Mr. Emm reported, he was working at Rowerdink Automotive Part, Delivery and he was pushing a crate that got stuck in the floor. The crate side popped open suddenly and he went backwards hitting a Hi-lo fork on his left side of his low back. He had immediate pain to his left lower back with pain radiating upward and shooting, numbness, burning and tingling sensations radiating into his left lower extremity. He had brusing to his left buttock. He informed his employer and was sent to Concentra Urgent care. He had x-rays of his back which was negative. He was prescribed Tylenol for pain as well as Flexeril, which he only took about 4-5 times. He had a few days in physical therapy but his pain increased. He was working for approximately 3 ½ weeks and returned for an appointment and was provided work restrictions of no lifting more than 10 lbs., his employer was not able to accommodate so he was off work. On another follow up physician appointment …show more content…
Emm at times was irritable and anxious throughout and had a normal casual gait with no antalgic. He had a forward flexion to approximately 80 degrees at which point he reported pain. Extension greater than 10 degrees, causes pain. Straight leg raise is positive on the right and negative on the left. He had full range of motion in bilateral lower extremities. Mr. Emm had tenderness to palpation over the left lumbar paraspinal musculature as well as the left sacroiliac tenderness, none is present on the right. Spasms are noted in the left lumbar paraspinal musculature but no masses are palpable. Dr. Isler impression was that lumbar back pain and left lower extremity radicular symptoms is likely multifactorial. Mr. Emm does have components of left sacroilitis and a questionable left L5 radiculopathy. Dr. Isler recommended EMG and MRI lumbosacral. Mr. Emm was prescribed Medrol dose pack, Mobic and muscle rub cream. She advised him not to take any other NSAIDS when he is taking