Orthotics


Diabetic Foot Requires Special Care
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Friday, 25 June 2010 00:00

History and Presenting Symptoms

A 66 year-old female presents with aching lower back pain and numbness extending into both feet. She reports having had occasional lower back pain for many years, but has only noticed the foot numbness in the past six months. This is getting more constant, which concerns her. She recalls no specific back or foot injuries. On a 100mm Visual Analog Scale, she rates her low back pain as usually 20-30mm. Both feet are equally numb, with no noticeable pattern or causative activity.

Exam Findings

Vitals. This 5’4’’ aging female weighs 168 lbs, which results in a BMI of 29. She is aware that she is bordering on obesity and has been unsuccessfully trying to lose weight. She hasn’t been able to exercise recently because of her back pain and numb feet. Her blood pressure is http://www.theamericanchiropractor.com/images/danchickissue6.jpgelevated at 144/96 mmHg and her pulse rate is 84 bpm.

Posture and gait. Standing postural evaluation finds evidence of abdominal obesity, with a loss of the lumbar curve, and an accentuated thoracic kyphosis. There is no significant lateral listing of her pelvis or spine. She demonstrates bilateral calcaneal eversion, with no evidence of medial arches bilaterally. During gait, both feet pronate substantially and flare outwards (toe-out).

Chiropractic evaluation. Motion palpation identifies numerous limitations in intersegmental spinal motion: the left SI joint, the lumbosacral junction on the left, L3/L4 on the right, T11/12 generally and at the cervicothoracic junction. Palpation finds generalized paraspinal muscle tenderness, but no specific muscle spasm in these regions. All active thoracolumbar spinal ranges of motion are limited slightly by aching pain and stiffness. Provocative orthopedic and neurological tests for nerve root impingement and/or radiculopathy are negative.

Lower extremities. Both feet are generally insensitive to both pinprick and dull pressure evaluation. No specific dermatomal or peripheral nerve pattern is identified. Manual testing finds no significant muscle weakness in the fibular (peroneal) or anterior tibial muscles on either side. The feet and ankles are moderately edematous and the skin is somewhat blotchy.

Imaging and Lab

A weightbearing lumbopelvic X-ray series finds generalized loss of lumbar disc heights, most obvious at the lumbosacral joint and L3/L4. The L3 vertebral body is translated forward approximately 5 mm. The sacral base angle and lumbar lordosis are both decreased, consistent with her postural analysis. Fasting glucose level is found to be 134 mg/dL.

Clinical Impression

"Diabesity" (central obesity and type 2 diabetes) with early peripheral neuropathy. This is accompanied by degenerative lumbar spondylolisthesis. She also provides evidence of poor support from the lower extremities, with hyperpronation and substantial calcaneal eversion bilaterally.

Treatment Plan

Adjustments. Specific, corrective adjustments for the SI joints and the lumbar and cervicothoracic regions were provided as needed, with good response. Manipulation of the feet and knees was also performed.

Support. Custom-made, flexible orthotics were provided, made of comfortable and supple viscoelastic materials. She was given instructions in proper shoe selection, including the importance of correct sizing. It turned out that her shoes were too small and she purchased better-fitting shoes (one full size larger), which then accommodated the inserts without difficulty.

Rehabilitation. She received instruction in a comprehensive spinal stabilization exercise program using elastic resistance tubing. She was shown how to incorporate an exercise log with her food diary, which she brought to each visit so her continued adherence to diet and exercise recommendations could be encouraged.

Response to Care

The adjustments were well-tolerated, and orthotics made a noticeable improvement in her postural alignment at the feet and the lumbopelvic region. Her low back symptoms resolved and her foot numbness decreased significantly. At eight weeks of 12 adjustments and daily home exercises, including wearing her orthotics, she was released to a self-directed maintenance program. She was encouraged to continue her diet and exercise program.

Discussion

The combination of obesity and type 2 diabetes (insulin insensitivity) is a growing problem. Once referred to as "adult onset," this type of diabetes is now seen in adolescents. One result of altered glucose levels is peripheral neuropathy, which can present as bilateral "glove and/or stocking" paresthesiae. If numb feet are repeatedly traumatized, they develop sores and infections, with a real risk of amputation. Proper shoe fit and frequent foot self-examination are necessary in order to prevent further deterioration of foot health.

