Orthotics


Pelvic and Hip Pain
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Saturday, 08 September 2007 09:00

History and Presenting Symptoms

A 27-year-old female describes a history of aching pain and tightness extending from her lower back into the pelvic region and both hips. She describes a recurrent pain that has bothered her since she was in a motor vehicle collision at the age of sixteen. As a passenger, she injured her right leg and hip during a frontal impact with a light post. No fractures were detected, but she had diffi culty walking for several months, and still gets very fatigued when walking or standing for more than 20 minutes. Her current pain is generalized to the posterior pelvis, but also involves her lower back and extends into both hips. On a 100mm Visual Analog Scale, she rates the pain in her lower back and pelvic region as varying from 30mm to 50mm.

Exam Findings

Vitals. This young woman weighs 152 lbs, which, at 5’9’’, results in a BMI of 22—she is not overweight. She reports that she attends yoga classes regularly and works out on a circuit training program at a local fi tness center. She has never smoked; she drinks beer occasionally; and her blood pressure is 118/76 mmHg with a pulse rate of 64 bpm.

Posture and gait. Standing postural evaluation fi nds a lower right iliac crest, and a low right greater trochanter. The left shoulder is somewhat lower than the right, but the spine demonstrates no signifi cant lateral curvature. Her knees are well aligned, but there is obvious medial bowing of the right Achilles tendon, with a lower medial arch on the right foot. During gait, the right foot toes-out and pronates excessively. Inspection of her shoes finds scuffing and wearing at the lateral aspect of the right heel.

Chiropractic evaluation. Motion palpation identifi es limitations in segmental motion at the right SI joint, with localized tenderness and loss of endrange mobility. Gaenslen’s and Yeoman’s tests for SI joint dysfunction both cause increased pain when the right side is stressed. Lumbar ranges of motion are within expected norms, and neurologic testing is negative for sensory, motor, and refl exive disorders.

Imaging

A lumbopelvic series (AP and lateral lumbopelvic views) is taken in the upright position during relaxed standing. An obvious discrepancy in femur head heights is noted, with the right side 6mm lower. A moderate lumbar curvature (5°) is convex to the right side, and the sacral base angle and measured lumbar lordosis are somewhat increased, but within normal limits. No loss of joint spacing or osteophyte formation is seen in the hip joints.

Clinical Impression

Chronic lumbopelvic misalignment, with mechanical dysfunction of the right sacroiliac joint complicated by leg length discrepancy. The difference in leg lengths is “functional,” since it is due to asymmetry of support in the lower extremities. The inequality results in a pelvic tilt and a slight lumbar curvature.

Treatment Plan

Adjustments. Specifi c chiropractic adjustments for the right sacroiliac joint and lumbar spine were provided as indicated. Manipulation of the right foot, including the navicular, cuboid, and calcaneal bones, was also performed. Support. Flexible, stabilizing orthotics were custom-made, and a pronation correction was added to the right side. The inserts provided support for her arches and included viscoelastic shock-absorbing material to decrease the biomechanical stress on her pelvis and sacroiliac joints.

Rehabilitation. She was shown a lumbopelvic muscle-training program to do in addition to her regular workouts. The “easy eight” exercises were performed daily at home using elastic exercise tubing.

Response to Care

The pelvis and foot adjustments were well tolerated, and the orthotics signifi cantly improved her postural alignment. After fi ve weeks of adjustments (eight visits) and daily home exercises, including wearing the orthotics, she was released to a self-directed maintenance program.

Discussion

This healthy and fi t young woman had a chronic pelvic misalignment caused by a prior injury. It was associated with pronation and biomechanical dysfunction in the right lower extremity. This asymmetry perpetuated her pelvic imbalance, in spite of a well-rounded fi tness program. She responded well to an appropriate combination of chiropractic adjustments, stabilization and support from custom-made orthotics, and specific exercises for the lumbopelvic support musculature.

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 .

 
Asymmetrical Pronation Linked to Juvenile Injury
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Friday, 06 July 2007 10:32

History and Presenting Symptoms

A 28-year-old male presents with recurring episodes of moderate low-back pain which always respond well to chiropractic adjustments, but eventually return. He recalls no specific back injuries, and cannot identify any triggering activities. On a Visual Analog Scale, he rates his low back pain currently at about 50mm. He has been able to avoid taking pain medication by getting regular chiropractic adjustments.

 

Exam Findings

Vitals. This active young man is 6 feet tall and weighs 176 lbs, resulting in a BMI of 24; his muscle definition indicates that he is not at risk of overweight. He doesn’t smoke, and his blood pressure is 116/78 mmHg with a pulse rate of 68 bpm. These findings are within the healthy range.

