This right handed concrete worker presented to our office with right-sided lower back pain. He was lifting a bag of concrete moving from left to right which she estimates weighing between 60 and 80 pounds. He did this repetitively throughout the day and subsequently developed right sided lower back pain. The pain is in the suprailiac region and is described as dull, achey. Is exacerbated by right rotation and right lateral bending.
His exam found him to have a right sided anatomical leg length discrepancy, tibial left (see above) and femoral retro torsion on the right with no internal rotation of the hip past 0 degrees (see picture of full internal rotation of the right hip and cmpare it with the left); left side had approximately 10 degrees internal rotation. He also has bilateral internal tibial torsion, R > L. Palpation findings revealed tightness in the lumbar multifidus and quadratus lumborum with a loss of lateral bending to the right at L2 through L4 and a loss of flexion about the right sacroiliac joint. Lower extremity reflexes were 2+ with bilateral symmetry; sensation to vibration was intact at the distal phalanges; motor strength was strong and graded as 5/5.
Think about the implications of his right-sided leg length discrepancy first. This places his foot and a relative supinated posture compared to the left. Remember that supination is plantar flexion, inversion and adduction.
His femoral retro torsion on the right limits his internal rotation at the hip. When his foot planted with a diminished progression angle secondary to the internal tibial torsion, and he has to rotate from left to right, very little, if any motion, can occur at the right hip and therefore must occur in the lumbar spine. Remember the lumbar spine has very limited range of motion begin with with most of that occurring at the L5-S1 junction, depending upon its anatomy. Now superimpose a long lever load and rotary force. Back pain!
We instructed him on proper lifting technique and also talked about keeping the shoulders and hips in the same plane when lifting or load. If he does need to lift a load and spin unilateral on his right lower extremity, we asked him to externally rotate the right lower extremity. He was treated with manipulation and neuromuscular acupuncture.
If you have somebody with unilateral lower back pain, think about the implications if they have any femoral torsion or version present
Dr. Ivo Waerlop, one of The Gait Guys.
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