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Orthotics
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Orthotics
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Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.
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Monday, 28 April 2008 13:06 |
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History and Presenting Symptoms
A 48-year-old male presents with persistent pain in his lower back region. He describes his back pain as an aching tightness, which has been progressively worsening over the past six months. On a Visual Analog Scale, he rates his current level of pain at around 35mm to occasionally 45mm. He is unable to identify any specific aggravating activities, but his efforts to lose weight by walking have made his low back symptoms more noticeable.
Exam Findings
Vitals. This middle-aged man is trying to lose weight by increasing his walking. He now weighs 187 lbs, which at 5’10’’ results in a BMI of 27; he is overweight, but not obese. He is down from 205 lbs one year ago. He reports that he has not used tobacco since he quit twelve years ago, but he is a regular drinker of alcohol, averaging three "lite" beers daily. His blood pressure is 128/86 mmHg, with a resting pulse rate of 76 bpm. These findings are at the upper end of the normal range, but have reportedly improved since he started his exercise program.
 Posture and gait. Standing postural evaluation finds a lower iliac crest on the right, and a low right greater trochanter. There is a moderate lumbar list to the right, with compensatory balancing in the thoracic spine, causing the left shoulder to be lower than the right. His right arch is significantly lower than the left, and the right calcaneus is everted. Palpation of the right arch when standing elicits no pain or tenderness in the plantar fascia. Gait evaluation finds hyperpronation with external foot flare on the right. The Navicular Drop Test demonstrates greater excursion of the right navicular bone from sitting to standing (non-weight bearing to weight bearing). Chiropractic evaluation. Motion palpation identifies several mild limitations in spinal motion: the right SI joint, L4/L5, T11/12, and at the cervicothoracic junction. Palpation finds some local tenderness in these regions, but no muscle tone or texture changes. Lumbar ranges of motion are full and pain-free, and neurological testing is negative.
Imaging Upright, weight-bearing X-rays of the lumbar spine demonstrate a moderate loss of intervertebral disc height at L4/L5, accompanied by small osteophytes. A mild lumbar curvature (5°) is noted, convex to the right side. A discrepancy in femur head heights is seen, and both the sacral base and iliac crest are lower on the right side, while the sacral base angle and measured lumbar lordosis are within normal limits. A collimated pelvic view with the femur heads centered finds a measured difference of 7mm in the heights of the femur heads, with the right side lower.
Clinical Impression
Moderate lumbar disc degeneration and osteoarthritis, and mild postural imbalance in the lumbar spine and pelvis. This is associated with asymmetry of arch support due to plastic deformation of the support ligaments, resulting in a functional short leg on the right side.
Treatment Plan
Adjustments. Specific chiropractic adjustments were provided for the involved spinal segments.
Support. Flexible, stabilizing orthotics were custom-made to support the plastic deformation in his right arch and calcaneus and to decrease the asymmetrical stress on the pelvis and spine. An additional layer of viscoelastic material was included to decrease shock transmission during walking.
Rehabilitation. He was shown a series of elastic tubing exercises to improve the strength and coordination of his deep spinal stabilizing musculature.
Response to Care
He responded rapidly to the adjustments and exercise, with an immediate decrease in symptoms. Within two weeks of receiving the orthotics, he was able to pursue his walking program without back pain. At a re-exam after eight treatments over two months, he demonstrated good spinal and pelvic alignment with his orthotics in place, and was released to a self-directed maintenance program.
Discussion
The combination of spinal degenerative change, excess weight, and biomechanical imbalance became problematic when aggravated by increased exercise activity. With no noticeable foot or arch symptoms, this patient was undergoing plastic deformation of his right arch. The Navicular Drop Test helped to identify this condition. The result was a chronic asymmetrical strain on his pelvis and spine that was easily addressed with chiropractic methods.
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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Orthotics
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Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.
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Friday, 29 February 2008 14:04 |
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History and Presenting Symptoms
The patient is a 32-year-old mom, who also works part-time at the local middle school, where she is the school nurse. She reports numerous episodes of aching and tightness in her right calf over the past three years. She denies any recollection of injury or overuse activities. She has no significant disability, as she is able to perform her job and family duties without restriction. She describes her persisting low-level right calf pain as about 25mm to 35mm on a 100mm Visual Analog Scale (VAS). It never really goes away, but does vary in intensity.
