Chapter 4 The malalignment syndrome

Related pain phenomena and the implications for medicine

One facet of the ‘malalignment syndrome’ seen in association with an ‘upslip’ and ‘rotational malalignment’ is the asymmetrical stress on soft tissues and joints that can eventually result in predictable sites of tenderness to palpation. With time, or as the result of a superimposed acute insult, these tender structures may become the source of overt localized and/or referred pain symptoms. The altered biomechanics also results in some commonly recognized pain patterns, injuries and ‘syndromes’ being seen with increased frequency in association with malalignment; right patello-femoral compartment syndrome is just one example (Figs 3.37, 3.38, 3.60 and see below). Unfortunately, treatment is often limited to the specific site of tenderness or pain, or to the particular pain syndrome, because of a failure to realize that these are but part of a greater entity: the ‘malalignment syndrome’. Correct the malalignment and the associated pain phenomena will often disappear spontaneously or with little additional treatment.

Some common clinical conditions (e.g. idiopathic scoliosis) are unfavourably affected by coexistent malalignment. In addition, symptoms resulting from malalignment can sometimes mimic clinical problems typically implicating one or more of the major organ systems of the body; in particular, the cardiovascular, rheumatological, orthopaedic and neurological. The confusion that can result when trying to establish a diagnosis may lead to needless and sometimes costly and even dangerous investigations that, in the end, still fail to come up with the right diagnosis and recommendations for appropriate treatment.

Pain caused by an increase in soft tissue tension

The malalignment-related increase in tension involving muscle, ligament, capsule or fascia can occur by different mechanisms. To summarize, those capable of increasing the vectored force in these tissues include:

1. an increase in the length-tension ratio with any increase in the distance between the origin and insertion

2. torsion of the vertebral, pelvic or appendicular bones relative to one another

3. ‘facilitation’ and ‘inhibition’, noted to affect specific muscles in an asymmetrical pattern

4. an attempt to splint a painful or unstable area

5. a ‘functional’ leg length difference (LLD).

The first four mechanisms have been discussed in detail in Chapter 3 under ‘Asymmetry of muscle tension’ ( Figs 3.42–3.47). A functional LLD affects tension in both static and dynamic situations. Take the example of a person whose right side of the pelvis is higher than the left when standing. There may be an increase in tension in right hip abductor muscles and the tensor fascia lata/iliotibial band (TFL/ITB) complex because the downward drop of the pelvis on the left side increases the distance between the origin and insertion of these same structures on the right (Fig. 4.1A). When weight-bearing on the short left leg during a walk or run, the left hip abductors have to work harder to counter any drop of the pelvis on the right, perhaps even to raise the pelvis further on the right side in order to allow the long right leg to clear the ground without hindrance to swing-through (Fig. 4.1B).

Fig. 4.1 Effect of functional leg length difference (right leg long in standing) on tension in the hip abductors and tensor fascia lata/iliotibial band complex. (A) Static: in standing, tension increases on the right side as the origin and insertion are separated and muscle contraction counteracts the drop of the pelvis to the left; the person can compensate by shifting the pelvis to the right (see Figs 2.58, 3.93). (B) Dynamic: when walking or running, tension increases on left weight-bearing as the left abductors contract to counter the drop of the right side of the pelvis and to help with clearance of the ‘long’ right leg.

Box 4.1 denotes the structures that most consistently show an increase in tension and/or tenderness as a result of these various mechanisms relating to an ‘upslip’ and ‘rotational malalignment’.

