A 48-year-old white man presented with a 6-month history of low back pain. He recalled the morning when he first noticed pain in his lumbar region; he awoke to find himself “hunched over” with marked difficulty standing up straight. The pain, which shifted back and forth from his right to left lumbosacral region, was described as aching, episodic, and fluctuating in intensity. He also had occasional bouts of pain and numbness that radiated into his buttocks and down to his knees, with the right lower extremity being more frequently affected. His back felt stiff and he had an especially hard time achieving a fully erect posture after prolonged sitting. He found a position of ease by lying flat on his back with his hips flexed, knees extended, and legs resting against a wall. He believed that this position stretched the tight muscles in his legs.
The patient denied a history of trauma or increased pain with coughing or sneezing. He also denied any bowel or bladder dysfunction. He had been seeing a chiropractor regularly and performing stretches and “core-strengthening exercises” at home, but this therapy gave him little relief. In addition, he had been prescribed cyclobenzaprine hydrochloride, but he did not like the groggy feeling caused by the drug, so he discontinued its use.
The patient's medical, social, and family histories were noncontributory. Physical examination revealed a well-nourished individual with no signs of acute distress. His vital signs included a blood pressure of 122/78 mm Hg, a body temperature of 98.0°F (36.7°C), a pulse of 80 beats per minute, and a respiratory rate of 16 breaths per minute. He had normal muscle strength (5/5) in his lower extremities bilaterally. His patellar and Achilles deep tendon reflexes were +2/4 bilaterally. He had decreases in normal passive ranges of motion as follows: hip flexion reduced by approximately 40% bilaterally, left hip internal rotation reduced by approximately 75%, left hip external rotation reduced by approximately 60%, left hip extension reduced by approximately 60%, and right hip extension reduced by approximately 35%.
An osteopathic structural examination revealed, in addition to the previously mentioned findings, an anterior rotation of the right innominate bone; a left-on-right backward sacral torsion; lumbar vertebrae L1-L2 flexed, rotated left, and sidebent left; and L3-L5 neutral, rotated right, and sidebent left.
Figure 1 lists diagnostic findings gathered during an osteopathic structural examination that may be suggestive of psoas syndrome.