Radiology


A Case of RA/DISH
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Radiology
Written by Paul Sherman, D.C.   
Sunday, 04 March 2007 10:38

Discussion:

 

 

RA/DISH is a disorder involving two conditions: rheumatoid arthritis (RA) and diffuse idiopathic skeletal hyperostosis (DISH), which is also known as Forestiers disease or ankylosing hyperostosis.1,3,5

RA is considered the most common inflammatory arthritide.1 It is a systemic connective tissue disorder that primarily affects the synovial lined joints.1 It is characterized by an inflammatory, hyperplastic synovitis (pannus formation), which causes cartilage and bone destruction ultimately leading to loss of joint function.1 It typically affects the small joints of the body, i.e., hands, wrists, elbows, shoulders, feet, knees and hips.1,5 It is usually seen bilaterally and affects the joints symmetrically.1,5 The onset of RA is generally between the ages of twenty and fifty and affects women more often than men.1,5 When RA is seen in older individuals above sixty years of age, the ratio of occurrence between men and women becomes almost equal.1 Generally speaking, rheumatoid arthritis rarely affects the axial skeleton, but when it does, the cervical spine is the most common region of involvement, resulting in anterior translation (movement) of the atlantoaxial complex 9.5 percent to 36 percent of the time.1 This forward translation is most often caused from erosion of the odontoid process or transverse ligament laxity from pannus formation.1 Laboratory tests such as the rheumatoid factor (RF) assist in confirming a diagnosis. A positive rheumatoid factor is usually seen in 70 to 80 percent of the patients with rheumatoid arthritis.1 Other laboratory tests such as a complete blood count (CBC), erythrocyte sedimentation rate (ESR) and anti-nuclearantibodies (ANA) assay may help to confirm and evaluate patients with rheumatoid arthritis.1

DISH is classified as a rheumatological abnormality characterized by marked proliferation of bone where the ligamentous and tendinous attachments to bony sites are found.1 DISH can affect the spine or extraspinal areas, but tends to develop most commonly in the anterior longitudinal ligament (ALL) of the spine.1 It tends to affect males more than females and is usually seen in patients over the age of fifty.5 The typical radiographic findings are characterized by large flowing ossifications, sometimes referred to as candle wax drippings, located along the anterolateral aspect of the vertebral bodies of at least four contiguous vertebrae, with relative preservation of the disc heights and absence of facet ankylosing and sacroiliac erosion/fusion.1,5 It should be noted, as a result of the large flowing ossification about the anterolateral aspect of the vertebral bodies, secondary complications of dysphagia can arise in approximately 20 percent of the patients, causing displacement of the pharyngeal air shadow.5 In addition, there is a higher incident of patients diagnosed with DISH having associated diabetes mellitus, approximately 13-49 percent of the time.1 Laboratory tests are generally unremarkable; however, patients with DISH tend to show hyperinsulinemia following glucose challenge tests.1,5 Evaluation of the HLA B8 antigen may be positive in approximately 40 percent of the patients with DISH.5


Differential Diagnosis:

 

 

Differential diagnoses should include other more common inflammatory arthritides like anyklosing spondylitis (AS) also known as Marie-Strumpell’s disease, as well as other inflammatory arthritides like psoriatic and Reiter’s arthritis.5 In addition, a common non-inflammatory arthritide like degenerative joint disease (DJD), also known as osteoarthritis or wear and tear disease, should not be overlooked as a possible differential diagnosis.5


Radiographic Findings:

 

 

The radiographs being depicted are those of an eighty-nine-year-old male patient who consulted me because of pain, stiffness, spasm and restricted range of motion in his cervical and cervicothoracic spine.

The patient’s X-rays revealed an increase in the atlantodental interspace (ADI), which normally should measure no greater than 3mm in an adult and 5mm in a child.1,5 Also noted is the presence of forward displacement of the posterior cervical line, prominent flowing bone spurs (candle wax drippings) and fusion of several vertebral segments along the anterior longitudinal ligament. The articular facets and many of the disc spaces of this patient’s cervical spine are still preserved. Reference X-rays for these abnormal findings.

