Spurling's Case Report
DOI: 3/3/2016. Patient is a 59-year-old male who lost his balance while unloading furniture from a truck and he fell, injuring his left hand and wrist, left shoulder, neck, back and hip. Per OMNI, he was initially diagnosed with fracture of the left hand and sprain/strain of the back and shoulder.
Per the medical report dated 05/06/16, the patient presented with pain to the shoulder, and lumbar and thoracic spine. He has been seeing a massage therapist which has been helpful. He presented with decreased strength and active range of motion, and increased pain impacting function with limited bending, lifting and twisting his back and elevating the left arm for activities of daily living and work related tasks. Patient has improved …show more content…
Range of motion (ROM) shows forward flexion and extension of 45 degrees, bilateral lateral flexion of 45 degrees and bilateral rotation to 80 degrees. Spurling’s test is positive on the left. Sensation of the left upper extremity is altered.
On examination of the left shoulder, there is tenderness at the lateral side. Range of motion (ROM) shows internal rotation to L2 with pain at end Range of motion (ROM). Forward flexion and abduction is 180 degrees. External rotation is 90 degrees. There is pain with strength testing.
On examination of the lumbar spine, there is lumbar paraspinal spasm and tenderness noted. Range of motion (ROM) of the thoracic and lumbar spine shows pain at extremes of flexion, pain with bilateral bending. Lumbar forward flexion is 60 degrees, extension is 10 degrees and bilateral lateral bending to 15 degrees. Straight leg raise is positive on the right.
Assessments include cervical radiculopathy, lumbar degenerative disc disease, sprain of the left rotator cuff, sprain of the ligaments of the lumbar spine, lumbosacral region radiculopathy and right sciatica. Patient will continue PT for the neck and lumbar spine, as patient have made improvement from this modality. Massage therapy is also requested for the lumbar
Per the medical report dated 05/06/16, the patient presented with pain to the shoulder, and lumbar and thoracic spine. He has been seeing a massage therapist which has been helpful. He presented with decreased strength and active range of motion, and increased pain impacting function with limited bending, lifting and twisting his back and elevating the left arm for activities of daily living and work related tasks. Patient has improved …show more content…
Range of motion (ROM) shows forward flexion and extension of 45 degrees, bilateral lateral flexion of 45 degrees and bilateral rotation to 80 degrees. Spurling’s test is positive on the left. Sensation of the left upper extremity is altered.
On examination of the left shoulder, there is tenderness at the lateral side. Range of motion (ROM) shows internal rotation to L2 with pain at end Range of motion (ROM). Forward flexion and abduction is 180 degrees. External rotation is 90 degrees. There is pain with strength testing.
On examination of the lumbar spine, there is lumbar paraspinal spasm and tenderness noted. Range of motion (ROM) of the thoracic and lumbar spine shows pain at extremes of flexion, pain with bilateral bending. Lumbar forward flexion is 60 degrees, extension is 10 degrees and bilateral lateral bending to 15 degrees. Straight leg raise is positive on the right.
Assessments include cervical radiculopathy, lumbar degenerative disc disease, sprain of the left rotator cuff, sprain of the ligaments of the lumbar spine, lumbosacral region radiculopathy and right sciatica. Patient will continue PT for the neck and lumbar spine, as patient have made improvement from this modality. Massage therapy is also requested for the lumbar