A Patient with Lumbar Spinal Stenosis – A Case Report

History: The patient presents with a 20-year history of intermittent low back pain, which has gradually worsened over the past four months to include sharp, radiating pain down both legs to the toes. Radicular symptoms are slightly worse on the right side. Symptoms are aggravated by standing and walking, while sitting provides complete relief of leg pain.

Physical Limitations:

• Unable to stand for more than 10 minutes without needing to sit.
• Unable to walk more than half a mile without requiring a sitting break.
• Reports the first hour of the day is the most symptomatic, making it difficult to get started.

The patient reports that her walking limitations prevent her from enjoying activities like walking on the NCR trail and attending family or social events. She is still able to grocery shop independently, as leaning over the cart allows her to walk longer distances.

Symptom Description: The patient describes her low back pain as a dull ache, slightly worse on the right. She describes the symptoms in both legs as sharp. (See body chart below for detailed illustration and description of symptoms.)

Physical Examination:

• Myotome testing: Normal; no strength deficits
• Dermatome testing: Normal; no sensory loss
• Reflexes: 1+ bilaterally for quadriceps and Achilles
• Lumbar flexion: 35 degrees
• Lumbar extension: 5 degrees, reproduced sharp pain down both legs
• Trunk flexion: Difficulty returning to upright position after forward bending
• Hip flexion: 100 degrees bilaterally
• Hip internal rotation: 15 degrees bilaterally
• Hip extension: 0 degrees bilaterally
• Thoracic extension: 10 degrees

Interpretation of Findings: The patient demonstrates significant loss of range of motion in the lumbar spine, hips, and thoracic spine. These limitations are consistent with common findings in individuals with lumbar spinal stenosis, particularly restricted extension at the hips, lumbar spine, and thoracic spine. Improving mobility in these areas can help reduce the amount of lumbar extension needed for upright postures, potentially improving standing and walking tolerance.

Treatment Approach: Initial treatment focused on manual therapy and stretching to improve hip and thoracic spine mobility. The rationale was that addressing these regions — where the patient had notable mobility restrictions — would be an effective first step in reducing symptoms associated with upright postures.

After four weeks of this approach, the patient doubled her standing and walking tolerance, going from 10 to approximately 20 minutes before needing a sitting break. Treatment then progressed to include lumbar-specific mobility and strengthening exercises to address deficits in lumbar extension.

Results:

• The patient was seen for 21 visits over the course of 12 weeks. At discharge, she achieved the following:
• Improved standing tolerance from 10 minutes to 30 minutes before needing to sit.
• Increased walking distance from 0.5 miles to 1.5 miles (about 45 minutes) before requiring rest.
• Complete resolution of morning stiffness and pain.

The patient was able to resume walking the NCR trail several days per week and felt better able to participate in family and social activities due to improved walking and standing tolerance. Although she continued to experience some symptoms in her back and legs at discharge, they were significantly reduced compared to when she began physical therapy.

Body chart comparison (Initial vs. Discharge) to show symptom location, intensity, and description