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Case Report |
MR Troyer, PT, DPT, is a staff physical therapist working in outpatient musculoskeletal rehabilitation in Philadelphia, Pa
Address all correspondence to Dr Troyer at: mtroyer1{at}msn.com
Submitted May 18, 2006;
Accepted February 21, 2007
 | Abstract |
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Case Description: The patient was a 25-year-old woman who reported the sudden onset of severe left-sided lumbosacral, lower quadrant, buttock, and thigh pain. The physical therapist examination revealed findings suggestive of a pelvic visceral disorder during the diagnostic process. The physical therapist referred the patient for medical consultation, and she was later diagnosed by a gynecologist with endometriosis and a left ovarian cyst.
Outcomes: The patient underwent laser laparoscopy and excision of the ovarian cyst followed by a regimen of gonadotropin-releasing hormone agonists. The intervention resulted in abolition of the lower quadrant pain and a significant reduction of the back and leg pain that enabled the patient to return to her normal activities.
Discussion: A thorough physical therapist examination that considers all of the musculoskeletal, visceral, and psychosocial components is essential to identify pelvic disorders such as endometriosis and other disease processes during the differential diagnosis of nonspecific low back pain. Medical consultation is necessary to provide proper diagnosis and intervention of endometriosis, but physical therapists also may have an important role in the identification of endometriosis and the management of the musculoskeletal aspects of the disorder.
| Introduction |
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 TopAbstract Introduction Case DescriptionInterventionOutcomeDiscussionAppendix.References |
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Low back pain is one of the most common musculoskeletal impairments in physical therapist practice, accounting for 36% to 53% of all client visits.8 The largest majority of cases of low back pain are categorized as nonspecific low back pain, defined as back pain of unknown origin extending from the gluteal fold to the upper lumbar vertebrae from an assumed musculoligamentous process.9,10 Although the prevalence of back pain is lowest between ages of 25 and 35 years, the incidence of nonspecific low back pain is high.10,11 The incidence and prevalence of endometriosis also are highest in the same age range as that of people with nonspecific low back pain.
Endometriosis is defined as the presence of endometrium external to the uterus.3 The endometrium is the lining of the internal cavity of the uterus that provides a barrier against infection, regulates menstruation, and assists implantation of the embryo.12 Cyclic changes occur in response to ovarian secretions, during which the endometrium undergoes necrosis, hemorrhage, and discharge leading to the process of menstruation.12 In some women, viable endometrial tissue attaches to pelvic visceral structures external to the uterus and proliferates within the pelvic cavity, resulting in endometriosis. The ectopic endometrial tissue is active and responds similarly to the eutopic endometrium during the menstrual cycle, resulting in internal pelvic bleeding, inflammation, and scarring.1,13
The cause of endometriosis is generally unknown. The most widely accepted theory is the implantation of viable endometrial tissue onto peritoneal visceral structures from retrograde menstrual flow into the pelvic cavity.14,15 However, the origin is multifactorial, also having hormone, immune, and genetic components.16 The relationship of endometriosis to estrogen is well-established.16 Two thirds of women with a diagnosis of endometriosis report having a family member with endometriosis.17 A large percentage of women with endometriosis have other comorbidities such as fibromyalgia, chronic fatigue syndrome, hypothyroidism, allergies, asthma, and autoimmune disorders.17 The associated risk factors are directly related to low body mass index (BMI), and family history and are inversely related to exercise.2,4
The hallmark symptoms are generalized pelvic pain, dysmenorrhea, and dyspareunia.3 The pain from endometriosis can cause disability by compromising physical activity and work productivity. The dyspareunia associated with the condition can adversely affect sexual intimacy and relationships. According to the American Society for Reproductive Medicine classification system, the severity of the pain from endometriosis is not dependent on the stage of the disorder.18 The greatest long-term chronic complication is infertility, with 30% to 40% of women with endometriosis being infertile.1
Despite the prevalence and musculoskeletal presentation of the disorder, there is a paucity of evidence in the peer-reviewed literature specific to endometriosis and low back pain to guide the decision-making process for the physical therapist.3,6,7 Endometriosis is important for physical therapists to consider during differential diagnosis because of the high morbidity and its tendency to manifest as nonspecific low back pain. Misdiagnosis and misclassification can occur within the physical therapist preferred practice patterns from the associated musculoskeletal symptoms, resulting in the pursuit of ineffective or inappropriate forms of intervention. A delay of appropriate intervention can place clients with endometriosis at risk for chronic, debilitating pain and infertility.
