Orthotics


Growth Asymmetry in an Outdoorsman
Orthotics
Written by John Danchik, D.C., F.I.C.C., F.A.C.C.   
Tuesday, 23 October 2012 18:00
History and Presenting Symptoms
A
 41-year-old male presents with recurring episodes of pain in his low back and left hip. He recalls no injury to the region, and cannot identify any precipitating activities or events. On a Visual Analog Scale, he rates his low back pain as varying from 30mm to 65mm, while the left hip pain is usually around 35mm.  He takes over-the-counter NSAIDs when the pain interferes with his daily activities, and that usually provides marginal relief.  He works as an RV (recreational vehicle) salesman and is also a volunteer nature trail guide. He is seeking non-drug treatment.
 
rvExam Findings
Vitals.This male patient weighs 168 lbs, which at 5’10’’ results in a BMI of 24.1; he is not overweight. He is a non-smoker, and his blood pressure and pulse rate are both within the normal range.

Posture and gait. Standing postural evaluation finds a lower iliac crest on the right, and a low right greater trochanter. The left shoulder is noticeably lower than the right, with no history of fracture or surgery. His lower extremities are symmetrical, with no significant calcaneal eversion, foot flare, or low medial arch. 

Chiropractic evaluation. Motion palpation identifies functional limitations in right lateral flexion and ipsilateral rotation at the L3/L4 and L4/L5 levels,with moderate tenderness and loss of endrange mobility.  Hip ranges of motion are full and pain-free. All provocative orthopedic and neurological tests are negative for nerve root impingement and/or disc involvement.
 
Imaging
AP and lateral lumbopelvic x-rays in the upright, standing position are taken while weight bearing. The heels are aligned directly under the femur heads, and both knees are extended.  A discrepancy in femur head heights is seen, with a measured difference of 7mm (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
Moderate anatomical leg length discrepancy (right short leg), with associated pelvic tilt and lumbar curvature. There is an accompanying history of recurrent mechanical low back pain and left hip pain.

Treatment Plan
Adjustments. Specific, corrective adjustments for the lower lumbar region were provided as needed, with good response.

Support. Individually designed stabilizing orthotics were supplied, and a permanent 5mm heel lift was added to the right side. These were introduced after the first week of regular adjustments.
 
Rehabilitation.  He was instructed in a daily core strengthening program (the “easy eight” exercises), to be done at home using elastic exercise tubing. His exercise log was reviewed at each visit to ensure adherence to the exercise recommendations.
 
Response to Care
This patient responded rapidly to his spinal and pelvic adjustments.  He reported no difficulty in wearing the orthotics, and no problems with the right heel lift.  He brought with him to every visit his exercise log, which documented his regular performance of the home exercises.  After eight visits over six weeks and daily home exercises, including wearing the orthotics with a heel lift, he successfully completed his re-examination and was released to a self-directed home stretching program.  He has been seen occasionally for wellness adjustments, and he reports that he now feels “unbalanced” when he is not wearing his orthotics.
 
Discussion
With no history of injury to his leg, hip, or pelvis, this patient apparently has an anatomical short leg due to growth asymmetry.  This condition, while not rare, is an often-overlooked cause of “mechanical” low back pain.  Spinal adjustments and core strengthening exercises provided relief and improved function, but the underlying structural leg length inequality had to be addressed.  Over time, this amount of discrepancy was bound to cause low back discomfort, and eventually degenerative changes in the spine and the hip joint of the longer leg.  In most cases, a permanent heel lift is best supplied with individually designed stabilizing orthotics, in order to ensure good foot biomechanics.
 
Consider Hobbies to Determine What’s Causing Pain
Orthotics
Written by Kirk Lee, D.C.   
Sunday, 22 July 2012 22:28
A
s chiropractors, when we conduct our case histories and examinations we typically determine mechanisms of injury to be related to specific instances of trauma, repetitive macrotrauma or microtrauma. However, we should also consider posture, activities of daily living and hobbies as these can sometimes be the root cause of a patient’s pain. Today we are going to take into consideration a patient whose hobby provided the underlying cause.

golfswingMr. S. is a well-known golfer in our area. He is 60 years of age, has won several county senior titles and has played at a very competitive level for many years. He presently plays at a “scratch” handicap. Mr. S. has been a patient for a number of years and has always understood the importance of regular chiropractic adjustments and exercise. Early this spring, he came to us with a new complaint of pain in his left low back area radiating into his left hip. Pain was also noted in the area along the lateral tibia of the left leg and continued pain over the lateral aspect of the foot. Mr. S. also feels that when he walks he is placing more pressure down on the left foot.

