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9/1/2015

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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Differentialdiagnosisofapatientwithlowbackandtoepain

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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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.
References

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1.BoissonnaultWG.Prevalenceofcomorbidconditions,surgeries,andmedicationuseinaphysicaltherapy
outpatientpopulation:amulticenteredstudy.JOrthopSportsPhysTher.199929(9):50619discussion205.
Epub1999/10/13[PubMed]
2.JetteAM,SmithK,HaleySM,DavisKD.Physicaltherapyepisodesofcareforpatientswithlowbackpain.
PhysTher.199474(2):10110discussion105.Epub1994/02/01[PubMed]
3.BattieMC,CherkinDC,DunnR,CiolMA,WheelerKJ.Managinglowbackpain:attitudesandtreatment
preferencesofphysicaltherapists.PhysTher.199474(3):21926Epub1994/03/01[PubMed]
4.LivelyMW.Sportsmedicineapproachtolowbackpain.SouthMedJ.200295(6):6426Epub2002/06/26
[PubMed]
5.WhiteAA,3rd,GordonSL.Synopsis:workshoponidiopathiclowbackpain.Spine(PhilaPa1976).
19827(2):1419Epub1982/03/01[PubMed]
6.PaiS,SundaramLJ.Lowbackpain:aneconomicassessmentintheUnitedStates.OrthopClinNorthAm.
200435(1):15Epub2004/04/06[PubMed]
7.NachemsonAL.Newestknowledgeoflowbackpain.Acriticallook.ClinOrthopRelatRes.1992(279):820
Epub1992/06/01[PubMed]
8.JarvikJG,DeyoRA.Diagnosticevaluationoflowbackpainwithemphasisonimaging.AnnInternMed.
2002137(7):58697Epub2002/10/02[PubMed]
9.HenschkeN,MaherCG,RefshaugeKM,HerbertRD,CummingRG,BleaselJ,etal.Prevalenceofand
screeningforseriousspinalpathologyinpatientspresentingtoprimarycaresettingswithacutelowbackpain.
ArthritisRheum.200960(10):307280Epub2009/10/01[PubMed]
10.HenschkeN,MaherCG,RefshaugeKM.Asystematicreviewidentifiesfiveredflagstoscreenforvertebral
fractureinpatientswithlowbackpain.JClinEpidemiol.200861(2):1108Epub2008/01/08[PubMed]
11.HenschkeN,MaherCG,RefshaugeKM.Screeningformalignancyinlowbackpainpatients:asystematic
review.EurSpineJ.200716(10):16739Epub2007/06/15[PMCfreearticle][PubMed]

