Differential Diagnosis:

1. Systemic inflammatory issue, possibly ankylosing spondylitis or psoriatic arthritis (she did not have skin lesions), due to morning stiffness and location of pain. Her SI joint stress tests were normal, which would possibly clear AS. She was cleared of RA (she did not have any small hand or foot joint complaints) with testing done by her MD to rule all these options out.
2. Multiple myeloma or cancer was briefly considered due to her difficulty sleeping at night, but the pain seemed related to position more than the constant unrelenting pain of something more insidious. She would have been referred to her physician if she had not responded promptly to conservative treatment.
3. Return of her fibroid tumors.

Objective Signs:
Posture: Slight increased lordosis with hyperextended knees bilaterally. Her body type was one of lax ligamentous makeup, but not EDS (Ehlers-Danlos Syndrome). Upper chest breather.

ROM:
Forward flexion decreased by 50% with visible arching of her back into lordosis as she tried to attain the position. She preferred to walk her hands down her thighs as she attempted to flex forward. She didn't have any referred pain into her legs with that activity.
Extension decreased by 50% with central back pain.
Side flexion decreased bilaterally by 15%.
Seated rotation decreased by 30% bilaterally with central back pain.
Poor lateral costal expansion (B).

Neurological testing: Normal SLR, intact motor strength of myotomes L2-S2, normal reflexes, negative plantar response, negative slump test, and sensation tests were normal. Lumbar cranial compression was positive, and caudal distraction was negative.

SI Joint Stress Tests: Normal

Hip: Positive right hip quadrant at full flexion/adduction

Palpation: Spasm noted in left lumbar paravertebral muscles with wasting of the right lumbar paravertebral and multifidus muscles at L3/4–L5/S1.

Joint Mobility: Restricted mobility at L3/L4 and L5/S1; excessive mobility at L4/5 with reactive spasm on palpation.

Initial Impression:
My initial impression of the patient’s problem was of a mechanical nature. Due to the inability to flex forward and return to neutral without using her hands to walk down and up her legs, I started to question clinical instability/hypermobility. The unpredictability of the pain during motion was another suggestion of clinical instability/hypermobility. She did not present with neurological symptoms or signs. She did not present with central stenosis signs with walking. The possibility of a herniated disc was high because of the positive lumbar compression test.

Question: What diagnostic imaging or tests would you order?