Definition

A functional or structural lateral curvature of the spine.


Symptoms

Fatigue in low back after prolonged standing, sitting, or exercise, muscular aches in low back or mid-back. Back or neck pain are later symptoms. Asymmetry is observed in standing position (i.e., one shoulder is higher, pelvis appears rotated or twisted, a visible hump is present on one side of the spine when standing or appears when patient bends over to touch toes.


Etiologic Considerations

Leg length differences

  • Prior leg or pelvis fractures
  • Severe knee or ankle injuries
  • Muscular imbalances (i.e., psoas spasms, tight hamstrings, tight tensor fasciae latae or iliotibial band, weak hip abductors (especially gluteus medius), weak oblique abdominals unilaterally)
  • Congenital or developmental hip disorders (i.e., congenital hip distraction or Perthes disease)
  • Congenital asymmetry of pelvis
  • Abnormal formation of a vertebrae

Injury or muscular imbalance

  • Severe sprain/strain of pelvis, lumbar or thoracic ligaments and muscles
  • Somatic dysfunction of the spine
  • Postural causes
  • Work related
  • Heavy book bags
  • Dominant hand syndrome
  • Mother’s back syndrome
  • Disc prolapse
  • Tissue contraction from extensive burns
  • Poor muscle tone
  • Nerve damage
  • Nutritional: Deficiency (i.e., rickets) or osteoporosis/osteomalacia

Neuromuscular disorders

  • Cerebral palsy
  • Charcot Marie Tooth Syndrome
  • Poliomyelitis or other viral causes
  • Muscular dystrophy
  • Spinal cord tumor or trauma
  • Congenital hypotonia

Discussion

Scoliosis is defined as a lateral curvature of the spine, but since the mechanics of the spine do not allow side bending without some rotation, scoliosis always involves both lateral side bending and rotation.

Diagnosis is initially made by physical exam. Observation of the subject from behind and bent over usually reveals the presence of asymmetry. It is often useful to take a standing X-ray that includes the upper part of the femur (thighbone), pelvis and low back and thoracic spine. Often the scoliosis extends well into the neck, and full spine X-rays are used.

Classic C shape curves show one side of the pelvis to be elevated and the shoulder on the same side to be depressed. In S shape curves, the shoulder on the same side is usually higher as well. Some cases of scoliosis can be seen on X-ray to begin very specifically at one individual joint level and motion palpation will easily reveal the limited direction of its motion. If the cause is not congenital, due to abnormal bone formation, or due to an injury that has damaged a disc, which then blocks movement in one or

successfully resolved by osteopathic treatment to the dysfunctional segment and treatment of the secondary effects of the problem area. Usually the cause of the scoliosis is more complex, however, and involves muscular imbalances or leg length differences. Leg length differences are easily corrected, once diagnosed, by inserts into the shoe of the short leg, or a thicker heal and sole added to that shoe, if height difference is in excess of 8 mm (that being the outside limit that can be accommodated inside most shoes). Running shoes may be made to accommodate 10 mm in some cases.

Muscular imbalances must be specifically diagnosed. The most common sites to cause scoliosis are the hip flexors, hamstrings, tensor fasciae latae, iliotibial band, teres, and latissimus dorsi. If weak, the following muscles will contribute to scoliosis: oblique abdominals, hip flexors, hip extensors, hip abductors, hip adductors, upper and lower abdominals, back extensors, and middle and lower trapezius.1

You can easily screen your own child throughout early growth and puberty to detect any asymmetry of spinal development, and you should. It is constantly a source of amazement when we examine a teenager who has obvious curvature of the spine and find that neither the patient nor the parent has ever noticed it. Simply have your child stand upright but naturally in bare feet on a hard, flat surface. Stand behind the child and observe. Is one shoulder is higher than the other? This is the most obvious usual sign of a C- or S-type curve. Does one scapula bulges out more than the other? Look to see if there is a bigger gap between the lower back and the arm on one side or if you see a skin fold on one side and not the other in the low back region on the side. Bend down so the pelvis is at eye level and place your level hands on the top of the pelvic bones just at the waist. Is one higher than the other? Is one side more forward than the other? Stand back and have the child touch his or her toes. Is one side of the spine higher, forming a hump? Lay the child down on the floor. Have the child bend his or her knees, lift his or her bottom off the floor, and then lower it again. Grab both ankles and extend the legs. Bring the legs together. Do the ankles meet at the ankle bone that sticks out? If you see any irregularity, you need to have your child properly evaluated by a trained specialist for the cause of these asymmetries to prevent a spinal curvature from becoming a lifelong problem.


Treatment

The treatment for spinal curvature problems varies, depending on the cause and age at which it is diagnosed.

The “short leg” scoliosis is the simplest to correct and usually to diagnose. If one leg is actually shorter than the other, the pelvis will tilt and rotate, causing the lumbar spine to curve, becoming concave on the side of the longer leg. Usually the vertebrae will then rotate toward the convex side. A secondary curve will then often develop in the thoracic spine, making an S-shaped curvature of the spine. This isn’t the end of it, as usually the neck will have some degree of lateral curvature, and a final accommodation to forward viewing will be made at the occiput/C1/C2 complex. Muscles on the concave side will shorten and those in the convex side will lengthen.

