Chiropractic Management of Knee, Foot and Low Back Pain ...



Chiropractic Management of Knee, Foot and Low Back Pain Caused By The Use of An Inappropriate Heel LiftABSTRACTObjective: The objective of this paper is to determine if knee, foot and low back pain caused by leg length inequality can be relieved by heel lift therapy, chiropractic adjustments and therapeutic ultrasonography.Clinical Features: A 26-year-old female chiropractic student had right medial knee pain, left lateral foot pain and bilateral low back and sacroiliac pain. Ultrasonography revealed mild effusion in the suprapatellar recess of the right knee and was used to rule out meniscal and ligamentous tears in the knee and fracture and Morton’s neuroma in the foot. Palpation revealed ASEX right and PIIN left sacroiliac joints with pronounced motion restriction. The patient was using a 12mm heel lift in her left shoe for a previously diagnosed anatomical short leg, and examination and marking of her full spine radiographs revealed a left leg deficiency of only 7mm.Intervention and Outcome: Therapeutic ultrasound was used on the acute right knee along with chiropractic adjustments of the entire spine as well as the ankle and foot, and replacement of the patient’s 12mm heel lift with an appropriate 7mm lift. The patient reported subjective improvements in low back, knee and foot pain following treatment.Conclusion:Key Words: leg length inequality, leg deficiency, low back pain, knee pain, foot pain, heel lifts, heel lift therapy, chiropractic adjustment, x-ray markingIntroductionWe discuss here a case of a 26-year-old chiropractic student who presented with right knee, left foot and low back pain and a previously prescribed heel lift used to address a leg length inequality. This article presents the features of this case as well as a discussion of appropriate management.Case ReportA 26-year-old chiropractic student reported a one-year history of chronic right knee pain following exertion and then an acute exacerbation of the knee pain following a thorough gait analysis performed by her fellow interns at their outpatient clinic. On the first visit, the patient reported the knee pain as an 8 out of 10 on the Visual Analog Scale, constant, and most pronounced during squatting or ascending or descending stairs. The pain was described as dull to sharp with a stabbing sensation upon squatting, and the patient’s gait was altered to avoid bending of the right knee. The patient also reported chronic low back and left foot pain and an increase in both following the latest exacerbation of her knee pain. The left foot pain was centered around the second and third metatarsals and described as a constant 3 out of 10 with brief flares up to 6 out of 10 on the VAS. The low back pain was diffusely located throughout the lumbar spine and sacroiliac joints and was rated a constant 2 out of 10 with flares up to 6 out of 10. All of the patient’s complaints were aggravated by physical exertion and prolonged time spent standing or walking and relieved by rest and ice.Social history revealed that the patient is single with no children or previous pregnancies. She was a chiropractic student at Logan College of Chiropractic in trimester 8 at the time of treatment and working as a senior intern at Logan’s outpatient health center in St. Peters. She has been involved in dance for over ten years but rarely has time to practice anymore. The patient was beginning a new exercise routine that was postponed due to her recent exacerbations of pain. Health history revealed that the patient has experienced low back pain since age ten when she was involved in a car accident. The patient has also experienced migraine headaches since age 10 which are often accompanied by nausea, vomiting, and sensitivity to light and sound. The headaches were occurring about once every two months at the time of examination. The patient was diagnosed with a left leg deficiency at age 16 by her local chiropractor and prescribed a 12mm heel lift to compensate for the inequality of the tibias. The patient described her left foot and right knee pain as insidious sequelae of years of dancing and attributed her pain, which comes on after prolonged upright activity, to localized osteoarthritis and exacerbation due to her currently altered gait.Physical exam revealed edema medial to the right patella with tenderness most pronounced medial and superior to the patella. Flexion of the right knee was limited during walking due to pain, and isolated knee flexion was limited to 50 degrees due to pain. Hip extenders and adductors were graded 4 out of 5 due to pain. Right femoro-tibial lateral deviation was restricted, and superior patellar glide produced tenderness in the medial and superior knee. Positive knee orthopedic tests included McMurray’s, Bounce Home, Patellar Grinding, Patellar Ballottement and Clarke’s Sign all on the right side. Examination of the left foot revealed pain centered around the second and third metatarsals and reduced dorsiflexion and eversion at the mortise joint, reduced anterior glide of the navicular and second cuneiform, and reduced anterior glide of the second and third metatarsal heads. The