Central Queensland University

Chiropractic Course File #: 0001

New Patient Form Date: 13/03/2020

Patient Name: John Doe Gender: Male

Date of Birth: 15/03/1990 Intern: Zac Williams

Vital Signs: To be completed by Intern prior to History

Pulse: 75 _/min. Resp: 17 /min. Temp: 37 / BP 140 / 70

Introduction/Complaint Summary:
30 year old massage therapist presents to clinic with
acute right sided lower back pain at L5-SIJ level.

Special Direction:
John is a very athletic individual playing social soccer, cricket and
other team based social activity’s

Supervisor Initials: ____

Date:

fq
Cases must be completed and signed-off within 72 hours of presentation.

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Central Queensland University NEW PATIENT FORM
Chiropractic Course
Patient Name: John Doe File #: 0001
Intern: Zac Williams

Chief Complaint John is a 30 year old massage therapist presenting with right sided lower back pain. The pain
is located on the lower right side of his back. Upon closer inspection the source of the pain is
1. Location located at the right Sacro Iliac joint. The pain has always been at that specific location and has
not shifted to any other areas, pain is unilateral in origin.
Pain originated whilst at work treating patients, John was in a fencers stance whilst applying
2. Onset
pressure to the patients back, the pain gradually built up from the initial incident throughout
that day and has been consistent ever since, there was a slight rotation component involved in
3. Duration this injury. The work station was no different to normal and John claims for it to be a
‘ergonomic set up’. The incident occurred on an intense work day that was strenuous and
exerting on the body.
4. Course
Pain has been present for 1 week, this is the first case of this type of injury occurring. Injury is
still in the acute phase
5. Type The pain has been constant since the first day of the injury, it is consistent in nature and does
not seem to progress noticeably through the day.
The pain is a sharp pain, rated at 6/10 consistently with it always being that value.
6. Radiating
The pain is localised in the right lower back region with the point of maximal tenderness being
the right SI with the region around it also radiating some pain. There is no referral of the pain
7. Relieving Factors to any limbs at all.
Pain is relieved by applying ice to the area, lying on the back and the side. Sports and running
also aggravate.
8. Aggravating Factors
No previous episodes
There is no previous treatment to this injury
9. Previous episodes Muscular tension around the area of the right QL associated with the pain but no other
symptoms have been reported
10. Previous management

11. Associated Symptoms Healthy History.

John has had a long history of playing soccer and has had numerous hamstring and calf
injuries, none of which that he has received treatment for, they have all been little niggles that
he has said he had ‘walked off’. All of these were in 2017. There have been no history of
Health History
surgeries/ accidents or any form of medications prescribed or taken.
• Medical history –
Johns parents are both alive and healthy ages 55 and 52 with no serious pathologies or any
illnesses/surgeries/
history of diseases.
Medications/accidents
John plays soccer with the local club and has recently lost his grand final, lives at home with his
• Family history mother and father and has a successful massage therapist business operating. John has a
partner and they have no signs of distress. Apart from these factors there has been no
• Psycho-social history evidence or indication that there has been and mental or psychosocial implicating factors.

There have been no change in the bowel or urinary patterns or function, no unexplained
• Systems Review weight loss or impaired sleeping patterns.

History Sign off: Comments:

Clinician:_________ Date:_________

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Case Summary
Inc. Pertinent history (chief compliant, history, past medical history, psychosocial and family history), Differential
diagnosis, Pertinent physical examination, Diagnosis, Treatment plan including interventions, Prognosis including
barriers to recover, Outcome Measures, Further investigations (if relevant), References and further reading.

Differential diagnosis
Right SI lumbar facet, piriformis syndrome, L4-L5 disc pathology

Physical examination
1. Gait
2. Observation
3. Range of motion
1. Active: Active range of motion of the lumbar spine, SIJ and hip
2. Passive: Passive range of motion of the lumbar spine, SIJ and hip
3. Resisted: resisted range of motion of the lumbar spine, SIJ, hip
4. Palpation
1. Static palpation of the lumbar spine, lumbrosacral junction, sacral base, SIJ, iliac crests
2. Motion palpation – motion palpation of the lumbar spine, SIJ, pelvis, hip and lower limb
5. Orthopaedic testing
1. Stork test – standing hip flexion test
2. Gaenslens - SIJ
3. Slump test – neural tension test
4. Yeomans – reproduces SI pain
5. SLR – 0-35 degrees indicates SIJ or piriformis syndrome
6. Sacral provocation – examines SIJ
7. Bonnet test – for piriformis syndrome
8. Distraction – to examine for Facet Syndrome
9. Compression- rules out disc pathology
10. Djerines triad – rules out disc pathology
11. Kemps – global screen – Disc pathology

6. Muscle testing
1. Piriformis muscle test
2. Hip flexion
3. Hip adduction
4. Knee extension
5. Big toe extension
7. Neurological testing
Lower limb myotome testing
8. Investigation / imaging
9. Chiropractic testing
10. Systems investigation (cardiovascular, respiratory, etc)

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Good Morning John, to get things started for today’s appointment I am going to running through
some specialised testing of specific areas that could be related to your injury, this will encompass
some basic movements, specialised tests and feeling of the skin and structures below with my
hands. Is this something that you feel comfortable with?

