Case Report
v
Diagnosis of Intermittent Vascular
Claudication in a Patient With a
Diagnosis of Sciatica
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Background and Purpose. The purpose of this case report is to illustrate
the importance of medical screening to rule out medical problems that
may mimic musculoskeletal symptoms. Case Description. This case
report describes a woman who was referred with a diagnosis of sciatica
but who had signs and symptoms consistent with vascular stenosis. The
patient complained of bilateral lower-extremity weakness with her pain
intensity at a minimal level in the region of the left sacroiliac joint and
left buttock. She also reported numbness in her left leg after walking,
sensations of cold and then heat during walking, and cramps in her
right calf muscle. She did not report any leg pain. A medical screening
questionnaire revealed an extensive family history of heart disease.
Examination of the lumbar spine and nervous system was negative. A
diminished dorsalis pedis pulse was noted on the left side. Stationary
cycling in lumbar flexion reproduced the patient’s complaints of
lower-extremity weakness and temporarily abolished her dorsalis pedis
pulse on the left side. Outcomes. She was referred back to her
physician with a request to rule out vascular disease. The patient was
subsequently diagnosed, by a vascular specialist, with a “high-grade
circumferential stenosis of the distal-most aorta at its bifurcation.”
Discussion. This case report points out the importance of a thorough
history, a medical screening questionnaire, and a comprehensive
examination during the evaluation process to rule out medical problems that might mimic musculoskeletal symptoms. @Gray JC. Diagnosis
of intermittent vascular claudication in a patient with a diagnosis of
sciatica. Phys Ther. 1999;79:582–590.#
John C Gray
582
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Key Words: Differential diagnosis, Sciatica, Vascular claudication.
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A thorough
screening is
I
n the United States, back pain is the second most
frequently reported reason that people seek medical care, it is the second leading cause of lost time
from work, and it results in more lost productivity
than any other medical condition.1 Approximately 85%
of back pain involves the lower back, and about 12% of
people with low back pain also have sciatica.1
In 1934, Mixter and Barr2 reported that sciatica was
caused by a herniated disk impinging on a lumbar nerve
root. They also described a surgical technique to remove
a portion of the disk and subsequently resolve the
symptoms. Many causes of sciatica exist, however, and
many causes of leg pain and paresthesia can mimic
sciatica. Some of the other conditions that can produce
or mimic sciatica are herpes zoster and postherpetic neuralgia,3,4 endometriosis of the sciatic nerve,5,6 bacterial
endocarditis,7 soft tissue tumors in the pelvis,8 diabetic
neuropathy (diabetic radiculopathy, proximal motor neuropathy, amyotrophy, Bruns-Garland syndrome),9 –11 psoas
muscle abscess,12 Sjögren syndrome,13 ischemia of the
sciatic nerve,14 and peripheral vascular disease.15
Arterial insufficiency of the distal aorta, iliac, or femoral
arteries is commonly associated with lower-extremity
(LE) aching, cramping, numbness, tightness, or fatigue
and, therefore, may mimic sciatica.14 –18 The symptoms
are most common in the calf but also occur in the thigh,
buttocks, or low back region if the occlusion is proximal.16,18 –22 Patients with arterial stenosis are more likely
to be heavy smokers than are people without stenosis.19,23 Other risk factors for stenosis are age (increased
risk with age greater than 40 years), gender (men are at
greater risk), hypertension, diabetes, obesity, sedentary
lifestyle, and a family history of coronary heart disease.23,24
important to rule out
The most common site
for atherosclerosis in
diseases that
people under the age of
40 years is the aortoiliac
may mimic
junction.23 Occlusion at
this junction may promusculoskeletal
duce muscle weakness,
numbness, paresthesia,
symptoms.
paralysis, cold and pale
legs with decreased or
absent peripheral pulses, and intermittent claudication of
the lower back, gluteal muscles, quadriceps femoris muscle, or calves.20 The symptoms typically appear after walking the same distance each time and resolve with rest, even
standing still.16 –19 The walking distance that produces
symptoms will usually decrease over time. Peripheral vascular disease involving a peripheral vessel, such as the iliac or
femoral artery, will usually produce symptoms in one
extremity, whereas aortic stenosis may produce symptoms
in both extremities as well as the buttocks or low back.19,20
An important component of an initial orthopedic evaluation is to differentiate the etiology of a patient’s pain
as being neuromusculoskeletal in origin versus being
visceral in origin. Screening for disease is important for
several reasons:
1. Many visceral diseases mimic orthopedic symptoms,
and a delay in diagnosis and appropriate treatment
may lead to morbidity or mortality.
