Due to the patient’s age, some of the diagnoses that should be considered are scoliosis secondary to lumbar disc disease with arthrosis, lumbar spinal stenosis, facet syndrome, myofascial pain syndrome, foot pronation.

Physical Exam Findings:

Examination of the lumbar spine demonstrated normal Ranges of Motion, normal dermatome evaluation and normal deep tendon reflexes. There is atrophy of the right multifidus and quadratus lumborum with a left lateral and rotary curvature at the lumbar spine. There are spasms of the left multifidus at the lumbar spine. Fixations existed between L4 and L5 as well as L5 and sacrum in which the sacrum was also fixed in anterior flexion, right side more than left. Gluteal spasms were inferior to the iliac crest however, palpation of the gluteal spasms did not create symptoms.

A 3D scan was performed of her feet, and it was determined that this patient had mild loss of medial arch on the right side. She did have orthotics for support but has not been wearing them lately.

Question: What is your working diagnosis at this point?