Orthotics


Recurrent Ankle Sprains
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Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Friday, 01 December 2006 13:55

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  

 
High Arches in a Yoga Instructor
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Tuesday, 28 November 2006 00:00

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

 
The Aging Foot
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Orthotics
Written by John Danchik, D.C.   
Tuesday, 14 November 2006 16:43

History and Presenting Symptoms

A 64-year-old female presents with recurring, unresolving episodes of moderate pain in her lower back and left knee.  She recalls no specific back or knee injuries, and states that these problems have developed over the past couple of years, getting more noticeable in the past six months.  On a 100mm Visual Analog Scale, she rates her low back pain as usually 40mm, while her left knee varies from 20mm to 50mm.  The knee gets worse after walking, and she takes over-the-counter NSAID’s for relief.

Exam Findings

Vitals.  This 5’6’’ female weighs 164 lbs., which results in a BMI of 27.  She knows she is overweight and is following a sensible diet, but she is having difficulty doing the needed walking because of pain.  She quit smoking twelve years ago.  Her blood pressure is 124/84 mmHg, and her pulse rate is 80 bpm.  These findings are within the normal range.

Posture and gait.  Standing postural evaluation finds generally good alignment, with intact spinal curves, and no significant lateral listing of her pelvis or spine.  She demonstrates bilateral calcaneal eversion, worse on the left, with a lower left arch.  During gait, both feet pronate substantially, and both feet flare outwards (toe-out).

Chiropractic evaluation.  Motion palpation identifies numerous limitations in spinal motion: the left SI joint, the lumbosacral junction on the left, L2/L3 on the right, T11/12 generally, and at the cervicothoracic junction.  Palpation finds no significant local tenderness or muscle spasm in these regions, and all active thoracolumbar spinal ranges of motion are limited slightly by aging, but are pain-free.  Provocative orthopedic and neurological tests for nerve root impingement and/or disc involvement are negative.

Lower extremities.  Both knees demonstrate full and pain-free movements, and no provocative orthopedic tests are positive.  Closer examination finds a low medial arch on the right foot, and no arch remaining on the left when standing.  Her left calcaneus also demonstrates greater eversion when bearing weight.  Manual testing finds no significant muscle weakness in the fibular (peroneal) or anterior tibial muscles on either side.

Imaging

Lumbopelvic and knee X-rays in the upright, standing position are taken while weightbearing.  There is some loss of lumbar disc heights, most obvious at the lumbosacral joint, and decreasing cephalad.  A slight discrepancy in femur head heights is noted, with a measured difference of 4mm (left side lower).  A moderate lumbar curvature (4°) is also seen, convex to the left side, and both the sacral base and the iliac crest are slightly lower on the left.  The sacral base angle and measured lumbar lordosis are increased, but still within normal limits.  No significant loss of joint spacing or osteophyte formation is seen in the knee joints.

Clinical Impression

Moderate lumbopelvic imbalance and spinal dysfunction associated with generalized loss of arch height (worse on the left) and aging of the knee joints and feet.

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 left foot and knee was also performed.

Support.  Custom-made, flexible stabilizing orthotics were supplied, which included bilateral pronation correction (varus wedges).  The patient described no problems in adapting to the orthotics, although close inspection found that the shoes she was wearing were one full size too small for her feet and she did need to purchase better-fitting shoes.

Rehabilitation.  She received instruction in a comprehensive spinal wellness exercise program using elastic resistance tubing.  She brought her exercise log to each visit so her adherence to the program could be encouraged.

Response to Care

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

Discussion

This patient’s history and physical examination are consistent with the commonly seen spinal effects of aging on the feet.  The combination of lower spinal symptoms with knee pain made worse by walking prompted an evaluation of the lower extremities during weight bearing.  The problem most in need of correction was the excessive pronation that was causing functional imbalance.

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 .

