Back Pain Joint Initial Letter

1/11/2024 Many thanks for your kind referral. History of Presenting Complaint The patient, a 35-year-old male, presents with persistent lower back pain for the past three months, exacerbated by prolonged sitting and physical activity. Aggravating Factors Pain increases with bending forward and lifting heavy objects. Relevant Past Medical History History of lumbar strain two years ago. Treatments already tried The patient has tried over-the-counter pain medications and physical therapy with minimal relief. Social and Exercise History The patient is a recreational runner and works a desk job. Medications Ibuprofen 400mg as needed. Allergies No known drug allergies. Physical Examination Stance: Pelvis tilted anteriorly. Asymmetry noted in the iliac crests. No rib ring dysfunction observed. Absence of sacrum swelling. Lumbar lordosis appears exaggerated. Muscle gripping strategies noted in standing. Signs of sacroiliac joint incompetence: Stork test positive on the right side. ASLR test positive bilaterally. Posterior pelvic pain provocation test positive. Pain to palpation of the long dorsal sacroiliac ligament. Three positive SIJ tests noted. Sacroiliac joint glide test shows reduced mobility. FABER and Patrick's tests positive. Hip joint examination: Tenderness over the greater trochanter on the right side. Tests for micro-instability of the hip are negative. Lumbar spine: Range of motion is limited in flexion and extension. Neurological examination of the lower limbs is normal. Clonus is absent. Lesaegue's sign is negative. Lumbo-Pelvic Muscle Function: Rectus abdominis muscle diastasis is absent. Tension of underlying fascia is normal. Functional stability of spine and pelvis is compromised. Trunk muscle function: Ability to contract stabilising muscles is reduced. Substitution strategies observed. Correction findings: Improvement in pain with correction of SIJ alignment. Nerve Impingements: No nerve impingement findings. Imaging: MRI shows mild disc bulge at L4-L5. Multifidus Muscle fatty infiltration (MMFI) at L5-S1. Plans: Recommend continuation of physical therapy focusing on core strengthening. Consider referral to a pain specialist for further management.