 

Treatment:

 

Treatment for RA/DISH should be directed toward obtaining meaningful symptomatic improvement, because there is no known cure for these two disorders.2 Patients afflicted with RA and/or DISH require that treatment goals be directed toward relieving pain, spasm, inflammation and trying to slow down or stop joint damage, as well as improve the patient’s sense of well-being and his ability to function.2,4 Medical physicians usually prescribe medication to help control these symptoms.2,4 Physical therapy, along with mild non-strenuous movements and exercises, may also help stabilize and strengthen joints and muscles to help to increase articular range of motion.2,4 Goals should also include emphasizing that patients obtain adequate rest and exercise.2,4 The X-rays depicted in this case revealed significant osseous changes resulting from DISH, along with anterior displacement of C1 from RA, which precluded any osseous manipulation or adjustments from being administered to this patient’s cervical spine. However, in carefully selected patients without significant upper cervical pathology, where there is no concern for injury to the spinal cord or other neurological elements, gentle and measured manipulation may be an option the chiropractic physician would want to consider.

Physiotherapy modalities, such as electro-muscle stimulation, ultrasound, hydrocollator therapy, soft tissue manipulation, trigger point therapy and light stretching, may be of help in reducing the patient’s symptomatology. It is prudent to remember, treatment should always be designed to fit the patient’s needs rather than the patient being required to fit the therapy.

All or some of the above procedures, depending upon the stage of the patient’s RA/DISH, may be of clinical benefit in ameliorating the patient’s active symptoms, which is a result of these two disorders. Stress reduction techniques can be helpful in assisting the patient in dealing with the emotional and physical challenges patients experience with these disorders.4

In some cases, where severe joint damage has occurred, surgery may be required to reduce pain and improve joint function, which may also help improve the patient’s ability to perform his normal activities of daily living. The procedures to accomplish this may include joint replacement, tendon reconstruction and synovectomy.4 In rare cases involving DISH, where ossification of the anterior longitudinal ligament (ALL) becomes so significantly calcified wherein it causes the patient difficulty with swallowing, the patient may need to undergo surgery in order to remove the bony spurs.2 In any event, the patient’s age, health status and stage of his disease would determine the most appropriate course of treatment.

Dr. Paul Sherman practiced in New Jersey for sixteen years. Presently, he is an assistant professor of clinical sciences and a post-graduate faculty instructor at the University of Bridgeport College of Chiropractic, Bridgeport, Connecticut. He is also an instructor and writer for Chirocredit.com, a chiropractic continuing education website. He can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .


References

1. Marchiori, Clinical Imaging with Skeletal, Chest and Abdomen Pattern Differentials, Mosby, 1999

2. MayoClinic.com article on diffuse idiopathic skeletal hyperostosis, May 2006

3. Resnick and Niwayama, Diagnosis of Bone and Joint Disorders, 2nd Edition, WB Saunders, 1988

4. U.S. Department of Health and Human Services, National Institutes of Health (NIH) Publication No. 04-4719, May 2004

5. Yochum and Rowe, Essential of Skeletal Radiology, 2nd Edition, Williams and Wilkins, 1996

 

 
The Cervical Acceleration / Deceleration Practitioner
Radiology
Written by Dwight C. Whynot, D.C.   
Friday, 01 December 2006 10:52

So, you want to treat patients that have suffered a cervical acceleration/deceleration (CAD) trauma. Then you must learn to examine and treat a CAD injured person properly and with the proper tools. First of all, if you have never treated these types of injuries before, then you should arm yourself with the knowledge of the etiology of CAD trauma. Courses like those given by Dr. Arthur Croft (CRASH) and Dr. Dan Murphy (CCST) can help you understand the mechanics behind the injury. But this, alone, won’t help you. Imagine that you have a real-life patient that is hurting in front of you and you need to evaluate that patient in such a way that you take that patient’s subjective symptoms and turn them into objective evidence—FACTS, the type of facts that a jury can understand and use in order to make an informed verdict.