2. Many people over the age of 60 years seek orthopedic
physical therapy, and this age group is at a greater risk
for visceral pathology and disease.
JC Gray, PT, OCS, FAAOMPT, is a clinical specialist in orthopedic manual therapy practicing at Sharp Rees-Stealy, San Diego, Calif. He is a member
of the faculty of the Ola Grimsby Institute, San Diego, Calif. Address all correspondence to Mr Gray at 13364 Corte Playa Cancun, San Diego, CA
92124-1539 (USA) ([email protected]).
This article was submitted June 30, 1997, and was accepted February 18, 1999.
© 1999 by the American Physical Therapy Association Inc
Physical Therapy . Volume 79 . Number 6 . June 1999
Gray . 583
medical screening questionnaire, and a comprehensive
examination.
Case Description
Patient
A 41-year-old Caucasian woman was referred for physical
therapy with a diagnosis of sciatica from her primary
care physician. She was initially evaluated by another
therapist whose assessment was “right upslip with right
anteriorly rotated ilium and a left posteriorly rotated
ilium.” Left radicular signs and symptoms were also
noted. The patient received only the evaluation and was
subsequently referred to another therapist ( JCG) due to
problems scheduling the patient for a return visit. A
brief re-evaluation was initiated to confirm the first
therapist’s findings and to become familiar with the
patient and her symptoms. After discovering that the
patient was complaining of bilateral LE weakness every
time she walked half a block, that she denied leg pain,
and that all LE nerve tension tests were negative, I
decided to perform an extensive history and orthopedic
examination before beginning any form of treatment.
Figure 1.
Diagram of locations of the patient’s symptoms. The dark circle represents pain, the crosshatching represents temperature changes of hot and
cold, the diagonal lines represent numbness, and the horizontal lines
represent muscle cramps.
3. The current managed care environment has reduced
the amount of time that primary care physicians
spend with their patients and has made it more
difficult to refer patients to specialists and to refer
them for diagnostic testing, which may lead to a delay
in diagnosing disease.
4. Patients who are referred for outpatient physical
therapy have high blood pressure, anemia, thyroid
problems, cancer, diabetes, kidney disease, liver disease, or heart disease at a frequency rate that varies
between 1 and 15 patients with a particular visceral
disease per 100 outpatients.27
5. Patients who are referred for outpatient physical
therapy have a family history of cancer, heart disease,
diabetes, or stroke at a frequency rate that varies
between 15 and 29 patients with a particular family
history per 100 outpatients.
The purpose of this case report is to illustrate the
importance of a thorough screening to rule out diseases
that may mimic musculoskeletal symptoms. The report
points out the importance of a thorough history, a
584 . Gray
The patient complained of bilateral LE weakness, commenting, “Every time I walk half a block, my legs @left
greater than right# feel like they’re going to collapse on
me.” The patient reported minimal (3/10: 05no pain,
105worst pain imaginable) pain in the region of her left
sacroiliac joint and left buttock, with periodic numbness
below her left knee and into the foot, which she noted
after walking (Fig. 1). She also reported sensations of
cold and then heat along the anterolateral aspect of the
left thigh during walking and periodic cramps in her
right calf muscle. Her symptoms were aggravated by
walking, and they were relieved by rest, including standing still. She reported that the pain was not worse at
night. She reported that the pain started suddenly,
without trauma, 2 months prior to her referral for
physical therapy. During the first week of her symptoms,
the patient was able to walk up to half a mile (0.8 km).
She reported having no LE pain, bowel or bladder
dysfunction, shortness of breath, chest pain, or arm pain.
No plain radiographs, magnetic resonance imaging,
computerized tomography scan, bone scan, or vascular
studies had been performed prior to her physical therapy evaluation.
One month prior to the onset of her symptoms, the
patient had a mild low back injury, with pain concentrated at her left buttock. The pain was minimal in
intensity after 1 month. Four years previously, she had
been in a motor vehicle accident in which her upper
back was injured. She received 6 months of physical
therapy, and the symptoms resolved. She reported having no previous history of LE injuries, surgery, or
symptoms.
