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

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

A Case Study

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.