Man grabbing his aching back in pain

REFERRED LOWER BACK PAIN: A CASE OF MISTAKEN IDENTITY

An 18-year-old athletic young man presented to the physical therapy clinic with a physician referral for low back pain and weakness in the lower back extensors.  Patient examination revealed an indiscriminate dull left lower flank pain with radiation toward the anterior lower abdominal region present intermittently for 2 years. There was no actual complaint of lower back pain or weakness from the patient. Manual muscle testing was 5/5 symmetrical and normal throughout upper and lower extremities including core. Neurological exam and special testing demonstrated normal results. Symptoms were not reproducible during routine musculoskeletal exam, inspiratory movements, Valsalva maneuver, or change in body position. Patient did, however, report occasional symptoms after performing leg lifts for abdominal strengthening during soccer practice. There were no reported bowel or bladder changes or discoloration of urine or output. Percussion over the involved area, however, moderately reproduced the symptoms. 

With such presentations whether related to trauma or of insidious origin, it is important to recognize that complaints of flank pain, low back pain, or pelvic pain may be of renal or urologic origin and after careful screening of subjective and objective information medical referral may be necessary.  

Chronic renal or ureteral pain tends to be vague, poorly localized, and easily confused with other types of pelvic or abdominal problems. The upper urinary tract consists of the kidneys and ureters while the lower urinary tract includes the bladder and urethra, each with specific pain referral patterns.  Information transmitted by renal and ureteral pain receptors is mediated by sympathetic nerves that enter the spinal cord at levels T10 to L1. There are identified areas of referred pain related to renal and ureteral lesions. Examples include shoulder pain due to pressure from diaphragm irritation due to pressure from a renal lesion or iliopsoas pain during movement due to a lesion on the outside of the ureter. Specifically, renal pain is typically felt in the posterior subcostal and costovertebral region and radiates across the low back forward around the flank toward the lower abdominal quadrant. Ureteral pain may begin posteriorly in the costovertebral angle and radiate anteriorly to the lower abdomen, upper thigh, or genital area on the same side as the pain source. Bladder or urethral pain is usually felt suprapubically or ipsilaterally in the lower abdomen and may present with low back pain being the only symptom. Prostatic pain is usually in the lower abdomen, suprapubic region or perineum and is referred to the low back, sacrum, genital region, or inner thighs. 

Since bladder and urinary function questions may be reluctantly answered by patients it may be necessary to review the importance of such questions in ruling out important causes or sources of pain. Such questions may include frequency of voiding, bladder control, infections, leaking, urine color or smell, urethral discharge, genital discomfort, discomfort with voiding, surgeries, stones, cancer, radiation, trauma, transplant, or family history. Pain in the flank, abdomen, groin, low back, pubic area, or thighs. 

In the above patient, symptoms were localized over the left lower flank with radiation toward the anterior lower abdominal region. The absence of solid reproducible findings during the exam components despite thoroughness lead to further questioning of the patient regarding bowel and bladder function and voiding ability. He did admit to occasional difficulty with emptying his bladder fully when prompted by requestioning. Although percussion along the costovertebral angle was negative, percussion over the ureteral line between the kidney and pelvis slightly reproduced the symptoms which gave the impression of a possible stone or blockage in the area creating a referred pain pattern. Patient was referred for urology consult and found to have a congenital convoluted ureteral stricture. Two weeks post operative follow up demonstrated normal function with no reproducible symptoms or flank pain during activity or at rest. 

Phil Hartley, PT, ECS

References

DeWolf WC, Fraley EE. Renal pain. Urology. 1975;6:403–8. [PubMed]

Walker, H., Hall, W. and Hurst, J. (1990) ‘Flank Pain 182’, in Clinical methods: The history, physical, and laboratory examinations. 3rd edition. LexisNexis UK. 

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