Box 4.1 Structures typically showing an increase in tension and/or tenderness with ‘malalignment syndrome’

Muscles (Fig. 3.43)

1. right infraspinatus and/or teres minor

2. thoracic paravertebral muscles, especially those adjacent to sites of vertebral rotational displacement and curve reversal (e.g. the thoracolumbar junction)

3. piriformis, particularly the right one with ‘right anterior’ rotation present

4. iliopsoas, particularly the left one with ‘left posterior’ rotation present

5. the left hip abductors and TFL/ITB complex

6. the right hamstrings

7. the left gastrocnemius/soleus complex

Ligaments (Figs 2.4, 2.5, 2.6, 3.61–3.68)

1. the iliolumbar and sacrotuberous ligaments, and those crossing the posterior sacroiliac joint (often evident bilaterally)

2. the long dorsal sacroiliac ligaments (Fig 2.19B)

3. the lumbosacral intervertebral ligaments and facet joint ligaments

With time, any soft tissue subjected to an increase in tension because of the malalignment is likely to become tender to palpation (e.g. sacrotuberous ligament; DonTigny 1985; Midttun & Bojsen-Moller 1986; Brendstrap & Midttun 1998). That structure may eventually develop an aching discomfort or become outright painful. Mechanisms that can precipitate what is often characterized as a deep, achy bone pain include:

1. a chronic increase in tension, particularly as it affects:

a. the muscles, which are supposed to relax after a contraction, and

b. the ligaments, whose nerve supply cannot elongate as easily nor as much as the elastic components (Hackett 1958; see Ch. 3: ‘Asymmetry of ligament tension’ and Ch. 8)

2. any additional increase in tension, as may occur with:

a. an acute stress incurred with a sudden movement or load imposed

b. a persistent or repetitive stress caused by a call for increased effort during work or an athletic activity (e.g. running up- and downhill or longer distances without having prepared with progressively demanding workouts)

3. the tense structure being ‘strung’ over a bony or other elevation, possibly even ‘snapping’ across that prominence; e.g. the TFL over the greater trochanter and the ITB over the lateral femoral condyle (Fig. 3.41); iliacus, iliopsoas/pectineus and rectus femoris over the anterior femoral head and acetabular rim (Figs 2.46B,C, 2.59, 3.42, 4.2).

The long-term resolution of the pain from these structures will depend primarily on regaining normal muscle tone which, in turn, depends largely on achieving and maintaining alignment.

Specificic sites of pain related to malalignment

The sometimes very specific and often predictable patterns of pain and tenderness to palpation seen in association with an SI joint ‘upslip’ and ‘rotational malalignment’ are primarily the result of the four factors outlined in Box 4.2.

Box 4.2 Causes of pain on palpation seen with an ‘upslip’ and ‘rotational malalignment’

1. a chronic increase in tension in a specific soft tissue structure (e.g. joint capsule, muscle, tendon or ligament)

2. unevenly distributed or excessive pressure within and around the joints, particularly those which are weight-bearing and/or subjected to a torsional stress by malalignment (e.g. the hip and knee joints; Figs 3.37, 3.60, 3.81, 3.82, 4.3)

3. an irritation or injury of nerve roots and peripheral nerves as a result of a chronic increase in traction, compression or a combination of these (Figs 3.12, 3.13, 3.37, 3.38 and ‘Implications for neurology and neurosurgery’ below).

4. a structure that is the source of referred pain to a distant site (Figs 3.12, 3.45, 3.46, 3.62, 3.63, 3.67, 4.8–4.10)

Therefore, even though the person may be asymptomatic, examination will usually reveal tenderness localizing to the specific structures that are typically put under stress by the malalignment. He or she must be considered at increased risk of developing an overtly painful condition with any superimposed physical or mental stresses that inadvertently place additional demands on any of these sites.

Emotional stress

An acute emotional stress may trigger a ‘fight or flight’ reaction, with temporary release of epinephrine and an increase in muscle tone. A chronic emotional response, such as one provoked by a stressful life style and/or persistent pain, is associated with an increase in circulating stress-related neuropeptides and persistent increase in epinephrine and cortisol levels (Holstege et al. 1996; Sapolsky & Spencer 1997). One effect is to persistently keep the level of the resting muscle tone above normal.