Exam Findings
Vitals. This active woman weighs 144 lbs which, at 5’3’’, results in a BMI of 26—she is somewhat overweight. She appears to carry most of her excess weight around her midsection—an indication of central adiposity. She is, otherwise, quite healthy, with blood pressure and pulse rate within the normal range. She is a non-smoker, and drinks alcohol occasionally with meals.
Posture and gait. Standing postural evaluation finds generally good alignment, with intact spinal curves, and no lateral listing of the pelvis or spine. She does show evidence of a right posterior ilium, with prominence of the right PSIS. She has noticeable right calcaneal eversion, with a lower right arch. 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 functional limitations at the L2/L3 and L4/L5 levels, with moderate tenderness and loss of endrange mobility. Hip and sacroiliac joint movements are full and pain free on both sides.
Primary complaint. Examination of her right calf muscles finds the soleus to be tender to palpation around its attachments into the posterior tibia. All right-ankle ranges of motion are full and pain free—except dorsiflexion, which is limited primarily by muscle tightness, not pain. Manual muscle testing finds slight weakness of the right anterior tibialis muscle, when compared to the left side.
Imaging. A-P and lateral lumbopelvic X-rays in the upright, standing position are obtained. A moderate discrepancy in femur head heights is seen, with the right measured lower by 4mm. A moderate right convex lumbar curvature (5°) is noted.
Clinical Impression. Chronic, recurrent muscle imbalance of the right soleus muscle with asymmetrical pronation and an increased right Q-angle. The biomechanical stress from the lower extremities is associated with secondary motion restrictions and asymmetries in the lumbar spine and pelvis.
Treatment Plan.
Adjustments. Specific, corrective adjustments for the pelvis and lumbar region were provided as indicated. Manipulation of the right ankle and arch was performed with the goal of increasing the range of right ankle dorsiflexion motion.
Support. Flexible, custom-made, stabilizing orthotics made with shock-absorbing materials were provided to support the arches and decrease calcaneal eversion, and to reduce the asymmetrical biomechanical forces being transmitted into the knee and spine. Rehabilitation. She was shown how to perform standing calf stretches with the knee bent (for the right soleus muscle), with the goal of increasing muscle flexibility and right ankle mobility in dorsiflexion. After two weeks, daily strengthening of anterior tibialis muscle was introduced, using elastic exercise tubing.
Response to Care
The spinal and pelvic adjustments were well tolerated, and she responded rapidly to the spinal adjustments and calf stretches. She adapted to and wore the stabilizing orthotics without difficulty, and she particularly appreciated the support when she was at work. After six weeks of adjustments (ten visits) and daily home exercises, she was released to a self-directed maintenance program.
Discussion
The combination of a low arch, increased Q-angle, and pelvic misalignment is not uncommon. This combination of mechanical findings often results in systems and eventual structural breakdown. Even a moderate amount of asymmetrical pronation, when exposed to repetitive or constant loading strain, can develop into chronic muscle tension, with shortening tightness. Spinal adjustments and very specific stretching/strengthening exercises provided relief, but the underlying functional asymmetry had to be addressed with custom-made, stabilizing orthotics for long-lasting results.
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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Orthotics
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Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.
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Thursday, 08 November 2007 16:22 |
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History and Presenting Symptoms
The patient is a 52-year-old male, who was previously treated successfully for a lumbar disc problem, and who now returns to this clinic reporting pain and skin thickening (callus formation) on the bottoms of both feet. He has tried several remedies, but his calluses always return.
Exam Findings
Vitals. This middle-aged, physically active corporate executive weighs 175 lbs, which at 5’10’’ results in a BMI of 25 – he is on the borderline of overweight. Because of the results of a recent key executive physical exam, which showed an increased low density lipoprotein (high LDL), he has been working out regularly and is generally quite fit. Physical inspection indicates that some of his excess weight may be lean body mass. He is a non-smoker, and his blood pressure is within the normal range.
