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Orthotics
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Orthotics
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Written by John Danchik, D.C., F.I.C.C., F.A.C.C.
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Thursday, 25 April 2013 19:24 |
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History and Presenting Symptoms
The patient, a 24-year-old male semi-professional hockey player, reports a recent right hamstring “grab” that just does not seem to be improving. His history includes several injuries to the same hamstring muscle during his collegiate playing career with mixed attempts to stretch and rehab. He also describes varying levels of pain in his lower back and left hip region, which has led him to ask for a complete musculoskeletal evaluation.
Exam Findings
 Vitals. This athletic young male weighs 175 pounds, which at 5’11’’ results in a BMI of 24.4: He is not overweight. He is a non-smoker, does not drink alcohol, and his blood pressure and pulse rate are at the lower end of the normal range. Posture and gait. Standing postural evaluation finds relatively good alignment with intact spinal curves but a slightly lower iliac crest on the right along with a lower-right greater trochanter. His spine appears to be well balanced above with no evidence of lateral curve or list. He also demonstrates right calcaneal eversion and a low medial arch (hyperpronation). A tendency to toe out on the right is seen during a standard gait screening, and he confirms his need to be conscious of the positioning of his right foot when skating.
Chiropractic evaluation. Motion palpation identifies a mild limitation in left sacroiliac motion with moderate tenderness and loss of endrange mobility. Compensatory fixations are identified at L4/5 and L2/3. Otherwise, all orthopedic and neurological testing is negative.
Primary complaint. Examination of his right lower extremity finds tenderness to palpation at the ischial insertion and in the medial belly of the hamstring muscle group. Straight leg raise is limited to 58° by hamstring tightness and pain, and active knee extension is restricted when the hip is placed in 90° of flexion. Manual muscle testing finds painful weakness in the right hamstring when only moderate resistance is provided.
Imaging
Because of his history of recurrent strains and the evidence for postural asymmetry, an upright lumbopelvic series is obtained. The standing AP lumbopelvic view shows a lateral pelvic tilt, a low sacral base on the right, and the right femur head is five millimeters lower.
Clinical Impression
Hamstring muscle injury associated with chronic biomechanical strain. A functional short leg on the right is accompanied by sacroiliac joint motion restriction and compensatory lumbar fixations.
Treatment Plan
Adjustments. Specific, corrective adjustments for the SI joints and lumbar region were provided as needed. Mobilization and manipulation were performed on his right arch, calcaneus, and navicular bone.
Support. Individually designed stabilizing orthotics were ordered for his street shoes, and a second pair was fitted into his hockey skates. They were designed to support the arches, decrease calcaneal eversion, and reduce the asymmetrical biomechanical forces being transmitted to the spine and pelvis.
Rehabilitation. He was initially instructed to perform sustained functional hamstring stretches four times a day. After one week, daily strengthening exercises for the right hamstring were progressed from light to strenuous resistance using elastic exercise tubing.
Response to Care
The spinal and pelvic adjustments were well tolerated, and once he began wearing the stabilizing orthotics, this active hockey player required very few re-adjustments. His compliance with the recommended exercises was excellent because he was quite motivated to improve his performance and to prevent future hamstring injuries. He was immediately able to wear his orthotics full time and reported an improved sense of edging and control in his skates. The right hamstring muscle regained full flexibility and balanced strength, and he was released from acute care to a self-directed home stretching and sports performance program after a total of eight visits over two months.
Discussion
While a hamstring muscle “grab” or “pull” is often just a simple strain injury, in some cases there is an underlying biomechanical fault that makes it recurrent. Careful evaluation of the patient’s spine and lower extremities identified the asymmetry in the feet and ankles as a major contributor to his symptoms. Fitting stabilizing orthotics into his skates helped to provide a better boot fit, improved his edge control, and enhanced long-term support for his lower extremities. As with this young man, athletes at all levels appreciate a thorough evaluation and advice that can help to improve sports performance.
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Orthotics
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Written by John Danchik, D.C., F.I.C.C., F.A.C.C.
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Sunday, 24 February 2013 22:30 |
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History and Presenting Symptoms
 This female patient is a 51-year-old small business owner and exercise enthusiast. She reports pain in the front of her left knee over the past several months, especially when exercising at the gym. She has no obvious swelling or discoloration and denies any specific injury. She reports that she takes over-the-counter medication for relief, but is worried about taking drugs in order to complete her exercise regimen.
