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Musculoskeletal Medicine and Pain  |   October 2020
Orthotics to Improve Pain in a Patient With Multiple Internal Fixations and Multilevel Thoracic Fusion
Author Notes
  • From the Veterans Affairs Medical Center in Hampton, Virginia (Dr Lipton); Dwight D. Eisenhower Army Medical Center in Fort Gordon, Georgia (Dr Kokoski); and Christopher Newport University in Newport News, Virginia (Ms Lipton). 
  • Dr Lipton is a professor of osteopathic manipulative medicine and physical medicine and rehabilitation. Dr Kokoski is the battalion surgeon for the 1-8 infantry. Ms Lipton is a Rokovich Scholar. 
  • Disclaimer: The views in this article are those of the authors and do not reflect the official policy or position of the Department of the Army, the Department of Defense, or the United States Government. 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Jordann E. Kokoski, DO, CPT, Eisenhower Army Medical Center, 300 E Hospital Rd, Fort Gordon, GA 30905-5741. Email: jdnnkoko@gmail.com
     
Article Information
Emergency Medicine / Neuromusculoskeletal Disorders / Pain Management/Palliative Care
Musculoskeletal Medicine and Pain   |   October 2020
Orthotics to Improve Pain in a Patient With Multiple Internal Fixations and Multilevel Thoracic Fusion
The Journal of the American Osteopathic Association, October 2020, Vol. 120, 672-676. doi:https://doi.org/10.7556/jaoa.2020.105
The Journal of the American Osteopathic Association, October 2020, Vol. 120, 672-676. doi:https://doi.org/10.7556/jaoa.2020.105
Abstract

The authors present the case of a 24-year-old man who sustained multiple injuries during a hard landing following a parachute jump. These injuries included a right sacral fracture, bilateral femoral fractures, a separated pubic symphysis, and compression fractures of the fifth and sixth thoracic vertebrae. He was treated with a right sacroiliac joint fixation, pubic symphysis fixation, open reduction internal fixation of his bilateral femurs, and fusion of the third through seventh thoracic vertebrae. The patient experienced back pain, bilateral hip pain, and bilateral knee pain resistant to chiropractic and medical treatments. The patient presented 2 years after his aforementioned surgical procedures for treatment of persistent postoperative pain at the Physical Medicine and Rehabilitation service at the Veterans Affairs Medical Center in Hampton, Virginia. His treatment involved gait correction achieved using a left-sided heel lift and a transition to custom molded orthotics that incorporated the lift. This treatment leveled his sacral base and resulted in a simultaneous decrease in his self-reported pain scores.

Back pain has been responsible for frequent office visits, lost productivity, multiple prescriptions with multiple side effects, and increased healthcare costs in the United States.1 The differential diagnosis of back pain is broad and sacral somatic dysfunction is a commonly overlooked cause;3 therefore, making the correct diagnosis is essential.2 
“Sacral somatic dysfunction” can be a reference to sacral base “unleveling.” The sacral base has been described as important in overall posture,46 and studies have described that leveling of the sacral base has led to a statistically significant reduction in overall self-reported pain scores.610 Custom molded orthotics have also proven useful in patients who are both pre- and post operative for foot and ankle surgery.11 Orthotics have also previously been described as beneficial in a patient with left-sided sacroiliac joint fixation (SIJF).12 
This case report describes the treatment of a patient with persistent symptoms of back, hip, and pelvic pain after right SIJF pubic symphysis fusion, bilateral femoral open reduction internal fixation (ORIF), and fusion of the third through seventh thoracic vertebrae (T3-7) using orthotics to level his sacral base. The treatment coincided with a decrease in his overall subjective pain scores. 
Report of Case
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). 
Figure 1.
(A) Pelvic radiograph of a 24-year-old man showing the presence of sacroiliac joint fixation and pubic symphysis fixation, as well as the proximal portions of bilateral femoral open reduction internal fixation to treat fractures of the left and right femurs, a separated pubic symphysis, and a right sacral fracture resulting from a parachute jump. (B) Thoracic radiograph showing spinal fusion of T3-7, performed 1 week after the fixations shown in Part A, approximately 2 years prior to his presentation with low back pain.
Figure 1.