Let’s take a look at a typical CAD injury evaluation. It looks like this in its simplest form:

HISTORY  EVALUATION  DIAGNOSTIC TESTING


According to the above examination flow chart, the doctor takes the history of the injury and records the appropriate responses that lead to the mechanism of injury. The history should focus on the patient’s past and current history so that the doctor can apply the latest evidence in the form of research studies to formulate the answer to questions on whether or not this injury could have happened—questions that relate to prior accidents, size of vehicles, seatbelts on/off, loss of consciousness, etc.

The doctor then performs the standard cervical evaluation by performing the needed orthopedic examination, neurological examination, ROM and muscle tests. This paints a picture as to how the patient was doing physically when the patient was initially examined. However, the examination process is very subjective and should not stop there. The doctor should take the subjective examination results and examine them in an objective manner by utilizing diagnostic tests.

All of the subjective complaints and tests that were found during the evaluation process need to be evaluated by utilizing diagnostic tests. The diagnostic tests that are chosen should be reliable and reproducible for what they are examining. For instance, the Guides to the Evaluation of Permanent Impairment, 5th edition, (AMA Guides), states that ROM testing should be evaluated utilizing dual inclinometry. Dual inclinometry is the most accurate and reliable means to perform ROM tests. The research literature also states that computerized duel inclinometry is the gold standard along with computerized muscle testing.1,2,3 Diagnostic tests then serve two purposes. Firstly, diagnostic tests are able to document the injury of the patient and, secondly, they are able to provide information that can be readily retested so that the doctor can prove whether or not the patient is improving, staying the same or getting worse. The subjective complaints and the diagnostic tests that should accompany them are listed in Table 1.

TABLE 1

Subjective Complaint
Diagnostic Tests That Should Accompany Them
Pain OA Questionaires (Oswetry, Neck Pain, Roland Morris, VAS, Headaches Disability Index), Pain Presure Treshold Testing (Algometry)

Numb/Tingling/Burning Pain

NCV testing, EMG testing, DSEP Testing
Disc Lesions
MRI
Fractures CT, Radiographs
Loss of Range of Motion

Loss of strength
cMT Testing
LMS Radiographs


Questionnaires provide a reliable means of documenting the patient’s level of pain and its impact on their activities of daily living (ADL’s).4,5 Questionnaires such as the Neck Pain Disability Index and the Rand-36 should be utilized. Even though they are considered to be subjective, they are a high form of subjective data. So high, in fact, that insurance companies such as United Healthcare with ACN require that the patient complete a health-oriented questionnaire to pre-authorize care and every time there is a request for more visits.

Nerve conduction velocity (NCV), electromyography (EMG), and dermatomal somatosensory evoked potential (DSEP) testing provide a valid and reliable means of documenting the patients neurological pain.6 The AMA Guides place objective neurological findings in a DRE Category III 15-18 percent Impairment of the Whole Person (AMA Guides Table 15-5). Foreman and Croft place the patient in a Grade III Major Injury Category (MIC) when there are neurological findings present. This is significant, because the treatment recommendations for a patient in a Grade III MIC are seventy-six visits or more. Therefore, the significance of performing neurological tests and other diagnostic tests on your patients goes beyond your simply evaluating the patient. You are able to create an objective treatment plan, a treatment plan that is not based on your opinion but based on the objective data and placed in a set of guidelines (Whiplash Injuries, 3rd edition, by Foreman and Croft).

MRI studies are very useful in evaluating the patient for disc lesions. Computed tomography (CT) is very useful in evaluating the skeletal structures for fractures, especially those that are missed by radiographic analysis. MRI studies that demonstrate a herniated disc at the level and on the side that would be expected for a subjective radiculopathy equates to a DRE Category II 5-8 percent Impairment of the Whole Person, according to Table 15-5 of the AMA Guides.