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.

 

 
To Stabilize Lumbar Fixations
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Sunday, 25 April 2010 00:00

History and Presenting Symptoms

A 56 year-old female describes a history of numerous episodes of lower back pain and disability. She reports that she has previously had physical therapy and chiropractic care, and has been evaluated by an orthopedic surgeon. None of the prior treatments has provided any long-term relief, since her low back pain returns, in spite of treatments and exercises. She says that she has evidence of spinal degeneration on her X-rays, but an MRI ordered by the orthopedic surgeon found no disc herniation or spinal stenosis. On a 100mm Visual Analog Scale, she rates her low back pain at about 45mm, with an occasional 80mm.

http://www.theamericanchiropractor.com/images/danchickartpic.jpgExam Findings

Vitals. The patient is a petite woman, who stands just over 5’ and weighs 122 lbs, resulting in a BMI of 23–she is not overweight. She has never smoked, and her blood pressure is 116/78 mmHg with a pulse rate of 68 bpm. She drinks wine and beer occasionally, and exercises regularly by walking briskly each morning with a neighborhood friend.

Posture and gait. Standing postural evaluation finds a lower iliac crest on the left, and a low left greater trochanter. The right shoulder is somewhat lower than the left, with no history of fracture or surgery. Her knees are well-aligned and there is no significant calcaneal eversion, foot flare, or low medial arch. Inspection of her shoes finds some scuffing and wearing at the lateral aspect of both heels.

Chiropractic evaluation. Motion palpation identifies several limitations in spinal motion at the right SI joint, the lumbosacral junction, L2/3, and at the cervicothoracic junction. Except for the right SI joint and the right piriformis and gluteus medius muscles, palpation elicits no significant tenderness, and all active spinal ranges of motion are full and pain-free. Her hip ranges of motion are also full and pain-free bilaterally.

Imaging

AP and lateral lumbopelvic X-rays in the upright, standing position are taken with the patient weight-bearing, heels aligned directly under the femur heads, and both knees extended. A substantial discrepancy in femur head heights is noted, with a measured difference of 8mm (left low femur head). A moderate left convex lumbar curvature (9°) is noted, and both the sacral base and the iliac crest are lower on the left side. There is noticeable loss of the L5/S1and L4/5 discs, with moderate osteophyte formation involving both motion segments. The sacral base angle and measured lumbar lordosis are within normal limits.

Clinical Impression

Multiple chronic lumbopelvic fixations, with an apparent anatomical leg length discrepancy (left short leg) and associated pelvic tilt and lumbar curvature. Evidence of chronic biomechanical stress is seen in the degenerative changes of the lowest spinal motion segments.

Treatment Plan

Adjustments. Specific chiropractic adjustments for the lumbosacral and sacroiliac joints were provided. Side-posture techniques were well tolerated in the lumbopelvic region, and resulted in very good articular releases.

Support. She was fitted with shock-absorbing, flexible custom-made orthotics based on imaging the foot in mid-stance (weightbearing). On a trial basis, she was temporarily fitted with a 4mm heel lift. A 6mm heel lift was permanently built onto the left orthotic. The stabilizing supports were introduced immediately, following the first week of regular adjustments. She had no difficulty in adapting to the heel lift or the orthotics.

Rehabilitation. She was instructed in a daily, at-home core strengthening program using elastic exercise tubing. The focus was on activation of her transverse abdominis and quadratus lumborum muscles, for improved spinal-pelvic stability.

Response to Care

This patient responded well to her spinal adjustments, and adapted well to her custom-made orthotics with the heel lift. After six weeks of adjustments (eight visits) and daily home exercises, she was released to a self-directed maintenance program.

Discussion

This patient had chronic lumbopelvic fixations, caused by her anatomical discrepancy in leg length, that had not been previously identified. In addition to spinal adjustments, her treatment included correction of her left short leg using a heel lift.

 

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.