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This latter question was not on the
first questionnaire. On follow-up
questioning, she said that her grandfather died at age 59 years of a
myocardial infarction (MI), her
grandmother died at age 31 years of
an MI, her father died at age 59 years
of an MI, and her mother, now aged
63 years, had a massive MI 5 years
previously.
Diet and Smoking Habits
The purpose of investigating the
patient’s diet was to determine
whether poor nutritional habits may
be contributing to her symptoms.
Daily ingestion of caffeine (coffee,
tea, or soda), for example, has been
shown to increase the urinary loss of
calcium, magnesium, sodium, and
potassium.28,29 Calcium and magnesium are important minerals for
maintaining optimal health and
function in bone, muscle, and nerve.
Smoking has many well-known
adverse health effects, including cancer, osteopenia, accelerated degenerative disk disease, and cardiovascular disease.24,30 –32 The patient drank
3 cups of nondecaffeinated coffee a
day, drank 1 glass of tea a day, and
had smoked a pack of cigarettes a
day for the past 26 years. She
reported that she did not take any
vitamins or dietary supplements.
Figure 2.
Initial medical screening questionnaire given to the patient.
General Health
The patient completed a general medical screening
questionnaire at the time of her initial evaluation with
her first physical therapist (Fig. 2). The results of this
questionnaire suggested that the patient did not have
any history or symptoms of visceral pathology or disease.
During my evaluation of the patient, she was given a
comprehensive medical screening questionnaire (Fig. 3).
This latter questionnaire consisted of 84 questions, compared with the former questionnaire with 30 questions.
The results of the comprehensive questionnaire showed
evidence of possible disease or dysfunction in both the
pulmonary and cardiovascular systems of the patient.
The patient marked “no” for a history of heart disease on
the first questionnaire, and she marked “yes” for a family
history of heart disease on the second questionnaire.
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Functional Status
The patient’s major functional limitation was her inability to walk more
than a block. She walked at work,
and her only form of physical exercise outside of work was walking. Her goal was to be able
to walk again for 2 miles (3.2 km).
Examination
The following examination was performed to confirm or
rule out involvement of the lumbar spine and the sciatic
nerve or lumbar nerve roots as a source of the patient’s
complaints and limited ability to walk.
Lumbar active range of motion. The purposes of taking
these measurements were to evaluate the patient’s willingness to move through full active range of motion
(AROM) and to identify any limitations in range of
motion (ROM) or reproduction of pain or other symptoms and note any deviations from the primary plane of
motion. Both contractile and noncontractile tissues were
Gray . 585
Lumbar passive range of motion. The
purpose of taking these measurements was to examine the patient’s
passive range of motion (PROM) in
an effort to determine whether the
symptoms were arising from a noncontractile tissue associated with the
lumbar spine and pelvis. In addition,
these measurements allowed the
therapist to examine the patient’s
willingness to let her spine move
through a full ROM and to identify
any limitations in ROM (gross as well
as segmental) as well as reproduction of pain or other symptoms.
Because PROM always exceeds
AROM, it is important to stress a
muscle, ligament, or joint to its end
ROM during PROM, even though
the AROM is pain-free. These measurements were obtained with the
patient kneeling (hips in 0° of flexion, knees bent 90°) with the buttocks supported by a treatment
table. This position helped to stabilize the pelvis and allowed for uninhibited motion of all the lumbar
segments, especially L5-S1. During a
standing PROM examination of the
lumbar spine, it is difficult to stabilize the pelvis. During a sitting
PROM examination of the lumbar
spine, the flexion of the lumbar
spine will limit the ROM of the L5-S1
segment, which means that segment
will not be tested through its full
ROM.
Figure 3.
Second medical screening questionnaire (abbreviated), developed by the author, given to the
patient during her second evaluation.
stressed. The patient was examined while standing with
her feet a shoulder width apart and pointed in their
normal comfortable direction and with her knees
extended. She was instructed to slowly move in the
requested direction, keeping her knees straight, until
she felt that she could go no farther due to tightness,
pain, or a reproduction of other symptoms (temperature
changes, numbness, cramps). The directions were forward bending, backward bending, side bending, and
rotation. She moved in each direction twice. The patient
demonstrated full lumbar AROM without reproduction
of her symptoms.