Given the likelihood of examining clients with the disorder and its associated symptoms, it is imperative to include endometriosis in the differential diagnosis in women of reproductive age with pelvic, lower back, and lower-extremity pain. The purposes of this case report are: (1) to educate physical therapists about the signs and symptoms associated with endometriosis that can manifest as a musculoskeletal problem and (2) to describe a screening process for endometriosis in women with nonspecific low back pain during the physical therapist examination and diagnostic process.
| Case Description |
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TopAbstractIntroductionCase DescriptionInterventionOutcomeDiscussionAppendix.References |
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The patient continued to experience constant and severe low back pain following discharge and sought consultation from her primary care physician the next day. He ordered plain film radiographs of the lumbar spine, which were taken 4 days after the onset of the symptoms. They revealed normal vertebral stature and density, well-maintained disk spaces, and normal facet joints and alignment. He also ordered magnetic resonance imaging (MRI) of the lumbar spine, which was normal without evidence of disk herniation or extradural defect. During the entire week following the onset of symptoms, she remained on self-imposed bed rest because of severe pain.
The patient's primary care physician referred her to an orthopedic surgeon 2 weeks after the onset of symptoms because of severe, persistent low back pain. In the written history, the orthopedic surgeon noted that the onset occurred after lifting boxes at work. He prescribed the narcotic analgesic Percocet,* issued a flexible lumbosacral garment for support, recommended continued use of the nonsteroidal anti-inflammatory and antispasmodic drugs, and advised use of a moist electric heating pad. He diagnosed the patient with acute low back pain and referred her to a physical therapist.
I examined the patient 3 weeks after the onset of the symptoms. During the interview, she reported severe, constant pain in the left lumbosacral region that occasionally radiated into the left lower abdominal quadrant, left buttock, and anterior thigh. The onset was sudden without a known cause, first occurring when she awoke in the morning. She reported that she had lifted boxes at work a couple of weeks prior to the onset but stated that the boxes were not heavy and that she was without discomfort during and after the lifting. She slept only 1 to 2 hours at a time because of the severity of the pain, and she had not returned to work since the onset of the symptoms. The pain was worse during ambulation and with prolonged sitting but was not increased with coughing and sneezing. She reported control of bowel and bladder function. She claimed the intensity had lessened since the initial episode but was still severe.
Review of Systems
The systems review was followed as outlined by the Guide to Physical Therapist Practice.19 The patient's past medical history included intermittent low back pain over the past 5 years, which she attributed to sitting, and increased urinary urgency-frequency over the past 2 years. She reported having no dysmenorrhea and pain during the menstrual cycle. She did not take any prescription or over-the-counter medications other than the previously stated pharmacotherapeutics. She was a nonsmoker and consumed alcohol socially. Her family history included maternal rheumatoid arthritis and hypothyroidism.
The patient's radial pulse was 68 pulses per second, and her blood pressure was 112/70 mm Hg. Auscultation of the heart and lungs using a stethoscope revealed that the heart had a normal rate and rhythm, and the lungs were clear. Her weight of 52.16 kg and height of 1.63 m corresponded to a BMI of 19.6 kg/m2, which is in the low normal range. The integumentary system was intact without peripheral edema, local discoloration, or palpable temperature change. The patient ambulated independently without ancillary support but with a slightly antalgic gait pattern on the left side. Sit-to-stand and supine-to-sit transfers were performed independently, but guardedly, and with a painful facial grimace.
