Care for hip pain by assessing total biomechanical function

Hip pain is usually cared for with a series of localized tests, followed by a multitude of local treatments. The localized tests can consist of the standard orthopedic and chiropractic tests, and move on up to hip x-rays and possible MRIs.

However, what modern health care egregiously fails to do is remember that hip pain can be directly or indirectly influenced by biomechanical faults far away from the site of symptoms.

That is why a comprehensive biomechanical examination must be done on all patients, with or without symptoms. A structural status report should be given to all patients, and a proactive plan should be recommended in an effort to prevent injuries and decelerate any degenerative changes that are developing in the structure. This should become the goal of the chiropractic profession. Unfortunately, the profession is currently educating the public to only address structural needs after they have become symptomatic, so an improved re-education of our communities is necessary.

The public needs to seek out doctors who can: 1) identify biomechanical defects through proper testing; 2) communicate this information to the patient; and 3) correctly manage the patient back to an improved biomechanical state. This should become the profession’s standard of care instead of the current objective, which is purely symptom based.

This Structural Fingerprint™ exam was designed to meet the biomechanical needs of all patients. Symptoms are merely the site of irritation, and not necessarily the location of greatest imbalance or dysfunction. Unless we have some method of evaluating the entire structure of a patient, many distortions, imbalances, and other contributing factors will be ignored, thus limiting the ultimate benefit a patient receives while under care. Secondly, any doctors who provide neuromusculoskeletal care should begin to standardize the testing that is done for the good of the public. Currently, pathology-based testing is still too evident, such as MRIs and x-rays taken in the supine position. These tests only encourage symptomatic relief, as they rarely provide any useful information.

The Structural Fingerprint Exam takes into consideration the entire kinetic chain, and provides a detailed assessment of the distortion patterns, imbalances and fixations. Seventy-five percent of the information gained on this exam comes from four x-rays taken in the standing position: A-P open mouth; lateral cervical; A-P L-S; and lateral L-S. Once this exam is completed, a proactive, corrective program can begin.

Case History
A patient came to my office in October 2003 for left hip pain, just posterior to the trochanter. He had had this pain for about 5 months. Originally, the patient a runner who ran approximately 30 miles per week for many years, decided to take 5 weeks off from running, hoping that would solve the problem. When it did not, he then saw several doctors, who provided medications for a bursitis, with no results. An MRI in September 2003 came back negative.

Figure 1. Lateral L-S x-ray examination stage, showing a 49° sacral base angle. Figure 2. A-P open-mouth x-ray showing rotated axis and imbalance in both the atlanto-odontoid space and the occipital-spinal relationship. Figure 3. Lateral cervical x-ray that shows a reduction of the normal cervical lordosis with an anterior translation producing an anterior gravity line.

Upon examination in my office, we first looked at his feet while in the standing position, and he pronated bilaterally. The positive tests that were found were Lasegue’s on the left, Patrick-Fabere on the left; and increased tenderness upon palpation over the left gluteal muscles, piriformis and hamstring. Leg lengths measured 33 1¼4 inches bilaterally.

Upon x-ray evaluation, a variety of imbalances were noted. On the lateral L-S (Figure 1), there was an anterior Ferguson’s gravity line as well as a 49° sacral base angle. The A-P L-S (not shown) was relatively balanced and hip joint spaces appeared unremarkable. The A-P open mouth (Figure 2) showed a rotated axis, an imbalance in the atlanto-odontoid joints, and an overall imbalance in the occipital-spinal relationship. The lateral cervical (Figure 3) showed a reduction of the normal cervical lordosis with an anterior translation producing an anterior gravity line.

The Advanced Conditioning™ program was designed to provide the necessary treatment to allow for biomechanical improvements, not just symptomatic relief. Abnormal biomechanics require time and re-education to improve. Just as the orthodontist allows 3 to 4 years for an improved alignment of the teeth, improvement of the neuromusculoskeletal system needs time as well.

