Lower Extremity Aging Concerns

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History and Presenting Symptoms
A 60-year-old female presents with recurring episodes of moderate pain in her lower back and right knee. As a full-time waitress/cashier, she spends almost half her workday on her feet. She recalls no specific back or knee injuries, and states that these problems have developed over the past couple of years and have been more noticeable in the past four months. On a 100 mm visual analog scale, she rates her low back pain as usually 45 mm, while her right knee varies from 25 to 60 mm. The knee feels worse after walking, and she takes over-the-counter NSAIDs for relief.
 
waitressExam Findings
Vitals.  This 5’ 5’’ female weighs 166 lbs, which results in a BMI of 27.6. She knows that she is overweight and is following a sensible diet, but is having difficulty doing the needed walking because of pain. She quit smoking 15 years ago. Her blood pressure is 118/79 mmHg and her pulse rate is 73 bpm. These findings are within the normal range.

Posture and gait.  Standing postural evaluation finds generally good alignment with intact spinal curves and no significant lateral listing of her pelvis or spine. She demonstrates bilateral calcaneal eversion that is worse on the right with a lower right arch. During gait, both feet pronate substantially, and both feet flare outward (toe-out).

Chiropractic evaluation. Motion palpation identifies numerous limitations in spinal motion: the right SI joint, the lumbosacral junction on the right, L2/L3 on the left, T11/12 generally, and at the cervicothoracic junction. Palpation finds no significant local tenderness or muscle spasm in these regions, and all active thoracolumbar spinal ranges of motion are limited slightly by aging, but are pain-free. Provocative orthopedic and neurological tests for nerve root impingement and/or disc involvement are negative.

Lower extremities.  Both knees demonstrate full and pain-free movements, and no provocative orthopedic tests are positive. Closer examination finds a low medial arch on the left foot, and no arch remaining on the right when standing. Her right calcaneus also demonstrates greater eversion when bearing weight. Manual testing finds no significant muscle weakness in the fibular (peroneal) or anterior tibial muscles on either side.
 
Imaging
Lumbopelvic and knee x-rays in the upright, standing position are taken while weight bearing. There is some loss of lumbar disc heights, most obvious at the lumbosacral joint, and decreasing cephalad. A slight discrepancy in femur head heights is noted, with a measured difference of 5 mm (right side lower). A moderate lumbar curvature (4°) is also seen, convex to the right side, and both the sacral base and the iliac crest are slightly lower on the right. The sacral base angle and measured lumbar lordosis are increased, but still within normal limits. No significant loss of joint spacing or osteophyte formation is seen in the knee joints.
 
Clinical Impression
Moderate lumbopelvic imbalance and spinal dysfunction associated with generalized loss of arch height (worse on the right) and aging of the knee joints and feet.
 
Treatment Plan
Adjustments. Specific, corrective adjustments for the SI joints and the lumbar and cervicothoracic regions were provided as needed with good response. Manipulation of the right foot and knee was also performed.

Support. Individually designed stabilizing orthotics were supplied, which included bilateral pronation correction (varus wedges). She described no problems in adapting to the stabilizing orthotics, although close inspection found that her shoes were too small for her feet and she did need to purchase better-fitting shoes.

Rehabilitation.  She received instruction in a comprehensive spinal wellness exercise program using elastic resistance tubing. She brought her exercise log to each visit so her adherence to the program could be encouraged.

Response to Care
The adjustments were well tolerated and the stabilizing orthotics made a noticeable improvement in her postural alignment at the feet and the lumbopelvic region. After eight treatment sessions over two months and daily home exercises, including wearing the orthotics, she was released to a self-directed home stretching program.
 
Discussion
This patient’s history and physical examination are consistent with the commonly seen spinal effects of aging on the feet. The combination of lower spinal symptoms with knee pain made worse by walking prompted an evaluation of the lower extremities during weight bearing. The problem most in need of correction was the excessive pronation that caused functional imbalance.