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Differentialdiagnosisofapatientwithlowbackandtoepain

JManManipTher.2013May21(2):8189.

PMCID:PMC3649355

doi:10.1179/2042618612Y.0000000023

Differentialdiagnosisofapatientwithlowbackandtoepain
ElizabethCooperWahl, 1DavidSmith, 2MarySesto, 3andWilliamBoissonnault 3
1
UniversityofWisconsinHospitalandClinics/MeriterHospital,Madison,WI,USA
2
DepartmentofPediatricandOrthopedics/Rehabilitation,DivisionofSportsMedicine,UniversityofWisconsinSchoolofMedicineandPublicHealth,
Madison,WI,USA
3
DepartmentofOrthopedicsandRehabilitation,UniversityofWisconsinMadison,Madison,WI,USA
Correspondenceto:ElizabethCooperWahl,UniversityofWisconsinHospitalandClinics/MeriterHospital,Madison,WI,USA.Email:ewahl@uwhealth.org
CopyrightW.S.Maney&SonLtd2013

Abstract

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Lowbackpainisoneofthemostcommonlytreatedconditionsbyoutpatientorthopedicphysicaltherapists.The
managementoflowbackpainisalsoresponsibleforalargeeconomicburdenintheUnitedStatesand
internationally,whichhighlightsoneofthemanyreasonswhyappropriatemedicalscreeningandreferralis
importantinthephysicaltherapysetting.Thepurposeofthiscasereportistodescribethesuccessfulphysical
therapistscreeningandsubsequentmedicaldifferentialdiagnosisofa36yearoldmalewithchroniclowerback
andtoepain.Initialphysicaltherapyevaluationsupportedadiagnosisofmechanicallowbackpain,butsymptom
progressionthroughtwotreatmentsessionsindicatedthatanonmechanicalsourceofpainwasinsteadthelikely
causeofthepatientssymptoms.Thereferringphysicianwascontactedbythephysicaltherapistandthepatient
wasscheduledforfurthermedicalexamination.Aconsulttorheumatologywasplacedandthroughcompilationof
clinical,laboratory,andimagingfindings,adiagnosisofhumanleukocyteantigenB27positive
spondyloarthropathywasmade.Evenwithphysicianreferral,itisimperativeforclinicianstobeproficientin
screeningfornonmechanicallowbackpainthatmaymimicamusculoskeletaloriginofsymptoms.
Keywords:Medicalscreening,Nonmechanicalbackpain,Physicaltherapy,Psoriaticarthritis,
Spondyloarthropathy
Background

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Lowbackpainisoneofthemostcommonlytreatedconditionsbyoutpatientorthopedicphysicaltherapists.13
Approximately85%ofthepopulationwillexperiencelowbackpain,4themajorityhavingnoidentifiablepatho
anatomiccauseforsymptoms.5Lowbackpainisalsoresponsibleforalargeeconomicburden,withmanagement
oftheconditioncostingupwardsof$50billioneachyear.6,7Thediagnosticchallengescombinedwithhighcosts
oftreatmentoflowbackpainhighlightthedifficultbutimportanttaskoftimelyandaccuratediagnosisinthe
physicaltherapysetting.
Diagnosticcategoriesthatdescribelowbackpainincludemechanical,nonmechanical,andvisceralsourcesoflow
backpain.8WhiletheoveralllifetimeprevalenceoflowbackpainintheUnitedStatesishigh,4theprevalenceof
seriouslowbackpainpathology(i.e.nonmechanicalandvisceral)islow.9Specifically,visceraldisordersaccount
for2%whileanonmechanicaletiologyaccountsfor1%oflowbackpain.8Althoughrare,seriouspathologysuch
asmetastaticcancerandcompressionfracturescanleadtosignificantmortalityandmorbidity.1012Therefore,
suspicionofnonmechanicalorvisceralcausesoflowbackpainwouldwarrantaphysicaltherapyreferraltoa
physicianforfurtherevaluation.
Ofparticularinteresttothiscaseisinflammatoryarthritis,andmorespecificallyspondyloarthropathy(SpA),which
affects121316to19%17ofthepopulationand5%ofthosewithchroniclowbackpain.18,19SpAencompasses
multiplediagnosesincludingankylosingspondylitis(AS),reactivearthritis,psoriaticarthritis(PsA),andarthritis
associatedwithinflammatoryboweldisease.Inflammatorybackpain(IBP)istheleadingfeatureofSpA.20,21The
conditionoftenpresentsaslowbackandpelvicregionpain,typicallypresentforatleast3months.Othercommon
clinicalfeaturesincludesacroiliitisandasymmetricalarthritisthatisfrequentlypresentinthelowerextremities.A
familyhistoryofinflammatoryarthritisisalsocommon.2023
Inthephysicaltherapysetting,adiagnosisofSpAisdifficulttomakeasdifferentiatingbetweenchroniclowback
painandIBPcanbechallenging.20AppropriateandtimelydiagnosisiscriticalsincethosewithSpAareat
increasedriskforcardiovascularcomplicationssuchasaorticinsufficiency,24heartconductiondisturbances,24
fibroticlungdisease,25uveitisleadingtoblindness,26andspinalcompressionfracturesrelatedtoosteoporosis.27
Furthermore,timelydiagnosisofSpAisimportantasearlydiseasemanagementcanleadtoimprovedqualityoflife
withappropriateintervention.20,28,29Thepurposeofthiscasereportistodescribethedifferentialdiagnosisand

