Scoliosis and Short Leg – An Osteopathic Manipulative Medicine Approach

Jonathon R. Kirsch, D.O., C-NMM/OMMAssociate PhysicianNeuromusculoskeletal Medicine/OMMMarshfield Clinic Stevens Point Center4100 N. Hwy 66Stevens Point, Wisconsin, 54482

Presenting at WAOPS Fall Seminar, Sept. 25-26, 2015

Learning Objectives

1. Describe postural strain, its effects on the body, its diagnosis and treatment.

2. Classify and Differentiate various types of scoliosis, and discuss its clinical significance.

3. Discuss management and OMT for scoliosis. 4. Describe diagnosis, implications, and appropriate

heel lift protocol for anatomical short leg. 5. Discuss gait, postural mechanics, and related

clinical presentations for the sacrum and pelvis regions.

Learning Objectives

1. Describe the use of radiographic studies in postural diagnosis and management.

2. Discuss and interpret the “Cobb Angle” measurement from an AP radiograph of the thoracolumbar spine.

3. Discuss and interpret sacral base unleveling measurement from an AP radiograph of the pelvis.

4. Discuss and interpret lumbosacral angle and pelvic index measurements from a lateral postural x-ray.

1. Discuss strategies for osteopathic manipulative treatment in functional scoliosis.

2. Perform structural exam of spine, noting asymmetry and lateral curvature.

3. Observe and document changes in asymmetries with the use of a heel lift before and after OMT.

4. Diagnose and treat somatic dysfunction in the pelvis, sacral, lumbar, and thoracic regions.

Learning Objectives

• 12 pieces of 20lb copy paper• Your hands

Materials Needed for This Lab

• Start with 12 pieces of standard copy paper (20lb)• Take 3 pages and stack them together.• Fold in half• Fold in half again• Fold in half a third time• Tape the open edges closed with scotch tape.• You now have a 1/8 inch heel lift for this lab!• Stack 2 of these together for ¼ inch lift.• Stack 4 together for ½ inch lift (total of 12 pages)

Construct a Heel Lift

The Consequences of Unlevel Foundations…

Postural Homeostasis

• Postural changes take place in order to coordinate visual, vestibular, and kinesthetic input

• Each person responds to asymmetric postural stress uniquely

• Changes occur in a more predictable pattern in the lumbopelvic region

Effects of Postural Strain -Bone and Joint

• Wolff’s law– Wedging of vertebral body and exostoses (spurs).– Can result in modified function and increased calcium

deposition• Increased functional demand + asymmetry joint degeneration

• Long term radiographic postural studies: progressive postural decline

• Lateral curves more likely to evolve if leg-length difference > 10 mm.

Postural Observation

• Asymmetry– Body position and

alignment– Spaces or gaps from one

side to the other– Key landmarks

• Rotoscoliosis screening– Levelness of key

landmarks• In static position• In dynamic position (when

patient bends forward)

Ideal Posture: Sagittal Plane

• Center of gravity should pass through following points:

• Just anterior to lateral malleolus• Just posterior to mid-knee• Femoral head• Anterior third of sacral base• Middle of body of L3• Humoral head• External auditory meatus

Iliolumbar Ligament Strain

• Anterior Sacral Rotation– Strains portions labeled

“1”.

• Posterior Innominate Rotation– Strains portions labeled

“2”

Iliolumbar Ligament – Postural Effects

• One of the first structures involved in postural decompensation

• Exhibits tenderness, edema, pain

• Groin pain• Hip pain

SCOLIOSIS

Scoliosis-defined as a pathological or functional lateral curve; an appreciable lateral deviation in the normally straight vertical line of the spine. (Dorland).

Demographics

• 10 in 200 children by age 10-15 are diagnosed• 1 in 200 children have clinical symptoms• Curves progress during rapid growth• Boys and girls are affected equally initially, but

in girls is 3-5 times more likely to progress• It usually stabilizes after the child stops

growing. • If the child stops growing with less than a 40

degree Cobb angle, adult progression is rare.

Naming by Side

Named according to the Convexity

Dextroscoliosis-curve that is sidebent left, scoliosis/convexity is to the right. Levoscoliosis-curve that is sidebent right, scoliosis/convexity is to the left.

