Cervical cord compression secondary to ossification of the posterior longitudinal ligament

STUDY DESIGN: Resident's case problem. BACKGROUND: A 52-year-old Chinese male with a 10-year history of gradually worsening right hip stiffness, weakness, and pain was referred to physical therapy by his orthopedist, who made a diagnosis of developmental dysplasia of the right hip, with possible Legg-Calve-Perthes disease. The patient reported multiple falls over the last several years and a gradual onset of low back pain with an onset of "electricity" down both legs. The patient also reported mild numbness in both forearms and the right hand over the previous several months. This resident's case problem illustrates how a physical therapist recognized the presence of an atypical musculoskeletal pathology through the use of hypothesis-driven clinical reasoning and detailed physical examination. DIAGNOSIS: Examination of the patient's lumbar and cervical spine and hips revealed joint dysfunctions. Neurological testing revealed hyperreflexia. Special testing revealed lower extremity clonus with a positive Babinski sign with gait disturbances. The patient was referred back to his primary physician and then to a neurologist and neurosurgeon. An MRI revealed cervical myelopathy due to ossification of the posterior longitudinal ligament from C3/C4 to C5/C6. The patient then underwent a C3 through C7 laminectomy. DISCUSSION: It is always imperative that sound clinical reasoning be used when performing physical therapy evaluations, regardless of the referral status of the patient. Patients with nonmusculoskeletal pathology may seek physical therapy services and it is the physical therapist's responsibility to complete a thorough examination and refer to specialists when appropriate.     

Differential diagnosis of spondylolysis in a patient with chronic low back pain

STUDY DESIGN: Resident's case problem. BACKGROUND: A 26-year-old male sought physical therapy services via direct access secondary to a flare-up of a chronic low back pain condition. The patient complained of recent onset of lumbosacral joint pain, including (1) constant right-sided deep-bruise sensation, (2) intermittent right-sided sharp stabbing pain, and (3) constant bilateral aching. The patient's past medical history included a hyperextension low back injury while playing football at age 17. Physical examination revealed (1) deep pain with palpation over the right lumbosacral joint region, (2) sharp right lumbosacral joint pain with 1 repetition of active trunk backward bending, and (3) a marked increase in pain and joint hypomobility with right unilateral joint assessment at the L4 and L5 spinal levels. DIAGNOSIS: The examining therapist referred the patient for radiographic evaluation due to strong suspicions of a pars interarticularis bony defect. Lumbar plain films, oblique views, revealed an L5 bilateral pars defect, leading to a diagnosis of a longstanding bilateral L5 spondylolysis. DISCUSSION: Patients with low back pain often seek physical therapy services. Identification of pathology requiring examination by other health care providers, leading to patient referral to other health care practitioners, is a potential important outcome of the therapist's examination. This resident's case problem illustrates the importance of a systematic examination scheme, including a thorough medical screening component that led to a patient referral for radiographic evaluation. The resultant diagnosis, although not representing serious pathology, did impact the therapist's patient plan of care.     

Decision making for a painful hip: a case requiring referral

STUDY DESIGN: Resident's case problem. BACKGROUND: The purpose of this resident's case problem is to describe a 39-year-old female patient with insidious onset of hip pain. This patient had discrete findings on subjective physical examination that prompted referral for further imaging studies of the left hip and pelvis. Despite having seen multiple providers, no imaging of the involved hip or pelvis had been performed. A prolonged duration of symptoms, severe gait disturbance with an associted Trendelenburg sign, difficulty sleeping, and an empty end feel with passive range of motion increased concern that a pathological process might be present. DIAGNOSIS: Imaging studies revealed a large destructive soft-tissue tumor later found to be non-Hodgkin's lymphoma. DISCUSSION: It is incumbent upon physical therapists to be aware of the potential for severe pathological conditions that mimic musculoskeletal complaints to exist and understand how to identify patients for whom further testing and/or referral may be appropriate. Existing guidelines for low back pain may assist with decision making in the absence of specific guidelines for when to request imaging in patients with nontraumatic hip and pelvis pain. Proficiency in screening for conditions not amenable to physical therapy treatment or that require consultation to other health care professionals is essential to physical therapy practice.     