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Differentialdiagnosisofapatientwithlowbackandtoepain

managementofapatientreferredtophysicaltherapyfortreatmentofmechanicallowbackpainthatwaseventually
diagnosedashumanleukocyteantigenB27(HLAB27)positiveSpA.
Toassistthereaderinfollowingthecomplextimingofeventsandclinicaldecisionmakingofthecasethatfollows,
aflowchartofeventshasbeenincluded(Fig.1).
Figure1
Flowchartdemonstratingclinicaldecisionmakingandtimelineofevents.

CaseDescription

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Patienthistory

A36yearoldmalewasreferredtophysicaltherapyforevaluationandtreatmentoflowbackpain.Atthetimeof
hisevaluation,thepatientpresentedwitha12monthhistoryofinsidiousonsetoflowbackpainandbilateral
secondtoepain.Thepatientfirstsoughtcareforhissecondtoepainfromhisprimarycarephysician.Hewas
referredtoapodiatristanddiagnosedwithmetatarsalgia.Despiteconservativemanagement,thepainpersisted
andafewmonthslater,hereporteddevelopmentoflowbackpain.
Duringtheinitialevaluation,thepatientdescribedhislowbacksymptomsasachingandconstant,locatedcentrally
inthelowerportionofthelumbarspine.Secondarily,hecomplainedoftightnessinhisthoracicspine.Hedenied
painradiationandnumbnessortinglingintothebuttocksorlowerextremities.Hissymptomswerenotedtobe
worseinthemorningwithimprovementbymiddayimpactactivitiessuchasvolleyballandrunning,bending
forward,transitioningfromforwardflexiontoupright,andlyingproneincreasedhispain.Onthenumericpain
ratingscale,thepatientreportedthathissymptomsrangedfroma0/10toa6/10.Sittingrelievedhispain,but
overallsymptomsremaineddespitereportedactivityreduction.Thepatientalsoexpressedconcernabouthis
continuedbilateralsecondtoepainlocatedthroughouttheentiredigit.Hewasunabletoidentifyaggravating
factorsorapinpointlocationofhistoepain,butreportedthatthepainwasworseinthemorning.
Pastmedicalhistorywasunremarkableforsignificantillnessesorsurgeries.Familyhistoryforillnesses,including
inflammatoryarthritis,wasalsounremarkableexceptformelanoma(maternalaunt).Reviewofsystemswas
negative.
Physicalexamination

