Orthotics


Motion Limitations Hamper Runner
Orthotics
Written by John Danchik, D.C., F.I.C.C., F.A.C.C.   
Wednesday, 25 September 2013 22:36
History and Presenting Symptoms
The patient, a 33-year-old female, is a marketing director who took up running for stress reduction and weight loss. She has been running for six months and has progressively increased her mileage. She is experiencing recurring and worsening pain in her left foot, as well as increased low-back tightness. She recalls no specific injury to her foot or back, but thinks she may favor her left foot while running.
 
Exam Findings
runner3Vitals. This active woman weighs 154 lbs, which at 5′6″ results in a BMI of 24.9—she is right on the normal/overweight borderline. She mentions that she has lost about 14 lbs since beginning regular running, and hopes to lose about 10 more (which would be appropriate for her height). She reports that she has never smoked, and that her blood pressure and pulse rate are both at the lower end of normal range. She drinks one to two glasses of white wine each week, usually with meals.

Posture and gait. Standing postural evaluation finds basically good alignment with intact spinal curves and no lateral listing of her pelvis or spine. She demonstrates bilateral calcaneal eversion, worse on the left with a lower left arch. Treadmill gait evaluation finds obvious hyperpronation of the left foot and ankle when walking, which is noticeably worse when running.

Chiropractic evaluation. Motion palpation identifies a limitation in right sacroiliac motion with moderate tenderness and loss of end-range mobility. Several compensatory fixations are identified throughout the thoracolumbar region. Yeoman’s provocative test elicits moderate pain upon prone extension of the right leg. All other spinal and neurological tests are negative, including sensory and reflex testing of the lower extremities.

Primary complaint. Palpation of the left 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.
 
Imaging
An x-ray series of the left 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
There is 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. This is in response to the increased biomechanical strain of her running program, which is accompanied by sacroiliac joint motion restriction and compensatory thoracolumbar fixations associated with altered gait.
 
Treatment Plan
Adjustments. Specific, corrective adjustments for the right sacroiliac joint and the thoracolumbar region were provided as needed. The left cuboid and navicular were adjusted while carefully avoiding placing pressure on the fourth metatarsal bone.

Support. Individually designed 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, one designed specifically for her running shoes and the other for job-related dress shoes.

Rehabilitation. All weight-bearing exercise was restricted for two weeks. Then, 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.
 
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 left 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. Flexible, shock-absorbing orthotics will incorporate arch support while reducing pronation and decreasing the stress of repetitive heel strikes on the foot and spine. 
 
Lower Extremity Aging Concerns
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Orthotics
Written by John Danchik, D.C., F.I.C.C., F.A.C.C.   
Thursday, 25 July 2013 19:13
History and Presenting Symptoms
A 60-year-old female presents with recurring episodes of moderate pain in her lower back and right knee. As a full-time waitress/cashier, she spends almost half her workday on her feet. She recalls no specific back or knee injuries, and states that these problems have developed over the past couple of years and have been more noticeable in the past four months. On a 100 mm visual analog scale, she rates her low back pain as usually 45 mm, while her right knee varies from 25 to 60 mm. The knee feels worse after walking, and she takes over-the-counter NSAIDs for relief.
 
waitressExam Findings
Vitals.  This 5’ 5’’ female weighs 166 lbs, which results in a BMI of 27.6. She knows that she is overweight and is following a sensible diet, but is having difficulty doing the needed walking because of pain. She quit smoking 15 years ago. Her blood pressure is 118/79 mmHg and her pulse rate is 73 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 that is worse on the right with a lower right arch. During gait, both feet pronate substantially, and both feet flare outward (toe-out).

Chiropractic evaluation. Motion palpation identifies numerous limitations in spinal motion: the right SI joint, the lumbosacral junction on the right, L2/L3 on the left, 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 left foot, and no arch remaining on the right when standing. Her right 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 weight bearing. 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 5 mm (right side lower). A moderate lumbar curvature (4°) is also seen, convex to the right side, and both the sacral base and the iliac crest are slightly lower on the right. 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 right) 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 right foot and knee was also performed.

Support. Individually designed stabilizing orthotics were supplied, which included bilateral pronation correction (varus wedges). She described no problems in adapting to the stabilizing orthotics, although close inspection found that her shoes were 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 stabilizing orthotics made a noticeable improvement in her postural alignment at the feet and the lumbopelvic region. After eight treatment sessions over two months and daily home exercises, including wearing the orthotics, she was released to a self-directed home stretching 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 caused functional imbalance.
 
Athlete Back on the Ice Thanks to Chiropractic Care
Orthotics
Written by John Danchik, D.C., F.I.C.C., F.A.C.C.   
Thursday, 25 April 2013 19:24
History and Presenting Symptoms
The patient, a 24-year-old male semi-professional hockey player, reports a recent right hamstring “grab” that just does not seem to be improving. His history includes several injuries to the same hamstring muscle during his collegiate playing career with mixed attempts to stretch and rehab. He also describes varying levels of pain in his lower back and left hip region, which has led him to ask for a complete musculoskeletal evaluation.
 
