【Lower Back and Left Glute Pain｜Physical Assessment, Treatment, and Recovery Progress】

In this post, I share the assessment, treatment approach, and pain progression of a patient visiting my practice for the first time.

Patient Background

The patient is a woman in her 30s, presenting with lower back pain and left gluteal pain.

She did not experience any pain radiating to her legs. While her daily activities were mostly unaffected, she felt discomfort while sitting and lying down, which disrupted her sleep.

Recently, she has been extremely busy, with long hours of desk work and added stress from interpersonal relationships. Her exercise routine at a sports club actually worsened her symptoms.

1. Initial Physical Assessment

• Straight leg raise test: Negative

• Single-leg stance: Right 5 sec, Left 8 sec

• Plank hold: Few seconds

There were no signs of nerve root involvement. However, weakness was evident in the quadriceps, hamstrings, and core muscles supporting the lower back.

Limited experience with core exercises contributed to the short plank hold duration.

2. First Treatment Session

• Checked lumbar spine and hip mobility

• Muscle massage and lymphatic massage for lower back and glutes

• Electrical acupuncture (pulsed) to relax deep muscles

• Hamstring and calf stretches

• Treatment duration: 80 minutes

Progress was scheduled to be reviewed after one week.

3. Second Treatment Session

• Pain scale: 10 → 5

• Repeated conditioning massage and electrical acupuncture

• Fascia release of lateral thigh using a foam roller

• Treatment duration: 80 minutes

Muscle relaxation and improved sleep were observed, indicating symptom reduction.

4. Third Treatment Session

• Pain scale: 5 → 3

• Electrical acupuncture not applied; standard acupuncture plus moxibustion per patient request

• Scapular and pelvic stretches performed

• Patient appeared calm and pain was significantly reduced

• Decided to continue with regular maintenance sessions

5. Recovery and Summary

• Anxiety about pain decreased

• Patient resumed training at the gym

• Currently attends every 2 weeks (60-minute standard session, 80 minutes when fatigued)

Because pain was significantly reduced after the first session, the second session repeated the same treatment approach. Treatment plans are adjusted flexibly depending on changes in symptoms and pain levels.

For anyone experiencing lower back or gluteal pain, early intervention is recommended to support sleep and overall daily health.

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Daisuke Tazawa

BODYWORKS AZABU

◎ Treatment details shared with consent

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