Chapter 1 The malalignment syndrome

A synopsis

Malalignment and traditional thinking

Etiology and recurrence of malalignment

Malalignment of the pelvis and/or spine is present in 80-90% of the adult population and has been held responsible for being the prime cause and/or an aggravating factor in anywhere from 50-60% of those suffering from back pain. While medicine in general continues to be relatively unaware of malalignment, how it presents and what problems it can cause, it is encouraging that over the past decade those involved in sports medicine, rheumatology and some other specialties have become increasingly aware that malalignment:

1. is one of the major causes of back pain and other musculoskeletal complaints, also the fact that it

2. can seemingly mimic or actually cause problems in every organ system (Ch. 4).

Those engaged in physically-demanding work or athletic activities, in particular, are at increased risk of injury to a musculoskeletal system already subjected to abnormal biomechanical forces by the malalignment (Chs 2, 3). These abnormal forces not only predispose to injury but, if they persist, may also impair recovery and return to a work setting or sport; at worse and, in athletes particularly, they may interfere with the person’s ability to realize their full potential (Chs 5, 6). In addition, there continues to be a major problem in that much of the research dealing with matters relating to weightbearing, ground reaction forces and muscle strength fails to take into account the biomechanical effects of malalignment. Reports of side-to-side differences in joint ranges of motion or weight-bearing, for example, lack meaning when we do not know whether the person enrolled in a particular study was in alignment or not. Asymmetries in muscle tension and strength may be simply secondary to the presence of malalignment that, to date, had not been diagnosed and any attempts at stretching and strengthening may prove futile until realignment has been achieved. Similarly, orthotics made while someone is out of alignment will just perpetuate the shift in weight-bearing subsequently, regardless of whether the subject is in or out of alignment, as well as increasing the risk of injury (Ch. 7).

The present chapter will outline:

1. the common presentations of malalignment of the pelvis and spine seen in clinical practice

2. the basic implications of malalignment in terms of altered biomechanics

3. the two presentations – an ‘upslip’ and ‘rotational malalignment‘ – with which the ‘malalignment syndrome’ is associated

4. diagnostic features and appropriate treatment measures

While the author does come from an athletic background, and while athletes who are out of alignment admittedly are more at risk of suffering complications with any further increase in activity because of the increased asymmetrical stresses already imposed on the musculoskeletal system, symptoms attributable to malalignment are similar in ‘athletes’ and ‘non-athletes’ alike. Also, please note that:

1. those with malalignment evident on examination are not necessarily symptomatic (Ch. 2), and

2. any symptoms reported may not necessarily be linked to the malalignment

There are, therefore, 12 possible combinations relating to alignment that one may encounter in clinical practice, namely:

1. the ‘athlete’ or ‘non-athlete’ who presents in alignment and is:

a. asymptomatic

b. symptomatic for some other reason (e.g. low back pain attributable to disc degeneration)

2. the ‘athlete’ or ‘non-athlete’ who presents with malalignment and is:

a. asymptomatic

b. symptomatic as a result of the malalignment

c. symptomatic as a result of causes other than the malalignment

d. symptomatic as a result of a combination of problems, not all of which are attributable to the malalignment (see Ch. 4: ‘Implications for cardiology’)

Reference, therefore, will henceforth be to a symptomatic or asymptomatic person presenting with malalignment, with the understanding that most of the material discussed applies to the ‘athletic’, ‘non-athletic’ and patient populations, unless specifically indicated otherwise; whereas:

1. Chapter 4 addresses particular pain phenomena caused by malalignment, also malalignment-related symptoms and signs that may confuse physicians dealing with patients in certain medical and surgical specialties