History and Presenting Symptoms
The patient is a 38-year-old male, who plays soccer in an adult league on weekends.  He describes recurring episodes of pain and swelling along the outside of his right ankle for the past several years.  He presents for treatment of his lower extremity biomechanical faults, and wants to prevent future problems and improve his athletic performance with chiropractic care.

Exam Findings
Vitals.  This athletic male weighs 160 lbs., which, at 5’10’’, results in a BMI of 23; he is not overweight.  He is a non-smoker, and his blood pressure and pulse rate are at the lower end of the normal range.

Posture and gait.  Standing postural evaluation finds generally good alignment, with intact spinal curves, but a slightly lower iliac crest on the right, which is confirmed by a lower right greater trochanter.  He also demonstrates right calcaneal eversion and a low medial arch (hyperpronation).  A tendency to toe out (foot flare) on the right is noted during gait screening.

Chiropractic evaluation.  Motion palpation identifies a mild limitation in right sacroiliac motion, with moderate tenderness and loss of end range mobility.  Several compensatory subluxations are identified throughout the lumbar region.  Otherwise, all orthopedic and neurological testing is negative.

Lower extremities.  Examination of his right foot and ankle reveals slight general swelling of his ankle, which is moderately tender to palpation along the outer aspect.  All right ankle ranges of motion are full and pain-free, except inversion, which is limited by tightness and localized pain along the lateral foot and ankle.  Manual muscle testing finds mild weakness in the right peroneal muscle, when compared to the left side.

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

Clinical Impression
History of recurrent inversion ankle sprains associated with hyperpronation and foot instability.  This is accompanied by sacroiliac 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 navicular bone was adjusted superiorly.

Stabilization.  Custom-made, flexible stabilizing orthotics were provided to support the arches and decrease calcaneal eversion, and to reduce the asymmetrical biomechanical forces being transmitted to the spine and pelvis.  Two pairs of stabilizing orthotics were ordered, one designed for his soccer shoes and the other for everyday shoe wear.

Rehabilitation.  He was initially instructed in daily self-mobilization and strengthening procedures, which included marble pick-up and towel-scrunching exercises.  After two weeks, daily strengthening of eversion and external rotation was introduced, using elastic exercise tubing.

Response to Care
The spinal and pelvic adjustments were well tolerated, and this active athlete required very few readjustments.  His compliance with the stabilization and exercise recommendations was very good, since he was quite motivated to improve his performance and to prevent future injuries to his ankle.  He adapted to and wore the orthotics without difficulty.  He faithfully filled out and brought in his exercise log at every visit, which provided an excellent opportunity to support his home-based efforts.

Within two weeks of receiving his orthotics, he completed several strenuous soccer practices without symptoms or swelling in the ankle.  He described a noticeable improvement overall in his athletic performance, saying that he felt “more stable.”  He was released from acute care to a self-directed maintenance program after a total of ten visits over two months.

Discussion
Interestingly, this athlete had been to several doctors before this encounter.  He was very frustrated by the lack of answers and recommendations.  His frequent and recurring inversion sprains occur in a foot and ankle that has poor medial support (a low medial longitudinal arch) and an everted calcaneus.  Biomechanical analysis found his right foot to be over flexible and unstable.

As is often found in these types of cases, the combination of specific adjustments, custom-made orthotic support, and strengthening of the lateral ankle support musculature brought about an excellent response.  This middle-aged athlete was very motivated to improve his sports performance, and he persisted with the recommended exercises.

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 44-year-old female patient is a yoga instructor, who reports the recent onset of pain under her left heel. The foot pain is most noticeable in the morning when she first starts to walk. When her foot bothers her, she notices that her entire back is stiff and less flexible during yoga poses. In addition to her frequent yoga classes and practice, she walks briskly for forty-five minutes every day and rides a bicycle about every other day. She rates her current level of left foot pain as getting up to about 75mm on a 100mm Visual Analog Scale, but subsiding as the day progresses.