 
Groin Strains
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Thursday, 25 February 2010 00:00

History and Presenting Symptoms

A 45-year-old male presents with occasional, moderate pain in his left hip and groin. He has been evaluated for hernia and arthritis, with no definitive diagnosis and no successful treatment. Physical therapy with various modalities and exercises felt good, but didn’t resolve his problem. He says that he has noticed these symptoms for at least the past six years, and possibly longer. He recalls no injury to his hip or groin, and reports that he has never been active in sports. On a 100mm Visual Analog Scale, he rates his left groin pain as about 40mm. He has not identified any specific activities that consistently worsen or improve the symptoms.

http://www.theamericanchiropractor.com/images/Danchick.jpg

Exam Findings

Vitals. This middle-aged male weighs 187 lbs, which at 5’11’’ results in a BMI of 27–he is slightly overweight, but has not established a regular exercise program because of his concern about his groin pain. He tries to eat a low-fat diet, but travels for business and is frequently unable to eat healthily. He was a pack-a-day cigarette smoker, but quit successfully four years ago. His blood pressure is 124/84 mmHg and his pulse rate is 80 bpm.

Posture and gait. Standing postural evaluation finds a lower iliac crest on the left, and a low left greater trochanter. The right shoulder is somewhat lower than the left, with no history of fracture or surgery. His knees are well-aligned, but there is medial bowing of the left Achilles tendon, associated with calcaneal eversion. Dynamic examination of walking revealed excessive pronation of the left foot.

Chiropractic evaluation. Motion palpation identifies several mild limitations in spinal motion: the left SI joint, the lumbosacral junction, T11/12, and the cervicothoracic junction. There is no localized tenderness in these regions, and all spinal and hip ranges of motion are full and pain-free. Provocative regional orthopedic and neurological tests are negative.

Lower extremities. Closer examination finds that the left medial arch of the foot is lower than the right when standing. When he is seated and non-weightbearing, the left arch appears equal to the right, and when he performs a toe-raise while standing, the left arch returns. Manual testing finds no significant muscle weakness in the hip abductor or adductor muscles, although the right adductor muscles are "sore" when stressed isometrically.

Imaging

AP and lateral lumbopelvic X-rays in the upright, standing position are taken while weightbearing. An obvious pelvic tilt and leg length discrepancy are noted, with the left femur head 7 mm lower. A moderate lumbar curvature (4°) is noted, convex to the left side, and both the sacral base and the iliac crest are lower on the left. The sacral base angle and measured lumbar lordosis are increased, but within normal limits. No loss of joint spacing or osteophyte formation is seen in the hip joints.

Clinical Impression

Moderate functional leg length discrepancy (left short leg) when standing, with associated pelvic tilt and slight lumbar curvature.

Treatment Plan

Adjustments. Specific, corrective adjustments for the SI joints and the lumbar, thoracic, and cervical regions, as well as soft tissue manipulation, were provided as needed. Manipulation of the left navicular, cuboid, and calcaneal bones was also performed.

Support. Flexible, custom-made stabilizing orthotics were supplied, with a pronation correction added to the left side. He had no difficulty in adapting to the orthotics.

Rehabilitation. He was shown a series of upright strengthening exercises for all hip ranges of motion, in order to speed the process of adaptation to the new alignment. After two weeks, he began a daily brisk walking program, progressing from 20 minutes to 40 minutes.

Response to Care

The spinal, pelvic, and foot adjustments were well tolerated, and the orthotics made a noticeable improvement in his postural alignment, at the feet and in the lumbopelvic region. After four weeks of adjustments (seven visits) and daily home exercises, including walking with orthotic support, he was released to a self-directed maintenance program.

Discussion

Chronic biomechanical stress can cause low-grade nociception that is difficult to track down. Had this patient been more athletically involved, it is likely that his lower extremity asymmetry would have become more obviously symptomatic. With chiropractic care and foot stabilization, he could safely initiate a walking and exercise program for health and weight control.

 

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.

