Study design: Resident's case problem.
Background: This paper describes the clinical course of a patient with low back pain (LBP) and left lower extremity pain and tingling, and how the physical therapist used clinical examination findings and a lack of improvement with conservative measures to initiate further medical evaluation, which resulted in a diagnosis of cancer as the primary cause of the patient's low back and hip pain.
Diagnosis: A 45-year-old man with chief complaints of left-sided LBP, left posterior thigh pain, and tingling along the anterolateral aspect of his left lower extremity was initially seen by a physical therapist in a direct access setting. Several components of the patient's history and physical examination were consistent with a mechanical neuromusculoskeletal dysfunction. However, there were signs and symptoms present that may have been suggestive of more serious underlying disease. Specifically, the patient's most intense pain was in the evening and into the night and an atypical pattern of restricted motion at the left hip was noted. Therefore, the physical therapist recommended that the patient schedule an appointment with his physician for medical evaluation. A short-term course of physical therapy treatment was also undertaken to address neuromusculoskeletal impairments. Despite 5 physical therapy visits over the course of a month, while the patient waited for his scheduled physician appointment, the patient's condition gradually worsened. After medical evaluation, the patient was eventually diagnosed with small cell carcinoma of the lung, with metastases to the spine and pelvis. Despite 2 cycles of chemotherapy, the patient succumbed to the cancer 5 months after he was first seen in physical therapy.
Discussion: It is important that physical therapists have an understanding of the clinical findings associated with the presence of serious underlying diseases causing LBP, as this information provides guidance as to when communication with the patient's physician is warranted.