***Much of the information on these cases have been falsified to protect patient information. This is not medical advice.***

Subjective: A 16 year old male tennis player arrives with low back pain. Pain has been gradually increasing over the last 5 weeks. He does recall a sudden onset of mild pain when he was reaching during backhand swing, and pain has worsened significantly since then. Pain goes down his posterior R leg all the way down to his leg. He does report numbness and tingling. Symptoms are present at all times, and he has a hard time getting out of bed and sitting for long periods. He has not played tennis since 5 weeks ago. He is unable to put on his shoes without excruciating pain. Before you continue to scroll, please take a moment to answer below questions.

– What patient reported outcome (PRO) would you like to take?

– What level of disability do you predict he will be at based on the PRO?

– What other questions would you like to ask?

Radiographs and MRI obtained with no evidence of fractures, but MRI shows disc bulge at L5-S1. Upon further questioning, he notes this is his first incident of low back pain that has made him miss time. He denies any incontinence, and other red flags. His goals are to sleep at night, put on his shoes again, and to play at a high level of tennis without pain. At this point, you ask if he has any other points he wants to bring up that you did not ask about; he says no. Before you continue to scroll, please take a moment to answer below questions. Total subjective time: 10 minutes

– What will you look at for your clinical exam, and how much time will it take?

– Which of your suggested tests are not important and can be performed later?

Objective:

• Seated dermatomal testing (30 seconds): numbness in L5 and S1 dermatome
• Seated slump test (30 seconds): positive R side
• Standing lumbar AROM (30 seconds): 25% of distance based on SFMA criteria; all other motions deferred. Although there is no major harm in testing other motions, I deferred because I found one thing we can test re-test, and I am fairly confident in my primary diagnosis of symptomatic disc bulge. He is also very irritable
• Functional assessment (30 seconds): Squat is painful at 50% depth, and all other movements deferred. He is already in pain, and we will first make sure squatting is pain free; we can do other more demanding tasks at future visits
• Supine hip PROM bilaterally and ASLR test (2 minutes): Positive R side ASLR, painful R PROM SLR compared to L (45 deg vs 90 deg), about 25% different hip ER PROM
• Total time of objective exam: 4 minutes
• Summary:
  • (+) ASLR R LE
  • (+) Slump R LE
  • 45 degrees PROM SLR vs 90 degrees
  • Pain with forward flexion
  • Unable to squat without pain
  • Oswestry disability index (ODI): 73% disability

– What are your top 3 diagnosis?

– What exercises will you provide for this person?

– What will you test re-test?

Intervention:

• Clamshells: Patient unable to perform more than 12, and unable to reach appropriate height. He was told to perform 2 more sets of 8 which he completed pain free. We then immediately tested ASLR and PROM SLR. ASLR still painful, however PROM SLR increased to 70 degrees
• Hip hinge: Patient was first asked “Do you have a coffee table, ottoman, or low chair to perform the next exercise?”. After confirming a coffee table, he stood facing away from the low table with his knee crease against the table. He was instructed to reach and touch his mid-shin. To make sure he posteriorly shifted his weight, he was instructed to imagine his hands are full and he needs to open a door behind him with his butt. He was also reminded to keep his knee crease against the table the whole time. Patient was able to complete this. Immediately after, AROM lumbar flexion was tested and patient reached 50% based on SFMA criteria
• Both were provided for homework: Clamshells 3×8 and hip hinge with table support 3×5
• Total intervention and treatment time: 7 minutes

Plan:

Diagnosis of symptomatic disc bulge was explained, but in patient-friendly language (5 minutes):

• These are common findings on MRI, but don’t always correlate with pain
• There is a possibility that surgery may be required if motor weakness, incontinence, function continues to worsen and exercise therapy and injections have been unsuccessful
• Exercises therapy will strengthen surrounding muscles so that tissues are less irritated

Prognosis (5 minutes):

• Prognosis is fair considering the immediate improvements with low level exercises, active baseline lifestyle, and acuity of event, however 73% disability is quite a lot
• It is normal to feel 20-30% better in two weeks, and he should be at nearly 20% disability at 4 weeks; at that point you can consider continuing therapy based on your testing scores, disability level, financial situation, self-confidence, time, and completed goals
• We should know if exercise therapy is not working well for you within the first 4 weeks, and if at 6 weeks there has been no improvements, a follow up with MD may be warranted for alternative interventions
• I recommend PT 1x/week, but could justify 2x if you would like. If you can not do 1x/week we will figure out a way to make it work although it may take longer

Total Treatment time: 31 minutes

– If you could choose 2 things, what would you re-test at follow up that you feel would be improved based on your HEP?

