PRESENTATION

A thirty two year old healthy looking male with no past health problems of significance complains of pain in the right upper lumbar region. The pain is sharp and stabbing and radiates downwards and around the groin to the scrotum and upper medial thigh about two inches below the hip. The pain has been present since waking this morning, and comes and goes but is never absent for more than ten to fifteen minutes at a time. The onset and offset of pain is not related to activity or postures. The patient ran a marathon two days earlier.

The patient saw his physician who prescribed tylenol and naprosyn and physical therapy.

On examination the patient was in no pain at the time of the examination.

Observation

Medium build, healthy with no excess weight. No postural deformities or deficits, no bruising or muscle deficits, no atrophy in the trunk or legs. No congenital abnormalities.

Spinal Scan Examination

Full range painfree movements with normal end feel. No neurological deficit. Compression and traction painfree. Straight leg raise and prone knee flexion were 90 degrees bilaterally and full range respectively with neither producing pain the slump test was negative. PA pressures are a little tender over T12 and L1 with some increased resistance to movement from hypertonicity.

Biomechanical Examination

Passive intervertebral movement tests at T12/L1 demonstrate some hypomobility into flexion and left side flexion. Passive accessory (arthrokinematic) tests were negative. The right L5/S1 joint was hypermobile into extension and there was mild instability into right rotation at L5/S1. The right hip was hypomobile into extension.

DIAGNOSIS AND MANAGEMENT

What other information or clinical tests do you need or are you ready to generate and diagnosis and management plan. E mail me for more information and I will put it up on this page in a week or so. The solution in about two weeks.

I changed the process a little. I was going to post all of the questions on the site with their answers but in the end decided to reply to each question individually. I did this for two reasons, first it was easier and second it is more realistic, you only get answers to the questions that you ask.

While the pain was proximate to running the marathon, it was some time later. If the patient had torn a muscle or done significant damage to a spinal segment, the pain would have been experienced much earlier. Pain modulating systems are generally not so good that they can abolish pain for two days. It is possible that the patient may have managed a low-level injury that was sub-clinical and then some minor provocation imposed on the injury made it symptomatic. Lets go with that for the moment and look at some of the other features.

The pain was not typical musculoskeletal pain. Some patients do complain of stabbing pain but it is an unusual descriptor in North America but less rare in England and some other Commonwealth countries. The pain was unpredictable and not related to physical stresses or their relief Although one query I had concerned this the paricipant asked could the patient jump up and down on the leg. The answer is that set up the pain which lasted 10 minutes. This could suggest sacroiliitis, if the next question had been did the SI stress tests reproduce the pain, the answer would have been no. This tends to argue against a mechanical cause. The pain was not constant or even continuous reducing the likelihood of it being inflammatory in nature. The pain radiated from the flank to the groin suggesting that whatever tissue was causing the symptoms, its derivation was somewhere between T12 and L2 and the scrotal component in the absence of sciatica (S4) would support higher levels rather than lower.

So far we have a non-mechanical, non-inflammatory condition arising from a tissue derived from the thoracolumbar high lumbar area. This by itself should be enough for you to back away from this patient and refer him back to his physician. One other test that would help cement this decision is heavy dull percussion over the kidney producing the patient's pain.

Provisional differential diagnosis: VISCEROGENIC PAIN. The low lumbar and hip dysfunctions were coincidental and had nothing to do with the patient's complaints. These musculoskeletal dysfunctions are commonly found on manual therapy courses in otherwise asymptomatic people. In any event, they were not at a level that would be easily associated with the pain that the patient was experiencing and even if they were, the type of pain and its behavior should have indicated to you that they probably were not a factor.

VISCEROGENIC - Renal Colic caused by kidney stones

This case history was modified from one given in the interactive patient and I have included its URL below as well as another that discusses kidney stones on a level that is meant for the educated patient and not the urolgist (this means that even I can understand it). The musculoskeletal information concerning the lumbosacral, hip and thoracolumbar region were inserted by me to complicate the picture.