9/1/2015

Differentialdiagnosisofapatientwithlowbackandtoepain

12.SternberghWC,3rd,GonzeMD,GarrardCL,MoneySR.Abdominalandthoracoabdominalaorticaneurysm.
SurgClinNorthAm.199878(5):82743,ix.Epub1999/01/19[PubMed]
13.HarperBE,ReveilleJD.Spondyloarthritis:clinicalsuspicion,diagnosis,andsports.CurrSportsMedRep.
20098(1):2934Epub2009/01/15[PMCfreearticle][PubMed]
14.HelmickCG,FelsonDT,LawrenceRC,GabrielS,HirschR,KwohCK,etal.Estimatesoftheprevalenceof
arthritisandotherrheumaticconditionsintheUnitedStates.PartI.ArthritisRheum.200858(1):1525Epub
2008/01/01[PubMed]
15.RudwaleitM,vanderHeijdeD,KhanMA,BraunJ,SieperJ.Howtodiagnoseaxialspondyloarthritisearly.
AnnRheumDis.200463(5):53543Epub2004/04/15[PMCfreearticle][PubMed]
16.SieperJ,BraunJ,RudwaleitM,BoonenA,ZinkA.Ankylosingspondylitis:anoverview.AnnRheumDis.
200261Suppl3:iii818Epub2002/10/17[PMCfreearticle][PubMed]
17.BraunJ,BollowM,RemlingerG,EggensU,RudwaleitM,DistlerA,etal.Prevalenceofspondylarthropathies
inHLAB27positiveandnegativeblooddonors.ArthritisRheum.199841(1):5867Epub1998/01/20[PubMed]
18.RudwaleitM,KhanMA,SieperJ.Thechallengeofdiagnosisandclassificationinearlyankylosingspondylitis:
doweneednewcriteria?ArthritisRheum.200552(4):10008Epub2005/04/09[PubMed]
19.UnderwoodMR,DawesP.Inflammatorybackpaininprimarycare.BrJRheumatol.199534(11):10747
Epub1995/11/01[PubMed]
20.AkgulO,OzgocmenS.Classificationcriteriaforspondyloarthropathies.WorldJOrthop.20112(12):10715
Epub2012/04/05[PMCfreearticle][PubMed]
21.RostomS,DougadosM,GossecL.Newtoolsfordiagnosingspondyloarthropathy.JointBoneSpine.
201077(2):10814Epub2010/02/16[PubMed]
22.GladmanDD.Clinicalaspectsofthespondyloarthropathies.AmJMedSci.1998316(4):2348Epub
1998/10/10[PubMed]
23.KhanMA.Updateonspondyloarthropathies.AnnInternMed.2002136(12):896907Epub2002/06/19
[PubMed]
24.PetersMJ,vanderHorstBruinsmaIE,DijkmansBA,NurmohamedMT.Cardiovascularriskprofileof
patientswithspondylarthropathies,particularlyankylosingspondylitisandpsoriaticarthritis.SeminArthritis
Rheum.200434(3):58592Epub2004/12/21[PubMed]
25.KanathurN,LeeChiongT.Pulmonarymanifestationsofankylosingspondylitis.ClinChestMed.
201031(3):54754Epub2010/08/10[PubMed]
26.RothovaA,SuttorpvanSchultenMS,FritsTreffersW,KijlstraA.Causesandfrequencyofblindnessin
patientswithintraocularinflammatorydisease.BrJOphthalmol.199680(4):3326Epub1996/04/01
[PMCfreearticle][PubMed]
27.ArdizzoneM,JavierRM,KuntzJL.[Ankylosingspondylitisandosteoporosis].RevMedInterne.
200627(5):3929Epub2005/11/09[PubMed]
28.BrandtJ,KhariouzovA,ListingJ,HaibelH,SorensenH,RudwaleitM,etal.Successfulshorttermtreatment
ofpatientswithsevereundifferentiatedspondyloarthritiswiththeantitumornecrosisfactoralphafusionreceptor
proteinetanercept.JRheumatol.200431(3):5318Epub2004/03/03[PubMed]
29.BraunJ,BrandtJ,ListingJ,ZinkA,AltenR,GolderW,etal.Treatmentofactiveankylosingspondylitiswith
infliximab:arandomisedcontrolledmulticentretrial.Lancet.2002359(9313):118793Epub2002/04/17
[PubMed]
30.CookC,HegedusE.Orthopedicphysicalexaminationtests:anevidencebasedapproach.UpperSaddleRiver,
NJ:PearsonEducation,Inc2008
31.LaslettM.Evidencebaseddiagnosisandtreatmentofthepainfulsacroiliacjoint.JManManipTher.
200816(3):14252Epub2009/01/03[PMCfreearticle][PubMed]
32.LaslettM.Painprovocationtestsfordiagnosisofsacroiliacjointpain.AustJPhysiother.200652(3):229Epub
2006/09/01[PubMed]
33.LaslettM,AprillCN,McDonaldB,YoungSB.Diagnosisofsacroiliacjointpain:validityofindividual
provocationtestsandcompositesoftests.ManTher.200510(3):20718Epub2005/07/26[PubMed]
34.DagfinrudH,KvienTK,HagenKB.TheCochranereviewofphysiotherapyinterventionsforankylosing
spondylitis.JRheumatol.200532(10):1899906Epub2005/10/06[PubMed]

