History and Presenting Symptoms
The patient is a 44-year-old female, who is the regional sales representative for several lines of gift items and pottery. She reports frequent pain in her feet, worse on the right side. The aching pain is located around the base of her first toes, both of which have a noticeable bulge. This pain is now interfering with her visits to customers, as her walking is becoming more difficult. She rates the pain in her feet as usually around 30mm to occasionally 45mm on a Visual Analog Scale.
Exam Findings
Vitals. This active businesswoman weighs 152 lbs., which, at 5’7’’, results in a BMI of 23—she is not overweight. She has never used tobacco products or alcohol, and her blood pressure is 124/84 mmHg and her pulse rate is 76 bpm. These findings are within the normal range.
Posture and gait. Standing postural evaluation finds generally good alignment, with intact spinal curves, and no lateral listing of her pelvis or spine. She demonstrates bilateral calcaneal eversion, worse on the right, with a lower right arch. During gait, both feet pronate substantially, and both feet flare outwards (toe-out).
Chiropractic evaluation. Motion palpation identifies limitations in segmental motion at L5/S1 and L2/L3, with some local tenderness. These segmental dysfunctions demonstrate loss of end range mobility in all directions. Additional subluxations are noted at T6/T7, and C5/6. Lumbar ranges of motion are full and pain-free, and neurological testing is negative.
Primary complaint. Examination of her feet reveals bilateral hallux valgus, with redness more apparent at the base of the right first toe. Mobility of the first metatarsophalangeal joint is limited on both sides, and the motion testing elicits pain in the right joint. Flexion and extension are particularly limited.
Imaging. No X-rays or other forms of musculoskeletal imaging were requested.
Clinical Impression
Bilateral hallux valgus (bunions) with bilateral hallux limitus (loss of flexion/extension mobility). This is associated with hyperpronation and calcaneal eversion. It is also accompanied by lumbar spinal joint motion restriction and compensatory thoracic and cervical subluxations.
Treatment Plan
Adjustments. Spinal adjustments were provided as indicated for the lumbar, thoracic, and cervical regions.
Mobilization and gentle traction manipulation of both first metatarsophalangeal joints were well-tolerated and eventually increased her flexion/extension mobility.
Support. Custom-made, stabilizing orthotics were provided to limit calcaneal eversion, support the arches, and decrease the chronic pressure stress on the first metatarsophalangeal joints. She had to be counseled in shoe selection and proper fit, as she had been wearing tight and short dress shoes for many years. In certain brands and styles of shoes, she found that she had to increase an entire shoe size in order to get the correct fit.
Rehabilitation. Initially, she performed self-mobilization exercises for her first toes, along with self-massage of her feet using a golf ball. After two weeks, she started a strengthening program using elastic exercise tubing. Her primary exercises were internal rotation of the leg from the hip (to decrease the foot flare) and internal rotation of the foot (to decrease the hallux valgus).
Response to Care
She responded well to the spinal and foot adjustments, and reported an initial decrease in symptoms. Once she began wearing her stabilizing orthotics regularly, she noted a further decrease in her symptoms, along with improved walking capacity. She was released to a self-directed maintenance program after a total of ten treatment sessions over two months.
Discussion
Hallux valgus and hallux limitus are commonly found in association with excessive pronation and calcaneal eversion. When combined with improper shoe selection, there is an inevitable development of gait disability and spinal compensations. Studies have found that many women wear shoes that are not suitable for their feet, and that most women have not changed shoe sizes for many years, while their feet have often grown larger and flatter. The best treatment for this complex problem is a conservative approach, with a combination of chiropractic adjustments, custom-made orthotic support, corrective exercises, and education.
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].