FF MSK INITIAL

Patient Consent Consent to Treatment and Information Sharing: Consent given Subjective Assessment: Presenting Complaint: Lower back pain, radiating into the left leg. History of Present Condition: Pain started 2 weeks ago after lifting a heavy box. Aggravating factors include prolonged sitting and bending. Easing factors include rest and lying down. Pain Scale: 6/10 at worst, 3/10 at best. Functional Impact: Difficulty with work (sitting at a desk), ADLs (putting on socks), and sports (unable to play football). Red Flags Screening: No red flags identified. Past Medical History: No relevant history. Medications: Ibuprofen 400mg as needed. Goals of Treatment: To reduce pain to 2/10 within 4 weeks, return to work duties, and be able to walk for 30 minutes without pain. Objective Assessment: Observation/Posture: Forward head posture, slight lateral shift to the right. Active and Passive ROM: Lumbar flexion limited to 60 degrees, pain with left lateral flexion. Strength Testing: Weakness noted in left hamstring (4/5). Pain on Palpation: Tenderness over L4/L5 and left paraspinal muscles. Special Tests: Positive Slump test on the left. Neurological Screen: Sensation intact, reflexes 2+ bilaterally. Functional Movement Tests: Pain with single leg stance on the left. Analysis: Analysis and Reasoning: Suspect lumbar discogenic pain with radicular symptoms. Possible nerve root irritation. Plan and Intervention: Education Provided: Advice on posture, body mechanics, and pain management strategies. Intervention(s) Commenced: Manual therapy to lumbar spine and soft tissue release to paraspinal muscles. Exercises: nerve glides and core stability exercises. 30 minutes. Home Exercise Programme: Nerve glides, core stability exercises, and postural correction exercises. Referral Required: No referral required at this time. Next Appointment Booked: Yes