Classification By Cause

• Idiopathic (70-90% scoliotic curves)– Unlevel sacral/cranial base– Sagittal plane biomechanics– Other unknown causes

• Congenital– 75% are progressive

• Acquired– Short leg syndrome, Psoas syndrome, Osteomalacia,

Inflammation, Irradiation, Sciatic irritibility, Healed leg fracture, Following hip fracture

Classify by LOCATION:Double Major Scoliosis

(most common)• Balanced curve• Subject to Degeneration

at Cross Over Areas of Curve

Single Thoracic Scoliosis• Cosmetically noticable• Heart and Lungs in

jeopardy with progression of scoliosis

Single Lumbar Scoliosis• Associated with

Arthritic change

Junctional thoracolumbar scoliosis• Less Common• Associated with Arthritis

often (due to long length of curve)

Classification By Reversibility

• Functional vs. Structural• Functional curves go

away with side bending, rotation, or forward bending

• Structural curves are fixed and do not reduce with side bending, rotation, or lift therapy

Classification By Severity• Mild Scoliosis (less than 20 degrees). • Moderate Scoliosis (between 20 and 45

degrees). • Severe Scoliosis (between 45 and 70 degrees).• Very Severe Scoliosis (Over 100 degrees).

FOM

•Angle of Lines across the top of the superior vertebral segment, and•Across the bottom of the inferior vertebral segment of a spinal scoliotic curve

•The perpendicular lines intersect to form an angle (“Cobb angle”)

Cobb Angle

Management in Mild Scoliosis

• Periodic Monitoring• OMT• Physical Therapy• Orthotics / Lift Therapy• Education

• Treat lumbar and pelvic somatic dysfunction.• Assess for anatomic leg length difference.• Long restrictor muscle stretch for side of

concavity (Hypertonic m. stretching)• Postural exercises for retraining• Possible heel lift for anatomical short leg.

OMT for Scoliosis - Overview

Management in Moderate Scoliosis (between 20 and 45 degrees)

• Bracing – consider in curves 20 to 50 degrees

• OMT, Exercise, Physical Therapy

• Orthotics• Education• Electrical stimulation

(debatable efficacy)

Management in Severe Scoliosis (between 45 and 70 degrees).

• OMT• Exercise, Education• Orthotics• Bracing• Electrical stimulation (debatable efficacy)• Surgery as possible last resort (1 in 1000 cases)

– Curves greater than 45 degrees– Prevents heart and lung complications

• At >75 degrees the distortions may also cause dangerous changes in the heart or lungs

SPONDYLOLISTHESIS

• Forward displacement of one vertebra over another– usually L5 over S1

DEFINITION

Clinical Presentation:

•Back pain plus or minus leg pain and tight hamstrings• Radicular pain more common in adult

• Painful extension• L5 nerve deficits

Classification Types• Type I: Dysplastic

Insufficiency of articulatory process• Type II: Isthmic

– Defect in Pars Interarticularis• Or Fracture

• Type III: Degenerative– Changes in apophyseal joints

• Type IV: Traumatic– Fracture other than in pars

interarticularis• Type V: Pathologic

– Secondary to Disease

Meyerding Grading System

• For each one quarter that the upper vertebra is displaced forward on the vertebra below– I (1-25%)– II (25-50%)– III (50-75%)– IV (more than 75%)

• Progression– Fastest ages 9-15– Rare progression over age of 20

Risk of Cauda Equina

• Can occur in isthmic spondylolisthesis above grade II (50% anterior movement)

• Can occur in dysplastic spondylolisthesis above grade I (25% anterior movement)

Postural Etiology

• Hyperlordosis transfers weightbearing from the vertebral bodies onto the articular facets

• Higher incidence is seen in gymnasts due to increase in backward bending.

Microtrauma Etiology

• Repetitive lumbosacral motion – Ex. Weight lifters,

soldiers carrying backpacks, and college football linemen

• Frequent postural stress, especially during growth spurt, contributes to the syndrome

Diagnosis

• Diagnostic Testing• Radiography (Ferguson’s Angle)• History (½ of patients asymptomatic)• Physical examination• Spinal palpation

• Neurologic testing

Palpatory Findings

• Anteriorly located spinous process• Sacral base motion exhibits laxity in anterior

motion• Paraspinal tissues – tissue texture changes and

tenderness• Iliolumbar ligament = bilateral tension and

subjective tenderness• Patient may present with lateral thigh and/or

groin pain

Radiographic Findings

• Lumbolumbar or lumbosacral lordotic angles are objective measurements of lumbar lordosis

• Hyperlordosis is significant in patients with sagittal plane postural problems

Lumbosacral Angle(AKA Feguson’s Angle or Sacral Base Angle)

1. Is a measure of lumbosacral lordosis

2. Angle between the top of the sacral base, and the horizontal plane.

3. Normal is 30-40 degrees.

Reference line

Line B

Line A

Conservative Management

• Treatment addressing the underlying instability, spinal mechanics, and patient homeostasis.