Observationofstandingposturerevealedslightlyincreasedthoracickyphosiswithnoothersignificantfindings.
Thepatientambulatedwithnospasticity,ataxia,orantalgiaduringgait,withfullandsymmetricalabilitytowalkon
heelsandtoesbilaterally.Aneurologicalscreenwascompleteddermatomes,myotomes,andreflexesofthelower
extremitywereintact.Thepassivestraightlegraisetestwasnegative,helpingtoruleoutaradicularcauseforthe
patientsdistalsymptomsgiventhehighsensitivityofthetest.30
Duringactiverangemotionofthelumbarspine,painwasreportedduringextensionandrightextensionquadrant.
Allmovementswerewithinnormallimits.PosteriortoanteriorspringtestingcentrallyatL3L5producedcentral
lowbackpain.Thepatientssubjectivecomplaintsoftightnessinthethoracicspinewereconsistentwithobjective
findingsasspringtestingrevealedhypomobilty,mostnotablyattheT7T12level.Otherfindingsincluded
decreasedhipflexorandhamstringextensibility.
Ascreenofthesacroiliacjoint(SIJ)regionwascompletedusingprovocationtestsasdescribedbyLaslett.3133
Thethighthrustwascompletedwithreportsoflowbackpainduringtherightandleftthighthrusttherewasno
complaintofSIJpainwitheithertest.Assessmentofthebilateralfirstandsecondmetatarsalphalangealjoint
revealeddecreasedflexionandextension,butnoprovocationofsymptomsoccurredwithtoemovement.Thetoes
wereobservedtobenormalinappearancewithnopresenceofrednessoredema.
Clinicalimpressionandtreatmentfollowinginitialphysicalexamination

Resultsoftheinitialevaluation,includingpainwithlumbarspineextensionandextensionquadrant,indicatedthat
thefacetjointmaybethesourceofthepatientscurrentsymptoms.Thesefindingscoupledwithdecreasedhip
flexorandhamstringextensibilityindicatedthatthepatientwouldlikelybenefitfromstretchingandstrengthening
ofthecoreandproximallowerextremitiestohelpimprovemuscularimbalances,therebyreducingstressonthe
facetregionofthespine.Thepatientwasprescribedexercisestoaddresshisimpairments,whichincludedcore
strengtheningandballrollingoverthehipflexorregion,usedtoassistinimprovingmuscularextensibilityofthe
proximallowerextremity.
Itisimportanttonotethattheinformationfromtheinitialevaluationwasobtainedthroughachartreview.The

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primaryauthor(EW)didnotcompletetheinitialexamination.Carewastransferredtotheprimaryauthoratthe2
weekfollowupappointmentastheexaminingtherapisthadrecentlybegunworkatanewclinic.
Physicaltherapyfollowup

Followingtheinitialexamination,thepatientwasseenfortwofollowupvisitspriortoreferralbacktothepatients
physician.Theclinicalimpressionandtreatmentduringthesevisitsensue.
Reexaminationandclinicalimpression

Overthecourseoftwophysicaltherapyvisits,thepatientwastreatedforsuspectedmechanicallowbackpain.
Duringthesefollowupvisits,hecontinuedtocomplainofcentrallowbackpain,butspecificallyindicatedconcern
overtheincreasingpainandstiffnessinhisthoracicspineandtoes.Hispainrangedfroma23/10onthenumeric
painratingscaleatthetimeofhisvisits,butincreasedtoa6/10duringtheearlymorninghours.Hereported
disruptedsleepwithcomplaintsofwakingduringtheearlymorninghoursandpainthatwasworseinthemorning
butdiminishedasthedaywenton.Hewasunabletoreportspecificpositionsoractivitiesthatprovokedhispain.
Objectively,thepatienthadcontinuedpainwithlumbarspineextension,butfurtherclarificationindicatedthatthis
wasnotthepatientsconcordantpain.Assessmentofthethoracicspinethroughactiverangeofmotionandspring
testingreproducedthepatientsreportofstiffnessduringthoracicspineflexionandcentralposteriortoanterior
mobilizationstoT7T12.Theexamineralsonotedhypomobilityinthesameregionofthethoracicspine.
Initially,painwithlumbarspineextensionandextensionquadrantindicatedalikelymechanicalcauseof
symptoms,butreassessmentindicatedthatthepainproducedwiththesemovementswasnotthesamepain
experiencedduringtheearlymorninganduponwaking.Theinabilitytoreproducethepatientspainwithactive
movementofthelumbarspine,inconjunctionwiththepresenceofhypomobilityinthethoracicspine,34the
patientsage,gender,morningpainandstiffness,worseningsymptomsdespiterest,andimprovementofsymptoms
asdayprogressedsuggestedanonmechanicalcauseofthepatientssymptoms.
Treatment