Posture and gait. Standing postural evaluation finds a lower right iliac crest and a low right greater trochanter. His knees are well aligned, but there is obvious medial bowing of the right Achilles tendon, and no medial arch on the right foot. When this is mentioned, he recalls a "bad sprain" injury to his right foot and ankle during high school football. He denies any persisting symptoms or current problems with the right foot or ankle.

Chiropractic evaluation. All active spinal ranges of motion are full and pain free, except that "aching stiffness" restricts left lateral flexion by 10°. Active palpation identifies a motion limitation in the right SI joint, which is also tender to direct pressure. Lumbosacral joint motion is restricted in left lateral flexion, with the feeling of generalized paraspinal muscle tightness. Provocative orthopedic and neurological tests for nerve root impingement and disc involvement are all negative.

Lower extremities. Closer examination reveals that he has no right medial arch when standing. His right calcaneus is noticeably everted when bearing weight. When seated and non-weightbearing, his right arch appears equal to the left, and manual testing finds no evidence of muscle weakness of the fibular or tibial muscles. The Navicular Drop test measures substantial asymmetry in excursion of the navicular bones when moving from sitting to standing (R = 3 mm of drop, L = 8 mm of drop from non-weight bearing to weight bearing). Palpation finds no significant tenderness in the right medial arch or plantar fascia.


Imaging

 

A lumbopelvic series (AP and lateral lumbopelvic views) reveals an obvious discrepancy in femur head heights, with a measured difference of 5 mm (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

 

Asymmetrical pronation likely due to previous injury, with associated pelvic tilt and lumbar curvature resulting in chronic biomechanical stress and recurring subluxations in the lumbopelvic region.

 

Treatment Plan

 

Adjustments. Specific, corrective adjustments for the SI and lumbosacral joints were provided—with good response, as previously. Manipulation of the right foot, including the navicular, cuboid, and calcaneal bones, was also performed.

Support. Custom-made, flexible stabilizing orthotics were supplied, with a pronation correction added to the right side. He had no problems in wearing the orthotics, finding them "very comfortable."

Rehabilitation. He was shown a series of lumbopelvic mobility exercises, using elastic exercise tubing at home. He was encouraged to continue his twice-weekly workouts at the local gym.


Response to Care

 

The lumbopelvic and foot adjustments were well tolerated, and the orthotics made a noticeable improvement in his postural alignment, both at the feet and the lumbopelvic region. After 6 weeks of adjustments (12 visits) and daily home exercises, including wearing the orthotics, he was released to a self-directed maintenance program.

 

Discussion

Excessive pronation and biomechanical asymmetries in the foot and ankle are often locally asymptomatic. In this active patient, the constant weightbearing stress to his SI and lumbosacral joints resulted in recurring spinal symptoms. Preventing chronicity is a vital aspect of chiropractic, and correction of this patient’s underlying pronation asymmetry was necessary. Having had no foot or ankle symptoms, he had not recognized that a previous lower-extremity sports injury could be a significant causative factor in his back problem. Fortunately, this was identified before any substantial degenerative changes developed.

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 .

 

 
Q-Angle Problems - Increased Running Increases Pain
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Monday, 04 June 2007 14:28

History and Presenting Symptoms

The patient is a 22-year-old recent college graduate, who reports a history of participation in many team sports in school, including field hockey, soccer, and softball. She admits that she has always had occasional knee problems, especially on the left side. She is now running regularly for fitness, and her left knee is noticeably sore and aching. More recently, she has developed stiffness and pain in her lower back, which is most noticeable after longer runs. She denies any specific injury to her knees or back, and reports that over-the-counter medications provide temporary relief.

 

Exam Findings

Vitals. This fit young woman weighs 126 lbs which, at 5’5’’, results in a BMI of 21—she is not overweight. She has never smoked tobacco, and her blood pressure and pulse rate are both at the lower end of 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, with hyperpronation on the left side. Measurement finds a standing Q-angle of 27° on the left and 24° on the right (20° is normal for women). Evaluation of running gait identifies a tendency to hyperpronate, especially on the left.

Chiropractic evaluation. Motion palpation identifies a limitation in lumbosacral motion, with loss of endrange mobility to the left at L5/S1. Compensatory subluxations are noted at T10/T11 and T7/T8. Neurologic testing is negative.

Primary complaint. Clinical examination of the left knee finds no evidence of ligament instability, meniscal damage, or patellar tracking problems. All knee ranges of motion are full and pain-free, bilaterally. Manual muscle testing finds no evidence of specific muscle weakness or regional neurological dysfunction.

 

Imaging

No X-rays or other forms of musculoskeletal imaging were considered clinically necessary.

