Neck Pain Aggravated by Foot Imbalance
by Dr. John J. Danchik, D.C.
History and Presenting Symptoms
The patient is a 32-year-old mother of three active young children, who presents with chronic neck pain and fatigue. She reports a motor vehicle collision four months ago, during which she received a hyperflexion/hyperextension “whiplash” injury. While her acute neck stiffness has improved, she describes persistent aching in her lower neck, varying from 4.0–7.5/10. She also has frequent occipital headaches requiring the use of pain relievers, and she has not been sleeping well, awakening frequently. These ongoing symptoms have resulted in a progressive tiredness that makes caring for her family difficult.
Exam Findings
Vitals. This active woman weighs 136 lbs, which at 5’6’’ results in a BMI of 22—her weight is healthy. 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. She reports that she has not smoked tobacco in about ten years. Posture and gait. Standing postural evaluation finds generally good alignment, with intact spinal curves, except for generalized cervical hypolordosis and anterior head translation. There is also a slight lateral tilt of her pelvis to the right, accompanied by right calcaneal eversion and a lower right medial arch. Dynamic treadmill gait evaluation finds hyperpronation of the right foot and ankle, with asymmetrical pelvic movements when walking at various speeds. Chiropractic evaluation. There is loss of regional cervical range of motion in all planes, but particularly in flexion, extension and right rotation. Motion palpation identifies several lower and upper cervical joint restrictions, with moderate tenderness and loss of end range mobility. Several compensatory fixations are noted in the lumbopelvic region. Neurological tests are negative, including sensory and reflex testing of the upper and lower extremities. Additional findings. Palpation of the right foot finds localized tenderness of the second, third and fourth metatarsal heads, with callus formation underneath. All foot and ankle joint ranges of motion are full and pain-free, bilaterally.
Imaging
A cervical X-ray series confirms the clinically-suspected hypolordosis with an anterior cervical gravity line. No contraindications to cervical manipulation are identified.
Clinical Impression
Chronic postural strain syndrome of the cervical spine, complicated by previous whiplash injury and asymmetrical pedal support. The right foot demonstrates loss of both the medial and anterior arches, with calcaneal eversion and hyperpronation during function. The asymmetry of the lower extremities affects her lumbopelvic region, adding to the postural strain.
Treatment Plan
Adjustments. Specific, corrective adjustments for the cervical and lumbopelvic regions were provided as needed. The right metatarsal heads were mobilized into an arched position, and the calcaneus and navicular bones were also adjusted. Support. A cervical support pillow was supplied, with instructions to spend as much time as possible in the supine position before (at least 30 minutes) and during sleep. This pillow was custom-fitted, based on four body measurements and a description of her mattress type. In addition, custom-made, flexible stabilizing orthotics designed to provide support for the calcaneus and the arches of the foot were provided. Rehabilitation. She was immediately started on a daily cervical posture corrective exercise – posterior translation against dynamic resistance. Marble pick-up and towel-scrunching exercises were also begun in an attempt to strengthen the intrinsic foot muscles.
Response to Care
She responded well to the spinal and foot adjustments, and reported a rapid decrease in her neck pain and headache symptoms. Once she received the cervical pillow and orthotic stabilizers, she reported feeling more energy and being much better rested. After five weeks of adjustments (10 visits), daily home exercises and using the cervical pillow and wearing the orthotics, she successfully completed her re-examination and was released to a self-directed maintenance program.
Discussion
While many cases of neck pain and headache respond well to a local approach consisting of cervical adjustments and use of a cervical support pillow, some are more complex. This patient showed a commonly seen combination of a forward head posture with increased anterior foot stress and loss of the metatarsal and medial arches. In her case, this was primarily unilateral, resulting in a lower extremity asymmetry with lumbopelvic consequences.
Dr. John J. Danchik, the seventh inductee to the ACA Sports Hall of Fame, is a clinical professor at Tufts University Medical School and formerly chaired the U.S. Olympic Committee’s Chiropractic Selection Program. Dr. Danchik lectures on current trends in sports chiropractic and rehabilitation. He can be reached at [email protected]