History and Presenting Symptoms
The patient is a 38-year-old male, who plays soccer in an adult league on weekends. He describes recurring episodes of pain and swelling along the outside of his right ankle for the past several years. He presents for treatment of his lower extremity biomechanical faults, and wants to prevent future problems and improve his athletic performance with chiropractic care.
Exam Findings
Vitals. This athletic male weighs 160 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 at the lower end of the normal range.
Posture and gait. Standing postural evaluation finds generally good alignment, with intact spinal curves, but a slightly lower iliac crest on the right, which is confirmed by a lower right greater trochanter. He also demonstrates right calcaneal eversion and a low medial arch (hyperpronation). A tendency to toe out (foot flare) on the right is noted during gait screening.
Chiropractic evaluation. Motion palpation identifies a mild limitation in right sacroiliac motion, with moderate tenderness and loss of end range mobility. Several compensatory subluxations are identified throughout the lumbar region. Otherwise, all orthopedic and neurological testing is negative.
Lower extremities. Examination of his right foot and ankle reveals slight general swelling of his ankle, which is moderately tender to palpation along the outer aspect. All right ankle ranges of motion are full and pain-free, except inversion, which is limited by tightness and localized pain along the lateral foot and ankle. Manual muscle testing finds mild weakness in the right peroneal muscle, when compared to the left side.
Imaging
No X-rays or other forms of musculoskeletal imaging were requested.
Clinical Impression
History of recurrent inversion ankle sprains associated with hyperpronation and foot instability. This is accompanied by sacroiliac 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 right navicular bone was adjusted superiorly.
Stabilization. Custom-made, flexible stabilizing orthotics were provided to support the arches and decrease calcaneal eversion, and to reduce the asymmetrical biomechanical forces being transmitted to the spine and pelvis. Two pairs of stabilizing orthotics were ordered, one designed for his soccer shoes and the other for everyday shoe wear.
Rehabilitation. He was initially instructed in daily self-mobilization and strengthening procedures, which included marble pick-up and towel-scrunching exercises. After two weeks, daily strengthening of eversion and external rotation was introduced, using elastic exercise tubing.
Response to Care
The spinal and pelvic adjustments were well tolerated, and this active athlete required very few readjustments. His compliance with the stabilization and exercise recommendations was very good, since he was quite motivated to improve his performance and to prevent future injuries to his ankle. He adapted to and wore the orthotics without difficulty. He faithfully filled out and brought in his exercise log at every visit, which provided an excellent opportunity to support his home-based efforts.
Within two weeks of receiving his orthotics, he completed several strenuous soccer practices without symptoms or swelling in the ankle. He described a noticeable improvement overall in his athletic performance, saying that he felt “more stable.” He was released from acute care to a self-directed maintenance program after a total of ten visits over two months.
Discussion
Interestingly, this athlete had been to several doctors before this encounter. He was very frustrated by the lack of answers and recommendations. His frequent and recurring inversion sprains occur in a foot and ankle that has poor medial support (a low medial longitudinal arch) and an everted calcaneus. Biomechanical analysis found his right foot to be over flexible and unstable.
As is often found in these types of cases, the combination of specific adjustments, custom-made orthotic support, and strengthening of the lateral ankle support musculature brought about an excellent response. This middle-aged athlete was very motivated to improve his sports performance, and he persisted with the recommended exercises.
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]