Such an increase in tone in the pelvic muscles has been shown to increase compression of the SI joints (van Wingerden et al. 2001; Richardson et al. 2002) and would similarly affect hip joints if malalignment were present. Joint compression, in turn, may:

1. make the joints feel ‘stiff’

2. precipitate or worsen joint pain

3. irritate joint nerve supply to the point of hypersensitivity; presumably, there is sensitization of both the peripheral and central nervous system fibres (Butler 2000; Butler & Moseley 2003, 2007; Moseley & Hodges 2005), also impaired output of sensory signals (e.g. proprioceptive) and misinterpretation of signals which, in turn, affects motor output

Emotional complications with regards to motor output may include:

1. muscle(s) triggered too easily and/or out of sequence because of the hypersensitivity to acetylcholine (see Ch. 3 and ‘IMS’, Ch. 8); hypersensitivity of nociceptive fibres results in a more readily evoked response with any further irritation of the joint, triggering reflex muscle contraction and worsening of the joint compression – in effect, initiating and perpetuating a vicious cycle

2. inadequate contraction as sensory signals may be scattered, not arrive in unison or be weak

3. increased tendency for ‘flare-ups’, with reflex spasm triggered more readily in reaction to a pain signal

4. problems on attempting a progressive rehabilitation programme; increasing the activity level now aggravates pain and triggers ‘flare-ups’ more easily

5. initially, intermittent avoidance of activity to avert these ‘flare-ups’ and pain; eventually, persistent avoidance ‘due to their fear of reinjury or an underlying belief that they are unable to perform because of their condition [fear avoidance]’ (Vlaeyen & Linton 2000; Vlaeyen & Vancleef 2007).

Physical stress

Acute stress

Even a minor lifting or twisting action that exerts a further acute traction or compression force on an asymptomatic but tender structure may cause it to now become overtly painful. The person is often diagnosed as having sustained a ‘sprain’ or ‘strain’.

Chronic or repetitive stress

The site may also become symptomatic when even a minor increase in stress is superimposed on a chronic or repetitive basis. A walker or runner with an ‘upslip’ or one of the ‘more common’ rotational patterns, for example, may be asymptomatic but on examination show increased tension and tenderness in the left hip abductors and TFL/ITB complex, attributable to the combined effect of the malalignment-related:

1. increase in tension in the left complex as a result of ‘facilitation’

2. shift to left lateral weight-bearing, separating origin and insertion

3. functional weakness and tendency to fatigue more easily on this side

If that person now increases the number of miles walked or run on a surface with a slope banked downward to the left (e.g. running against the traffic in Canada or the USA, or with the traffic in the UK; walking clockwise on a hillside), there will be an accentuation of the left lateral shift, and the tendency toward supination and genu varum on this side (Figs 3.31, 3.36, 4.4A). The combination of increased mileage and left traction forces may, with time, make the already tender left hip abductors and TFL/ITB complex overtly symptomatic. Increasing the amount of up- and downhill running also puts more demand on this complex bilaterally; the more susceptible left complex is, however, again more likely to become symptomatic. Similarly, the left one is at increased risk with cutting actions (e.g. playing rugby, soccer or American football).

In essence, one is dealing with a type of ‘overuse’ injury. The person may get some relief on a slope banked upward to the left (Fig. 4.4B). Understandably, lateral traction forces are decreased with the left foot now on the upside and a straightening of the legs, possibly also some levelling of the pelvis which very likely is high on the right side because of the malalignment (Figs 2.72, 2.73, 2.76B). However, this practice should not be encouraged for safety reasons if it means running on a road going with the traffic.

Fig. 4.4 Effect of a slope on the increased tension in the left hip abductors and tensor fascia lata/iliotibial band complex. Malalignment has already caused an increase in tension through ‘facilitation’ and the tendency to left supination. (A) Downslope to left increases the tension by accentuating supination. (B) Upslope to left decreases the tension by counteracting supination.

Standard treatment measures that would be appropriate for a ‘sprain’ or ‘strain’ or a suspected ‘overuse injury’ are usually instituted. The injury in both cases may respond to such treatment, combined with rest, and the pain subside with healing. Unfortunately, if the malalignment is not corrected at the same time, the person remains at increased risk of having the same injury recur upon resuming the activity.

