the patella and Achilles, and no sensation deficits. His lumbar paraspinals are not tender and neither are his sacroiliac joints. He has a negative FABER test, which is a provocative maneuver designed to illicit sacroiliac joint pain. His hip flexors and knee extensors are very tight with passive range of motion. His hips have slightly restricted range of motion but no pain is produced with passive movement.