Case Study of Low Back Pain

Hon Maurice - Registered Physiotherapist & Private Practice

Translation: Henry Lam - President of HKADMS & Registered Physiotherapist (HK)

 02 April 2020

Ms. P was a 16-year-old female with a complaint of low back pain with stretching and some numbness down the left leg. She takes extra-curricular dance classes and hopes to be a professional dancer in the future. She originally believed to have hurt her back while practicing a dance routine as her back pain set in shortly after dancing one day. She saw the doctor several times and was given muscle relaxants, anti-inflammatory medication in addition to physiotherapy, which helped relieve some of the symptoms, but the pain always recurred. Eventually, the doctor suggested she take an x-ray and MRI of the lumbar region but nothing significant was found. After about 2 months, she came to see me.

 

In the initial visit which was already almost 3 months since her supposed injury, the lower back pain still persisted and there was still a mild numbness down the left leg. She told me she has tried all the stuff before: ultrasound, acupuncture, pelvic traction, stretching etc. but the pain would return shortly after. A more in-depth subjective examination revealed that she had been dancing ballet since a very young age. From my previous experiences in treating dancers, I took this to be very important information and decided to examine her left hip in greater detail.

 

Functionally, she is indeed limited by her paraspinal and gluteus muscle tightness. Trunk bending, sit to stand she already felt the back pain. There was no obvious pain on hip abduction in standing but resisted hip abduction in side-lying caused a dull ache/soreness. The quadrant and FADIR tests were used to test the integrity of the hip and there was a significant difference between the good side (right) and the affected bad side (left). Some of the numbness and stretch down the left leg was also replicable when internally rotating and adducting the hip and there was a slight “catching” at certain points of the hip quadrant test. This finding seems to point to some sort of hip impingement, so the initial goal is to try to loosen some of the muscles like the iliopsoas, gluteus muscles, tensor fascia latae etc via soft tissue work and stretching. Acupuncture and interferential therapy were also used to aid muscle relaxation but they were also focused in the hip area. The first session in this direction proved to give as much relief towards the back pain as directly treating the back.

 

Subsequent sessions involved hip distraction stretches, with the aim of opening up the joint space. Each stretch was held for 20 seconds with 10 second rest for 5 minutes. Hip strengthening exercises in forms of single-leg mini squats, single-leg bridging on a fit ball, in addition to core exercises and eccentric hamstring exercises were added to help improve the pelvic mechanics by reducing her anterior pelvic tilt. She was very compliant with the exercises done at the clinic and she continued to do them at home.

 

After about 6 sessions the progress finally appeared to be significant, with the stretch and numbness down the left leg gone and the FADIR and quadrant tests were not as provocative. There was still some pain in the lower back but it was bearable and she had already returned to dance classes. As the hip seemed to be more mobile and with correction to her posture via core and hamstring/gluteus muscle work, the lower back symptoms slowly went away. She was able to return to her dancing pain-free after 12 sessions but I cautioned her to continue with the stretches and strengthening or the symptoms may return.

 

I think this is a good learning case since the patient herself was so focused on her back complaint that she narrowed the focus for the medical team that provided her with treatment. Since everything was so focused on treating the symptoms of the lower back, it was easy to overlook her hip as a possible root cause. I address her initial complaint as a supposed injury because I was not sure whether there was indeed an acute injury or just that her hip caused her back to tighten up after dancing. Thankfully, having worked with dancers in the past and knowing some of their common repetitive movements gave me confidence to try something different and I am glad it worked out.

