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To enhance your diagnostic reasoning skills, follow these steps:
- Review the Information: Carefully read through the content in each section of the case scenario.
- Consider the Question: Reflect on the Diagnostic Reasoning Question presented. Take your time to think about your answer.
- Compare Your Answer: Attempt to answer the question before viewing our suggested answer. When ready, click “View Suggested Answer” to compare it with your own.
Repeat these steps for each section of the case scenario. Please note that the suggested answers are only indicative and not exhaustive. They serve as guidelines and should not be considered complete answers.
Patient’s History
In the sections below, you will find case history information designed to guide you through a systematic approach to performing a focused and relevant case history. This process will help you narrow down the potential causes of the patient’s complaint. As you go through the material, we encourage you to answer the questions provided to test and enhance your diagnostic reasoning skills.
Who is the patient and where is the pain?
When was the onset and what caused the onset?
Daniel, a 38-year-old warehouse worker, presents with a four-month history of persistent lower back pain, primarily localized to the right sacroiliac and right buttock regions. The pain began gradually following an increase in his workload, which included repetitive heavy lifting and prolonged standing.
Diagnostic Reasoning Question
What are the possible causes of Daniel’s lower back pain?
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- Lumbosacral Joint Dysfunction
- Sacroiliac Joint Dysfunction
- Quadratus Lumborum Myofascial Pain Syndrome
- Iliolumbar Ligament Strain
- Piriformis Syndrome
- Lumbar Disc Herniation
- Lumbar Facet Syndrome
- Ankylosing Spondylitis
- Space-Occupying Lesions (e.g., tumor, metastasis)
- Infection (e.g., osteomyelitis)
What are the pain characteristics?
What are the aggravating and relieving factors?
What has been the course of the pain?
Daniel describes his pain as a deep, aching discomfort, occasionally sharp when bending to the side or standing on one leg. His symptoms are aggravated by prolonged standing, sitting, or walking on an incline. He reports relief with heat, stretching, and lying down with his knees bent. The pain has not resolved and tends to occur in episodes, often related to his work activities.
Diagnostic Reasoning Question
What does the episodic, activity-related pattern and lack of full resolution suggest about the underlying cause of his pain?
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The episodic and non-resolving nature of Daniel’s pain, particularly in response to work-related physical stressors, suggests a mechanical or postural dysfunction. The pattern of pain fluctuating with activity levels and partial relief from conservative measures such as rest, heat, and stretching points away from an acute injury or structural pathology.
Are there any associated symptoms?
On further questioning, Daniel reports no leg weakness, numbness, or pain radiating down the leg, and denies any bowel or bladder dysfunction. He notes that his back pain is noticeable in the morning but usually improves within a few minutes of getting up. He also mentions experiencing an aching sensation in his right hip, particularly when he sleeps on his right side, which he finds curious.
Diagnostic Reasoning Question
How does the information provided help the diagnostic process?
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The absence of red flags (e.g. neurological deficits or bowel/bladder involvement) lowers the likelihood of serious pathology such as disc herniation or cauda equina syndrome. The transient morning stiffness and positional hip discomfort, especially the pain over the lateral right hip when lying on that side, point to musculoskeletal or postural factors, such as soft tissue irritation (e.g., gluteal tendinopathy or trochanteric bursitis), poor sleep posture, or asymmetric loading from daily activity. Additionally, the short-lived morning back stiffness makes inflammatory conditions like ankylosing spondylitis less likely.
Is there any past history that may be relevant to the current complaint?
Daniel’s history reveals a low back muscle strain two years ago, which resolved with rest. He has no history of spine surgery, fractures, or inflammatory conditions such as ankylosing spondylitis.
Diagnostic Reasoning Question
How does Daniel’s past history help the diagnostic process?
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Daniel’s history of repetitive strain and overuse increases the likelihood of a mechanical musculoskeletal condition. The absence of prior spinal surgeries or known inflammatory disorders makes degenerative or inflammatory spinal pathology less likely.
His physically demanding occupation, involving repetitive lifting, prolonged standing, and asymmetrical postures, likely contributes to chronic muscular tension and the potential development of myofascial trigger points.
