History and Presenting Symptoms
A 64-year-old female presents with recurring, unresolving episodes of moderate pain in her lower back and left knee. She recalls no specific back or knee injuries, and states that these problems have developed over the past couple of years, getting more noticeable in the past six months. On a 100mm Visual Analog Scale, she rates her low back pain as usually 40mm, while her left knee varies from 20mm to 50mm. The knee gets worse after walking, and she takes over-the-counter NSAID’s for relief.
Exam Findings
Vitals. This 5’6’’ female weighs 164 lbs., which results in a BMI of 27. She knows she is overweight and is following a sensible diet, but she is having difficulty doing the needed walking because of pain. She quit smoking twelve years ago. Her blood pressure is 124/84 mmHg, and her pulse rate is 80 bpm. These findings are within the normal range.
Posture and gait. Standing postural evaluation finds generally good alignment, with intact spinal curves, and no significant lateral listing of her pelvis or spine. She demonstrates bilateral calcaneal eversion, worse on the left, with a lower left arch. During gait, both feet pronate substantially, and both feet flare outwards (toe-out).
Chiropractic evaluation. Motion palpation identifies numerous limitations in spinal motion: the left SI joint, the lumbosacral junction on the left, L2/L3 on the right, T11/12 generally, and at the cervicothoracic junction. Palpation finds no significant local tenderness or muscle spasm in these regions, and all active thoracolumbar spinal ranges of motion are limited slightly by aging, but are pain-free. Provocative orthopedic and neurological tests for nerve root impingement and/or disc involvement are negative.
Lower extremities. Both knees demonstrate full and pain-free movements, and no provocative orthopedic tests are positive. Closer examination finds a low medial arch on the right foot, and no arch remaining on the left when standing. Her left calcaneus also demonstrates greater eversion when bearing weight. Manual testing finds no significant muscle weakness in the fibular (peroneal) or anterior tibial muscles on either side.
Imaging
Lumbopelvic and knee X-rays in the upright, standing position are taken while weightbearing. There is some loss of lumbar disc heights, most obvious at the lumbosacral joint, and decreasing cephalad. A slight discrepancy in femur head heights is noted, with a measured difference of 4mm (left side lower). A moderate lumbar curvature (4°) is also seen, convex to the left side, and both the sacral base and the iliac crest are slightly lower on the left. The sacral base angle and measured lumbar lordosis are increased, but still within normal limits. No significant loss of joint spacing or osteophyte formation is seen in the knee joints.
Clinical Impression
Moderate lumbopelvic imbalance and spinal dysfunction associated with generalized loss of arch height (worse on the left) and aging of the knee joints and feet.
Treatment Plan
Adjustments. Specific, corrective adjustments for the SI joints and the lumbar and cervicothoracic regions were provided as needed, with good response. Manipulation of the left foot and knee was also performed.
Support. Custom-made, flexible stabilizing orthotics were supplied, which included bilateral pronation correction (varus wedges). The patient described no problems in adapting to the orthotics, although close inspection found that the shoes she was wearing were one full size too small for her feet and she did need to purchase better-fitting shoes.
Rehabilitation. She received instruction in a comprehensive spinal wellness exercise program using elastic resistance tubing. She brought her exercise log to each visit so her adherence to the program could be encouraged.
Response to Care
The adjustments were well tolerated, and the orthotics made a noticeable improvement in her postural alignment, at the feet and the lumbopelvic region. After six weeks of adjustments (twelve visits) and daily home exercises, including wearing the orthotics, she was released to a self-directed maintenance program.
Discussion
This patient’s history and physical examination are consistent with the commonly seen spinal effects of aging on the feet. The combination of lower spinal symptoms with knee pain made worse by walking prompted an evaluation of the lower extremities during weight bearing. The problem most in need of correction was the excessive pronation that was causing functional imbalance.
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].