History and Presenting Symptoms
A 37 year-old male presents with a report of pain in his lower back and right hip. Further discussion elicits a history of previous right hamstring strain during high school soccer, along with several episodes of ankle sprains. He has had arthroscopic surgery to evaluate recurrent left knee pain and stiffness, which found no specific problem. He performs stretches daily to maintain flexibility in his iliotibial connective tissues, since they are frequently identified as tight and short. Because of his prior lower extremity symptoms, he does not currently participate in any competitive or recreational sports.
Vitals. This athletic male weighs 151 lbs, which, at 5’9’’, results in a BMI of 22; he is not overweight. He is a non-smoker, and his blood pressure and pulse rate are at the lower end of the normal range.
Posture and gait. Standing postural evaluation finds generally good alignment throughout the spine, although he shows evidence of a right posterior ileum. He also has mild bilateral calcaneal eversion, with a lower right arch. There is moderate medial bowing of the Achilles tendons when standing, especially on the right, with a tendency to toe out (foot flare) that is more prominent on the right side.
Chiropractic evaluation. Motion palpation identifies a limitation in right sacroiliac motion, with moderate tenderness and loss of endrange mobility. Also identified are moderate limitations in segmental motion at L4/L5 and L5/S1, with local tenderness. Additional fixations are noted at T12/L1, T9/T10, and C5/6. Lumbar ranges of motion are generally full and pain-free. Neurologic and provocative orthopedic testing is negative. Examination of the knees and ankles finds no ligament instability, and all knee and ankle ranges of motion are full and pain-free. Manual testing finds weakness of the right psoas muscle, in comparison to other lower extremity muscles.
Upright, weight-bearing X-rays of the lumbar spine demonstrate moderate loss of intervertebral disc height at L4/L5 and L5/S1, but no osteophyte formation is seen at those levels. There is a slight discrepancy in femur head heights (4 mm), and iliac crest heights (3 mm), but no significant lateral curvature of the lumbar spine.
Chronic mechanical dysfunction of the pelvis and lumbar spine associated with poor biomechanical support from the lower extremities. By history, there is a pattern of several lower extremity conditions, which are consistent with his identified asymmetry.
Adjustments. Specific diversified chiropractic adjustments for the sacroiliac, lower lumbar, thoracic, and cervicothoracic spinal regions were provided as indicated.
Support. Flexible, custom-made stabilizing orthotics were fitted to support the arches and decrease calcaneal eversion.
Rehabilitation. This patient was shown dynamic resistance exercises using elastic tubing to begin strengthening his spinal stabilizers and core pelvic musculature. He was also instructed to gradually initiate a daily brisk walking program while wearing his orthotics, in order to re-balance his hip and pelvic muscles.
Response to Care
He responded well to his spinal adjustments, and adapted quickly to his orthotics. His compliance with the walking and stabilization exercise recommendations was very good, once the correlation between his previous lower extremity conditions and his current back problem was explained. The home-based spinal stabilization program was also quite easy and enjoyable, so he made continued progress. After 6 weeks of adjustments (10 visits) and daily home exercises, he was symptom-free and released to a self-directed home stretching program.
Whenever I see the combination of back complaints and a history of lower extremity problems, I look for asymmetry of the feet and legs. If this is present, I know that effective chiropractic care must address the lower extremity imbalances and also retrain the core stabilizing musculature of the lower spine and pelvis. In this case, the patient’s chiropractic care included shock-absorbing orthotics to support his strained lower extremities, and specific exercises to improve his core stability.
Dr. John J. Danchik, the seventh inductee to the ACA Sports Hall of Fame, is a clinical professor at Tufts University Medical School and formerly chaired the U.S. Olympic Committee’s Chiropractic Selection Program. Dr. Danchik lectures on current trends in sports chiropractic and rehabilitation.