Category: Orthotics

History and Presenting Symptoms

The patient is a 32 year-old personnel manager who has taken up running for stress reduction and weight control. She has been running for six months, and has been progressively increasing her mileage. She is experiencing recurring and worsening pain in her right foot, also increased low-back tightness. She recalls no specific injury to her foot or back, but thinks she may be favoring her right foot when running.

Exam Findings

This active woman weighs 148 lbs, which, at 5’5’’, results in a BMI of 25—she is on the borderline of being overweight. When told this, she says that she has lost about twelve pounds since beginning regular running, and hopes to lose about five more (which would be appropriate for her height). She reports that she hasn’t smoked for four years, and her blood pressure and pulse rate are both at the lower end of normal range. She drinks a few glasses of wine each week, usually with meals.

Vitals.

Posture and gait.

Chiropractic evaluation.

Primary complaint.

Palpation of the right foot finds the fourth metatarsal bone to be quite tender to digital pressure just proximal to the metatarsal head. Manual testing finds no specific muscle weakness, nor is there significant asymmetry in muscle mass or leg diameter. All ankle joint ranges of motion are full and pain-free, bilaterally. Motion palpation identifies a limitation in left sacroiliac motion, with moderate tenderness and loss of endrange mobility. Several compensatory subluxations are identified throughout the thoraco-lumbar region. Yeoman’s provocative test elicits moderate pain upon prone extension of the left leg. All other spinal and neurological tests are negative, including sensory and reflex testing of the lower extremities. 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. Treadmill gait evaluation finds obvious hyperpronation of the right foot and ankle when walking, which is noticeably worse when running.

Imaging

An X-ray series of the right foot finds an area of slightly increased density in the distal third of the fourth metatarsal bone. Based on the clinical and plain radiographic findings, she was referred for a bone scan of the lower extremities and feet. This study identified an area of increased uptake in the distal third of the fourth metatarsal bone, consistent with a stress response.

Clinical Impression

Early stress fracture of the fourth metatarsal bone. While no actual fracture line is present, the plain film and bone scan findings support the clinical indication of a “stress reaction” of bone, which is responding to the increased biomechanical strain of her running program. This is accompanied by sacroiliac joint motion restriction and compensatory thoraco-lumbar subluxations associated with altered gait.

Treatment Plan

Specific, corrective adjustments for the left SI joint and the thoraco-lumbar region were provided as needed. The right cuboid and navicular were adjusted, while carefully avoiding placing pressure on the fourth metatarsal bone. 

Adjustments.

Support.

Rehabilitation.

All weight-bearing exercise was restricted for two weeks. Then, marble pick-up and towel-scrunching exercises were initiated to strengthen the intrinsic foot muscles. After four weeks, she was permitted to gradually return to her distance-running program. Custom-made, stabilizing orthotics were supplied to help provide support through the entire gait cycle, maintain the arches, limit calcaneal eversion, and decrease heel-strike impact. Two pairs of stabilizing orthotics were ordered for her:one designed specifically for running shoes and the other for job-related dress shoes.

Response to Care

She responded well to the spinal and foot adjustments, and reported a rapid decrease in her foot symptoms with rest. After four weeks away, she built back up to her previous running program. She reported no return of the right foot pain, and also noted a subjective feeling of smoother and more efficient gait with the orthotics. She has now been running regularly and without difficulty for the past four months.

Discussion

Metatarsal stress fractures often occur when moderate biomechanical asymmetries are stressed by rapid increases in weight-bearing exercise. Shock-absorbing orthotics incorporate arch support, while reducing pronation and decreasing the stress of repetitive heel strikes on the foot and spine.

 

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].

History and Presenting Symptoms

An 18-year-old baseball player presents with aching pain and tightness in his left lower leg.  He describes a collision injury during a game four days earlier, which resulted in pain and bruising in the front of his leg after sliding into second base.  Despite repeated icing, the area still feels swollen.  He describes this as “shin splints.”

Exam Findings

Vitals. This very fit young athlete weighs 150 lbs, which, at 5’10’’, results in a BMI of 23—he is not overweight.  He is a non-smoker, and his blood pressure and pulse rate are both at the lower end of normal range.

Posture and gait. Standing postural evaluation finds generally good alignment throughout his spine and pelvis, with normal spinal curves and no lateral curvature or listing. The knees and ankles are also well aligned, with no knee varus or valgus, and no calcaneal eversion or foot flare.  Both medial arches are somewhat high, and gait evaluation finds excessive supination, with insufficient pronation.