Exam Findings
hockeyplayerVitals.  This athletic young male weighs 175 pounds, which at 5’11’’ results in a BMI of 24.4: He is not overweight. He is a non-smoker, does not drink alcohol, and his blood pressure and pulse rate are at the lower end of the normal range.

Posture and gait. Standing postural evaluation finds relatively good alignment with intact spinal curves but a slightly lower iliac crest on the right along with a lower-right greater trochanter. His spine appears to be well balanced above with no evidence of lateral curve or list. He also demonstrates right calcaneal eversion and a low medial arch (hyperpronation). A tendency to toe out on the right is seen during a standard gait screening, and he confirms his need to be conscious of the positioning of his right foot when skating.

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

Primary complaint.  Examination of his right 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 58° 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 right 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 is obtained. The standing AP lumbopelvic view shows a lateral pelvic tilt, a low sacral base on the right, and the right femur head is five millimeters lower.
 
Clinical Impression
Hamstring muscle injury associated with chronic biomechanical strain. A functional short leg on the right is accompanied by sacroiliac joint motion restriction and compensatory lumbar fixations.
 
Treatment Plan
Adjustments.  Specific, corrective adjustments for the SI joints and lumbar region were provided as needed. Mobilization and manipulation were performed on his right arch, calcaneus, and navicular bone.

Support.  Individually designed stabilizing orthotics were ordered for his street shoes, and a second 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 right 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 hockey player required very few re-adjustments. His compliance with the recommended exercises was excellent because he was quite motivated to improve his performance and to prevent future hamstring injuries. He was immediately able to wear his orthotics full time and reported an improved sense of edging and control in his skates. The right hamstring muscle regained full flexibility and balanced strength, and he was released from acute care to a self-directed home stretching and sports performance program after a total of eight visits over two months.
 
Discussion
While a hamstring muscle “grab” or “pull” is often just a simple strain injury, in some cases there is an underlying biomechanical fault that makes it recurrent. Careful evaluation of the patient’s 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 provide a better boot fit, improved his edge control, and enhanced long-term support for his lower extremities. As with this young man, athletes at all levels appreciate a thorough evaluation and advice that can help to improve sports performance.
 
 
Joint Pains Bother Fitness Seeker
Orthotics
Written by John Danchik, D.C., F.I.C.C., F.A.C.C.   
Sunday, 24 February 2013 22:30
History and Presenting Symptoms
jointpainsfitnessThis female patient is a 51-year-old small business owner and exercise enthusiast.  She reports pain in the front of her left knee over the past several months, especially when exercising at the gym.  She has no obvious swelling or discoloration and denies any specific injury.  She reports that she takes over-the-counter medication for relief, but is worried about taking drugs in order to complete her exercise regimen.
 
Exam Findings
Vitals.  This active, middle-aged woman weighs 138 lbs, which at 5’4’’ results in a BMI of 23.7 – not overweight, but at the higher end of normal. She is a non-smoker, and her blood pressure and pulse rate are both at the lower end of the normal range.

Posture and gait.  Standing postural evaluation finds generally good alignment throughout her pelvis and spine.  She has a mild bilateral knee valgus and moderate calcaneal eversion and hyperpronation on the left side.  Measurement finds a standing Q-angle of 27° on the left and 23° on the right (20° is normal for women).

Chiropractic evaluation.  Motion palpation identifies a limitation in lumbosacral motion, with moderate tenderness and loss of endrange mobility to the left at L5/S1.  A compensatory fixation is also noted at T10/T11.  Neurologic testing is negative.

Primary complaint.  Examination of the left knee indicates no ligament instability, but there is a positive patellar grinding test.  All knee ranges of motion are full and pain free, bilaterally.  Manual muscle testing finds no evidence of muscle weakness.
 
Imaging
No x-rays or other forms of musculoskeletal imaging were requested.
 
Clinical Impression
Patello-femoral arthralgia on the left, associated with an elevated Q-angle and foot pronation.  This is accompanied by lumbosacral joint motion restriction and compensatory lower thoracic fixation.
 
Treatment Plan
Adjustments.  Specific, corrective adjustments for the lumbosacral joint and the lower thoracic region were provided as needed.  Manipulation of the left knee into external rotation was performed to decrease the internal rotation associated with hyperpronation and her elevated Q-angle.

Support.  Individually designed stabilizing orthotics were provided to support her arches and decrease her Q-angles. Two pairs of stabilizing orthotics were ordered – one designed specifically for her gym shoes and the other for her job-related dress shoes.

Rehabilitation.  Due to her active lifestyle, no specific rehabilitation exercises were provided. She continued with her frequent activities at the local gym.
 
