Scoliosis... the sideways spinal curve that could be causing your uneven shoulders and hips!
Updated: Feb 14, 2021
Scoliosis is defined as a sideways curve (sometimes alongside a twist) of the spine by over 10 degrees. It is estimated that 3-4% of the population have a scoliosis.
In fact, Usain Bolt has a scoliosis... as do I!
Scoliotic curves are different from the normal front to back spinal curves that I describe in my other Blog post: 'Spinal Curves & Pelvic Tilts... Sagittal Plane Imbalances'.
In most cases (80%), the cause of scoliosis is unknown a.k.a 'idiopathic'. There may be a genetic link in some cases or it can be due to rarer neuromuscular conditions (such as muscular dystrophy or cerebral palsy) or connective tissue disorders (such as Ehlers-Danlos Syndrome or Marfan's syndrome).
Types of scoliosis
Scoliosis most often starts in children age 10-15 years old but it can begin at different ages:
Before birth (Congenital)- often forms in the first 6 weeks of pregnancy. May be picked up in antenatal scans but sometimes only noticed as a toddler or adolescent. Causes are unknown. This type of scoliosis may be associated with kidney, bladder, cardiovascular, lung or oesophagus issues.
In young children (Infantile/Juvenile) / 'early onset'- 0-3 years old (1% of cases) / 3-10 years old (10-15%).
In older children and teenagers (Adolescent)- 11-18 years old (around 90% of cases).
As adults (Degenerative/'De Novo')- starts after the age of 40 years old, secondary to disc and facet joint degeneration or conditions such as osteoporosis.
Non-structural scoliosis- also known as functional scoliosis. Occurs due to a compensations such as difference in leg lengths or disc herniations/nerve irritation.
Signs of scoliosis
On observation, you may notice...
Uneven shoulder height
Uneven hip height/one hip sticking out to the side
A lean to one side
Ribs protruding on one side more than the other
Shoulder blades sticking out, sometimes with a more flattened mid back front to back curve (decreased kyphosis)
Clothes not fitting well
Assessing Scoliosis: Special Tests, X-rays and the Cobb Angle
Monitoring scoliosis in the first 5 years of life and in adolescence is important in particular, as this is when the spine develops the most. The earlier the intervention, the more chance there is to prevent progression.
Checks done by Chiropractors and other musculoskeletal specialists may include:
Adam's forward bend test- to look for a rib hump and other asymmetries. This may be checked in sitting as well as standing (as in standing a structural leg length difference may affect how the spine looks). This test is better for diagnosing thoracic (mid back) scoliotic curves.
Devices such as Scoliometers- measure the angle of trunk rotation (over 7 degrees shows a high correlation with a curve 20 degrees or more). However, these may not be very accurate alone in tracking progression over time.
X-rays may be done if a scoliosis is suspected (or MRI/CT scans). From these, a measurement called the Cobb Angle is made. This measurement helps guide management...
Cobb Angle Measurements
10 degrees: The minimum angle to define a scoliosis.
10-25 degrees: Mild scoliosis. Regular check ups (every 4-6 months) may be recommended to see if the curve is progressing until skeletal maturity.
25-40 degrees: Moderate scoliosis. A back brace may be needed if the child hasn't reached skeletal maturity (or if the curve is progressing >5 degrees between any 6 month check up).
40 degrees+: Surgery may be required to correct the curve if bracing hasn't already helped.
Will my curve progress?
Many people with scoliosis will not have progression of their curve past skeletal maturity but others may see their curves continue to progress over the years. As a general rule:
Curves measuring 30 degrees or less at skeletal maturity tend to stop progressing (or progress very slowly) and require no treatment.
Curves measuring 50 degrees or more at skeletal maturity tend to worsen about 1 degree per year throughout adulthood. (In these cases surgery may be recommended to avoid further spinal deformity).
Skeletal maturity can be measured on X-ray by the Risser Sign (along the iliac crest, stages 0-5), among other methods. Skeletal maturity is normally reached by 17-19 years of age.
The main risk factors for progression include:
Large curve/Cobb angle. In general, the larger the curve’s Cobb angle, the more likely it will progress.
Significant skeletal growth remaining. The more skeletal growth/maturity remaining, the greater the risk for curve progression.
