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Hip and Low Back Pain in a Patient Presenting with Limb Length Inequality and Sacroiliac Joint Dysfunction:

A Case Study

LEG LENGTH INEQUALITY

Regional Interdependence is a concept within the musculoskeletal physical therapy evaluation that lacks emphasis. This term refers to the concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, a patient’s primary complaint. 1 In our physical therapy educational curriculum here at UNC, this has been described as “not chasing the pain,” as the site of the pain is more often time than not, not the source of the pain. Understanding the kinematic links in the lower quarter will allow for differentiation and identification of the tissue causing the pain, and it is my opinion that you cannot fully understand a patient’s complaints without examining and understanding the kinetics involved. This is not to say that faulty biomechanics won’t cause an issue, but in some patients, they will. This is activity dependent and differs from patient to patient. There is no question that a patient’s local area of primary complaint should be examined initially and treated as indicated with current best evidence, but it is also pertinent and evidence based to screen the regions above and below the area of primary dysfunction and then work to determine proper prioritization of intervening in these other regions during a patient’s course of care. 1 Clinical observations of successful changes in a patient’s signs and symptoms following interventions [such as foot orthoses, spinal manipulation, muscle energy techniques, activity modifications, etc] to address lower quarter malalignments add to the plausibility and evidence for the regional interdependence model of evaluation. 2

For this reason, case reports of physical therapy examination and management of patients using a functional assessment approach are helpful to students and practitioners in order to display causative relationships. My particular interests revolve around the inter-relationship of lumbar spine, sacroiliac joint, hip, knee, ankle, and foot biomechanics. Specifically, limb length inequality and sacroiliac joint dysfunction and potential effects up and down the kinetic chain. For this reason, I will present a comprehensive case report of a patient with numerous lower quarter impairment complaints relating to a diagnosed limb length inequality and presenting with a concomitant ilial rotation, and treatment outcomes following orthotic prescription to correct malalignments.

Learning Objectives:

  • Describe and present evidence for the Regional Interdependence Model to a physical therapy evaluation
  • Link lower quarter kinematic chain relationships and the effect of a limb length inequality
  • Link lower quarter kinematic chain relationships and the effect of a sacroiliac joint dysfunction (ilial rotation, specifically)
  • Present evidence for the effectiveness of various physical therapy interventions in addressing causative issues and their role in a successful rehabilitation course
  • Present evidence for custom orthotic prescription in the case of limb length inequality
  • Present case study of a patient in regards to subjective, objective, assessment, treatment, and outcome information
  • Submit complete write-up for approval for publication in the Journal of Orthopaedic and Sports Physical Therapy following edits from committee member feedback

Final Products

Evidence Table

PDF of Case Report for Publication

Special Thanks To:

Liz Waddell for your time and dedication to assistance with this research effort.

Patricia Pande for allowing me to use your wealth of knowledge, your home (including drinking your amazing coffee), and your clinical expertise in the pursuit of my own clinical ambitions. Also, thanks for your willingness to provide me with your insightful and honest feedback in hopes of producing an even better final product prior to publication.

Karen McCulloch for your continued guidance throughout this Capstone and throughout my candidacy for the Doctoral Physical Therapy degree here at UNC-CH.

Philip Witt for your willingness to provide your wealth of clinical expertise in providing me with feedback on this clinical case report.

Mike Gross for your guidance in developing and facilitating this Capstone idea; in addition to all the humor during my work study hours at the Hillsborough Clinic this year.

 

References:

1. Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional interdependence: A musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther. 2007;37(11):658-660. doi: 10.2519/jospt.2007.0110.

2. Gross MT. Lower quarter screening for skeletal malalignment–suggestions for orthotics and shoewear. J Orthop Sports Phys Ther. 1995;21(6):389-405.

4 Responses to “Hip and Low Back Pain in a Patient Presenting with Limb Length Inequality and Sacroiliac Joint Dysfunction: A Case Study”

  1. Mike Gross

    Kendall- very nice job with the evidence table and the case report. Prior to submission to a journal, you will want to clean up some of the writing issues. For example, as you give the history of patient problems, you have sentence fragments for your first attempt at a sentnece under eah new entry (e.g., ankle sprain injuries). Figures need figure legends and tables need table headings so that tables and figures “stand alone”. Some of the figures should be reshot. Good work here. Mike Gross

    Reply
  2. kendalls

    Erin,
    Liz already responded with the appropriate answer to your question, but thought I would thank you for checking out my Capstone and providing me with your valuable feedback! As Liz said, despite all the varus posting, she has been able to avoid any further ankle sprains despite continuing to participate in her dance-based group exercise class. I feel that the lower quarter mal-alignments that she was experiencing were perpetuating her ankle sprains, so putting her feet and therefore legs and pelvis into proper alignment has allowed her to increase her stability and decrease any risks of spraining her ankles! Thanks again!

    Kendall

    Reply
  3. Liz Waddell

    Erin, I’m happy to report no ankle sprains with the orthotics – even with all of the varus posting! I am much more stable now. I feel that the muscles in my feet and LEs are functioning better now that the length-tension relationship has been normalized. I have not been doing any specific proprioceptive exercise, but it has allowed me to be more active which has included dance-based group exercise with balance components.
    Liz

    Reply
  4. etoomey

    Hi Kendall!

    First off holy cow! I am thoroughly impressed by your case report. Your case highlights an all too familiar patient history, characterized by failed interventions, frustrations, and ultimately the avoidance of activities as a result of incessant pain. Before reading your case I was unfamiliar with the term Regional Interdependence. This model certainly warrants consideration in patient cases such as the one you described. It also serves as an important reminder to investigate the patient from a global standpoint in an effort to develop clinically relevant relationships between the area of primary dysfunction and the area of the patient’s primary complaint.

    Just out of curiosity, did any elements of your intervention address the patient’s recurrent ankle sprains (ie proprioceptive training)? I would be interested to know if the orthotic modifications were sufficient in preventing subsequent sprains in an obviously overly prone patient.

    Overall, great job Kendall! I know you put your heart (and time) into this project and it definitely shows. I really hope you pursue the submission of this case report!

    Erin

    Reply

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