Response to Care
The adjustments for the spine and knee were well-tolerated, and she reported what appeared to her to be a rapid decrease in symptoms.  After this patient began wearing her orthotics regularly, she indicated noticing a substantial decrease in knee irritation with use, and a firmer foot plant during aerobics.  Within three weeks of receiving her orthotics, she related that she was performing all of her favorite workout routines with no knee pain or limitation.  She was released to a self-directed stretching program after a total of eight treatment sessions over two months.
 
Discussion
Several factors in this case make it quite interesting.  This high-powered business woman used her gym time as both a form of recreational relaxation and a place for business networking.  As her knee began to bother her more, she was driven to begin using anti-inflammatory drugs.  She did start wearing more supportive footwear, but her underlying biomechanical problem had not been sufficiently addressed.
 
When women are physically active, their naturally higher Q-angles are frequently a source of lower extremity pain. Patello-femoral arthralgia (previously known as chondromalacia patellae) has been recognized as a biomechanical tracking disorder of the kneecap in the femoral groove.  The best treatment is a conservative approach, with a combination of chiropractic adjustments, stabilizing orthotic support, and – when indicated – rehabilitative strengthening sessions using exercise tubing.
 
 
A Better Life by Avoiding the Knife
Orthotics
Written by John Danchik, D.C., F.I.C.C., F.A.C.C.   
Monday, 24 December 2012 02:05
History and Presenting Symptoms
kneepain14The patient is a 44-year-old male who describes persistent pain and occasional stiffness in his right knee that is not associated with any specific activity.  He reports at least two years of recurring episodes of medial knee pain that just comes and goes with no swelling or inflammation.  Previous evaluations, including a knee MRI, have resulted in a diagnosis of a torn meniscus.  Surgery has been offered; but with no guarantee of significant pain reduction, he has declined to undergo arthroscopic repair.
 
Exam Findings
Vitals. This male patient weighs 170 lbs., which at 5’ 9.5’’ results in a BMI of 24.7. He is not overweight but getting close.  He was a moderate cigarette smoker (eight per day) from his late teens into his mid-twenties, but he has been nicotine free for almost 20 years.  His blood pressure and pulse rate are at the upper end of the normal range.

Posture and gait. Standing postural evaluation finds generally good alignment with a slight forward head carriage but otherwise intact spinal curves and a balanced pelvis. He has a mild bilateral knee valgus with moderate calcaneal eversion and hyperpronation on the right side. A tendency for the right foot to flare out is noted during gait screening.

Chiropractic evaluation.  Motion palpation identifies a limitation in right sacroiliac (SI) movement with definite tenderness and loss of end-range mobility.  Several compensatory subluxations are identified throughout the lumbar region.  Otherwise, all spinal orthopedic and neurological testing is negative.

Primary complaint. Examination of his right knee finds no ligament instability and no limitation, pain, or “click” on McMurray testing.  Mild pain and crepitus are found during Apley’s grinding test.  All knee ranges of motion are full and pain free, bilaterally.  Manual muscle testing finds mild weakness in the right sartorius muscle when compared to the left side.
 
Imaging
No X-rays or other forms of musculoskeletal imaging were requested since multiple X-rays and an MRI of the knee had been performed during the initial surgical discussion period.
 
Clinical Impression
Biomechanical asymmetry of the lower extremities with probable meniscal irritation at the right knee.  This is accompanied by SI joint motion restriction and compensatory lumbar subluxations.
 
Treatment Plan
Adjustments. Specific, corrective adjustments for the SI joints and lumbar region were provided as needed.  The right proximal tibia was adjusted into internal rotation with additional medial pressure for the valgus malposition.

Stabilization.  Individually designed stabilizing orthotics were provided to support the arches, to decrease the medial pressure on his right knee, and to reduce the asymmetrical biomechanical forces being transmitted up the lower extremity to the pelvis and spine.

Rehabilitation. This patient performed daily exercises with elastic tubing to retrain and strengthen his right sartorius muscle for improved medial knee support.  He also worked to strengthen internal rotation action of his right hip to decrease the tendency to toe out.  In addition, he was supplied with a dietary supplement for joint health that contained glucosamine and chondroitin sulfates.
 
Response to Care
The spinal and extremity adjustments were well tolerated, but knee pain recurred until he had been regularly performing his rehab exercises for almost two weeks.  He reported no difficulty in wearing the orthotics in all of his shoes.  Over the next month, he described a noticeable improvement in his knee function with an eventual complete cessation of the previous pain and stiffness.  He was released from active problem care to a self-directed home stretching program after a total of eight visits over six weeks.
 
Discussion
This patient had received the medical opinion that, at some point, surgery would be the only answer for his chronic knee pain.  Fortunately, he persisted in searching for alternatives.

The combination of spinal and extremity adjustments, nutritional supplementation, and better support for the medial knee from improved muscle function and stabilizing orthotics resulted in an excellent response.  In fact, he is now embarking on a wellness plan that includes addressing his lifestyle choices to improve his diet and overall health.
 
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