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Orthotics
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Orthotics
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Written by John Danchik, D.C.
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Tuesday, 14 November 2006 16:43 |
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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
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Orthotics
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Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.
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Thursday, 28 September 2006 23:40 |
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 History 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
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Orthotics
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Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.
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Monday, 28 August 2006 20:31 |
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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
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Orthotics
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Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.
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Friday, 23 June 2006 17:29 |
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History and Presenting Symptoms
The patient is a 32 year-old personnel manager who has taken up running for stress reduction and weight control. She has been running for six months, and has been progressively increasing her mileage. She is experiencing recurring and worsening pain in her right foot, also increased low-back tightness. She recalls no specific injury to her foot or back, but thinks she may be favoring her right foot when running.
Exam Findings
This active woman weighs 148 lbs, which, at 5’5’’, results in a BMI of 25—she is on the borderline of being overweight. When told this, she says that she has lost about twelve pounds since beginning regular running, and hopes to lose about five more (which would be appropriate for her height). She reports that she hasn’t smoked for four years, and her blood pressure and pulse rate are both at the lower end of normal range. She drinks a few glasses of wine each week, usually with meals.
Vitals.
Posture and gait.
Chiropractic evaluation.
Primary complaint.
Palpation of the right foot finds the fourth metatarsal bone to be quite tender to digital pressure just proximal to the metatarsal head. Manual testing finds no specific muscle weakness, nor is there significant asymmetry in muscle mass or leg diameter. All ankle joint ranges of motion are full and pain-free, bilaterally. Motion palpation identifies a limitation in left sacroiliac motion, with moderate tenderness and loss of endrange mobility. Several compensatory subluxations are identified throughout the thoraco-lumbar region. Yeoman’s provocative test elicits moderate pain upon prone extension of the left leg. All other spinal and neurological tests are negative, including sensory and reflex testing of the lower extremities. Standing postural evaluation finds generally good alignment, with intact spinal curves, and no lateral listing of her pelvis or spine. She demonstrates bilateral calcaneal eversion, worse on the right, with a lower right arch. Treadmill gait evaluation finds obvious hyperpronation of the right foot and ankle when walking, which is noticeably worse when running.
Imaging
An X-ray series of the right foot finds an area of slightly increased density in the distal third of the fourth metatarsal bone. Based on the clinical and plain radiographic findings, she was referred for a bone scan of the lower extremities and feet. This study identified an area of increased uptake in the distal third of the fourth metatarsal bone, consistent with a stress response.
Clinical Impression
Early stress fracture of the fourth metatarsal bone. While no actual fracture line is present, the plain film and bone scan findings support the clinical indication of a "stress reaction" of bone, which is responding to the increased biomechanical strain of her running program. This is accompanied by sacroiliac joint motion restriction and compensatory thoraco-lumbar subluxations associated with altered gait.
Treatment Plan
Specific, corrective adjustments for the left SI joint and the thoraco-lumbar region were provided as needed. The right cuboid and navicular were adjusted, while carefully avoiding placing pressure on the fourth metatarsal bone.
Adjustments.
Support.
Rehabilitation.
All weight-bearing exercise was restricted for two weeks. Then, marble pick-up and towel-scrunching exercises were initiated to strengthen the intrinsic foot muscles. After four weeks, she was permitted to gradually return to her distance-running program. Custom-made, stabilizing orthotics were supplied to help provide support through the entire gait cycle, maintain the arches, limit calcaneal eversion, and decrease heel-strike impact. Two pairs of stabilizing orthotics were ordered for her:one designed specifically for running shoes and the other for job-related dress shoes.
Response to Care
She responded well to the spinal and foot adjustments, and reported a rapid decrease in her foot symptoms with rest. After four weeks away, she built back up to her previous running program. She reported no return of the right foot pain, and also noted a subjective feeling of smoother and more efficient gait with the orthotics. She has now been running regularly and without difficulty for the past four months.