Examination
The patient completed a pain body diagram for a visual representation of her symptoms. The pain was illustrated across the lumbosacral region and distally into the left buttock and left lower abdominal quadrant just proximal to the anterior superior iliac spine and anterior iliac crest (Fig. 1). Roach et al20 used intraclass correlation coefficients (ICCs) to estimate test-retest reliability of the body diagram for referencing pain and found ICCs of .58 to .94.
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Disability due to low back pain was assessed using a modified version of the Oswestry Disability Questionnaire (ODQ) as described by Fairbank et al.22 The patient's ODQ score was 56%. Fritz and Irrgang23 found an ICC of .90 for test-retest reliability of scores on a modified ODQ.
Standing posture was inspected in the frontal and sagittal planes as described by Magee.24 Frontal-plane analysis revealed symmetry of the shoulders, iliac crests, posterior superior iliac spine, and spinal column. Sagittal-plane analysis revealed an accentuated lumbar lordosis and thoracic kyphosis. Active lumbar spine forward flexion and lateral flexion were tested with the patient in a standing position, as described by Boissonnault,25 and were 25% restricted, with pain increased at the end-range. Active lumbar spine extension was tested in a standing position and was 10% restricted; she reported no increased pain with this movement. Active thoracic spine rotation was tested in a sitting position, as described by Boissonnault,25 and was 25% restricted, with increased pain in the lumbosacral region at the end-range. Passive lumbar range of motion and repeated movements were deferred because of her acute distress level. Shoulder active range of motion tested in a sitting position was within normal limits and without intensification of symptoms. Hip passive range of motion was tested in the supine position, as described by Magee,24 and was within normal limits and pain-free. The Patrick test was negative for pain.
Neuromuscular testing was performed for both lower extremities. Manual muscle testing from the hip to the ankle, as described by Hislop and Montgomery,26 was 4/5 throughout testing. Deep tendon reflexes for L4 and S1 were tested, as described by Magee,24 using the 5-point National Institute of Neurological Disorders and Stroke myotatic scale, with grades from 0 to +4.27 The knee jerk and plantar reflexes were +2, bilaterally. Sensation was tested for pinprick along the L1 to S2 dermatomes and was categorized as normal, diminished, or absent.28 Dermatomal sensation was normal throughout both lower extremities. Neural tension was tested in a supine position with the passive straight leg raise (SLR) and crossed SLR tests, as described by Magee.24 The patient had intensification of lumbosacral pain with passive SLR at 60 degrees on the left side, but without reproduction of buttock or leg pain. The crossed SLR test was negative. Soft tissue palpation testing revealed marked tenderness over the left lower abdominal quadrant just distal to the anterior superior iliac spine and over the left lumbar paraspinal region just superior to the iliac crest.
Evaluation, Diagnosis, and Prognosis
The diagnostic process followed a rationale consistent with the treatment-based classification system described by Delitto et al.29 This classification system is a clinical guideline index that classifies low back pain on the basis of a patient's history, behavior of symptoms, and clinical signs29 and has been shown to have discriminant validity.30 Hypotheses were developed during the diagnostic process that would be affirmed, rejected, or revised based on the findings of the tests and measures. Deyo31 described the differential diagnosis of low back pain as falling into 3 categories: mechanical (musculoskeletal), nonmechanical (neoplasia, infection), and visceral (pelvic, renal, gastrointestinal). Hypotheses generated during the examination would fall into 1 of the 3 categories to determine whether the condition was of musculoskeletal origin and manageable by physical therapy intervention or of nonmusculoskeletal origin and requiring medical consultation.
Certain mechanical and nonmechanical disorders could be excluded during the diagnostic process from the patient interview and systems review. The negative MRI rendered a diagnosis of herniated nucleus pulposus and neoplasm unlikely because MRI has high sensitivity for both disease processes32,33 and is considered the gold standard for diagnosing a herniated nucleus pulposus.32 Although computerized tomography is the preferred modality for fractures and osseous abnormalities, spondylolisthesis and vertebral fracture were unlikely given the negative MRI and plain film radiographs.32 Urinalysis ruled out urinary tract infection and pregnancy.
