In September, 2017, after serving for four years as the director of sports injuries and sports biomechanics at Christian Brothers Academy in Albany, New York, I received approval that would allow me to treat students in the school during the school day once a week.
Before treatment each student had to first go through a complete biomechanical exam in my office, then go through a report of findings with their parents to decide if they wanted to go through weekly treatments at the school. To date, we have over 45 students getting treated weekly.
Case presentation
In early November 2017, the mother of one of my patients called and told me her ninth grade son had hurt his back, and she asked if could I see him that day at the school. I told her to send him down, but that I wouldn’t treat him prior to an examination.
He came in that afternoon on crutches, and said he had severe low-back pain and couldn’t put his right leg down due to pain and weakness. He had been in pain for the past two months, getting worse each day; earlier, he had seen an orthopedist who took prone X-rays and diagnosed the problem as sacralization and suggested that if the boy took some time off, he’d be fine.
I called the boy’s mother in to discuss the issue. I told her we needed an MRI, and as we have a special relationship with a local MRI facility, the patient’s out-of-pocket cost would be reduced. The mother agreed and they set up an appointment for the next day. We ordered a lumbar MRI with a sagittal short tau inversion recovery (STIR) image, which enhances the bright signal of fluid, or inflammation of the bone. It can also be called a “fat-suppression technique,” further enhancing the bright signal of fluid.
Terry Yochum, DC, and spondylolisthesis
I have lectured with Terry Yochum, DC, nearly 55 times over the past nine years, and have listened to his spondylolisthesis lecture in detail. (Spondylolisthesis is a misalignment of vertebra, usually at the base of the spine.) Yochum is one of the foremost authorities on spondylolisthesis and he taught me well.
I suspected that this patient was either suffering from a severe disc injury or a pending spondylolisthesis—or active spondylolisthesis—in the lumbar spine. Either type of spondylo meant the young man had bone-marrow edema (bone inflammation) present, and treatment would be the same in either case. These conditions are rather common and should be learned by every practicing chiropractor, because if you are not familiar with the diagnosis and treatment of spondylolisthesis, you’ll never get this type of patient better.
The MRI report showed this patient had significant edema, or a stress reaction, of the right L4 pedicle (Figure 1). This is also known as a “pending spondylo,” as there is no pars defect. Regardless of terminology, the treatment is the same: a custom fitted Boston overlap brace to be worn 23 out of 24 hours a day for 12 to 16 weeks. It must be fitted by a certified orthotist. This brace puts the pelvis into flexion, taking stress off the injured area.
Etiology of pending spondylo
Etiology of pending spondyloYochum coined this name during his comprehensive study of spondylolisthesis. This type of injury is due to abnormal loading of the right L4 pedicle. The body’s response is inflammation and, ultimately, a stress fracture or spondylolisthesis if not treated properly.
The biomechanical faults along with this patient’s particular activities had produced this unilaterally stressed condition. Because of his inability to stand, we had to treat his pain first so we could ultimately perform a complete exam to determine his biomechanical faults. We used cold laser therapy three times a week until his pain was gone (Figure 2). It took 12 days to eliminate this patient’s pain, after he had suffered for two months prior to therapy.
Biomechanical exam
We were now able to perform a biomechanical exam, which includes a physical exam, a digital foot scan, and four standing X-rays. We educate patients and families on biomechanical faults by showing them “Crooked Man” (Figure 3). This is the graphic we use in the consult and report of findings so they understand what biomechanical faults are.
We explain that imbalances originate in the feet, and there is a domino-like effect going up the structure that produces increased stress at multiple levels. In this young man’s case, it was his right L4 pedicle.
On exam, we found the right femoral head was almost 7 mm higher than the left femoral head (Figure 4). On digital foot scan, we found that he bilaterally pronated and that his arch collapse was even on both feet (Figure 5). Therefore, his treatment would begin with custom orthotics with a 7 mm lift on his left orthotic.
Cold laser therapy
The primary goal with this type of injury is to reduce both the pain and bone marrow edema as soon as possible. Cold laser therapy is the most efficient method when looking to reduce pain, reduce inflammation, and heal injuries. We told the patient to come into our office three times per week for the three to four months of healing, as our hope was to reduce this timeframe. The patient is a baseball player, and he wanted to be back in time for part of the baseball season.
We applied laser to the treatment area each visit without adjusting the L4/L5 region. When bone marrow edema is present, regardless of where it’s present, the bone is at grave risk of fracturing. Therefore, adjustments to that area of the spine and activity were contraindicated for the three to four months of treatment. Also, anterior slippage can only occur when an injury like this is in the acute state, and there is inflammation present.
Second MRI
At nine weeks, the patient reported feeling extremely well. He wanted to be released to play baseball. You shouldn’t send an athlete back to regular activity until a new MRI with STIR image verifies the edema is gone. You don’t need the complete MRI—only the STIR sequence, which five minutes.
The patient’s family was willing to pay for this test, even though it was likely too early to see complete improvement.
The test was ordered and, although I thought he was doing substantially better, the fact that “significant bone marrow edema” was present on his original MRI suggested it was unlikely that all edema was gone. Cold laser is a tremendous therapy, one that we use in our practice as we see so many athletes and it works efficiently. But my concern was that the patient would be disappointed by the MRI report at this stage.
The next day, the report was faxed to my office. It read, “Marrow edema seen on the prior MRI, involving the right L4 pedicle and pars interarticularis, is resolved.” (Figure 6.)
Conclusion
Our staff, the patient and his family were elated. We did not expect complete healing in only nine weeks. There are several reasons for this excellent outcome, however, that can be posited: The pending spondylolisthesis was diagnosed and treated appropriately. The patient and the patient’s family were compliant with the rigid guidelines needed to heal the injury. And cold laser therapy was a highly effective modality in treating this condition.
Tim Maggs, DC, has been in practice nearly 40 years, and is the developer of the Concerned Parents of Young Athletes (CPOYA) network, with the goal of offering middle and high school athletes a biomechanical exam prior to each sports season. The network, in partnership with Foot Levelers, provides training, resources, networking opportunities, and more for DCs interested in working with youth athletes. Maggs can be contacted at runningdr@aol.com or through CPOYA.com.
