History and Presenting Symptoms

The patient is a 28-year-old graphic artist who has been running regularly for the past ten years.  She reports the recent onset and gradual worsening of pain in the front of her right lower leg, which is now limiting her physical activity routines.  The leg pain is described as an “aching soreness” that has been getting progressively worse.  She denies any specific injury and has no obvious swelling or discoloration.  Her right 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 right buttock region.  She is planning on running her first half-marathon in four months.

Exam Findings

Vitals: This healthy and active young woman weighs 120 lbs. which, at 5’3’’, results in a BMI of 21—she is definitely not overweight.  She is a non-smoker, 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 right posterior ileum.  She has mild calcaneal eversion, with a lower right arch.  Treadmill gait evaluation finds obvious hyperpronation of the right foot and ankle when running.  Measurement finds a standing Q-angle of 26° on the right and 22° on the left (20° is normal for women).

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

Primary complaint: Palpation of the right 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 right ankle, associated with an elevated Q-angle and foot pronation. This is accompanied by right sacroiliac joint motion restriction and dysfunction.

Treatment Plan

Adjustments: Specific side-posture adjustments for the right sacroiliac joint were provided.  Manipulation of the right navicular and calcaneal bones was performed to decrease the biomechanical stress on the medial arch and subtalar joint.

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

Rehabilitation: Full-range resistance exercises for the anterior tibialis muscles were performed daily, using exercise tubing, and recorded in a diary. 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 a subjective feeling of smoother gait and less stressful heel strikes. After a total of 12 treatment sessions, she successfully completed her first half-marathon run. 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 training volume and levels of physical stress increase.  This seems to be especially true in the lower extremities.  Shock-absorbing 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.

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 29 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 .

History and Presenting Symptoms

A 42 year-old male presents with recurring episodes of moderate pain in his low back and right hip.  He denies injuring the region and cannot identify any precipitating activities or events.  On a Visual Analog Scale, he rates his low back pain as varying from 25mm to 60mm, while the right hip pain is usually around 30mm.  He takes over-the-counter NSAID’s when his back pain interferes with his daily activities, and that usually provides sufficient relief.  He works as a car salesman and a baseball referee and is seeking non-drug treatment.

Exam Findings

Vitals. This male patient weighs 170 lbs which, at 5’11’’, results in a BMI of 24; he is not overweight.  He is a non-smoker, his blood pressure is 124/84 mmHg, and his pulse rate is 80 bpm.  These findings are within the normal range.

Posture and gait. Standing postural evaluation finds a lower iliac crest on the left, and a low left greater trochanter.  The right shoulder is noticeably lower than the left, 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 left lateral flexion and ipsilateral rotation at the L3/L4 and L4/L5 levels, with moderate tenderness and loss of end range 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 (left side lower).  A moderate lumbar curvature (6°) is noted, convex to the left side, and both the sacral base and the iliac crest are lower on the left side.  The sacral base angle and measured lumbar lordosis are within normal limits. 

Clinical Impression

Moderate anatomical leg length discrepancy (left short leg), with associated pelvic tilt and lumbar curvature.  There is an accompanying history of recurrent mechanical low back pain and right hip pain.

Treatment Plan

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

Stabilization. Custom-made stabilizing orthotics were supplied, and a permanent 5 mm heel lift was added to the left 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 left heel lift.  He brought his exercise log with him to every visit, which documented his regular performance of the home exercises.  After three weeks of adjustments (10 visits) 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 maintenance 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 is not rare, and 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 custom-made stabilizing orthotics, in order to ensure good foot biomechanics.

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 29 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 .