Family Medicine · Year 3 · from Family Medicine

Case 3: Acute Low Back Pain

Patient Demographics

• Age: 35 years old
• Sex: Male
• Occupation: Warehouse worker

Chief Complaint

"I threw out my back lifting at work 3 days ago. I can barely move."

History of Present Illness

Mr. Marcus Williams is a 35-year-old warehouse worker presenting with acute low back pain for 3 days. He was lifting a heavy box at work when he felt sudden pain in his lower back. The pain is constant, rated 7/10, located in the lower lumbar region, and worsens with movement, bending, and prolonged sitting. He has been unable to work since the injury.

He denies radiation of pain to the legs, numbness or tingling, weakness in the legs, or difficulty with urination or bowel movements.

Review of Systems

• Positive: Lower back pain, muscle spasms, difficulty sleeping due to pain
• Negative: No leg pain, no numbness or tingling, no weakness, no bowel or bladder dysfunction, no fever, no unexplained weight loss, no history of cancer

Past Medical History

• No chronic conditions
• No prior back surgery
• Previous episode of back pain 5 years ago (resolved with conservative treatment)
• No allergies

Red Flag Assessment

Physical Examination

• Vital Signs: BP 130/82, HR 78, Temp 98.2F
• General: In obvious discomfort, guarding movement
• Back:
• Tenderness to palpation over bilateral paraspinal muscles L4-S1
• Limited flexion (touches mid-thigh)
• No step-off deformity
• No midline spinous process tenderness
• Neurological:
• Strength 5/5 bilateral lower extremities (hip flexion, knee extension, ankle dorsiflexion, plantar flexion)
• Sensation intact to light touch L4-S1 dermatomes bilaterally
• Deep tendon reflexes 2+ bilateral patellar and Achilles
• Straight leg raise negative bilaterally
• Gait: Antalgic but stable

Assessment

1. Acute nonspecific low back pain - Mechanical, without radiculopathy or red flags

Management Plan

Imaging: NOT INDICATED

• No red flags present
• Imaging would not change management
• Incidental findings on MRI are common and may lead to unnecessary interventions

Activity Recommendations:

• Stay active - This is the most important recommendation
• Avoid bed rest (associated with delayed recovery)
• Return to normal activities as tolerated
• Work modification: light duty for 1-2 weeks, avoiding heavy lifting
• Provide work restriction note for employer

Pharmacologic Treatment:

1. First-line: NSAIDs

• Ibuprofen 600 mg every 6-8 hours with food (max 2400 mg/day)
• OR Naproxen 500 mg twice daily
• Use for 1-2 weeks

1. Muscle relaxant (short-term):

• Cyclobenzaprine 5-10 mg at bedtime for muscle spasms
• Limit to 1-2 weeks due to sedation

1. Avoid opioids - Not indicated for acute nonspecific low back pain

Non-pharmacologic Treatment:

• Superficial heat (heating pad) for symptom relief
• Early mobilization
• Gentle stretching as tolerated

Patient Education:

• Prognosis is excellent: 90% of acute back pain improves within 4-6 weeks
• Staying active speeds recovery; bed rest delays it
• Some discomfort with activity is expected and not harmful
• Core strengthening after acute phase resolves can prevent recurrence

Physical Therapy Referral:

• Not indicated initially for acute episode
• Consider if not improving by 4-6 weeks

Return Precautions

• New weakness in legs
• Numbness in groin or saddle area
• Loss of bladder or bowel control
• Fever
• Significant worsening despite treatment
• No improvement after 4-6 weeks

Follow-Up

• Return in 2-4 weeks if not improving
• Work status re-evaluation as needed

Work Restrictions Documentation

"Patient may return to light duty with restrictions: no lifting > 10 lbs, no repetitive bending or twisting, frequent position changes every 30-60 minutes. Re-evaluation in 2 weeks."

Teaching Points

1. Avoiding unnecessary imaging: Imaging for acute low back pain without red flags does not improve outcomes and may lead to overtreatment of incidental findings.

1. Activity over bed rest: Decades of evidence show that staying active leads to faster recovery than bed rest.

1. Opioid avoidance: Acute low back pain should be managed with NSAIDs and muscle relaxants. Opioids are not superior and carry significant risks.

1. Setting expectations: Most acute back pain resolves within 4-6 weeks. Patients who understand this are less likely to seek unnecessary interventions.

1. Yellow flags: While not present in this case, psychological factors (catastrophizing, fear-avoidance) are important predictors of progression to chronic pain.

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