586 . Gray
The patient was instructed to completely relax without helping or
resisting the motions performed by
the therapist. Each position was held
for at least 5 seconds at the end of the available ROM if
the patient did not report pain or discomfort. Only one
repetition was performed in each direction. The directions were backward bending, side bending, and rotation. Forward bending was tested in a sitting position for
better stabilization of the pelvis. Combined motions of
extension,sidebending(ipsilateral),androtation(contralateral) were also performed in a kneeling position. In
my opinion, these motions compress the disk, facet joint
(cartilage, menisci), and nerve roots in the intervertebral foramen on the concave side of the side-bending
motion and stretch the disk, facet joint capsule, muscles,
and ligaments on the convex side of the side-bending
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motion. The patient demonstrated full lumbar PROM
without reproduction of her symptoms.
Lumbar spine muscle testing. The purpose of this examination is to rule out spinal muscle tissue as a source of
the pain or symptoms. This test was skipped because the
lumbar AROM and lumbar PROM tests did not reproduce the patient’s symptoms. I decided to spend the
remaining time available for the evaluation performing
test procedures that were more likely to reproduce the
patient’s symptoms.
Special tests of the lumbar spine. The purpose of the
lumbar compression and heel-drop tests was to help rule
out the lumbar spine as a source of the patient’s
symptoms. Lumbar compression was produced through
the patient’s shoulders while she was seated with the
therapist standing behind her. The procedure was performed with the patient in an erect sitting posture, in a
slouched position (lumbar flexion), and with exaggerated lumbar lordosis (lumbar extension). The therapist
produces a compressive force with his or her hands
pushing down on the patient’s shoulders for up to 10
seconds in each posture. Reproduction of the patient’s
low back pain or LE symptoms is considered a positive
test. Various structures (disks, vertebrae, nerve roots,
facet joints, and ligaments) are stressed in the 3 different
postures. The theory is that if pain occurs in all 3
postures, then the disks or vertebrae are involved
because these are the only tissues that are stressed in all
3 postures (Ola Grimsby, Ola Grimsby Institute Residency Program, San Diego, Calif). The heel-drop test is
performed in a standing position. The patient rises up
onto his or her toes and then quickly drops all of the
body weight onto the heels. The patient is instructed to
keep his or her knees straight. If no pain or other
symptoms occur, then the procedure is repeated with
the body weight dropping a little quicker. The test is
considered positive if there is a reproduction of low back
pain or LE symptoms. This test may produce pain in
individuals with symptomatic diskogenic disease, facet
joint arthropathy, lumbar foraminal stenosis, vertebral
compression fractures, spondylolysis (acute or unstable
fracture), or spondylolisthesis (Ola Grimsby, Ola
Grimsby Institute Residency Program, San Diego, Calif).
In this patient, lumbar spine compression in the 3
different postures and the standing heel-drop test were
all negative.
Lower-extremity strength testing. The purposes of this
test were to examine the patient’s willingness and ability
to exert maximum isometric resistance against an external force and to confirm or rule out lumbar nerve root
or sciatic nerve compression. Muscle testing was performed as a screening examination. I instructed the
patient to resist, “as hard as you can,” the motion that I
induced. The following muscles were tested with the
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patient in a seated position: iliopsoas, quadriceps femoris, hamstring, anterior tibialis, and extensor hallucis
longus. The seated position was used, modified for some
muscles as described by Kendall and McCreary,33 to
facilitate the examination, save time, and minimize the
number of positional changes the patient would have to
make during the evaluation. Triceps surae muscle
strength was assessed in a one-legged stance for 10
repetitions. The patient demonstrated Normal strength
(5/5) in her LEs during the isometric break-test for
strength.
Sensation. The purpose of this test was to rule out
sensory abnormalities that may be due to nerve root
damage, peripheral neuropathy, vascular deficiencies, or
systemic disease (eg, diabetes). A brief screening examination was performed on this patient to determine
whether more time should be spent on sensory examination. If abnormalities are noted with light touch, then
further investigation might include pinprick, temperature, vibration, or proprioception testing.
A horsehair brush was lightly stroked over the dermatomes of the LEs to detect any differences (either
increased or decreased) between the LEs in the patient’s
perceived sensation to light touch. As I stroked one
dermatome in the left leg and the same dermatome in
the right leg, I asked the patient, “Does this...feel the
same as this?” She demonstrated normal sensation to
light touch in her LEs.
Lower-extremity deep tendon reflexes. This test was not
performed because the above tests of the nervous system
were all negative, and I was conserving time to examine
other tissues of the body.
