Orthotics


Heel Pain in a Cross-Country Runner
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Wednesday, 27 August 2008 09:32

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 . 

 
Upper Extremity Conditions and Orthotic Support
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Friday, 27 June 2008 12:17

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 .

 
Plastic Deformation, Back Pain in a Walker
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Monday, 28 April 2008 13:06

History and Presenting Symptoms

A 48-year-old male presents with persistent pain in his lower back region. He describes his back pain as an aching tightness, which has been progressively worsening over the past six months. On a Visual Analog Scale, he rates his current level of pain at around 35mm to occasionally 45mm. He is unable to identify any specific aggravating activities, but his efforts to lose weight by walking have made his low back symptoms more noticeable.

 

Exam Findings

Vitals. This middle-aged man is trying to lose weight by increasing his walking. He now weighs 187 lbs, which at 5’10’’ results in a BMI of 27; he is overweight, but not obese. He is down from 205 lbs one year ago. He reports that he has not used tobacco since he quit twelve years ago, but he is a regular drinker of alcohol, averaging three "lite" beers daily. His blood pressure is 128/86 mmHg, with a resting pulse rate of 76 bpm. These findings are at the upper end of the normal range, but have reportedly improved since he started his exercise program.


Posture and gait. Standing postural evaluation finds a lower iliac crest on the right, and a low right greater trochanter. There is a moderate lumbar list to the right, with compensatory balancing in the thoracic spine, causing the left shoulder to be lower than the right. His right arch is significantly lower than the left, and the right calcaneus is everted. Palpation of the right arch when standing elicits no pain or tenderness in the plantar fascia. Gait evaluation finds hyperpronation with external foot flare on the right. The Navicular Drop Test demonstrates greater excursion of the right navicular bone from sitting to standing (non-weight bearing to weight bearing). Chiropractic evaluation. Motion palpation identifies several mild limitations in spinal motion: the right SI joint, L4/L5, T11/12, and at the cervicothoracic junction. Palpation finds some local tenderness in these regions, but no muscle tone or texture changes. Lumbar ranges of motion are full and pain-free, and neurological testing is negative.

Imaging Upright, weight-bearing X-rays of the lumbar spine demonstrate a moderate loss of intervertebral disc height at L4/L5, accompanied by small osteophytes. A mild lumbar curvature (5°) is noted, convex to the right side. A discrepancy in femur head heights is seen, and both the sacral base and iliac crest are lower on the right side, while the sacral base angle and measured lumbar lordosis are within normal limits. A collimated pelvic view with the femur heads centered finds a measured difference of 7mm in the heights of the femur heads, with the right side lower.

 

Clinical Impression

Moderate lumbar disc degeneration and osteoarthritis, and mild postural imbalance in the lumbar spine and pelvis. This is associated with asymmetry of arch support due to plastic deformation of the support ligaments, resulting in a functional short leg on the right side.


Treatment Plan

Adjustments. Specific chiropractic adjustments were provided for the involved spinal segments.

Support. Flexible, stabilizing orthotics were custom-made to support the plastic deformation in his right arch and calcaneus and to decrease the asymmetrical stress on the pelvis and spine. An additional layer of viscoelastic material was included to decrease shock transmission during walking.

Rehabilitation. He was shown a series of elastic tubing exercises to improve the strength and coordination of his deep spinal stabilizing musculature.

Response to Care

He responded rapidly to the adjustments and exercise, with an immediate decrease in symptoms. Within two weeks of receiving the orthotics, he was able to pursue his walking program without back pain. At a re-exam after eight treatments over two months, he demonstrated good spinal and pelvic alignment with his orthotics in place, and was released to a self-directed maintenance program.

 

Discussion

The combination of spinal degenerative change, excess weight, and biomechanical imbalance became problematic when aggravated by increased exercise activity. With no noticeable foot or arch symptoms, this patient was undergoing plastic deformation of his right arch. The Navicular Drop Test helped to identify this condition. The result was a chronic asymmetrical strain on his pelvis and spine that was easily addressed with chiropractic methods.

 

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 .