 

腰背痛的個案研究

作者: 韓卓勛 - 私人執業物理治療師

中文翻譯: 林漢威 - 香港舞蹈醫學及科學會主席 及 香港註冊物理治療師

今年16歲的P小姐感覺腰背痛,並有左腳拉扯疼痛及麻木感。她課餘參加跳舞班,立志成為一名專業舞蹈者。有一天在跳舞堂後,她感到腰背痛,所以她起初認為是跳舞時弄傷,引致腰背疼痛。她看了多次醫生,醫生處方了肌肉鬆藥、消炎藥及給予物理治療轉介,某些症狀是舒緩了,但疼痛還是經常復發。之後醫生轉介她接受X光及磁力共振檢查,沒有任何異常發現。大約2個月後她輾轉來到我的物理治療診所接受我的治療。

 

自從她”受傷”以後,她來到我的診所已經是3個月的事,她下腰背部痛感仍在,左腳仍有輕微的麻木感。她之前接受過的治療包括超聲波、針灸、腰背盆骨牽引,拉筋等,但是痛感會很快再出現。從她口述的主觀性檢查中,得悉她從小時候就開始跳芭蕾舞。從我以往治療舞者的經驗,這是非常重要的信息,因此決定詳細地檢查她的左髖。

 

 

在功能上,她的腰椎旁和臀部肌肉緊張。當她軀幹彎曲時,或由坐著至站立時,她會感到腰背痛。她站立時髖外展不會引起疼痛,但側卧時髖外展作對抗性的向心收縮時會引起疼痛/酸痛。Hip Quadrant和FADIR檢查可測試髖關節的完整性,好側(右)和痛側(左)存在明顯的差異。當髖關節內旋並內收時,左髖有麻木感和拉扯的疼痛,並且在Hip Quandrant 檢查中,在特定點上有輕微的激痛。這些可能表明左髖出現髖關節撞擊綜合症。因此初期目標是通過軟組織鬆弛手法及拉筋來放鬆肌肉,如髂腰肌肌群、臀部肌群、闊筋膜張肌等,亦配合針灸和干擾波療法來幫助臀部肌肉放鬆,第一節療程的方向是減輕腰背疼痛,達致治療背腰部的效果。

 

隨後的治療包括髖關節牽引伸展,目的是打開關節空間。每次伸展保持20秒,伸展之間有10秒休息,重覆至5分鐘。除了增加核心肌群和股二頭肌的離心收縮鍛鍊外,還增加了單腳少幅度蹲,健身球上單腳橋的髖關節鍛煉,通過減少她的盆骨前傾來幫助她改善背盆力學。她對被給予的復康運動非常順從地在家中鍛鍊。

 

經過約6次療程,P小姐的進展理想,左腳的拉扯疼痛和麻木感消失了,Hip quadrant 及FADIR檢查沒有之前那麼明顯。腰背部仍然有些疼痛,但可以忍受,而最重要的是她回復上舞蹈堂。由於髖關節活動幅度理想,並通過核心肌群和股二頭肌/臀部肌肉的鍛鍊糾正了她的姿勢,因此腰背部症狀逐漸消失。經過12次療程後,她得以無痛地恢復跳舞步,當然要叮囑她繼續進行拉筋和鍛煉,否則症狀可能會再出現。

 

這是一個很好的學習案例,因為患者非常關注自己的腰背部疼痛,因此限制了治療團隊的關注範圍,致可能只集中在治療腰背部的症狀而忽略了的髖關節的問題。由於沒有一個確切的急性受傷,她最初描述的的疼痛可能是在跳舞後引起臀部肌肉及髖關節繃緊。慶幸的是透過之前治療舞者的經驗,知道他們一些重複性的動作,使我嘗試不同的思考角度去幫助患者。

References:

1. Askling CM, Tengvar M, Tarassova O, Thorstensson A. Acute hamstring injuries in Swedish elite sprinters and jumpers: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med 2014;48(7):532-539.

2. Reiman, M. P., & Matheson, J. W. (2013). Restricted hip mobility: clinical suggestions for self-mobilization and muscle re-education. International journal of sports physical therapy, 8(5), 729–740

Disclaimer Statement:

This article was accomplished by the author in his/her personal capacity. The opinions expressed in this article do not reflect the view of the official statement of CUHK and HKADMS. It is intended for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Always consult with an appropriate professional for specific advice related to your situation.

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