Mobility of neural tissue. The purpose of this test was to
rule out restricted mobility of neural structures intrinsic
or extrinsic to the nerve as well as inflammation or
sensitization of the lumbar spinal nerve roots or the
sciatic nerve as a source of the symptoms. The straightleg-raising (SLR) test, or Lasègue’s test, was performed
with the patient in a supine position.34 I held the
patient’s knee in extension and allowed her ankle to
relax. As I passively raised her leg, increasing hip flexion,
I told the patient, “Tell me when your hamstring muscles
feel tight.” The hip was then passively rotated medially
(internally) and adducted as the ankle was passively
dorsiflexed to provide maximum tension on the neural
tissues (sciatic nerve).35 The test is considered positive if
there is a reproduction of the posterior LE pain.
Cram’s (bowstring) sciatic nerve tension test was also
performed with the patient in a supine position.36 The
starting position was the same as for the SLR test. The leg
was passively raised until the patient noted symptoms or
Gray . 587
significant hamstring muscle or neural tension, at which
point the knee was flexed slightly (20°) to abolish the
symptoms and any hamstring muscle or neural tension.
Next, the hip was flexed to the point that symptoms or
hamstring muscle or neural tension was produced. The
hip was then extended slightly to again abolish the
symptoms. At this time, I produced firm digital pressure,
just proximal to the popliteal fossa, against the posterior
tibial nerve division of the sciatic nerve to elicit symptoms. Clinically, I have found that a sharp localized pain
behind the knee indicates sensitization of the nervous
system (sciatic nerve) or a mildly irritated nerve. Pain
radiating to the buttock or foot, with or without paresthesia, is usually indicative of a more serious lesion to the
sciatic nerve or lower lumbar spinal nerve roots. The
sitting slump test was performed with the patient seated
and her knee passively extended, her ankle passively
dorsiflexed, her trunk in a slouched posture, and her
head actively flexed to her chest (modified from Maitland37). A positive test results in a reproduction of leg
pain or symptoms. The SLR test, Cram’s test, and the
sitting slump test for nerve tension were all negative.
Pulse. The purposes of palpation were to look for
diminution in the pulse amplitude of the LEs and to
check for asymmetry in the strength of the arterial pulse
from one extremity to the other. The distal arterial
pulses of the foot and ankle were examined. The purpose was not to locate the exact level of any potential
vascular compromise, but to determine whether a vascular abnormality existed that would explain the patient’s
symptoms. The patient had a moderately diminished
(grade 2/4) left dorsalis pedis pulse at rest. The right
dorsalis pedis pulse at rest was normal (grade 4/4). The
posterior tibialis muscle pulses were difficult to palpate
on this patient and, therefore, were not graded.
Special test of the vascular system (van Gelderen bicycle
test). Exercise testing is an important part of a complete evaluation in patients suspected of having occlusive
vascular disease. Pulses are palpated at rest and then
quickly after the patient has exercised to induce symptoms.38 Ischemia secondary to exercise causes the
peripheral arterial beds to dilate.38,39 This dilation of the
peripheral arterial beds decreases the peripheral vascular resistance, which diminishes the pulse amplitude.38,39
The van Gelderen bicycle test is designed to stress the LE
vascular system without causing any central canal or
foraminal stenosis that could be misinterpreted as intermittent neurogenic claudication.40 The patient was
instructed to cycle at a moderate pace (90 rpm) for 5
minutes or until she felt the onset of her symptoms.
Lumbar flexion (high seat height with low handle bars)
was used to help minimize any effect from a neurogenic
claudication, which would be exacerbated in lumbar
extension and relieved by lumbar flexion. A positive test
588 . Gray
is indicated by a reproduction of some or all of the
patient’s symptoms in the same extremity that demonstrates a decrease in the pulse amplitude of a particular
arterial branch. The test reproduced the patient’s symptoms, and her legs collapsed as she stepped off the
bicycle after 5 minutes. Her dorsalis pedis pulse on the
left side was temporarily abolished (grade 0/4).
Evaluation
I suspected that the patient had intermittent vascular
claudication secondary to occlusive vascular disease. The
lumbar spine was ruled out as a source of the buttock or
leg symptoms because the following tests were negative:
AROM and PROM testing, lumbar compression in 3
different postures, and the heel-drop test. Sciatica or
nerve root lesions were ruled out as a source of the
buttock or leg symptoms because the following tests were
negative: strength testing of the LEs, sensation to light
touch in the LEs, SLR test, sitting slump test, and Cram’s
test. Vascular claudication was considered the most likely
diagnosis due to the patient’s history of smoking; strong
family history of cardiovascular disease; LE weakness
when walking the same distance each time; symptoms
aggravated only by walking and not by a change in body
position or posture; relief of symptoms with rest, even
when standing (which helped rule out neurogenic claudication); decrease in the strength of the dorsalis pedis
pulse at rest; and a positive van Gelderen bicycle test.
