Orthopedics - Back Pain
Orthopedics & Podiatry Main Menu
A condition of
pain in the lower (lumbar-sacral) back region, with or without radiation of
symptoms to the buttocks or lower extremities, in the non-pregnant patient.
Initial Diagnosis and management
history and performance of physical examination. Special attention to
presence or absence of "red flags" to include: age <18 or >55; history of
malignancy, steroid use, or HIV positivity; weight loss or constitutional
symptoms; structural deformity; anal or urethral sphincter disturbance;
saddle anesthesia; gait disturbance; or widespread neurologic deficit.
If red flags are
present, diagnostic testing may include plain radiographs; CBC; ESR; bone
scan; CT scan and/or MRI scan and electrodiagnosis as indicated.
If red flags are
absent a diagnostic workup is generally not necessary.
for the first 2 weeks consists of: reassurance that most episodes resolve
uneventfully within 6 weeks; encouragement to maintain as close to normal
activity as is tolerable; avoidance of bed rest greater than 24 hours;
NSAIDS (unless contraindicated); muscle relaxants for up to one week;
acetaminophen as needed; weak opiates (codeine; propoxyphene) unless
contraindicated; passive modalities (e.g. ice, heat) for symptomatic
relief, profiling for active duty personnel or duty limitations.
Ongoing management and objectives
If pain has not
improved in 2 weeks: re-evaluate for "red flags", change NSAID, and
consider referral to Physical Therapy for evaluation and treatment while
continuing to follow patient.
profile is needed
- Any limitations that affect strength, range
of motion, and general efficiency of feet, legs, lower back and pelvic
- Slightly limited mobility of joints,
muscular weakness, or other musculo-skeletal defects that may prevent
hand-to-hand fighting and disqualifies for prolonged effort.
- Defects or
impairments that require significant restriction of use
Specifications for the profile
- Weeks 1-2
- Run at own pace and distance
- No marching greater than 2 miles
- No sit ups
- No ruck sacks
- No lifting greater than 15lbs
- No repetitive bending
- Weeks 2-4
- Gradually return to normal activity
Patient/Soldier Education or Self care
- See attached sheet
- Demonstrate deficits that exist
- Describe/show soldier his/her limitations
- Explain injury and treatment methods
- Use diagram attached to describe injury,
location and treatment.
- Instruct and demonstrate rehab techniques
- Demonstrate rehab exercises as shown in
- Warm up before any sports activity
- Participate in a conditioning program to
build muscle strength
- Do stretching exercises daily
- Ask the patient to demonstrate newly
learned techniques and repeat any other instructions.
- Fine tune patient technique
- Correct any incorrect ROM/stretching
demonstrations or instructions by repeating and demonstrating information
or exercise correctly.
- Encourage questions
- Ask soldier if he or she has any questions
- Give supplements such as handouts
- Schedule follow up visit with primary care
- If pain persists or worsens
- The pain does not improve as expected
- Patient is having difficulty after three
days of injury
- Increased pain or swelling after the first
- Patient has any questions regarding care
Indications for referral to specialty care
signs with abnormal imaging studies (urgent consult if worsening) -
Orthopedics Spine referral with xrays done. Consider MRI prior
to referral (without contrast unless tumor suspected).
signs with normal imaging studies (urgent if worsening) Orthopedic Spine referral.
radiculopathy unresponsive to therapy - Orthopedic
referral. MRI of lumbar spine prior to referral (without contrast
radiographs associated with red flags - Orthopedics
Spine referral. MRI of lumbar spine prior to referral (without contrast
Loss of bladder or
bowel control - (urgent) Neurosurgery referral.
conditions such as, Urologic, GI, Gynecologic, Vascular, Neurologic,
Rheumatologic, or Systemic - referral to subspecialty appropriate to
affected organ system.
If pain has not
improved within 6 weeks, refer to Physical Medicine and Rehabilitation for
evaluation and management.
Referral criteria for return to Primary
symptoms; or, implementation of continuing treatment program that can be
managed in primary care portal with periodic subspecialty follow-up.
back pain without true radicular symptoms > 6 months – consider permanent
profiling addressing such as lifting limitations and sit-up limitations.
MEB referral goes
to TAMC Orthopedic MEB and Peblo MED regarding mechanical back pain.