Friday, January 1, 2010

Building the High School Athlete Practice!&pid=42

Click here to read this article published in the American Chiropractor January 2010.  

Biomechanical X-Rays

Ordinary medical x-rays have become outdated and are not taken today for anything except broken bones and signs of disease. Many people have had x-rays taken and heard those famous words, “They’re negative.” Get enough negatives, and doctors now question the value of the plain film x-ray. X-rays have clearly lost their sexiness and value.

The more glamorous imaging tests are the MRI, the CT scan, the PET scan, and bone scans. These tests provide information the traditional x-ray does not. Magnetic resonance imaging (MRI) is a test that uses a magnetic field and pulses of radio wave energy to make pictures of organs and structures inside the body. In many cases, the MRI gives different information about structures in the body than can be seen on an X-ray, ultrasound, or computed tomography (CT) scan. The MRI also may show problems that cannot be seen with other imaging methods. A CT scan uses x-rays to make detailed pictures of structures inside of the body, but the amount of radiation used by a CT scan is significantly greater than the radiation used with plain film x-ray. A positron emission tomography (PET) scan is a unique type of imaging test that helps doctors see how the organs and tissues inside your body are actually functioning. A bone scan is a test that helps doctors find damage to bones, like cancer that has spread to the bones, and see problems like infections and trauma to the bones. A bone scan can often reveal a problem days to months earlier than a regular x-ray test.

So, we might ask, where’s the value in the plain film x-ray? It’s simple. We live with a pathology (disease)-based healthcare system. If there is no pathology—no tumor, cancer, or another disease showing on the x-ray film—the “expert” will claim the x-ray is “negative.” What this means is negative for disease or fractures, but not negative for biomechanical (architectural) information.

Because our bodies are biomechanical (architectural) structures, an x-ray, especially one taken with the patient standing, gives a great deal of information regarding that person’s wear and tear patterns and biomechanical imbalances. An x-ray can give a clear status report of where an individual has elevated stress in his skeletal system. There are many predictability factors that we can see when we look at an x-ray from a biomechanical point of view. We can also use the x-ray to rule out pathology. There are many silent diseases and diseases that can mimic basic strain/sprain injuries. The plain film x-ray is the least expensive and simplest screening to use to find such diseases. Finally, the x-ray gives a powerful visual picture of the situation to the patient himself. Successful cases originate when a well educated patient knows and understands what’s happening inside his body.

When we use x-rays as part of the Structural Fingerprint® exam, the number of films taken is dramatically reduced. In a standard medical x-ray series of the neck, for example, five to 11 x-rays can be taken. In the standard medical x-ray series of the low back, five views are typically taken. The Structural Fingerprint® exam begins with only two x-ray views from the front (see Figure 1) and two from the side (see Figure 2). These views minimize the patient’s exposure to radiation while still providing significant information on him. The x-rays also give doctor and patient a starting point for increased biomechanical improvement. Proper treatment and rehab can be recommended based on what these x-rays show.

Front View, Neck (Open-Mouth View)

The front open-mouth view provides much detail, especially with regard to the nervous system and the upper neck. This area of the body is typically involved in many injuries, including sports and automobile whiplashes, and the upper spine has a direct influence over the body’s nervous system, as the spinal cord exits the skull and enters the top two vertebrae, the atlas and axis. Many patients’ chronic headaches are caused by misalignments of these two vertebrae. This x-ray also shows the relationship and alignment of these two vertebrae and the skull.

The normal open-mouth view (see Figure 3) shows key reference points used to determine the status of this patient. The two short vertical lines need to be in line with each other. If they aren’t, the second vertebra, the axis, is misaligned and predictably irritating the spinal cord at that level. The pairs of arrows point to spaces on the left and right sides that should be equal in size. These spaces assure that the two top vertebrae are aligned and the spinal cord receives minimal irritation as it travels to other parts of the body from the brain. Finally, the spine needs to be centered in the open mouth.