(A) Pelvic radiograph of a 24-year-old man showing the presence of sacroiliac joint fixation and pubic symphysis fixation, as well as the proximal portions of bilateral femoral open reduction internal fixation to treat fractures of the left and right femurs, a separated pubic symphysis, and a right sacral fracture resulting from a parachute jump. (B) Thoracic radiograph showing spinal fusion of T3-7, performed 1 week after the fixations shown in Part A, approximately 2 years prior to his presentation with low back pain.
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. 
Table.
Examination Summary for a Patient With Multiple Injuries and Subsequent Operations Following a Parachute Jump
Visit Anterior superior iliac spine Sacral sulcus Inferior lateral sacral angle
First Superior on the left Deep on the right Superior on the left
Second (10 d) Level Level Level
Third (33 d) Level Level Level
Fourth (54 d) Level Level Level
Table.
Examination Summary for a Patient With Multiple Injuries and Subsequent Operations Following a Parachute Jump
Visit Anterior superior iliac spine Sacral sulcus Inferior lateral sacral angle
First Superior on the left Deep on the right Superior on the left
Second (10 d) Level Level Level
Third (33 d) Level Level Level
Fourth (54 d) Level Level Level
×
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. 
Figure 2.
Radiograph showing the location of our 24-year-old patient's sacroilicac joint fixation and pubic symphysis fixation (A) before and (B) 6 weeks after orthotic placement with hardware intact.
Figure 2.
Radiograph showing the location of our 24-year-old patient's sacroilicac joint fixation and pubic symphysis fixation (A) before and (B) 6 weeks after orthotic placement with hardware intact.
Discussion
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. 
Conclusion
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. 
Acknowledgment
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. 
References
Freburger JK, Holmes GM, Agans RP, et al. The rising prevalence of chronic low back pain. Arch Intern Med. 2009;169(3):251-258. doi: 10.1001/archinternmed.2008.543 [CrossRef] [PubMed]
Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001;. 344(. 5):.  363-. –370. doi: 10.1056/NEJM2001020134405083. [CrossRef] [PubMed]
Cohen SP, Chen Y, Neufeld NJ. Sacroiliac joint pain: a comprehensive review of epidemiology, diagnosis and treatment. Expert Rev Neurother. 2013;13(1):99-116. doi: 10.1586/ern.12.148 [CrossRef] [PubMed]
Irvin RE. Invited response (the postural structural model, with boundary conditions). J Bodyw Mov Ther. 2011;15(2):144-148. doi: 10.1016/j.jbmt.2011.01.014 [CrossRef] [PubMed]
Irvin RE. Why and how to optimize posture. In: Vleeming A, Mooney V, Stoeckart R, Wilson P. Movement. , Stability, and Lumbopelvic Pain Integration of Research and Therapy. Elsevier; 1997:239-252.
Lipton JA. The use of orthotics in the reduction of self-reported pain scores in a Veterans Affairs population: a retrospective study. AAO J. 2013;23(3):9-12.
Hoffman KS, Hoffman LL. Effects of adding sacral base leveling to osteopathic manipulative treatment of back pain: a pilot study. J Am Osteopath Assoc. 1994;94(3):217-226. [CrossRef] [PubMed]
Lipton JA. The use of heel lifts and custom orthotics in reducing self-reported chronic musculoskeletal pain scores. AAO J. . 2009;19:15-21.
Irvin RE. Reduction of lumbar scoliosis by use of a heel lift to level the sacral base. J Am Osteopath Assoc. 1991;91(1):34-44. [PubMed]
Lipton JA, Mitchell LJ. Orthotic correction of postural unleveling in a patient with ankylosing spondylitis. J Am Osteopath Assoc. 2014;114(2):125-128. doi: 10.7556/jaoa.2014.026 [CrossRef] [PubMed]
Beitl WC, Noll KH. Postsurgical orthotic devices. Foot Ankle Clin. 2001;6(. 2):.  297-. –314. doi: 10.1016/s1083-7515(03)00097-4 [CrossRef] [PubMed]
Lipton JA. Lift treatment in naval special warfare (NSW) personnel:a retrospective study: OSTMED-DR. AAO J. . 2000;37:31-37.
Lipton JA. Use of orthotics to treat persistent low back pain after left sacroiliac joint fixation: a case report. AAO J. 2016;26:7-11.