Computerized range of motion testing (cROM) is very useful in determining the degree of the loss of cervical function. ROM testing is able to reliably indicate a physical impairment in people suffering from chronic whiplash.2

Computerized muscle testing (cMT) is an excellent way of determining a loss of muscle function, because it is not based on a subjective standard. In order to reliably determine that a patient has a decrease in muscle strength, the patient must have at least a 35 percent loss in strength. This means that a doctor would not be able to reliably determine a loss in strength if it is only a 25 percent loss. Muscle strength should be compared from left and right measurements and they should not exceed more than 10 percent.

Radiographs should be taken and then digitized to examine for motion segment integrity loss (MISL) as defined by the AMA Guides. The AMA Guides state that the only way to evaluate a patient for MSIL is by utilizing the flexion/extension films and measuring for an increase in translational or rotational movement. Translation and rotation are biomechanical terms. Translation is movement of a body in straight line and should not exceed 3.5mm in the cervical spine. Rotation is defined as movement of body about a fixed point and should not exceed 11 degrees in the cervical spine (AMA Guides Table 15-5). These are significant findings according to the AMA Guides because, if the patient has MSIL, as defined by the flexion/extension radiographs, then the patient is placed in a Category IV 25-28 percent Impairment of the Whole Person. This equates to the same thing as a greater than 50 percent compression fracture of a vertebral body. What does this mean clinically? It means that you would not adjust someone at C5 if they had a 50 percent fracture of the C5 vertebrae and, therefore, you should not adjust someone that has an increased motion segment at C5 either. The only objective way to determine the MSIL is by having the radiographs digitized. This allows an outside source to determine the injury and how bad that injury is. If the defense attorney tries to refute the findings, he looks very incompetent in front of the jury because he is arguing against the facts.

As you can imagine, the jury likes to have concrete facts of the case to make an informed decision. This is why shows like CSI are very popular right now. For those of you that get frustrated at the thought of treating personal injury cases, it’s probably due to the fact that you are not collecting all of the objective evidence and providing only subjective data to the attorneys. Give the plaintiff’s attorney facts to argue with, not opinion. Believe me, there will be enough opinions flying out of the defense attorney. Get the equipment that will objectively gather the data, like computerized ROM testing and computerized muscle testing and algometry. The proper treatment protocols for treating CAD injuries can be found in Foreman and Croft’s, Whiplash Injuries, 3rd Edition, and the AMA Guides, 5th Edition. If you are not following the protocols set forth in these two texts, you are going to become increasingly frustrated. A very good friend of mine once stated, “Learn the rules, play by the rules, and win by the rules.”

Dr. Dwight C. Whynot is in fulltime practice in Johnson City, Tennessee. Dr. Whynot gives license-renewal lectures on Evidence-Based Chiropractic Practices which are promoted by the International Chiropractors Association and sponsored by Myologic and Spinal-logic Diagnostics. For questions regarding evidence-based practice procedures, email questions to This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

For 12-hours CCE license renewal lecture dates and places call the ICA at 1-800-423-4690. For more information on Myologic or Spinal-logic, go to www.myologic.com or www.spinallogic.com.

