Look Closer: The Answer May Not Be Obvious

:dropcap_open:E:dropcap_close:ven with everything we do in the evaluation process of our patients, sometimes outside forces like activities of daily living, job, family and financial stress can complicate the presenting vertebral subluxation complexes and its resulting signs and symptoms. Sometimes even the littlest postural changes can affect our outcomes.
gaitcycleWhen we conduct our evaluation and management of a patient, we benefit from a thorough history based on a review of the patient’s case history or other admitting information that we request the patient to fill out. This is followed with a one-on-one consultation to review the case history where we ask additional questions to further assist our decision making. This history covers the requirements of chief complaint, history of present illness, review of the symptoms and past family and social history. 
Then we perform the appropriate examination that we feel clinically is necessary to provide us with needed information in evaluating posture, ranges of motion, functional movement patterns, palpation findings, orthopedic and neurological findings. We also have to take into consideration that documented information is required to meet the billing requirements for the level of E&M that we feel is appropriate for billing purposes.
Using a digital foot scanner to evaluate the three arches of the feet to establish the patient’s pronation index will determine if he/she may benefit from the recommendations of stabilizing orthotics. Evaluation of the patient’s gait cycle using a system of analysis provides us a baseline of the different phases of the gait cycle to compare both the right and left sides. If the patient is a runner, we should conduct the analysis in both the walking and running phases. We may go as far as asking our patients about activities of daily living or a description of their job duties. How much information you feel you need to obtain through the evaluation and management process to help you with your level of medical decision making is totally based on your clinical judgment. Just keep in mind that you must always obtain enough patient data to support the level of E&M for which you are billing.
Ms. W. is a 28-year-old runner who runs an average of five miles, four to five times a week. She has been under our office’s care for the majority of her adult life. She first consulted our office with complaints of low back pain and chronic Iliotibial Band Syndrome. Following a treatment plan of chiropractic adjustments, core strengthening exercises, and stabilizing orthotics, Ms.W. responded very well and now enjoys the benefits of a wellness lifestyle. Recently, she began experiencing pain in the right shoulder area which was about three to four weeks in duration. Pain is more pronounced on the posterior side. She describes the pain as a 5-6 on a scale of 10. She also notes it develops during her run and is usually gone the following morning. 
There is no history of trauma or other known reasons for the pain. We conducted a re-evaluation of Ms. W., which included a new digital foot scan (it had been three years since her last pair of new stabilizing orthotics) and a new gait analysis for both walking and running since the pain comes on while she is running. Nothing major is derived from our re-evaluation, but we begin adjusting the right shoulder. After several weeks of treatment, no noticeable changes have been noticed within the shoulder. It has improved slightly, but the pain still flares up each time she runs.
:dropcap_open:I asked her how long she had been carrying the water bottle while she was running.:quoteleft_close:
One evening after work I drove over to see my good friend Dr. Knight, who practices 12 miles west of me, for an adjustment. I notice my patient, Ms W., is out ahead of me on this country road. Realizing it is her, I stay some distance back to see if I notice any asymmetry in her gait that we did not pick up on the treadmill. What I did notice was how she was flaring her right elbow and how she was holding it in an abducted posture. I then noticed the culprit that was causing this abnormal posturing. It was a water bottle! When I finally pulled up beside her I asked how her shoulder was feeling and she mentioned it had been getting tighter and sorer over the last mile. 
I asked her how long she had been carrying the water bottle while she was running. She told me she had been doing it for about a month since her belt she normally wore that carried her water had broken. As she was explaining it to me you could see a quizzical look come over her face. She asked me, “Do you think my shoulder pain is caused from me carrying the water bottle?” I smiled and said, “Let me have your bottle, finish your run and I will see you tomorrow!”
We all know that ADLs and prolonged postures can be major causes that slow the healing powers of the body. As our patients enjoy the great benefits of a chiropractic lifestyle, through the many services that we can provide them, we must always consider the not so obvious when it comes to our patients!

A 1980 graduate of Palmer College of Chiropractic, Dr. Kirk Lee is a member of the Palmer College of Chiropractic Post Graduate Faculty and Parker College of Chiropractic Post Graduate Faculty. He has lectured nationwide on sports injuries and the adolescent athlete, and currently practices in Albion, Michigan.

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