Lumbar muscle sprain/strain

Question 1

How does lumbar muscle sprain present?

Answer 1

Sharp intense pain for 1 to 2 days; muscle spasm; most patients recover within 3 months.

Absence of red-flag symptoms.

Pain radiation does not extend beyond the knee.

Absence of fever, fluctuance, exquisite tenderness to palpation- rules out infection.

Lack of pain on flexion or relief on extension.

Hx of prior LBP or prior treatment

Question 2

What co-morbidities are seen with lumbar muscle sprain?

Answer 2

Obesity, stress and psychiatric comorbidities- patients may report depression, anxiety, family or work stressors, or fear-avoidance behaviours.

Question 3

What are red flag symptoms for back pain?

Answer 3

If any of the following factors are present further imaging is needed:
Recent significant trauma, or milder trauma in age >50 years
Unexplained weight loss
Immunosuppression
History of cancer
Intravenous drug use
Prolonged use of corticosteroids
Osteoporosis
Age >70 years
Focal neurological deficit with progressive or disabling symptoms
Duration of lower back pain >6 weeks.

Question 4

What do you include in the examination of lumbar muscle sprain?

Answer 4

Benign physical examination, diagnosis is one of exclusion.
Negative FABER, Gaenslen’s , or Schober’s testing:

Tenderness to palpation at the sacroiliac (SI) joint and positive result for the FABER (flexion, abduction, and external rotation).

Gaenslen’s (maximal hip flexion plus contralateral hip extension) tests may suggest SI joint dysfunction

A positive Schober’s test indicates reduced lumbar flexion.
Scoliosis or kyphosis- Can be observed in either standing or forward flexion positions. Usually, mild degrees of spine curvature do not contribute to pain but severe cases may be painful and warrant surgical consultation.

Question 5

What are the risk factors for lumbar muscle sprain?

Answer 5

• Obesity
• FHx of degenerative disc disease
• Poor musculotendinous flexibility and abnormal posture
• Stress and psychiatric comorbidities
• Female sex
• Heavy physical and occupational activities
• Tobacco use

Question 6

What are the investigations for lumbar muscle sprain?

Answer 6

None. Clinical diagnosis.

Lumbar spine x-ray- eliminate fracture, spondylolisthesis, or tumour diagnoses. X-rays should not be ordered for non-specific lower back pain of <6 weeks’ duration as it has no effect on outcomes.

Question 7

What is the management for lumbar muscle sprain?

Answer 7

Patient information and advice- Information on the nature of low back pain and sciatica and encouragement to continue with normal activities. Promote and facilitate return to work or normal activities of daily living for people with low back pain with or without sciatica.

Exercise- Consider a group exercise programme (biomechanical, aerobic, mind–body or a combination of approaches) within the NHS for people with a specific episode or flare-up of low back pain with or without sciatica.

Manual therapy treatment package- Consider manual therapy (manipulation, mobilisation or soft tissue techniques (for example, massage)) for managing low back pain with or without sciatica, but only as part of a treatment package including exercise, with or without psychological therapy.

Psychological therapies treatment package- CBT, treatment must include exercise

Combined physical and psychological programmes

Pharmacological treatments:

• Offer oral NSAIDs for managing low back pain, taking into account potential differences in gastrointestinal, liver and cardio-renal toxicity, and the person’s risk factors, including age.
• When prescribing oral NSAIDs for low back pain, think about appropriate clinical assessment, ongoing monitoring of risk factors, and the use of gastroprotective treatment.
• Prescribe oral NSAIDs for low back pain at the lowest effective dose for the shortest possible period of time.
• Don’t offer paracetamol or opioids.