Duringthefollowupvisitsthatprecededreferralbacktothephysician,thepatientsimpairmentswereaddressed
throughstrengtheningandstretchingexercises.Inclinic,strengtheningexercisestargetingthethoracolumbar
regionofthespinewereaddedtohisprogramandincludedextensionbasedstrengthening(i.e.pronechintuck
withliftoftrunkofftable).Strengtheningexerciseswereindicatedgiventhekyphoticpostureofthepatient,andto
helppreventpotentialfuturedeformitythatmayoccurifanonmechanicalcauseofsymptomswasconfirmed.To
addressthestiffnessinthethoracicspine,thepatientwastreatedwithgradeIII+mobilizations,asdescribedby
Maitland,35targetingthehypomobileregions.Athome,thepatientcompetedthoracicextensionoverachairand
sidelyingrotationofthethoracicspinetoaddressspinalhypomobilityinadditiontohisprescribedstrengthening
program.
Thebathankylosingspondylitisfunctionalindex(BASFI)andthebathankylosingdiseaseactivityindex
(BASDAI)wereadministeredtoobtainabaselinereadingofthediseaseprocessandfunctionalstatusofthepatient
givenapotentialnonmechanicalcauseofsymptoms.AnoutcomemeasurespecifictoASwaschosenbecauseAS
hasbeenreportedtobethemostcommonsubtypeofSpA.17Theseindicesarescoredona010scaleandhave
beenfoundreliableandsensitivetochangeinthosewithAS.36,37Thepatientscoreda10anda34,respectively.
Highernumbersindicategreaterfunctionaldeficitsordiseaseactivity.38Activediseaseprocessisconsideredwitha
scoreof4orgreaterontheBASDAI.38
Conclusionofinitialphysicaltherapyfollowupvisits

Attheconclusionofthetwofollowupvisits,itwasnotedthatthesymptomspresentmaybeindicativeofIBP.
InitiallydescribedbyCalinetal.,39IBPisconsideredifapatientmeetsatleastfourofthefollowingfivefeatures:
(1)ageofonset<40years(2)durationofbackpain>3months(3)insidiousonset(4)morningstiffnessand(5)
improvementwithexercise(Table1).ThispatientmetfourofthefivecharacteristicsofIBP,suggestingthatIBP
shouldbeconsideredasadifferentialdiagnosis.Inflammatorybackpainisaleadingsymptominthosewith
SpA20,21,40andhasbeencitedtobepresentinupto85%ofthosewithSpA,41indicatingthatasystemiccauseof
thepatientssymptomsmaybepresent.Thereferringphysicianwascontactedbythephysicaltherapistregardinga
potentialnonmechanicalcauseofpain.Thepatientwasscheduledwithhisphysicianforfurtherexamination.
Table1
CharacteristicsofinflammatorybackpainasdescribedbyCalinet
al.39
Medicalreferralanddiagnostictesting

ThepatientwasseenforaphysicianfollowupvisittothoroughlyevaluateforSpA.Radiographsofthespinewere
completedandwerenegativeforfindingsconsistentwithSpA.AbilateralL5parsinterarticularisdefectwasnoted,

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Differentialdiagnosisofapatientwithlowbackandtoepain

aninterestingfindingwhichmayhelpexplainthecomplaintsofpainwithextensionandextensionquadrantupon
previousclinicalexamination.PertinentfindingsnotedbythephysicianincludedthelikelypresenceofIBPandtoe
swellingconsistentwithleftgreaterthanrightdactylitis,(sausagedigit)anoftensubtlefeatureofSpA(Fig.2).15
Thedactylitiswasanewfinding,notpresentduringpreviousphysicianorphysicaltherapyexamination.
Figure2
Imagedemonstratingleftsecondandthirdtoedactylitis(A)andrightthird
andfourthtoedactylitis(B)ofthepatientdescribedinthiscase.
Giventhesefindings,bloodworkwasorderedtofurtherscreenforSpA.ResultsrevealedapositiveHLAB27
antigen,abloodmarkeroftenpresentwithSpA.15AlthoughthepresenceoftheHLAB27antigenissignificant,it
isalsoverysensitive,15meaningthatapositivefindingcanbepresentinthosewithoutthedisease.Additional
findingsaretypicallyneededtoestablishadiagnosisofSpA,15and,therefore,amagneticresonanceimaging
(MRI)ofthepelvicregiontoscreenforsacroiliacinvolvementthatwasnotpresentonradiographswascompleted.
ReferralforadvancedimagingincasesofsuspectedSpAmaybeindicatedasdiagnosiscanbedelayedby811
yearsduetolackofradiographicchangesearlyinthediseaseprocesswhenusingplainimagingin
isolation.15,23,42,43ResultsoftheMRIdemonstratedmildedemaandenhancementoftheleftSIJwithsmall
erosions,potentiallyrepresentingearlyinflammatorysacroiliitis.
Conclusionofinitialmedicalworkup