He denies any falls or accidents. When we asked him if he had changed any activity in his exercise program, he stated he was doing the same thing he had in the past. Examination of his gait cycle demonstrated a longer stance phase on the left side in comparison to the right. Video analysis also noted a slight limp with his left leg when he proceeded through the stance phase of gait. Muscle testing noted a weakened abductors bilaterally and gluteus maximus on the left. The left foot showed reduced dorsiflexion while walking and through active and passive ranges of motion. A digital foot scanner demonstrated that Mr. S. had symmetry of all three arches on the right foot, but on his left foot the lateral arch had dropped significantly. Showing Mr. S. the results of his scan, he remembered that he started doing some golf drills that helped him keep more pressure on his left side when finishing his swing, and that they put a lot of stress on the outside of his foot. He stated, “The pain did start a few days after I started those drills!”

Our treatment included stabilizing orthotics to provide his feet with symmetrical stability. Also, we adjusted the left foot after we determined his reduced dorsiflexion was due to a misaligned calcaneus and talus. Abduction exercises and glute-strengthening exercises were all recommended to provide additional stability to further enhance the chiropractic full spine adjusting. We hypothesized that Mr. S. was focusing so much on his weight transfer in his golf swing that he was placing excessive stress on the outside of his left foot. Coupled with rotation stress during his swing finish he developed a neuro-musculoskeletal condition through his changes in his normal biomechanical movement patterns.

Although he could not initially recall a mechanism of injury for the complaints that brought him back into our office, after examination and further questions about his lifestyle and hobbies we were able to determine the root cause of his pain. Since we had no history of any additional trauma, some activity in his daily living had to be a contributing factor. This is an important step to apply with any patient who complains of pain without injury. Consider a patient’s hobbies and see if what they do for fun could be the source of their pain.

A 1980 graduate of Palmer College of Chiropractic, Dr. Kirk Lee is a member of the Palmer College of Chiropractic Post Graduate Faculty and Parker College of Chiropractic Post Graduate Faculty. He has lectured nationwide on sports injuries and the adolescent athlete, and currently practices in Albion, Michigan.

 
Back Surgery Averted for a Teenaged Boy
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Orthotics
Written by John Danchik, D.C., F.I.C.C., F.A.C.C.   
Friday, 01 June 2012 21:03

History and Presenting Symptoms

The patient is a 13-year-old boy who was identified at a school screening to have a discrepancy in his shoulder heights. His parents were advised to contact an orthopedic surgeon for further evaluation. They reported that the orthopedist found evidence of a scoliosis, but recommended a “watch and wait” approach. No treatment was offered, but if the boy’s spinal curve increased, he (the orthopedist) would be available to perform spinal corrective surgery. The boy’s parents are requesting a second opinion, and any recommendations for non-invasive, conservative care. The patient has no back symptoms, and neither he nor his parents recalls any back injury. He is regularly active in several physical activities, including softball and swimming.

baseballboyExam Findings

Vitals. This 5’4’’ tall, athletic 13-year-old boy weighs 112 lbs, which results in a BMI of 19.2 – he is within the healthy range.

Postural examination. Standing postural evaluation identifies a left low pelvis, and a right low shoulder. His knees are well-aligned, but he has an obvious medial bowing of the left Achilles tendon, with a lower medial arch on the left foot.

Chiropractic evaluation. Motion palpation identifies several mild limitations in spinal motion: the left SI joint, the lumbosacral junction, T11/12, and at the cervicothoracic junction. Palpation finds no local tenderness in these regions, and he has full and pain-free active spinal ranges of motion. Thoraco-lumbar lateral bending is equal for both sides, and the Adams forward bending test finds no evidence of rib hump or persisting curve.

Lower extremities. Closer examination finds that the left medial arch of the foot is lower than the right when standing. When he is seated and non-weightbearing, the left arch appears equal to the right. And when he performs a toe-raise while standing, the left arch returns. Manual muscle testing finds no evidence of muscle weakness in the peroneal or anterior tibial muscles.

Imaging

A P-A full-spine film demonstrates a C-curve scoliosis, which encompasses the lumbar and thoracic regions. The sacral base is lower on the left by 3 mm, and the Cobb angle is 12°. A collimated pelvic view with the femur heads centered finds a difference of 6 mm in the heights of the femur heads, with the left side lower.

Clinical Impression

Here we have a classic case of a functional scoliosis associated with a unilateral flexible flat foot. By definition, this eliminates the concern of a progressive idiopathic scoliosis, which had given the parents cause for worry. The condition is accompanied by multiple areas of mild joint motion restriction and compensatory spinal fixations.

Treatment Plan

Adjustments. Specific adjustments for the lumbopelvic and thoracolumbar spinal regions were provided as needed. Manipulation of the left foot, including the navicular and cuboid bones, was performed.

