Patient Demographics: 38 y.o. female; stay-at-home mom with three kids (13yo, 10yo, 8yo).
Reason for referral: mid-back pain, L>R flank/side pain
Current history: Pt reports L>R mid-back and side pain. Pt states pain frequently wraps around to the
front, just below her ribs. Pt reports pain began about 6 months ago, does not recall anything specifically
causing the pain, pain has been up and down over the six months but has been getting worse over the
last 3 weeks.
Medical history: depression, anxiety
Pain: dull  grabbing, sharp
 Worst: 8/10
 Best: 3/10
Aggravating factors:
 Twisting
 Wiping after bowel movement
 Breathing deep
 Overhead reaching, reaching into backseat of car
Easing factors:
 Supine/hooklying
 Sitting with back supported
Consistent pain:
Inconsistent pain:
Differential Diagnosis: What are you
thinking at this point? Possible MSK
diagnoses? What referrals would you
suggest?
PCP made referrals to:
 GI: negative MRI, no significant finding with endoscopy; pain not coming from GI system
 Cardiologist: all tests were negative; No concerns with heart or lungs
 Dietician: offered changes to diet; no dietary changes improved pain
Examination:
Posture: cervical lordosis, thoracic kyphosis, increased flank space on L side, elevated L shoulder
Gait: decreased trunk movement, trunk forward flexion, decreased weight shift to L side
ROM: Thoracic spine
 Flexion: 12 deg w p!
 Extension: 25 deg w p!!
 R sidebend: 15 deg w p!!
 L sidebend: 30 deg w p!
ROM: Shoulders
 Flexion: WNL B
 Abduction: WNL B
 Internal rotation: WNL B
 External rotation: WNL B
MMT: Shoulders
 Flexion: 5/5 w “twinge” B
 Abduction: 5/5 w p! on L
 Internal rotation: 5/5
 External rotation: 5/5
Core strength: 3/5
Palpations:
 Tension and tenderness to R>L thoracic paraspinals
 Tension and tenderness to R latissimus dorsi, lower trapezius, superior serratus posterior,
serratus anterior, intercostals of ribs 9-12
 Hypomobility and tenderness of central and unilateral R>L PA’s to T-8-L1
 Minimal hypomobility and tenderness with unilateral PA’s to costovertebral joints to T8-T12
Diagnosis: What is your diagnosis? What other information might you want?
Keys to diagnosing this patient:
 Increased pain with deep inhalation
 Report of having hiccups more often
 Tension, trigger points, and PAIN to R>L Diaphragm
Final diagnosis: spasm of diaphragm