• Stretch hamstrings, improve lumbar and abdominal strength, and flexibility

• Promote anti-lordotic posture• Boston Brace for antilordosis (9-12 mo.)• OMT, orthotics, patient education• Exercise - stabilize the lumbosacral region,

diminish the lumbar lordosis, flexion-type only

Goals of OMM in Spondylolisthesis• Reduce Lumbar Lordosis and somatic

dysfunction• Help promote lympathic drainage• Promote optimal stability of

weightbearing posture– Directed at support structures, eg.

Pelvis– Correct Sacral Base Unleveling with

heel lift orthotic– Thoracic spine and thoracolumbar

junction• Quadratus lumborum and the

iliolumbar ligament• Avoid HVLA**

SHORT LEG SYNDROME AND LIFT THERAPY

Anatomic versus Functional

• Anatomic Short Leg- One leg is anatomically shorter than the other.

• Functional Short Leg- one leg appears shorter than the other but is secondary to pelvic dysfunction or other structural imbalance or scoliotic curve.

Effects of Short Leg• Pelvis side shifts and rotates

toward long leg• Innominate rotates anterior on

side of short leg or posterior on side of long leg

• Foot of long leg pronates, internally rotating lower leg

• Lumbosacral angle increases by 2 to 3 degrees

• Lumbar spine has convexity on short leg side (sidebending away from short leg)

Lateral Curves over Time

• Sacral base unlevels in coronal plane

• Curve forms in one spinal region - C-shaped curve

• Over time, other spinal curvatures develop– S-shaped curve– Thoracic curve may

develop with convexity opposite the lumbar spine

Sacral Mechanics with Short Leg

• In short leg there will be lumbar sidebending, affecting sacral mechanics through the L5-Sacrum mechanical relationship.

• Lumbar sidebending to the left (see figure) if chronic, will be associated with a left oblique axis sacral somatic dysfunction

• Lumbar sidebending convexity is usually on the side of the short leg (DiGiovanna)

Sacral Motion in Gait• Left rotation

on a left oblique axis

• Left oblique axis is engaged

• L5 RR

• Right rotation on a right oblique axis

• Right oblique axis is engaged

• L5 RL

• Example: When the left leg is weight bearing, then the left axis of the sacrum is engaged. • Spinal column sidebends to the left (the weight bearing side)

• The weight pins the upper pole of the sacrum on the weight bearing side. • As free lower extremity swings forward, it carries the free pole of the sacrum anteriorly,

creating rotation of the sacrum about the Oblique Axis.• We call this a left rotation on a left oblique axis. This is normal.

Sacral Base Unleveling – Associated Findings

• If sacral base is inferior on one side in the coronal plane, and

• If this is due to leg length inequality, • Then the following are typically inferior on the

side of inferior sacral base: – Greater trochanter of femur– PSIS– iliac crest

Innominate Dysfunction in Short Leg• Innominate rotation dysfunction

can give rise to functional short leg, as acetabulum is anterior to mid-line of bone.– Anterior rotation contralateral

short leg– Posterior rotation ipsilateral

short leg Anterior Innominate

ASIS inferiorPSIS superior

Anatomic short leg can give rise to compensatory innominate rotation dysfunction.

Short right leg Right anterior innominateShort left leg Left anterior innominate

Short Leg Diagnosis• Check for sacral and innominate shear.• OMT should be directed to all related

somatic dysfunctions prior to diagnosis• Observe iliac crest height, femoral head

height, sacral base leveling, degree of scoliotic compensatory curvatures, angle of the scapula, etc…

• Obtain standing postural x-ray

• Vertical lines are drawn from femoral heads

• A sacral base line is constructed across the top of the sacrum, to femoral head lines

AP Postural Xray Interpretation

• Intersection of sacral base line and femoral head lines gives femoral head height differential (C and C’ in diagram)

Treatment Short leg Syndrome

• OMT directed to the spine, pelvis, LE’s, all associated musculature, ligaments and fascia.

• If leg length discrepancy is apparent after somatic dysfunction addressed, order standing postural x-ray series.

• If the Standing Postural Series reveals a femoral head discrepancy of >5mm., consider heel lift therapy.