Cancer as a cause of low back pain in a patient seen in a direct access physical therapy setting

STUDY DESIGN: Resident's case problem. BACKGROUND: This paper describes the clinical course of a patient with low back pain (LBP) and left lower extremity pain and tingling, and how the physical therapist used clinical examination findings and a lack of improvement with conservative measures to initiate further medical evaluation, which resulted in a diagnosis of cancer as the primary cause of the patient's low back and hip pain. DIAGNOSIS: A 45-year-old man with chief complaints of left-sided LBP, left posterior thigh pain, and tingling along the anterolateral aspect of his left lower extremity was initially seen by a physical therapist in a direct access setting. Several components of the patient's history and physical examination were consistent with a mechanical neuromusculoskeletal dysfunction. However, there were signs and symptoms present that may have been suggestive of more serious underlying disease. Specifically, the patient's most intense pain was in the evening and into the night and an atypical pattern of restricted motion at the left hip was noted. Therefore, the physical therapist recommended that the patient schedule an appointment with his physician for medical evaluation. A short-term course of physical therapy treatment was also undertaken to address neuromusculoskeletal impairments. Despite 5 physical therapy visits over the course of a month, while the patient waited for his scheduled physician appointment, the patient's condition gradually worsened. After medical evaluation, the patient was eventually diagnosed with small cell carcinoma of the lung, with metastases to the spine and pelvis. Despite 2 cycles of chemotherapy, the patient succumbed to the cancer 5 months after he was first seen in physical therapy. DISCUSSION: It is important that physical therapists have an understanding of the clinical findings associated with the presence of serious underlying diseases causing LBP, as this information provides guidance as to when communication with the patient's physician is warranted.     

Differential diagnosis of a patient referred to physical therapy with low back pain: abdominal aortic aneurysm

STUDY DESIGN: Resident's case problem. BACKGROUND: A 38-year-old man with a history of chronic episodic low back pain (LBP) was referred to physical therapy by his physician. DIAGNOSIS: Concerns ascertained from the patient's history included an insidious onset of unrelenting, deep, boring pain that was constant, irrespective of movements or posture changes, or time of day. In addition, the patient reported night pain and the inability to find relief in recumbent positions. The primary warning signs associated with the physical examination were unremarkable examination of the lumbar spine, pelvis, and hip regions (symptoms not altered and minimal impairments detected), and a strong nontender, palpable pulse noted over the left lateral lumbar region, with the patient prone, and over the midline and left upper/lower abdominal quadrants, with the patient supine. Suspicion of the presence of an abdominal aortic aneurysm led the therapist to immediately refer the patient to an allopathic physician. The subsequent abdominal ultrasound and computed tomography scanning revealed a 10-cm-diameter abdominal aortic aneurysm. The patient was immediately hospitalized and underwent surgical repair within two days. DISCUSSION: LBP is the most frequent condition for patients seeking care from physical therapists in outpatient settings. The challenge for clinicians is to recognize patients in whom LBP may be related to underlying pathological conditions. A prompt referral of patients presenting with suspicious findings to the appropriate physician may lead to a more timely diagnosis, with the goal of minimizing or preventing morbidity and mortality. LEVEL OF EVIDENCE: Differential diagnosis, level 4.J Orthop Sports Phys Ther. 2008;38(9):551-557, published online 3 June 2008. doi:10.2519/jospt.2008.2719.     

