History and Presenting Symptoms
The patient is a 32-year-old mom, who also works part-time at the local middle school, where she is the school nurse. She reports numerous episodes of aching and tightness in her right calf over the past three years. She denies any recollection of injury or overuse activities. She has no significant disability, as she is able to perform her job and family duties without restriction. She describes her persisting low-level right calf pain as about 25mm to 35mm on a 100mm Visual Analog Scale (VAS). It never really goes away, but does vary in intensity.
Exam Findings
Vitals. This active woman weighs 144 lbs which, at 5’3’’, results in a BMI of 26—she is somewhat overweight. She appears to carry most of her excess weight around her midsection—an indication of central adiposity. She is, otherwise, quite healthy, with blood pressure and pulse rate within the normal range. She is a non-smoker, and drinks alcohol occasionally with meals.
Posture and gait. Standing postural evaluation finds generally good alignment, with intact spinal curves, and no lateral listing of the pelvis or spine. She does show evidence of a right posterior ilium, with prominence of the right PSIS. She has noticeable right calcaneal eversion, with a lower right arch. Measurement finds a standing Q-angle of 26° on the right and 22° on the left (20° is normal for women).
Chiropractic evaluation. Motion palpation identifies functional limitations at the L2/L3 and L4/L5 levels, with moderate tenderness and loss of endrange mobility. Hip and sacroiliac joint movements are full and pain free on both sides.
Primary complaint. Examination of her right calf muscles finds the soleus to be tender to palpation around its attachments into the posterior tibia. All right-ankle ranges of motion are full and pain free—except dorsiflexion, which is limited primarily by muscle tightness, not pain. Manual muscle testing finds slight weakness of the right anterior tibialis muscle, when compared to the left side.
Imaging. A-P and lateral lumbopelvic X-rays in the upright, standing position are obtained. A moderate discrepancy in femur head heights is seen, with the right measured lower by 4mm. A moderate right convex lumbar curvature (5°) is noted.
Clinical Impression. Chronic, recurrent muscle imbalance of the right soleus muscle with asymmetrical pronation and an increased right Q-angle. The biomechanical stress from the lower extremities is associated with secondary motion restrictions and asymmetries in the lumbar spine and pelvis.
Treatment Plan.
Adjustments. Specific, corrective adjustments for the pelvis and lumbar region were provided as indicated. Manipulation of the right ankle and arch was performed with the goal of increasing the range of right ankle dorsiflexion motion.
Support. Flexible, custom-made, stabilizing orthotics made with shock-absorbing materials were provided to support the arches and decrease calcaneal eversion, and to reduce the asymmetrical biomechanical forces being transmitted into the knee and spine. Rehabilitation. She was shown how to perform standing calf stretches with the knee bent (for the right soleus muscle), with the goal of increasing muscle flexibility and right ankle mobility in dorsiflexion. After two weeks, daily strengthening of anterior tibialis muscle was introduced, using elastic exercise tubing.
Response to Care
The spinal and pelvic adjustments were well tolerated, and she responded rapidly to the spinal adjustments and calf stretches. She adapted to and wore the stabilizing orthotics without difficulty, and she particularly appreciated the support when she was at work. After six weeks of adjustments (ten visits) and daily home exercises, she was released to a self-directed maintenance program.
Discussion
The combination of a low arch, increased Q-angle, and pelvic misalignment is not uncommon. This combination of mechanical findings often results in systems and eventual structural breakdown. Even a moderate amount of asymmetrical pronation, when exposed to repetitive or constant loading strain, can develop into chronic muscle tension, with shortening tightness. Spinal adjustments and very specific stretching/strengthening exercises provided relief, but the underlying functional asymmetry had to be addressed with custom-made, stabilizing orthotics for long-lasting results.
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].