Lift Therapy

• Initiated to help body return to better structural alignment and function

• The patient’s postural mechanisms are reeducated toward ideal posture

• Paraspinal muscle tension and other spinal physiologic parameters become more symmetrically normalized

• Level foundation of vertebral column

“Flexible Spine”Mild to Moderate Strain

• Spine is flexible• No more than mild to moderate strain is noted

in the myofascial system• Begin with 1/8-inch lift and lift at a rate no

faster than 1/16 of an inch per week, or 1/8 of an inch every 2 weeks.

“Fragile Patient”

• Arthritic, osteoporotic, aged, having significant acute pain, etc.

• Begin with 1/16-inch lift and lift no faster than 1/16 of an inch every 2 weeks.

Sudden Loss of Length

• Recent sudden loss of leg length on one side, (eg. following fracture or a recent hip or knee replacement surgery)

• Patient had a level sacral base before the fracture or surgery

• Lift the full amount that was lost.

Lift Therapy in Children

• Monitor children with lifts closely• Wolf’s Law may cause longer leg to grow

faster• Check bone length on X-ray if possible

and monitor leg lengths• Fryette found that in his pediatric

patients the short leg would grow to equal the long leg with lift therapy, over time.

Heel Lift Therapy

• Final lift is ½- ¾ amount of total discrepancy, unless is immediately after a surgery where height was lost, and full amount of change can be corrected.

• A maximum of ¼ inch should be lifted inside of shoe, if greater, lift outside of shoe.

• If need to lift > ½ inch, should also lift sole of shoe to prevent compensatory inominate rotation.

• Gait evaluation • Standing postural

asymmetry examination• Seated postural

examination– did anything change?

• Have your instructors check your findings

Perform a structural exam with attention to coronal plane asymmetry and lateral curves

Standing Sidebending Test

•Slide hand down thigh toward knee

•Look at curve in thoracolumbar spine

•Smooth curve?

•Abrupt changes in curve?

Gross Spinal Flexion Test

Rotoscoliosis

•With standing forward flexion, observe thoracic spine for any rotational humping on one side.

•This indicates a lateral curve

•For eg., a hump on the left signifies a lateral group curve in the spine, which is sidebending right, with rotation left.

• The patient stands - feet are hip’s width apart - knees extended • The physicians's - fingers on the iliac crest - thumbs thumbs rest on the posterior superior iliac spines (PSIS).

• Ask the patient, “Bend forward slowly without flexing the knees”

• Physician feels and observes the

superior movement of the PSIS (The side which moves first and furthest indicates restriction of the iliosacral joint on the same side.)

STANDING FLEXION TEST

Sidebending: Mid-Thoracic Region (T4 to T8)

• The hands of the examiner are placed on the shoulders over the acromion process.

• A downward and medial pressure is exerted, depressing the shoulder on one side and then on the other.

• Check for asymmetry in ease of shoulder movement in the inferior direction, on each side.

Rotation - (T8 to T11)• Place hands are on the

shoulders • Rotate the trunk to both

sides.• Check for symmetry or

asymmetry.

Note: The lower thoracic spine has greater rotation than the upper due to rib attachments that restrict the upper region.

Hip flop

• Patient supine• Knees up, feet on table,

lift buttocks off table, then down again, and straighten legs

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Medial malleolus position

Grasp ankles bilaterally, with thumbs Inferior to medial malleolus on each side

Make sure lower extremities are lying straight

Assess relative levelness of medial malleolus (superior/inferior)

Record position of Side of Lateralization

ASIS Levelness

Pubic Tubercle Levelness

ASIS Compression Test• Have the patient lie supine. The patient

is then asked to raise his/her bottom up off the table and then set it back down again.

• Doctor Stands with head and shoulders centered over the patient.

• Contact the ASIS – Stabilize one ASIS while applying

pressure at a 45 degree angle to the other ASIS

• Positive test - restricted movement of the Sacroiliac joint -> rock like motion

• Negative test - a sense of give or resilience => bounce or spring like motion

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SLR (hamstring tension)

Setting the Pelvis (Prone)

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Quad tension and Psoas tension

PSIS

Ischial Tuberosity

• Gluteal curve- where thigh joins gluteus muscle.

• Palms approximately 4” apart.• Push superiorly, slightly laterally until you run

into a very firm bone (ischial tuberosity).• Is the ischial tuberosity superior or inferior on

the lateralized side?

Lumbosacral Spring Test• Patient Prone• Physician at Side of Table• Place Heel of Hand over

Lumbosacral Junction (L5-S1)• Keep arms straight, and lean with

body• Spring Several Times –• Negative Test is a Mobility to

Springing (motion is felt at joint)• Positive Test is Restriction to

Anterior Springing

Decreased Sacral Base Asymmetry indicates a Negative TestIncreased Sacral Base Asymmetry indicates a Positive Test

SPHINX TEST

Sacral Motion Testing• Motion testing over the 4 Corners of the Sacrum• Place thumb on the right sacral base. Keep arms extended.