There are many causes for a short leg: congenital causes; one leg may simply not grow as fast as its partner; diseases of the hip, such as Perthes Disease, may cause the leg to be shortened; a fracture of the leg or ankle may alter its growth or length (longer or shorter, but usually shorter, especially if it has occurred in a bone not fully developed); or even a knee injury or ankle sprain. In each case, all that is needed is an accurate diagnosis and a properly measured lift to the shoe of the short leg. Standing pelvic view X-rays are usually needed for accurate diagnosis and a scanogram X-ray is ideal. This gives exact measurement of the leg length differences.

Even these measures are not absolute since the standing posture can be affected by muscular imbalances that mimic leg length discrepancies. We have seen many standing X-rays that clearly show one leg being longer than the other, but the cause of the patient’s scoliosis was muscular or postural, and not attributable to the short leg.

A similar cause of scoliosis is the “apparent short leg.” In this case, the legs are not actually uneven in length but appear to be so, due to spinal imbalances. The pelvis is a common site for these dysfunctions, which can be fairly complex. Although an osteopath may phrase these problems in terms of positions of bones, this is for convenience only. The problem is rarely—if ever—just “bone out of place,” as is the common lay understanding, but in reality a functional problem of the structural framework, which includes not only the bones but also the ligaments, surrounding musculature and fascia.

in order to avoid treatments directed at only part of the problem (i.e., just the bone positioning), and thus not ever addressing the real cause. In reality, osteopaths think in terms of limitations to function, and it is through restoring proper function that asymmetry of the spine is best corrected.

There are many causes of pelvic and lumbo/pelvic dysfunction. Obviously, slip and fall type injuries can have serious long-term complications if left untreated—or even when treated, if they have been traumatic enough.

Since the leg itself is attached to the large pelvic bones, the ilium, any injury that leaves this bone rotated forward or backward will alter the apparent length of the leg and will cause the pelvis to twist , the lumbar spine to rotate, and a spinal curve to result. Muscular imbalances will also cause the position of the pelvis to alter and affect apparent leg length. Common examples of this are tight hamstrings on one side, pulling on the ilium and restricting its movement forward, or tight psoas muscles, limiting movement of the hip backward and pulling the ilium forward, thus limiting its rotation backward.

As a general class, muscular imbalances are the most common cause of scoliosis. The most striking examples of this were the result of the polio epidemic of the 1950s. When the polio victims recovered, it was observed that paralysis of large muscle groups on one side of the body caused the spine to twist and rotate.

Muscular imbalances can also result in other similar, if less dramatic, spinal curvatures. A benign form of this arises out of hand dominance, as a result of using one side of the musculature of the upper torso more frequently for daily tasks. The common pattern for strongly right-handed individuals is a concave right thoracic, concave left lumbar scoliosis. Usually noted is a pronated left foot, a tightness of the left iliotibial band, and a weakness of the right gluteus medius, left hip adductors, and left oblique abdominals. In left-handed individuals, the reverse findings are common.

Not surprisingly, faulty postural habits are a common contributing factor in the origin of scoliosis pattern. It is important to observe your children (and yourself) for improper body mechanics when standing, sitting, and lying. Habitually standing on one leg with the other bent is a common problem, as is lying on one side ,leaning on an elbow, and supporting the head with one hand while watching television or doing homework. Habitually sitting on one leg is another. The position for writing at a desk also often causes problems. For example, right-handed individuals usually sit with their upper torso counterrotated to write.

Simple daily tasks like driving an automobile often leave one hip flexed for long periods. Carrying heavy book bags or purses often causes muscular imbalances of the spine, as does carrying heavy babies for long periods. Another common problem is the position we sit in at work, which can cause chronic spinal rotation.

Obviously, from the list of causes and the complexity of this problem, you are going to need some expert help in diagnosis and therapy. I am, of course, biased in the direction of osteopathy for your choice of therapy, since I have done my training as an osteopath and know the results that can be obtained by it. You may however, have an absolutely superb medical doctor, chiropractor, physiotherapist, sports therapist, or massage therapist whom you trust and respect, who can help you with this problem. Above all else, whomever you consult, make sure you incorporate a specific exercise program to help deal with the muscular imbalances that are almost always a major—or the major—factor causing this problem. Do not expect someone else to reverse scoliosis for you. This is one condition that, without your help, probably will not be solved. I would be very wary of any physician, whatever his or her specialty, who tells you his or her treatment alone will correct your child’s or your own scoliosis. There is, however, no doubt that a knowledgeable practitioner can speed your progress and provide essential help in restoring normal spinal function and muscular balance. The following general exercise program has been proven effective in reversing lateral curvatures of the spine and is a wise addition to most rehabilitative programs for scoliosis.

Konstancin Exercises

This exercise program is one of the few proven methods shown to help reduce the severity of scoliosis. Obviously the earlier the spinal curvature is diagnosed, hopefully prior to the end of the growth phase, the better is the result, but even long standing curvature of the spine can benefit from this exercise program. As with all other forms of self-improvement, regularity is essential for optimum results.