References
1. Bohannon RW, Andrews AW. Standards for Judgments of Unilateral Impairments in Muscle Strength. Perceptual and Motor Skills 1999, 89, 878-883.
2. Dall’Alba P., Sterling M., Treleaven J., Edwards S., Jull G.. Cervical Range of Motion Discriminates Between Asymptomatic Persons and Those With Whiplash. Spine 2001; 26; 2090-2094 (October 1, 2001)
3. Jasiewicz J., Treleaven J., Condie P., Jull G.. Wireless Orientation Sensors: Their Suitability to Measure Head Movement for Neck Pain Assessment. Manual Therapy. September 2006.
4. Ware JJ, Sherbourne CD. The MOS 36-Item short form survey (SF-36). I. Conceptual framework and item selection. Medicare 1992; 30:473-83.
5. Hsieh JCY, Phillips RB, Adams AH, Pope MH. Functional outcomes of low back pain: comparison of four treatment groups in a randPhysical Medicine Rehabilitation 80:1273-1281, 1999omized controlled trial. Journal of Manipulative & Physiological Therapeutics 1992; 15(1):4-9
6. Haig AJ, Tzeng H-M, LeBreck DB. The value of the Electrodiagnostic Consultation for patients with upper extremity nerve complaints: A Prospective Comparison with the History and Physical Examination. Archives of Physical Medicine Rehabilitation 80:1273-1281, 1999.

 
Osteitis Pubis
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Radiology
Written by Dr. Terry R. Yochum, D.C.; D.A.C.B.R.; Fellow, A.C.C.R. and Dr. Chad J. Maola, D.C.   
Friday, 01 December 2006 10:16

HISTORY:

Both of these female patients are complaining of focal pain at the pubic articulation. One of them developed this pain after a difficult delivery of a child and the other patient after surgery for a retroverted uterus.

 


Figures 1 & 2. Characteristic changes are visible at the pubic symphysis with subchondral sclerosis, articular erosions, small osteophyte formation and a slight offset of the pubic bones. This radiographic appearance is characteristic of osteitis pubis.

Discussion:
Osteitis pubis is a painful condition of the pubic symphysis articulation characterized by bony resorption and spontaneous reossification. Although the pathogenesis is uncertain, the most common related antecedent event is surgery within close proximity to the symphysis.1

Clinical Features
Onset of signs and symptoms is usually within one to three months after surgery in the locality of the symphysis pubis articulation. The frequency of this postsurgical complication is between 1 percent and 3 percent. The most common types of surgery are for the prostate, bladder, urethra, uterus and cervix. Statistically, prostate surgery is the most commonly associated surgical procedure. Additional causes include pregnancy, trauma, and, often, unknown factors.1

Symptomology may be localized or referred and is usually described as groin burning.2 Pain is often excruciating on direct palpation. Exercise or activities involving thigh adduction, trunk flexion or even walking may refer pain to the perineal, testicular, suprapubic or inguinal area. In addition, an audible click in the area of the pubic symphysis may be heard during these activities. Postejaculatory pain referral to the scrotum and perineum has been noted in males. The symptoms are generally relieved by rest. Redness or heat is usually not present. The gait is antalgic, with trunk flexion and waddling to prevent symphyseal stress.

Pain typically subsides over an indefinite period up to one or two years, but may require arthrodesis.1,3 With persistent pain and biomechanical alterations in gait, early sacroiliac degenerative changes could ensue.2
Radiologic Features

There is a radiographic latent period after the onset of symptoms of one to three weeks; however, some patients will never manifest definitive radiologic changes. When present, the findings may simulate joint infection.1,2

The most characteristic radiographic appearance is a bilateral and usually symmetric involvement of the pubic bone and adjacent rami. Irregularity of the joint margin, subchondral sclerosis, and a moth-eaten type of osteoporosis, with widening of the joint space can be striking. 3 With resolution, there is reconstitution of normal bone density, but the joint margin frequently remains irregular and may even be ankylosed.1


References
1. Yochum TR, Rowe LJ: Essentials of Skeletal Radiology, 3rd ed., Williams & Wilkins, Baltimore, Maryland, 2005.
2. Cibert J: Post-Operative Osteitis Pubis Cause and Treatment, Br. J. Urol, 24:213, 1952.
3. Pauli S, et al., Osteomyelitis Pubis Versus Osteitis Pubis, Br. J. Sports Med. (1):71, 2002


