BACK AND LEG PAIN - SOCCER

Abstract

1167 HISTORY: 23-year-old male soccer player with six month history of sudden low back pain. Pain developed when bending to pick up an object. Pain localized to the low back and radiated down the posterior aspect of the thigh and calf. Pain described as aching with intermittent "electric" shooting pain, and was exacerbated by sitting. Initial diagnosis by a primary care physician was "muscular strain." He was given a flexion-based home exercise program, which exacerbated symptoms. He was sent to physical therapy (P.T.) and started an extension-based program. He made modest gains, then plateaued and was discharged from P.T. Magnetic resonance imaging (M.R.I.) at an outside medical facility revealed a "disc herniation," but was not available for review. Patient was referred for a second opinion. At our initial consultation he complained of continued pain with numbness in the same distribution. He denied fever, chills, weight loss, night sweats, bowel or bladder incontinence or weakness. PHYSICAL EXAM: Healthy, 23-year-old male, with antalgic gait favoring the right side. Active range of motion of the lumbosacral (L.S.) spine was within normal limits except flexion, which was limited by pain in the right buttock and posterior thigh at 30 degrees. Right straight leg raise (S.L.R.) reproduced pain. Contralateral and reverse S.L.R.s were not painful. Manual muscle testing 5/5 in bilateral lower extremities (L.E.) except right hip extension 4+/5, and right ankle dorsiflexion 5−/5. Right knee extension 5−/5, limited by posterior thigh pain. Sensory exam normal to light touch and pinprick. Deep tendon reflexes were: 2+ patellar, 1+ left internal hamstring, absent right internal hamstring, 2+ left Achilles and 0-1 right Achilles. Plantar response was flexor. No pain to palpation in lumbar and gluteal regions. Discogenic radiculopathy - acute vs. chronic. Spondylolysis or spondylolesthesis associated radiculopathy. Chronic lumbosacral myofascial pain. TESTS AND RESULTS: Right L.E. elecrodiagnostic studies: Normal nerve conduction studies and F-wave latencies. Slowing of right H-reflex (1.4 millisec > left). Needle electromyography normal except: increased insertional activity and >30% polyphasics in peroneus longus. Medial gastrocnemius with potentials >6mV, and guteus maximus with multiple small nascent potentials. M.R.I. of the L.S. spine: L5-S1 right paracentral disc protrusion with compression of S1 nerve root. No neuroforaminal narrowing. Short tau inversion recovery (STIR) images increased signal in right S1 nerve root. FINAL/WORKING DIAGNOSIS: Chronic right S1 radiculopathy from protruded L5-S1 disc. Severe denervation and re-innervation of the right gluteus maximus muscle. Chronic denervation with peripheral sprouting in peroneus longus and medial gastrocnemius muscles. Pain control with tramadol and gabapentin. Physical therapy program for centralization and stabilization. Program focused toward strengthening hip extension, knee flexion and ankle eversion. Advanced to endurance activities through pain tolerance. Returned to all competitive sports in two months with ninety percent improvement in pain. Repeat electrodiagnostic studies at six months.