 

Clinical Impression

Excessive Q-angle on the left, associated with calcaneal eversion and hyperpronation. This is accompanied by lumbosacral and lower thoracic joint motion restrictions and compensatory subluxation.

 

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 her elevated Q-angle and hyperpronation. Both feet were adjusted as needed, especially the navicular bones.

Support. Custom-made, flexible stabilizing orthotics were provided to support all three arches and decrease the Q-angles. These included bilateral pronation corrections at the heel. As is necessary for most physically active patients, two pairs of stabilizing orthotics were ordered —one designed specifically for her running shoes and the other for her dress shoes at work.

Rehabilitation. Due to her active lifestyle, no specific rehab exercises were required. She was encouraged to perform a comprehensive stretching program after each run.

 

Response to Care

She reported a rapid response to the spinal and knee adjustments. After she began wearing her orthotics regularly during her runs, she reported a definite reduction in knee soreness, as well as a smoother stride and gait. Within three weeks of receiving her orthotics, she related that she had successfully increased her mileage in preparation for an upcoming 10K run, with no knee pain or back problems. She was released to a self-directed maintenance program after a total of ten treatment sessions over two months.

 

Discussion

The Q-angle is formed by the quadriceps muscle (primarily the rectus femoris) and the patellar tendon. This measurement quantifies the quadriceps muscle’s pull from the pelvis to the patella, and the patellar tendon’s pull from the tibia. Since large forces are transmitted through the patella during knee movement, any increase in the angle can result in a variety of symptoms, as well as problems in the pelvis or lumbar regions.

Because of their wider pelvic anatomy, women naturally have higher angles at their knees. The standing Q-angle is an objective method of measurement that includes the valgus stresses on the knee and internal rotation forces due to excessive foot pronation. Since we are most concerned with understanding how the knee functions during daily and sports activities, it makes more sense to obtain this important measurement while in a weight-bearing position.

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 .

 

 

 
Increased Running Increases Pain
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Friday, 04 May 2007 13:48

racewalkingHistory and Presenting Symptoms

A 33-year-old female presents with ongoing pain and discomfort in her left lower leg, which responds only temporarily to anti-inflammatory medications. She has been running regularly for the past six months, but develops left leg pain whenever she tries to increase her mileage. She ices her leg for fifteen minutes after each run, and performs stretches before and after she runs. She has tried wearing off-the-shelf shoe inserts to lessen the impact of heel-strike shock to her feet, but feels that they offered little protection. She describes her current level of leg pain as usually around 40mm on a Visual Analog Scale.

 

Exam Findings

Vitals. This physically active woman has taken up running in order to help control her weight. She has managed to lose about fifteen pounds over the past six months and now weighs 138 lbs, which, at 5’6’’, results in a BMI of 23; she is no longer overweight. She does not smoke and does not drink alcohol, and her blood pressure and pulse rate are both at the lower end of the normal range.

Posture and gait. Standing postural evaluation finds a lower iliac crest on the left, and a low left greater trochanter. The right shoulder is slightly lower than the left, with no history of fracture or surgery. The spinal curves are intact. She has substantial calcaneal eversion and hyperpronation on the left side, with a moderate outward flare of her left foot. The left medial arch is significantly lower than the right when standing, but it is not tender to direct pressure.  

Chiropractic evaluation. Palpation finds the left posterior tibialis muscle to be tight, tender and ropey, with the tenderness concentrated in the lower part of the muscle and extending into the tendon at the medial ankle. Pain is elicited when providing manual resistance to isometric contraction of the posterior tibialis muscle. There is also moderate tenderness in the right sacroiliac joint, and segmental dysfunction is found at the L4/L5 level on the left. Lumbar, knee, and ankle ranges of motion are full and pain-free, and circulatory and neurological tests are negative.

 

Imaging

Upright, weight-bearing X-rays of the lumbar spine and pelvis confirm a discrepancy in femur head heights, with the left side 7mm lower. A slight left convex lumbar curvature (5°) is noted, and both the sacral base and the iliac crest are lower on the left. The sacral base angle and measured lumbar lordosis are within normal limits.

 

Clinical Impression

Posteromedial shin splints caused by tibialis posterior tendinitis and excessive pronation. This is associated with calcaneal eversion and complete loss of the medial longitudinal arch on the left side. These lower extremity asymmetries result in a functional left short leg, which is being aggravated by her attempts to increase her running mileage.

 

Treatment Plan

Adjustments. Specific chiropractic adjustments for the lower extremities and the involved spinal regions were provided as needed. Transverse friction was applied to the tibialis posterior tendon to increase local circulation and stimulate collagen repair.

Support. Custom-made, flexible stabilizing orthotics were provided to support the left medial arch and decrease the asymmetrical stress on the tibialis posterior tendon and muscle. This included a varus wedge pronation correction for her left calcaneal eversion.

