Orthotics


Metatarsal Stress Fracture
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Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Friday, 23 June 2006 17:29

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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Leg Pain in a Ball Player
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Wednesday, 24 May 2006 11:25

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 This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

 
Bunions Bother a Businesswoman
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Thursday, 27 April 2006 03:07

History and Presenting Symptoms

The patient is a 44-year-old female, who is the regional sales representative for several lines of gift items and pottery. She reports frequent pain in her feet, worse on the right side. The aching pain is located around the base of her first toes, both of which have a noticeable bulge. This pain is now interfering with her visits to customers, as her walking is becoming more difficult. She rates the pain in her feet as usually around 30mm to occasionally 45mm on a Visual Analog Scale.

Exam Findings

Vitals.  This active businesswoman weighs 152 lbs., which, at 5’7’’, results in a BMI of 23—she is not overweight.  She has never used tobacco products or alcohol, and her blood pressure is 124/84 mmHg and her pulse rate is 76 bpm.  These findings are within the normal range.

Posture and gait.  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.  During gait, both feet pronate substantially, and both feet flare outwards (toe-out).

Chiropractic evaluation. Motion palpation identifies limitations in segmental motion at L5/S1 and L2/L3, with some local tenderness. These segmental dysfunctions demonstrate loss of end range mobility in all directions.  Additional subluxations are noted at T6/T7, and C5/6. Lumbar ranges of motion are full and pain-free, and neurological testing is negative.

Primary complaint. Examination of her feet reveals bilateral hallux valgus, with redness more apparent at the base of the right first toe.  Mobility of the first metatarsophalangeal joint is limited on both sides, and the motion testing elicits pain in the right joint.  Flexion and extension are particularly limited.

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

Clinical Impression

Bilateral hallux valgus (bunions) with bilateral hallux limitus (loss of flexion/extension mobility). This is associated with hyperpronation and calcaneal eversion. It is also accompanied by lumbar spinal joint motion restriction and compensatory thoracic and cervical subluxations.

Treatment Plan

Adjustments. Spinal adjustments were provided as indicated for the lumbar, thoracic, and cervical regions.

Mobilization and gentle traction manipulation of both first metatarsophalangeal joints were well-tolerated and eventually increased her flexion/extension mobility.

Support. Custom-made, stabilizing orthotics were provided to limit calcaneal eversion, support the arches, and decrease the chronic pressure stress on the first metatarsophalangeal joints. She had to be counseled in shoe selection and proper fit, as she had been wearing tight and short dress shoes for many years. In certain brands and styles of shoes, she found that she had to increase an entire shoe size in order to get the correct fit.

Rehabilitation. Initially, she performed self-mobilization exercises for her first toes, along with self-massage of her feet using a golf ball.  After two weeks, she started a strengthening program using elastic exercise tubing.  Her primary exercises were internal rotation of the leg from the hip (to decrease the foot flare) and internal rotation of the foot (to decrease the hallux valgus).

Response to Care

She responded well to the spinal and foot adjustments, and reported an initial decrease in symptoms. Once she began wearing her stabilizing orthotics regularly, she noted a further decrease in her symptoms, along with improved walking capacity. She was released to a self-directed maintenance program after a total of ten treatment sessions over two months.

Discussion

Hallux valgus and hallux limitus are commonly found in association with excessive pronation and calcaneal eversion. When combined with improper shoe selection, there is an inevitable development of gait disability and spinal compensations. Studies have found that many women wear shoes that are not suitable for their feet, and that most women have not changed shoe sizes for many years, while their feet have often grown larger and flatter. The best treatment for this complex problem is a conservative approach, with a combination of chiropractic adjustments, custom-made orthotic support, corrective exercises, and education.

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 .

 
Hamstring Injury in a Hockey Player
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Monday, 27 March 2006 02:07

hockeyinjuredHistory and Presenting Symptoms

The patient is a 26-year-old male amateur hockey player, who reports a recent left hamstring “pull” that just doesn’t seem to be getting better.  His history includes numerous injuries to the same hamstring muscle when he played in college, with mixed attempts to stretch and rehab.  He also describes varying levels of pain in his lower back and right hip region, and requests a comprehensive musculoskeletal evaluation.

Exam Findings

Vitals. This athletic young male weighs 166 lbs, which, at 5’10’’, results in a BMI of 24; 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 left, along with a lower left greater trochanter. His spine appears to be well-balanced above, with no evidence of lateral curve or list. He also demonstrates left calcaneal eversion and a low medial arch (hyperpronation). A tendency to toe out on the left is seen during gait screening, and he confirms that he needs to be conscious of his left foot position when skating.

Chiropractic evaluation. Motion palpation identifies a mild limitation in right sacroiliac motion, with moderate tenderness and loss of end range mobility. Compensatory subluxations are identified at L4/5 and L2/3. Otherwise, all orthopedic and neurological testing is negative.

Primary complaint. Examination of his left lower extremity finds tenderness to palpation at the ischial insertion and in the medial belly of the hamstring muscle group.  Straight leg raise is limited to 60° by hamstring tightness and pain, and active knee extension is restricted when the hip is placed in 90° of flexion.  Manual muscle testing finds painful weakness in the left hamstring, when only moderate resistance is provided.

Imaging

Because of his history of recurrent strains and the evidence for postural asymmetry, an upright lumbopelvic series was obtained.  The standing AP lumbopelvic view shows a lateral pelvic tilt, a low sacral base on the left, and the left femur head is 5 mm lower.