9/1/2015

Differentialdiagnosisofapatientwithlowbackandtoepain

35.MaitlandGD.Peripheralmanipulation.3rdedn.London:ButterworthHeinemann1991
36.GarrettS,JenkinsonT,KennedyLG,WhitelockH,GaisfordP,CalinA.Anewapproachtodefiningdisease
statusinankylosingspondylitis:theBathAnkylosingSpondylitisDiseaseActivityIndex.JRheumatol.
199421(12):228691Epub1994/12/01[PubMed]
37.CalinA,GarrettS,WhitelockH,KennedyLG,OHeaJ,MallorieP,etal.Anewapproachtodefining
functionalabilityinankylosingspondylitis:thedevelopmentoftheBathAnkylosingSpondylitisFunctionalIndex.
JRheumatol.199421(12):22815Epub1994/12/01[PubMed]
38.ZochlingJ.Measuresofsymptomsanddiseasestatusinankylosingspondylitis:AnkylosingSpondylitis
DiseaseActivityScore(ASDAS),AnkylosingSpondylitisQualityofLifeScale(ASQoL),BathAnkylosing
SpondylitisDiseaseActivityIndex(BASDAI),BathAnkylosingSpondylitisFunctionalIndex(BASFI),Bath
AnkylosingSpondylitisGlobalScore(BASG),BathAnkylosingSpondylitisMetrologyIndex(BASMI),
DougadosFunctionalIndex(DFI),andHealthAssessmentQuestionnairefortheSpondylarthropathies(HAQS).
ArthritisCareRes(Hoboken).201163Suppl11:S4758Epub2012/05/25[PubMed]
39.CalinA,PortaJ,FriesJF,SchurmanDJ.Clinicalhistoryasascreeningtestforankylosingspondylitis.JAMA.
1977237(24):26134Epub1977/06/13[PubMed]
40.BraunJ,InmanR.Clinicalsignificanceofinflammatorybackpainfordiagnosisandscreeningofpatientswith
axialspondyloarthritis.AnnRheumDis.201069(7):12648Epub2010/06/23[PubMed]
41.BrandtJ,BollowM,HaberleJ,RudwaleitM,EggensU,DistlerA,etal.Studyingpatientswithinflammatory
backpainandarthritisofthelowerlimbsclinicallyandbymagneticresonanceimaging:many,butnotallpatients
withsacroiliitishavespondyloarthropathy.Rheumatology(Oxford).199938(9):8316Epub1999/10/09
[PubMed]
42.MauW,ZeidlerH,MauR,MajewskiA,FreyschmidtJ,StangelW,etal.Clinicalfeaturesandprognosisof
patientswithpossibleankylosingspondylitis.Resultsofa10yearfollowup.JRheumatol.198815(7):110914
Epub1988/07/01[PubMed]
43.FeldtkellerE,KhanMA,vanderHeijdeD,vanderLindenS,BraunJ.Ageatdiseaseonsetanddiagnosis
delayinHLAB27negativevs.positivepatientswithankylosingspondylitis.RheumatolInt.200323(2):616
Epub2003/03/14[PubMed]
44.vanderLindenS,vanTubergenA,HiddingA.Physiotherapyinankylosingspondylitis:whatistheevidence?
ClinExpRheumatol.200220(6Suppl28):S604Epub2002/12/05[PubMed]
45.KraagG,StokesB,GrohJ,HelewaA,GoldsmithC.Theeffectsofcomprehensivehomephysiotherapyand
supervisiononpatientswithankylosingspondylitisarandomizedcontrolledtrial.JRheumatol.199017(2):228
33Epub1990/02/01[PubMed]
46.LawLA,HaftelHM.Shoulder,knee,andhippainasinitialsymptomsofjuvenileankylosingspondylitis:a
casereport.JOrthopSportsPhysTher.199827(2):16772Epub1998/02/25[PubMed]
47.CoronadoRA,SheetsCZ,CookCE,BoissonnaultWG.Spondyloarthritisinapatientwithunilateralbuttock
painandhistoryofCrohndisease.PhysTher.201090(5):78492Epub2010/03/20[PubMed]
48.RudwaleitM,TaylorWJ.Classificationcriteriaforpsoriaticarthritisandankylosingspondylitis/axial
spondyloarthritis.BestPractResClinRheumatol.201024(5):589604Epub2010/11/03[PubMed]
49.HeuftDorenboschL,LandeweR,WeijersR,WandersA,HoubenH,vanderLindenS,etal.Combining
informationobtainedfrommagneticresonanceimagingandconventionalradiographstodetectsacroiliitisin
patientswithrecentonsetinflammatorybackpain.AnnRheumDis.200665(6):8048Epub2005/10/13
[PMCfreearticle][PubMed]
50.vanderLindenS,ValkenburgHA,CatsA.Evaluationofdiagnosticcriteriaforankylosingspondylitis.A
proposalformodificationoftheNewYorkcriteria.ArthritisRheum.198427(4):3618Epub1984/04/01
[PubMed]
51.BraunJ,SieperJ,BollowM.Imagingofsacroiliitis.ClinRheumatol.200019(1):517Epub2000/04/07
[PubMed]
52.RudwaleitM,vanderHeijdeD,LandeweR,ListingJ,AkkocN,BrandtJ,etal.Thedevelopmentof
AssessmentofSpondyloArthritisinternationalSocietyclassificationcriteriaforaxialspondyloarthritis(partII):
validationandfinalselection.AnnRheumDis.200968(6):77783Epub2009/03/20[PubMed]
53.HelliwellPS,TaylorWJ.Classificationanddiagnosticcriteriaforpsoriaticarthritis.AnnRheumDis.200564
Suppl2:ii38Epub2005/02/15[PMCfreearticle][PubMed]
54.TaylorW,GladmanD,HelliwellP,MarchesoniA,MeaseP,MielantsH.Classificationcriteriaforpsoriatic