The patient interview and systems review revealed signs and symptoms consistent with a musculoskeletal impairment. She had an episodic history of low back pain during sitting. Her symptoms followed a musculoskeletal pattern, with pain in the lumbosacral area, buttock, hip, and thigh that was exacerbated with postural change. In addition, her high NPRS scores and her ODQ score of 56% revealed a high degree of perceived disability. On the basis of these findings, she was classified as having stage I mechanical low back pain.29,34
The findings from the tests and measures also were consistent with a musculoskeletal impairment. She had an exaggerated lordosis and thoracic kyphosis, tenderness with palpation over the lumbar paraspinal musculature, a painful restriction of lumbar flexion, and a painless full range of lumbar extension. These findings correlated with an extension syndrome.29,34 The tests and measures affirmed the earlier hypothesis of a mechanical disorder and were suggestive of "impaired joint mobility, motor function, muscle performance, range of motion, and reflex integrity associated with spinal disorders,"19(pp223-229) with an expected prognosis of recovery in 8 to 24 physical therapy visits in accordance with the Guide to Physical Therapist Practice. The negative passive SLR test and MRI excluded herniated nucleus pulposus. The negative Patrick test and lack of point tenderness rendered a diagnosis of sacroiliac joint impairment unlikely.
However, visceral pathology could not be excluded during the differential diagnosis. The patient had reported urinary urgency-frequency over the past 2 years and a family history of a maternal rheumatologic and endocrine disorder. Her age, sex, and BMI placed her in a risk category for known pelvic disorders.2 She also reported severe pelvic pain, which is common in several prevalent pelvic disorders ranging from benign to life-threatening, such as pelvic inflammatory disease, renal calculi, ovarian cyst, ovarian torsion, and endometriosis.35 Based on these findings and the epidemiology, there was at least a moderate pretest probability for a visceral disorder.36
Although the tests and measures supported a musculoskeletal impairment, they also supported visceral pathology. She had marked point tenderness in the left lower quadrant, which correlates with known gynecological and gastrointestinal disorders.37 Of particular concern was the severe and sudden onset of pain, which had not significantly diminished, and the considerable functional disability in this young and otherwise healthy adult. Furthermore, the pain was constant, was worse with walking and bending, and interrupted her sleep. Roach et al38 found a sensitivity of 0.98 for a serious back problem when combining the findings of constant pain, pain worse with walking and bending, and sleep disturbance. Because some of the more severe musculoskeletal impairments and nonmechanical disorders had been excluded by the imaging and the tests and measures, the cluster of combined data from the examination was suspicious for a visceral disorder during differential diagnosis (Appendix). Given the degree of morbidity of the various pelvic visceral disorders and the potential for pathology outside of our preferred practice patterns, consideration had to be given to medical referral. The diagnostic process is summarized in Figure 2.
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| Intervention |
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TopAbstractIntroductionCase DescriptionInterventionOutcomeDiscussionAppendix.References |
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Spinal stabilization exercises also were selected to be introduced after 1 to 2 weeks of physical therapy intervention if early pain relief was achieved. Spinal stabilization exercises are effective in reducing pain and improving function in people with acute and chronic low back pain.42,43 The patient would be instructed in proper posture and body mechanics. During the 2-week period, ongoing assessment of the effectiveness of the intervention and screening for additional signs and symptoms would continue. Thereafter, if the patient's condition did not improve, if her condition worsened, or if there were more "red flags," she would be referred back to the orthopedic surgeon with a recommendation for medical consultation to assess the possible visceral component.
However, the large cluster of data suggesting back pain of visceral origin and the associated morbidity with the potential visceral disorders led to a reconsideration of the plan to delay medical consultation for 2 weeks. I contacted the patient on the same day of the examination and instructed her to return to the orthopedic surgeon for immediate medical consultation with a recommendation of a referral to a gynecologist. Physical therapy intervention also was recommended while the patient received a medical workup, but she elected to discontinue physical therapy intervention until a medical diagnosis could be made. I referred the patient back to the orthopedic surgeon, who re-examined the patient 5 days later and concurred with my assessment of a suspected gynecological visceral source, and he referred her to a gynecologist.