patient also exhibited tightness and mild pain centered around the left sacroiliac joint and general stiffness in the cervico-thoracic region of the spine. Seated Kemp’s test was positive bilaterally, with extension on each side producing pain on the same side. Prone lumbar and sacroiliac tests could not be performed in a diagnostic sense for the low back due to knee pain elicited during testing. Palpation revealed a left sacroiliac joint fixation in an anterior-superior and externally rotated position, restrictions in extension at the second, third, fourth, seventh and eight thoracic vertebrae, a counter-rotation at the first and second cervical vertebrae, and hypertonic lumbar erector spinae and upper trapezius muscles.Ultrasonography was performed to assess both the right knee and the left foot pain. The knee exam revealed mild effusion in the suprapatellar synovial recess and an old hypoechoic cyst adjacent to the lateral meniscus but no internal derangement of the medial meniscus, extensor mechanism or posterior compartment. The foot exam showed no evidence of stress reaction, periosteal irregularity or Morton’s neuroma in association with the foot pain and was essentially negative. In response to the patient’s pain patterns, multiple foot fixations and current use of a heel lift, the patient’s full-spine radiographs taken for her previous classes in Logan Basic Technique were marked and assessed according to the Logan Basic Technique X-ray marking protocol1. This assessment revealed a true leg deficiency of 7 millimeters on the left side, which did not agree with the patient’s previous diagnosis and prescribed use of a 12-millimeter heel lift on that side.Intervention and OutcomeA combination of ultrasound and interferential current was used to treat the acute right knee pain, and chiropractic adjustments were performed to correct all palpatory findings within the spine, pelvis and left foot. Post-isometric relaxation stretching was used to treat the hypertonic erector spinae and upper trapezius muscles. The patient was also issued a new 7mm heel lift to replace her old 12mm lift based on the results of the full-spine X-ray analysis. The patient began using the new heel lift immediately and was treated about one time per week for one month. The patient reported a 75% improvement in right knee pain, a 60% improvement in left foot pain, and complete resolution of her low back pain and cervicothoracic pain and stiffness following the one month of treatment and wearing of the new heel lift.DiscussionLeg length inequality is one of the most controversial topics in all of chiropractic. First of all, chiropractors do not all agree on the prevalence of anatomical, or true, leg deficiency within the general population. Second, there is the concept of the functional leg deficiency, or the idea that biomechanical changes or problems can create the appearance or presentation of a leg deficiency. While there exist several styles of chiropractic that are largely based around the assessment of the functional leg deficiency, this paper will only address the topic of anatomical leg deficiency.Anatomical leg deficiency has been linked to many biomechanical problems and resulting pain patterns. Some examples of these problems include excessive pronation of the foot of the short leg1, patellar tracking problems and knee pain2, 3, pelvic torsion and unlevelling4, 5, hip dysfunction and pain6, low back pain6, 7, gait abnormalities7, asymmetric weight bearing8, and scoliosis9. No complete agreement exists in the normal trends of such changes due to leg deficiency, but agreement does exist regarding an overall change in biomechanics and weight bearing.Assessment of leg deficiency is performed in several ways. One method is to physically measure the legs using a tape measure. Measurements are taken from the medial malleoli to either the umbilicus or the anterior superior iliac spines, usually in the supine position. A second method is by palpation of anatomical landmarks, which usually consists of the posterior superior iliac spines, the posterior inferior iliac spines, the greater trochanters of the femurs, and the femoro-tibial joints. Orthopedic tests such as Allis’ test are often used in combination with this method. The third method of assessment is via radiographic study, which usually means plain film x-ray or scanogram, and can include pelvic or full-spine anterior to posterior radiographs. Much research has been done to investigate the accuracy and precision of the different methods of assessing leg deficiency. Some studies have found that clinicians with a good working knowledge of the kinetic chain from the spine to the feet can predictably diagnose an anatomical leg deficiency based on palpation of pelvic landmarks10, 11. Supine and prone measurements have also been shown to be somewhat repeatable and match up well with radiographic findings10, 12. Most studies agree, however, that leg deficiency is a diagnosis best made radiographically. In a review of the common radiographic methods used to assess leg deficiency, Lawrence (JMPT Sept 1985) concluded that virtually all radiographic methods that include femoral head