Compilationofallpresentclinical,laboratory,andimagingfindingssuggestedamedicaldiagnosisofSpA.When
diagnosingSpA,acombinationoffindingsisnecessary.Literaturehassuggestedthattheprobabilityofdisease
shouldbeatleast80%priortoconsideringadiagnosisofSpA.15Nogreaterthan5%ofthechroniclowbackpain
populationsuffersfromSpA,19thusestablishingthepretestprobability.Acombinationofclinicalfeatures(
Table2)isusedtoincreasethepretestprobabilityof5%toa80%posttestprobability.15,18Inthisparticular
case,thepatientdemonstratedcharacteristicsconsistentwithIBP,HLAB27(+),MRI(+),anddactylitis,
suggestinguptoa98%probabilityofSpA[Table3(A)].TheBASFIandBASDAIwerereadministeredscores
ofa157anda606werereportedrespectivelyindicatingworseningofdiseaseactivity.Giventhispatientsclinical
presentation,aconsulttorheumatologywasobtained.
Table2
AdditionalSpAfeatures15

Table3
PreandposttestprobabilityofSpAinthepatientdescribedinthis
case(A)15,18withcomparisontotheAssessmentofSpondyloArthritis
InternationalSocietyclassificationcriteria(B)48,52
Consulttorheumatology

ThepatientwasevaluatedbytherheumatologistandwasdiagnosedwithHLAB27positivespondyloarthropathy.
Hewasstartedonindomethacin,anantiinflammatorydrug,andwasscheduledtofollowupwiththe
rheumatologist6weekslater.Atfollowup,thepatientreportednochangeinsymptomsvariousareasofred
patcheswerenotedoverthescalp,knee,andelbowconsistentwithpsoriasis,anotherfeatureofSpA(Fig.3).15
ThepresenceofpsoriasissuggestedthatthepatientmaybesufferingfromPsA,aspecifictypeofSpA.Giventhe
lackofsymptomaticreliefwithantiinflammatories,thepatientwasprescribedHumira,anantitumornecrosis
factorinjectablemedicationadministeredsubcutaneouslyevery2weeks.Completeresolutionofsymptomswas
reportedwithregularuseofHumira.
Figure3
Demonstrationofpsoriasisovertherightkneeofthepatientdescribedinthis
case.
Continuedphysicaltherapyintervention

ThroughoutthemedicalexaminationleadingtoadiagnosisofSpAandbeyond,thepatientdescribedinthiscase
continuedinphysicaltherapyonamonthlybasistotrackprogress,addressspinalhypomobilityandprogressspinal
strengtheningexercises.Monthlyfollowupspermittedthepatienttofocusonindependentmanagementofhis
symptomsathomewhilestillallowingforclinictimetoprogressexercisesandprovideeducation.44,45Inaddition
toprogressionofextensionbasedstrengtheningexercises,thepatientwastreatedwithgradeIIItoIV
mobilizations35tothethoracicspine.Athome,thepatientcontinuedwithhisstrengtheningexercisesandwas
encouragedtokeepanactivelifestyle.Thepatientpurchasedafoamrolltoindependentlyworkonspinalmobility.

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Incombinationwithpharmacologicalmanagement,thepatientwasdischargedfromphysicaltherapy7months
afterinitialevaluationwithcompleteresolutionofhissymptoms.Heunderstoodtheimportanceofcontinuedhome
interventionandwasindependentinitscompletion.
Discussion