The program designed for the patient was 6 months with 40 adjustments scheduled over that time frame. We started three times a week for 6 weeks, then after a re-exam, two times a week for 6 weeks, then another re-exam and then once a week for 6 weeks. This concluded with once every 2 weeks for 2 months. In that time frame, there were a variety of complementary activities and supplies we recommended.

We fitted the patient with custom-made orthotics to address his bilateral pronation and stabilize his posture. The distortions found in his biomechanics as seen on the x-rays were also an indication that a balancing of the structure was needed in every possible way. Stabilizing orthotics are mandatory when maximum biomechanical improvements are the goal.

Ninety percent of the patients in my practice are fitted with custom-made orthotics, as biomechanical improvements are the goal for all of them. These orthotics also provide shock absorption, which is an added benefit when attempting to reduce the shock that is transferred through the injured joint.

We prescribed some rehabilitative exercises, as well as recommended use of a therapeutic stick-like object and tennis ball to address the tightening of the hip muscles that produced much of the pain and tightness he suffered. This process continued for 6 months, and patient management was the key to improvement. Patients can get bored or lose focus, so it is the doctor’s job to keep them alert as to what needs to be done, including keeping their appointments. Conditions like this can take years to come on.

Figure 4. A-P open-mouth x-ray examination stage, left, and 6 months into patient’s care program, right.

Six months later, the patient had resumed running approximately 2 months into the program. We did two re-exams along the way, with both demonstrating a continued improvement in both symptoms and range of motion. At the 6-month re-exam, we also retook all four x-rays to determine how much specific biomechanical change had taken place. The A-P open mouth (Figure 4) showed considerable improvement as compared to the original x-ray. The atlanto-odontoid spaces were much more even, as well as the improvement in the axis rotation and occipital spinal relationship.

Figure 5. Lateral cervical x-ray of examination stage, left, and 6 months into patient’s care program, right, showing significant improvement in support of the head.

The lateral cervical x-ray (Figure 5) also showed significant improvement over the original x-ray, as the weight of the head was now being shared much more evenly by most of the bones of the neck. And the lateral L-S (Figure 6) showed an improvement in the sacral base angle, going from 49° to 45°.

Figure 6. Lateral L-S x-ray, 6 months into care program, showing a 45º sacral base angle.

The goals of most practitioners today stop at symptomatic relief. This is encouraged by traditional Western medicine, as well as by an insurance industry that promotes limited care in return for reimbursement. At the same time, no one is educating our communities on the benefits of structural management. Osteoarthritis has become a way of life, and aftercare (symptomatic relief) is the norm. A lifetime of medications, joint replacements, joint fusions, and reduced happiness is all a part of the aging process in this country.

This is unacceptable, especially when our profession holds the key to longevity, health, and happiness. Just keep better mobility of all joints, as well as the person, and you will increase blood flow, flexibility, and happiness. As I tell my elderly patients, they can’t throw dirt on you as long as you’re moving, so keep moving. They laugh, kind of get what I’m saying, and they make their next appointment.

The patient discussed earlier began with me when he was 28 years old, but the improvements in his biomechanics will undoubtedly change his life. He happens to now be spending a year in Qatar, but upon returning, he understands it is a lifetime deal he and I are involved in, and my goal is to help keep him active, young, and healthy, as much as I am able to. If the goal of our profession was to educate our communities, examine and learn the biomechanical defects of all athletes, workers, and the general population before they break down—and then manage these people back to improved biomechanics and a higher standard of life—you can only imagine what could happen. And, most enjoyable, we would help people realize there is a better answer than just popping pills or waiting until it is a surgical matter. If our profession could only see the bigger picture out there and unite for the good of society, we would all die with smiles on our faces.

Timothy J. Maggs, DC, specializes in sports and industrial medicine and is a graduate of the National College of Chiropractic. He writes on sports medicine and speaks at numerous engagements. Maggs can be reached via email: runningdr@aol.com.