My patient: Radicular L. Back Pain
My patient “Rad” has been coming to the clinic for about 4 weeks now with complaints of low back pain and radicular symptoms into the right thigh, right medial foot, and slightly into the right calf.
My patient has lordosis of the lumbar spine and significant kyphosis of the thoracic spine. The patient is active and wants to return to activities like swimming, walking long distances, and simply standing for long periods of time without having symptoms in the right leg.
The primary complaint is numbness and tingling in the medial right calf and foot. The patient also has some numbness and tingling into the lateral thigh which occurs less frequently, but can cause the patient discomfort from time to time. All of his symptoms are aggrivated with long periods of standing, walking, and swimming. He does not feel pain, but simply notes a discomfort disscribed as a constant part of his thigh or foot “falling asleep”.
As student physical therapist, it is my challenge to remedy this patients condition to the best of my abilities. This has lead me to find the best evidence for how I can help. You can follow along!
Up until now, I have focused on manual therapy techniques to relieve pain and improve the biomechanics around the joint segments of his L4-5 lumbar segments on the right which show significant muscle guarding and stiffness. At this current clinic, gaining mobility in the spine is encouraged with extension press ups. The patient has seen improvements with the combination of press up extensions and manual therapy.
Breifly looking at some pictures of dermatomal and peripheral nerve patterns, we can take a look at my clinical reasoning to determine that the patients symptoms are not distal to the spinal nerves of the lumbar spine. Or at least, the majority of the symptoms origin from a more proximal location along the nerves exiting the lumbar spine.
Looking at these diagrams, you can observe my reasoning for proximal nerve compression involving spinal nerve roots instead of more distally located compression. Distal compression of the nerve may indeed be present, however, the primary symptoms follow a sensory pattern that indicates possibility of L3, L4 involvement on the right side.
So is there muscular involvement? Myotome testing is negative. However, there is noted weakness of the right gluteus maximus and medius muscles compared to the left side. The innervation for these muscles involves the superior gluteal nerve with spinal innervation involvement of L4,5,S1.
When performing slump tests, streight leg raise with tibial nerve bias, and femoral nerve tension tests, the patient has noted positive symptom aggrivation. The symptoms were especially aggravated in the medial foot with a tibial nerve bias straight leg raise.
So this gives you some idea of the presentation of my patient. I am on a quest to determine if nerve mobilization to nerves containing (L2, L3 due to some discrepancy on the pattern of these nerves in the thigh), L4, L5 nerve roots will improve patient symptoms in the foot and lateral thigh.
I am researching an article: Effectiveness of neural mobilization in patients with spinal radiculopathy: A critical review