Clinical decision making associated with an undetected odontoid fracture in an older individual referred to physical therapy for the treatment of neck pain

STUDY DESIGN: Resident's case problem. BACKGROUND: The purpose of this paper is to provide the examination of and decision-making process for a patient referred to physical therapy for the treatment of neck pain following trauma. She was found to have an underlying odontoid fracture that precluded physical therapy intervention. DIAGNOSIS: This case involved a 73-year-old woman who had a sudden onset of neck and left upper extremity pain after a fall 15 days prior to her initial physical therapy visit. Conventional cervical spine radiographs completed 1 day prior to her initial physical therapy visit were negative for a fracture. However, several components of this patient's history and physical examination were consistent with a condition for which physical therapy intervention would not be indicated until more definitive cervical spine diagnostic imaging had been completed; more specifically, the physical therapist was primarily concerned about the possibility of an undetected fracture. The referring physician was contacted and immediate magnetic resonance imaging was requested, which revealed a type II fracture of the odontoid. Thirty-four days after her fall, the patient underwent a C1-C2 fusion. DISCUSSION: When evaluating patients with neck pain who have a history of cervical spine trauma, it is important that physical therapists understand the clinical findings associated with cervical spine fractures, as these findings provide guidance for the use of cervical spine diagnostic imaging and medical referral prior to implementing physical therapy interventions. LEVEL OF EVIDENCE: Diagnosis, level 4.     

Diagnosis of a rare source of upper extremity symptoms in a healthy woman after weight lifting

STUDY DESIGN: Resident's case problem. BACKGROUND: The popularity of weight training has increased dramatically during the past 20 years. With the increase in popularity of weight training, the rate of injury has also increased dramatically. The types of injuries range from benign to life threatening. DIAGNOSIS: The patient was a 21-year-old woman originally referred for pelvic pain who presented with new complaints of right upper extremity swelling, discomfort, and cyanosis after recently beginning a comprehensive weight-lifting program. Additional signs, including paresthesias decreased pulses, and venous distension, warranted a timely referral by the physical therapist bavk to the referring physician. DISCUSSION: The primary injury in this case report was hypothesized to have been induced by the recent start of a weight-lifting program, with no other significant contributing risk factors. A comprehensive examination by the physical therapist revealed clinical signs of an upper extremity deep vein thrombosis, leading to a same-day referral back to the referring physician. Further research, resulting in a clinical decision rule for upper extremity deep vein thrombosis or estimates of diagnostic accuracy of clinical signs and symptoms, would improve the diagnostic process.     

Identification of abnormal hip motion associated with acetabular labral pathology

STUDY DESIGN: Resident's case problem. BACKGROUND: Recent literature has suggested that acetabular labral pathology secondary to femoroacetabular impingement (FAI) may be a precursor to early-onset hip osteoarthritis. The purpose of this resident's case problem was to explore the extent to which abnormal movement at the hip is a possible contributor to acetabular labral pathology. DIAGNOSIS: The patient was a 25-year-old female with a 4-year history of anterior-medial groin pain. Based on a combination of the clinical examination and magnetic resonance imaging findings, she was given a diagnosis of acetabular labral tear by her orthopaedic surgeon and referred to a physical therapist for assessment. Movement analysis during a single-leg step down, running, and a drop jump maneuver revealed excessive hip adduction and internal rotation on the involved side, which reproduced her symptoms. Application of a hip-strapping device resulted in decreased hip adduction and internal rotation, and an immediate decrease in symptoms. DISCUSSION: The reduction in pain secondary to controlling hip motion suggests that excessive frontal and transverse plane hip motions may contribute to FAI. Accordingly, physical therapy intervention aimed at controlling and reducing hip adduction and internal rotation during activities may be indicated in patients who present with this movement pattern associated with anterior hip/groin pain. LEVEL OF EVIDENCE: Differential diagnosis, level 4.J Orthop Sports Phys Ther. 2008;38(9):558-565, published online 3 June 2008. doi:10.2519/jospt.2008.2790.     