– What would be your return to sport testing criteria and how would that dictate exercises you give next?

Follow up: At 2nd visit a week later, patient did not feel functionally any better with ADLs our sport, but was able to squat further, had more AROM lumbar flexion, retained the 70 degrees of PROM SLR, and was able to complete 15 clamshells with improve height. New HEP was squats to tolerance, single leg RDLs, and step ups with slow control down. Patient was unable to attend 3rd visit because he woke up one night with too much pain to get out of bed. Patient went to emergency room due to pain, and had a microdiscectomy performed 2 days after his ED visit. Based on MD preference, patient was referred to PT at 6 weeks post-op in which his ODI was 6% disability, PROM SLR was only 70 degrees but no pain, had poor calf raise endurance on his R side, and negative on all previously provocative tests. From week 6 to week 10, rotation was added back in gradually, and patient began lifting again. At 10 weeks patients was returned to lifting with strength coach, and then began tennis specific movements at week 12. Week 12 post-op the athlete was tested for discharge with below tests:

Results (12 weeks post-op)

Calf Raise Test:

• L calf: 10% height drop
• R calf: 33% height drop
• Positive peak power LSI = 88%
• Positive work LSI: 91%
• Negative work LSI: 97%

Core Strength

• Trunk curl up test: Pass
• Sidebridge test: Pass (>30 seconds)
• Endurance of extensors: Pass (>60 seconds)
• Abdominal dynamic test: Pass (>25 reps)
• Plank: Pass (100 seconds)
• Bridge hold: Pass (2 minutes)
• Loaded forward reach test (>50 cm)

Hip Strength

• Abduction LSI: 107%
• Adduction LSI: 108%
• Add:Abd ratio R: 110%
• Add:Abd ratio L: 107%
• PT:BW abduction R: 1.7 Nm/kg
• PT:BW abduction L: 1.6 Nm/kg

Functional Tests (Double Leg Counter Movement Jump )

• Concentric Impulse LSI: 91%
• Eccentric RFD LSI: 100%
• Height: 1″ higher than pre-injury

– Is he good to return to sport?

– Is there anything you would restrict?

– Is there anything else you would test?

– What interventions, if any would you provide based on results?

He was told to work on his calf endurance and was educated on a progression. He did not need to come to PT for rehab, but was told to come back in 2 weeks for testing. His strength coach and AT gradually returned him to sport over the next 2 weeks both with technical drills and workload.

Outcome:

He came back 2 weeks later and retested countermovement jump, single leg vertical jump, and calf raise test again. He maintained the same measures on the countermovement jump, had 87% LSI for his vertical jump test, and improved to 18% height loss on calf raise. Although he did not pass all tests, he improved significantly without formal PT, and he was safe to play. He was discharged from PT as he met all his goals, and we felt his test scores were sufficient although he will return post or pre season to retest. He has returned to prior level of function and is competing with no issues.

Reflection

• It’s really easy to keep repeating that 60% of people have disc bulges with no pain, but that still means 40% do. I am all for non-surgical methods, but it should always be on your mind if things go south. The patient should be educated on all possibilities, and it’s certainly possible to talk about the not-so-good possibilities while also staying optimistic. You should not be an advocate of PT, but an advocate of the patient. Be sure to check your biases when needed. A surgeon once told me that he likes being a surgeon, but loves being a doctor; alluding that “doctors” figure out the best route for the patient even if it’s not what they’re great at.
• That’s a lot of data and measurements we take for clearance. Although he did not pass all of them, we felt he was safe because he got more measures than probably 90% of patients do upon full return; most of the less-tested athletes do fine for this particular injury. Additionally, testing is a double-edged sword if you think black and white. If you test enough things, you will find deficiencies and may wrongfully hold someone out. It’s important for you to use that data to determine if someone is safe to play vs. at peak performance. This also means that you don’t need to do all of those tests and fancy tech. Testing actually takes longer than evals…how do you feel about that?
• Intervention-wise, sure you can “just load it”. In fact you can do whatever you want…as long as it works. Yes, I do clamshells. I use them in several ways, and most of the time they are a low level exercises that’s comfortable and provides immediate improvements upon retests. I am fully aware of all the EMG research and the functional training argument. We work the rotator cuff in OKC and CKC even though most sports use it an open chain matter, why is it so taboo for the hip to do OKC exercises? I will do a intervention if it is effective and gets people better in a concise manner.
• Did I miss out on a lot of things? For me, I think about what matters most in the moment, and what can impact the patient the most. End of the day, everyone I see is going through a full battery of tests for that body region, but how they get there may be different. For that reason, I like to focus on small chunks at a time. This also makes your treatments faster. The more people you see the more people you help.