Lumbar Fatigue: A Case Study

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A visit note dated 10/10/2017 indicated that the claimant was driving an 18-wheeler and was caught in an accident with a car. He had an emergency room visit for this injury. He presented with a hand pain that increased to 7/10 when he tried to use it. He stated that his first metacarpal joint pain was at 7/10. He also had lower back pain rated as 6/10 with left leg numbness and tingling radiating to his left foot. Objective findings showed decreased edema on the right hand with tenderness over the extensor tendons. He had weak muscle testing grip and extension strength. There was muscle spasm along the lumbar paraspinal muscles with tenderness. There was a decreased sensation on the left L3, L4, L5, and S1 nerve root distribution. There was a positive straight leg raise test on the left. X-ray of the right hand dated 09/29/2017 was negative for fracture or dislocation. X-ray of the lumbar spine was negative for a mild degenerative joint …show more content…
He also had right hand pain with swelling, numbness, and tingling, which he reported had already decreased. He complained of lumbar spine pain rated at 8-10/10 radiating to his left leg and toes with increased numbness and tingling involving the left scrotum. He also had lower extremity weakness. Objective findings showed decreased edema on the right hand with tenderness over the extensor tendons. He had weak muscle testing grip and extension strength. There was muscle spasm along the lumbar paraspinal muscles with tenderness. There was a decreased sensation on the left L3, L4, L5, and S1 nerve root distribution. He was diagnosed with a sprain of the metacarpophalengeal joint of the right thumb, sprain of the right shoulder girdle, and sprain of the ligaments of the lumbar spine. Continued physical therapy and continued limited duty were

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