Dr. Terry R. Yochum is a second generation chiropractor and a Cum Laude Graduate of National College of Chiropractic, where he subsequently completed his radiology residency. He is currently Director of the Rocky Mountain Chiropractic Radiological Center in Denver, Colorado, and Adjunct Professor of Radiology at the Southern California University of Health Sciences, as well as an instructor of skeletal radiology at the University of Colorado School of Medicine, Denver, CO. Dr. Yochum can be reached at 303-940-9400 or by e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Dr. Chad J. Maola is a 1990 Magna Cum Laude Graduate of National College of Chiropractic. Dr. Maola is a Chiropractic Orthopedist and is available for post-graduate seminars. He may be reached at 303-690-8503 or e-mail This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

 
Vacuum Phenomenon
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Radiology
Written by Dr. Terry R. Yochum, D.C.; D.A.C.B.R.; Fellow, A.C.C.R. and Dr. Chad J. Maola, D.C.   
Tuesday, 14 November 2006 16:16

DISCUSSION
The vacuum sign (of Knuttson) is an important early radiographic finding.1 Essentially, this represents collections of nitrogen gas in nuclear and annular fissures and presents as an area of linear radiolucency in the disc space.2  Studies have shown this to be a common sign of disc aging and degeneration, with an incidence of two to three percent in the general population.2 The collection of nitrogen in the discal fissures is thought to originate from adjacent extracellular fluid. 

In movements of the spine that produce a lowered pressure in the disc, such as in extension, nitrogen is released from the adjacent extracellular fluid and, due to the pressure gradient, accumulates in the discal fissures.  On Magnetic Resonance imaging, the disc shows diminished signal intensity due to dehydration, and a signal void at the vacuum site.  This collection of gas can be made to disappear with spinal flexion and reappear with spinal extension.1,2  Disc infections do not demonstrate this sign, due to fluid collections in the fissures.1,2 Central vacuum phenomena correspond to fissuring of the nucleus pulposus, while peripheral lesions represent rim lesions where the annulus fibrosus has been disrupted from its attachment to the vertebral body margin.2

In the peripheral joints, especially the hip, shoulder, and knee, a vacuum sign does not denote degenerative joint changes.2  This is produced as an accompanying physiologic phenomenon, usually induced by the position of the patient in a position of traction when the exposure was made.  Gas in the symphysis pubis is a normal finding during pregnancy and up to three weeks postpartum and may be seen as a vertical, thin radiolucency.

As the disease process progresses in the disc, the degenerative signs become more severe.  Subluxation phenomena are more readily recognizable, and lateral, anterior, and posterior vertebral body displacements of a measurable degree occur.  Flexion/extension films usually reveal decreased motion in these displaced segments.  Disc height is markedly diminished, with greater than twenty-five percent loss of its vertical dimension.  Loss of disc height can also be due to infection, which should be excluded by careful scrutiny for the loss of the vertebral body endplates.2

Dr. Terry R. Yochum is a second generation chiropractor and a Cum Laude Graduate of National College of Chiropractic, where he subsequently completed his radiology residency.  He is currently Director of the Rocky Mountain Chiropractic Radiological Center in Denver, Colorado, and Adjunct Professor of Radiology at the Southern California University of Health Sciences, as well as an instructor of skeletal radiology at the University of Colorado School of Medicine, Denver, CO. Dr. Yochum can be reached at 303-940-9400 or by e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Dr. Chad J. Maola is a 1990 Magna Cum Laude Graduate of National College of Chiropractic.  Dr. Maola is a Chiropractic Orthopedist and is available for post-graduate seminars.  He may be reached at 303-690-8503 or e-mail This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

 
Librarian Overdue for Pelvic Pain Relief
Radiology
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Tuesday, 17 October 2006 11:44

hipimbalanceHistory and Presenting Symptoms

A 37-year-old female describes a history of occasional pain in her lower back region, most noticeable on the left side.  She states that her low back pain “just seems to come and go,” with no obvious triggering activities.  Her pain is localized to the posterior hip region, and does not extend below the pelvis.  She is a recreational runner who usually enjoys hiking, snowboarding, and occasional soccer games with friends, but she denies any specific injury or trauma to her lower back.  On a 100mm Visual Analog Scale, she rates the pain in her lower back and pelvic region as varying from 30mm to 50mm.  She takes over-the-counter NSAID’s when the pain in her lower back interferes with her daily activities or her job duties as the manager of the local library.