These injuries may actually fail to respond to standard treatment measures if malalignment persists or keeps on recurring.

It appears that the persistence of chronic tension or compression forces attributable to malalignment can interfere with the ability of the tissue to heal following a superimposed acute or chronic injury.

In other words, recovery is slowed or may fail to occur until the stress caused by these forces is removed on realignment. Box 4.3 lists some ways in which the persistence of this stress could affect healing unfavourably.

Box 4.3 Negative effect of malalignment stresses on healing

1. It interferes with the flow of blood needed for:

a. the delivery of scavenger and repair cells, oxygen and nutrients

b. the removal of damaged tissue and clearance of waste

2. Stretching a ligament results in excessive tension on nerve fibres long before the connective tissue components are affected because the nerve fibres have relatively less elasticity (Hackett 1956, 1958). The stretching can result in:

a. irritation of the nociceptive axons, release of neuropeptides and initiation of a neurogenic inflammatory response (Willard 1995, 2007; see also Chs 7, 8)

b. eventual frank hypersensitivity and even neuralgic pain, and

c. aggravation of connective tissue degenerative processes.

3. The stresses relating to ongoing malalignment can then perpetuate these insults:

a. to the nerves, with even relatively minor ongoing traction or compression forces risking development of a chronic painful condition

b. to the bones and joints (e.g. disturbance of the nerve supply and constant compression of joint surfaces accelerates degeneration by interfering with cartilage nutrition and repair).

In summary, the recognition of the specific sites of tenderness and of the pain patterns typically associated with malalignment should:

1. raise suspicions that malalignment is indeed present

2. prompt a search for other features of the ‘malalignment syndrome’

3. help to ensure appropriate treatment, the key component of this being realignment to remove any abnormal tension and/or compression forces and to promote healing.

Common pain syndromes caused or aggravated by malalignment

A syndrome is a constellation of signs and symptoms attributable to a unifying cause. Although we may identify the syndrome and even recognize the cause, we must, however, always ask ourselves whether the syndrome or that cause may not be part of an even larger entity. A typical example is that of the person who presents with right knee pain of unknown origin. We may quickly arrive at a diagnosis of ‘patellofemoral compartment syndrome’ (PFCS) on the basis of the outward tracking of the patella on knee extension, a positive apprehension test and tenderness of the patellar tendon origin and the medial and lateral patellar facets. We have established patellofemoral compartment syndrome as the ‘cause’ of the pain but, in reality, it may amount to no more than having established the ‘location’ of the pain. We have not answered the questions of ‘what caused the PFCS to develop in the first place?’, ‘why at this time?’ and ‘why on the right side and not the left, or bilaterally?’

If we look further, we might note that this individual pronates markedly with the right foot, causing the right knee to collapse into valgus on weight-bearing; whereas the left foot pronates less so, remains in neutral or actually supinates on toe-walking or hopping. The right lower extremity is in more obvious external rotation, the left less so or even in neutral or turned inward past midline (Fig. 3.19).

By looking beyond the right knee and at the kinetic chain, we have established the reason for the pain: excessive external rotation coupled with right pronation and increased valgus stress on the right knee, with an increase of the Q-angle and lateral patellar tracking (Figs 3.37, 3.81, 4.5). The combined effect is an increase in tension in the right patellofemoral complex. Increasing the pressure with which the patella is forced onto the underlying femoral groove and condyles, and decreasing the accuracy with which the patellofemoral surfaces match up as the patella tends to track more laterally can eventually result in increased wear and tear, inflammation and pain.

Fig. 4.5 Stresses predisposing to right patellofemoral compartment syndrome. (A) With malalignment: the tendency toward right pronation and knee valgus has here increased the Q-angle to 10 degrees. The right patella now tracks more laterally on knee extension, increasing the stress on the compartment. (B) On realignment: the Q-angle is reduced to almost 0 degrees; improved patellar tracking (relatively straight upward and downward) decreases the stress on the compartment.

