37-year-old Male Soccer Player With Low Back Pain

Abstract

HISTORY: A 37-year-old male with history of acne presented with a several year history of low back pain. His pain acutely worsened 1 year prior to presentation and again 2 weeks prior to presentation without obvious mechanism of injury or trauma. Pain was localized to the midline low back without radiation. He described it as an ache or stiffness. Pain worsened with forward flexion and improved with stretching and ibuprofen. He denied any focal weakness, numbness, tingling, mechanical symptoms, changes in bowel or bladder function, skin changes or family history of back pain. He was previously evaluated by an outside physician and reported to have unremarkable lumbar spine radiographs. Prior treatments included ibuprofen as need, soft tissue work and stretching, which provided modest relief. PHYSICAL EXAMINATION: Strength and light touch sensation were full throughout the bilateral lower extremities. Bilateral patellar and Achilles reflexes were physiologic and symmetric. Gait was antalgic favoring the left leg. Lumbar spine range of motion was limited and painful. There was mild tenderness with palpation of the midline lumbar spine and bilateral SI joints. Modified Schober's test demonstrated only 1 cm of movement. DIFFERENTIAL DIAGNOSIS: 1) Lumbar strain; 2) Spondylosis; 3) Spondylolisthesis; 4) Inflammatory spondyloarthropathy; 5) Radiculopathy TEST AND RESULTS: Lumbar radiographs demonstrated large, asymmetric osteophyte formation at numerous levels from L2-S1 as well as multilevel bridging syndesmophytes compatible with an underlying inflammatory spondyloarthropathy. Hip radiographs demonstrated slight irregularity of the SI joints concerning for chronic sacroiliitis. FINAL WORKING DIAGNOSIS: Low back pain likely secondary to axial spondyloarthropathy. TREATMENT AND OUTCOMES: The patient was prescribed naproxen 500 mg twice daily for 7 days and referred to physical therapy. Referral to Rheumatology was discussed, but the patient elected to wait if no benefit from naproxen. At 1-month follow up, the patient had almost complete resolution of pain after the 7-day course of naproxen. He had only mild pain with extension of the spine and no pain with playing soccer or running.