History and Presenting Symptoms
A 25-year-old female presents with a combination of recurring pain in the lower back region and pain and tightness in the front of her right hip. She is very frustrated by her condition, since she has already had six weeks of physical therapy for her hip pain (with only a little relief), and she received four months of chiropractic care (with moderate relief of her back pain). Her prior treatments included adjustments and diathermy heat for her back and stretches and mobilization for her hip. She has had no specific injuries to these regions, and she can’t identify any precipitating activities. On a 100mm Visual Analog Scale, she rates the pain in her lower back as varying from 20mm to 40mm, and her right hip pain as varying wildly from 0mm to 65mm. She is on her feet a lot in her occupation as a dance instructor for young girls.
Exam Findings
Vitals. This active young woman weighs 142 lbs, which at 5’9’’, results in a BMI of 21; she is definitely not overweight or obese. She is a vegan, a non-smoker, and drinks alcohol only rarely. Her blood pressure and pulse rate are at the lower end of the normal ranges.
Posture and gait. Standing postural evaluation finds a lower iliac crest on the right, and a low right greater trochanter. She also demonstrates a mild bilateral knee valgus and static pronation of the right foot (calcaneal eversion with low medial arch). The left foot and ankle show a normal, non-pronated alignment. Gait screening is negative for limp or noticeable asymmetry.
Chiropractic evaluation. Motion palpation identifies functional limitations at the L2/L3 and L4/L5 levels, with moderate tenderness and loss of endrange mobility. Hip ranges of motion are full and pain-free on both sides. The Thomas test finds a painful tightness of the right iliopsoas muscle. She finds it difficult to lie comfortably on her back while her legs are extended.
Imaging
Because of her persistent, non-responsive low back and hip pain, AP and lateral lumbopelvic X-rays in the upright standing position are obtained. A discrepancy in femur head heights is seen, with a measured difference of 5mm (right side lower). A moderate right convex lumbar curvature (6°) is noted, and both the sacral base and the iliac crest are lower on the right side. The sacral base angle is a somewhat elevated, but the lumbar lordosis is within normal limits.
Clinical Impression
Moderate functional leg length discrepancy (right short leg), with associated pelvic tilt and lumbar curvature. There is a chronic shortening of the right iliopsoas muscle, and a significant history of recurrent mechanical low back pain and occasional right hip pain.
Treatment Plan
Adjustments. Specific, corrective adjustments for the lumbar spinal region were provided as needed, with good response. Additional manual therapy included contract/relax stretches for the iliopsoas muscle.
Stabilization. Custom-made, flexible stabilizing orthotics were supplied, with a varus pronation wedge under the medial aspect of the right calcaneus. She had no difficulty in adapting to the orthotics.
Rehabilitation. She stretched her right iliopsoas muscle at least four times each day, after a brief brisk walking warm-up. She also strengthened her hip extensor muscles in the upright position using elastic exercise tubing.
Response to Care
This patient responded rapidly to her spinal adjustments and active resistance stretches. She immediately began wearing her orthotics in all of her shoes, and especially at work. After six weeks of adjustments (10 visits) and daily home exercises, she was released to a self-directed maintenance program.
Discussion
A relatively slight functional short leg can produce chronic symptoms in people who experience a lot of weightbearing biomechanical stress. This situation will often be identified in long-distance runners, dancers, and in occupations such as drill press operators and warehouse stockers. A moderate amount of asymmetrical pronation, when exposed to repetitive or constant loading strain, can develop into chronic muscle tension, with shortening tightness. Spinal adjustments and very specific stretching and strengthening exercises provided relief, but the underlying functional leg length inequality had to be addressed with stabilizing orthotics for long-lasting results.
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 [email protected].