Exam Findings
Vitals. This active, middle-aged woman weighs 138 lbs, which at 5’4’’ results in a BMI of 23.7 – not overweight, but at the higher end of normal. She is a non-smoker, and her blood pressure and pulse rate are both at the lower end of the normal range.
Posture and gait. Standing postural evaluation finds generally good alignment throughout her pelvis and spine. She has a mild bilateral knee valgus and moderate calcaneal eversion and hyperpronation on the left side. Measurement finds a standing Q-angle of 27° on the left and 23° on the right (20° is normal for women).
Chiropractic evaluation. Motion palpation identifies a limitation in lumbosacral motion, with moderate tenderness and loss of endrange mobility to the left at L5/S1. A compensatory fixation is also noted at T10/T11. Neurologic testing is negative.
Primary complaint. Examination of the left knee indicates no ligament instability, but there is a positive patellar grinding test. All knee ranges of motion are full and pain free, bilaterally. Manual muscle testing finds no evidence of muscle weakness.
Imaging
No x-rays or other forms of musculoskeletal imaging were requested.
Clinical Impression
Patello-femoral arthralgia on the left, associated with an elevated Q-angle and foot pronation. This is accompanied by lumbosacral joint motion restriction and compensatory lower thoracic fixation.
Treatment Plan
Adjustments. Specific, corrective adjustments for the lumbosacral joint and the lower thoracic region were provided as needed. Manipulation of the left knee into external rotation was performed to decrease the internal rotation associated with hyperpronation and her elevated Q-angle.
Support. Individually designed stabilizing orthotics were provided to support her arches and decrease her Q-angles. Two pairs of stabilizing orthotics were ordered – one designed specifically for her gym shoes and the other for her job-related dress shoes.
Rehabilitation. Due to her active lifestyle, no specific rehabilitation exercises were provided. She continued with her frequent activities at the local gym.
Response to Care
The adjustments for the spine and knee were well-tolerated, and she reported what appeared to her to be a rapid decrease in symptoms. After this patient began wearing her orthotics regularly, she indicated noticing a substantial decrease in knee irritation with use, and a firmer foot plant during aerobics. Within three weeks of receiving her orthotics, she related that she was performing all of her favorite workout routines with no knee pain or limitation. She was released to a self-directed stretching program after a total of eight treatment sessions over two months.
Discussion
Several factors in this case make it quite interesting. This high-powered business woman used her gym time as both a form of recreational relaxation and a place for business networking. As her knee began to bother her more, she was driven to begin using anti-inflammatory drugs. She did start wearing more supportive footwear, but her underlying biomechanical problem had not been sufficiently addressed.
When women are physically active, their naturally higher Q-angles are frequently a source of lower extremity pain. Patello-femoral arthralgia (previously known as chondromalacia patellae) has been recognized as a biomechanical tracking disorder of the kneecap in the femoral groove. The best treatment is a conservative approach, with a combination of chiropractic adjustments, stabilizing orthotic support, and – when indicated – rehabilitative strengthening sessions using exercise tubing.
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Orthotics
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Written by John Danchik, D.C., F.I.C.C., F.A.C.C.
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Monday, 24 December 2012 02:05 |
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History and Presenting Symptoms
 The patient is a 44-year-old male who describes persistent pain and occasional stiffness in his right knee that is not associated with any specific activity. He reports at least two years of recurring episodes of medial knee pain that just comes and goes with no swelling or inflammation. Previous evaluations, including a knee MRI, have resulted in a diagnosis of a torn meniscus. Surgery has been offered; but with no guarantee of significant pain reduction, he has declined to undergo arthroscopic repair.
Exam Findings
Vitals. This male patient weighs 170 lbs., which at 5’ 9.5’’ results in a BMI of 24.7. He is not overweight but getting close. He was a moderate cigarette smoker (eight per day) from his late teens into his mid-twenties, but he has been nicotine free for almost 20 years. His blood pressure and pulse rate are at the upper end of the normal range.
Posture and gait. Standing postural evaluation finds generally good alignment with a slight forward head carriage but otherwise intact spinal curves and a balanced pelvis. He has a mild bilateral knee valgus with moderate calcaneal eversion and hyperpronation on the right side. A tendency for the right foot to flare out is noted during gait screening.
Chiropractic evaluation. Motion palpation identifies a limitation in right sacroiliac (SI) movement with definite tenderness and loss of end-range mobility. Several compensatory subluxations are identified throughout the lumbar region. Otherwise, all spinal orthopedic and neurological testing is negative.