Are there any red flags?
The following questions are asked to identify any “red flags” that could suggest serious pathology. Even if the patient has previously mentioned related information during the case history, it is recommended to revisit these questions to ensure a comprehensive evaluation.
- Do your symptoms disappear even for a short time? “Yes, when I can rest and also after stretching my back.”
- Does the pain wake you up at night? “Sometimes when I sleep on my right side, but not always.”
- Have you noticed any discoloration of your urine? “No.”
- Have you had any bladder or bowel problems since the onset of your pain? “No.”
- Do you feel weak in your legs? “Not really.”
- Have you recently experienced fever, chills, night sweats, or vomiting? “No.”
- Have you recently had any unexplained weight loss? “No.”
- Do you have a history of cancer or HIV? “No.”
Diagnostic Reasoning Question
Do any of Daniel’s answers raise red flags?
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No red flags.
Differential Diagnosis
Diagnostic Reasoning Question
Based on Daniel’s history, which differential diagnoses should be considered, and why?
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Based on Daniel’s history of gradual-onset, right-sided lower back pain worsened by physical activity and relieved by rest and stretching, the following differential diagnoses should be considered:
Quadratus Lumborum Myofascial Pain Syndrome
- His description of deep, aching pain with occasional sharp episodes, worsened by side bending and prolonged postures, is characteristic of myofascial pain.
- His work involves repetitive lifting and prolonged standing, which are common triggers for QL muscle overuse and trigger point formation.
Sacroiliac Joint Dysfunction
- Localized pain near the sacroiliac region, worsened by asymmetrical loading (e.g., standing on one leg), suggests possible involvement of the SI joint.
Lumbar Facet Joint Syndrome
- The mechanical nature of the pain and lack of neurological symptoms raise the possibility of facet joint irritation, especially with extension or side bending movements.
Greater Trochanteric Pain Syndrome
- His report of aching pain in the lateral hip, especially when lying on the right side, may indicate soft tissue irritation over the greater trochanter, such as gluteal tendinopathy or bursitis.
Lumbar Disc Pathology (less likely)
- Although possible, the absence of radicular pain, numbness, or weakness makes significant disc herniation or nerve root involvement less likely.
Reflection Point
Pause and consider whether the key elements of a thorough and relevant patient history have been addressed. Are there any additional questions you would have asked? If so, what are they, and why would they be important?
Before reviewing the physical examination findings below, take a moment to reflect on which physical examination procedures you would perform to accurately assess this patient.
Physical Examination
In the sections below, you will find physical examination findings for this patient. The material outlines a systematic approach to conducting a focused and relevant physical examination aimed at narrowing down the potential causes of the patient’s complaint. As you review the material, we encourage you to answer the questions provided to test and enhance your clinical reasoning and diagnostic skills. Additionally, consider whether all essential elements of the physical examination have been thoroughly addressed.
Vital Signs
Daniel’s blood pressure, heart rate, and temperature are normal.
Diagnostic Reasoning Question
Why are normal vital signs relevant in this case?
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Normal vitals help rule out infection or systemic inflammatory conditions that could contribute to low back pain, such as ankylosing spondylitis or osteomyelitis.
Inspection
Daniel’s posture is slightly asymmetrical, with a mild lateral shift of his torso to the left in standing. His right pelvis appears elevated, and there is no visible atrophy or swelling. He reports discomfort when standing on his right leg for extended periods. A likely functional lumbar scoliosis is observed, with a convexity to the left and a flattened lumbar lordosis.
While seated, he leans slightly to the right. In the prone position, there is elevation of the right pelvis and an apparent right leg shortening of approximately 2 cm compared to the left.
Diagnostic Reasoning Question
How do Daniel’s inspection findings inform the diagnostic process?
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Daniel’s inspection findings support a mechanical musculoskeletal origin for his symptoms. The asymmetrical posture, right pelvic elevation, and a potentially functional scoliosis convex to the left suggest unilateral muscle tightness or imbalance, likely involving the right quadratus lumborum.