The abnormal open-mouth view (see Figure 4) suggests stress and irritation to the supportive soft tissues (tendons and muscles) that are pulling the spine into a distorted position. It also increases the likelihood the nervous system is being irritated at that level. It’s impossible to know exactly what tissues are involved, but these types of imbalances can produce stresses at the highest level of the nervous system, and these stresses predictably will produce an array of symptoms. Symptoms that can be caused by the imbalances seen in Figures 3, 4, and 5 include headaches, neck pain, imbalance issues, digestive disorders, asthma, and allergies. As I tell patients, “Our goal is to get you closer to the norm. We know that will be better for you than what we see in your current state”.

Case Study #1

It’s not unusual to find abnormal open-mouth views (see Figure 5) in routine exams. As you can see, there is tremendous imbalance between the spine and the open mouth. There is also an imbalance between the atlas (top vertebra) and the axis (second vertebra). With six months of proper treatment and rehabilitation, however, we see improvements (see Figure 6) in both alignment and balance.

The head, which is approximately 10 percent of body weight, has a great influence on our overall weight distribution and body alignment. While there are established norms for the cervical curve of the neck, known as a lordotic curve, we also see many abnormal findings on x-ray. Let’s begin by looking at a normal side view x-ray (Figure 7). The forward lordotic curve provides shock absorption for the head. The head is approximately 10 percent of the body-weight. The vertical line running through the bones of the neck is the weight-bearing line. This is the center of gravity of the head and verifies that the weight of the head is being supported by the entire neck, not just a few segments of the neck. The disc spaces (indicated by arrows) should be equal in size with each other and basically rectangular in shape.

The abnormal side view of the neck (Figure 8) shows multiple problems. First, the weight-bearing center of gravity line lies in front of the spine, which indicates that the center of gravity of the head is creating significant abnormal stress in the lower half of the neck. Over time, the muscles and joints of the neck will become more and more restricted, which will lead to premature lower joint changes including degeneration. In addition, because the head lies in front of the rest of the body, the entire body must compensate, which can lead to stresses in all supportive muscles, tendons, and joints in the body. This leads to increased vulnerability to injuries and premature breakdown of other muscles, tendons, and joints.

Case Study #2

Figure 9 shows the lack of a normal curve and the forward lean of the neck (making the center of gravity sit significantly forward), plus premature wear and tear (degeneration) of the discs (better known as osteoarthritis) in the mid to lower neck.

The side view neck x-ray taken at the start of care (see Figure 9) shows a 46-year-old golfer who had to nearly quit playing because of neck and right shoulder pains. Within months, his symptoms improved to the point he was able to play again. The improvement, shown in Figure 10, took the better part of one year.

Front View, Pelvis and Low Back

This view reminds us of the importance of overall balance in our structure. The pelvis can rotate in many different directions and produce imbalances in our pelvis and low back, which means that the correlating muscles on the two sides of the body can be working differently. This will also affect leg length because, more often than not, a short leg is really a rotated pelvis, not a leg that’s shorter than the other. The most important issue is that imbalances in our structures are the precursors to injuries and premature breakdown. This x-ray view can show many breakdowns.

There are three key questions to ask when viewing the normal x-ray (see Figure 11). First, is the height of the pelvis (indicated by the horizontal line) even on the right and the left? Second, is there alignment between the spine and the joint in the front of the pelvis (the symphysis pubes, indicated by the vertical line)? Third, are the shapes of the obturator foramen (the two holes at bottom of the pelvis) equal in size and shape, suggesting that the pelvis is balanced on both sides? More often than not, one or more of these imbalances will be seen on x-rays, and sometimes, all three imbalances will be present (see Figure 12).

Side View, Pelvis and Low Back

The side view of the low back can show significant information that will help the doctor predict the capacity, or tolerance, of a person’s low back or the potential for disability over the course of the patient’s lifetime. This view has three key measurements: the center of gravity, the sacral base angle, and the status of the discs. This information, in combination with the other views and tests, becomes the starting point in developing a corrective program for the patient.