Looking at the larger picture, namely the alignment of the pelvis and spine, we might find that he or she actually presents with an ‘upslip’, one of the ‘more common’ patterns of ‘rotational malalignment’, or both, and the resulting tendency to right external rotation, pronation and valgus stress. If the right side of the pelvis were higher than the left on standing – which it is in about 80% or more of those with a ‘rotational’ presentation and most of those with an ‘upslip’ – the increase in pressure within the right patellofemoral compartment could be compounded by:

1. keeping the right knee slightly flexed in an attempt to lower the pelvis on that side (Fig. 2.90)

2. secondary wasting of right vastus medialis (Figs 3.57, 3.58) that may relate to:

a. unfavourable reorientation of the muscle fibres (Figs 3.59. 3.60)

b. decrease in muscle tension with right quadiceps ‘inhibition’ and, if there is also right innominate ‘anterior’ rotation, approximation of the origin and insertion (Fig. 3.42)

c. inability to muster as strong a contraction as usual, on account of these changes

Malalignment: implications for medicine

The patellofemoral syndrome discussed above did not represent just an isolated phenomenon but was an integral part of a larger entity, the ‘malalignment syndrome’, and so it can be with a number of other well-known medical conditions. In that regard, malalignment is of significance because it can:

1. aggravate an existing condition

2. mimic a medical condition

3. precipitate such a condition

The following are some examples from clinical practice that help illustrate these points.

1. Some clinical presentations may be unfavourably affected by coexistent malalignment. For example, someone with idiopathic scoliosis may become symptomatic only whenever the malalignment recurs (Fig. 4.6A). These symptoms presumably result from their attempts to cope with the malalignment-related changes. In particular, there is now the pelvic obliquity and compensatory scoliosis superimposed on their underlying condition. The altered biomechanics creates additional stresses on:

a. the thoracolumbar and lumbosacral junctions, which probably accounts for their frequent complaint of mid- and low back pain whenever malalignment has recurred

b. the facet joints and discs, as a result of any increase of L1–L4 rotation into the exacerbated lumbar convexity (Figs 2.96, 4.6A, 4.33)

2. Some of the structures that become tender and/or painful as a result of being put under increased stress, and certain of their common referral sites, are in close proximity to areas classically identified with problems in major organ systems. Both the deep iliolumbar and the anterior SI joint ligaments, for example, are capable of referring to McBurney’s point and mimicking appendicitis (Fig. 3.46).

3. Malalignment-related symptoms may mimic some common pain phenomena. Irritation of myofascial tissue at the C4-C5 level, for example, can present like a ‘carpal tunnel syndrome’ yet nerve conduction tests will prove negative and symptoms disappear with vertebral realignment (Fig. 3.12Bii). In others, increased tension with narrowing of the thoracic outlet can affect the brachial plexus to precipitate an actual carpal tunnel syndrome (Fig. 3.13).

Fig. 4.6 A patient with advanced idiopathic scoliosis (a lumbar levoscoliosis of 37 degrees when in alignment). (A) With coexistent pelvic malalignment: the L1-L4 vertebrae have rotated into the marked left lumbar convexity to the point at which the spinous processes of T12, L1, and L2 successively overlie the right pars interarticularis of the vertebra below; that of L4 is starting to come back to the midline. The left lumbar facet joints have been opened, the right ones compressed. The pelvis is oblique, with the right iliac crest and sacral base lower than that on the left as a result of ‘left anterior, right posterior’ rotation. (B) With realignment: the L1-L4 rotation is less pronounced, and the T12-L2 spinous processes now lie distinctly separate from the right pars and comparatively closer to the midline. The opening of the left facet joints is not as marked, and the pelvis and sacral base is level.

A failure to recognize these facets of the ‘malalignment syndrome’ runs the risk of causing confusion, which may result in investigations that are at best harmless, albeit perhaps not required, and at worst costly or dangerous and may lead to misdiagnosis and inadequate or even inappropriate treatment. The following discussion will concentrate on:

1. some of the more common pain phenomena and syndromes that may be attributable to malalignment or can be affected by the presence of malalignment, and

2. how these conditions may overlap with problems typically dealt with by some of the medical specialties.

