Author: Lindsay Parlee, MD
Senior Editor: Heather Rainey, MD
Editor: Christopher Miller, MD

Patient Presentation:
A 16-year-old male presented with acute thoracolumbar back pain in the setting of subacute lumbar back pain. The lumbar back pain had started months ago after rowing.

History:
The patient had been receiving treatment for lumbar muscle spasm in the setting of pain with reduced range of motion (ROM) in all planes, normal lumbar radiographs, and absence of red flag symptoms. He experienced only trivial improvement in ROM and pain severity despite one month of rest, physical therapy, and trials of cyclobenzaprine, ibuprofen, ketorolac, and methylprednisolone, and so he moved on to additional treatment. This included chiropractic adjustments and dry needling, which resulted in modest improvements in pain and dysfunction. <br> <br>At the time of presentation, however, he returned to the clinic with acute worsening and a change in the character of his back pain. He reported midline thoracolumbar pain with radiation of the pain toward the right hip, and for the first time he reported pain waking him from sleep at night.

Physical Exam:
Vitals: T 97.6, HR 104, RR 14, O2 99% <br>General: uncomfortable but not ill, antalgic gait <br>HEENT: normocephalic, atraumatic <br>Cardiovascular: regular rate and rhythm, no murmur, no rub, no gallop <br>Pulmonary: no respiratory distress, lung sounds clear to auscultation <br>Gastrointestinal: abdomen non-distended and soft <br>Integumentary: no rash, no abrasions, lacerations, excoriations, ecchymosis, petechiae <br>Musculoskeletal: <br>Back: <br>Inspection: no erythema, no ecchymosis, no deformity, no scoliosis, normal bulk <br>and tone <br>Palpation: tenderness to palpation thoracolumbar spinous processes, right <br>paraspinal region, right anterior superior iliac crest. <br>Active range of motion: forward flexion 75, extension 5, lateral flexion 10 <br>bilaterally. <br>Strength: 5/5 hip flexion, 5/5 hip extension, 5/5 knee flexion, 5/5 knee extension, 5/5 dorsiflexion, 5/5 plantarflexion, 5/5 ankle inversion, 5/5 ankle eversion. <br>Dynamic Tests: Romberg negative, straight leg test negative bilaterally <br>Reflexes: patellar reflex 2+, Achilles reflex 2+ <br>Sensation: sensation to light touch intact bilateral lower extremities <br>Vascular: dorsalis pedis 2+

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