Female sex. Girls are around 7 times more likely to have their spinal curves progress to moderate or severe scoliosis and require treatment. Very athletic teenage girls with delayed menses are at most risk of progression.
Curve in the Thoracic spine. A scoliosis curve located in the upper/mid back is more likely to progress than a curve located in the lower back (lumbar spine). A thoracic curve is one of the most common patterns in idiopathic scoliosis with 90% occurring on the right side. A double major curve usually involves a right thoracic and a left lumbar curve. Both of these two curves are the most common curve patterns to progress. Thoracolumbar and lumbar curves often are to the left.
Does scoliosis cause pain and other symptoms?
There is some controversy regarding scoliosis specifically being a cause of back pain. Not everyone who has scoliosis will have back pain and the degree of the Cobb angle does not always correlate with the severity of people's pain.
However, current trends in literature seem to point to more back pain being reported in scoliosis patients compared to the general population. This may be because a scoliotic curve can cause trunk imbalances that increase the likelihood of muscle spasms and other issues, which can in turn lead to pain. One study found that patients diagnosed with adolescent idiopathic scoliosis were 42% more likely to report back pain than those without scoliosis.
In more advanced curves, due to changes in the shape and size of the thorax, idiopathic scoliosis may affect pulmonary (lung) and cardiovascular (heart) function, as well as causing psychological distress.
Hands on therapy such as Chiropractic, Osteopathy and Physiotherapy, as well as home exercises/Pilates/Yoga may help with pain and improve posture and flexibility. However, these options have not been shown in research to be able to physically reduce the size of a curve or slow down progression of curves.
Only very specific, very intense scoliosis exercise programs, such as the Schroth Method, have been shown to be effective in preventing the progression of scoliosis.
Spinal braces, sometimes alongside these specific exercise programs, are a more commonly used option in larger curves in children/adolescents with higher risk of progression.
If braces still fail to prevent progression, surgery (using rods/spinal fusion) would be the final option.
(See above for the Cobb angles that correspond to usual treatment options).
Most people with idiopathic scoliosis have mild curves that never progress enough to require bracing or surgery.
Personally, for the patients I see with mild/moderate scoliosis I often use spinal mobilisation/manipulation, soft tissue techniques such as massage/dry needling/taping and home exercise programs to try and decrease joint and muscle tightness and improve core activation and strength. This often involves breathing exercises, as well as both frontal (side to side), transverse (rotational) and sagittal (front to back) mobilisation and strengthening techniques.
* For more information on the Core and these planes of movement, see my Blog posts 'The Core...' and 'Spinal Curves & Pelvic tilts (Sagittal plane imbalances)...'.
As for myself, I follow these same principles to manage any discomfort I get... chiropractic treatment, massage, home flexibility routines involving Yoga and Pilates/strength training to keep me going!
So, in conclusion... If you've noticed some of the above scoliosis signs in yourself or your child it may be worth having a check up with a musculoskeletal professional to see if a scoliosis is present and, if so, if any further treatment or imaging needs to be considered, especially if any pain is present as well.
Further Information & Links:
Homepage - Scoliosis Association (sauk.org.uk)
Find a Specialist (britscoliosissoc.org.uk)
Scoliosis: Symptoms, Treatment and Surgery (spine-health.com)
Cobb's angle - Physiopedia (physio-pedia.com)
Adam's forward bend test - Physiopedia (physio-pedia.com)
Idiopathic Scoliosis Treatment & Management: Approach Considerations, Treatment Indications, Medical Therapy (medscape.com)
Adolescent Idiopathic Scoliosis: Diagnosis and Management - American Family Physician (aafp.org)
Risser Signs, Skeletal Age, and Scoliosis: How are they related? (scoliosiscarecenters.com)
Will My Curve Worsen? Four Key Factors For Scoliosis Curve Progression | Virginia Spine Institute (spinemd.com)
The Impact of Small Spinal Curves in Adolescents Who Have Not Presented to Secondary Care (nih.gov)
14 Myths about Scoliosis, Revisited! - Scoliosis Clinic UK - Treating Scoliosis without surgery
Schroth Method | Schroth Exercise | Schroth Therapists (scoliosis3dc.com)
Schroth Method Exercises Explained - Bing video
Scoliosis Treatment - Hudson Valley Scoliosis