The gynecologist examined the patient 1 week after the physical therapist examination and ordered an ultrasound of the pelvic cavity and a Pap smear, both of which were negative. Ten days after the physical therapist examination, the patient returned to her primary care physician, who ordered a computerized tomography scan of her pelvic cavity, which also was negative. Blood tests performed at the same time revealed elevated liver enzyme levels, and she sought consultation from a liver specialist hepatologist 2 weeks after the physical therapist examination. The hepatologist ordered an MRI scan of the abdominal and pelvic cavity, which was suggestive of endometriosis and a left ovarian cyst. The hepatologist then referred the patient back to the gynecologist 3 weeks after the physical therapist examination. The gynecologist performed a laparoscopy 3 weeks later, which confirmed ectopic endometrial implants on the right and left pelvic walls, the bladder, and the anterior cul-de-sac, and the patient was diagnosed with endometriosis. The laparoscopy and biopsy are the gold standard for the diagnosis and staging of endometriosis.44,45 The laparoscopy also confirmed the presence of a left ovarian cyst. The sequence of medical referral from the physical therapist is summarized in Figure 3.
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a gonadotropin-releasing hormone (GnRH) agonist. Thereafter, she received monthly injections of Lupron,
a GnRH agonist, for a period of 4 months. GnRH agonists are frequently used for retarding endometrial development by nature of their reduction of estrogen production.46 | Outcome |
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TopAbstractIntroductionCase DescriptionInterventionOutcomeDiscussionAppendix.References |
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In an interview with the patient 9 months after the initial physical therapist examination, she reported significant improvement of her symptoms. The pain that initially was referred, severe, and constant had reduced to localized, mild, and intermittent. Prior to intervention, the pain from the endometriosis had severely limited her functional status, as demonstrated by the interrupted sleep, need for bed rest, inability to work, and inability to leave the home for longer than 30 minutes. Following surgery and medical management, she was able to sleep without interruption, walk and stand throughout the entire day without severe pain, and return to full-duty work status. Because ongoing physical therapy intervention was not provided beyond the initial visit, there were no comparison findings for the review of systems and tests and measures following the medical intervention.
| Discussion |
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TopAbstractIntroductionCase DescriptionInterventionOutcomeDiscussionAppendix.References |
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In this case, I referred the patient to the medical community for consultation, during which time she was examined by several physicians and underwent multiple medical tests. She later was diagnosed with endometriosis by a gynecologist who performed laser laparoscopy and initiated pharmacotherapeutics, which resulted in a significant resolution of her symptoms. In view of the extensive medical course from the onset of symptoms before a diagnosis could be attained and an effective plan of care could be implemented, a more streamlined medical referral process and a more efficient selection of medical diagnostic tests would help minimize the disability period, increase the likelihood of a successful outcome, and provide better utilization of care.