Clinical diagnosis of vertebrobasilar insufficiency: resident's case problem

STUDY DESIGN: Resident's case problem. BACKGROUND: Vertigo and visual disturbances are common symptoms associated with vertebrobasilar insufficiency (VBI), but the physical examination procedures to verify the existence of VBI have not been validated in the literature. The objective of this resident's case problem is to demonstrate how a patient's complaint of vertigo and visual disturbances, combined with positive clinical examination findings, can be a potential medical screening tool for VBI. DIAGNOSIS: The patient in this report was initially referred to physical therapy for neck pain. However, the patient's chief concerns identified during the history were (1) vertigo, (2) visual disturbances, (3) headache, and (4) right shoulder region pain. Clinical VBI tests were performed, whereby the patient's vertigo and visual disturbances were reproduced with cervical spine extension. The patient was sent back to the referring physician to be evaluated for possible VBI. Diagnostic imaging tests were ordered. Carotid ultrasound revealed 80% to 90% stenosis in the proximal left internal carotid artery, and magnetic resonance angiography of the extracerebral vessels showed greater than 90% stenosis of the left internal carotid artery. DISCUSSION: VBI may be present in patients with subjective reports of vertigo and visual disturbances that are reproduced with VBI physical examination procedures.     

Minocycline-induced lupus in adolescents: clinical implications for physical therapists

STUDY DESIGN: Resident's case problem. BACKGROUND: In the United States, minocycline is a frequently prescribed medication for the treatment of moderate to severe acne, a common condition in adolescents. The use of minocycline has been associated with severe adverse effects that frequently comprise a musculoskeletal component, including drug-induced lupus. Physical therapists have the responsibility to identify drug reactions that mimic musculoskeletal symptoms. The patient described herein was a 15-year-old adolescent boy who had taken minocycline for 14 days. He was initially treated by his primary physician on the 15th day of minocycline therapy for symptoms of fever, joint swelling, and a rash. The patient presented to a physical therapist on the 22nd day with complaints of severe myalgia, arthralgia, and severely limited mobility secondary to pain. The patient was referred to a pediatric rheumatologist because of the systemic nature and severity of the symptoms. DIAGNOSIS: The patient was subsequently diagnosed as having drug-induced lupus by a pediatric rheumatologist. The patient's myalgia and arthralgia subsided within 6 weeks, but his strength, coordination, and endurance did not reach their prior levels for 3 to 4 months. DISCUSSION: Physical therapists who include a comprehensive pharmacovigilance component in their patient examination may recognize musculoskeletal symptoms that arise from a nonmusculoskeletal origin. Minocycline is commonly prescribed in the United States as an antibiotic and for treatment of acne and rheumatoid arthritis. Therefore, physical therapists should screen for minocycline use when an adolescent patient or a patient with rheumatoid arthritis presents with diffuse musculoskeletal symptoms. An automated medication monitoring system would provide physical therapists with a means of accessing current information on medication use.     

Pathological origins of trunk and neck pain: part I - pelvic and abdominal visceral disorders

An important initial responsibility for a physical therapist examining a patient with back or neck pain is to determine whether the symptoms are a result of mechanical musculoskeletal dysfunction or of a pathological disorder such as visceral pathology or other diseases that would not be amenable to physical therapy management. This responsibility is magnified as direct access legislation continues to be passed. To assist the therapist in this decision making process, this article includes a neuro anatomic overview of visceral pain, along with general evaluation principles and information that suggest the presence of a variety of pathological conditions. In addition, signs and symptoms of specific gastrointestinal and urogenital diseases are presented to familiarize the therapist with conditions that may be manifested as trunk or neck pain. The two subsequent articles in this series will address additional sources of pathological pain, including disorders of the cardiovascular and pulmonary systems and diseases of the musculoskeletal system. J Orthop Sports Phys Ther 1990;12(5);192-207.     