Gait analysis
Front on view - patient has a limited extension on the right side through the hip. Right sided PSIS
is lower then the left.
Side view - Limited extension of the hip on the right side, causing a decrease in stride length on
the right hand side. Anterior (forward) pelvic tilt on the left side. Patient has slight eversion of
both feet. Slight forward head carriage
Heel & Toe examination negative finding
Tandem examination negative finding

AROM of the Lumbar spine AROM of the Hip

o flexion – flexion tight and stiff localised
at the L5 region
o extension - extension also painful and
stiff localised around the L5 region
o lateral flexion (left & right) normal
o rotation (left & right) – normal
o Flexion – normal
o Extension – limited on right side and
painful at end range – this is due to this
motion loading the right sided SIJ
o Abduction – normal findings
o Adduction – normal findings
o Internal rotation - normal findings
o External rotation – normal findings

Movement screen AROM Lumbar / Hip & leg screen = full squat
No difficulty in doing squat

Reason for this screen is to look for

L spine (rounding, extending)
LPHC (Lumbo-pelvic hip complex)
Knees (In or out)
Feet (invert, evert)

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Static palpation lumbar spine Static palpation pelvis
o SP’s / TVP’s – o SI joint – Right sided SI joint is sitting
normal findings lower when compared to the left]
o Facet joints / pillars – o Ischial tuberosity’s – normal findings
right L5 facet warm – o PSIS – left sided PSIS is higher then the
and red indicating left.
inflammation and o ASIS – lower on the right hand side
dysfunction when compared to the left.
o Quadratus o Greater trochanter – lower on right
lumborum- increased hand side
tone on the right side o Gluteus maximus – increased muscle
o Erector spinae- tone and decreased muscle power (right
increased tone on the sided)
o Hamstring – increased muscles tone and
right side
decreased muscle power (right sided)
o Psoas – increased
o Recuts femoris – normal findings
tone o Sartorius – normal findings
o Multifidus – normal
findings
Static palpation Sacro-
iliac joint
o Sacrum S1-5 – S1 /
sacral base is at a
lower level on the
right side when
compared to the left
o Iliac crest – slightly
lower on the right
side when
compared to the left
o Sacroiliac ligaments
increased tightness
on the right side
o Piriformis – normal
finding

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PROM / Motion Palpation (MP) and/or Resisted ROM.
AROM of the Lumbar spine
o flexion – flexion tight and stiff localised
at the L5 region. Reduced range of motion
o extension - extension also painful and
stiff localised around the L5 region –
reduced range of motion
o lateral flexion (left & right) normal
o rotation (left & right) – normal
AROM of the Hip
o Flexion – normal
o Extension – limited on right side and
painful at end range – this is due to this
motion loading the right sided SIJ. When
compared to left leg roughly 5 degrees
less
o Abduction – normal findings
o Adduction – normal findings
o Internal rotation - normal findings
o External rotation – normal findings

o Hip, Pelvis and T/L screen = springing

Special Tests
Orthopaedic testing Muscle testing
1. Trendelenburg – hip screen = 13. Piriformis muscle test -
positive on the right side. positive result – muscle
2. Gaenslens – SIJ = positive result weakness right side
on the both sides as produces 14. Hip flexion – negative result
pain. Right side more painful
15. Hip adduction – negative
3. Slump test – neural tension test
result
= negative finding
4. Yeomans – reproduces SI pain – 16. Knee extension – negative
Positive with right being more result
painful then left 17. Big toe extension – negative
5. SLR – 0-35 degrees indicates SIJ result
or piriformis syndrome
Positive right ride more painful
over left
6. Sacral provocation – examines
SIJ – positive result reproduces
pain on the right hand side
7. Bonnet test – for piriformis
syndrome – negative result
8. Distraction – to examine for
Facet Syndrome – negative
result
9. Compression- rules out disc
pathology – negative result
10. Djerines triad – rules out disc
pathology – negative result
11. Kemps – global screen – Disc
pathology – reproduces pain
12. Fabers – SIJ – positive

Functional testing / functional rehab =Cat – cow

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SMR- completes appropriate sensory, motor and reflex examination
o Motor Examination of lower limbs –
myotome examination of the lower limb
– no abnormal findings