 
Wellness Support for an Obese Patient
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Thursday, 28 September 2006 23:40

orthoticblueHistory and Presenting Symptoms

A 32-year-old male presents with a history of mild to moderate lower back pain, and aching tightness in his neck.  He states that his back pain comes and goes, with no specific triggering activities.  His neck tension is worse with long and stressful workdays.  He participates in no recreational sports or exercise activities, and recalls no back or neck injuries.  On a 100mm Visual Analog Scale, he rates the low back pain as usually 30-40mm, and his neck tightness as around 25mm.

Exam Findings

Vitals.  This man weighs 221 lbs, and is 5’10’’ tall.  This calculates to a BMI of 32—he is obese.  His waist measures 48 inches at the largest point above the ASIS, confirming that he has abdominal obesity, and is not just big and/or muscular.  His blood pressure is somewhat elevated at 142/90 mmHg, and his pulse rate is 80 bpm.

Posture and gait.  Standing postural evaluation identifies the effects of abdominal obesity, with a loss of the lumbar curve, and an accentuated thoracic kyphosis, with a forward head carriage.  There is no obvious lateral listing of the pelvis or lateral curvature of the spine.  He has mild bilateral knee valgus and bilateral calcaneal eversion, and very flat medial arches.  During gait evaluation, both feet flare outward and pronate substantially.

Chiropractic evaluation.  Motion palpation identifies several limitations in intersegmental spinal motion: the right SI joint, L4/L5 on the left, L2/L3 on the right, T11/12 generally, and several levels at the cervicothoracic junction.  There is no specific spinal tenderness or spasm of the paraspinal muscles, but adipose tissue is prevalent throughout.  All active thoracolumbar spinal ranges of motion are limited slightly by general stiffness.  Neurological tests are negative for nerve root impingement, but straight leg raise is limited bilaterally by hamstring shortening and tightness.

Imaging

Upright, weight-bearing X-rays of the lumbar spine demonstrate loss of intervertebral disc height at L4/L5 and L5/S1, with moderate osteophyte formation at those levels.  There is no discrepancy in femur head or iliac crest heights, and no lateral listing or lateral curvature.  The sacral base angle and lumbar lordosis are both decreased; this is consistent with the postural analysis.

Clinical Impression

Chronic spinal stress syndrome due to obesity.  This is accentuated by poor support from the lower extremities, with bilateral knee valgus, hyperpronation and calcaneal eversion.

Treatment Plan

Adjustments.  Specific, corrective adjustments for the identified subluxations were provided as needed, with good response.  Specific manipulation of both feet and knees was also performed.

Support.  Custom-made, flexible stabilizing orthotics were provided, to support the arches and decrease stress to the knees and back during walking.  A custom-made cervical traction pillow was ordered, based on four specific measurements.

Rehabilitation.  He was started on a localized spinal activation and strengthening program, using elastic resistance tubing for the multifidus muscles—first in extension, then into rotation and lateral flexion.  In addition, he was counseled on building up to sixty minutes a day of moderate physical activity for weight loss.  He chose to walk for thirty minutes during lunchtime and, after two weeks, added an additional thirty minutes before his evening meal.  He used an exercise log as part of his motivation for sustaining his healthy behaviors, which included returning to a previously successful healthy diet program. 

Response to Care

He tolerated his adjustments well, and adapted to the orthotics and cervical support pillow with no difficulty.  His low back symptoms resolved quickly and, shortly thereafter, his neck tightness disappeared.  His brisk walking program did not exacerbate his back pain, even when he increased to a total of sixty minutes daily.  After six weeks of adjustments (twelve visits) he was released to a maintenance program with instructions to continue his exercise and healthy diet program.

Discussion

Obesity is increasing in prevalence in all industrialized countries, since few of us must perform physical labor to obtain our food.  The accumulated weight places increased stress on the lower extremities and spine, resulting in chronic symptoms and accelerating degenerative changes.  Specific spinal adjustments and custom support for the spine and lower extremities need to be combined with individualized exercise instructions for best results.  An exercise/dietary log can improve patient adherence to recommended lifestyle changes.

