Question
QUESTION: Hello Dr. Gillman,

    In advance, thank you for your time and opinion. I am a 29yr old female that has been suffering for two years with severe neck, lower back pain as well as the sacroiliac area. A quick background for you:

?Scored 7/9 on hypermobility test (danced ballet growing up)
?Fell from a cheerleading mount at 14 which is when hip/back problems began. I saw a Chiropractor who adjusted my hips and the pain was gone. Was always extremely flexible on right side, still flexible on left but not as much. Chiropractor said that I tore ligaments or tendons (?) under left leg from the fall. My hips/legs were uneven for a few months.
?I have been in graduate school the last 2 years so I spent countless hours driving to school and hunched over a computer.

    I was pain free until age 27. Was already active but started a new workout routine that was ballet/yoga/pilates based. I definitely pushed myself too hard right before my back pain all started. I did many leg lifts to the back that probably caused a compression injury to my lower back. I woke up one morning and couldn抰 stand straight up.
    That lasted for 5 days until a chiropractor realigned me so I could stand up straight. I sought chiropractic care for over a year, 3 times a week as well as massage and muscle stimulation without any real relief. The pain was debilitating.

?MRI diagnosed 2 ruptured discs. One in C5/C6 and one in L4/L5.
?Chiropractors have indicated that my 1st rib, sacrum and lower vertebra have been subluxated/fixated.
?I do not have referred pain down my legs but when I was getting regular adjustments my arm would go numb.

    I have seen many doctors over the last 2 years (Orthopedics & Chiropractors). Everyone tells me something different. Most told me to avoid exercise and stretching at all costs because the hypermobility.
    I have just relocated from FL to CA due to my husband抯 job. My physical therapist in FL was only able to treat me for a few weeks prior to moving. He said I should ignore what all the other doctors told me. I need to mobilize my spine and strengthen my core as well as gluts. I have been using a foam roller which is extremely helpful as well as stretching my psoas muscles, hamstrings and quadratus lumborum.
    My PT in FL said that my lower spine is hyperlordordic from tight hip flexors/lower back muscles & weak abs/gluts. I also have a military neck and a rotated pelvis (right side rotated posteriorly left side rotated anteriorly) which has also created scoliosis in my lower back causing my rib cage to rotate to the right as well. Occasionaly I have trouble breathing and routinely have a "choking" sensation in my neck. My sternum also continues to pop along with my left SI joint. I have been doing exercises on my own since I moved and have just recently started to see a huge difference in my pain. If I don抰 stretch & or exercise I am miserable & my left SI joint will lock up. My x-rays also show a 9mm leg length discrepancy with the right leg being shorter.

   This is where I need your expertise: The new PT here in CA said that any stretching will make things worse. This contradicts what has been working. I believe I have a muscle imbalance from the disc herniations which are both on the left side and years of over working/over stretching my right leg. Would you agree? I know I am not a doctor and many others have said the same thing but the only thing that has worked is the stretching.

  My plan - pending your opinion- is to find another physical therapist. My other question is: why does my right hip continue to roll back? I walk every day and have been for 2 years to strengthen those ligaments. I understand the long hours of sitting/driving have probably exasperated the problem & it takes time for tissue to go back to normal. Again I am thinking this is a muscular problem. If so which other muscles should I be stretching or stimulating with my tens unit? When I sit I feel as if everything is twisting clockwise and my muscles spasm on the left side of my body by my rib cage. I have been driving with a book under my right hip and that helps but I need to do something that will fix this!

    What do you suggest in terms of treatment moving forward? On a side note- I have pelvic wedges at home as well as a zero gravity chair, heating pad, tens unit you name it. Also my Chiropractor gave me a device called a Denneroll that is supposed to help put the curve back in my neck. It is uncomfortable so I am not exactly consistent in using it. These days I back off when things hurt in fear that I will make it worse. I feel as if I have tried everything a little bit because of the conflicting opinions. I feel that if this is not resolved soon that I will have permanent damage.

