By Drs. Terry Yochum and Tim Maggs
We all are victims, in many ways, of the existing healthcare crisis. The auto industry is addressing their crisis through new laws for improved mileage per gallon and stricter pollution controls. The energy crisis continues to drive searches for more efficient and alternative means to produce renewable energy. The healthcare crisis, unlike the above two, is merely shifting responsibilities with regard to who will pay for it. This “system” will continue until it can no longer sustain itself.
As Chiropractors, we are interested in the neuro-musculoskeletal system (NMS). The current healthcare system has three major flaws in addressing NMS disorders: 1) we wait until someone breaks, 2) we only look at the site of the break, and 3) our goal is to only remove the pain or symptoms. This approach costs exponentially more, as we all know it is less expensive to “pay now” vs. “pay later”—especially when the proactive approach will produce slower aging, delayed degeneration, and a much greater quality of life.
Joint replacement surgery is a growth industry. Between 2000 and 2009, the incidence of total knee replacements increased by 120%. Osteoarthritis, the leading arthritis (better known as the “wear and tear” arthritis), led to 21.7 million ambulatory care visits and more than 3 million inpatient hospitalizations, and medical expenditures most likely attributed to osteoarthritis cost $62.1 billion in each year between 2008 and 2011.
As Chiropractors, we know that a joint that has lost mobility is predisposed to a more rapid degeneration. We know that joints will fixate when under greater stress (abnormal mechanical loading), such as with traumas or biomechanical imbalances. These fixations prevent people from moving or exercising, which is the breeding ground for obesity, elevated blood pressure, increased anxieties, elevated cholesterol, and much more. We know that we, as a profession, are the most equipped to both detect and improve biomechanical fixations and imbalances. This approach will make a dramatic impact on the “fixing” of this healthcare crisis.
Altered Biomechanics and Bone Marrow Edema?
According to an article published in the journal Radiology 1996 by Mark E. Schweitzer, M.D. and Lawrence M. White, M.D. from Thomas Jefferson University Hospital in Philadelphia, a unique study was performed to evaluate the effects of altered biomechanical stress on the human skeleton.
Twelve asymptomatic volunteers (six women and six men) ranging between the ages of 19 and 41 were chosen to be evaluated in this biomechanical study. All 12 of these asymptomatic volunteers had MR images of their hips, knees, ankles, and feet performed at the commencement of the study. No evidence of pathology or bone marrow edema was seen affecting any of these 12 volunteers, and the MR imaging was done bilaterally. They were evaluated again two weeks after a pad had been used to achieve altered weight bearing with overpronation of one foot. Three volunteers underwent imaging a third time, two weeks after overpronation was stopped.
The alteration in weight bearing was accomplished by placing an extra-large 9/16 in. (1.4 cm) longitudinal metatarsal arch pad underneath the lateral aspect of one foot to increase pronation. This orthotic was placed in the shoe, but the volunteers did not undergo casting with the foot in this position. Therefore, movement was altered somewhat voluntarily. The volunteers were instructed not to alter their daily or recreational activities in any way other than that caused by the pronation. The volunteers were given an adequate number of pads for all pairs of their shoes. The pads were placed unilaterally to minimize discomfort.
After two weeks of altered weight bearing, MR images of both the lower extremities were obtained in the STIR (short tau inversion recovery) or fluid sensitive (or fat suppression images) imaging sequence. All three sets were done with STIR sequences.
The results of these MR images were that 11 of the 12 volunteers demonstrated changes, and the overpronated side only was affected in 10. One of the volunteers with medial involvement had the findings only on the non-overpronated side. These changes were seen most frequently in the foot, four metatarsals, and calcaneus. Changes were predominately lateral in six volunteers. The tibia was affected in three volunteers—one proximately and one distally—and in an additional three volunteers, the femur was involved—one affecting the proximal femur and two affecting the distal femur. Eleven of these 12 volunteers had pain directly over the areas where bone marrow edema was identified. At MR follow-up, after the pad was removed in two of the three volunteers, the MR images returned completely to normal. But in the third volunteer, MR images demonstrated minimal persistent edema, with approximately 50% having been resolved. All of the volunteers were completely asymptomatic immediately after the pad removal and at clinical follow-up (one week, one month, and one year)1.
Bone is dynamic, undergoing hypertrophy in response to stress. Alternatively, after immobilization from casting or paralysis or in a gravity free environment, bone atrophy occurs. What was most interesting about this study is that bone marrow edema and symptoms directly over the area of edema were created with only two weeks of altered biomechanical weight bearing with overpronation of one foot.
One wonders if there would be altered biomechanics (subluxation) of the lower extremity and/or the lumbar spine for an extended period, what kind of stress this would place on the human skeleton, and what long-standing effects it could have on premature degenerative changes within the freely moveable joints of the spine and/or pelvis and lower extremities. The results of this study clearly show that increased signal intensity on fluid sensitive images or STIR images (fat suppression images) can occur and may represent a bone contusion or bone bruise. The results of this study indicate that the increased signal intensity is the result of a bony response to the stress created upon it without actual fracture occurring. On the basis of Schweitzer’s study, I believe that the altered biomechanics should be added to the list of causes of increased intramedullary signal intensity on T2 and/or STIR weighted images.
