Interesting Case

[Guest guest]

Hello all,I had a new patient this week present with something I've not seen before. Maybe you guys can offer suggestions.The patient is a 58 year old male in relatively good shape. He is self employed as a contractor/re-modeler. His complaint is right gluteal pain (7-8/10)with tingling into his toes. These symptoms have been present for about 8 months. However the symptoms only come on in the morning when he first bends over. His forward flexion is significantly reduced with pain and tingling to the point that he struggles to put socks on. He walks around his house for 45 minutes which helps loosen him up, then loads his truck for the day. During the drive there is slight

discomfort, but by the time he gets to the job site, he is able to function relatively pain free for the remainder of the day doing the physical labor that his work entails. He feels good in the evenings, but thin first thing in the morning he has pain upon flexion again.His MD ordered MRI of his lumbar spine which showed mild disc bulges, but no compromise to any nerve. He said that the MD spent 45 minutes with him going over the MRI and concluded that it was essentially a normal study. He has tried deep tissue massage of the gluteal region which gives short term relief, the next morning is slightly better reportedly. His massage therapist suggest that he come to me for evaluation.When I saw him he had virtually no symptoms as it was in the afternoon two days ago. He had a slight decrease in lumbar flexion. He was able to touch the

floor with his finger tips, but said that he was able to put his palms on the floor a year ago before these symptoms started. Reflexes and muscle strength were normal as were lumbar orthopedic tests. His right leg was slightly short due to restrictions in his right SI. Right piriformis was mildly tender to palpation. I adjusted his pelvis which evened out the leg length and stretched the piriformis and taught him the stretch to do at home upon waking up to see if it was tighter. After the adjustment he was able to flex a little farther and reported feeling a little looser, but since symptoms were not present when he came into the office couldn't tell how much better it was. I scheduled him for first thing this morning to see him when symptoms are present. When he arrived this morning, he was only able to flex about 45 degrees and reported 7/10 pain in the right gluteal region. I evaluated him and

piriformis was tight and tender to palpation. I had the massage therapist work on the area and she was able to decrease his symptoms by about 95% and significantly improve forward flexion after about 40 minutes of work periodically checking him off of the table. She worked for another 10 minutes and then instructed him to get off of the table and come out of the treatment room. When he bent forward to put his shoes on, his symptoms returned to about 50% of when he arrived. I then found that his right leg was short again and adjusted that which improved symptoms slightly, but still not to 95% where he was during the massage. The patient reported that the improvement that he had was similar to his morning routine to loosen his back, and figured that he would be able to function normally the rest of the day.I am a bit confused by his presentation. Any suggestions as to where to go from here

would be appreciated. Ron Aitchison, D.C. NW Physical Medicine & Rehab 311 W. Evergreen Blvd, Suite 100 Vancouver, WA 98660 (360)694-2225