History and Presenting Symptoms
A 21-year-old female cross-country runner presents with pain around her right heel that extends into the underside of her large toe, and is limiting her running. The pain has been present for about six weeks and has not responded to her use of stretching, ice and ibuprofen. She has also noticed that her altered gait is beginning to cause a build-up of tightness and stiffness in her back. She describes a recent history of increasing her running to about sixty-five miles a week in training for the upcoming season of her college cross country team. She denies any specific injuries or direct trauma.
Exam Findings
Vitals. This athletic young woman weighs 138 lbs which, at 5’7″, results in a BMI of 22; she is not overweight and appears very fit. She describes a healthy diet and only an occasional intake of alcohol (wine). She has never used tobacco products, and her blood pressure and pulse rate are both within the normal ranges.
Posture and gait. Standing postural evaluation finds generally good alignment, with a slightly increased lumbar lordosis. She demonstrates bilateral calcaneal eversion, worse on the right, with a low right arch. Treadmill gait evaluation finds obvious hyperpronation of the right ankle and foot, which flares outward when walking. The pronation and foot flare are both accentuated when she runs at her usual training and racing paces.
Chiropractic evaluation. The lumbar spine is moderately tender throughout, and she demonstrates a generalized loss of vertebral mobility, with specific fixations noted at L5/S1, L3/L4, and the thoracolumbar junction. Her right SI joint is tender to pressure into extension. Otherwise, all orthopedic and neurological provocative testing of the spine and pelvis is negative.
Primary complaint. Palpatory examination of the right foot elicits no tenderness to medial/lateral squeezing or percussion of the right calcaneus. Moderate point tenderness is noted at the insertion of the plantar fascia into the anterior aspect of the calcaneus. Extension of the toes during foot dorsiflexion elicits a “pulling” pain from the large toe into the heel. All right foot and ankle ranges of motion are full and pain free and manual muscle testing finds no evidence of weakness when compared to the left side.
Imaging
X-rays of the right foot demonstrate a normal-appearing calcaneus, talus and midfoot, with no evidence of stress fracture, sclerosis or periosteal response.
Clinical Impression
Chronic strain of the plantar connective tissues and muscles, with altered gait causing moderate lumbar spine and sacroiliac joint dysfunction. There is no evidence of plantar fascitis, stress fracture or subtalar joint arthritis.
Treatment Plan
Adjustments. Specific, corrective adjustments for the lumbar region and right SI joint were provided as needed, with good response. The right calcaneus was adjusted anteriorly and both navicular bones were adjusted superiorly.
Support. Flexible, stabilizing orthotics were custom made, using viscoelastic, shock-absorbing materials and fitted to support the arches and to reduce calcaneal eversion (pronation correction) and impact at heel-strike.
Rehabilitation. The patient was shown marble pick-up and towel-scrunching exercises to improve the coordination of her foot intrinsic muscles. Once she had her orthotics, she also performed standing Achilles tendon stretches with knee straight, and then bent.
Response to Care
She was limited to brisk walking for the first week, and she gradually incorporated short periods of running during the next two weeks. Once she had adapted to her orthotics, she returned to her full training program with no recurrence of foot pain, and no persisting back symptoms. She was released to a self-directed chiropractic maintenance program after a total of eight visits over six weeks.
Discussion
Athletes frequently develop lower extremity symptoms, especially as they increase their training programs. The foot and heel regions are particularly susceptible to athletic overuse injuries, as most sports and training activities include a component of running, which places large amounts of stress on the anatomical structures of the foot and ankle. Any mild biomechanical asymmetry can produce local or distant symptoms. In this case, both foot pain and back pain resulted from the combination of an aggressive training program with chronic stress on the feet and arches.
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].