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. 

The sacral base is the primary weight-bearing structure used to determine whether the pelvis is level.⁷ Musculoskeletal pain can occur secondary to postural asymmetry, which can arise from a short leg, leading to gait dysfunction and an unlevel sacral base.⁸ The goal of lift treatment is not to correct a leg length discrepancy, but to level the sacral base.^5,6 For example, if someone has an osseous leg length discrepancy and a level sacral base, they are compensated and may not benefit from a heel lift. Additionally, it is important to understand that there are osseous causes (eg, fracture, infection, congenital) and muscular imbalance causes (eg, side dominance) of leg length discrepancies, the latter of which is much more prevalent. To say the least, gait is a dynamic synthesis of osseous and muscular factors, and the sum total is treated by leveling the sacral base. The side on which to place the lift is not governed by a static radiograph, but rather through a dynamic physical examination.^12,13 

Sacroiliac joint (SIJ) arthrodesis has been previously described in the literature.^12,14 Surgery for this condition may be considered in cases of trauma or injury leading to destruction or instability of the SIJ; pain at the SIJ can also be caused by SIJ dysfunction. Pain may be an indication for SIJ fixation surgery, though SIJ pain as an indication for surgery is not universally accepted¹² unless as a last resort following attempts at alternative and more conservative treatments.¹⁵ 

SIJF can be accomplished using either a unilateral or a bilateral approach, but the risks and benefits of unilateral fixation vs bilateral fixation are unclear. One citation showed a mechanical advantage of using a lengthened screw (bilateral) as opposed to a short sacral screw (unilateral) in artificially fractured pelvic models.¹⁶ Two lengthened screws at S1 and S2 were then found to be superior to the single lengthened screw.¹⁷ Another study reported negative outcomes in a patient following a bilateral fixation.¹⁸ 

A contributing factor to sacroiliac dysfunction, and pelvic ring dysfunction in general, is pubic symphysis disruption, as in the case presented here.¹⁹ Pubic symphysis disruption can be associated with instability of the pelvic girdle, which is usually the result of high-powered mechanisms of injury, such as falls from a height or motor vehicle collisions. The common approach to correcting this is an anterior fixation of the pubic symphysis and posterior fixation of the pelvic girdle via SIJF if the posterior pelvic ring is unstable. While fixation of the anterior pelvic ring has not been shown to affect the movement of the posterior pelvic ring, and vice versa, a combined anterior and posterior fixation has shown the greatest improvement in cases of displacement of the pubic symphysis.¹⁹ 

Surgical procedures following trauma, including SIJF, pubic symphysis fixation, thoracic fusion, and ORIF of bilateral femurs, are of benefit in stabilizing fractures. Noninvasive adjunct treatment, such as our treatment with a heel lift followed by CMOs that incorporate the heel lift, has been described in the past to be effective in reducing self-reported musculoskeletal pain scores,^5,6,8,20-21 as it was in this case. 

This case of a 24-year-old man with a 2-year history of chronic back, hip, and knee pain following a right SIJF, ORIF of bilateral femurs, pubic symphysis fusion, and a 4-level thoracic fusion demonstrates successful self-reported pain reduction after treatment of the unleveled sacral base and gait dysfunction with a heel lift and CMO. This case demonstrates that, even in the presence of significant internal fixations, the judicious use of orthotics to lower self-reported pain scores is a treatment option to consider. 

We dedicate this article to the memory of Robert Irvin, DO, whom we regard as the academic subject matter expert on the use of orthotics in levelling the sacral base.