Plan
I referred the patient back to her physician for reevaluation to rule out occlusive vascular disease. Due to
the seriousness of the diagnosis and the patient’s family
history of sudden death from MI, I referred her immediately. Concurrent treatment of the patient’s sacroiliac
joint (SIJ) and buttock was not considered because she
needed to focus on obtaining a quick and accurate
medical diagnosis to confirm or rule out intermittent
vascular claudication. The pain in the region of the SIJ
and buttock was minor during the lumbar spine evaluation and did not inhibit her functional status. In addition, the symptoms could be explained by a proximal or
aortic lesion.16,18 –22 The abdominal aorta bifurcates into
the left and right common iliac arteries at the level of the
L4 vertebrae (anterolaterally on the left side).41 The
common iliac arteries divide into internal and external
branches at the level of the lumbosacral junction, anterior to the SIJ.41 The internal iliac artery continues to
descend posteriorly to the superior margin of the
greater sciatic foramen.41
To treat the SIJ and buttock with exercise was contraindicated because the patient was thought to have occlusive vascular disease and the exact location and degree of
stenosis was unknown. Manipulation to the lumbar spine
or the SIJ also is contraindicated in people with atherosclerosis.42,43 Modalities such as ultrasound and superfi-
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cial heat or cold are known to influence blood flow and
would also be contraindicated.44 – 47
Outcome
The patient was subsequently seen by her primary care
physician, who reported finding “poorly palpated pulses
in her feet, no popliteal pulses, and probably somewhat
reduced pulses over the femoral areas.” His assessment
was “rule out claudication.” The patient was then
referred to a vascular specialist. The specialist noted that
the symptoms the patient described were somewhat
unusual for vascular related disease. He noted that “her
right femoral @area# is palpable; her left femoral @area# is
palpable and slightly diminished. She also has diminution of the posterior tibial pulses bilaterally, but the
dorsalis pedis pulses are intact.” His impression was
“asymmetric distribution of the pulses in a young lady
with atypical symptoms.” He ordered an angiogram to
rule out a vascular etiology. Subsequently, the patient
received an aortogram with runoff arteriogram. The results
of this test demonstrated a “high-grade circumferential
stenosis of the distal-most aorta at its bifurcation.”
Aortic graft surgery was recommended to the patient.
The physician also strongly recommended to the patient
that she quit smoking. Two months after her physical
therapy evaluation, the patient underwent angioplasty,
with stents implanted into the aorta. A stent is a tiny
metal structure that is mounted on the angioplasty
balloon. When the balloon is inflated, the stent expands.
After the balloon is deflated, the stent remains in place.
It now provides a scaffolding for the newly widened
artery. Within a few weeks, the endothelium, the natural
lining of the artery, will grow over the metallic stent.
Following the surgery, the patient reported the complete
relief of all of her symptoms, including the pain in the
region of her SIJ and buttock. According to the patient,
these stints were supposed to last 3 to 5 years; however,
the stints failed after 18 months, and the patient subsequently underwent synthetic graft surgery to her distal
aorta.
Discussion
The physical therapy diagnosis in this case was reached
by trying to rule out or confirm the primary diagnosis of
sciatica. The possibility of a disease was found through a
careful history, medical screening questionnaire, and
physical examination. The “red flags” in this case were as
follows: primary complaint of LE weakness and givingout in the absence of a strong pain component, progressively decreasing distance of walking and a specific
walking distance that brought on symptoms every time,
extensive and severe family history of cardiac disease,
symptoms with walking and stair climbing that decreased
with rest (standing), cold and hot sensations in her
thigh, and onset of symptoms without trauma. Physical
therapists should never minimize their evaluation of a
Physical Therapy . Volume 79 . Number 6 . June 1999
patient just because the patient is referred with a medical diagnosis and symptoms that may appear to match.
Acknowledgment
I acknowledge the support and assistance of AnneMarie
Kaiser in the preparation of the manuscript.
