History and Presenting Symptoms
The patient is an eight-year-old boy being brought in by his parents, who are concerned about his awkward style of running. He has no symptoms or painful limitations, but his mother and father are both worried that his inefficient gait could lead to future problems. They have noticed that he is a less-effective participant on his soccer and baseball teams because of his running style. Upon further questioning, the father relates a personal history of difficulty running as a child, and an inability to excel in school and team sports. He wants his son to be spared these limitations, and be able to keep up with his friends and teammates.
Exam Findings
Vitals. This active young male weighs 66 lbs, which, at 4’4’’, results in a BMI of 17; this is considered a “healthy weight,” since he is within the 50-85th percentile for his age. His pulse is 92 bpm, and his respirations are 16/minute; all within normal ranges for his age.
Posture and gait. Standing postural evaluation finds generally symmetrical development, with intact spinal curves. There is no evidence of lateral curve or list, and his iliac crests are level. His knees are moderately valgus and both Achilles tendons demonstrate medial bowing. They insert into calcanei that are everted, and there is complete absence of both medial arches (pes planus). A distinct tendency to toe out is seen during gait screening, and he hyperpronates bilaterally. When performing a toe raise, however, the medial arches reappear, indicating that these are not rigid flat feet. Additional testing is performed on a treadmill at several speeds, while barefoot and wearing sports shoes. This confirms that, after heel strike, the feet roll medially and flare outwards, resulting in a very ineffective toe off.
Chiropractic evaluation. Motion palpation identifies a mild limitation in right sacroiliac motion, with moderate tenderness. A compensatory subluxation is identified at L4/5 on the left. No joint fixations are found in the feet and ankles. Manual testing finds moderate weakness of the posterior tibialis muscles bilaterally. Deep tendon reflexes in both lower extremities are somewhat sluggish, but all other neurological and orthopedic tests are negative.
Imaging
No imaging studies were performed.
Clinical Impression
Lack of development of the medial longitudinal arches with hyperpronation. This is associated with loss of medial support at the ankles and knees, and has resulted in sacroiliac joint motion restriction and a compensatory lumbar subluxation.
Treatment Plan
Adjustments. Specific, corrective adjustments for the SI joints and lumbar region were provided, as indicated.
Support. Custom-made, flexible, stabilizing orthotics were ordered to support the arches, decrease calcaneal eversion and knee valgus, and to reduce the asymmetrical biomechanical forces being transmitted to the spine and pelvis.
Rehabilitation. He was shown how to perform daily strengthening exercises for the posterior tibialis muscles, using elastic exercise tubing.
Response to Care
His father made sure that he did his exercises regularly, and he tolerated the spinal and pelvic adjustments with little difficulty. Once he began wearing the stabilizing orthotics, both he and his father noticed an immediate improvement in his running efficiency. He described it as feeling more “springy” when he ran; while his father noticed that he didn’t throw his arms out while running. He required only a few adjustments for his segmental dysfunctions, and was released from care after a total of eight visits over six weeks.
Discussion
This young man had apparently inherited his dad’s flat feet, and he was unable to run efficiently with his friends. While he didn’t have any symptoms, he was definitely at risk for eventual foot, ankle, knee, and/or spinal problems and injuries. The additional support from stabilizing orthotics helped realign his feet for more effective walking and running. Once the underlying biomechanical fault was minimized, he responded rapidly to the muscle strengthening exercises and chiropractic adjustments. Both he and his parents have been informed of the need to monitor his feet as he continues to grow, and to return for a new pair of flexible orthotics as soon as his feet have grown by one-and-a-half shoe sizes.
Dr. John J. Danchik is the seventh inductee to the American Chiropractic Association Sports Hall of Fame. He is the current chairperson of the United States Olympic Committee’s Chiropractic Selection Program and lectures extensively in the United States and abroad on current trends in sports chiropractic and rehabilitation. Dr. Danchik is an associate editor of the Journal of the Neuromusculoskeletal System. He can be reached by e-mail at [email protected].