Deep vein thrombosis in an athletic military cadet

STUDY DESIGN: Resident's case problem. BACKGROUND: A 21-year-old healthy athletic male military cadet with complaint of worsening diffuse left knee pain was evaluated 4 days after onset. The knee pain began 2 hours after completing a long car trip, worsened over the subsequent 3 days, and became almost unbearable during the return trip. The patient reported constant pain, limited knee motion, and difficulty ambulating. In addition, he was unable to perform physical military training or attend academic classes due to the severe left knee pain. Past medical history revealed a mild left lateral calf strain 21/2 weeks prior, which completely resolved within 24 hours of onset. DIAGNOSIS: Our physical examination led us to either monoarticular arthritis, pseudothrombophlebitis (ruptured Baker's cyst), or a lower leg deep vein thrombosis (DVT) as the cause of knee pain. Diagnostic imaging of this patient revealed a left superficial femoral vein thrombosis and popliteal DVT, with bilateral pulmonary emboli (PE). DISCUSSION: A systematic differential diagnosis was undertaken to rule out a potentially fatal DVT diagnosis as the cause of knee pain, despite minimal DVT risk factors. The physical therapist in a direct-access setting must ensure timely evaluation and referral of a suspected DVT, even when patient demographics cause the practitioner to question the likelihood of this diagnosis. The physical examination findings, clinical suspicion, and established clinical prediction rules can accurately dictate the appropriate referral action necessary.     

The use of nonthrust manipulation in an adolescent for the treatment of thoracic pain and rib dysfunction: a case report

STUDY DESIGN: Case report. BACKGROUND: Back pain is a common presentation of patients in the orthopedic physical therapy setting. In an athletic environment, back pain can limit an athlete's ability to perform running, cutting, and throwing. This case report describes the use of a spinal nonthrust manipulation in conjunction with therapeutic exercise for the management of thoracic and rib pain in an adolescent athlete. CASE DESCRIPTION: A 16-year-old male presented to the outpatient clinic without physician referral. His chief complaint was right-sided thoracic and rib pain during running, jumping, cutting, and kicking that began 1 month before the initial physical therapy visit. He had no previous episodes of pain or associated injuries. A screening examination for serious underlying pathology was negative. After physical examination, it was determined that manual therapy was indicated. A thoracic nonthrust manipulation was applied to the painful area (the right-side thoracic facet joints of segments 5-7). OUTCOMES: Immediately after the thoracic nonthrust manipulation, the patient experienced a decrease in tenderness to palpation of the thoracic erector spinae musculature and the associated intercostal spaces of ribs 6 through 8 (a decrease of 1-2 points on the pain scale), an increase in thoracic side-bending active range of motion recorded at T3 and T9, and improved chest expansion, which had been limited by pain before treatment. DISCUSSION: This case report demonstrates the use of a spinal nonthrust manipulation that seems to have helped an adolescent return to pain-free sports activity, with an immediate decrease in pain after 1 visit. Follow-up telephone calls were made 1 month and 9 months after treatment, in which no return of symptoms was reported.     

Acute onset-low back pain and hip pain secondary to metastatic prostate cancer: a case report

Prostatic cancer is the second most common cancer among North American men and the second leading cause of cancer deaths. It may be incidental or contribute to the cause of mechanical back pain. With such high mortality associated with metastasis, early detection is essential for appropriate medical management. Chiropractors are often consulted for back pain of mechanical origin and are in a position to detect conditions in which serious organic pathology may contribute to, or mimic benign musculoskeletal back pain. Patient history and clinical examination coupled with imaging may greatly increase the index of suspicion of prostatic involvement. Outlined is a case where imaging and examination confirmed a diagnosis of organic disease in an individual who opted for chiropractic care for his back pain, but for whom immediate medical management was essential.     

Diagnosis of medial knee pain: atypical stress fracture about the knee joint

STUDY DESIGN: Resident's case problem. BACKGROUND: A 19-year-old female, currently enrolled in a military training program, sought medical care for a twisting injury to her right knee. The patient reported her symptoms as similar to an injury she incurred 1 year previously while enrolled in the same military program. The patient's past medical history included a nondepressed fracture of the medial tibial plateau and complete tear of the deep fibers of the medial collateral ligament. DIAGNOSIS: Physical exam revealed nonlocalized anterior and medial knee pain without evidence of internal derangement. Initial knee and tibia radiographs were unremarkable. Referral for orthopedic physician evaluation resulted in concurrence with the therapist's diagnosis and plan of care, and the patient was allowed to continue with limited physical training demands. Despite periods of rest, the patient's symptoms progressively worsened upon attempts to resume running. The examining therapist referred the patient for magnetic resonance imaging (MRI) due to the patient's worsening symptoms, normal radiographs, and concern for a proximal tibia stress fracture. MRI revealed a severe proximal tibial metaphysis stress fracture. DISCUSSION: Stress fractures are commonly encountered injuries in individuals subjected to increased physical training demands. Early evaluation may not yield well-localized findings and may mimic other conditions. Nonmusculoskeletal conditions should be considered in the management of patients with stress fractures. This resident's case problem illustrates the importance of serial physical examinations and collaboration with other healthcare practitioners in the comprehensive assessment and management of a patient with a severe stress fracture.     

