By Laurence Kirk

Patient: Ms A., a 35yr old female equestrian height 5ft 4ins weight 10stone

Complaint: Acute low back pain of two weeks duration as a result of mucking out a stable whilst on holiday.


Ms A had suffered acute recurrent low back pain from the age of 19
years after falling from a horse (X-rays at the time revealed no fractures).

From that time she developed slight weakness and hypoaesthesia of the entire left lower leg diagnosed by a neurologist as “stocking syndrome” When she became more active with her equestrian career and was riding regularly she had few problems although she was always aware of the reduced sensation in her left leg.

Her current pain was described as continuous and sharp in nature and
localised to the left lower back, there was some referral of pain into the posterior left thigh accompanied by pins and needles into the left lower. The pain was generally aggravated by activity by changes in position, sitting for long periods, and there was impulse pain on coughing or sneezing. There was no morning stiffness reported

Ms A was generally stoic by nature and had developed effective coping strategies over the years to allow her to work through her discomfort and continue to compete at a relatively high level, unfortunately the recent exacerbation had proved to be one straw too many.


Standing examination revealed an asymmetry of posture with an
elevated left ileum and mild lumbar structural scoliosis concave to the
left. On palpation the lumbar erector spinae were hypertonic and tender with focal areas of tenderness over the left iliac crest and psis. The left lower limb appeared to be slightly longer than the right (<1.5cm). Range of active motion was reduced and painful in the lumbar spine for flexion and left rotation/side bending. Restriction of motion and tenderness was also noted in the cervical spine.

Neurological examination was somewhat curious; there
appeared to be complete anaesthesia of the entire left lower limb other than the medial border of the foot. Reflexes were normal and equal but the left lower limb showed generally reduced muscle strength. Neural tension tests interestingly were all negative (although these tests are acknowledged as being somewhat unreliable) percussion was unremarkable. Peripheral pulses were slightly reduced on the left. Provocative testing for sacroiliac
involvement appeared positive on the left.


Ms A had already seen her GP and had been prescribed diazepam
and ibuprofen. Treatment was directed to restore a degree of function to the left S/I joint and relieve the acute pain associated with this. Gentle conservative approaches were used given the severity of discomfort. This took the form of rhythmic oscillatory mobilisation of the S/I and lumbar spine and soft tissue treatment of the involved musculature. A knee swinging exercise was recommended to improve proprioceptive ability in the lower back

After the first treatment 5 days later Ms A noted a significant increase in mobility and reduction in pain. Of more interest was the observation that slight sensations had been noted in the previously anaesthetic left lower leg. On testing the L5 dermatome exhibited some sensitivity to both light touch, and vibration.

On the third visit Ms A felt very much improved and extremely grateful that sensation in her left leg after 16 years was now all but back to normal (1 year follow up indicated that the improvement had been maintained).

Was the actual treatment responsible for the resolution of her long term paraesthesia? Could the strenuous exertion of mucking out the stable and moving into awkward postures have triggered off some recovery mechanism? Is it likely that nerves which have been dysfunctional for 16 years can recover in a matter of weeks? Was her problem vascular rather than neurological, mediated via the sympathetic outflow to the lower limb rather than somatic innervation?

[boxibt style=”success”]Case Courtesy of

Laurence Kirk

Lief House
3 Sumpter Close
120-122 Finchley Road
London NW3 5HR
Tel: 020 7435 6464
Fax: 020 7431 3630

Details of training can be obtained from the Registrar at the above address
There is an out-patient clinic at the College
For further details and appointments, telephone 020 7435 7830[/boxibt]