Question
QUESTION: My son has just returned from 14 mo deployment, aprx 10 months in pain in his hip/low back graduating to severe. 4-5 months ago they thought it was his SI joint and shot him with novacaine something and cortizone said he would have immediate relief if that was it, which he didnt, this was with only an xray, in sept. they gave him an epidural still with no relief.  He returned 11.22 and today they did an MRI and told him he has a herniated L1 disc. We have a great chiropractor in our hometown that we see more than our general md.  He has seen randy when he has been home in the past for manipulations/adjstms and got him into a lift 4-5 yrs ago that he used to wear faithfully till someone told him was a 'crock' think it was an army dr...this last deployment he chose not to wear it, could this have exaberated and caused this herniation?  I cant begin to explain and Im sure you can imagine the stress and strain these soldiers put on thier bodies with their packs, running, jolting, air assaults, not to mention the few ied blasts he was involved in, let alone the conditions they live in, hydration, diet, add into that work outs etc.  My husband had a herniated disk 20 odd years ago that was treated by a chiro (not our current) quite succesfully with traction (from what i remember) and the usual adjstms, electro shock etc....they have only today FINALLY diagnosed him and already heard the words surgery and 12 months downtime...he is due to come home saturday unless they tell him something different tomorrow which he will cancel his block leave and not come home as he wants to move on with this.  what i would like and i am not so sure the army will advise him or allow him to do it: is while he is home be seen and treated for the 30 days he is here by our chiro....what do you suggest?  thanks so much, im sure the army is going to tell him no, not to seek any treatment while home and probably wouldnt pay for it either, but 30 days is some time to put between the big S word.  he is only 26 but this was his 4th deployment and i think these austere environments they put them in for him, is taking its toll.  i watched him hobble off that plane like a cripple, i have no right as i can only be thankful he made it home again whole and in one piece but my first reaction - like seeing him come home wounded.  at least today they FINALLY gave him some pain meds...he said this past 8 months pain was his constant buddy and had made him grouchy and hard to get along with just trying to get through that on top of everythng else....mitzi

ANSWER: Hi Mitzi,

I'm sorry your son has endured this for so long.  I'd sure like to see the MRI results and learn more just in what way L1 is herniated.  This is an unusual area to have a herniation.  It is almost always L4 or L5, sometimes L3.  L1?  Also, is it a fresh, new herniation or is it a dried-up old one?   Fresh new ones will be metabolized and resorb over time in most cases.   With old ones, treatment can be helpful.  It's a matter of trying it.  I'd suggest the chiropractor employ lumbar flexion-distraction technique.  He should know what that is. He would need a F-D table, and not all DC's spend the money on it or want to take the time to do it.  You can view the exact table and method on line at:  www.biomedcentral.com/1471-2474/7/16
The chiropractor can contact the bones above L1 and stretch and mobilize L1 and below.  If this provides any relief after one or two sessions, then he should continue to obtain treatment 2x-3x/week with monitoring of symptoms.  As pain reduces, he should be progressed more into exercises.  I too would clear any soft tissues the spine with Graston Technique (see www.grastontechnique.com).   I'd be happy to peek at his MRI report if you send it to me.

Mitzi, regarding the heel lift:  Some people do very well with a lift.  It is not a procedure to be done routinely by any doctor, but when a patient has short limb and small lift in the shoe consistently takes away their back pain, then the lift is a good idea.  With custom foot orthotics, the lab can build a lift into one.  This way the whole foot is elevated as opposed to just the heel.  Errors in employing a lift include assuming you have to correct the entire limb discrepancy as observed on x-ray or posture analysis.  It's best to just use a little lift to start, then find the one that is most comfortable that provides pain relief.  If someone can get back pain relief without using a lift, that's the best way to go.

Hope this helps!

Dr. G

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

QUESTION: Yes the lift was a custom job. Dana had the "measurements" or whatever that would be called but a cast was made of his foot and ordered from an orthodix place, leather.  It did give him instant relief, as a matter of fact he wore through 2 of them which is unusual in every day life but for his "profession" being on his feet,the amount of stress/pounding , not so much.  It actually was an issue depending on the type of footwear he was wearing, running shoe, combat boot (flexible) and black leather marching boot (stiff) as one didn't always fit the other dending on how the footwear was made. After his 1st deployment 04-04 that insert came back paper thin. So he wore through 1 and 1/2 lifts and at this time has a brand new one since he quit wearing it a year ago when he deployed.  Thats why when he told me he wasnt wearing it, he had just bought new assault boots (lightweight, breathable) from Oakley which is a new favorite with these guys, it wouldnt fit so he didnt wear it. Thats when I heard the comment about it not being a miracle cure for his back anyways.(this is surprising attitude to a certain degree, as chiro care and homeopathic treatment as been an intrigal part of keeping our backs healthy in our family)  I reminded him that it did work, he was the one that noticed a difference wearing it and he was the one to request new ones when they wore down.  I guess that is neither here nor there, but I really wonder where he didnt wear or stopped wearing it what that would have done, making his body compensate for something that had routinely offset his skeleton/frame.
As far as the MRI, he didnt speak to anyone in his chain of command before leaving to come home, they just started 30 day block leave 12.10 so I thought he may not be able to reach anyone. He picked up his meds /dispensed and that was it. I wanted him to find out if he had to sign a release if he were to request the mri faxed once he got here but I dont know if that was an option when he went in yesterday.  I am hoping, if I can convice him to try some of the above treatment, that he can contact the medical facility on post and get that MRI.  Im sure the Army  wont agree to pay for this but at this point out of pocket cost to try something during these 30 days will be far worth it.
 Our current chiro does not have a table, but the chiro that treated my husbands herniated disc years ago, does.  Matter of fact he is the other chiro in town that works on my chiro when he needs adjst, they work on each others back when the need arises, so I feel extremely comfortable there.  During conversations he has told me the two trust each others "methods".  I think I have good resources I am just not sure about getting  that MRI, getting it from a regular civvy facility is one thing, the Army I dont know.  If its an option and we can get ahold of them, I would certainly appreciate any feedback you would give.  Just one other thing, what i was reading about herniated disc etc, mentioned hydration.  Not sure in what regards that was assessed to, as in an injury or herniated disc?  But in a desert climate, 120 degree temps etc pushing their bodies beyond fatigue...this last deployment he actually almost succumbed to heat exhaustion, and that is a first for him out of 4 deployments.  Staying hydrated is 2nd only to dodging bullets for these guys while over there.  Could this have been a factor in amongs other things that might have contributed to the breaking down of the bodies ability to stay healthy, muscular/skeletal wise?  Thank you so much for your responses, I hope I can continue and possibly fax you the MRI, believe me if I get my hands on them I will.

