Second opinion about x-ray of pelvis with 9mm lift

by SJ

AP radiograph taken standing with 9mm heel insert on right side. Right side is on the right.

AP radiograph taken standing with 9mm heel insert on right side. Right side is on the right.

Dear Dr. Lewis,

I am hoping you will provide a second opinion about my recent x-ray; especially noting issues which might contribute to my low back pain and intermittent radiculopathy (beyond my L5-S1 disc herniation ca. 16 months ago).

In particular I am interested in your professional opinion about:
(1) the apparent twist in my lumbar vertebrae: could this contribute to low back pain? It seems to have gotten worse, in comparison with my x-ray from 16 months previous; any idea what might cause it and (if it is causing a problem) how it might be corrected?

(2) my right sacrum and sacroiliac joint: I am not really sure what is going on there--can you enlighten me? More of my (intermittent) sacroiliac pain is on the left side, which to me looks (more) normal.

(3) the length and angle of my femoral necks: Are they still within the range of normal human variation? Any evidence of a CAM or pincer deformity?

I also noticed that my acetabula are not quite even. Could any of these (or other) issues be making me sit or walk oddly?

Any other issues that you notice?

Thank you very much for your expertise.

Hello SJ,
The 9mm lift looks about right. If you went any higher it might help your back more, but then distort the pelvis. All things being equal, I'd stay at 9mm.

(1)You clearly have a lumbarisation of the S1 segment; it's a fairly common anomaly and they certainly give more trouble in my experience. It's hereditary, and one of the reasons that back pain runs in families. Your children should also being lower back exercises every day before arising from bed. Prevention is better than a cure; 50% of them will have trouble as bad as yours, or worse.
That twist certainly contributes to your back pain; the facets at L5/L6 and L6/S1 are asymmetrical, and no, it's not correctable; in fact the lift may have made them look worse. It would be interesting to compare with a view of the pelvis without the lift, also taken standing.

(2)There are question marks about the right SI joint. It could be ankylosis, or even infection, but you'll notice the sacrum is much wider on the right, almost 30% more. I suspect the unusual appearance of the right SI may be due to the gross rotation of the sacrum. A CT scan might be in order.

(3)The femoral necks do appear shortened but I think (uncertain, out of my scope) probably also related to the lift, or the way your were standing. No CAM, very tiny, probably insignificant pincers, but certainly early degenerative change in the left hip; caused by a lifetime of short leg, can't change that. Your children should be assessed at some stage to prevent this happening in their hips; a lift at an early stage is problematic with kids but certainly worth a consideration.
The right acetabular space above is within normal limits, but you are right, the medial joint space does appear lessened and hazy; is the left hip stiff, painful?

Remember, I'm not there to examine you, put all the pieces of your history together, SJ. Opinions from Professor Web should often be taken with a pinch of salt!

In short though, a 9mm short leg with a lumbarisation is always going to try both you and your chiropractor. Keep exercising, keep fit as you can, walk and swim, and don't move the deep freeze and grand piano.

I hope this contributes some.

Dr B

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Jun 03, 2018
Pelvic asymmetry
by: SJ

Dear Dr. B,

Thank you very much for your careful second opinion.

You mentioned there might be a "gross rotation of the sacrum". Based on my observations and measurements on the x-ray I think there might be pelvic asymmetry due to posterior rotation of the right innominate, such as is discussed in

Timgren, J. and S. Soinila. 2006. Reversible pelvic asymmetry: An overlooked syndrome manifesting as scoliosis, apparent leg length difference, and neurologic symptoms. Journal of manipulative and physiological therapeutics 29(7): 561-565.

"Of the 150 patients, 130 (87%) presented with asymmetry of the pelvic girdle, resulting in a difference between iliac crest levels... Pelvic asymmetry was invariably associated with changes in the spine and apparent leg length" (p. 562).

"Our results support the view that pelvic asymmetry is clinically significant because reestablishment of symmetry correlated with diminishing symptoms" (p. 564).

If my right innominate was rotated posteriorly relative to the left, that would tend to rotate my sacrum axially as you suggested it might be, and in the same direction as the lumbar vertebrae in the radiograph. It seems to me this kind of pelvic alignment would wreak havoc in my lumbar spine, as you noted "That twist certainly contributes to your back pain".

