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Orthotics
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Orthotics
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Written by John Danchik, D.C., F.I.C.C., F.A.C.C.
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Friday, 01 June 2012 21:03 |
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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.
 Exam 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.
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Orthotics
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Written by Kirk Lee, D.C.
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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.
 I 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:
- Frost HM. Wolff's Law and bone's structural adaptations to mechanical usage: an overview for clinicians Angle Orthod. 1994;64(3):175-88.
- 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.
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Orthotics
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Written by John Danchik, D.C., F.I.C.C., F.A.C.C.
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Wednesday, 29 February 2012 17:09 |
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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.
 Exam 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
 Adjustments. 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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Orthotics
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Written by Kirk Lee, D.C.
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Saturday, 19 November 2011 03:58 |
H ow many times have you heard from an athlete, “Make me run faster!” or “Improve my performance!”? Many athletes would gladly take a little pain for better performance and faster speed. However, ignoring the warning signs of pain can be a no-no! We know that the long-term outcome of living for today and not for the future can lead to chronic and disabling injuries. We have all experienced patients who do not follow our recommendations to reduce their workload, decrease training intensity, reduce the amount of miles they are running, etc. It becomes a mental block for many athletes who tell you they will, but really they won’t. First and foremost, it is not your fault. Unfortunately, many novice athletes think taking a few days off or even reducing their training program will affect their performance, whether they are runners or even football players.
If they don’t take your recommendation and refuse to take some time off for their bodies to heal and recover, then eventually they could develop a serious or chronic injury that begins to affect their  activities and eventually activities of daily living. The following is a commonly used grading scale for measuring the level of overuse-type injuries in runners. This is only a guideline for you to use during consultation, similar to an Oswestry pain scale.
- Pain comes on after the run, but does not affect time and/or distance
- Pain occurs during the run, but does not affect time and/or distance
- Pain occurs during the run and is affecting time and/or distance
- Pain is severe enough that patient cannot run
- Pain is severe enough that it affects all activities of daily living
As chiropractors, when we think about increasing the speed of a runner or even a walker, our number-one focus must be on stabilizing any existing vertebral subluxation complexes. We should work on furthering our assessment and treatment protocols to the rest of the musculoskeletal chain. Over the years I have spent a lot of time around the track and listened to numerous high school athletes and track coaches. A popular topic of conversation is about getting the runner to “turn over” his/her stride as fast as possible.
Many drills are done to work on that one phase of running, which means we are talking about power and how quickly we can generate that power. To get a better understanding we must know which muscles come into play to perform this outcome. We know that we increase our power as we go from walking to running to sprinting.
The primary power is generated from the hip extensors during the first half of stance phase, the hip flexors at the time of toe off, the knee extensors during the second half of stance, the ankle plantar flexors just before toe off, along with the hip abductors. (1)
The hamstring and gluteus maximus generate the power to pull the body forward by actively extending the hip after initial contact, when our foot is placed ahead of the body. Then, during the second half of stance phase, the quadriceps and gastrocnemius contract to push us forward by extending the knee and plantar flexing the foot. The hip abductors then contract to provide lift. Finally, the psoas propels the leg into swing phase by flexing the hip.
Thus the total amount of power generated increases as speed increases. The relative contribution from each of these muscle groups changes such that relatively more power is generated proximally (at the hip) as speed increases. (1) Based on this information alone, we must put our focus on a subluxation-free and strong musculature of the hip area.
Making Runners Faster
We also know that another leading cause of stride asymmetry is abnormal foot function caused by muscle imbalances. Ultimately, to make a runner faster two important keys are necessary. The first is the runner must have a consistent stride rate, or symmetrical stride. The second is a symmetrical stride length. The average stride rate ranges between 180-200 strides per minute.
Have the runner count his number of steps for 15 seconds and multiply by four. He should do this over several portions of his run to come up with a reasonable average. Then you can determine the speed at which a runner runs by multiplying the steps he takes per second (known as cadence) by the stride length.
To get an accurate measure of stride length I recommend doing what has worked for me for over 25 years – gait analysis using video and computer programs. Regardless of which program you use, it is important to do a follow-up analysis of your patient after a recommended course of care. You should check to see if your recommended treatment plan is improving stride length and improving symmetry in the three phases of the gait cycle. To learn more about what programs I use in my practice, visit my website at www.albionrundoctor.com or you can send a query to
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
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Research has shown that the main difference between long and short distance runners is the length of stride and not the rate of stride. (2) The average stride length is 2.5 feet long. So to walk one mile it takes approximately 2,000 steps. A common cause of overuse injuries comes from an abnormal symmetry in a patient’s stride length. Let’s do some math: Our patient is walking a one-mile race. Her right leg stride is 2 feet 3 inches and her stride with the left is 2 feet 5 inches, then, over the period of that mile, the right leg takes 100 steps that are 2 inches shorter. This totals to 200 inches or 16 feet 6 inches of distance variable. Substantial? Absolutely!
