History and subjective complaints
The patient has suffered from a postural imbalance most of her life, causing stress and strain to the pelvic and spinal areas. The patient states that she has received chiropractic care “on and off” most of her life.
As the patient has grown older, she has experienced more frequent and intense pain in her lower back, right leg, and feet. She was 52, when she learned that some of the problems she was experiencing when standing or walking were the result of flat feet (pes planus), lack of arch support, heel spurs, and a neuroma. There are other contributing factors to her overall health and well-being: fibromyalgia, diverticulitis, and excess weight.
Upon her first office visit, the patient was experiencing problems walking at a slow, strolling pace. She reported having constant lower back pain and a great deal of right leg and right thigh pain. She particularly noticed the pain in her right thigh when she climbed stairs, bearing weight on that leg. She also had severe pain in her feet that included numbness in her toes, at times.
Objective findings
The patient is a medium-framed, slightly overweight Caucasian female, 53 years of age. She is a full-time customer service representative, a position which requires her to be seated most of her workday. In addition to working full-time, she is also a certified massage therapist and is on her feet for long periods during evenings and on weekends, to treat her clients.
Vital index
Height: 5 ft. 2 in.
Weight: 146 pounds
Blood pressure: Systolic, 132; Diastolic, 86
Objective and neurological findings
- Gaenslen’s test positive with right leg.
- Nachlas’ test positive, with radiation down the right thigh.
- Morton’s squeeze test positive for chronic onset of interdigital neuroma in both feet.
- Positive pain indicators in 13 of the 18 tender points for fibromyalgia.
Clinical impression and working diagnosis
The patient’s lower back pain was rooted in the lower lumbar area, where she has a curve. She also experienced pain from the ilium, torquing forward. Additionally, her right leg is shorter than the left, and the tightening of the muscles that is part of fibromyalgia also intensified her pain. The patient had a neuroma, or entrapment of the nerve, in her left metatarsal.
Postural imbalances in the pedal foundation were also contributing to her musculoskeletal conditions, as well as obstructing the efficacy of chiropractic adjustments received prior to current care.
Treatment
The patient received a program of specific lumbosacral and lower extremity adjustments. She also regularly received routine checks of her leg length, routine manipulation of vertebrae, and did hip rotator exercises—hip flexors and extenders. Muscle trigger point therapy was also initiated to help manage her fibromyalgia symptoms.
The patient was also fitted for custom-made stabilizing orthotics, to address her spinal/pelvic instability and foot conditions. She had begun wearing well-known name brand sandals at the time she learned of her flat feet, lack of arch support, heel spurs, and neuroma. The sandals offered some stability to her low back, but did not correct her postural imbalances. They also didn’t provide adequate arch support.
The patient currently receives chiropractic care every two weeks, minimum, gets a massage every two weeks, and wears her custom-made stabilizing orthotics every day.
Results
After only eight weeks of receiving adjustments and wearing the orthotics, the patient was no longer experiencing pain in the SI joint area. In addition, the neuroma was corrected without surgery. She no longer has numbness in her toes. And, within a few days of doing hip rotator exercises, she found relief from her leg pain.
Adjustments, orthotic support, and hip rotator exercises proved to be very successful for this patient, as did the muscle trigger point therapy. Additionally, the myofascial release for legs and hips was very beneficial.
Discussion
This case is interesting because there were several contributing factors to the patient’s constant pain. For her, the use of custom-made stabilizing orthotics is not just a method for correcting one thing—it’s an overall approach to improved health and wellness.
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. He 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 has been in private practice in Massachusetts for 29 years. He can be reached by e-mail at [email protected].