A 50 year old software analyst presented with right leg pain with Ultrasound scans revealing a small proximal hamstring tear as well as Achilles tendinopathy but something didn’t look right?
The pain had come on after a heavy gardening session and now was limiting his walking to 10min. It was also aggravated by prolonged sitting, which generally will not aggravate a muscle tear. Examination revealed a positive straight leg test(testing the sciatic nerve) on the affected side as well as reduced reflexes at S1. There was also guarding in the right psoas, glut medius and piriformis muscles, as well as hypomobility in L5 anterior disc and right subscapularis.
Treatment aimed at restoring musculoskeletal balance improved this patients’s leg pain by 30% and walking to 15min, but progress had plateaued. I sent him back to his GP for a lumbar MRI suspecting a L5/S1 disc prolapse, but his GP was reluctant to investigate as he had improved to some degree. We continued with treatment for a little longer until it was clear we had achieved all we could with Physiotherapy. This time I was a little more direct with his GP, and a subsequent MRI revealed the source of this man’s pain…. a large right posterolateral disc prolapse with extruded fragments compressing the S1 nerve root!
This case demonstrates that GPs are not always correct when it comes to musculoskeletal conditions and Physios should trust their extensive training in this area. It’s also for us to recognise our limitations and refer on when a patient is not responding to treatment as we would expect.
This patient went on to have a microdiscectomy and is recovering well.
