Background
The patient is 26 years old. Cohabiting, no children. Works as an engineer with a lot of sedentary work. Previously healthy, but has had pain (VAS 4) in the lower back on the right side for the past five years. The pain increases to VAS 6 with prolonged sitting, which makes office work difficult. One year ago, the patient had an episode of red eye, but currently has no eye symptoms.
The patient sees a doctor due to increased pain (VAS 5) in the lower back. The pain is located low in the lumbar region and towards the right side. The back is stiff and painful in the morning, but improves after about half an hour. Moderate activity provides some relief, while rest does not help. The patient experiences regular nighttime pain. The symptoms vary between periods of more and less pain. The patient occasionally uses Paracetamol when the pain is at its worst, but with little effect.
Consultation video
Medical history
- Doctor
What can I help you with?
- Patient
I have had pain in my lower back for quite a long time, but it has gotten worse recently.
- Doctor
Where is the pain mostly located?
- Patient
Low in the back, mostly on the right side.
- Doctor
How long have you had it like this?
- Patient
Actually for several years… maybe around five years, but over the past year it has become more bothersome.
- Doctor
How is it when you get up in the morning?
- Patient
I am quite stiff and affected by pain when I get up, but it eases a bit after about half an hour.
- Doctor
What happens if you are moderately active?
- Patient
It actually gets a little better when I move.
- Doctor
Does it get better if you rest?
- Patient
No, not really. Rest doesn't help that much. And I also have pain at night.
- Doctor
Is there anything that makes it worse?
- Patient
Yes, if I sit for a long time, it gets worse. It has become a problem at work.
- Doctor
Have the symptoms been the same all the time?
- Patient
No, it varies. Some periods are worse, others are a little better. I find it difficult to understand the pattern.
- Doctor
Do you use painkillers?
- Patient
Just Paracet occasionally when it is at its worst, but it does not help much.
- Doctor
Have you had other symptoms, for example with the eyes?
- Patient
I had a red eye about a year ago and got some eye drops, but I don't remember much more about it. There is nothing with the eyes now.
Standard examination
Perform standard examination:
- 1 Inspection
- 2 Active movements
- 3 Passive movements
- 4 Isometric movements
- 5 Palpation
Tentative diagnosis
based on medical history and standard examination- Right-sided sacroiliac joint arthritis.
Examination
Special tests to strengthen or weaken the likelihood of the tentative diagnosis.
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1. Location of pain
Doctor
Can you show where you feel the pain most?
Patient
Points low at the back of the pelvis on the right side, over the area of the sacroiliac joint.
It is located back here, on the right side.
Findings
- The pain is indicated on the right side over the sacroiliac joint.
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2. Forward bend
Doctor
Can you bend forward?
Patient
Bends with noticeable discomfort. The pain is located low at the back on the right side.
Yes, it gets worse back there.
Findings
- The pain worsens when bending forward.
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3. Hip movement
Doctor
I want to examine your hip joint a little.
Patient
Indicates diffuse, somewhat indeterminate pain. The pain is felt mostly at the back of the pelvis on the right side, not clearly in the groin.
It is felt, but it is mostly located at the back.
Not really in the groin.
Findings
- Indeterminate diffuse pain with hip movement, mostly at the back of the right pelvis and not in the groin.
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4. FABER test
Doctor
Now I will do a test of the hip and pelvis. Let me know if it triggers the pain you feel.
Patient
Quickly recognizes the pain at the back on the right side.
Yes, it hurts at the back on the right side.
Findings
- Pain on the right side at the back during FABER test.
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5. Sacroiliac joint compression test
Doctor
I am going to press a little over the pelvis. Let me know if it triggers the pain.
Patient
Recognizes the same pain in the right posterior pelvic region.
Yes, it hits the same spot.
Findings
- Pain on the right side at the back during sacroiliac joint compression test.
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6. P4 test
Doctor
Now I am doing a new provocation test. Let me know if you feel the same pain.
Patient
The pain is located at the back of the right pelvis, not down the leg or at the front in the groin.
Yes, there it comes again at the back on the right side.
Findings
- Pain on the right side at the back during the P4 test.
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7. Palpation of the right sacroiliac joint in prone position.
Doctor
Lie on your stomach, then I will press a little over the area at the back.
Patient
Reacts with recognizable local pain upon pressure on the right sacroiliac joint.
Yes, that is exactly where I hurt.
Findings
- Pain when the doctor presses on the right sacroiliac joint in the prone position.
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8. Neurological examination of the lower extremities
Doctor
I also want to check strength and sensation in the legs.
Patient
No neurological deficits.
It feels normal.
I do not notice any weakness.
Findings
- Normal strength and sensation in both lower extremities.
Learning points
- 1 Pelvic and low back pain localized posteriorly over the sacroiliac joint.
- 2 Morning stiffness, night pain, changes over time and improvement with moderate activity are important details in the medical history.
- 3 Hip movement can cause diffuse pain, but the pain is still described posteriorly and not in the groin.
- 4 The neurology in the lower extremities is normal.