History and Presenting Symptoms
The patient is a 49-year-old male who reports frequent aching and stiffness in his lower back. He denies any back injuries, but does relate an injury to his right knee that resulted in a full tear of his anterior cruciate ligament (ACL). Two years ago, he had a surgical reconstruction of the ACL using a patellar tendon graft. He says he still has occasional grinding and rare sharp pain in his right knee. Using a 100mm Visual Analog Scale, he rates the frequent pain in his low back at around 40mm, while the rare knee pain is a brief 65mm. He avoids the use of medications, but does get frequent massages, which provide some relief from his back pain.
Exam Findings
Vitals. This active male patient is 5’10″ tall and weighs 162 lbs. This results in a BMI of 23, which is within the normal range. He states that he works out twice a week at a local gym, and plays golf regularly. He is a non-smoker, and both his blood pressure and pulse rate are also within the normal ranges.
Posture and gait. Standing postural evaluation finds generally good alignment, with no lateral curvatures or listing of the spine. An increased lumbar lordosis is noted, and the pelvis tilts forward. His right knee demonstrates a mild valgus alignment and calcaneal eversion, and foot pronation is more prominent on the right side. Observation of gait identifies a tendency for the right foot to flare outward, and inspection of his shoes finds scuffing and wearing at the lateral aspect of his right heel.
Chiropractic evaluation. Motion palpation identifies a limitation at the lumbosacral joint, with moderate tenderness and loss of endrange mobility to the right at L5/S1. Additional subluxations are noted at T10/T11 and T5/T6. Lumbar ranges of motion are full and pain-free, except for extension, which is limited to 20° by pain localized to the right lumbosacral junction. This finding is confirmed by Kemp’s test, which is positive for localized pain when performed to the right side.
Lower extremities. Examination of the right knee finds no ligament instability, or evidence of patellar tracking problem. All knee ranges of motion are full and pain-free. Manual muscle testing finds no specific muscle weakness around the knees or ankles. Neurologic testing of the lower extremities is negative.
Imaging
No X-rays or other forms of musculoskeletal imaging were requested.
Clinical Impression
Mechanical dysfunction with postural imbalance of the lumbopelvic region. There is also evidence of poor biomechanical support from the previously injured right knee, which has undergone ACL reconstruction surgery.
Treatment Plan
Adjustments. Specific, corrective adjustments for the lumbosacral and thoracic spinal regions were provided as needed. No manipulation of the right knee or ankle was indicated. The cuboid bone of the right foot was adjusted several times.
Support. Custom-made, flexible stabilizing orthotics were provided to improve foot/ankle symmetry and to support the right knee.
Rehabilitation. This patient was shown a postural correction exercise using exercise tubing for his anteriorly rotated pelvis.
Response to Care
He responded well to his spinal adjustments, and was quite diligent in performing his corrective exercise. He also adapted well to his orthotics, and reported no more episodes of right knee pain. After four weeks of adjustments (eight visits) and daily home exercises, he was symptom-free and had regained full lumbar function. He returned to playing golf with no problems, and was then released to a self-directed maintenance program.
Discussion
In addition to a classic lumbopelvic postural problem, this patient demonstrated an asymmetry of lower extremity alignment associated with injury and surgical repair. Chiropractic adjustments to the lumbosacral and thoracic regions were combined with a specific postural correction exercise, and support for the foot and ankle. This patient had undergone successful post-surgical rehabilitation and the examination found no evidence of ligament instability or muscular weakness around the knee. However, close inspection and gait evaluation identified a lower extremity asymmetry that was contributing to his spinal problems. Custom-made stabilizing orthotics are frequently necessary after surgical repair procedures of the lower extremities, due to the persisting imbalances.
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].