There were some data from the physical therapist's patient interview and tests and measures that were lacking in this case and could have aided the diagnostic process. Clients with pelvic pain syndromes frequently have a history of anxiety, depression, or abuse,48,49 which requires screening during the history. In addition, a standard abdominal screen should include auscultation for bowel sounds and bruits, percussion to assess the underlying abdominal contents, and palpation for masses.25,37 As Fritz and Wainner explained, "Although according to the Guide [the Guide to Physical Therapist Practice], the end result of the diagnostic process should most often be a classification grouping based largely on impairments and functional limitations instead of pathoanatomy, individual tests may be used to focus the examination or detect conditions not appropriate for physical therapy management."36(p1548) A thorough physical therapist examination that considers all of the musculoskeletal, visceral, and psychosocial components is necessary to identify pelvic disorders such as endometriosis and other disease processes during the diagnostic process in patients with nonspecific low back pain.49,50
The decision whether to refer patients with pelvic pain syndromes to a specialist or to refer them to a specialist and also provide physical therapy intervention is based on careful consideration of the musculoskeletal and nonmusculoskeletal aspects of the examination. Pelvic disorders such as endometriosis can produce secondary musculoskeletal impairments that may be amenable to physical therapy intervention.7,51 Pelvic visceral disorders frequently produce lumbar, sacroiliac, and pelvic-floor referred pain, which can result in muscle spasms, trigger points, and connective tissue dysfunction.7,51 Trigger points are common in the muscles of the pelvic floor and lumbar spine and are a frequent source of chronic pelvic pain and urinary urgency-frequency syndrome.7,51 Furthermore, endometriosis tends to be a chronic and recurrent disorder, and repeat laparoscopies are common. Repeat laparoscopies have been associated with adhesive disease,52 which can produce secondary musculoskeletal impairments. A study by Peters et al53 suggested that laparoscopy alone did not substantially improve long-term outcomes in women with pelvic pain syndromes such as endometriosis, and physical therapy intervention often was required as part of an integrative approach to achieve resolution.
Conversely, a number of primary musculoskeletal impairments can manifest as a gynecological visceral pathology. Dysfunction of the hip, spine, sacroiliac joints, and anterior and posterior abdominal walls can produce pelvic pain.54,55 Pain of musculoskeletal origin is referred along sclerotomes and can create symptoms similar to those of visceral origin, which are referred along the same roots.54 Therefore, lower quadrant pain can be a symptom familiar to both musculoskeletal and visceral impairments. Musculoskeletal dysfunction can cause muscle spasm and myofascial trigger points of the lower back, abdomen, and pelvic floor that can be misinterpreted as a pelvic visceral disorder.54–56 Current management of pelvic pain syndrome has taken a multidisciplinary approach, which includes physical therapy intervention to address the primary and secondary musculoskeletal impairments.7,51,54–56 Interventions such as use of modalities, pelvic-floor strengthening, internal and external trigger point management, myofascial manual therapy, stretching and flexibility exercises, spinal mobilizations, nerve glides, and relaxation exercises all have been recommended as effective physical therapist management of pelvic pain.7,51,54–56
This case report highlights the importance for physical therapists to consider endometriosis during differential diagnosis because of its ability to cause musculoskeletal symptoms and manifest as nonspecific low back pain. Because of the high prevalence and similar age incidence of endometriosis and nonspecific low back pain, it is possible that physical therapists will encounter women with endometriosis-related low back dysfunction. As was evident in this case, physical therapists may be the practitioners who first identify visceral pathology and are influential in those patients' recovery. A thorough examination that provides screening for the visceral, musculoskeletal, and psychosocial aspects of impairment will serve to refine the diagnostic process, enable early recognition of endometriosis and other pelvic pain syndromes, and hasten intervention.
Future research is necessary to identify clusters of associated signs and symptoms in women with nonspecific low back pain and documented endometriosis. Such research may enable the development of diagnostic criteria to effectively identify endometriosis in patients with nonspecific low back pain. Future research also is necessary to investigate the prevalence of women in their reproductive years with nonspecific low back pain who are referred for physical therapy intervention. This research may serve to identify a population at risk for endometriosis and assist primary care physical therapists in recognizing endometriosis during differential diagnosis. Finally, future research is necessary to investigate the short- and long-term outcomes from physical therapy intervention in clients with documented endometriosis and secondary musculoskeletal impairments.
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TopAbstractIntroductionCase DescriptionInterventionOutcomeDiscussionAppendix.References |
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| Footnotes |
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* Endo Pharmaceuticals, 100 Endo Blvd, Chadds Ford, PA 19317. 
Warner Chilcott Inc, 100 Enterprise Dr, Rockaway, NJ 07866.
Tap Pharmaceuticals Inc, Lake Forest, IL 60045.
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TopAbstractIntroductionCase DescriptionInterventionOutcomeDiscussionAppendix.References |
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