Case of the Week: 10-24-11 Lumbar Lateral Shift +2 | Modern Manual Therapy Blog

Case of the Week: 10-24-11 Lumbar Lateral Shift +2


Another lateral shift case so soon? Sometimes I goes years without seeing a true lumbar lateral shift. This year I had two in two months. The latest is a bit different than the last case.

Subjective: Pt reports chronic history of right lower lumbar pain for the past three years. She previously had treatment from another CertMDT PT in the area with good resolution, but Sx would often return. In MDT courses, they teach if the Sx return, it is the clinician's fault for not educating the patient enough in prophyaxis!

I find when a patient says provider "x" told them "y," the truth often is somewhere in between. More than likely she did not remain compliant with her old ther ex, or it is possible it was not emphasized enough she should do her HEP forever.

Her Sx were worse within the past four weeks, and she also had new complaints of left knee pain that was worsening in the past two weeks.

Objective:
observations: right iliac crest moderately elevated, moderate lumbar lateral shift to the left, ambulated with antalgic gait, decreased stance time on left LE.

Repeated motions:
SGIS left WNL, painful
SGIS right sev loss, painful during motion

What's the first goal in treatment of a lateral shift patient? Correct the shift!

This went as expected after 10-15 minutes of overpressure in the lateral shift correction position, she was standing more upright, but not able to maintain the correction. I progressed her to lumbar rotation in flexion with overpressure. Rotation was trunk to the left, to close the right for far lateral derangement reduction. Several sets of this and she was walking upright, and left the clinic feeling much better. We also reviewed shift correction in a doorway for HEP and she was instructed on the use of a lumbar roll for sitting.

+1

The patient stated on treatment 3 she was walking more upright, had much less right LBP, and wanted us to address her left knee pain. She had difficulty ambulating, and using stairs.

Objective:
knee flexion

  • left 115/hard end feel
  • right WNL/soft end feel
knee extension
  • left 0/hard end feel/painful
  • right -10 (hyper) firm
myofascia: severe restrictions with tenderness to the left ITB in lengthening and transverse play
Hip IR and ER were surprisingly WNL bilaterally with firm end feels

After 7-10 minutes of left ITB TASTM and functional release plus Mulligan tibial IR mobilizations, she had near full left knee flexion, but extension was still blocked. She was able to walk with much less pain. 

She was instructed on having her husband roll her ITB with a rolling pin for 5 minutes twice a day until next follow up.

+2

Pt continued to report much less right lower back pain, but was slightly more shifted today. Rotation in flexion (trunk to left) reduced the shift and abolished her lower back pain. TASTM was again performed to left ITB and I added transverse release, plus A/P thrust to the proximal tibia for flexion and to the distal femur for extension. Her left knee flexion and extension were WNL afterward with minimal pain at end range extension. She was prescribed repeated knee extension in open chain sitting upright. This is not normally my preferred knee loading strategy, as I normally show it in standing with overpressure, but I wanted to avoid repeated trunk flexion to avoid aggravating her lumbar derangement. 

While walking around to assess her functional improvement, I noticed her right iliac crest was still moderately elevated. Instead of testing for it, with useless tests like supine to long sit and Gilet's test, I corrected for it with some isometric manipulation or CR of the hip flexors with right LE off of the table on the right side. After 4 to 5 reps of this, and we tested walking again. The patient felt as if she was walking and WB differently,  plus her right iliac crest was no longer elevated visually or to palpation.

As a progression, I will probably add some QL and psoas release on the right side if her hip hikes again, otherwise just show her some standing hip extension stretches with self generated overpressure if it stays level.

Discussion:

The lateral shift, despite history of being chronic was an acute exacerbation, which explains why it was easily corrected with end range loading and unloading strategies. The patient's left knee most likely had dysfunction from increased WB over the years of repeatedly shifting to the left in standing. It was surprising how fast it returned to full flexion and almost full extension.

Here are some possibilities why the patient may have had recurrences:

  • she was never instructed on the use of a lumbar roll
  • she was performing her shift correction incorrectly
  • iliac crest rotation may not have been addressed by previous MDT only practitioner
  • she most likely has some hip hiker and flexor adaptive shortening that needs to be addressed
I will keep you updated on her progress, but 3 visits in and she is doing much better!

2 comments:

  1. Dr. Bill Misner PhDDecember 4, 2012 at 4:04 PM

    Are you willing to comment on a S-O-A-P I write of my symptoms & presentation onset of lateral shift last 3-miles of National Trail Marathon Championship run by 72-y runner {me}?

    ReplyDelete
  2. Dr Misner, sure, email me at religiosopt@gmail.com Are you a PT?

    ReplyDelete