Mitzi

ANSWER: Hi Mitzi,

His body hydration may not have anything to do with his disc hydration, since the disc hydration is an effect of disc degeneration or breakdown and not total body H2O levels.   I would suggest foot orthotics made from something other than leather.   Leather can get moldy, cruddy, and break-down.  There are better synthetic materials out there, including "orthoplast", for example, that he can wash. Also, given the heat, some of the synthetic orthotics can be modified by punching holes in them, like 100 holes.  This will reduce their weight, allow them to breath, and help drain water if he gets wet.  A podiatrist with experience making orthotics for athletes should know what I'm talking about.   There was an article on this sort of orthotic, designed for water sports, published in a podiatric association journal a few years ago.  I made a similar orthotic for a steeplechase athlete (they hurdle and land in a water pit).  I hope his lift is not too great, not more than a half centimeter or so.  I would like to know just how the amount of lift was determined.  Please tell me that.   Depending on the anatomy and flexibility of his foot and the amount of lift, he may be able to get away with pre-fab (off the shelf) orthotics, with ALINE brand being the one I have in mind (see www.aline.com).  If this is the case, then he'd have a cost effective option with a durable pre-fab that has a lifetime guarantee (unless you drill holes in it).    Lastly, it is my understanding that VA hospitals all have DC's, or they're supposed to by law, and he may be able to tap into that, too.   You can contact the American Chiropractic Association for more details.

I hope this all helps, Mitzi.   I'm glad to offer whatever assistance I can.

'Regards,

Dr. G
www.drgillman.com


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

QUESTION: Im not sure how the lift was determined other than our chiropractor made the measurements from his exrays (he takes them standing up, dont know if this is with all chiros?) but I remember seeing the x-rays and the notations/measurements on the exrays themselves and that was sent into the orthotics company along with his foot mold.  I think we went with leather, and I could be wrong here, Dana, our chiro had leather and used other materials in his own and the leather in his estimation wore longer than the other materials in his experience? I do know the orthotics company asked questions like what kind of environment, what type of shoe it would be worn in.  At them time I think he was in garrison, on post, before he deployed.  He has never been in an environment that has a lot of water other than moisture from his foot sweating.  The lifts he has currently are in good shape, one partial worn cuz he quit wearing em and the other brand new.  When he returned from his 1st tour in Iraq and it was worn paper thin (we had not re-ordered more at that time) our chiro sent that lift to the orthotics company as they requested it when we did re-order, wanting to see how it worn, held up etc in the conditions he was in over there.  Now, I havent asked him where the 2 lifts are since he got back, I hope he has kept them or not lost track of them.  Everything goes into storage when they deploy for that long and since he has gotten back has moved into a rental house and gotten all of his things out of storage.  Anyway, in order to order a new lift he would have to do the mold again of his foot, probably the x-rays and all of that to get new ones.  

Where he quit wearing them this past year do you think that had anything to do with the disk herniating?  He is not opposed to getting his MRI from the medical facility at Ft. Campbell.  As a matter of fact, his PT there told him when he picked up his meds, by all means to see his chiro when he got home.  Can you tell me, requesting the MRI, would it be easier or more expedient to have our chiro request them, his md here hasnt seen Randy for geesh 6 yrs possibly.  They would have to be faxed, jor over-nighted I am assuming, but do they or would they release the MRI to us, myslef w/o being a doctor?  Im sure you probably are familiar with the general procedure with medical files/x-rays/ MRI's but not an army installation.  He gave me a couple of names of the doctor and pt he has been seen by since he got home 11.22 so that is something to start with and something I would like to do Monday morning.  I would like to get a copy if this works out, get it to our Dr. Lilenquist and the other in town, Dr. West and possibly send it off to yourself.

Answer
Mitzi,

It is not valid to determine how much of a lift is needed by measuring lower back or pelvic xrays.  Anyone doing that is clearly in error.   There are too many variables.  To know exactly how much of a lift is needed, there would need to be xrays taken of the leg, thigh, and pelvis, and all the bones would have to be measured and compared.   Then you still would have to guess, because the xray picture is a projection and not a true representation of the limb length (just like your shadow is bigger than you are...).   The DC can request the MRI results by fax.