9/1/2015

Differentialdiagnosisofapatientwithlowbackandtoepain

arthritis:developmentofnewcriteriafromalargeinternationalstudy.ArthritisRheum.200654(8):266573Epub
2006/07/28[PubMed]
55.ZochlingJ,vanderHeijdeD,BurgosVargasR,CollantesE,DavisJC,Jr,DijkmansB,etal.ASAS/EULAR
recommendationsforthemanagementofankylosingspondylitis.AnnRheumDis.200665(4):44252Epub
2005/08/30[PMCfreearticle][PubMed]
56.UhrinZ,KuzisS,WardMM.Exerciseandchangesinhealthstatusinpatientswithankylosingspondylitis.
ArchInternMed.2000160(19):296975Epub2000/10/21[PubMed]
57.WidbergK,KarimiH,HafstromI.Selfandmanualmobilizationimprovesspinemobilityinmenwith
ankylosingspondylitisarandomizedstudy.ClinRehabil.200923(7):599608Epub2009/05/01[PubMed]
58.PassalentLA,SoeverLJ,OSheaFD,InmanRD.Exerciseinankylosingspondylitis:discrepanciesbetween
recommendationsandreality.JRheumatol.201037(4):83541Epub2010/03/03[PubMed]
59.AggarwalR,MalaviyaAN.ClinicalcharacteristicsofpatientswithankylosingspondylitisinIndia.Clin
Rheumatol.200928(10):1199205Epub2009/07/21[PubMed]
60.GladmanDD,AntoniC,MeaseP,CleggDO,NashP.Psoriaticarthritis:epidemiology,clinicalfeatures,
course,andoutcome.AnnRheumDis.200564Suppl2:ii147Epub2005/02/15[PMCfreearticle][PubMed]
61.SlobodinG,ReyhanI,AvshovichN,BalbirGurmanA,BoulmanN,EliasM,etal.Recentlydiagnosedaxial
spondyloarthritis:genderdifferencesandfactorsrelatedtodelayindiagnosis.ClinRheumatol.201130(8):107580
Epub2011/03/02[PubMed]
62.BraunJ,SieperJ.Thesacroiliacjointinthespondyloarthropathies.CurrOpinRheumatol.19968(4):27587
Epub1996/07/01[PubMed]
63.OzgocmenS,BozgeyikZ,KalcikM,YildirimA.Thevalueofsacroiliacpainprovocationtestsinearlyactive
sacroiliitis.ClinRheumatol.200827(10):127582Epub2008/05/07[PubMed]
64.SieperJ,vanderHeijdeD,LandeweR,BrandtJ,BurgosVagasR,CollantesEstevezE,etal.Newcriteriafor
inflammatorybackpaininpatientswithchronicbackpain:arealpatientexercisebyexpertsfromtheAssessment
ofSpondyloArthritisinternationalSociety(ASAS).AnnRheumDis.200968(6):7848Epub2009/01/17
[PubMed]
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