 
Runner for the Cure Develops Heel Pain
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Friday, 25 December 2009 00:00

History and Presenting Symptoms

A 25-year-old female presents with pain around her right ankle and heel. The pain has been present for about three weeks and gets worse upon weightbearing activity. She also relates running about six times per week for five miles a day, in preparation for her first half-marathon run in support of breast cancer awareness. She denies any specific injuries or direct trauma. Her medical doctor has diagnosed plantar fascitis, but she is not responding to the non-steroidal anti-inflammatory medications he prescribed.


Exam Findings

Vitals. This active young woman weighs 127 lbs. which, at 5’5’’, results in a BMI of 22; she is not overweight. She does not use tobacco products, and her blood pressure and pulse rate are within the normal range. Posture and gait. Standing postural evaluation reveals basically good alignment, but a decreased lumbar lordosis. She demonstrates bilateral calcaneal eversion, worse on the right, with a lower right arch. Gait evaluation finds obvious hyperpronation of the right foot and ankle when walking, which is accentuated when running. Chiropractic evaluation. The lumbar spine is moderately tender throughout, and she demonstrates a generalized loss of vertebral mobility, with few specific fixations. Orthopedic and neurological provocative testing of the spine and pelvis is negative. Primary complaint. Palpatory examination of the right foot elicits significant tenderness to medial/lateral squeezing of the right calcaneus. No point tenderness is noted at the insertion of the plantar fascia into the anterior aspect of the calcaneus. All right foot and ankle ranges of motion are full and pain free. Also, manual muscle testing reveals no evidence of weakness when compared to her left side.

 

Imaging

A lateral X-ray of the right foot demonstrates a calcaneus and talus that appear normal. There is no evidence of fracture, sclerosis or periosteal reaction.

 

Clinical Impression

Stress response in the right calcaneus bone, with moderate lumbar spine joint dysfunction. There is no evidence of plantar fascitis or subtalar joint malfunction.


Treatment Plan

Adjustments. Mobilization and adjustments were provided to the lumbopelvic region. The right calcaneus was adjusted anteriorly and both navicular bones were adjusted superiorly. Support. Flexible, stabilizing orthotics with shock-absorbing viscoelastic materials were custom made to support all three arches of each foot, in order to decrease calcaneal eversion and heel-strike shock. Rehabilitation. A foot-wheel device was recommended to improve the coordination of her foot intrinsic muscles. Once she had her orthotics, she also performed standing Achilles tendon stretches with knee straight, and then bent.

 

Response to Care

She was told to avoid walking as much as possible for the first week, and then only limited walking for two more weeks. She was permitted to increase her walking over the following three weeks and gradually incorporated short periods of running. At six weeks, she returned to her training program with no recurrence of heel pain, and she was released to a self-directed home stretching program after a total of 10 visits over two months.


Discussion

Stress fractures generally occur in the lower extremities, beginning as a stress response that can progress to a frank fracture. It is often said that a stress fracture is a normal response of bone to abnormal doses of stress. The rear foot or heel area of athletes is particularly susceptible to these overuse injuries, as most sports and training activities include a component of running, which places large amounts of stress on the anatomical structures of the foot and ankle. There is a higher incidence of stress fractures in young women (10:1), which is thought to be associated with their smaller bone structure, decreased lean body mass, and possible poor nutrition secondary to eating disorders.

Initial radiographs may be negative in up to 70% of patients with stress fractures. The radiographic evidence of stress fractures often lags two to three weeks behind the onset of symptoms. Typically, there will be a dense margin of sclerosis perpendicular to the trabecular meshwork and parallel to the posterior contour. Serial radiographs or radionuclide bone scans may be necessary when the initial diagnosis is questionable. In this case, the exam findings and response to treatment were clear, and no further imaging was needed.


 

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.

 
Audit Proof Your Practice
Orthotics
Written by Dr. Paul B. Bindell, D.C.   
Sunday, 25 October 2009 00:00

The curse is that insurance companies use computers to burden and audit you. The blessing is greater because the computer protects you from audits, minimizes paperwork and eliminates 95% of paper filing.

 

Doctors praise Electronic Health Record (EHR) computers. When audited, those doctors produced high quality SOAP records that matched the bills. The only loss was a small amount of time to deal with the audit.