Discussion
Metatarsal stress fractures often occur when moderate biomechanical asymmetries are stressed by rapid increases in weight-bearing exercise. Shock-absorbing orthotics incorporate arch support, while reducing pronation and decreasing the stress of repetitive heel strikes on the foot and spine.
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
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Orthotics
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Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.
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Wednesday, 24 May 2006 11:25 |
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History and Presenting Symptoms
An 18-year-old baseball player presents with aching pain and tightness in his left lower leg. He describes a collision injury during a game four days earlier, which resulted in pain and bruising in the front of his leg after sliding into second base. Despite repeated icing, the area still feels swollen. He describes this as “shin splints.”
Exam Findings
Vitals. This very fit young athlete weighs 150 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 both at the lower end of normal range.
Posture and gait. Standing postural evaluation finds generally good alignment throughout his spine and pelvis, with normal spinal curves and no lateral curvature or listing. The knees and ankles are also well aligned, with no knee varus or valgus, and no calcaneal eversion or foot flare. Both medial arches are somewhat high, and gait evaluation finds excessive supination, with insufficient pronation.
Chiropractic evaluation. Motion palpation and joint play analysis identifies a mild limitation in lumbosacral motion, with moderate tenderness and loss of end range mobility at the left of L4/L5.
Primary complaint. Examination of the left lower leg finds moderate tenderness and tightness along the anterior tibialis musculature. There is loss of sharp sensation discrimination in the lateral aspect of the foot, but no numbness or paresthesia. The left foot intrinsic muscles demonstrate no weakness, and he has no difficulty performing toe extension. All ankle ranges of motion are full and pain-free, except inversion is limited by the tightness of the anterior tibialis muscle. The left cuboid is tender to palpation and demonstrates a lateral subluxation.
Imaging. No X-rays or other forms of musculoskeletal imaging were requested.
Clinical Impression
Anterior compartment syndrome in the left lower leg, associated with mild neurological compression.
Treatment Plan
Adjustments. Specific, corrective adjustments for the lumbar spine and left cuboid were provided as needed.
Support. Custom-made, stabilizing orthotics were supplied to support the high arches and decrease the shock stress on the legs and spine from excessive supination.
Rehabilitation. Initially, frequent Proprioceptive Neuromuscular Facilitation (PNF) stretching followed by icing treatments was performed to lengthen and relax the anterior tibialis musculature. As improvement was noted, isotonic resistance exercising in inversion activated and strengthened the antagonists of the anterior tibialis muscle. Finally, a comprehensive strengthening program using exercise tubing prepared him for a return to full athletic capability.
Response to Care
The stretches and adjustments were well tolerated, and he reported a decrease in symptoms within the first 24 hours. After two weeks of care, he was able to return to practice, including light running. He responded well to the orthotics, and was released from care after a total of eight treatment sessions over six weeks.
Discussion
The commonly used term “shin splints” is a non-specific description of pain in the lower leg. Several conditions can produce pain in this area, and must be differentiated for effective treatment. High arches and excessive pronation may predispose athletes to the development of shin splints. While most causes of shin splints are easily treated with conservative means, anterior compartment syndrome that causes neurological impairment may need to be surgically decompressed.
Persistent pain in the lower leg following sports activities may indicate an increase in intramuscular pressure in one of the osteofascial compartments. Acute trauma can cause the internal pressure of a muscle to elevate excessively during exercise and stay high for a prolonged period post-exercise. While there are five fascial compartments, the anterior compartment is most frequently involved, making the pain area similar to shin splints. Sensory changes are often evident distally; paresthesias may involve the first web space, the instep, or the lateral aspect of the foot. If elevated intracompartmental pressures persist, permanent damage to muscle tissue and nerves can develop, making early surgical decompression of the involved compartment mandatory.
Prompt, conservative care allowed this relatively mild case to be treated without surgery. The custom-made, stabilizing orthotics provided support and shock absorption during future athletic activities, and no recurrences were reported.
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
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