Clinical Impression

Hamstring muscle injury is associated with chronic biomechanical strain.  A functional short leg on the left 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. Mobilization and manipulation were performed on his left arch, calcaneus and navicular bone.

Support. Custom-made, stabilizing orthotics were ordered for his work and recreational shoes, and a third pair was fitted into his hockey skates.  They were designed to support the arches, decrease calcaneal eversion, and reduce the asymmetrical biomechanical forces being transmitted to the spine and pelvis.

Rehabilitation. He was initially instructed to perform sustained functional hamstring stretches four times a day.  After one week, daily strengthening exercises for the left hamstring were progressed from light to strenuous resistance, using elastic exercise tubing.

Response to Care

The spinal and pelvic adjustments were well tolerated and, once he began wearing the stabilizing orthotics, this active athlete required very few re-adjustments. His compliance with the exercise recommendations was excellent, since he was quite motivated to improve his performance and to prevent future hamstring injuries. He was able to wear his orthotics full time immediately, and reported an improved sense of edging and control in his skates. The left hamstring muscle regained full flexibility and balanced strength, and he was released from acute care to a self-directed maintenance and sports performance program after a total of 10 visits over two months.

Discussion

While a hamstring muscle “pull” can be just a simple strain injury, in some cases there is an underlying biomechanical fault that makes it recurrent.  Careful evaluation of the spine and lower extremities identified the asymmetry in the feet and ankles as a major contributor to his symptoms.  Fitting stabilizing orthotics into his skates helped to improve his edge control, provide a better boot fit, and enhanced long-term support for his lower extremities. As with this young man, even amateur athletes appreciate a thorough evaluation and advice that can improve sports performance.

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.  He 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 has been in private practice in Massachusetts for 30 years.  He can be reached by e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

 
Lumbopelvic Pain during Pregnancy
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Monday, 27 February 2006 01:11

History and Presenting Symptoms

A 33-year-old female reports the recent onset of persistent aching pain and tightness in her lower back region.  The pain extends into both buttocks, and occasionally is felt around the left hip and into the left groin.  She is into her 7th month of her second pregnancy, and says that her back pain has increased with her additional weight and postural changes.  She reports that she had some back pain during and for a few months after her first pregnancy, but that, this time, it seems much worse.  She has been trying to continue with a daily 20-minute walking program, but is finding that difficult because it increases the tension in her lower back region.  On a 100mm Visual Analog Scale, she rates the pain in her lower back and pelvic region as varying from a constant 25mm to 50mm recently.

Exam Findings

Vitals.  This gravid female has put on about 30 pounds in the past couple of months, and currently weighs 162 lbs, which, at 5’6’’, is within the expected range.  She has never used tobacco, and stopped drinking alcohol as soon as she learned she was pregnant.  She has had several pre-natal check-ups, and her blood pressure and pulse rate are within normal ranges.  (BP—118/76 mmHg; pulse rate—68 bpm).

Posture and gait.  Standing postural evaluation finds a hyperlordotic lumbar spine and a forward-tilted pelvis, which are associated with her enlarged abdomen.  No lateral listing or curvature of her spine is seen, and her iliac crests and greater trochanters are level.  She has a slightly widened stance, with moderate valgus alignment at the knees.  There is also medial bowing of both Achilles tendons, with pes planus and hyperpronation bilaterally.  During gait, both feet demonstrate an obvious toe-out (foot flare).

Chiropractic evaluation.  Motion palpation identifies a very tender limitation in segmental motion at the left SI joint, and subluxations at L5/S1 and L2/L3.  Kemp’s test provokes pain localized to the lower lumbar spine when performed to both sides, and reproduces the left hip and groin pain when done to the left.  Spinal ranges of motion are otherwise normal and pain-free, and neurologic testing is negative for sensory, motor, and reflexive disorders.

Imaging. No radiographs were ordered, in consideration of her current pregnancy.

Clinical Impression

Chronic biomechanical strain of the lumbopelvic region is exacerbated by postural changes associated with the increased load of pregnancy.  There is also poor support from the lower extremities, with excessive pronation interfering with her walking program.

Treatment Plan

Adjustments.  Side posture adjustments were performed to the left sacroiliac joint and the lumbar spinal segments.

Support.  She was fitted with custom-made, stabilizing orthotics based on foot imaging in mid-stance.  The inserts were designed to provide support for her arches and decrease the biomechanical stress on her pelvis and sacroiliac joints during her pregnancy and after her delivery.

Rehabilitation.  She was shown a standing posterior tilt exercise for the pelvis (pelvic extension) to activate and strengthen the abdominal support muscles and her transverse abdomens in particular.  This exercise used the progressive resistance of elastic exercise tubing.  She was also instructed to perform abdominal floor exercises (Kegels).

Response to Care

The adjustments were well tolerated, and resulted in immediate release of tension and rapid reduction in pain levels.  She adapted easily to her orthotic inserts, and said that she noticed much greater stability in her feet and spine during walking.  She performed her daily home exercise program regularly and with no strain or difficulty.  She was treated weekly during the remainder of her pregnancy and then for six weeks after her delivery (a total of 12 visits).  At that point, she was released to a self-directed maintenance program.

Discussion

The process of pregnancy, delivery, and post-partum places a great amount of structural stress on a woman’s body.  In this case, poor support from the lower extremities increased the biomechanical strain, resulting in substantial distress.  She responded well to the chiropractic adjustments, but she also needed the additional support from custom-made orthotics and professional guidance for specific postural exercises. (She delivered a healthy 7.2 lb. baby girl.)

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.  He 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 has been in private practice in Massachusetts for 30 years.  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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