References
1 Praemer A, Furner S, Rice DP. Musculoskeletal Conditions in the United
States. Park Ridge, Ill: American Academy of Orthopaedic Surgeons;
1992:23–33.
2 Mixter WJ, Barr JS. Rupture of the intervertebral disc with involvement of the spinal cord. N Engl J Med. 1934;211:210 –214.
3 Helfgott S, Picard D, Cook J. Herpes zoster radiculopathy. Spine.
1993;18:2523–2524.
4 Watson C, Deck J, Morshead C, et al. Post-herpetic neuralgia: further
post-mortem studies of cases with and without pain. Pain. 1991;44:105–117.
5 Dhôte R, Tudoret L, Bachmeyer C, et al. Cyclic sciatica: a manifestation of compression of the sciatic nerve by endometriosis, a case
report. Spine. 1996;21:2277–2279.
6 Takata K, Takahashi K. Cyclic sciatica: a case report. Spine. 1994;19:89–90.
7 Hunder G. When musculoskeletal symptoms point to endocarditis.
Journal of Musculoskeletal Medicine. 1992;9:33– 40.
8 Ball A, Serpell J, Fisher C, Thomas J. Primary soft tissue tumours of
the pelvis causing referred pain in the leg. J Surg Oncol. 1991;47:17–20.
9 Naftulin S, Fast A, Thomas M. Diabetic lumbar radiculopathy:
sciatica without disc herniation. Spine. 1993;18:2419 –2422.
10 Barohn R, Sahenk Z, Warmolts J, Mendell J. The Bruns-Garland
syndrome (diabetic amyotrophy): revisited 100 years later. Arch Neurol.
1991;48:1130 –1135.
11 Pascoe MK, Low PA, Windebank AJ, Litchy WJ. Subacute diabetic
proximal neuropathy. Mayo Clin Proc. 1997;72:1123–1132.
12 Haines J Jr, Chop W Jr, Towsley D. Primary psoas abscess: an often
insidious infection. Postgrad Med. 1990;87:287–288.
13 Kaplan J, Rosenberg R, Reinitz E, et al. Invited review: peripheral
neuropathy in Sjögren’s syndrome. Muscle Nerve. 1990;13:570 –579.
14 Lamerton AJ, Bannister R, Withrington R, et al. “Claudication” of
the sciatic nerve. BMJ. 1983;286:1785–1786.
15 Frawley JE. Clinical features of vascular insufficiency in the limbs.
Aust Fam Physician. 1984;13:812– 816.
16 Sliwa J, Wiesner S, Novick A, Charuk G. Concurrent musculoskeletal
pain in a patient with symptomatic lower extremity arterial insufficiency. Arch Phys Med Rehabil. 1989;70:848 – 850.
17 MacNab I, McCulloch J. Backache. Baltimore, Md: Williams &
Wilkins; 1990:22–25.
18 Goodman CC, Snyder TEK. Differential Diagnosis in Physical Therapy.
2nd ed. Philadelphia, Pa: WB Saunders Co; 1995:77–146.
19 Boissonnault WG, Bass C. Pathological origins of trunk and neck
pain, part II: disorders of the cardiovascular and pulmonary systems.
J Orthop Sports Phys Ther. 1990;12:208 –215.
20 Goodman CC. The cardiovascular system. In: Goodman CC, Boissonnault WG, eds. Pathology: Implications for the Physical Therapist.
Philadelphia, Pa: WB Saunders Co; 1998:263–353.
21 Halperin JL, Creager MA. Arterial obstructive diseases of the
extremities. In: Loscalzo J, Creager MA, Dzau VJ, eds. Vascular Medicine:
A Textbook of Vascular Biology and Diseases. Boston, Mass: Little, Brown
and Co Inc; 1992:835– 865.
Gray . 589
22 Fairbairn JF II. Clinical manifestations of peripheral vascular disease. In: Juergens JL, Spittell JA Jr, Fairbairn JF II, eds. Peripheral
Vascular Disease. Philadelphia, Pa: WB Saunders Co; 1980:3–15.
35 Butler D, Gifford L. The concept of adverse mechanical tension in
the nervous system, part 1: testing for “dural tension.” Physiotherapy.
1989;75:622– 629.
23 Krajewski LP, Olin JW. Atherosclerosis of the aorta and lower
extremity arteries. In: Young JR, Olin JW, Bartholomew JR, eds.
Peripheral Vascular Diseases. 2nd ed. St Louis, Mo: Mosby; 1996:208 –224.
36 Cram RH. A sign of sciatic nerve root pressure. J Bone Joint Surg Br.
1953;35:192–195.
24 Hooi JD, Stoffers HE, Kester AD, et al. Risk factors and cardiovascular diseases associated with asymptomatic peripheral arterial occlusive disease: The Limburg PAOD Study. Scand J Prim Health Care.
1998;16:177–182.
25 Kerr EA, Mittman BS, Hays RD, et al. Managed care and capitation
in California: How do physicians at financial risk control their own
utilization? Ann Int Med. 1995;123:500 –504.
26 Davis K, Schoen C. Assuring quality, information, and choice in
managed care. Inquiry. 1998;35:104 –114.
27 Boissonnault WG, Koopmeiners MB. Medical history profile: orthopaedic physical therapy outpatients. J Orthop Sports Phys Ther. 1994;20:2–10.
28 Massey L, Wise K. Effects of dietary caffeine on mineral status.
Nutritional Research. 1984;4:43–50.
37 Maitland GD. The slump test: examination and treatment. Australian Journal of Physiotherapy. 1985;31:215–219.
38 Roon AJ. The history and physical examination of the patient with
peripheral vascular disease. In: Miller DG, Roon AJ, eds. Diagnosis and
Management of Peripheral Vascular Disease. Menlo Park, Calif: AddisonWesley Publishing Co Inc; 1982:1–16.
39 Cox JM. Low Back Pain: Mechanism, Diagnosis, and Treatment. 5th ed.
Baltimore, Md: Williams & Wilkins; 1990:257–308.
40 Dyck P, Doyle JB Jr. “Bicycle test” of van Gelderen in diagnosis of
intermittent cauda equina compression syndrome: case report.
J Neurosurg. 1977;46:667– 670.
41 Williams PL, Warwick R, Dyson M, et al. Gray’s Anatomy. 37th ed.
New York, NY: Churchill Livingstone Inc; 1989:662– 858.
29 Bergman EA, Massey LK, Wise KJ, Sherrard DJ. Effects of dietary
caffeine on renal handling of minerals in adult women. Life Sci.
1990;47:557–564.
42 Kleynhans AM, Terrett AG. The prevention of complications from
spinal manipulative therapy. In: Glasgow EF, Twomey LT, Scull ER,
Kleynhans AM, eds. Aspects of Manipulative Therapy. 2nd ed. New York,
NY: Churchill Livingstone; 1985:161–175.
30 Lash TL, Aschengrau A. Active and passive cigarette smoking and
the occurrence of breast cancer. Am J Epidemiol. 1999;149:5–12.
43 Hartman LS. Handbook of Osteopathic Technique. 2nd ed. New York,
NY: Chapman & Hall; 1985:23–27.
31 Egger P, Duggleby S, Hobbs R, et al. Cigarette smoking and bone mineral
density in the elderly. J Epidemiol Community Health. 1996;50:47–50.
44 Knight KL. Cryotherapy: Theory, Technique, and Physiology. Chattanooga, Tenn: Chattanooga Corp; 1985:33– 42.
32 Battié MC, Videman T, Gill K, et al. Smoking and lumbar intervertebral disc degeneration: an MRI study of identical twins. Spine.
1991;16:1015–1021.
45 Michlovitz SL. Cryotherapy: the use of cold as a therapeutic agent.
In: Michlovitz SL, ed. Thermal Agents in Rehabilitation. Philadelphia, Pa:
FA Davis Co; 1986:73–98.
33 Kendall FP, McCreary EK. Muscles: Testing and Function. 3rd ed.
Baltimore, Md: William & Wilkins; 1983:129 –183.
46 Michlovitz SL. Biophysical principles of heating and superficial heat
agents. In: Thermal Agents in Rehabilitation. Philadelphia, Pa: FA Davis
Co; 1986:99 –118.
34 Kosteljanetz M, Bang F, Schmidt-Olsen S. The clinical significance
of straight-leg raising (Lasègue’s sign) in the diagnosis of prolapsed
lumbar disc: interobserver variation and correlation with surgical
finding. Spine. 1988;13:393–395.
590 . Gray
47 Ziskin MC, Michlovitz SL. Therapeutic ultrasound. In: Michlovitz
SL, ed. Thermal Agents in Rehabilitation. Philadelphia, Pa: FA Davis Co;
1986:141–176.
Physical Therapy . Volume 79 . Number 6 . June 1999