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Case 6b

Lumbar back

Background

The patient is 44 years old. Single. Works as an officer in the army, with varied office work and some service in the field. Previously healthy.

Over the past year, the patient has noticed local pain (VAS 4) in the lower back both at rest and during activity. The pain increases when sitting, when the patient stands up from a seated position, and with coughing, sneezing, or straining. Over the past month, the patient has had radiating pain (VAS 6) in the left leg down to the forefoot. In recent weeks, there has been numbness and tingling in the left buttock region, lateral thigh, and calf, toward the forefoot medially. Ibuprofen and acetaminophen have had little effect. The patient is seeking medical advice to find out what is wrong.

Consultation video

Medical history

  1. Doctor

    What can I help you with?

  2. Patient

    I have had pain in my lower back for quite a while, but in the last month it has started to go down into my left leg as well.

  3. Doctor

    How long have you had back pain?

  4. Patient

    Over the past year, I have felt it in my lower back, both when I am active and when I am resting.

  5. Doctor

    What makes the back pain worse?

  6. Patient

    Sitting is bad. It also hurts when I stand up again. And if I cough, sneeze, or strain, I feel it strongly.

  7. Doctor

    Can you describe the pain that goes down the leg?

  8. Patient

    It goes down the left leg and towards the forefoot.

  9. Doctor

    Have you also felt tingling or numbness?

  10. Patient

    Yes, in the past few weeks there has been tingling and numbness in the left buttock, on the outside of the thigh and calf, and further towards the forefoot.

  11. Doctor

    Have you noticed weakness in the foot or leg?

  12. Patient

    Yes, I think the left foot is weaker, especially when I try to lift it.

  13. Doctor

    Have you tried anything for this?

  14. Patient

    I have taken Ibux and Paracetamol, but it has had little effect.

  15. Doctor

    What do you think about this yourself?

  16. Patient

    I would like to know what is actually wrong, because this is starting to affect both work and what I do otherwise.

Standard examination

Perform standard examination:

  1. 1 Inspection
  2. 2 Active movements
  3. 3 Passive movements
  4. 4 Isometric movements
  5. 5 Palpation

See functional tests for the back →

Tentative diagnosis

based on medical history and standard examination
  • nerve root involvement of the left L5 nerve root.

Examination

Special tests to strengthen or weaken the likelihood of the tentative diagnosis.

  1. 1. Forward bend and side bend

    Doctor

    Can you bend forward?

    Can you bend sideways to the left?

    Patient

    Bends forward carefully, but stops before full range with clear pain reaction.

    Pulling in the lower back and down into the left calf.

    During side bending, the same interrupted movement and recognizable radiation occur.

    Yes, it goes down into the calf again.

    Findings

    • Pain in the lower back and down into the left calf during forward bending and side bending to the left.

  2. 2. Walking and function test

    Doctor

    I want you to try squats, walking on your toes, and walking on your heels.

    Patient

    Squats and walking on your toes are performed with some caution. Heel walking on the left side is clearly weaker.

    The left side fails slightly there.

    Findings

    • Reduced strength when walking on heels on the left side.

  3. 3. Slump test

    Doctor

    Now I want to do a test where we put the nerve slightly on stretch. Let me know if it causes familiar pain.

    Patient

    Reacts clearly, but controlled, with radiation to the left calf and not just local back pain.

    Yes, now it goes down into the left calf.

    Findings

    • Pain radiating to the left calf during Slump test.

  4. 4. Lasègue test

    Doctor

    I am lifting your leg. Tell me when you feel the symptoms.

    Patient

    Indicates known radicular pain radiation, not just a stretching sensation at the back of the thigh.

    There it goes down the calf in the same way.

    Findings

    • Pain radiating to the left calf during Lasègue test.

  5. 5. Strength testing

    Doctor

    Pull the left foot up towards you and resist.

    Lift your left big toe and hold it.

    Patient

    Gives clearly way during dorsiflexion in the left ankle.

    It is weaker there.

    Also clearly reduced strength during dorsiflexion of the left big toe.

    It is harder on the left.

    Findings

    • Reduced strength during dorsiflexion of the left ankle and left big toe.

  6. 6. Sensation

    Doctor

    I will test the sense of touch on your foot. Let me know if it feels different on the left side.

    Patient

    Reports reduced sensation on the dorsal side of the forefoot, especially between the 1st, 2nd, and 3rd toes.

    It feels less there.

    Especially here on the forefoot.

    Findings

    • Reduced sensitivity to pricking and touch on the dorsal forefoot between the 1st, 2nd, and 3rd toes.

Learning points

  1. 1 The combination of local lumbar pain and radicular radiation.
  2. 2 Connection between sensory loss, motor loss, and function test in possible L5 involvement.
  3. 3 It is important to test movement, nerve stretch, heel walking, and specific strength in the ankle and big toe.
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