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FewcasestudieshavebeenpublishedwithinthephysicaltherapyliteratureregardingadiagnosisofSpA.Lawand
Haftel46publishedacasestudydescribingapatientwithadiagnosisofjuvenileASpresentingwithinitial
symptomsinvolvingthehip,knee,andshoulderjoints.Coronadoetal.47documentedacaseofSpAwith
alternatingbuttockpainandconcurrentCrohnsdisease.Tothebestofourknowledge,nocasereporthasbeen
publishedinthephysicaltherapyliteraturedescribingSpAwithtoeinvolvement.
Thiscasereporthighlightstheimportanceofcontinuedreexaminationthroughoutanepisodeofcare.Whilethe
patientinourcaseinitiallydemonstratedcharacteristicsconsistentwithamechanicalcauseofpain,subsequentre
examinationfindingsraisedsuspicionofanonmechanical,inflammatorycauseforhissymptoms.Theexamination
findingsofconcernincludedmorningpainandstiffnessthatimprovedbymidday,worseningofsymptomswith
rest,sleepdisturbances,toedactylitis,andpsoriasis.Theabovecombinationoffindings,alongwiththe
inflammatorychangesoftheSIJpresentonMRIandthepositiveHLAB27antigen,ledtotheeventualdiagnosis
ofHLAB27positivespondyloarthropathy.Amorespecificdiagnosisofpsoriaticarthritiswasalsosuggested
giventhepresenceofpsoriasis.
DiagnosisofSpAisoftendifficultasthereisnosinglefindingthatpointstowardsthisdiagnosis.15,48Instead,
symptomsarevariable,inconsistent,andsubtleorfleetingearlyinthediseaseprocess,leadingtoadelayin
diagnosis.15,23,42,43Consequently,therehavebeenmanyproposedcriteriaaimedtoassistcliniciansindiagnosing
SpA.Untilrecently,apopularandestablishedsetofcriteriawastheModifiedNewYorkCriteria.Thecriteria
consideredclinicalsigns,symptoms,andradiographicfindingsofsacroiliitiswhenmakingadiagnosis.4850
Unfortunately,appropriateandtimelydiagnosismaybelimitedwhenusingtheModifiedNewYorkCriteriadueto
diagnosticdelaysassociatedwithuseofplainimagingandthevariabilityingradingofsacroiliitis.51
Mostrecently,theAssessmentofSpondyloArthritisInternationalSocietyproposedcriteriatoassistinthediagnosis
ofSpA,takingintoconsiderationtheincreasedutilizationofMRIinmedicine.ItconcludedthatadiagnosisofSpA
couldbemadetwodifferentways[Table3(B)].Ifoption1ismet,thesensitivityandspecificityare662and973%,
respectively,withapositivelikelihoodratio[(+)LR]of25552andaposttestprobabilityof975%.Foroption2,
thesensitivityandspecificityvaluesare829and844%,respectively,witha[(+)LR]of5352andaposttest
probabilityof89%.48,52Thisstudyfoundthatonly30%ofthosediagnosedwithaxialSpAdemonstratedplain
radiographicfindingsconsistentwithSpA.52Theproposedclinicalcriteriaaresimilartothoseproposedby
Rudwaleitetal.,15whichsuggestedtheprobabilityofdiseasebeatleast80%priortomakingthediagnosis.
AmorespecificdiagnosisofPsAwasconsideredforourpatientsimilartoSpA,manycriteriahavebeenproposed
toaidinthediagnosticprocess.Unfortunatelytheliteraturehasnotdemonstratedclearlysuperiorcriteria.53
Therefore,inanattempttostandardizethediagnosisofPsA,aninternationalgroupofpsoriaticarthritisresearchers
createdtheClASsificationcriteriaforPsoriaticARthritis(CASPAR).Thecriteria,914%sensitiveand987%
specific,requireacumulativescoreof3todiagnosePsAinthepresenceofinflammatoryarticulardisease
involvingthespine,joints,orentheses.54Ascoreof3maybeobtainedbymeetingavarietyofcharacteristics
withassignedpointvalues(Table4).AlthoughtheproposedcriteriaaimtobridgethegapinthediagnosisofPsA,
itisnotwithoutitslimitations.ThemostnotablelimitationusingtheCASPARcriteriaisthelongerdurationof
diseaseinthestudysubjects.Onaverage,thepatientsenrolledinthisstudyhadsymptomsforapproximately12
years.54Thislimitationquestionsthesensitivityandspecificityofthecriteriainpatientsearlyinthediseaseprocess.
Table4
CAPSAR54*

