DOI: 6/1/2014. Patient is a 46-year-old male dishwasher who sustained injuries to his right shoulder, back and both legs when he slipped and fell while detaching grill.
Per IME report dated 08/24/15 by Dr. Katz, it was noted that the IW has received conservative management that includes PT, acupuncture, massage therapy, 7-8 low back injections, back brace/cane and heat/ice treatments. It was opined that the IW’s cervical/lumbar and right shoulder condition warrants further treatment in orthopedics. Recommendation was made for further PT 3 times per week for 6 weeks and re-evaluation and second opinion with a spine surgeon as the IW is status post multiple epidural injections to the lower back, with no improvement. Further treatment option including possible surgery will be pending on the outcome of the second opinion.
Based on the latest medical report dated 11/11/16, Reversed Straight leg raise is positive bilaterally. Lasegue test is positive at 45 degrees, bilaterally. Patrick’s maneuver is positive with reproduction of pain the bilateral groin, back and bilateral sacroiliac area. Muscle strength testing shows 4/5 with bilateral hip/knee flexion/extension, and left foot dorsiflexion. There is hypoesthesia noted at bilateral L5-S1 dermatomes. …show more content…
On lumbar examination, there is tenderness on palpation of L1-S1 paraspinal muscles, bilaterally. Lumbar active range of motion shows increased flexion at 55 degrees, extension at 5 degrees, bilateral rotation to 10 degrees and lateral flexion to 10 degrees. Patient needs to start PT for functional and objective improvement, to increase active range of motion, decrease pain for strengthening and lumbar stabilizer exercises and to improve daily
Per IME report dated 08/24/15 by Dr. Katz, it was noted that the IW has received conservative management that includes PT, acupuncture, massage therapy, 7-8 low back injections, back brace/cane and heat/ice treatments. It was opined that the IW’s cervical/lumbar and right shoulder condition warrants further treatment in orthopedics. Recommendation was made for further PT 3 times per week for 6 weeks and re-evaluation and second opinion with a spine surgeon as the IW is status post multiple epidural injections to the lower back, with no improvement. Further treatment option including possible surgery will be pending on the outcome of the second opinion.
Based on the latest medical report dated 11/11/16, Reversed Straight leg raise is positive bilaterally. Lasegue test is positive at 45 degrees, bilaterally. Patrick’s maneuver is positive with reproduction of pain the bilateral groin, back and bilateral sacroiliac area. Muscle strength testing shows 4/5 with bilateral hip/knee flexion/extension, and left foot dorsiflexion. There is hypoesthesia noted at bilateral L5-S1 dermatomes. …show more content…
On lumbar examination, there is tenderness on palpation of L1-S1 paraspinal muscles, bilaterally. Lumbar active range of motion shows increased flexion at 55 degrees, extension at 5 degrees, bilateral rotation to 10 degrees and lateral flexion to 10 degrees. Patient needs to start PT for functional and objective improvement, to increase active range of motion, decrease pain for strengthening and lumbar stabilizer exercises and to improve daily