Saturday, April 2, 2016
Low Back Pain and Orthotic Devices: Email Advice
Hello Dr Blake-
I have severe lower back pain and disc disease. I noticed my lower back at sacrum is twisted to the left and my left hip sways to left and my right ankle pronates with nerve pain between right large toe and second toe. I am walking with a cane in the morning my back is badly twisted in the AM
I found a pair of orthotics that were custom made at the Saint Francis Sports Med Clinic decades ago. I started using them yesterday and the pain has greatly improved and I can walk up steps now with increased strength and reduced pain.
My question is would you be able to to make a new pair of orthotics for my back pain since it has been so long? I do not know if a podiatrist provides this service for back pain.I was diagnosed with scoliosis as a child and I have always pronated.
Dr Blake's response:
Thank you for the email and I will be happy to re-eval your biomechanics. The low back (in fact the whole body) loves symmetry. Sounds like you pronate more on the right and that becomes a high priority to level the pronation between the two sides. You actually need some pronation in your feet for shock absorption, but it is my job to eliminate the excessive amounts, or the abnormal positions, or at least the asymmetry. I have many patients with low back pain helped with pronation control, or just good biomechanics, since excessive supination (AKA underpronation) is one of the commonest causes of low back pain and of course treated opposite of pronation control.
When you are dealing with the low back and biomechanics, you always need to look at structural, functional, or combination short leg syndrome. This causes the base of the spine to be always tilted at L5S1. The body will need to constantly fight this to right itself, and muscle spasms in the low back can be produced. We will check for this also.
The pronation control you are experiencing is probably some version of "double crush" syndrome. If your low back disease is causing nerve irritation, even slightly, you can get symptoms down stream when there is a second irritation to the same nerve, thus double crush. The foot pronation, when excessive, can irritate the tarsal tunnel at your ankle where the posterior tibial nerve lies (a branch of the sciatic nerve). Controlling that pronation can relieve these symptoms, as it seems to have done.
There are so many other helps for your low back including: sitting posture, sleeping concerns (mattress), tight hamstrings, etc. A back specialist into rehabilitation should always be part of the team. In San Francisco, Dr Robert and Irene Minkowsky do a good job at analyzing and treating these pelvic tilts you describe. They are at 2000 Van Ness Avenue. You describe an anteriorly rotated right pelvis to the right (possibly from pronation or weak external hip rotators like the iliopsoas) with a laterally externally rotated left pelvis. The source of these rotations can come from the foot, hip muscles, sacro-iliac joint, or scoliosis. Sorting them all out is funner for the health care providers than the patient, but it your symptoms improve, you will being to have fun also. It will be good to see you. Rich