Exam Findings

Vitals.  This active female weighs 162 lbs. which, at 5’10’’, results in a BMI of 23—she is not overweight or obese.  She reports that she works out regularly on the resistance machines at a local exercise center, and runs at least twelve miles each week.  She is a non-smoker, drinks wine moderately, and her blood pressure and pulse rate are within normal ranges (BP: 118/76 mmHg; pulse rate: 64 bpm).

Posture and gait.  Standing postural evaluation finds evidence of a lower iliac crest on the right, but the greater trochanters are level.  The left ilium is rotated forward, with prominence of the left ASIS.  Her knees and ankles are well aligned, but there is obvious medial bowing of both Achilles tendons, with pes planus and hyperpronation bilaterally.  During gait, both feet demonstrate a moderate toe-out.  Inspection of her shoes finds scuffing and wearing at the lateral aspect of both heels.

Chiropractic evaluation.  Motion palpation identifies limitations in segmental motion at the left SI joint, with localized tenderness.  The left SI joint demonstrates loss of end range mobility, and pain is reported during motion testing.  Gaenslen’s and Yeoman’s tests for SI joint dysfunction both cause increased pain when performed on the left side.  Lumbar ranges of motion are within expected norms, and neurologic testing is negative for sensory, motor, and reflexive disorders.

Imaging

A lumbopelvic series (AP and lateral lumbopelvic views) is taken in the upright position during relaxed standing.  The sacral base angle is 38° and the lumbar lordosis measures 46°.  There is no significant discrepancy in femur head or iliac crest heights, and no lateral listing or lateral curvature is noted.

Clinical Impression

Moderate lumbopelvic misalignment, with chronic mechanical dysfunction of the left sacroiliac joint.  Poor biomechanical support is noted in the lower extremities, which exacerbates her lumbopelvic dysfunction syndrome.

Treatment Plan

Adjustments.  Specific chiropractic adjustments for the lumbosacral and sacroiliac joints were provided as needed.  Side-posture adjustments were well-tolerated and resulted in good articular releases.

Support.  She was fitted with custom-made, flexible stabilizing orthotics, based on foot imaging in mid-stance.  The inserts were designed to provide support for her arches and decrease the biomechanical stress on her pelvis and sacroiliac joints during the entire gait cycle.

Rehabilitation.  She was instructed in a daily core strengthening program at home using elastic exercise tubing.  The focus was on activation of her transverse abdominis musculature, for improved spinal-pelvic stability.

Response to Care

This patient responded well to her spinal adjustments, and she adapted very quickly to her orthotics.  She performed her daily home exercise program regularly, and demonstrated good exercise performance at her weekly rehab review sessions.  After eight weeks of adjustments (twelve visits) and daily home exercises, she was released to a self-directed maintenance program.

Discussion

This patient had a chronic pelvic misalignment, which was associated with pronation and biomechanical dysfunction in the lower extremities.  Her chiropractic treatment plan included orthotics to support her strained lower extremities, and specific exercises to improve her core pelvic stability.  She responded well to her adjustments, but also needed support from the orthotics and professional guidance for her corrective exercises.

Dr. John J. Danchik is the seventh inductee to the American Chiropractic Association Sports Hall of Fame.  He is the current chairperson of the United States Olympic Committee’s Chiropractic Selection Program and lectures extensively in the United States and abroad on current trends in sports chiropractic and rehabilitation.  Dr. Danchik is an associate editor of the Journal of the Neuromusculoskeletal System.  He can be reached by e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

 

 
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