Spring anteriorly• Place thumb on the left sacral base. Keep arms extended.

Spring anteriorly• Place thumb on the right ILA. Keep arms extended. Spring

anteriorly• Place thumb on the left ILA. Keep arms extended. Spring

anteriorly• Record (+), (-), or (+/-).

– + means a sense of resiliency, springs back– - means little to no motion, bricklike– +/- means some motion

• Record your findings on your Sacral Motion Testing Worksheet.

• Psoas/Hamstring • Femoroacetabular• Innominate• Sacrum• Lumbar• Thoracic• Short Leg Syndrome?

– Functional– Anatomic

Make Your Diagnosis of Somatic Dysfunction

Effects of Short Leg• Pelvis side shifts and rotates

toward long leg• Innominate rotates anterior

on side of short leg or posterior on side of long leg

• Foot of long leg pronates, internally rotating lower leg

• Lumbosacral angle increases by 2 to 3 degrees

TREATMENT SECTIONScoliosis and Lateral Curves

• Treat sacral and innominate dysfunction.• Assess for anatomic leg length difference.• Thoracic and lumbar type 2 dysfunctions• Thoracic and Lumbar treatment of type 1 group

curves. • Long restrictor muscle stretch for side of

concavity (Hypertonic m. stretching)• Postural exercises for retraining• Possible heel lift for anatomical short leg.

OMT for Scoliosis - Overview

APPLICATION OF HEEL LIFTSPre-OMT

• Add 1/8 inch lift under the heel of the side with the high iliac crest

• Observe what happened– Did the asymmetry increase ? – Did the compensatory curves change ?

• Add ¼ inch lift and repeat observations.

Exaggerate the lateral curves

• Place lifts under the heel of the side with the low iliac crest, place enough lift to level iliac crest.

• Observe what happened– Did the asymmetry increase ? – Did the compensatory curves change ? – Observe what happened to the primary and

secondary curves

Use lifts to level the iliac crests and sacral base

OMT PART ONE: INNOMINATE / HIP

Hamstring Stretch – For Shortened Hip Extensors, 4613.11A

Iliopsoas Stretch

Muscle energy for posterior innominate technique

Muscle energy technique for anterior innominate technique

OMT PART TWO: LUMBO-SACRAL

For Non-Neutral Dys.

11. A high velocity, low amplitude thrust is applied antero-superiorly to the pelvis while providing counterforce through the patient's shoulder

12. Recheck

Dx: L3-5NSlRr

Lumbar HVLA – for Neutral Dys.

KIM 213A

TX: Unilateral Sacral Flexion (Sacral Shear) DX: Left unilateral sacral flexion

KIM 213A

KIM 216A

RECHECK SYMMETRY

• Repeat the standing postural examination on your partner – Did your findings

change?– What changed – Is your partner a

candidate to be evaluated for possible lift therapy?

• Place lifts under the heel of the side with the low iliac crest. Place enough lift to level the iliac crests.

• Observe what happened– Did the asymmetry decrease? – Did the compensatory curves change?

Use lifts to level the iliac crests and sacral base

• Does your partner still have a low iliac crest on standing, after OMT?

• Did you successfully treat all the somatic dysfunctions that could be contributing to the high/low iliac crest/sacral base?

• Is it an acute or chronic problem? (recent lower extremity surgery, or long term?)

• Is further work-up for short leg indicated?

What is next?

Sources• Steinberg, Akins, Baran, Orthopaedics in Primary Care, 3rd ed., LWW,

Philadelphia, 1998, Pg. 154-156• Kuchera and Kuchera, Osteopathic Principles in Practice, 2nd ed., revised.

Greyden Press, Columbus, Ohio, 1994. • Ward, editor, Foundations for Osteopathic Medicine., 2nd ed., LWW,

Philadelphia, PA 2003• Chila, Foundations for Osteopathic Medicine, 3rd Ed., 3rd ed., LWW,

Philadelphia, PA 2010, pg. 437-480.• The Muscle Energy Manual, Mitchell, Fred L., Volume 3, pg. 33-52. • An Osteopathic Approach to Diagnosis and Treatment, DiGiovanna, pp.

300-301• Kimberly, P., Outline of Osteopathic Manipulative Procedures, “The

Kimberly Manual”, 2006 ed., (2008 update), Walsworth Pub Co, Marceline, MO., 2008.