Researchfocusingonphysicaltherapyandinflammatoryarthritisislimited.Mostoftheresearchavailablehas
focusedonASandthebenefitofexerciseonfunction.Theliteraturehasreportedthatexerciseincombinationwith
pharmacologicalmanagementisconsideredthestandardofcare,55butexercisespecificsarenotwelldocumented
throughnumerousstudies.Keyfindingshaveindicatedthathometherapyishelpfulinimprovingfunctionand
spinalmobilitywhencomparedtonotreatment,34whilesignificantimprovementsinpainorfunctionwerenot
demonstratedwhencomparingsupervisedexercisetohomeexercise.34Otherbenefitsofhometherapyincludeda
lowereconomicburden,aswellasimprovedconvenienceandtimeeffectivenessinthetreatmentofASwhen
treatmentconsistedofrecreational/cardiovascularexercisesandspecificbackexercises.56Althoughtherearemany
documentedbenefitsofhomephysicaltherapy,itisinterestingtonotethatgrouptherapywasfoundtobemore
effectivethanhometherapyforimprovingspinalmobilityandglobalassessment.34Otherimportantfindingsfrom
theliteratureincludedimprovementsinpain,stiffness,andfunctionwithcompletionofleast200minutesofactivity
56

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56

weekly. Inaddition,manualtherapyandselfmobilizationswerereportedtoimprovespinalmobility,posture,
andchestexpansion.57Manualtherapytreatmentincludedpassiverangeofmotionexercises,softtissue
mobilizationtothespineandstretchingoftightmusclesusingacontractrelaxmethod.57Itshouldbenotedthat
furtherresearchisrequiredtodetermineoptimalduration,frequency,andtypeofexerciseinthetreatmentofAS
andSpA.58
Insummary,thiscaseillustratessomeoftheinherentchallengesassociatedwithdiagnosingpatientswithSpA.The
presenceofdactylitisisauniquefeatureofthiscase.AlthoughthisfeatureisacharacteristicofSpA,itistypically
notthoughtofasahallmarksignasarefeaturessuchasahistoryofinflammatoryboweldisease,familyhistoryof
inflammatoryconditions,uveitisandlargejointinvolvement.15,21,59Infact,thesepreviouslylistedcharacteristics,
commonlyseeninSpA,wereabsentinthepatientdescribedinthiscase.AspecificdiagnosisofPsA,suggestedby
rheumatology,mayhelptoexplainthedistalsymptomoftoedactylitis,amorecommonfeatureofPsAthanthe
otherdiagnosesincludedundertheSpAumbrella.60GenderdifferencesalsoplayaroleinthepresentationofSpA.
ArecentstudyfoundthatmalesdiagnosedwithSpAweremorelikelytohaveIBPasaninitialsymptom61and
whileperipheraljointpainislesscommoninmales,whenperipheraljointsareinvolved,thehips,shoulders,and
feetaremorecommonlyaffected.16Furthermore,theabsenceofSIJfindingsuponclinicalexaminationisan
interestingfeatureofthiscase.Whenthispatientinitiallypresentedtophysicaltherapy,heonlycomplainedof
centrallowbackpainwithnoindicationofSIJpainsubjectively.Althoughlowbackpainiscommonlyseenin
thosewithSpA,23themostcommonsymptomofearlySpAissacroiliitis.23,43,62,63Despitethis,duringthe
medicalandphysicaltherapyclinicalexamination,whichincludedplainimaging,thispatientdidnotdemonstrate
findingsconsistentwithSIJpathology,whileadvancedimagingrevealedsubtleearlyinvolvement.
GiventhevariabilityindiagnosisofSpA,determiningwhenmedicalreferralisnecessaryfornonmechanical
causesoflowbackpaincanbedifficult.Inthecaseofinflammatoryarthritis,werecommendmedicalreferralinthe
presenceofIBP.TheCalincriteria(Table1),oneofmanycriteriausedtodiagnoseIBP,isasensitivemeasurethat
mayhelptoserveasastartingpointforaclinician,indicatingwhenmedicalreferralmaybenecessary.64
Conclusion

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Thiscasereportdescribestheclinicalreasoningprocessforapatientreferredtophysicaltherapywithadiagnosis
oflowbackpainwitheventualdiagnosisofSpA.Thiscasehighlightsthediagnosticdifficultyalongwithmany
commonsignsandsymptomsconsistentwithadiagnosisofSpA.Progressionofthisdiseaseoftenresultsin
significantmorbidityhighlightingtheimportanceofappropriateandtimelypatientreferraltoaphysician.
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