Chiropractic evaluation. Motion palpation and joint play analysis identifies a mild limitation in lumbosacral motion, with moderate tenderness and loss of end range mobility at the left of L4/L5.

Primary complaint. Examination of the left lower leg finds moderate tenderness and tightness along the anterior tibialis musculature.  There is loss of sharp sensation discrimination in the lateral aspect of the foot, but no numbness or paresthesia.  The left foot intrinsic muscles demonstrate no weakness, and he has no difficulty performing toe extension.  All ankle ranges of motion are full and pain-free, except inversion is limited by the tightness of the anterior tibialis muscle.  The left cuboid is tender to palpation and demonstrates a lateral subluxation.

Imaging. No X-rays or other forms of musculoskeletal imaging were requested.

Clinical Impression

Anterior compartment syndrome in the left lower leg, associated with mild neurological compression.

Treatment Plan

Adjustments. Specific, corrective adjustments for the lumbar spine and left cuboid were provided as needed.

Support. Custom-made, stabilizing orthotics were supplied to support the high arches and decrease the shock stress on the legs and spine from excessive supination.

Rehabilitation. Initially, frequent Proprioceptive Neuromuscular Facilitation (PNF) stretching followed by icing treatments was performed to lengthen and relax the anterior tibialis musculature. As improvement was noted, isotonic resistance exercising in inversion activated and strengthened the antagonists of the anterior tibialis muscle. Finally, a comprehensive strengthening program using exercise tubing prepared him for a return to full athletic capability.

Response to Care

The stretches and adjustments were well tolerated, and he reported a decrease in symptoms within the first 24 hours.  After two weeks of care, he was able to return to practice, including light running.  He responded well to the orthotics, and was released from care after a total of eight treatment sessions over six weeks.

Discussion

The commonly used term “shin splints” is a non-specific description of pain in the lower leg.  Several conditions can produce pain in this area, and must be differentiated for effective treatment.  High arches and excessive pronation may predispose athletes to the development of shin splints.  While most causes of shin splints are easily treated with conservative means, anterior compartment syndrome that causes neurological impairment may need to be surgically decompressed.

Persistent pain in the lower leg following sports activities may indicate an increase in intramuscular pressure in one of the osteofascial compartments.  Acute trauma can cause the internal pressure of a muscle to elevate excessively during exercise and stay high for a prolonged period post-exercise.  While there are five fascial compartments, the anterior compartment is most frequently involved, making the pain area similar to shin splints.  Sensory changes are often evident distally; paresthesias may involve the first web space, the instep, or the lateral aspect of the foot.  If elevated intracompartmental pressures persist, permanent damage to muscle tissue and nerves can develop, making early surgical decompression of the involved compartment mandatory.

Prompt, conservative care allowed this relatively mild case to be treated without surgery.  The custom-made, stabilizing orthotics provided support and shock absorption during future athletic activities, and no recurrences were reported.

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].

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].

History and Presenting Symptoms

A 33-year-old female reports the recent onset of persistent aching pain and tightness in her lower back region.  The pain extends into both buttocks, and occasionally is felt around the left hip and into the left groin.  She is into her 7th month of her second pregnancy, and says that her back pain has increased with her additional weight and postural changes.  She reports that she had some back pain during and for a few months after her first pregnancy, but that, this time, it seems much worse.  She has been trying to continue with a daily 20-minute walking program, but is finding that difficult because it increases the tension in her lower back region.  On a 100mm Visual Analog Scale, she rates the pain in her lower back and pelvic region as varying from a constant 25mm to 50mm recently.

Exam Findings

Vitals.  This gravid female has put on about 30 pounds in the past couple of months, and currently weighs 162 lbs, which, at 5’6’’, is within the expected range.  She has never used tobacco, and stopped drinking alcohol as soon as she learned she was pregnant.  She has had several pre-natal check-ups, and her blood pressure and pulse rate are within normal ranges.  (BP—118/76 mmHg; pulse rate—68 bpm).

Posture and gait.  Standing postural evaluation finds a hyperlordotic lumbar spine and a forward-tilted pelvis, which are associated with her enlarged abdomen.  No lateral listing or curvature of her spine is seen, and her iliac crests and greater trochanters are level.  She has a slightly widened stance, with moderate valgus alignment at the knees.  There is also medial bowing of both Achilles tendons, with pes planus and hyperpronation bilaterally.  During gait, both feet demonstrate an obvious toe-out (foot flare).

Chiropractic evaluation.  Motion palpation identifies a very tender limitation in segmental motion at the left SI joint, and subluxations at L5/S1 and L2/L3.  Kemp’s test provokes pain localized to the lower lumbar spine when performed to both sides, and reproduces the left hip and groin pain when done to the left.  Spinal ranges of motion are otherwise normal and pain-free, and neurologic testing is negative for sensory, motor, and reflexive disorders.

