History and Presenting Symptoms

A 21-year-old female cross-country runner presents with pain around her right heel that extends into the underside of her large toe, and is limiting her running. The pain has been present for about six weeks and has not responded to her use of stretching, ice and ibuprofen. She has also noticed that her altered gait is beginning to cause a build-up of tightness and stiffness in her back. She describes a recent history of increasing her running to about sixty-five miles a week in training for the upcoming season of her college cross country team. She denies any specific injuries or direct trauma.

Exam Findings

Vitals. This athletic young woman weighs 138 lbs which, at 5’7", results in a BMI of 22; she is not overweight and appears very fit. She describes a healthy diet and only an occasional intake of alcohol (wine). She has never used tobacco products, and her blood pressure and pulse rate are both within the normal ranges.

Posture and gait. Standing postural evaluation finds generally good alignment, with a slightly increased lumbar lordosis. She demonstrates bilateral calcaneal eversion, worse on the right, with a low right arch. Treadmill gait evaluation finds obvious hyperpronation of the right ankle and foot, which flares outward when walking. The pronation and foot flare are both accentuated when she runs at her usual training and racing paces.

Chiropractic evaluation. The lumbar spine is moderately tender throughout, and she demonstrates a generalized loss of vertebral mobility, with specific fixations noted at L5/S1, L3/L4, and the thoracolumbar junction. Her right SI joint is tender to pressure into extension. Otherwise, all orthopedic and neurological provocative testing of the spine and pelvis is negative.

Primary complaint. Palpatory examination of the right foot elicits no tenderness to medial/lateral squeezing or percussion of the right calcaneus. Moderate point tenderness is noted at the insertion of the plantar fascia into the anterior aspect of the calcaneus. Extension of the toes during foot dorsiflexion elicits a "pulling" pain from the large toe into the heel. All right foot and ankle ranges of motion are full and pain free and manual muscle testing finds no evidence of weakness when compared to the left side.

Imaging

X-rays of the right foot demonstrate a normal-appearing calcaneus, talus and midfoot, with no evidence of stress fracture, sclerosis or periosteal response.

Clinical Impression

Chronic strain of the plantar connective tissues and muscles, with altered gait causing moderate lumbar spine and sacroiliac joint dysfunction. There is no evidence of plantar fascitis, stress fracture or subtalar joint arthritis.

Treatment Plan

Adjustments. Specific, corrective adjustments for the lumbar region and right SI joint were provided as needed, with good response. The right calcaneus was adjusted anteriorly and both navicular bones were adjusted superiorly.

Support. Flexible, stabilizing orthotics were custom made, using viscoelastic, shock-absorbing materials and fitted to support the arches and to reduce calcaneal eversion (pronation correction) and impact at heel-strike.

Rehabilitation. The patient was shown marble pick-up and towel-scrunching exercises 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 limited to brisk walking for the first week, and she gradually incorporated short periods of running during the next two weeks. Once she had adapted to her orthotics, she returned to her full training program with no recurrence of foot pain, and no persisting back symptoms. She was released to a self-directed chiropractic maintenance program after a total of eight visits over six weeks.

Discussion

Athletes frequently develop lower extremity symptoms, especially as they increase their training programs. The foot and heel regions are particularly susceptible to athletic 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. Any mild biomechanical asymmetry can produce local or distant symptoms. In this case, both foot pain and back pain resulted from the combination of an aggressive training program with chronic stress on the feet and arches.

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 This e-mail address is being protected from spambots. You need JavaScript enabled to view it . 

History and Presenting Symptoms

A 43-year-old female presents with persistent pain in and around her left shoulder, accompanied by tightness extending into her middle back region. Upon further discussion, she recounts a history of a right carpal tunnel syndrome that was treated surgically, with only partial improvement. She has also had several episodes of left elbow tendinitis. She denies any obvious traumas or injuries to her upper extremities. Because of her various upper extremity problems, she is unable to participate in any regular physical activity, and has gradually gained weight over the past ten years. She is an independent real estate agent.

Exam Findings

Vitals.

This self-employed woman weighs 158 lbs, which, at 5’6’’, results in a BMI of 26; she is overweight, but not obese. She is a non-smoker, but does drink alcohol (one to two glasses of wine) daily. Her blood pressure and pulse rate are in the normal ranges.

Posture and gait.

Standing postural evaluation finds noticeable unleveling of her shoulders, with the left shoulder carried lower and more forward than the right. The left scapula is protracted, and her left arm is internally rotated. While her head is well-balanced, and the spinal curves appear normal, she demonstrates an obvious pelvic tilt, with her right iliac crest lower than the left. When standing and walking, there is medial bowing of the right Achilles tendon, accompanied by calcaneal eversion, a low medial arch, and the tendency to toe out (foot flare) on the right side.

Chiropractic evaluation.

Motion palpation identifies moderate limitations in segmental motion at T3/T4 and T4/T5 with local tenderness, as well as restriction of rib motion at the associated costotransverse joints on the left. Cervical and lumbar ranges of motion are generally full and pain-free. Examination of her wrists, elbows and shoulders finds no ligamentous instability, and all upper-extremity joint ranges of motion are full and pain free. The sole exception is the left humerus, which is restricted in external rotation with moderate tenderness and loss of endrange mobility. Manual testing finds moderate weakness of the left teres minor and infraspinatus muscles, along with shortening of the left pectoralis muscles.

Imaging

Upright, weight-bearing X-rays of the cervicothoracic and lumbopelvic regions demonstrate a discrepancy in femur head heights, with the right femur 6mm lower. There is a very slight lateral curvature of the lumbar spine (4°), with the convexity to the right. No significant degenerative changes are noted.

Clinical Impression

Chronic mechanical dysfunction of the left shoulder associated with muscular imbalance and asymmetrical biomechanics in the pelvis and lower extremities. By history, there is a pattern of several upper extremity conditions, which are consistent with these identified asymmetries and imbalances.

Treatment Plan

Adjustments.

Specific chiropractic adjustments for the sacroiliac and thoracic spinal regions were provided as indicated, along with respiratory mobilization of the affected ribs.

Support.

Flexible, stabilizing orthotics were custom-made to support the arches, decrease calcaneal eversion, and support the functional leg length discrepancy.

Rehabilitation.

This patient was shown dynamic resistance exercises using elastic tubing for the external rotator musculature of the left shoulder, accompanied by door stretches for the left pectoralis muscles. Her program was progressed to include the scapular retractors on the left side, along with postural awareness instruction for daily activities.

Response to Care

This patient performed her home exercises regularly and adapted quickly to her stabilizing orthotics. She responded rapidly to the specific spinal and sacroiliac adjustments and the rib mobilizations. After eight weeks of adjustments (twelve visits) and daily home exercises, her upper extremities and spine were completely symptom-free, and she was released to a maintenance/wellness care program.

Discussion

Whenever a patient has multiple upper-extremity complaints and a thoracic spine involvement, I always want to evaluate the overall balance and function of the spine and pelvis in addition to the local problem. In this case, a previously unrecognized (and asymptomatic) asymmetry of the lower extremities was identified, which was causing a functional short leg. When this type of global malfunction is present, effective chiropractic care must address the lower extremity imbalances while, at the same time, treating the local shoulder dysfunction.

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 This e-mail address is being protected from spambots. You need JavaScript enabled to view it .