The flattened lumbar lordosis and positional shifts in standing, sitting, and prone positions further indicate compensatory patterns linked to soft tissue dysfunction rather than structural pathology. These findings, combined with the absence of atrophy, swelling, or neurological signs, help rule out more serious conditions and guide the clinician toward a myofascial or postural source of pain.
Range of Motion
Daniel demonstrates limited and mildly painful lateral flexion to the left. Lateral flexion to the right is less restricted and produces mild discomfort. Forward flexion is slightly limited. Lumbar extension is near normal. Trunk rotation to the left is somewhat painful and limited.
Diagnostic Reasoning Question
How do Daniel’s range of motion limitations contribute to the differential diagnosis?
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Daniel’s range of motion findings indicate an asymmetric pattern of restriction, with greater limitation and discomfort during left lateral flexion and left trunk rotation, suggesting involvement of right-sided lumbar musculature, likely the right quadratus lumborum.
The mild limitation in forward flexion and preserved extension further support a mechanical, soft-tissue origin rather than structural instability or neurological compromise. These findings align with myofascial dysfunction or muscle imbalance as the likely cause of his symptoms.
Palpation
Palpation over the region identified by Daniel (around the right sacroiliac joint and lower portion of the right buttock) produced mild tenderness without palpable nodularity. Mild discomfort was also noted on palpation of the right lateral hip region, again without evidence of nodularity. In contrast, palpation of the right lumbar paraspinal area revealed increased muscular tenderness, raising suspicion of quadratus lumborum involvement.
With the patient in left side-lying position, focused palpation of the right quadratus lumborum revealed exquisitely tender points that reproduced Daniel’s symptoms.
Functional assessment of the lumbar spine, sacroiliac joints, and right hip was essentially normal, with the exception of mild movement rigidity noted in the lumbar region.
Diagnostic Reasoning Question 1
How does the pattern of tenderness on palpation help differentiate between potential sources of Daniel’s pain?
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The mild tenderness over the sacroiliac and lateral hip regions without nodularity suggests these areas may be sites of referred pain rather than primary pathology. In contrast, the presence of localized, reproducible tenderness in the right quadratus lumborum, particularly when side-lying, strongly supports this muscle as the primary pain generator.
Diagnostic Reasoning Question 2
What is the significance of symptom reproduction during palpation of the quadratus lumborum in the side-lying position?
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Symptom reproduction in this position confirms the presence of active trigger points in the quadratus lumborum, linking palpation findings to Daniel’s reported pain and supporting a myofascial origin rather than joint or nerve-based pathology.
To effectively examine the quadratus lumborum for trigger points, a procedure referred to as the Quadratus Lumborum Compression Test is used as described below:
Quadratus Lumborum Compression Test
- Position the patient lying on their unaffected side, so the involved side is uppermost.
- Ask the patient to reach their upper arm overhead, which helps elevate the rib cage and open the space between the 12th rib and the iliac crest. For some patients, insert a small lumbar roll or pillow under the waist to widen that space further and facilitate muscle access.
- With the involved side uppermost, palpate the quadratus lumborum muscle along its insertion from the iliac crest to the 12th rib/transverse processes.
- Apply firm compression (pressure) vertically through the muscle belly toward the iliac crest.
- Ask the patient whether the applied pressure reproduces their characteristic pain pattern (local or referred).
- A positive test is one in which the patient reports familiar pain when the quadratus lumborum is compressed.
Patient Position for Trigger Point Examination
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Neurological Examination
Neurological screening of the L2 to S1 nerve roots revealed normal findings.
Diagnostic Reasoning Question
Why was a neurological examination of the L2 to S1 nerve roots performed in this patient with quadratus lumborum involvement as the most likely diagnosis?
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The neurological examination of the L2 to S1 nerve roots was conducted to rule out radiculopathy or other neurological causes of lower back and referred pain. Although Daniel’s symptoms and physical findings were more consistent with a myofascial source, it is essential to exclude nerve root involvement, particularly due to the proximity of symptoms to the lumbar and sacroiliac regions.