Zaidi HA, Montoure AJ, Dickman CA. Surgical and clinical efficacy of sacroiliac joint fusion: a systematic review of the literature. J Neurosurg Spine. 2015;23(1):59-66. doi: 10.3171/2014.10.SPINE14516 [CrossRef] [PubMed]
Foley BS, Buschbacher RM. Sacroiliac joint pain: anatomy, biomechanics, diagnosis, and treatment. Am J Phys Med Rehabil. 2006;85(12):997-1006. doi: 10.1097/01.phm.0000247633.68694.c1 [CrossRef] [PubMed]
Zhao Y, Zhang S, Sun T, et al. Mechanical comparison between lengthened and short sacroiliac screws in sacral fracture fixation: a finite element analysis. Orthop Traumatol Surg Res. 2013;99(5):601-606. doi: 10.1016/j.otsr.2013.03.023 [CrossRef] [PubMed]
Alvis-Miranda HR, Farid-Escorcia H, Alcalá-Cerra G, Castellar-Leones SM, Moscote-Salazar LR. Sacroiliac screw fixation: a mini review of surgical technique. J Craniovertebr Junction Spine. 2014;5(3):110-113. doi: 10.4103/0974-8237.142303 [CrossRef] [PubMed]
Schütz U, Grob D. Poor outcome following bilateral sacroiliac joint fusion for degenerative sacroiliac joint syndrome. Acta Orthop Belg. 2006;72(3):296-308. [PubMed]
Phieffer LS, Lundberg WP, Templeman DC. Instability of the posterior pelvic ring associated with disruption of the pubic symphysis. Orthop Clin North Am. 2004;35(4):445-v. doi: 10.1016/j.ocl.2004.06.004 [CrossRef]
Kendall JC, Bird AR, Azari MF. Foot posture, leg length discrepancy and low back pain–their relationship and clinical management using foot orthoses-–an overview. Foot (Edinb. ). 2014;24(2):75-80. doi: 10.1016/j.foot.2014.03.004 [CrossRef] [PubMed]
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 Orthop Sports Phys Ther. 2007;37(7):380-388. doi: 10.2519/jospt.2007.2429 [CrossRef] [PubMed]
Figure 1.
(A) Pelvic radiograph of a 24-year-old man showing the presence of sacroiliac joint fixation and pubic symphysis fixation, as well as the proximal portions of bilateral femoral open reduction internal fixation to treat fractures of the left and right femurs, a separated pubic symphysis, and a right sacral fracture resulting from a parachute jump. (B) Thoracic radiograph showing spinal fusion of T3-7, performed 1 week after the fixations shown in Part A, approximately 2 years prior to his presentation with low back pain.
Figure 1.
(A) Pelvic radiograph of a 24-year-old man showing the presence of sacroiliac joint fixation and pubic symphysis fixation, as well as the proximal portions of bilateral femoral open reduction internal fixation to treat fractures of the left and right femurs, a separated pubic symphysis, and a right sacral fracture resulting from a parachute jump. (B) Thoracic radiograph showing spinal fusion of T3-7, performed 1 week after the fixations shown in Part A, approximately 2 years prior to his presentation with low back pain.
Figure 2.
Radiograph showing the location of our 24-year-old patient's sacroilicac joint fixation and pubic symphysis fixation (A) before and (B) 6 weeks after orthotic placement with hardware intact.
Figure 2.
Radiograph showing the location of our 24-year-old patient's sacroilicac joint fixation and pubic symphysis fixation (A) before and (B) 6 weeks after orthotic placement with hardware intact.
Table.
Examination Summary for a Patient With Multiple Injuries and Subsequent Operations Following a Parachute Jump
Visit Anterior superior iliac spine Sacral sulcus Inferior lateral sacral angle
First Superior on the left Deep on the right Superior on the left
Second (10 d) Level Level Level
Third (33 d) Level Level Level
Fourth (54 d) Level Level Level
Table.
Examination Summary for a Patient With Multiple Injuries and Subsequent Operations Following a Parachute Jump
Visit Anterior superior iliac spine Sacral sulcus Inferior lateral sacral angle
First Superior on the left Deep on the right Superior on the left
Second (10 d) Level Level Level
Third (33 d) Level Level Level
Fourth (54 d) Level Level Level
×