    I should mention that my Dad has suffered with pain in his back & neck my entire life due to an injury & arthritis. Additionally, my older sister has also had serious back pain for the last 10 years or so. No injury but she is relatively inactive. Regardless, a genetic component may be the culprit as well. I have seen 4 orthopedic doctors and no one has mentioned arthritis but I am scheduled to see a Rheumatologist to rule it out.
    My last question- which treatment how long do you feel it will take for me to get to a place where I can sit down comfortably? I have a 4th interview for an amazing opportunity but as of now I can抰 sit for drive for more than 15-20 minutes comfortably. (Since I have been stretching & exercising it抯 more like an hour maybe even two) They will wait but I need to give them a ball park. As of now I don抰 have a doctor to give me this time frame.

   Please forgive me for the long story & numerous details. I just wanted to be able to give you a background. THANK YOU FOR YOUR TIME. You have no idea how much it is appreciated.

Respectfully,
Megan

ANSWER: Hi Megan,

Your long story and details makes it easier for me to provide a quality reply.   Childhood injuries that do not completely heal or heal with 100% return of function can fester and be a source of pain as we become adults.     We see this all the time, "ever since that clip in high school football," or "ever since I landed on my butt on the tobogan run."   You get the idea.    Also, true, simple osteoarthritis is genetic, and you may have early signs, enough to cause symptoms.    Your scoliosis likely has been with you for a long time, and it, too can be a source of back or hip/pelvic pain, but that's not aways a given.   Many folks with scoliosis have no pain.    I can tell you what absolutely does not work: tens.  TENS is only a way to control pain while it is turned on, but it has no effect on changing your pain or making anything heal or function better.   Exercise is, for sure, therapeutic.    However, there are exercises that can also cause mechanical wear and tear and cause you to have more pain.    Sit ups, or toe touches,  or any posture that flexes your lumbar spine, absolutely will compress the lumbar intervertebral discs.  This is well established (see papers by Stuart McGill, PhD).    "Spine-neutral" exercises, which some Pilates instructors are more keen on, can be helpful in engaging your musculature without stressing the discs.   The MRI clearly stated "ruptured" and not bulged or protruded?   There's a big difference.   Regardless, you need to keep your body strong and conditioned, and need to do the right kinds of exercises.  Cardiovascular exercise also is good for you, so don't rule out running or spin classes, etc. if you can do these without provoking pain.    As for leg lengths, the only way to really know if you have a short leg is to measure each of your limbs via x-ray (called a scanogram).   Leg length discrepancy cannot be effectively known by looking a picture of you pelvis and drawing a line across your hips.   This method is wrought with error.    It does not take into account pelvic rotation, ankle asymmetric overpronation, or subtle differences in knee extension angles, all of which can cause the x-ray projection to appear skewed when it hits the screen/film.   The old fashioned tape measure from hip to lateral ankle has the human error component, but if done repeatedly, it can give you an idea if there may be one limb longer than another.    The problem then becomes what to do about this.   If you put a platform under the short limb (e.g. in your shoe), and you lift your limb the full amount of the discrepancy, let's say 1/4 inch for argument's sake, it might truly level your hips/pelvis.    But, what does it do to your knees if they were in alignment (e.g. only the femur, the bone above your knee, was short)?  And, what if your lower back has adapted to the subtle scoliotic curve over the years?  Would you make more pain by trying to even it out?   These are things we do not completely understand.   Some people clearly have a short limb, be it from the femur or from their leg (tibia/fibula) and they can feel it - and they feel very balanced and with less pain when they wear a lift in their shoe or have one shoe's sole modified to be thicker (by a cobbler).    Others have one arch that goes flatter than another, thus dropping that limb down lower then the opposite limb during each step.  This person needs a good quality, high-arched, foot orthotic (e.g. Sole Supports), and not a heel lift.  Some need both...       So let's now talk about your neck curve.   There is very poor correlation between your neck curve and your health.   While everyone agrees that we should have cervical spine curve that measures about 40 degrees (+/-), not everyone does.  Some folks with perfect neck curves have terrible neck pain, and some with reverse curves (whether from trauma or just how they developed) have no pain at all.    There is no proof that using a fulcrum such as that Denneroll or any other will ultimately change your neck curve, and there is no proof that changing your neck curve will change your symptoms.  You can see some of the AllExperts questions from people that are aggressively trying to change their neck curves in a chiropractic office, at three times per week for months, and with the end result being no appreciable change in their curve, but now they have chronic neck pain.   I would suggest playing with the device on a regular bases, but no not force yourself to suffer with it.      Let's talk about treatment.   The connective tissue that weaves throughout your body, comprises about 30% of your entire body weight, is a support structure, stabilizer, facilitator of movement, and a guide for your tendons to attach to your bones is:   fascia.     Fascia is pain sensitive.   It has it's own nerve supply.   In fact, when you strain something and feel the pain of it, the pain signal comes not from the muscle, but from the fascia that surrounds the muscle.     Fascia can become tight, adhered, fibrosed (scarred), and can be a great generator of joint dysfunction and pain.   Except for easy cases, Chiropractors cracking bones often cannot alleviate fascial tension, and PT's rubbing or stretching your muscles cannot alleviate fascial adhesions or fibrosis.    It takes a bit more work.    Find a practitioner from these lists:  Grastontechnique.com     FAKTR.com  and ACBSP.com     The FAKTR group often are DC's who have a good handle on how to do soft tissue work and also rehab exercises.      The ACBSP are the sports-oriented chiropractors, with the "Diplomate" level being the kings.    If you find someone that has a good profile in your region but they are not close to you, call them and see who they know .      If the right mix of therapeutic procedures, including skilled joint manipulation, expert soft tissue therapy such as FAKTR or Active Release, and the right kind of exercises are performed, you should experience a difference in a few weeks for sure.   Weeks.   