1. Hip Abduction

Begin on your back with knees bent and arms over your head. Slowly allow the right knee to drop to the side to the floor, or as close to the floor as is comfortable, then slowly rise back to center. Repeat this 10 times and then repeat exercise with the left leg.

2. Pelvic/Lumbar Roll

Begin as with exercise number one. Slowly bring both knees toward your chest at about a 45° angle. Allow both legs together to roll to the side toward the floor as far as comfortably possible. Slowly raise both legs back to center. Repeat toward the other side. Repeat entire exercise ten times. Initially, do not over twist too far; gradually increase this exercise’s excursion over a period of weeks.

3. Right Angle Pelvic Tilt

From the starting position as in exercise one, raise your legs to a 90° angle or until the lower back (small of back) touches the floor. Hold this position for a count of ten. Return to starting position and repeat exercise ten times.

4. Straight Leg Raise

This is a fairly advanced exercise that must be done carefully and slowly. If this exercise causes lower back pain or leg pain, then start slowly and only gradually increase the degree of elevation until a 90° angle can be obtained. Do not do this exercise if you have a disc-related injury. Begin on your back with the arms over your head. Slowly raise legs to a 90° angle. Try not to arch your back while doing this exercise. Repeat slowly ten times. If this exercise is difficult or painful, only do one or two repeats and slowly increase to ten repeats over a period of a month or two.

5. Straight Leg Raise with Head Flexion

Begin on your back with arms over your head. Slowly raise legs to 90° and flex head forward. Hold this position according to the timetable below:

Week 1: Hold 30 seconds and repeat exercise 3 times.

Week 2: Hold 45 seconds and repeat exercise 3 times.

Week 3: Hold 60 seconds and repeat exercise 4 times.

Week 4: Hold 75 seconds and repeat exercise 4 times.

Week 5: Hold 90 seconds and repeat exercise 4 times.

Week 6: Hold 105 seconds and repeat exercise 5 times.

Week 7: Hold 120 seconds and repeat exercise 5 times.

6. Low Back Extensions

Begin on your stomach with your legs restrained by a strap (or have someone hold them down). Raise your upper body and hold according to the time schedule in the previous exercises. At first raise your upper body only a few degrees; gradually increase the amount of extension.

7. Low Back Extensions (Advanced Exercise)

Begin face down on a table with upper half or your body overhanging the edge at 90° and lower legs restrained by a strap or assistant. With arms clasped behind your neck, slowly raise (extend) your back to level or slightly beyond into extension. Slowly lower back to starting position. Repeat ten times. You will also find a specific back apparatus, the “roman chair” at most exercise equipment supply outlets, which accommodates this very useful exercise with maximum efficiency and comfort. Note: This is an advanced exercise and you may need to slowly build up to it with the other back exercises and begin with only 2 or 3 repetitions and slowly increase over a period of weeks before 10 repetitions are possible. Also note that if there is known disc thinning or instability in the lumbar region, do not do this exercise!

8. Standing Squat

Begin standing, knees straight and palms on thighs. Lean forward slightly and slide hands down to knees, keeping the back and neck as straight as possible, then return to upright position slowly. Exhale while going down and inhale while going up. Repeat ten times.

9. Standing Pelvic Tilts

Begin standing with back against a wall and hands at sides. Keep knees slightly bent and feet two inches away from wall. Tilt pelvis and flatten your low back against the wall. Hold for count of five and relax. Repeat ten times.

10. Standing Pelvic Tilts/Arms Raised

Same as above except with arms held above head. Repeat ten times.

11. Standing Flexion Toward Toes

Begin standing with hands on thighs. Forward bend with knees straight and slowly attempt to touch toes. Obviously, some people may not reach this goal and only get to knees. The aim is to increase this range slowly and safely. Repeat ten times. Known disc sufferers beware this exercise! Extreme flexion exercises can cause posterior disc bulges to aggravate.

12. Sitting Flexion

Begin sitting with arms behind neck and knees at 90°. Slowly lean forward until abdomen and chest rest on thighs and then slowly raise upright. Repeat ten times.

13. Sitting Side Bending

Sitting with hands behind the neck as in exercise 12, lean slowly to the left as far as possible, then raise upright slowly. Repeat to right. Do this exercise for ten cycles.

14. Sitting Trunk Rotation

Sitting with hands behind neck, rotate left as far as possible slowly and return to neutral, then rotate to the right and return. Repeat cycle ten times.

15. Kneeling Pelvic Tilt

Begin on hands and knees, do pelvic tilt by rotating your pelvis to create an arch in your lower back, and hold for 6 seconds. Repeat ten times.

16. Classic “Pointer”

Begin on hands and knees. Lift right arm and left leg and stretch as far as possible. Hold for count of five. Repeat with opposite leg and arm. Repeat cycle ten times.

1. The best book on the subject of the proper testing of muscle strength is Muscles: Testing and Function, by Florence Peterson Kendall, Patricia Geise Provance, and Elizabeth Kendall McCreary (Baltimore, MD: Williams and Wilkins, 1993).

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