History and Presenting Symptoms
A 44-year-old female patient is a yoga instructor, who reports the recent onset of pain under her left heel. The foot pain is most noticeable in the morning when she first starts to walk. When her foot bothers her, she notices that her entire back is stiff and less flexible during yoga poses. In addition to her frequent yoga classes and practice, she walks briskly for forty-five minutes every day and rides a bicycle about every other day. She rates her current level of left foot pain as getting up to about 75mm on a 100mm Visual Analog Scale, but subsiding as the day progresses.
Exam Findings
Vitals
This active and generally healthy female is 5’6’’ tall and weighs 142 lbs, which results in a BMI of 23; she is not overweight. Her blood pressure is 114/72 mmHg, with a pulse rate of 64 bpm. She reports that she has never used tobacco products and does not drink alcohol or soda pop. She has been a vegetarian for twelve years, and she watches her diet carefully for proper protein and nutrient intake.
Posture and gait.
Standing postural evaluation finds very good alignment throughout the pelvis and spine, with no lateral lists or spinal curvatures. No pronation or toe out is noted during screening evaluation of gait.
Chiropractic evaluation.
Motion palpation identifies a mild limitation in lumbosacral motion, with moderate tenderness and loss of endrange mobility to the left at L5/S1. A compensatory subluxation is noted at T10/T11. Neurologic testing is negative for nerve root impingement or peripheral nerve damage.
Lower extremities.
Examination of the left foot and ankle finds no ligament instability, and all foot and ankle ranges of motion are full and pain-free. Palpation over the anteromedial portion of the plantar aspect of the left calcaneus elicits substantial “pinpoint” pain and discomfort. Manual testing finds no evidence of weakness in the ankle or foot muscles. Evaluation of foot alignment during mid-stance finds both medial arches to be quite high. Motion palpation identifies a mild limitation in lumbosacral motion, with moderate tenderness and loss of endrange mobility to the left at L5/S1. A compensatory subluxation is noted at T10/T11. Neurologic testing is negative for nerve root impingement or peripheral nerve damage. Standing postural evaluation finds very good alignment throughout the pelvis and spine, with no lateral lists or spinal curvatures. No pronation or toe out is noted during screening evaluation of gait.
Imaging
X-rays of the feet show a small bony spur on the left calcaneus, at the insertion of the plantar fascia. Otherwise, there is normal joint spacing and alignment, with no evidence of osteoarthrosis or other structural pathology.
Clinical Impression
High medial arches with resulting excessive supination (insufficient pronation). Increased biomechanical stress has been placed on the plantar fascia, resulting in the development of a chronic traction spur at the calcaneal insertion. There is moderate secondary spinal involvement, which has probably been minimized by her frequent yoga practice.
Treatment Plan
Adjustments.
Specific adjustments for the lumbosacral and thoracolumbar spinal regions were well-tolerated. Manipulation of the cuboid and calcaneus bones on both feet produced noticeable reduction of tension in the plantar fascia.
Support
Soft tissue mobilization of the plantar fascia was performed, along with cross-fiber friction to tolerance at the calcaneal insertion. Custom-made, flexible stabilizing orthotics were ordered to support the lateral and anterior arches. These orthotics included an additional layer of shock absorption materials to reduce impact stress throughout the entire gait cycle.
Rehabilitation.
She was encouraged to continue with her active lifestyle and yoga practice, including her frequent walking and cycling. Since she was in generally good condition, she did not require any specific corrective exercises.. Soft tissue mobilization of the plantar fascia was performed, along with cross-fiber friction to tolerance at the calcaneal insertion. Custom-made, flexible stabilizing orthotics were ordered to support the lateral and anterior arches. These orthotics included an additional layer of shock absorption materials to reduce impact stress throughout the entire gait cycle.
Response to Care
Once she began wearing her shock-absorbing orthotics, she noted a substantial decrease in tension and tenderness of the plantar fascia. Within two weeks of receiving the orthotics, she reported that she was able to perform all her exercise and personal activities with no foot or back pain or limitation. She was released to a self-directed maintenance program after a total of eight treatment sessions over two months.
Discussion
When the medial arches are high, the corresponding lateral and anterior arches are often low or collapsed, resulting in excessive strain and tension on the plantar fascia. Lack of pronation increases impact forces at heel strike; these forces are then transmitted up the kinetic chain to the spine. Excessive supination is much less common than excessive pronation, but is frequently an underlying factor in chronic stress on the plantar fascia at the calcaneal insertion.
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]