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 .

 
Awkward Gait in a Young Runner
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Monday, 28 August 2006 20:31

History and Presenting Symptoms

The patient is an eight-year-old boy being brought in by his parents, who are concerned about his awkward style of running. He has no symptoms or painful limitations, but his mother and father are both worried that his inefficient gait could lead to future problems. They have noticed that he is a less-effective participant on his soccer and baseball teams because of his running style. Upon further questioning, the father relates a personal history of difficulty running as a child, and an inability to excel in school and team sports. He wants his son to be spared these limitations, and be able to keep up with his friends and teammates.

Exam Findings

Vitals. This active young male weighs 66 lbs, which, at 4’4’’, results in a BMI of 17; this is considered a “healthy weight,” since he is within the 50-85th percentile for his age. His pulse is 92 bpm, and his respirations are 16/minute; all within normal ranges for his age.

Posture and gait. Standing postural evaluation finds generally symmetrical development, with intact spinal curves. There is no evidence of lateral curve or list, and his iliac crests are level. His knees are moderately valgus and both Achilles tendons demonstrate medial bowing. They insert into calcanei that are everted, and there is complete absence of both medial arches (pes planus). A distinct tendency to toe out is seen during gait screening, and he hyperpronates bilaterally. When performing a toe raise, however, the medial arches reappear, indicating that these are not rigid flat feet. Additional testing is performed on a treadmill at several speeds, while barefoot and wearing sports shoes. This confirms that, after heel strike, the feet roll medially and flare outwards, resulting in a very ineffective toe off.

Chiropractic evaluation. Motion palpation identifies a mild limitation in right sacroiliac motion, with moderate tenderness. A compensatory subluxation is identified at L4/5 on the left. No joint fixations are found in the feet and ankles. Manual testing finds moderate weakness of the posterior tibialis muscles bilaterally. Deep tendon reflexes in both lower extremities are somewhat sluggish, but all other neurological and orthopedic tests are negative.

Imaging

No imaging studies were performed.

Clinical Impression

Lack of development of the medial longitudinal arches with hyperpronation. This is associated with loss of medial support at the ankles and knees, and has resulted in sacroiliac joint motion restriction and a compensatory lumbar subluxation.

Treatment Plan

Adjustments
. Specific, corrective adjustments for the SI joints and lumbar region were provided, as indicated.

Support. Custom-made, flexible, stabilizing orthotics were ordered to support the arches, decrease calcaneal eversion and knee valgus, and to reduce the asymmetrical biomechanical forces being transmitted to the spine and pelvis.

Rehabilitation. He was shown how to perform daily strengthening exercises for the posterior tibialis muscles, using elastic exercise tubing.

Response to Care

His father made sure that he did his exercises regularly, and he tolerated the spinal and pelvic adjustments with little difficulty. Once he began wearing the stabilizing orthotics, both he and his father noticed an immediate improvement in his running efficiency. He described it as feeling more “springy” when he ran; while his father noticed that he didn’t throw his arms out while running. He required only a few adjustments for his segmental dysfunctions, and was released from care after a total of eight visits over six weeks.

Discussion

This young man had apparently inherited his dad’s flat feet, and he was unable to run efficiently with his friends. While he didn’t have any symptoms, he was definitely at risk for eventual foot, ankle, knee, and/or spinal problems and injuries. The additional support from stabilizing orthotics helped realign his feet for more effective walking and running. Once the underlying biomechanical fault was minimized, he responded rapidly to the muscle strengthening exercises and chiropractic adjustments. Both he and his parents have been informed of the need to monitor his feet as he continues to grow, and to return for a new pair of flexible orthotics as soon as his feet have grown by one-and-a-half shoe sizes.

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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