History and presenting symptoms
The patient is a 12 year-old girl, who was identified at a school screening as having a discrepancy in her shoulder heights. Her parents were advised to seek further evaluation by an orthopedic surgeon. They reported that the orthopedist found evidence of a scoliosis, but recommended a “watch and wait” approach. He offered no treatment, but said that, if her spinal curve increased, he would be available to perform spinal corrective surgery.
The girl’s parents are requesting a second opinion, and any recommendations for conservative care. The patient has no back symptoms, and she recalls no back injury. Her delivery was relatively easy and uncomplicated, as reported by the parents. She is regularly active in several physical activities, including soccer and softball.
Exam Findings
Vitals. This 5’0’’ tall, athletic 12 year-old girl weighs 105 lbs, which results in a BMI of 20—she is not overweight.
Postural examination. Standing postural evaluation identifies a right low pelvis, and a left low shoulder. Her knees are well-aligned, but she has an obvious medial bowing of the right Achilles tendon, with a lower medial arch on the right foot.
Chiropractic evaluation. Motion palpation identifies several mild limitations in spinal motion: The right SI joint, the lumbosacral junction, T11/12, and at the cervicothoracic junction. Palpation finds no local tenderness in these regions, and she has full and pain-free active spinal ranges of motion. Thoracolumbar lateral bending is equal to both sides, and Adams test finds no evidence of rib hump or persisting curve.
Lower extremities. Closer examination finds that the right medial arch of the foot is lower than the left when standing. When she is seated and non-weightbearing, the right arch appears equal to the left. And when she performs a toe-raise while standing, the right arch returns. Manual muscle testing finds no evidence of muscle weakness in the peroneal or anterior tibial muscles.
Imaging
A P-A full-spine film demonstrates a C-curve scoliosis, which encompasses the lumbar and thoracic regions. The sacral base is lower on the right by 3 mm, and the Cobb angle is 12°. A collimated pelvis view with the femur heads centered finds a difference of 6 mm in the heights of the femur heads, with the right side lower.
Clinical Impression
This is a classic case of a functional scoliosis associated with a unilateral flexible flat foot (pes planus). By definition, this eliminates the concern of a progressive idiopathic scoliosis, which had caused the parents so much concern. The condition is accompanied by multiple areas of mild joint motion restriction and compensatory spinal subluxations.
Treatment Plan
Adjustments. Specific adjustments for the lumbopelvic and thoracolumbar spinal regions were provided as needed. Manipulation of the right foot, including the navicular and cuboid bones, was performed.
Support. Custom-made stabilizing orthotics were provided to ensure balanced support for both arches and to reduce weight-bearing asymmetry. Particular emphasis was placed on wearing the supports in her athletic shoes.
Rehabilitation. Because of her age and athletic pursuits, no specific rehabilitation exercises were provided. She was able to continue in her sports activities without difficulty.
Response to Care
The spinal and foot adjustments were well tolerated, since she was young and symptom-free. The orthotics improved her postural alignment and eliminated the shoulder discrepancy. After three months of care, repeat full-spine X-rays with her orthotics in place found only a minimal (3 mm) leg length discrepancy, a level sacral base, and a 5° Cobb angle (which is considered non-scoliotic). She was released to a self-directed maintenance program after a total of 10 treatment sessions over three months.
Discussion
This active 12 year-old girl responded well to a combination of spinal adjustments and custom-made orthotics. Although she was asymptomatic, her parents considered her at risk for spinal surgery, based on the specialist’s opinion. Chiropractic evaluation found her scoliosis to be functional, and her flat foot was found to be flexible. Appropriate conservative care was initiated, and was ultimately very successful. In most cases, a functional scoliosis responds well to chiropractic care, and is unlikely to require surgery.
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. He 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 has been in private practice in Massachusetts for 29 years. He can be reached by e-mail at [email protected].