A 24-year-old man presented to the physical medicine and rehabilitation service at the Veterans Affairs Medical Center in Hampton, Virginia, 2 years after his initial injury, with multilevel complaints of pain, including chronic low back pain. The patient reported that, in 2014, he had experienced a hard landing during a parachute jump. His injuries included fractures of the left and right femurs, a separated pubic symphysis, a right sacral fracture, and fracture of T5 and T6. At that time, his femoral fractures were immediately treated with ORIF and his sacral fracture with a right-sided SIJF. One week after ORIF, he underwent a spinal fusion of T3-7. As a result of this accident, the patient also sustained a traumatic brain injury resulting in migraines, as well as difficulty with speech, short-term memory, and word selection. The patient had previously been treated pharmacologically with standard doses and courses of various narcotics and sumatriptan, all of which had left his system at least 30 days prior to presentation. At the time of presentation, he was only taking 15 mg of meloxicam once per day without relief. The patient reported that previous attempts at chiropractic care were also unsuccessful in relieving his persistent postoperative low back pain, resulting in a decision to cease chiropractic services at least 30 days prior to presentation. The patient reported that his average pain level was a 3 to 4/10 with elevation of pain to 8/10 approximately 2 times per week. The patient denied any other medical conditions or cancer history. The patient did not desire further surgery.
The patient underwent a comprehensive physical examination with multiple normal negatives excluded from this brief case study. In this description, we detail only the pertinent positives of the directed physical examination. Specifically, visual gait analysis revealed hyperpronation in stance phase. On palpation, the patient was noted to have a superior left anterior superior iliac spine (ASIS) with an asymmetrical sacral sulcus (deep on right) and a superior left inferior lateral angle (ILA) of the sacrum. Radiographs were reviewed, showing internal fixation present in the thoracic spine, pubic symphysis, right SIJ, and bilateral femurs (
Figure 1).
Following the physical examination, the patient's rotated left ilium was diagnostically derotated until the ASIS was even on both sides, at which point the left leg was found to be shorter than the right at the malleoli.
12 An in-shoe 6-mm heel lift was placed in his left shoe, and the patient ambulated approximately 1000 feet without incident. The method of heel lift selection has been previously published,
12,13 indicating that a 6-mm lift is useful in most appropriate situations, including in elderly people. An in-shoe 9-mm lift is used for more marked leg length discrepancies up to half an inch based on the physician's judgement.
9,12,13
Adjunctive osteopathic manipulative medicine was not used in this patient. His sacral base was checked after his 1000-foot walk and was found to be level, as evidenced by symmetrical sacral sulcus and inferior lateral sacral angles. The patient was instructed to wear the heel lift for at least 2 weeks at all times except when in bed or bathing, and to return to the office to be fitted for in-shoe custom-molded orthotics (CMO). The CMO subsequently provided had a left-sided heel lift built in and also addressed the patient's hyperpronation in the stance phase of gait.
At the patient's second visit 10 days following initial presentation, he reported that the 6-mm heel lift had reduced his pain to 1/10, with only 1 episode of 8/10 pain involving the hip and pelvic region. Physical examination confirmed a level sacral base via palpation of symmetrical sacral sulcus, inferior lateral sacral angles, and ASIS.
The patient underwent follow-up imaging of lower extremities with a computed tomographic scan to measure anatomical leg length. Imaging revealed the right lower extremity to be 879.4 mm and the left lower extremity to be 880.1 mm. While it may seem counterintuitive to place a lift under the opposite side of the osseous short leg (as determined by a standing postural radiograph), this was intentional because the goal was to level the patient's sacral base.
At the third follow-up visit approximately 33 days after our initial evaluation, the patient returned for reevaluation of his sacrum. He reported 1/10 on a pain scale and no side effects. The physical examination revealed level ASIS, sacral sulcus, and ILAs of the sacrum. The patient was checked again at 54 days after the initial visit and reported 0/10 pain. He again was found to have level ASIS, sacral sulcus, and ILA of the sacrum (
Table). For the first time since his polytrauma 3 years prior, he was continuously pain-free and able to enjoy a higher quality of life.
Radiographs (
Figure 2) show the intact significant hardware present in both pre- and posttreatment films; we show these to reassure novice physicians that such patients can be treated with orthotics without breaking hardware. We based our treatment success on the correlation between palpatory changes and patient-reported pain scores.