 
Recurring Calf Strains
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Friday, 29 February 2008 14:04

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

 
Callus Formation in a Corporate Executive
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Thursday, 08 November 2007 16:22

History and Presenting Symptoms

 

The patient is a 52-year-old male, who was previously treated successfully for a lumbar disc problem, and who now returns to this clinic reporting pain and skin thickening (callus formation) on the bottoms of both feet. He has tried several remedies, but his calluses always return.

Exam Findings

Vitals. This middle-aged, physically active corporate executive weighs 175 lbs, which at 5’10’’ results in a BMI of 25 – he is on the borderline of overweight. Because of the results of a recent key executive physical exam, which showed an increased low density lipoprotein (high LDL), he has been working out regularly and is generally quite fit. Physical inspection indicates that some of his excess weight may be lean body mass. He is a non-smoker, and his blood pressure is within the normal range.

Posture and gait. Standing postural evaluation finds a slight lumbar list to the right, with compensatory balancing in the lower thoracic spine. He has a forward pelvis, and a decreased lumbar lordosis. He also demonstrates bilateral flat feet (pes planus), with no medial arches and bilateral calcaneal eversion. Both feet toe out during walking.

Chiropractic evaluation. The lumbar spine is moderately tender throughout, and he demonstrates a generalized loss of vertebral mobility. Motion palpation identifies limitations in segmental motion at L4/L5 and L5/S1, with some local tenderness. These segmental dysfunctions demonstrate loss of endrange mobility in all directions. Additional subluxations are noted at T9/T10 and C6/7. Orthopedic and neurological provocative testing of the spine and pelvis is negative.

Primary complaint. Lower extremity examination finds thickening of the skin and tenderness to palpation over the heads of the second and third metatarsal bones on both feet. This is in the anterior transverse arch region. All foot and ankle ranges of motion are full and pain-free, and manual muscle testing finds no evidence of weakness in the surrounding musculature. Squeeze test is negative for interdigital irritation.

Imaging

Upright, weight-bearing X-rays of the lumbar spine demonstrate moderate loss of intervertebral disc height at L4/L5 and L5/S1, with small osteophyte formation at those levels. A slight discrepancy in femur head heights is noted, with a difference of 3mm (right side lower). A moderate lumbar curvature (4°) is noted, convex to the right side, and both the sacral base and the iliac crest are lower on the right. The sacral base angle and measured lumbar lordosis are within normal limits.

Clinical Impression

 

Repetitive biomechanical stress to the tissues underneath the 2nd and 3rd metatarsal heads, resulting in callus formation. This is accompanied by chronic lumbopelvic spinal subluxations secondary to long-standing biomechanical stress on the anterior arches of the feet.

Treatment Plan

Adjustments. Specific adjustments were provided to the lumbopelvic region. Both feet also received adjustments for collapsed anterior transverse metatarsal arches.

Support. He was fitted with custom-made, flexible stabilizing orthotics designed to provide support for the anterior transverse arches, under the metatarsal heads. The orthotics were made with viscoelastic, shock-absorbing materials, in order to support all three arches and limit gravitational stress when standing and walking.

Rehabilitation. This active patient was told to continue his personal exercise program. He was instructed in a series of foot exercises (marble pick-up and towel-scrunching) to improve the coordination and strength of his anterior foot intrinsic muscles.

Response to Care

He responded well to the adjustments and exercises, and reported a rapid decrease in foot symptoms. Initially, he didn’t notice any change when wearing his orthotics, but within three weeks he no longer had any of the previous irritation in his feet. After eight weeks, his calluses were softer, and he had no more progression. He was released to a self-directed maintenance program after a total of ten treatment sessions over two months. When re-evaluated at a six-month check-up visit, he reported that his calluses had decreased significantly, and were no longer causing problems.

Discussion

This high-powered, active executive experienced unusual levels of repetitive biomechanical stress to his anterior arches, which resulted in callus formation. He responded well to conservative chiropractic care and custom-made orthotics. The best treatment for these types of problems is a conservative approach, with a combination of chiropractic adjustments, flexible orthotic support, corrective exercises, and education.

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 .

 

 
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