Case Study: The Lumbar Spine

DOI: 12/8/2014. The patient is a 54-year-old male janitor who sustained a work-related injury to his back and buttocks when he slipped on a soap that he accidentally dropped on the floor. Per OMNI, he was diagnosed with pain to the lower back and spasms.
Per the PT notes dated 09/21/15, the patient has had 66 visits for the back. Patient is feeling much better with treatment.
Based on the initial evaluation report dated 06/16/16, the patient complains of lower back pain radiating to both buttocks, left calf and hamstring, which occurs 50-80% of the time. It has not changed since it started. Intensity is moderate and it inhibits activity. Pain is rated as 7-8/10. Patient describes the feeling associated with this complaint as dull, sharp, aching, spasmodic, numbing and tingling.
There was muscle hypertonicity present bilaterally. Digital palpation for trigger points was positive. Multiple active trigger points are stimulated with moderate digital pressure to the lumbar muscles and are associate d with consistent referred pain. Trigger points are located on the bilateral gluteus medius and maximus, quadratus lumborum, thoracolumbar fascia and paralumbar. Subluxations are noted at L2, L3, L4 and L5. Range of motion (ROM) were reduced in all ranges with pain. Flexion is 40 degrees. Extension is 15 degrees. Lateral motion is 15 degrees bilaterally. Kemp’s test (bilaterally), Straight Leg Raising test (bilaterally) and Milgram’s test is