Support. Individually designed stabilizing orthotics were provided to ensure balanced support for both arches and to reduce weight-bearing asymmetry. Particular emphasis was placed on wearing the supports in his athletic shoes.

Rehabilitation. Because of his age and athletic pursuits, no specific rehabilitation exercises were provided. He was able to continue in his sports activities without difficulty.

Response to Care

All spinal and foot adjustments were well tolerated, since he was young and symptom free. The orthotics improved his postural misalignment and eliminated the shoulder discrepancy. After two months of care, repeat full-spine x-rays with his orthotics in place found only a minimal (3 mm) leg length discrepancy, a level sacral base, and a 6° Cobb angle (which is considered non-scoliotic). He was released to a self-directed home stretching program after a total of eight treatment sessions over two months.

Discussion

This active 13-year-old boy responded well to a combination of spinal adjustments and stabilizing orthotics. Although he was asymptomatic, his parents worried about him being a potential candidate for spinal surgery, based on the specialist’s opinion. Chiropractic evaluation found his scoliosis to be functional, and his flat foot was found to be flexible. Appropriate conservative care was initiated, and was ultimately very successful. In most cases, a functional scoliosis responds well to chiropractic care, and is unlikely to require surgery.

 
Understanding the Mechanism of Plantar Fascitis
Orthotics
Written by Kirk Lee, D.C.   
Friday, 16 March 2012 21:22
A
s chiropractors, our primary focus of care is the chiropractic adjustment. Based on our education in science, art and philosophy, we decide how and where to apply the chiropractic adjustment. Our treatment of a patient’s condition is based on the reduction or stabilization of the resulting subluxation complexes. We listen to our patients’ concerns and answer their questions, but we know that the expression of pain is not the finite reason for our care. We do not let symptoms dictate what we feel is the underlying cause of a patient’s complaint. For example, we know biomechanically and physiologically that subluxations in the lumbar spine can be a contributing factor in neck pain and headaches. However, when a patient’s complaint is not spine related, we have a tendency to use modalities, hot/cold application, give a recommendation to change shoes, ergonomic correction at our work stations, and often we treat the symptom instead of the underlying factor.

footbones2I get numerous emails from doctors who have questions regarding plantar fascia conditions. It is a common ailment for runners, but anyone can develop plantar fascitis. You probably have more patients with plantar fascia problems than you realize because the first signs and symptoms are usually foot pain with difficulty walking when arising out of bed in the morning. Once they have walked a little the pain usually resolves. When they come into our offices later in the day for their other complaints, they might not mention the condition. 
 
Let’s review the anatomy of the foot. Structurally the foot is made up of three arches: lateral longitudinal, anterior transverse and medial longitudinal. These arches form the rigid foundation of the foot, thus the importance of maintaining anatomical height. On radiographic views we can use the landmarks of the cyma line, which demonstrates an S-shaped curve between the talonavicular and calcaneocuboid joints. As the foot transfers the lateral weightbearing forces medial, the navicular drops (rolls inward or pronates), but the talus also slides anteriorly. During supination the talus posteriorly glides. The normal heel-to-toe transition that is important in having a symmetrical gait must have symmetry between pronation and supination. If the talus is constantly being translated forward excessively, the calcaneous will start to shift posterior and superior, causing more tension on the plantar fascia by further lengthening.

We know that the plantar fascia pain is the result of excessive traction of the fascia. Wolff’s law tells us the mechanical stresses will influence and cause hard and soft tissue to distort in direct correlation to the amount of stress imposed on them. 1 Thus, there is a possibility of a heel spur developing. Since the spur is last in forming, the pain is more a result of the excessive tension being placed on the plantar fascia.
 
If a patient demonstrates excessive foot pronation or hyperpronation, then the foot is more flexible, with fallen arches. Effective treatment of the condition must include stabilization of the asymmetrical patterning that the foot is going through. Commonly observed in this patient is reduced dorsiflexion of the foot and ankle. This is usually the result of a tight Achilles tendon, for which the foot must compensate throughout the stance phase of the gait cycle. This creates even more stress on the plantar fascia. For additional anatomical and biomechanical understanding, review the windlass effect that John Hicks first described in 1954.2

When we consider the biomechanical phenomenon that takes place in the foot during the weightbearing portion of the gait cycle, we can see why Leonardo Da Vinci stated, “The human foot is a masterpiece of engineering and a work of art.” So in our treatment plan we must consider adjusting the foot to make sure all joints are moving normally, as well as evaluate for weakened musculature or tight tissue structures like the anterior and posterior tibialis and the Achilles tendon. Scan the patient to identify their pronation index (which helps determine if stabilizing orthotics should be recommended). Possible shoe-type recommendations may be necessary based on foot structure and activity levels. It is extremely important to evaluate the gait cycle once you have made your corrections and recommendations. If compensatory patterns were being developed from favoring the pain and/or restricted movements resulting from subluxations, then some neuromuscular re-education may be necessary to further bring about a symmetrical gait cycle for a patient.
 
