History and Presenting Symptoms
A 61-year-old female presents with a recent history of occasionally moderate pain in her lower back. Although the pain responds well to chiropractic adjustments, it invariably recurs within a couple of days. While there are no specific triggering activities, being on her feet and engaged in physical activity does seem to bring on the pain more rapidly. She describes her current level of low back pain as usually around 35mm to occasionally 45mm on a Visual Analog Scale.
Exam Findings
Vitals. This maturing, physically active woman (she performs water aerobics at least twice each week and walks 1.5 miles every day) weighs 143 lbs. which, at 5′ 6″, results in a BMI of 23; she is not overweight. She reports that she has been a non-smoker for over 30 years, and limits her alcohol intake to one glass of wine per day. Her blood pressure and pulse rate are at the lower end of the normal range.
Posture and gait. Standing postural evaluation finds a lower iliac crest on the left, and a low left greater trochanter. The right shoulder is slightly lower than the left, with no history of fracture or surgery. She has a mild bilateral knee valgus and moderate calcaneal eversion and hyperpronation on the left side, with a noticeable outward flare of her left foot. Palpation of the left arch, when standing, finds it significantly lower than the right, but it is not tender to direct pressure. The Navicular Drop test demonstrates greater excursion of the left navicular bone when moving from sitting to standing (non-weight bearing to weight bearing).
Chiropractic evaluation. Motion palpation identifies limitations in segmental motion at L4/L5 and L5/S1, with some local tenderness. These segmental dysfunctions demonstrate loss of end-range mobility in all directions. Additional fixations are noted at T9/T10, C5/6, and C2/3. Lumbar ranges of motion are full and pain free and neurological testing is negative.
Imaging
Upright, weight-bearing X-rays of the lumbar spine demonstrate moderate loss of intervertebral disc height at L4/L5 and L5/S1, with small osteophyte formation at those levels. A discrepancy in femur head heights is seen, with a measured difference of 6mm (left side lower). A moderate lumbar curvature (6°) is noted, convex to the left side, and both the sacral base and the iliac crest are lower on the left side. The sacral base angle and measured lumbar lordosis are within normal limits.
Clinical Impression
Moderate lumbosacral osteoarthrosis and disc degeneration, with mechanical dysfunction associated with poor biomechanical support from the lower extremities. There is a functional short leg on the left side. The asymmetry in the lower extremities is clearly demonstrated by the loss of left arch stability seen on the Navicular Drop test. There is noticeable hyperpronation, arch collapse, and foot flare consistent with left arch collapse, with the expected effects in the pelvis and spine.
Treatment Plan
Adjustments. Specific chiropractic adjustments for the lower extremities and the involved spinal regions were provided as needed.
Support. Individually designed, stabilizing orthotics were provided to support the left arch and calcaneus (pronation correction) and decrease the asymmetrical stress on the knees and back.
Rehabilitation. This patient was instructed to perform an at-home series of back exercises using elastic tubing to develop and maintain coordinated strength in her spinal stabilizers (paraspinal musculature) and core (trunk and pelvic) musculature.
Response to Care
She responded well to the adjustments and exercise, and reported a rapid decrease in symptoms. Within two weeks of receiving her orthotics, she reported that she felt she had more energy, and no longer had the previous nagging low back pain. She was released to a self-directed home stretching program after a total of eight treatment sessions over six weeks.
Discussion
This patient had no foot or arch pain; however, she was undergoing plastic deformation of her arches, which for unknown reasons was accelerated in the left foot. This produced a chronic, asymmetrical strain on her pelvis and spine. Her condition was documented with a test for stability of the arches—the Navicular Drop test. This highlighted the asymmetry in her lower extremities and provided for an easy discussion of the benefits of long-term orthotic support.