A 25-year-old male presented to our clinic with chronic low back and right hip pain that had persisted for over a year. The pain was described as dull, deep, and occasionally sharp, radiating down into the mid-calf during flare-ups.
The patient rated it at 10/10 at its worst, and aggravated by work activity. The patient works as a welder, a physically demanding job requiring repetitive lifting, bending, and extended hours in static postures.
He reported that stretching occasionally relieved his symptoms, while over-the-counter medications such as Aleve provided only temporary benefit.
Chief Complaints
- Lower Back and Hip Pain
- Radiating Pain down the right leg toward the calf.
Frequency: Daily, Onset was one year ago
Medical & Lifestyle History
- The patient was involved in a motor vehicle accident in 2017, in which the vehicle flipped and resulted in a cervical spine fracture.
- He was treated in the emergency department without surgical intervention.
- The patient had seen other chiropractors prior to this visit but reported minimal improvement.
- Performs weightlifting 1–2 times per week.
- Commutes 30+ minutes per day and spends several hours seated during travel or rest.
- Uses over-the-counter pain relievers (Aleve) as needed.
- Positive for diabetes.
Examination Findings
Initial chiropractic examination and orthopedic testing revealed measurable restrictions and segmental dysfunction in the lumbar and pelvic regions.
Lumbar Range of Motion (ROM):
- Flexion: 50° (normal 60° – restricted)
- Extension: 20° (normal 25° – restricted)
- Lateral Flexion Left: 20° (normal 25° – restricted)
- Lateral Flexion Right: 20° (normal 25° – restricted)
- Rotation Left: 25° (normal 30° – restricted)
- Rotation Right: 25° (normal 30° – restricted)
The lumbar spine demonstrated significant motion restriction and mechanical dysfunction consistent with chronic lumbar segmental dysfunction and sacroiliac joint involvement.
Customized Care Plan
To address both the underlying mechanical dysfunction and the patient’s symptoms, a Spinal Corrective Care Plan was developed over an initial 4–6 week period consisting of:
- 16 Sessions of Spinal Decompression Therapy
- 8 Chiropractic Adjustments
- 2 Re-examinations
- 1 Ergonomic Recommendations
- 3 Home Exercises
- 1 Final X-ray
Initial Results
During his first progress re-evaluation, the patient reported minimal perceived improvement (approximately 5% better). and expressed concern about the lack of noticeable change.
- Continued lower back pain with intermittent shooting leg pain.
- Stretching compliance: daily.
The patient was encouraged to continue with his care plan and improve consistency with home-based traction and exercises.
Final Outcome
The second re-exam date Aug 8 2025 showed significant improvement rated at 70% since beginning care. He noted that his lower left-sided pain is now less consistent, and his tolerance for standing and sitting has improved.
He reported feeling stronger, more relaxed, more alert, and experiencing less pain overall, along with improvements in sleep quality.