Implications for cardiology and cardiac rehabilitation

Chest pain of musculoskeletal origin is a complaint that can be related to malalignment, one that a cardiologist may have to differentiate from angina and other symptoms typical of coronary artery disease. In cardiac rehabilitation, musculoskeletal symptoms caused by malalignment are:

1. responsible for some of the more frequently encountered complaints that staff have to deal with in exercise classes on a day-to-day basis

2. one of the more common reasons for the temporary or permanent interruption of a patient’s exercise programme.

The following case studies of patients enrolled in a cardiac rehabilitation program show that malalignment:

1. may not be a problem for the patient until he or she begins to exercise

2. may not be evident on initial examination but may develop with progressive increase in exercise, particularly if this now involves an asymmetric and/or torsional component

3. can result in needless investigation and ongoing patient discomfort as a result of failure to suspect malalignment in the first place.

Case History 4.1 Mrs. O.J.

1. History: two myocardial infarcts in 1994; five-vessel coronary artery bypass graft in 1995; since then, occasional angina, brought on by effort and relieved by nitroglycerine spray

2. On referral: in alignment; no musculoskeletal problems noted

3. Course: 4weeks after starting the programme, complained of interscapular pain when using the rower

4. Findings: T8 vertebral body right rotational displacement (spinous process to the left); acute pain on trunk extension, flexion and especially rotation while sitting, also with direct posteroanterior and medial pressure on the T8 spinous process

5. Treatment: realignment of T8 resolved the problem

Case History 4.2 Mr. D.S.

1. History: myocardial infarct in 1997 at age 49; going on to uneventful five-vessel coronary artery bypass graft

2. On referral: no musculoskeletal complaints; malalignment of the pelvis and compensatory scoliosis but no indication of tenderness in muscles or ligaments typically put under stress

3. Course:

a. managed to progressively increase the exercise level without a problem even though the malalignment had never been corrected

b. shortly after graduating to a home program (including regular light weights and exercises with more of a torsional component), he presented with interscapular pain; in addition to the previously noted pelvic malalignment, examination now also revealed T4 and T5 rotational displacement and bilateral tender, tense adjacent paravertebral muscles

c. pelvic and vertebral realignment resolved the problem and allowed him to resume an exercise program but avoiding any torsional stresses

Case History 4.3 Mrs. M.M.

1. History: myocardial infarct 1995, one-vessel coronary artery bypass graft in 1996; rehabilitation programme started in August 1996

2. Discharge clinic (1997): note was made that the programme had been interrupted from Dec. 18, 1996 to Jan. 29, 1997 because of ‘low back pain’, which had persisted and was now localized to the right ‘buttock’, pointing to the lumbosacral region or nearby underlying right sacroiliac joint

3. Findings: pelvic malalignment with ‘right anterior’ rotation, also T7 rotational displacement; tenderness localizing to the left 7th costochondral junction and the ligaments crossing the posterior aspect of the right sacroiliac joint; facet stress tests negative

4. Course: realignment of the pelvis and spine resolved the low back pain and allowed return to exercising

Case History 4.4 Mrs. K.M.

1. History: pulmonary hypertension requiring the repair of an atrioseptal defect; for 3months postoperatively, ongoing tightness of the sternotomy scar area and discomfort in the left anterior chest region, leading to $30,000 of repeat investigations (including cardiac catheterization), which were all negative

2. Findings: acutely tender bilateral 4th and 5th costochondral junctions (those on the left corresponding to her site of pain); left rotation of the T6 vertebra with displacement of the 4th, 5th and 6th ribs bilaterally (similar to the T5 vertebra rotational displacement in Fig. 2.94); malalignment of the pelvis and spine

3. Course: ‘cardiac’ symptoms resolved completely on realignment combined with massage of the anterior chest and thoracic paravertebral muscles

(Redrawn courtesy of Travell & Simons 1983.)