Primary complaint. Examination of his right knee finds no ligament instability and no limitation, pain, or “click” on McMurray testing. Mild pain and crepitus are found during Apley’s grinding test. All knee ranges of motion are full and pain free, bilaterally. Manual muscle testing finds mild weakness in the right sartorius muscle when compared to the left side.
Imaging
No X-rays or other forms of musculoskeletal imaging were requested since multiple X-rays and an MRI of the knee had been performed during the initial surgical discussion period.
Clinical Impression
Biomechanical asymmetry of the lower extremities with probable meniscal irritation at the right knee. This is accompanied by SI 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 proximal tibia was adjusted into internal rotation with additional medial pressure for the valgus malposition.
Stabilization. Individually designed stabilizing orthotics were provided to support the arches, to decrease the medial pressure on his right knee, and to reduce the asymmetrical biomechanical forces being transmitted up the lower extremity to the pelvis and spine.
Rehabilitation. This patient performed daily exercises with elastic tubing to retrain and strengthen his right sartorius muscle for improved medial knee support. He also worked to strengthen internal rotation action of his right hip to decrease the tendency to toe out. In addition, he was supplied with a dietary supplement for joint health that contained glucosamine and chondroitin sulfates.
Response to Care
The spinal and extremity adjustments were well tolerated, but knee pain recurred until he had been regularly performing his rehab exercises for almost two weeks. He reported no difficulty in wearing the orthotics in all of his shoes. Over the next month, he described a noticeable improvement in his knee function with an eventual complete cessation of the previous pain and stiffness. He was released from active problem care to a self-directed home stretching program after a total of eight visits over six weeks.
Discussion
This patient had received the medical opinion that, at some point, surgery would be the only answer for his chronic knee pain. Fortunately, he persisted in searching for alternatives.
The combination of spinal and extremity adjustments, nutritional supplementation, and better support for the medial knee from improved muscle function and stabilizing orthotics resulted in an excellent response. In fact, he is now embarking on a wellness plan that includes addressing his lifestyle choices to improve his diet and overall health.
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Orthotics
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Written by John Danchik, D.C., F.I.C.C., F.A.C.C.
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Tuesday, 23 October 2012 18:00 |
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History and Presenting Symptoms
A 41-year-old male presents with recurring episodes of pain in his low back and left hip. He recalls no injury to the region, and cannot identify any precipitating activities or events. On a Visual Analog Scale, he rates his low back pain as varying from 30mm to 65mm, while the left hip pain is usually around 35mm. He takes over-the-counter NSAIDs when the pain interferes with his daily activities, and that usually provides marginal relief. He works as an RV (recreational vehicle) salesman and is also a volunteer nature trail guide. He is seeking non-drug treatment.
 Exam FindingsVitals.This male patient weighs 168 lbs, which at 5’10’’ results in a BMI of 24.1; he is not overweight. He is a non-smoker, and his blood pressure and pulse rate are both within the normal range.
Posture and gait. Standing postural evaluation finds a lower iliac crest on the right, and a low right greater trochanter. The left shoulder is noticeably lower than the right, with no history of fracture or surgery. His lower extremities are symmetrical, with no significant calcaneal eversion, foot flare, or low medial arch.
Chiropractic evaluation. Motion palpation identifies functional limitations in right lateral flexion and ipsilateral rotation at the L3/L4 and L4/L5 levels,with moderate tenderness and loss of endrange mobility. Hip ranges of motion are full and pain-free. All provocative orthopedic and neurological tests are negative for nerve root impingement and/or disc involvement.
Imaging
AP and lateral lumbopelvic x-rays in the upright, standing position are taken while weight bearing. The heels are aligned directly under the femur heads, and both knees are extended. A discrepancy in femur head heights is seen, with a measured difference of 7mm (right side lower). A moderate lumbar curvature (6°) is noted, convex to the right side, and both the sacral base and the iliac crest are lower on the right side. The sacral base angle and measured lumbar lordosis are within normal limits.
Clinical Impression
Moderate anatomical leg length discrepancy (right short leg), with associated pelvic tilt and lumbar curvature. There is an accompanying history of recurrent mechanical low back pain and left hip pain.
Treatment Plan
Adjustments. Specific, corrective adjustments for the lower lumbar region were provided as needed, with good response.
Support. Individually designed stabilizing orthotics were supplied, and a permanent 5mm heel lift was added to the right side. These were introduced after the first week of regular adjustments.