My chiro does not seem to think this is a problem: when I asked if he could "take a careful, 3D look at my pelvic girdle alignment", he replied that "the degree of motion of the Sacral iliac joints and or the pubic symphysis is between 1 - 3 degrees (minimal) which are the joints that comprise the pelvic girdle which would not allow for any real dynamic or static re-alignment changes that you may think are probable or possible."

Have you seen or treated pelvic asymmetry? Am I crazy to think that my pelvis could be misaligned, and this might contribute to my back pain?

Hello SJ, apologies for the long delay in replying.

There is certainly palpable movement, or lack thereof, in the SI joints; using the technique of Gillet, fixations are easily detected.

The gross rotation of your sacrum is certainly unusual; then come all the chicken and egg questions; did the short leg, 9mm is quite a lot, cause it, or as your research questions suggests, did the pelvic distortion cause an apparent short leg?

All put together, the lumbo-sacral anomaly, the short leg, the early degenerative changes in the hip, all point to the need for extra care, daily exercises and an acceptance that some things are not for you. The vacuum cleaner is probably one of them.

Not many patients who go reading the chiropractic literature; it's good to take an active part in your own health.

I hope you are winning.

Dr b

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Interesting challenges of the day

1. Mr S is a 76 year old man with neck pain of some 9 months duration. Luckily, most of the discomfort is upper cervical which is only rarely arthritic; his lower cervical spine is a degenerative mess that I've left alone. After seven treatments his pain and stiffness is 50 percent better, and he's happy in the circumstances. He can sleep through the night now and that makes a huge difference.

2. Mr P is 32 year old man with very severe lower back pain radiating to the big toe which is 30 percent numb. He had an episode three weeks ago, took anti inflammatories and was soon better as is typical of the medial disc herniation. But before it healed, after a trivia it came roaring back, much worse. The characteristic crossed sign was evident; sitting in a chair, straightening the right leg provoked severe left back pain and tingling in the leg. He's doing well.

3. Severe lower back pain is scary; just ask Mrs P. Just watching her get out of the car I she was in trouble; she had a slipped disc at L4 making her lean towards the opposite side; luckily she had no pain in the leg. Despite family pressure that this was far too severe for a chiropractor, she persevered. Within five days she was standing upright, and after two weeks almost painfree. 

Despite a hectic job, she wisely took my advice and stayed home for what I call exercising bed rest.

4. Mr S has had lower back, groin and back of thigh and calf pain for fourth months.

He has a pincer deformity in the hip causing the stabs in the groin, and a degenerative facet causing the sciatica. Both are responding well to chiropractic and he's well pleased; sixty five percent better after three treatments.

5. Mr T is a wise man; he's taken a warning TIA seriously and has lost 15 pounds, and has at least as much again to lose. A change to a low starch diet and half hour daily walk has made the difference; but the walking is making his foot and back miserable. The expensive orthotic is hopeless; luckily his hips and back are fine, but he needs a simple heel lift.

6. I too have had serious lower back issues, luckily fixed by my own chiropractor; so I too have to do my exercises, take care when lifting supers full of honey, gardening and using the chainsaw. Regaining the function of your spine is just as important as the pain.

7. My own granddaughter, only 7 is hypermobile giving her pelvic, knee and ankle issues. Xrays show a mildly dysplastic hip. Years ago we would have called it growing pains. She too regularly needs chiropractic care and luckily responds well. Increased range of motion is more difficult than too stiff in my opinion. Our care is for kids too.

8. This 65 year old lady is a serious gardener; every day she is bending, lifting and digging for 2 to 3 hours a day. It regularly catches her in the sacroiliac joint, so she has a treatment once a month that sorts it out. She does her lower back exercises faithfully.

9. This 88 year old lady is an inspiration; every day she is busy in the community. With a nasty scoliosis she manages very well with a chiropractic adjustment every six weeks and exercises faithfully done.  

10. Mr X is a 71 year old retired man who wants to continue with maintenance care every six to eight weeks; he had suffered from two years of lower back pain when he first came a year ago. He has no discomfort now after 8 chiropractic treatments, but is aware that danger lurks.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.

12. Mr D is a 38 old year man with chronic shoulder pain after a rotator cuff tear playing cricket. It responded well to treatment, but he knows he must do his exercises every day; for two years he couldn't sleep on that shoulder.

13. Mr D, a 71 year old man, has a severe ache in the shoulder and midback since working above his head. Trapped nerve tests are negative but he has advanced degenerative joints of Luschka; after just two treatments he is 50 percent better. Can we reach 90?

And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.

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