Rehabilitation. Dynamic resistance exercises for the left posterior tibialis muscle were performed daily, using exercise tubing. She continued her current running program, and was able to introduce a graduated increase in her training distance after four weeks of care.

 

Response to Care

She responded well to the spinal and extremity adjustments, and reported a rapid improvement with the friction massage and exercise. Within two weeks of receiving her orthotics, she returned to her progressive training program. She gradually increased her running mileage, with no return of her previous leg symptoms. She was released to a self-directed maintenance program after a total of ten treatment sessions over two months.

 

Discussion

Pain in the posteromedial aspect of the lower leg is a variant type of shin splints that is frequently associated with excessive pronation of the foot and ankle. Her previous use of generic shock-absorbing insoles had provided little benefit, since she required specific, customized support for her calcaneus and medial arch.

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 .

 
Surgical Repair “Kneeds” Extra Care
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Wednesday, 04 April 2007 12:21

History and Presenting Symptoms

The patient is a 49-year-old male who reports frequent aching and stiffness in his lower back. He denies any back injuries, but does relate an injury to his right knee that resulted in a full tear of his anterior cruciate ligament (ACL). Two years ago, he had a surgical reconstruction of the ACL using a patellar tendon graft. He says he still has occasional grinding and rare sharp pain in his right knee. Using a 100mm Visual Analog Scale, he rates the frequent pain in his low back at around 40mm, while the rare knee pain is a brief 65mm. He avoids the use of medications, but does get frequent massages, which provide some relief from his back pain.

Exam Findings

Vitals. This active male patient is 5’10" tall and weighs 162 lbs. This results in a BMI of 23, which is within the normal range. He states that he works out twice a week at a local gym, and plays golf regularly. He is a non-smoker, and both his blood pressure and pulse rate are also within the normal ranges.

Posture and gait. Standing postural evaluation finds generally good alignment, with no lateral curvatures or listing of the spine. An increased lumbar lordosis is noted, and the pelvis tilts forward. His right knee demonstrates a mild valgus alignment and calcaneal eversion, and foot pronation is more prominent on the right side. Observation of gait identifies a tendency for the right foot to flare outward, and inspection of his shoes finds scuffing and wearing at the lateral aspect of his right heel.

Chiropractic evaluation. Motion palpation identifies a limitation at the lumbosacral joint, with moderate tenderness and loss of endrange mobility to the right at L5/S1. Additional subluxations are noted at T10/T11 and T5/T6. Lumbar ranges of motion are full and pain-free, except for extension, which is limited to 20° by pain localized to the right lumbosacral junction. This finding is confirmed by Kemp’s test, which is positive for localized pain when performed to the right side.

Lower extremities. Examination of the right knee finds no ligament instability, or evidence of patellar tracking problem. All knee ranges of motion are full and pain-free. Manual muscle testing finds no specific muscle weakness around the knees or ankles. Neurologic testing of the lower extremities is negative.

Imaging

No X-rays or other forms of musculoskeletal imaging were requested.

Clinical Impression

 

Mechanical dysfunction with postural imbalance of the lumbopelvic region. There is also evidence of poor biomechanical support from the previously injured right knee, which has undergone ACL reconstruction surgery.

Treatment Plan

Adjustments. Specific, corrective adjustments for the lumbosacral and thoracic spinal regions were provided as needed. No manipulation of the right knee or ankle was indicated. The cuboid bone of the right foot was adjusted several times.

Support. Custom-made, flexible stabilizing orthotics were provided to improve foot/ankle symmetry and to support the right knee.

Rehabilitation. This patient was shown a postural correction exercise using exercise tubing for his anteriorly rotated pelvis.

Response to Care

He responded well to his spinal adjustments, and was quite diligent in performing his corrective exercise. He also adapted well to his orthotics, and reported no more episodes of right knee pain. After four weeks of adjustments (eight visits) and daily home exercises, he was symptom-free and had regained full lumbar function. He returned to playing golf with no problems, and was then released to a self-directed maintenance program.

Discussion

In addition to a classic lumbopelvic postural problem, this patient demonstrated an asymmetry of lower extremity alignment associated with injury and surgical repair. Chiropractic adjustments to the lumbosacral and thoracic regions were combined with a specific postural correction exercise, and support for the foot and ankle. This patient had undergone successful post-surgical rehabilitation and the examination found no evidence of ligament instability or muscular weakness around the knee. However, close inspection and gait evaluation identified a lower extremity asymmetry that was contributing to his spinal problems. Custom-made stabilizing orthotics are frequently necessary after surgical repair procedures of the lower extremities, due to the persisting imbalances.

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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