This case report involves a patient with both acute and chronic pain conditions who sought chiropractic services. I am certain this type of patient has presented to you for care. It is possible you were able to perform a differential diagnosis and determine a working diagnosis. Hopefully, your evaluation and management enabled the patient to obtain relief of the pain with your treatment plan.
Investigating the Patient's Chief Concern: "I Hurt All Over"
Subjective: This 50-year-old male patient states that he has been experiencing aching in his back and legs for the past six months. He claims that he has never experienced this type of pain in his life. The aching pain hurts throughout the day and walking increases the pain, which he states is in a range of 5-10/10. He notices cramping in the legs and a sensation of heaviness.
Normally, sitting reduces the pain, but for the past two weeks, he has experienced sharp, shooting pain down the left leg from the buttocks with some "patchy" regions of pain in the left lower extremity and foot while sitting in his easy chair. The pain in the buttocks and left leg does ease if he leans to the right while sitting. He denies any recent trauma or treatment for the pain.
This patient did seek chiropractic services from you 10 years ago for lower back pain, Your working diagnosis was a lumbar facet syndrome, which resolved with a few spinal manipulations. This episode was caused by a change in employment, which required a great deal of lifting and prolonged driving of a truck.
He claims to dislike the taste of water and hydrates with only carbonated beverages or beer. His current employment does require a considerable amount of sitting and is stressful. His primary care physician diagnosed mild obesity, hypercholesterolemia and hypertension. He was advised to lose weight and commence an exercise program, and received a prescription for 40 mg of rosuvastatin (Crestor) to lower his cholesterol.
Objective: This middle-aged, Caucasian male is a mildly obese mesomorph demonstrating painful behavior. He is pleasant, but a bit confused. His son accompanies him and provides specific history data.
- Vital signs: height 5'11", weight 220, BP 150/94, pulse 86/minute, blood oxygen 95.
- Gait: slow and antalgic with forward leaning. Pain in the left piriformis when sitting on a hard chair, which reduces when leaning to the right.
- Pain in the hip flexors bilaterally when rising to stand. Pain in the quadriceps when walking. Palpation of the lumbar paravertebral and left piriformis muscles is painful.
- Posture: Slight forward antalgic leaning, pelvic obliquity with posterior inferior left ilium and anterior superior right ilium.
- Gillet: SIJ fixation left.
- Long sit test demonstrates left functional leg-length deficiency supine and right functional leg-length deficiency seated.
- Sit up produces pain in the left iliopsoas and the left piriformis.
- Straight-leg-raise test: Right lower extremity 90 degrees without pain; left lower extremity 25 degrees with pain at the left sciatic notch that radiates down the posterior thigh and the lateral aspect of the lower leg inferior to the knee.
- Flexion abduction and external rotation with extension of the left hip produces pain with restricted range of motion in the left iliopsoas; flexion adduction and internal rotation of the left hip produces pain in the left piriformis.
- Posterior joint dysfunction of the lumbosacral joints with pain, reduced range of motion and hypertonicity of the paravertebral muscles.
3-part peripheral neurological exam:
- Sensory testing: intact for pain and light touch bilaterally upper and lower extremities.
- Motor testing: Difficult to test because of pain in muscles with resistance.
- Deep-tendon reflexes 2+ bilaterally upper and lower extremities.
- Pathological reflexes are absent (Babinski and Hoffman's).
Assessment / Working Diagnosis
- Chronic pain syndrome (G89.4)
- Piriformis syndrome (G57.01)
- Drug-induced statin myopathy (G72.0)
Plan of Action
- Contact the prescribing physician with patient's permission; provide your working diagnoses and recommendations to discontinue exercise and statin medications for a period of 4-12 weeks ("statin holiday").
- Prescribe an increase in hydration with 75-100 ounces of water per day.
- Conservative chiropractic management following statin holiday and reduced statin myopathy signs.
Have you seen this type of patient in the clinical setting? An excellent source of information regarding the examination of a patient with piriformis syndrome is: "Diagnosis and Management of Piriformis Syndrome: An Osteopathic Approach."1
Quiz Time
To enhance the learning experience, here are a few multiple-choice questions regarding this case. What are the subjective findings that would support the working diagnoses?
1. Chronic pain syndrome caused by patient taking statin medication:
a. Duration of pain for more than three months
b. Prescription of statin medication
c. No history of trauma
d. All of the above
2. Piriformis syndrome caused by walking exercise and statin medication:
a. Duration of pain for only two weeks
b. Prescription of statin medication
c. New exercise plan with walking
d. All of the above
3. Hypohydration
a. Absence of water consumption
b. Body weight
c. Fluid intake included only carbonated drinks and beer
d. All of the above
Clinical Pearls
Patients will present with both acute and chronic neuromusculoskeletal-type pain conditions that are caused by statin medications. Chiropractic physicians should be responsible for diagnosing the condition, and properly communicating with the patient and the prescribing physician or primary care provider. Reducing the dosage, changing the brand of statin, and a stain holiday are all reasonable suggestions.
"The most severe adverse effect of statins is myotoxicity in the form of myopathy, myalgia, myositis or rhabdomyolysis. Clinical trials commonly define statin toxicity as myalgia or muscle weakness with creatine kinase (CK) levels greater than 10 times the normal upper limit. Rhabdomyolysis is the most severe adverse effect of statins, which may result in acute renal failure, disseminated intravascular coagulation and death.
"The exact pathophysiology of statin-induced myopathy is not fully known. Multiple pathophysiological mechanisms may contribute to statin myotoxicity. This review focuses on a number of them. The prevention of statin-related myopathy involves using the lowest statin dose required to achieve therapeutic goals and avoiding polytherapy with drugs known to increase systemic exposure and myopathy risk. Currently, the only effective treatment of statin-induced myopathy is the discontinuation of statin use in patients affected by muscle aches, pains and elevated CK levels."2
Quiz Answers:
1. D
2. D
3. D
References
- Boyajian-O'Neill LA, McClain RL, Coleman MK, Thomas PP. Diagnosis and management of piriformis syndrome: an osteopathic approach. J Am Osteopath Assoc, 2008 Nov;108(11):657-64. Full-text access: Read Here
- Tomaszewski M, Stêpieñ KM, Tomaszewska J, et al. Statin-induced myopathies. Pharmacol Rep, 2011;63:859-66. Full-text access: Read Here