Imaging. No radiographs were ordered, in consideration of her current pregnancy.

Clinical Impression

Chronic biomechanical strain of the lumbopelvic region is exacerbated by postural changes associated with the increased load of pregnancy.  There is also poor support from the lower extremities, with excessive pronation interfering with her walking program.

Treatment Plan

Adjustments.  Side posture adjustments were performed to the left sacroiliac joint and the lumbar spinal segments.

Support.  She was fitted with custom-made, stabilizing orthotics based on foot imaging in mid-stance.  The inserts were designed to provide support for her arches and decrease the biomechanical stress on her pelvis and sacroiliac joints during her pregnancy and after her delivery.

Rehabilitation.  She was shown a standing posterior tilt exercise for the pelvis (pelvic extension) to activate and strengthen the abdominal support muscles and her transverse abdomens in particular.  This exercise used the progressive resistance of elastic exercise tubing.  She was also instructed to perform abdominal floor exercises (Kegels).

Response to Care

The adjustments were well tolerated, and resulted in immediate release of tension and rapid reduction in pain levels.  She adapted easily to her orthotic inserts, and said that she noticed much greater stability in her feet and spine during walking.  She performed her daily home exercise program regularly and with no strain or difficulty.  She was treated weekly during the remainder of her pregnancy and then for six weeks after her delivery (a total of 12 visits).  At that point, she was released to a self-directed maintenance program.

Discussion

The process of pregnancy, delivery, and post-partum places a great amount of structural stress on a woman’s body.  In this case, poor support from the lower extremities increased the biomechanical strain, resulting in substantial distress.  She responded well to the chiropractic adjustments, but she also needed the additional support from custom-made orthotics and professional guidance for specific postural exercises. (She delivered a healthy 7.2 lb. baby girl.)

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 30 years.  He can be reached by e-mail at [email protected].

History and Presenting Symptoms

A 46-year-old female presents with recurrent, sharp pain in her low back.  These episodes usually resolve within a few days, but she is concerned that they are becoming more frequent.  Using a Visual Analog Scale, she describes the usual pain level in her lower back as around 35mm.  She doesn’t recall any injury to her back, and can’t identify any specific cause for her pain.  She states that she just “takes it easy” for a few days, and the pain resolves.

Exam Findings

Vitals.  This patient is 5’5’’ tall, and she weighs 138 lbs, which is a BMI of 23; she is not overweight.  Her blood pressure is 124/76 mmHg, with a pulse rate of 76 bpm.  She reports that she has never used tobacco products, and averages 4-5 glasses of wine per week.

Posture and gait.  Standing postural evaluation finds generally good alignment throughout her pelvis and spine, except for an accentuated lumbar lordosis.  She has a mild bilateral knee valgus and moderate calcaneal eversion, with hyperpronation bilaterally.  During gait, both feet demonstrate a tendency to toe-out.  Inspection of her shoes finds scuffing and wearing of the lateral aspect of both heels.  She states that she usually wears shoes with higher heels for work, and that she has noticed that all her shoes wear out quickly.

Chiropractic evaluation. Kemp’s testing produces sharp pain localized to the lumbar spine when performed to both sides.  Motion palpation identifies functional limitations in extension at the L3/L4 and L4/L5 levels, with moderate tenderness and loss of endrange mobility.  Neurological tests are negative for nerve root impingement.

Imaging

A-P and lateral lumbopelvic X-rays in the upright position are taken during relaxed standing.  The sacral base angle is 48°, the lumbar lordosis measures 62°, and the lumbar gravity line (from L3) falls anterior to the sacrum.  There is evidence of chronic facet imbrication, with sclerosis seen at L3/L4 and L4/L5.  There is no discrepancy in femur head or iliac crest heights, and no lateral listing or lateral curvature is noted.

Clinical Impression: Chronic facet syndrome with lumbar hyperlordosis and increased sacral base angle.  This postural stress is being exacerbated by her choice of heel heights, and by her tendency to overpronate during gait.

Treatment Plan

Adjustments.  Flexion distraction and side posture adjustments for the lower lumbar region were provided, as needed, with good response.
Stabilization.  Custom-made, flexible orthotics were supplied, and she was told to limit her heel height to 1” maximum.  She was found to be wearing shoes that were too small for her feet, and needed to increase one full size for proper fit.

Rehabilitation.  She was instructed in a daily core strengthening program, to be done at home, using elastic exercise tubing.  The focus was on activation of her transverse abdominis musculature, for improved spinal stability.