Primary spinal intradural extramedullary hydatid cyst in a child

BACKGROUND/OBJECTIVE: Spinal hydatid cyst is a serious form of hydatid disease affecting less than 1% of the total cases of hydatid disease. We present a case of pathologically confirmed primary intradural spinal cyst hydatid in an otherwise healthy patient who showed no other evidence of systemic hydatid cyst disease. CASE REPORT: An 8-year-old boy presented with back pain, left leg pain, and difficulty in walking. The patient had no other signs of systemic hydatid cyst disease. An intradural extramedullary cystic lesion was identified with magnetic resonance imaging and was shown to be a hydatid cyst by histopathologic examination after the surgical removal. CONCLUSION: Although extremely rare, primary intradural extramedullary hydatid cyst pathology might be the cause of leg pain and gait disturbance in children living in endemic areas.     

Abdominal aortic aneurysms: case report

A 71-year-old male presented to a chiropractic clinic with subacute low back pain. While the pain appeared to be mechanical in nature, radiographic evaluation revealed an abdominal aortic aneurysm, which required the patient to have vascular surgery. This case report illustrates the importance of the history and physical examination in addition to a thorough knowledge of the features of abdominal aortic aneurysms. The application of spinal manipulative therapy in patients with (AAA) is also discussed.     

Isolated knee pain: a case report highlighting regional interdependence

STUDY DESIGN: Case report. BACKGROUND: A number of pain referral patterns for sacroiliac dysfunction have been reported in the literature. However, very little has been written about pain localized to the knee joint for cases involving sacroiliac dysfunction. CASE DESCRIPTION: A 25-year-old female runner was self-referred to physical therapy for medial knee pain of 4(1/2) weeks' duration without a significant onset event. The pain completely curtailed her training for the Boston Marathon. Examination of the patient's knee and hip did not reveal any abnormal findings and there was no reproduction of pain with any test procedures except for medial knee joint tenderness to palpation. Additional, more proximal examination suggested significant asymmetry of sacral bony landmarks of the pelvic girdle without significant findings on the provocation tests of the sacroiliac joint. A single session of manual therapy procedures directed to the pubic symphysis and sacroiliac joint ipsilateral to the side of knee pain was provided. OUTCOMES: The patient was able to return to running without further incident of knee pain after a single therapy session. DISCUSSION: This case suggests the importance of regional interdependence in the examination of patients with an apparently common clinical problem. Furthermore, the case describes a previously unreported presentation of local knee pain possibly attributable to sacroiliac joint dysfunction.     

Guillain-Barré syndrome as differential diagnosis of intervertebral disk-induced nerve root compression

INTRODUCTION: Diagnosis of Guillian-Barré Syndrome usually is not difficult, but diagnostic failure occurs for the variable initial presentation. Diagnosis is based on physical examination showing loss of motor strength in more than one limb and loss of deep tendon reflexes. Ventilatory assistance, pharmacologic maintenance of cardiovascular homeostasis, corticosteroids, IgG and plasma exchange are the dominant therapeutic measures. CASE: This article reports on a case of a 59-year old surgeon suffering from degenerative disc disease in the lumbar spine. The patient developed a severe course of the Guillian-Barré Syndrome with persisting motor weakness of the legs. CONCLUSION: If the primary problem at presentation is limb and back pain the pathology appears to be in the musculoskeletal rather than in neurological system. The awareness of this presentation of Guillian-Barré-Syndrome will eliminate delay in diagnosis.