On the other hand, there are horror stories from colleagues that did not have good notes. The auditors came, found the documentation did not match the billing, and demanded refunds from a few thousand to more than half a million dollars. Then the auditors filed complaints with state boards and departments of fraud. If notes do not match billing, an audit will turn your life into hell.

 

You have the ability to audit proof your office. It begins with fully integrated EHR management and a documentation computer that guarantees notes and billings match. The patient is signed in, the patient’s name automatically appears in the adjusting room, enters the SOAP note including the services performed, the taps and clicks are converted into a dictation quality note, and the documentation generates the charges. The patient signs out electronically, verifying the services and accepting responsibility to pay. In the event of an audit, there is a perfect match between the notes and billing, and electronic proof that the patient received the services.

 

Take a realistic look at your practice. Do your notes and bills match? If your answer is, "NO," then you are open to a devastating audit. For your own benefit, fix this dangerous situation before the auditor comes. Use an EHR system and bill only for documented services.  

Hell 

Are there times you perform a service, bill for it, but do NOT document it? An insurance auditor will use this to prove fraud, and there is nothing you can do after the fact to prove the falseness of the accusation. When using an EHR program where documentation produces the billing, there is never a bill that is not documented.

 

How frequently does a patient tell you something that you do not include in your records? What recommendations to patients are not in writing? Computerized SOAP documentation makes it simple, fast and easy to include these things. Using a tablet computer with handwriting recognition, it is a breeze to just jot something into the progress note and have it appear as if it was typed. Some programs integrate with Dragon Naturally Speaking, allowing you to dictate, converting your speech into typed text. The critical point is to record everything that the patient tells you, as well as to record all the advice and recommendations you gave.

 

A cash, pay as you go, practice does NOT protect you from audits. Although it reduces the chances of being audited, there are many cash practices that have been audited. The courts ruled that, as soon as a patient submits a receipt for services to insurance, you are held to the same standard as if you were a participating doctor accepting assignment. This means that, even in a practice where every patient pays you up front and you never send anything directly to an insurance company, the insurance company has the right to audit. Some cash practice doctors have had an extremely rude awakening, being required to refund substantial amounts, and then having to deal with departments of insurance fraud. The bottom line is that, no matter what type of practice you have, it is critical that your billing and documentation match.

 

Documentation extends beyond SOAP notes. Do you send letters to patients? Better EHR office management and documentation systems include templates for letters and documents, and save a copy of each in the patient’s file. Narrative reports are saved as part of the electronic record.

There should be a record of every phone call, including the date and time of the call, who was spoken to and what was said. EHR systems include phone logs in each patient file, and this phone log may save you a lot of grief. A real life example: Several years ago a mechanic came in with severe low back and leg pain. The doctor determined the patient had a disc lesion, and treated it. The patient felt relief and went home with instructions for bed rest and to return the next day. The patient did not return. The doctor called to find out what happened. The patient’s wife answered and reported that the patient felt so much better that he was outside, under his truck, replacing the transmission. The doctor entered this in the patient’s phone log. A few weeks later, the doctor received a records request from an attorney. The records with the log were sent to the attorney, and that was the end of it. The doctor learned that the patient ruptured his L5 disc while changing the transmission, but was blaming the doctor. If the log had not been maintained, the doctor would have had a nasty malpractice suit.

 

Even in a practice where every patient pays you up front and you never send anything directly to an insurance company, the insurance company has the right to audit.

Police reports, MRI or other reports, pictures, explanation of benefits (EOB’s) and other documents need to be part of the patient’s records. EHR programs include the ability to scan these things into the patient’s file, making them accessible at the touch of a button.

 

In an audit, it is necessary to prove that you are always aware of clinically special items about a patient. This could be a message regarding a condition (osteoporosis, gibbus formation, disc herniation, spina bifida) or to use a specific procedure. EHR programs include these notices as pop ups in the patient’s file, and the record of these pop ups can be printed easily.

Dr.-Paul-BindellThe blessing of the right EHR computer system is that it protects you from audits, saves you time in the office, and increases your income. The time to accept and use this blessing is before an auditor pays you a visit.

 

 
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