References:
  1. Frost HM. Wolff's Law and bone's structural adaptations to mechanical usage: an overview for clinicians Angle Orthod. 1994;64(3):175-88. 
  2. Malone TR, Bolgla LA. Plantar Fasciitis and the Windlass Mechanism: A Biomechanical Link to Clinical Practice. J Athl Train. 2004 Jan-Mar;39(1):77–82.
 
A 1980 graduate of Palmer College of Chiropractic, Dr. Kirk Lee is a member of the Palmer College of Chiropractic Post Graduate Faculty and Parker College of Chiropractic Post Graduate Faculty. He has lectured nationwide on sports injuries and the adolescent athlete, and currently practices in Albion, Michigan.
 
Providing the “Racer’s Edge” to a Young Runner
Orthotics
Written by John Danchik, D.C., F.I.C.C., F.A.C.C.   
Wednesday, 29 February 2012 17:09

History and Presenting Symptoms

T
he patient, a 27-year-old female, is a media designer who has been running regularly for the past eight years.  She reports the recent onset and gradual worsening of pain in the front of her left lower leg, which is now limiting her regular physical activities.  The leg pain is described as an “aching soreness” that has been getting progressively worse.  She recalls no specific injury, and has no obvious swelling or discoloration.  Her left leg pain becomes particularly noticeable when she runs downhill or tries to increase her mileage.  There is also now a mild persistent aching in her left buttock region.  She is planning on running her first 10k race in four months.

runnercrossingfinishlineExam Findings

Vitals. This active young woman weighs 122 lbs, which at 5’4’’ results in a BMI of 20.9 – she is at normal weight.  She doesn’t drink alcohol or smoke, 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 spine, although she shows evidence of a left posterior ileum.  She has mild calcaneal eversion, with a lower left arch.  Treadmill gait evaluation indicates obvious hyperpronation of the left foot and ankle when running.  Standing Q-angle is measured at 27° on the left and 22° on the right (20° is normal for women).

Chiropractic evaluation. Motion palpation identifies a limitation in her left sacroiliac motion, with mild tenderness and loss of endrange mobility.  Yeoman’s provocative test elicits moderate pain upon prone extension of the left leg.  Neurologic testing is negative.

Primary complaint. Palpation of the left lower leg finds tenderness and tightness of the muscle insertions in the lower third of the tibia, along the anterolateral aspect.  Manual testing identifies mild weakness of the tibialis anterior, extensor hallucis longus, and extensor digitorum longus muscles, and the isometric testing elicits increased pain in these muscles.  There are no sensory or reflex changes, and no significant asymmetry in muscle mass or leg diameter.  All ankle joint ranges of motion are full and pain-free, bilaterally.

Imaging

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

Clinical Impression

“Shin splints” in the deceleration muscles of the left ankle, along with an elevated Q-angle and foot pronation.  This is accompanied by left sacroiliac joint motion restriction and dysfunction.

Treatment Plan

orthoticblueAdjustments. Specific side-posture adjustments for the left sacroiliac joint were provided.  Manipulation of the left navicular and calcaneal bones was performed to reduce the biomechanical stress on the medial arch and sub-talar joint.

Support. Individually designed stabilizing orthotics were provided to support the arches and decrease impact at heel strike.  Two pairs of orthotics were ordered: one for her job-related dress shoes and the other for her running shoes.

Rehabilitation. Full-range resistance exercises (using surgical tubing) for the anterior tibialis muscles were performed daily; her efforts were recorded in a log.  This program progressed to focus on strengthening the eccentric (deceleration) phase in particular.  She was able to continue her distance-running training program.

Response to Care

She responded well to the sacroiliac and foot adjustments, and reported a rapid decrease in her leg symptoms.  Within two weeks (after introducing the orthotics), she was able to return to her previous distance-running training program.  She reported that she felt that her gait was smoother, and that she felt her heel strikes were less stressful.  After a total of eight treatment sessions she successfully completed her first 10k race.  She described moderate, bilateral post-run leg soreness, which resolved within two days.  She then returned to regular running with no persistent or recurrent discomfort.

Discussion

Moderate biomechanical asymmetries can become more prominent (and symptomatic) when levels of physical stress and training volume increase.  This seems to be especially true in the lower extremities.  Shock-absorbing stabilizing orthotics incorporate support for the arches while they reduce pronation and decrease the stress of repetitive heel strikes on the foot and spine.  Anterolateral shin splints indicate a problem with deceleration of the foot at heel strike, which requires improvement of eccentric strength of the anterior tibialis muscle and its co-contractors.


 
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