Plantar Case Studies

Range of motion shows flexion of 85 degrees, extension of 30 degrees, and lateral tilt of 25 degrees bilaterally. Straight leg raise is positive on the right at 90 degrees for low back pain. Bechterew's test is positive on the right. The patient has diminished sensation in the right L4, L5 and S1 dermatomes. Deep tendon reflexes are absent in the right knee and right ankle.

Per medical report dated 01/23/15, the patient reported of middle and lower back pain and bilateral leg pain with tingling. He was diagnosed with thoracic compression fracture and lumbar spondylolisthesis.

On the IME report dated 10/07/15 by Dr. Ingber, it was indicated that further treatment should include PT 2-3 times a week for the next 2-3 months. Further trigger point injections every 2 weeks as well as 2-3 lumbar ESI is reasonable.

On examination, cervical and lumbar spine is restricted in all planes with increased pain. Muscle guarding is also noted. The patient is not able to heel and toe walk. He is obese and deconditioned. Straight leg raise (SLR) is positive bilaterally. Muscle guarding is noted along cervical paraspinal and trapezius muscle groups bilaterally. Sensation is normal to light touch, pinprick, and temperature along all dermatomes of the bilateral upper extremities, except right C6-8, decreased to

There is pain with lumbar flexion and extension. There is no aberrant behavior. The patient feels that he can perform increased activities of daily living with his current medications.

Treatment plan includes follow-up with orthopedics, follow-up with psychology, Dr. Gandolfo for additional treatments for major depressive disorder, additional PT 2 x 3 sessions to treat the lumbar spine, additional PT for vestibular rehabilitation, follow-up with neurologist, referral for psychology and follow-up with primary care physician (PCP).

The patient is a 50 year old male construction worker who sustained a work-related injury while lifting heavy boxes of metals. In an office visit dated 12/14/13, patient complaints of intermittent severe low back pain which radiates to bilateral lower extremities. The claimant had an epidural injection, which significantly alleviated right leg pain for a short period of time. Unfortunately pain has returned. It is in the right leg as well as severe pain in the lower back. The claimant wishes to consider surgical intervention due to severity of pain. Objective examination reveals weakness in the right extensor halucis longus and anterior tibialis which are 4+/5. The claimant has diminished sensation along the dorsum of right foot. The claimant has a positive straight leg raise.

Per PT treatment log dated 11/18/15, the patient has attended 19 PT visits for the thoracic and lumbar spine from 08/27/15 through 11/13/15.

DOI: 06/23/2011. This is a case of 41-year-old male maintenance worker who sustained injury to the low back while taking off a sliding door of a patio. As per OMNI notes, patient is diagnosed with lumbar disc disorder with myelopathy. MRI of the lumbar spine dated 6/28/15 revealed recurrent left paramedian L4-5 disc herniation with caudal extrusion of a 10 mm fragment into the left L5 lateral recess. As per office notes dated 7/25/16, the patient is status post redo left L5-S1 discectomy performed on 4/20/16. It was also noted that the patient had a prior L5 laminotomy several years ago. He subsequently did well. However, he had recurrence of his pain. Pain is radiating into his left leg worse on the right leg. This was unresponsive to conservative

10/30/15 Medical Evaluation reported neck, low back, and left sacroiliac pain. Physical examination of the lumbar spine revealed decreased ROM on

On examination of the right shoulder, there is pain on range of motion. Abduction was 160 degrees. Forward flexion was 165 degrees.

On examination, he has moderate pain to palpation to the lumbar spine and paravertebral muscles over the bilateral facet joints at L4-L5-S1. He has a positive straight leg raise test to the right.

According to the treatment plan, Allana returned to see Dr. Scott on 08/03/15. She told him that she had a bad headache yesterday, and her low back pain was really cranky. According to the treatment plan, she was to go back and see Dr. Scott about two times a week after the August 3rd appointment. The chiropractic visits consisted of repetitive treatment to her cervical spine and to her low back. She told Dr. Scott at times that she thought she felt better, and then on other dates of treatment, she talked about how her

Per the medical report dated 08/12/16 by Dr. Gunderson, the patient had neck pain, as well as headaches, dizziness and blurred vision. The neck pain radiated into both shoulders, but more so on the right, and occasionally she had tingling in her upper extremities. She described the neck pain as severe and intermittent, and not related to any specific activity, and relieved with massage. The pain in her lower back was in the beltline and radiated into both lower extremities, more so on the left. She described the pain as moderately severe and constant, and not related to any activity, and only relieved with nerve medicines. On examination, the patient had tenderness in the lower cervical region about C5 to C7. Range of motion of her neck was 75% of normal. Motor, sensory, and reflex examinations in the upper extremities were normal. On examination of the lumbar spine, the patient could dress and undress without difficulty. She had a bent forward posture and gait. She had reduced lumbar motion and with maximum forward flexion, her fingertips were 12 inches from the floor. Lateral flexion was 50% of normal, and she had no active extension in the lumbar spine. Motor, sensory, and reflex examinations in the lower extremities were normal. There was paravertebral tenderness about L4-5 bilaterally, as well as in both sacroiliac and sciatic notch regions. Straight leg caused hip and thigh pain at 50 degrees bilaterally. Of note, X-rays of the cervical spine demonstrated disc degeneration at C5-6. X-rays of the lumbar spine were normal. Patient sustained

Based on the medical report dated 01/20/16, the patient reports that his low back pain is rated as 9/10 into the right lower extremity. It’s experienced between 76% and all of the time he is awake. Some of the patient’s daily activities are being prevented by this symptom. He reports numbness and tingling in his right lower extremity.