'Hope this was helpful.

Dr. G

---------- FOLLOW-UP ----------

QUESTION: Hi Dr. G,

   Talk about a good day! I was so excited to get your response & opinion. Thank you! I think you may have found the missing piece to the puzzle. I hope I understood this correctly...The scarred fascia on my left side is most likely causing my left si joint to lock up, which rotates my pelvis (also causing the leg length discrepancy) and in turn causes compensatory scoliosis which further aggravates the discs. This is pretty much the same type of injury from years ago, just now I am older and have injury my discs because of it. So in addition to early signs of arthritis the imbalance in my tissue is throwing everything else off as well? By the way, thanks for the advice on my cervical curve. I wasn't exactly convinced it was the main issue. Especially because after more than a year of consistent adjustments nothing improved.

    By the way, they did specific that those discs were ruptured. I saw a surgeon and he said I didn't need surgery but that was it- no other advice. I must say that when I work out and hear a few pops my pain is very minimal for about a day or so which leads me to believe the problem definitely lies within joint dysfunction. In other words, I am convinced that whatever is causing my pelvis(tight fascia) to rotate is also causing pain.

    I looked up the associations you mentioned. My insurance is amazing and covers pretty much everything except chiropractic care. I saw only one physical therapist on the list and they are not "in network". I hope to find a professional that is skilled at soft tissue therapy. Do you know of any other associations that I should keep an eye out for?

  Additionally, I have been told by many people to avoid pilates (which similar to what caused the injury & is very painful) due to my hypermobility and running. I guess I need to find someone that can look at the mechanics of my body as I perform exercises. My form in pilates may be faulty due to the hypermobility. Do you think the hypermobility is as much of a factor as everyone else does? You have given me a new perspective and hope that I can get back into an active, healthy lifestyle soon.

Thanks again for your time & God bless you.

Respectfully,

Megan

Answer
Hi Megan,

I don't know what else to mention.   I guess that you really need to try to cross-reference DC's on the lists I provided you.   If you can find a diplomate level chiropractor who is certified in Graston Technique and who also did the FAKTR program, then you're likely in really good hands.   I do know that hypermobility is a problem, and you always need to do strength and stability training and not any prolonged stretching or repetitive spine bending movements.    It's too bad about your insurance.    It is not a fair or logical system.   Nevertheless, adding GT/FAKTR along with your physical training could really help, and DC's have the most experience with this.    

Best regards,

Dr. G'