views could reliably detect leg deficiency13. Of the varying radiographic methods, the scanogram has shown to be the most accurate14. Research has also shown that pelvic obliquity can also reliably be detected by radiographic studies15, and that there is good inter-examiner reliability in patient positioning for such radiographic assessments16. Of special concern, however, is the diagnosis of leg deficiency in growing children due to the fact that growth spurts can occur asymmetrically and even out over time, making a premature and incorrect diagnosis a risk17, 18. Post-operative patients receiving hip or knee replacements also require extra attention due to the possibility of a short leg arising from the surgical procedure19.While palliative care, including adjustments, therapies and modalities, can be of great use in treating the compensatory problems that arise due to leg deficiency, the key to treating patients with leg deficiency is to functionally equalize the length of the legs via heel lifts or special shoe construction or modification. In control subjects, heel lifts have been shown to alter pelvic tilt, version of the iliac bones, and lateral shift of the pelvis and scapular belt20. Studies have shown positive results in the reduction of low back pain in patients with a leg deficiency by use of heel lifts up to 10mm21, 22. Above 10 or 12mm, lifts are best used in combination with a buildup of the soles of the shoes on the short leg side21, 23.While heel lifts generally work well in the treatment of structural leg deficiency, there are certain precautions of which clinicians should be aware. Heel lifts alter the position of the foot by increasing plantarflexion of the ankle and extension of the toes. These changes are more pronounced as heel lifts increase in height. This change in foot posture equates to different dispersion of forces within the pelvis. Research has found that heel lifts decrease the lateral force in the short leg, but they also increase the maximum medical force in the long leg and the vertical force in both legs24. While some of these changes may be desired, caution should be used when prescribing lifts due to the drastic biomechanical changes that may occur. One study reports that a right hip arthroplasty patient was given a heel lift following surgery only to result in chronic, intractable pain in his hip and groin due to chronic psoas syndrome. Re-examination revealed an absence of any leg deficiency, and removal of the lift along with osteopathic manipulative treatment resulted in complete remission of pain25. And finally, compliance may present another problem with heel lift therapy. In a study of military cadets who were examined and determined to have a leg deficiency, mean compliance in wearing the lift during training as prescribed was found to be only 38%. Eighteen out of seventy-six cadets reported 70 to 100% compliance, while the remaining fifty-six reported less than 70% compliance26.ConclusionThis case report concerns a 26-year-old chiropractic student who presented with right knee, left foot, and low back pain following the use of an excessively high heel lift. Analysis of full-spine radiographs produced a corrected leg deficiency measurement, and prescription of a shorter heel lift, as well as chiropractic adjustments, PIR stretching and passive modalities lead to complete resolution of the low back pain, a 75% reduction in knee pain and a 60% reduction in foot pain. The research literature most strongly supports radiographic studies in the diagnosis of leg deficiency and heel lift and or sole buildup of shoes on the short leg side for its treatment. More research is needed regarding the specific biomechanical changes resulting from leg length inequality. The patient reported no further exacerbations and was transferred out of the treating student intern’s care following completion of his student clinic requirements.ReferencesHutti LJ (Ed) Textbook of Logan Basic Methods, 4th ed. Edited from the original manuscript of HB Logan. LBM, Inc., Chesterfield, MO 2006.Rothbart BA, Estabrook L. 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Conservative correction of leg-length discrepancies of 10mm or less for the relief of chronic low back pain. Arch. Phys. Med. Rehab. Nov 2005, 86(11): 2075-80.Golightly YM, Tate JJ, Burns CB, Gross MT. Changes in pain and disability secondary to shoe lift intervention in subjects with limb length inequality and chronic low back pain: a preliminary report. J. Ortho. Sports Phys. Ther. Jul 2007, 37(7): 380-8.Meyer PE, Petersen D. Compensation in leg length inequality with orthopedic shoe measures. Orthopade. Jun 1992, 21(3): 174-83.Schuit D, Adrian M, Pidcoe P. Effect of heel lifts on ground reaction force patterns in subjects with structural leg-length discrepancies. Phys. Ther. Aug 1989, 69(8): 663-70.Rancont CM. Chronic psoas syndrome caused by the inappropriate use of a heel lift. J. Am. Osteopath. Assoc. Sep 2007, 107(9): 415-8.Goss DL, Moore JH. Compliance wearing a heel lift during 8 weeks of military training in cadets with limb length inequality. J. Ortho. Sports Phys. Ther. 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