As doctors of chiropractic we understand the meaning and importance of symmetry. All joints from the spinal joints to the hip joints must move to their fullest innate potential. If you want to sing the bone-and-joint song, starting with “the foot bone is connected to the ankle bone,” then be my guest! We also know that another leading cause of stride asymmetry is abnormal foot function caused by muscle imbalances.
These imbalances can cause inversion or eversion of the foot and the functional movement patterns of hyperpronation, resulting from an anatomical breakdown of the three arches of the foot. Stabilizing the three arches of the foot with stabilizing orthotics to allow a normal heel-to-toe transfer in walking or a midfoot-to-toe transfer in running is very important. Remember, when recommending stabilizing orthotics, it is important to also recommend appropriate footwear.
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.
References
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Guten, G. Running Injuries: “Kinetics Overview”, pg 16. 1997 W.B. Saunders Company
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Rompottie, K. “A study of stride length in running” International Track and Field: 249-56. 1972
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Orthotics
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Written by John J. Danchik, D.C.
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Tuesday, 28 December 2010 12:55 |
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History and Presenting Symptoms
A 37 year-old male presents with a report of pain in his lower back and right hip. Further discussion elicits a history of previous right hamstring strain during high school soccer, along with several episodes of ankle sprains. He has had arthroscopic surgery to evaluate recurrent left knee pain and stiffness, which found no specific problem. He performs stretches daily to maintain flexibility in his iliotibial connective tissues, since they are frequently identified as tight and short. Because of his prior lower extremity symptoms, he does not currently participate in any competitive or recreational sports.
Exam Findings
Vitals. This athletic male weighs 151 lbs, which, at 5’9’’, results in a BMI of 22; 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 throughout the spine, although he shows evidence of a right posterior ileum. He also has mild bilateral calcaneal eversion, with a lower right arch. There is moderate medial bowing of the Achilles tendons when standing, especially on the right, with a tendency to toe out (foot flare) that is more prominent on the right side.
Chiropractic evaluation. Motion palpation identifies a limitation in right sacroiliac motion, with moderate tenderness and loss of endrange mobility. Also identified are moderate limitations in segmental motion at L4/L5 and L5/S1, with local tenderness. Additional fixations are noted at T12/L1, T9/T10, and C5/6. Lumbar ranges of motion are generally full and pain-free. Neurologic and provocative orthopedic testing is negative. Examination of the knees and ankles finds no ligament instability, and all knee and ankle ranges of motion are full and pain-free. Manual testing finds weakness of the right psoas muscle, in comparison to other lower extremity muscles.
Imaging
Upright, weight-bearing X-rays of the lumbar spine demonstrate moderate loss of intervertebral disc height at L4/L5 and L5/S1, but no osteophyte formation is seen at those levels. There is a slight discrepancy in femur head heights (4 mm), and iliac crest heights (3 mm), but no significant lateral curvature of the lumbar spine.
Clinical Impression
Chronic mechanical dysfunction of the pelvis and lumbar spine associated with poor biomechanical support from the lower extremities. By history, there is a pattern of several lower extremity conditions, which are consistent with his identified asymmetry.
Treatment Plan
Adjustments. Specific diversified chiropractic adjustments for the sacroiliac, lower lumbar, thoracic, and cervicothoracic spinal regions were provided as indicated.
Support. Flexible, custom-made stabilizing orthotics were fitted to support the arches and decrease calcaneal eversion.
Rehabilitation. This patient was shown dynamic resistance exercises using elastic tubing to begin strengthening his spinal stabilizers and core pelvic musculature. He was also instructed to gradually initiate a daily brisk walking program while wearing his orthotics, in order to re-balance his hip and pelvic muscles.
Response to Care
He responded well to his spinal adjustments, and adapted quickly to his orthotics. His compliance with the walking and stabilization exercise recommendations was very good, once the correlation between his previous lower extremity conditions and his current back problem was explained. The home-based spinal stabilization program was also quite easy and enjoyable, so he made continued progress. After 6 weeks of adjustments (10 visits) and daily home exercises, he was symptom-free and released to a self-directed home stretching program.
Discussion
Whenever I see the combination of back complaints and a history of lower extremity problems, I look for asymmetry of the feet and legs. If this is present, I know that effective chiropractic care must address the lower extremity imbalances and also retrain the core stabilizing musculature of the lower spine and pelvis. In this case, the patient’s chiropractic care included shock-absorbing orthotics to support his strained lower extremities, and specific exercises to improve his core stability.
Dr. John J. Danchik, the seventh inductee to the ACA Sports Hall of Fame, is a clinical professor at Tufts University Medical School and formerly chaired the U.S. Olympic Committee’s Chiropractic Selection Program. Dr. Danchik lectures on current trends in sports chiropractic and rehabilitation.
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