Rehabilitation. He was instructed in a daily core strengthening program (the “easy eight” exercises), to be done at home using elastic exercise tubing. His exercise log was reviewed at each visit to ensure adherence to the exercise recommendations.
Response to Care
This patient responded rapidly to his spinal and pelvic adjustments. He reported no difficulty in wearing the orthotics, and no problems with the right heel lift. He brought with him to every visit his exercise log, which documented his regular performance of the home exercises. After eight visits over six weeks and daily home exercises, including wearing the orthotics with a heel lift, he successfully completed his re-examination and was released to a self-directed home stretching program. He has been seen occasionally for wellness adjustments, and he reports that he now feels “unbalanced” when he is not wearing his orthotics.
Discussion
With no history of injury to his leg, hip, or pelvis, this patient apparently has an anatomical short leg due to growth asymmetry. This condition, while not rare, is an often-overlooked cause of “mechanical” low back pain. Spinal adjustments and core strengthening exercises provided relief and improved function, but the underlying structural leg length inequality had to be addressed. Over time, this amount of discrepancy was bound to cause low back discomfort, and eventually degenerative changes in the spine and the hip joint of the longer leg. In most cases, a permanent heel lift is best supplied with individually designed stabilizing orthotics, in order to ensure good foot biomechanics.
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Orthotics
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Written by Kirk Lee, D.C.
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Sunday, 22 July 2012 22:28 |
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A s chiropractors, when we conduct our case histories and examinations we typically determine mechanisms of injury to be related to specific instances of trauma, repetitive macrotrauma or microtrauma. However, we should also consider posture, activities of daily living and hobbies as these can sometimes be the root cause of a patient’s pain. Today we are going to take into consideration a patient whose hobby provided the underlying cause.
 Mr. S. is a well-known golfer in our area. He is 60 years of age, has won several county senior titles and has played at a very competitive level for many years. He presently plays at a “scratch” handicap. Mr. S. has been a patient for a number of years and has always understood the importance of regular chiropractic adjustments and exercise. Early this spring, he came to us with a new complaint of pain in his left low back area radiating into his left hip. Pain was also noted in the area along the lateral tibia of the left leg and continued pain over the lateral aspect of the foot. Mr. S. also feels that when he walks he is placing more pressure down on the left foot.
He denies any falls or accidents. When we asked him if he had changed any activity in his exercise program, he stated he was doing the same thing he had in the past. Examination of his gait cycle demonstrated a longer stance phase on the left side in comparison to the right. Video analysis also noted a slight limp with his left leg when he proceeded through the stance phase of gait. Muscle testing noted a weakened abductors bilaterally and gluteus maximus on the left. The left foot showed reduced dorsiflexion while walking and through active and passive ranges of motion. A digital foot scanner demonstrated that Mr. S. had symmetry of all three arches on the right foot, but on his left foot the lateral arch had dropped significantly. Showing Mr. S. the results of his scan, he remembered that he started doing some golf drills that helped him keep more pressure on his left side when finishing his swing, and that they put a lot of stress on the outside of his foot. He stated, “The pain did start a few days after I started those drills!”
Our treatment included stabilizing orthotics to provide his feet with symmetrical stability. Also, we adjusted the left foot after we determined his reduced dorsiflexion was due to a misaligned calcaneus and talus. Abduction exercises and glute-strengthening exercises were all recommended to provide additional stability to further enhance the chiropractic full spine adjusting. We hypothesized that Mr. S. was focusing so much on his weight transfer in his golf swing that he was placing excessive stress on the outside of his left foot. Coupled with rotation stress during his swing finish he developed a neuro-musculoskeletal condition through his changes in his normal biomechanical movement patterns.
Although he could not initially recall a mechanism of injury for the complaints that brought him back into our office, after examination and further questions about his lifestyle and hobbies we were able to determine the root cause of his pain. Since we had no history of any additional trauma, some activity in his daily living had to be a contributing factor. This is an important step to apply with any patient who complains of pain without injury. Consider a patient’s hobbies and see if what they do for fun could be the source of their pain.
A 1980 graduate of Palmer College of Chiropractic, Dr. Kirk Lee is a member of the Palmer College of Chiropractic Post Graduate Faculty and Parker College of Chiropractic Post Graduate Faculty. He has lectured nationwide on sports injuries and the adolescent athlete, and currently practices in Albion, Michigan.
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