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2006
Case Study
A 23 year old college student presents to the office complaining of low back pain. The pain is achy in nature, is located nearly midline and does not radiate.
She first noticed it about 6 months ago when she started an exercise program consisting of running and lifting weights. It seems to hurt more when she runs longer distances.
She has never had any injuries to her back.
CORE OMM Curriculum for Students, Interns, & Residents
2006
2006
You treat her and have a return of symmetry and good range of motion in all areas. However, you note a persistent positive standing flexion test on the right, though the seated flexion test is negative. The patient returns in one month, she had relief of pain for about one week after her first treatment, but has experienced the same pain every since. On exam you find all the same dysfunctions that you had on your first exam. You treat her again and the dysfunctions once again resolve. At her next follow-up, all the same dysfunctions are present.
2006
Diagnostics
What do you think the diagnosis is?
Short Leg Syndrome What tests can you use to confirm this? Postural X-ray series This should be done shortly after the pelvis has been balanced with OMT, otherwise the x-rays may only reflect the innominate rotation. This patient is found to have an 8 mm sacral base unleveling with the right side being lower than the left.
2006
2006
Biomechanics
When the sacral base is unlevel, the body compensates to try to keep the eyes level. Early in the process the thoracic and lumbar spine form a long C-shaped curve that is concave away from the short leg. With more time the compensatory mechanisms redistribute and an S-shaped curve forms with the lumbar concavity away from the short leg and the thoracic concavity towards the short leg.
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Musculature
Postural muscles - (made to support the body against gravity for long periods) - Respond to stress by becoming tight.
Phasic muscles - (antagonist to the postural muscles) - Respond to stress by becoming weak.
CORE OMM Curriculum for Students, Interns, & Residents
2006
Netter
2006
Consequences
Ligaments (such as the iliolumbar ligament) will calcify if under prolonged stress. Bone will remodel when under stress. Within the compensatory curve wedging of the vertebrae will occur. Joint degeneration will occur with arthritis of the hip on the long leg side.
2006
Iliolumbar Ligaments:
Note the attachments onto the ilium
Diagnosis
After treatment a persistent standing flexion positive with seated flexion negative also points to a short leg.
Postural X-rays will show an unleveling of the sacral base. Anything above 5 mm may be significant. Above 10 mm of unleveling the likelihood of multiple compensatory curves forming is greatly increased.
2006
Lumbosacral Implications
- 33-35% of patients with short legs have a lumbar concavity away from the short leg side. - All other possible combinations of lumbar and thoracic concavities occur with much lesser frequency.
2006
Treatment
If unleveling is significant, a heel lift is often needed. Maximum of inch in the shoe. Chronic Short leg, the goal may be only - of total unleveling. Normally the lift is put under the short side. Especially if the lumbar curve side-bends away from the short leg.
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Treatment - continued
With OMM to address compensatory curves, lift therapy to create less than 1mm of sacral base unleveling will result in 80% reduction in pain.
OMM is necessary, or old patterns of compensation probably will not resolve even with lift therapy.
2006
2006
Kimberly Manual,
CORE OMM Curriculum for Students, Interns, & Residents
Millennium Edition
2006
References
American Osteopathic Association, Foundations for Osteopathic Medicine, 2nd ed. 2003.
2006