As part of the ‘T3’ or ‘T4 syndrome’ (see Ch. 5):

1. rotational displacement of any of the vertebrae in the T3 to T7 region but most often involving T3 or T4

2. can result in referred pain that typically involves:

a. the hand and fingers, and less often part or all of the arm, either uni- or bilaterally (in which case it is symmetrical) and/or

b. parts of the head and neck (Fig. 4.9).

Fig. 4.9 ‘T3’ or ‘T4’ syndrome: common areas of upper limb symptoms. The upper diagram shows classical areas of head pain.

(Courtesy of McGuckin 1986.)

Angina coexistent with symptomatic malalignment

As indicated above, the person with malalignment may present with symptoms that can mimic angina. Like the general population, 80% of those with a cardiac condition can be expected to be out of alignment (see Ch. 2). Hence, there may be those who:

1. present with an apparent cardiac problem but whose symptoms are strictly on account of a malalignment problem

2. have symptoms caused strictly by their cardiac condition, while the malalignment remains asymptomatic in terms of not causing any ‘cardiac-like’ symptoms

3. have overlapping symptoms, caused both by the cardiovascular system and the malalignment

Typical of the latter presentation is the patient with known ‘unstable angina’ whose ‘cardiac’ symptoms may come on either at rest or with effort and may or may not respond to nitroglycerine spray, or do so incompletely or inconsistently. One must always rule out the possibility that this is not someone whose symptoms at any one time may vary because:

1. they actually do suffer from ‘unstable angina’, and the recurrence of the angina at any time triggers a further increase in muscle tension that can more easily precipitate symptoms from muscles that are already tense and tender because of the malalignment

2. the angina may itself be triggered by the increase in the cardiac workload and cardiovascular changes that occur as a result of pain caused by the malalignment (e.g. secondary increase in blood pressure and heart rate)

3. the symptoms are strictly on the basis of the malalignment, and hence can also come on at rest and will fail to respond to nitroglycerine.

Always remember to consider malalignment in the differential diagnosis when a patient presents with angina, particularly when there are features that do not exactly fit the ‘cardiac picture’ and there is possibly a musculoskeletal component.

When dealing with any patient referred for cardiac rehabilitation, examination of their musculoskeletal system should be part of the initial assessment, including a look at pelvic and spine alignment. Musculoskeletal complaints are common and a major cause for patients interrupting or discontinuing their exercise programme to get over some complication, particularly back, hip and knee pain. Malalignment makes it more likely for these complications to develop or become symptomatic. Those who are already out of alignment on entering an exercise programme are also at increased risk of becoming symptomatic or aggravating malalignment-related musculoskeletal symptoms. Becoming aware of malalignment, diagnosing it at the initial outpatient visit and treating it on a preventative basis (or at least keeping an eye on it as the patient starts in the programme) would go a long way toward making their participation in a cardiac rehabilitation programme less likely to be interrupted and more likely to be progressive and enjoyable.

Dentistry

As indicated in Ch. 3, malalignment affects the joints from the toes up to the head and neck. Temporomandibular joint involvement ranges from initial minimal displacement, which can progress to subluxation and frank dislocation as the capsule and supporting ligaments are gradually stretched beyond the point of being able to provide adequate support and the muscles can no longer compensate. There results a very obvious palpable, or even visible (and sometimes, audible) displacement of the mandible on opening and closing of the jaw. Constant protective splinting, primarily of the temporal and masseter muscles, eventually results in tenderness to outright pain from that joint region which may suggest involvement of the gums and teeth.

Rotational displacement of the upper cervical vertebra, with irritation or compression of C1, C2 and C3, can cause localized pain in the base and sides of the neck and referred pain and paraesthesias in the forehead, temporal and mandibular regions (Fig. 3.12A,Bi). This pain may be hard to differentiate from the gnawing, ‘deep’ pain sometimes associated with dental problems (Blum 2004a,b).

Unilateral excessive bite, or worse still, grinding of the teeth, has been identified as either: