+ What are the relevant components of this patient’s history and physical examination, and why?

Relevant History:

• Where exactly is the patient’s pain? What are the other details of the pain, including onset, duration, radiation, quality, severity?
• Has this ever happened before?
• Was there trauma/injury recently or in the past?
• Is the pain worsening over time?
• What makes the pain better or worse?
• What has been tried so far to treat the pain? Oral medications? Physical therapy? Injections? Surgery?
• Has any workup been performed so far, or has the patient sought medical care for this problem before?
• Are there associated neurologic symptoms, such as numbness, tingling, weakness, gait dysfunction, bowel or bladder dysfunction, or saddle anesthesia?
• Past Medical and Surgical History
• Medications
• Social history, including work details and current work status.

Relevant Physical Examination:

• Vital signs
• Inspection
• Palpation of lumbar spine and bilateral lower limbs
• Manual muscle testing of bilateral lower limbs
• Sensory and reflex testing of bilateral lower limbs
• Special testing: straight leg raise, slump sit, FAIR, FABER, Ober

+ Challenge Question

• What are you trying to assess with the FAIR test, and how do you perform it?

+ Challenge Answer

• The FAIR test stands for flexion, adduction, and internal rotation of the hip. It is a test for piriformis irritation of the sciatic nerve which may be responsible for a patient’s shooting pain down the leg. The FAIR test is performed typically by having the patient lie supine, flexing the hip of the affected lower extremity to 60 degrees, and adducting the hip while internally rotating it. This is designed to stretch the piriformis and potentially irritate an already-irritated sciatic nerve, thus reproducing the patient’s symptoms of pain +/- numbness/tingling down the lower extremity. If the patient’s pain is reproduced, the test is positive and indicates sciatic nerve irritation likely due to piriformis syndrome.

+ What is your differential diagnosis for this patient?

• Lumbar radiculopathy (particularly L4 or L5), piriformis syndrome, lateral femoral cutaneous neuropathy, sciatic neuropathy, greater trochanteric pain syndrome, SI joint dysfunction, IT band syndrome, primary hip joint pathology, common fibular (peroneal) neuropathy, deep fibular (peroneal) neuropathy, anterior horn cell disease.

+ What specific workup would you arrange for this patient?

• There is no immediate imaging or laboratory workup required at this point in time.

+ What are your specific management recommendations for this patient?

• Prescribe physical therapy to start, focusing on core strength, stability, gait, gluteal, hip girdle musculature activation, coordination, progressive strengthening, and range of motion with work on postural mechanics. There is no urgent indication to rush to testing (MRI lumbar spine or EMG of left lower extremity). There is gradual onset left 4/5 dorsiflexion weakness, but this is not sudden-onset and the limb is not profoundly weak, so urgent testing or surgical consultation is not required. Over the counter oral pain medications would be appropriate as well, such as acetaminophen, NSAIDs, or antineuropathic pain agents such as gabapentin, if appropriate based on medical history and current medications.

+ Your recommendations lead to the following:

• The patient performs 2 months of physical therapy with a daily home exercise program, yet his pain and weakness are unchanged. He has tried oral pain medications without significant relief.

+ What is your next step?

• This is not an easy question, but essentially 2 tests would be appropriate to consider, and either is a legitimate choice as long as you are prepared to explain your reasoning for ordering either test, and how you might act on the results. Arguably an EMG/nerve conduction study of the left lower extremity is the most appropriate next step, given the unclear etiology of the patient’s symptoms, unclear special testing on physical examination, and differential diagnosis considerations of peripheral neuropathy (sciatic, common fibular, etc.), radiculopathy, or lateral femoral cutaneous neuropathy. Based on the EMG results, you may elect to proceed with a lumbar spine MRI without contrast if the EMG indicates lumbar radiculopathy, and then move forward with an epidural steroid injection (either interlaminar or transforaminal approach - be prepared to explain rationale for all your choices). If the patient’s clinical presentation was much more supportive and clear to indicate a radiculopathy, you might consider proceeding with lumbar spine MRI and epidural steroid injection.

+ What is your next step?

• Personally inform the patient of the test results and next steps. No matter what the report says (MRI, EMG, X-ray, etc.) always take the time to personally tell your patient the results of the test and the next steps. This may be in the form of an office visit, a phone call, a secure message, or a mailed letter. This electromyographer may have documented that they had an educational discussion, but ultimately the only thing that matters here is: did you personally educate the patient, explain the test findings, and offer a treatment plan?

+ How would you respond?

• “I know this is a very difficult situation you are dealing with. I want you to be assured that my chief goal is to diagnose the cause of your problem so that we can know how to properly treat it. Please explain to me what you understand about the MRI test vs. the EMG test and I’d be happy to talk about it some more.”

• “What other questions do you have for me today?”

• Note: Always take the time to inquire and find out what your patient understands about the diagnosis/workup/treatment plan, before simply ordering the test. The patient needs to understand the value of each test you order and why you are ordering it over another test. In this way you can reach a “team-based” solution that the patient feels invested in.