As practitioners, we must remain cognizant that patients may present with more than one condition simultaneously. Therefore, a thorough neurological screen ensures that coexisting pathologies, such as nerve compression, are not overlooked. The normal findings in this case helped reinforce a diagnosis of a non-neurological source of pain.
Watch the following video for a demonstration of the neurological examination of the L2 to S1 nerve roots.
Reflection Point
Considering the patient’s history and examination findings thus far, please take a moment to reflect on which special tests would be most appropriate to evaluate this patient further.
Special Tests
The Lumbar Quadrant Test was performed and yielded normal findings.
Diagnostic Reasoning Question
What is the significance of a negative Lumbar Quadrant Test in the context of Daniel’s lower back pain?
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A negative Lumbar Quadrant test suggests that zygapophyseal (facet ) joint irritation or nerve root compression is unlikely to be contributing to Daniel’s symptoms.
Watch the following video for a demonstration of the Lumbar Quadrant test.
The FABER test is performed and found to be negative.
Diagnostic Reasoning Question
Why was the FABER test performed in this patient, and what does a negative result indicate?
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The FABER test was performed to assess for possible intra-articular hip pathology or sacroiliac joint dysfunction, both of which can refer pain to the lower back, buttock, or lateral hip. A negative result helps rule out these joint-related sources of pain and supports a soft tissue or myofascial origin.
Watch the following video for a demonstration of the FABER Test.
The Thigh Thrust test was performed and was found to be negative.
Diagnostic Reasoning Question
What is the clinical purpose of the Thigh Thrust test?
ViewHide Suggested Answer
The Thigh Thrust test is used to assess for sacroiliac joint dysfunction by applying a posterior shear force through the femur to stress the SI joint. A positive test reproduces the patient’s familiar pain, typically in the buttock or sacroiliac region, and suggests SI joint involvement. A negative test makes sacroiliac pathology less likely and supports consideration of other causes, such as myofascial or lumbar spine-related pain.
Watch the following video for a demonstration of the Thigh Thrust Test.
Reflection Point
Please pause and assess whether all the essential elements of a thorough and relevant physical examination have been completed for this patient. Are there any additional procedures you would have performed? If so, why?
Diagnosis
Diagnostic Reasoning Question
Based on the available information, what is the most likely diagnosis?
ViewHide Suggested Answer
Quadratus Lumborum Myofascial Pain Syndrome.
This case is a fictional educational scenario created for learning purposes. Any resemblance to real persons is coincidental.
References and Suggested Further Readings:
Travell, Simons and Simons. Myofascial Pain and Dysfunction: The Trigger Point Manual. 3rd edition. Wolters Kluwer, 2019.
de Franca GG, Levine LJ. The quadratus lumborum and low back pain. J Manipulative Physiol Ther. 1991 Feb;14(2):142-9. PMID: 1826922.
Sirh SJ, Sirh SW, Mun HY, Sirh HM. Importance of quadratus lumborum muscle trigger point injection and prolotherapy technique for lower back and buttock pain. Front Pain Res (Lausanne). 2022 Nov 22;3:997645.
Yıldırım Uslu E. Effect of Quadratus Lumborum Block in Patients With Acute-Subacute Unilateral Lumbar Strain. Cureus. 2024 May 24;16(5):e61014.
Giamberardino M, Affaitati G, Fabrizio A, Costantini R. Myofascial pain syndromes and their evaluation. Best Pract Res Clin Rheumatol. 2011 Apr;25(2):185-98.
Hong C. Treatment of myofascial pain syndrome. Curr Pain Headache Rep 2006; 10:345.
Jennifer E Finley J. Physical Medicine and Rehabilitation for Myofascial Pain. www.emedicine.medscape.com
Review Quiz
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The answer is????
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Copyright © Educom Pty Ltd: All content on the acemsk.com website, including text, graphics, videos, and downloadable files, is the property of Educom Continuing Education, a division of Educom Pty Ltd, and is protected by copyright and other intellectual property laws under international conventions. Unauthorized use or duplication of this material without express written permission from Educom Pty Ltd is strictly prohibited.
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