Exam Findings

Vitals

This active and generally healthy female is 5’6’’ tall and weighs 142 lbs, which results in a BMI of 23; she is not overweight. Her blood pressure is 114/72 mmHg, with a pulse rate of 64 bpm. She reports that she has never used tobacco products and does not drink alcohol or soda pop. She has been a vegetarian for twelve years, and she watches her diet carefully for proper protein and nutrient intake.

Posture and gait.

Standing postural evaluation finds very good alignment throughout the pelvis and spine, with no lateral lists or spinal curvatures. No pronation or toe out is noted during screening evaluation of gait.

Chiropractic evaluation.

Motion palpation identifies a mild limitation in lumbosacral motion, with moderate tenderness and loss of endrange mobility to the left at L5/S1. A compensatory subluxation is noted at T10/T11. Neurologic testing is negative for nerve root impingement or peripheral nerve damage.

Lower extremities. 

Examination of the left foot and ankle finds no ligament instability, and all foot and ankle ranges of motion are full and pain-free. Palpation over the anteromedial portion of the plantar aspect of the left calcaneus elicits substantial "pinpoint" pain and discomfort. Manual testing finds no evidence of weakness in the ankle or foot muscles. Evaluation of foot alignment during mid-stance finds both medial arches to be quite high. Motion palpation identifies a mild limitation in lumbosacral motion, with moderate tenderness and loss of endrange mobility to the left at L5/S1. A compensatory subluxation is noted at T10/T11. Neurologic testing is negative for nerve root impingement or peripheral nerve damage. Standing postural evaluation finds very good alignment throughout the pelvis and spine, with no lateral lists or spinal curvatures. No pronation or toe out is noted during screening evaluation of gait.

Imaging

X-rays of the feet show a small bony spur on the left calcaneus, at the insertion of the plantar fascia. Otherwise, there is normal joint spacing and alignment, with no evidence of osteoarthrosis or other structural pathology.

Clinical Impression

High medial arches with resulting excessive supination (insufficient pronation). Increased biomechanical stress has been placed on the plantar fascia, resulting in the development of a chronic traction spur at the calcaneal insertion. There is moderate secondary spinal involvement, which has probably been minimized by her frequent yoga practice.

Treatment Plan

Adjustments.

Specific adjustments for the lumbosacral and thoracolumbar spinal regions were well-tolerated. Manipulation of the cuboid and calcaneus bones on both feet produced noticeable reduction of tension in the plantar fascia.

Support

Soft tissue mobilization of the plantar fascia was performed, along with cross-fiber friction to tolerance at the calcaneal insertion. Custom-made, flexible stabilizing orthotics were ordered to support the lateral and anterior arches. These orthotics included an additional layer of shock absorption materials to reduce impact stress throughout the entire gait cycle.

Rehabilitation.

She was encouraged to continue with her active lifestyle and yoga practice, including her frequent walking and cycling. Since she was in generally good condition, she did not require any specific corrective exercises.. Soft tissue mobilization of the plantar fascia was performed, along with cross-fiber friction to tolerance at the calcaneal insertion. Custom-made, flexible stabilizing orthotics were ordered to support the lateral and anterior arches. These orthotics included an additional layer of shock absorption materials to reduce impact stress throughout the entire gait cycle.

Response to Care

Once she began wearing her shock-absorbing orthotics, she noted a substantial decrease in tension and tenderness of the plantar fascia. Within two weeks of receiving the orthotics, she reported that she was able to perform all her exercise and personal activities with no foot or back pain or limitation. She was released to a self-directed maintenance program after a total of eight treatment sessions over two months.

Discussion

When the medial arches are high, the corresponding lateral and anterior arches are often low or collapsed, resulting in excessive strain and tension on the plantar fascia. Lack of pronation increases impact forces at heel strike; these forces are then transmitted up the kinetic chain to the spine. Excessive supination is much less common than excessive pronation, but is frequently an underlying factor in chronic stress on the plantar fascia at the calcaneal insertion. 

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