It is of interest to note that I (Dr. Yochum) personally interviewed Dr. Mark Schweitzer and asked him if any of these 12 volunteers had lower back pain and/or sacroiliac pain. He told me that those questions were never asked of these volunteers. From my Chiropractic perspective, I would have to believe that many these patients would have had sacroiliac and/or lower lumbar pain. It would have been interesting to perform pre- and post-MRI images of the bones adjacent to the sacroiliac joint and/or the lumbar facets to determine whether bone marrow edema could have been identified there as a result of the altered biomechanical stress from the disturbance of the lower kinetic chain.
Imaging Bone Marrow Edema
Imaging stress to the human skeleton may be done by means of plain films, bone scan, CTl, or MRI scan. The most sensitive imaging modality to detect stress to the human skeleton reflected as bone marrow edema is magnetic resonance imaging. While bone scans can certainly reflect an increase in turnover of bone, they are not as sensitive as the 1% sensitivity of marrow change occurring with MRI scans.
Understanding this concept becomes extremely important to evaluating the highly motivated athlete who may or may not have the presence of a spondylolysis and/or spondylolisthesis on plain film radiographs and may only be seen by means of magnetic resonance imaging scans. It is possible that a patient may have normal plain film radiographs, yet have pain on extension and have in fact the early fatigue fracture (stress fracture) of spondylolysis and be hidden or “PENDING.” Since the plain film radiographs may not be sensitive enough to detect the “PENDING” spondylolysis or certainly not see edema adjacent to existing pars defects (spondylolysis), specialized physiologic imaging such as magnetic resonance imaging should be given clinical consideration.
On standard MR imaging with standard T1- and T2-weighted images, it is quite possible that bone marrow edema may be missed on the T2-weighted image in a patient who may be “PENDING” without defect or in a patient with an existing pars defect who may have bone marrow edema adjacent to the pars defect. With that being the case, it is important that an additional imaging series referred to a “short tau inversion recovery” (STIR)—otherwise known as fluid sensitive images or fat suppression images—be performed routinely in patients where there is a high suspicion of the possibility of a hidden or pending pars defect or bone marrow edema adjacent to an existing pars defect. The imaging sequence of choice, which should be added to the standard routine MRI scan is a sagittal STIR imaging sequence, will unequivocally rule in or out the possibility of bone marrow edema in the region of the pars interarticulares with or without a defect.
For further discussion of patient management and evaluation of the problematic cases of spondylolysis and/or spondylolisthesis in the lower lumbar spine and how it relates to the highly motivated athlete, please see chapter 5 of Dr. Yochum’s textbook, “Essentials of Skeletal Radiology.”2
The industry is pushing for all care to be evidence based. The irony is that under this heading, less imaging is encouraged. Less treatment is encouraged. And in the end, less correction will have been done. The Chiropractic profession would do well to redefine our identity and to associate itself closely with the detection and correction of biomechanical faults—an identity our forefathers fought hard to protect. We would then be the only profession whose goal would be to correct these structural imbalances (even in the absence of symptoms), and not just provide symptomatic care. This identity would enhance the public’s perception of our profession, as the public is begging for someone to help them achieve structural preservation, especially when this approach would improve their long-term quality of life.
To achieve this result, we must look at all people from a biomechanical perspective, as everyone has biomechanical faults and imbalances. Just as the orthodontist improves the alignment of the teeth long before problems occur, it’s easy to understand the benefit of doing this to the NMS system as well. As seen in Figure 1, all people have biomechanical imbalances, and these imbalances always originate in the feet.
If we ignore the imbalances in the feet, we would be ignoring the importance of a balanced foundation. Introductory Architecture teaches the importance of a balanced foundation. This is the very reason our office puts every patient into custom orthotics at the beginning of all correction programs.
Biomechanics of Feet
There are three arches in each foot, with each being critically important for providing foundational balance. Upon scanning of the feet (Figure 2), it is easily detectable if any or all of these arches have fallen. Most patients have multiple fallen arches, when scanned in the standing position. In addition, aging, gravity, and stress over time will encourage further falling of these arches, which will alter centers of gravity in every joint of the body. Abnormal centers of gravity, combined with aging, will further accelerate the degenerative process in joints.
The simple solution to current foot/structural imbalances as well as future structural weaknesses is to put the patient into custom-made functional orthotics at the start of their corrective program. Regardless of whether the patient appears to have pronated, supinated, or even normal arches, the digital foot scan will demonstrate that most people will have some degree of fallen arches, as well as imbalances with body weight distribution. Secondly, although we don’t test for this in our office, a significant percentage of people will overpronate during the gait cycle, and this overpronation is blocked with custom-made functional orthotics. Many injuries, especially sports injuries, occur at or are aggravated during this overpronation phase.
After we digitally scan each patient, along explaining Figure 1 (Crooked Man) and the potential for acceleration of degeneration if left imbalanced, most people will excitedly agree to the inclusion of custom orthotics as soon as possible. All people have a similar lifetime goal—to have a higher quality of life combined with greater activity.
More patients wearing custom orthotics in your office will convert to improved clinical results, improved patient satisfaction, and greater patient compliance. And, if an office can “manage” patients properly, patients will require new orthotics every two years, keeping more people engaged in active care. This truly is the beginning of making your practice more successful and fixing the healthcare crisis.
1 Schweitzer, M. E., White, L.M. “Does altered biomechanics cause marrow edema?” Radiology, Mar 1996, Vol. 198:851–853.
2 Yochum T. R., Rowe, L. J. Essentials of Skeletal Radiology, 3rd ed., 2005, Chapter 5.