A Case of Change in Work Out as the Presenting Symptoms of Multiple Myeloma

Abstract

HISTORY: A 56 year-old active black male presented with 5 months of worsening chronic pain: right hip pain changed location and low back pain flared. His pain had not responded to maintenance exercises (weightlifting, running, stationary cycling), dry needle, massage, stretch, or anti-inflammatories. Past medical history included lumbar disc bulge, lumbar spondylolysis, right superior labral tear, sports lifting-related Osgood-Schlatter’s, cervical laminectomy, chronic right rectus femoris strain. PHYSICAL EXAMINATION: Compared to examination seven months prior, physical examination was significant for decrease in lumbar spine flexion, extension, lateral lean, and rotation and normal symmetric strength testing over the bilateral lower extremities. Forward bending as if to tie shoes, lifting objects, and walking several blocks reproduced his pain. DIFFERENTIAL DIAGNOSIS: 1.Lumbar vertebral body fracture 2.Herniated disc 3.Lumbar or sacroiliac joint sprain or dysfunction 4.Lumbar paraspinal muscles strain 5.Malignancy - primary or secondary 6.Infection - osteomyelitis TESTS AND RESULTS: Serum protein electrophoresis: elevated IgM level Bone marrow biopsy #1: smoldering multiple myeloma Bone scan #1: negative. Lumbosacral x-ray: stable spondylolysis MRI lumbosacral spine: stable lumbar disc bulge, new L2 infiltrative lesion. Non-contrast CT: L2 lytic process with pathologic fracture Bone scan #2: photopenic foci at L2 and right scapula Skeletal survey #1: negative Bone marrow biopsy #2: plasma cell neoplasm Skeletal survey #2: lesions at L2, left pelvis, bilateral proximal femurs as well as bilateral osteoarthrosis of glenohumeral joints and left sacroiliitis FINAL WORKING DIAGNOSIS: Stage 2 multiple myeloma TREATMENT AND OUTCOMES: 1.Radiation and chemotherapy 2.Clamshell TLSO for lumbar lordosis 3.Simplifed exercise program: upright stationary cycle, overhead reach, back extension stretches. Focus on core strength, hip flexibility. 4.Advance to stairs, pool running, captain’s chair, bird dog, and abdominal press 5.Avoid overhead lifting and compressive spine exercises 6.Treatment complicated by pulmonary embolism. 7.Tolerance of bending and lifting improved participation in household activities. 8.Goal: to return to weight lifting exercises and outdoor biking.