Response to Care

This patient responded rapidly to her spinal adjustments.  She had very little difficulty in adapting to the custom-made, flexible orthotics, and she reported that the slightly larger shoes with lower heels were much more comfortable.  She was consistent with her home exercise program, as demonstrated by her exercise log.  After six weeks of adjustments (10 visits) and daily home exercises, including wearing the orthotics in properly fitted shoes with lower heels, she was released to a self-directed maintenance program.

Discussion

This case demonstrates the importance of investigating all sources of underlying biomechanical stress, especially when a spinal condition is chronic or recurrent.  Shoe-related postural problems are not uncommon, particularly in women.  Many women don’t check their shoe size for many years, and they often wear shoes that are too small for their feet.  Heel height can complicate spinal facet syndromes, resulting in a poor response to chiropractic care.

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 can be reached by e-mail at [email protected].

History and Presenting Symptoms

The patient is a 41-year-old male, who describes persistent pain and occasional stiffness in his left knee, which is not associated with any specific activity.  He reports several years of recurring episodes of medial knee pain that just comes and goes, with no swelling or inflammation.  Previous evaluations, including a knee MRI, have resulted in a diagnosis of a torn meniscus.  Surgery has been offered; but with no guarantee of significant pain reduction, he has declined to undergo arthroscopic repair.

Exam Findings

Vitals: This male patient weighs 172 lbs., which, at 5’10’’, results in a BMI of 24; he is not overweight, but getting close.  He is a long-time moderate cigarette smoker (10/day), and his blood pressure and pulse rate are at the upper end of the normal range.

Posture and gait: Standing postural evaluation finds generally good alignment, with a slight forward head carriage, but otherwise intact spinal curves and a balanced pelvis.  He has a mild bilateral knee valgus, with moderate calcaneal eversion and hyperpronation on the left side.  A tendency for the left foot to toe out (foot flare) is noted during gait screening.

Chiropractic evaluation: Motion palpation identifies a limitation in left sacroiliac (SI) movement, with definite tenderness and loss of endrange mobility.  Several compensatory subluxations are identified throughout the lumbar region.  Otherwise, all spinal orthopedic and neurological testing is negative.

Primary complaint: Examination of his left knee finds no ligament instability and no limitation, pain, or “click” on McMurray testing.  Moderate pain and crepitus is found during Apley’s grinding test.  All knee ranges of motion are full and pain-free, bilaterally.  Manual muscle testing finds mild weakness in the left sartorius muscle, when compared to the right side.

Imaging

No X-rays or other forms of musculoskeletal imaging were requested, since multiple X-rays and an MRI of the knee had previously been performed.

Clinical Impression

Biomechanical asymmetry of the lower extremities, with probable meniscal irritation at the left knee.  This is accompanied by SI joint motion restriction and compensatory lumbar subluxations.

Treatment Plan

Adjustments.  Specific, corrective adjustments for the SI joints and lumbar region were provided as needed.  The left proximal tibia was adjusted into internal rotation, with additional medial pressure for the valgus malposition.

Stabilization. Custom-made, flexible orthotics were provided to support the arches, to decrease the medial pressure on his left knee, and to reduce the asymmetrical biomechanical forces being transmitted up the lower extremity to the pelvis and spine.

Rehabilitation. This patient performed daily exercises with elastic tubing to retrain and strengthen his left sartorius muscle for improved medial knee support.  He also worked to strengthen internal rotation action of his left hip, to decrease the tendency to toe out.  In addition, he was supplied with a dietary supplement for joint health that contained glucosamine and chondroitin sulfates.

Response to Care

The spinal and extremity adjustments were well tolerated, but knee pain recurred until he had been regularly performing his rehab exercises for two weeks.  He reported no difficulty in wearing the orthotics in all of his shoes.  Over the next two months, he described a noticeable improvement in his knee function, with an eventual complete cessation of the previous pain and stiffness.  He was released from active problem care to a self-directed maintenance program after a total of 15 visits over three months.

Discussion

This patient had received the “learned opinion” that, at some point, surgery would be the only answer for his chronic knee pain.  Fortunately, he persisted in searching for alternatives. The combination of spinal and extremity adjustments, nutritional supplementation, and better support for the medial knee from improved muscle function and custom-made orthotics resulted in an excellent response.  In fact, he is now embarking on a wellness plan that includes addressing his lifestyle choices to improve his health potential.  He has made a commitment and a plan to quit his smoking.  He has already improved his diet, and is exercising regularly now for fitness.

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].