This patient’s exam should include a thorough evaluation of the lumbar spine, sacroiliac joints and gluteal region. Motion palpation of this patient’s lumbar spine indicated no pain or fixations. Functional testing included Straight Leg Raise, Kemps Test and Goldthwaite’s Test. Range of motion was not evaluated due to limitations from the pain.

Functional Tests were negative for issues at the lumbar spine. There were muscle spasms and inflammation at the right gluteal region and pain at the right IT band at the greater trochanter region. Palpation at the lateral thigh and top of foot did not reproduce pain.

This patient was sent for plain film X-ray of the lumbopelvic spine.

R  L

Imaging indicated anomalies at the lumbosacral junction including a tropism at L5/S1 region. The right joints were more sagittaly oriented and the left joints were more coronally oriented. This patient also has a lateral rotary curvature concavity to the right with a pelvic lateral tilt. It is undetermined at this time if this patient’s curvature is secondary to muscle spasms associated with this injury. 

Questions: At this point, what is your working diagnosis for this patient?