Low Back Pain Case History #2
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A 38-year-old male came to my office complaining of acute moderate low back and anterior thigh pain and mild to moderate right medial longitudinal arch pain that flared up after doing yardwork over the previous weekend. The patient also stated that he had difficulty sleeping and mild tingling in the anterior thigh areas bilaterally. |
Initial Exam Findings
Lumbosacral ranges of motion were restricted on extension, right rotation, and right lateral bending. Moderate paraspinal muscle hypertonicity was noted in the lumbar-sacral area. The right Straight Leg Raise test was positive for pain (VAS: 5/10) in the lumbosacral and right sacroiliac areas at 30 degrees. All other orthopedic and neurological testing was essentially negative.
A-P Lumbopelvic X-ray showed pelvic obliquity with wedging of L4 and L2. (Fig 1). Lateral view showed a thinning disc at L5. (Fig 2)
Standing posture analysis showed pelvic tilting and hyperlordotic lumber curve. (Fig. 3 & 4)
A digital foot scan showed bilateral asymmetrical foot pronation with increased foot pronation on the right foot. (Fig. 5 & 6)
Clinical Impressions
The patient was diagnosed with bilateral asymmetrical foot pronation, lumbosacral and right sacroiliac fixation/subluxations, and lumbosacral and bilateral anterior thigh trigger points.
Treatment Plan
The patient was treated with conservative chiropractic spinal adjustments and adjustments to their feet, knees, and hips. The pronated feet were adjusted to increase stabilization bilaterally. The knees were adjusted bilaterally for a posterior tibia along with hip adjustments that addressed bilateral interior femur head rotation.
The patient was prescribed full-length InMotion®+ orthotics from Foot Levelers for his workout shoes, dress-length InMotion+ for his dress shoes, and a foot roller for home care. Foot taping was utilized until the orthotics arrived.
Trigger point therapy, along with cryotherapy and cold laser, was utilized on the low back, anterior thighs, and right foot.
The patient was shown how to do low back stretches and how to use an ice bath for the right foot at home. He was also supplied with an ice pack for his lower back. Proper sitting and sleeping posture were discussed with the patient, as he has a sitting desk job.
Response to Care
The patient was treated twice weekly for four weeks and then re-evaluated. This patient missed one appointment in the second week but responded gradually and consistently after the first two weeks. After the patient was re-evaluated, treatment consisted of once-weekly treatments and the return of him to his normal gym workouts. After eight weeks of care, all symptomatology resolved with only occasional mild right foot discomfort after working out.
References:
- Souza TA. Differential diagnosis for the chiropractor. Gaithersburg: Aspen Pubs, 1998:326
- 5 Cambron, J. A., Dexheimer, J. M., Duarte, M, & Freels, Shoe Orthotics for the Treatment of Chronic Low Back Pain: A Randomized Controlled Trial. The Archives of Physical Medicine and Rehabilitation, Volume 98, Issue 9, September 2017, Pages 1752-1762
- Guyton A. Basic Neuroscience. 2nd edition. Philadelphia: W.B. Saunders, 1991
- Fulton M. Lower back pain: new protocols for diagnosis and treatment. Rehab Management 1988; Nov/Dec:39-42\