In the normal side view x-ray (see Figure 13), we want to look first at the center of gravity from the side. This horizontal line, better known as the Ferguson’s gravity line, shows if the weight-bearing line in the low back is ahead of, normal, or behind where it should be. We also want to measure the sacral base angle, where normal ranges between 36 and 42 degrees. If the gravity line is ahead of or behind normal, or if the angle is greater than or less than normal, the capacity and tolerance of the low back are reduced and compromised. Typically, an increased sacral base angle accompanies an anterior gravity line, while a reduced sacral base angle accompanies a posterior gravity line. Both are associated with back injuries related to where the abnormal mechanical loading falls.

Finally, we look at the disc spaces. We cannot actually see a disc on an x-ray; what we see is the space it occupies. We can then determine if that space has been compromised. (An MRI is required to determine actual disc status.) If any discs appear narrower than other discs, this is a strong suggestion that the narrower disc joint has lost normal mobility, possible due to abnormal stress through that joint or injury to that joint. The joint that typically narrows first, or degenerates first, is L5, the last joint of the low back. If another joint shows degeneration in the absence of narrowing of the L5 disc space, this suggests there was an injury there some time in the past, and normal mobility was never fully restored.

In the abnormal low back x-ray shown in Figure 14, we see multiple issues that will have a huge impact on this person’s life. First, there is a forward center of gravity line (long vertical line). This line should be going through the short vertical line, but here the body’s center of gravity is significantly in front of where it should be. This lowers the capacity and tolerance of the low back and compromises the functions of the associated muscles and joints.

Second, the sacral base angle is 56 degrees, which makes the angle greater than optimal (36–42 degrees). This also lowers the capacity and tolerance of the low back, making it less functional and more vulnerable to injury.
Case Study #3

It’s not unusual to find abnormal side views of the pelvis and low back (see Figure 15). This patient came into our office with severe and chronic low back pain. With 12 months of proper treatment and rehabilitation, improvements were made (see Figure 16).

Degeneration (Osteoarthritis) Shown on X-Rays

Abnormal mechanical loading caused by structural imbalances is a leading cause of joint breakdown. Because our standard healthcare system does not care for the musculoskeletal system, degeneration is seldom prevented. I have no doubt that this negligence condition exists in nearly all people over the age of 50. Abnormal loading leads to fixation of joints, shortening of muscles and tendons, and restricted mobility. When fixation of a joint exists for five to 10 to 15 years, a joint begins to break down and the disc space begins to narrow. There is a roughening of the tops and bottoms of the vertebrae the disc lies between, and the injury progresses.

In the neck, or cervical spine (see Figure 17), the most common joint space to degenerate first is the C5/6 disc space (arrow). Because the C5/6 joint is under the greatest stress in the neck, this joint becomes the most likely to undergo the degeneration process.


In the low back, or lumbar spine (see Figure 18), the joint space that most commonly degenerates first is the L5/S1 disc space (arrow). The L5/S1 joint is under the greatest stress in the low back and is most likely to degenerate.


Many doctors tell us that the degeneration of joints is an old person’s disease. We need to remember, however, that the joints above and below the degenerated joints may be healthy, but they are the same age. “Old person’s disease” is thus a very weak argument. Degeneration is caused by abnormal loading and negligence. It produces major losses in the quality of life and costs us massive amounts of money to treat. Degeneration needs to be addressed long before it begins.

How Early Should X-Rays Be Taken?

I recommend that children should receive their first Structural Fingerprint® exam with x-rays at age 12. The arches of the feet are developed by this age and show weakness or strength. The patient’s posture is developed by age 12, and all information is there, ready to be detected. When corrective programs are designed, no one gets results faster than the 12-year-old child.

If clinical reasons necessitate x-rays for younger children, the x-rays should be considered.