15 yr old LBP

[honker23]

Looking for some answers from you all in regards to EMG/MRI/Clinical exam on a 15 yo male with 8 month history of back pain. I am a PT and had this kid referred to me from his PCP with "hamstring strain." His initial injury was 8 months ago during football. Since then his legs feel heavy and he is unable to participate past 75% without pain in the proximal HS area. He has pain at night in supine that is relieved with position changes. His exam is remarkable for a disc(no true weakness or loss of sensation) and has had an MRI showing a moderate L5-S1 post/postmedial disc herniation. Ortho recommended ESI, but his PCP talked him into trying PT. Obviously this isn't a HS strain...we don't need to go into that. I told the PCP that I didn't feel this was an 8 month HS strain and agreed with ortho that this was a back issue. The PCP then ordered an EMG which came back as "normal" Now he is using this to say go to PT for rehab.

Sorry for going on, but my real question is....What does the literature say about MRI/clinical exam vs. EMG in this scenario. I know there are many other issues with this case. I am just wondering about expectations with the EMG in this case, would you expect it to pick up something with this history or not.

Thanks!

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[SSdoc33]

Looking for some answers from you all in regards to EMG/MRI/Clinical exam on a 15 yo male with 8 month history of back pain. I am a PT and had this kid referred to me from his PCP with "hamstring strain." His initial injury was 8 months ago during football. Since then his legs feel heavy and he is unable to participate past 75% without pain in the proximal HS area. He has pain at night in supine that is relieved with position changes. His exam is remarkable for a disc(no true weakness or loss of sensation) and has had an MRI showing a moderate L5-S1 post/postmedial disc herniation. Ortho recommended ESI, but his PCP talked him into trying PT. Obviously this isn't a HS strain...we don't need to go into that. I told the PCP that I didn't feel this was an 8 month HS strain and agreed with ortho that this was a back issue. The PCP then ordered an EMG which came back as "normal" Now he is using this to say go to PT for rehab.

Sorry for going on, but my real question is....What does the literature say about MRI/clinical exam vs. EMG in this scenario. I know there are many other issues with this case. I am just wondering about expectations with the EMG in this case, would you expect it to pick up something with this history or not.

Thanks!

if its just back pain, an EMG wont show anything. youneed to have axonal damage from radiculopathy. im not surprised EMG is normal.

also, if it just LBP, ESI wont help.

agree with PCP. Pt is the way to go. focus on extension-bias core work.

 

[honker23]

He is limited in lumbar flexion, has reproduction of buttock/HS pain with lumbar extension. PA glides to the LS spine reproduces his post thigh pain. Ext/SB to the side of pain reproduces his symptoms. His left HS will not give way with MMT, but with repeated testing, he will fatigue earlier on the left side.
Are you thinking this is discogenic pain referring to post thigh vs NRC from the disc? MRI did report moderate foraminal narrowing. If there was some inflammation/compression of the root could he have normal EMG with these symptoms?
We did try core work in pain free positions(neutral) for 3-4 weeks waiting for his other appointments, no better. He's getting inpatient, football season is coming.
Thanks.

 

[Ludicolo]

Young football player w/ chronic LBP, worse in supine. Is he a lineman? Possibly spondylolisthesis? Maybe check L-spine flexion/extension films.

EMG can be normal in a radic, especially if a patient has only pain/sensory symptoms. But I agree this doesn’t sound radicular, although his flexion-biased pain may be discogenic.

 

[honker23]

Not a lineman, they did flex/ext films and MRI, no evidence of spondylolisthesis.

You answered my main question about EMG, thanks!

Pain/sensory issues are his main concern, except at high level activities-sprinting, football drills, etc...he feels fatigued legs with his pain.

 

[facetguy]

Try repeating the MRI with STIR or 'FatSat' images, looking specifically for subtle signs of edema in the pars area which is usually missed on MRI unless STIR is specifically done. He may have a spondylolysis that is developing (a "pending spondylolysis").

 

[RUOkie]

I'm with SSdoc33 on this one. Work on agressive core work. Honestly, I would be less concerned about pain when he is with you. Work on stability in extension as well even if it hurts a bit. In flexion/rotation, I would be a little less agressive.

 

[ampaphb]

also, if it just LBP, ESI wont help.

Overbroad, and far too dogmatic.

ESIs can bathe the posterior aspect of a protruding disc. Clearly is less likely to be effective than facet injections, but none of us should ever be arrogant enough to say something as definitive as "ESI won't help"

 

[Cyres]

Random thoughts.

Sacroiliac or iliosacral dysfunction accompanying the prolapsed disc? Pain in extension, lateral flexion, with limited flexion ROM might, in part, be from a hyper nutated sacrum. That would produce additional closure of the foramina/on the nerve root already impinged from the prolapse. The obliquity would also irritate the piriformis which could cause the buttock pain and affect the sciatic nerve. Growth spurt related HS tightness creating a posterior rotation of the iliums and a muscle length contractile insufficiency might also generate the pain and early fatigue, though I imagine HS stretching was included from day one.

Likely not present, but something out of the box to screen for since the condition doesn't seem to be responding well to standard treatments.

 

[lobelsteve]

Overbroad, and far too dogmatic.

ESIs can bathe the posterior aspect of a protruding disc. Clearly is less likely to be effective than facet injections, but none of us should ever be arrogant enough to say something as definitive as "ESI won't help"

ESI may help, but why do it?
It won't fix anything, but may make the pain go away so therapy and time can heal this up?

Facet vs disc vs SIJ or 1% chance it is other.
EMG is voodoo in 15 y/o with axial/referred LBP.
Establish the right diagnosis before aggressive treatment.

 

[honker23]

Thanks for your responses. I was most interested in your thoughts on the EMG...."voodoo" as lsteve says, I like that. I just thought it was a waste of time and money and shouldn't change how we should treat the kid, but I'm not the expert on EMGs. I know the ESI won't change his disc protrusion, but in my experience once the inflammation and pain subside we can really make some progress with core work. With continuous pain, the TA is really inhibited and has a tough time stabilizing prior to movements. So I have been pushing the kid and family to follow the orthopods advice and get the injection followed by some PT to see if he can return to some of his activities. PS...not being argumentative, but SI in a 15 yr old male really seems like a stretch and he only had 1 of 6 provocative tests (spring) but that was because he has a disc at that level. Thanks again.

 

[PMR 4 MSK]

I see these cases as let time take care of the problem, and nurse him along the way to improve the symptoms - NSAID and/or gabapentin, PT to decrease pain and increase function, ESI as last resort if pain is bad enough. His symptoms are at least aprtly radicular, so ESI does stand a good chance of helping. I hate sticking needles into teens, though.

 

[truthseeker]

15 year old boys go through growth spurts. It is possible that he simply has a transitional leg length discrepancy. try to inferiorly glide his ilium on the sore side and see if he doesn't love it. If it eases his symptoms, have him do it nightly until his growth spurt stops. put a 1/4 inch lift in the other shoe. have him wear it in all shoes until his legs are more equal.

I had almost the exact symptoms present in a 15 year old. put a lift in one shoe, symptoms went away. He came back a year later with the same symptoms on the other side (the one that used to be short and had the lift put in the shoe) legs were the same length, took the lift out and no more symptoms. came back as a senior, similar symptoms on the originally short side, that side was now long and put the lift in the originally long leg's shoe and symptoms went away.

Just sayin'