Posture and gait. Standing postural evaluation finds a slight lumbar list to the right, with compensatory balancing in the lower thoracic spine. He has a forward pelvis, and a decreased lumbar lordosis. He also demonstrates bilateral flat feet (pes planus), with no medial arches and bilateral calcaneal eversion. Both feet toe out during walking.
Chiropractic evaluation. The lumbar spine is moderately tender throughout, and he demonstrates a generalized loss of vertebral mobility. Motion palpation identifies limitations in segmental motion at L4/L5 and L5/S1, with some local tenderness. These segmental dysfunctions demonstrate loss of endrange mobility in all directions. Additional subluxations are noted at T9/T10 and C6/7. Orthopedic and neurological provocative testing of the spine and pelvis is negative.
Primary complaint. Lower extremity examination finds thickening of the skin and tenderness to palpation over the heads of the second and third metatarsal bones on both feet. This is in the anterior transverse arch region. All foot and ankle ranges of motion are full and pain-free, and manual muscle testing finds no evidence of weakness in the surrounding musculature. Squeeze test is negative for interdigital irritation.
Imaging
Upright, weight-bearing X-rays of the lumbar spine demonstrate moderate loss of intervertebral disc height at L4/L5 and L5/S1, with small osteophyte formation at those levels. A slight discrepancy in femur head heights is noted, with a difference of 3mm (right side lower). A moderate lumbar curvature (4°) is noted, convex to the right side, and both the sacral base and the iliac crest are lower on the right. The sacral base angle and measured lumbar lordosis are within normal limits.
Clinical Impression
Repetitive biomechanical stress to the tissues underneath the 2nd and 3rd metatarsal heads, resulting in callus formation. This is accompanied by chronic lumbopelvic spinal subluxations secondary to long-standing biomechanical stress on the anterior arches of the feet.
Treatment Plan
Adjustments. Specific adjustments were provided to the lumbopelvic region. Both feet also received adjustments for collapsed anterior transverse metatarsal arches.
Support. He was fitted with custom-made, flexible stabilizing orthotics designed to provide support for the anterior transverse arches, under the metatarsal heads. The orthotics were made with viscoelastic, shock-absorbing materials, in order to support all three arches and limit gravitational stress when standing and walking.
Rehabilitation. This active patient was told to continue his personal exercise program. He was instructed in a series of foot exercises (marble pick-up and towel-scrunching) to improve the coordination and strength of his anterior foot intrinsic muscles.
Response to Care
He responded well to the adjustments and exercises, and reported a rapid decrease in foot symptoms. Initially, he didn’t notice any change when wearing his orthotics, but within three weeks he no longer had any of the previous irritation in his feet. After eight weeks, his calluses were softer, and he had no more progression. He was released to a self-directed maintenance program after a total of ten treatment sessions over two months. When re-evaluated at a six-month check-up visit, he reported that his calluses had decreased significantly, and were no longer causing problems.
Discussion
This high-powered, active executive experienced unusual levels of repetitive biomechanical stress to his anterior arches, which resulted in callus formation. He responded well to conservative chiropractic care and custom-made orthotics. The best treatment for these types of problems is a conservative approach, with a combination of chiropractic adjustments, flexible 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
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Orthotics
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Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.
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Saturday, 08 September 2007 09:00 |
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History and Presenting Symptoms
A 27-year-old female describes a history of aching pain and tightness extending from her lower back into the pelvic region and both hips. She describes a recurrent pain that has bothered her since she was in a motor vehicle collision at the age of sixteen. As a passenger, she injured her right leg and hip during a frontal impact with a light post. No fractures were detected, but she had diffi culty walking for several months, and still gets very fatigued when walking or standing for more than 20 minutes. Her current pain is generalized to the posterior pelvis, but also involves her lower back and extends into both hips. On a 100mm Visual Analog Scale, she rates the pain in her lower back and pelvic region as varying from 30mm to 50mm.
Exam Findings
Vitals. This young woman weighs 152 lbs, which, at 5’9’’, results in a BMI of 22—she is not overweight. She reports that she attends yoga classes regularly and works out on a circuit training program at a local fi tness center. She has never smoked; she drinks beer occasionally; and her blood pressure is 118/76 mmHg with a pulse rate of 64 bpm.
Posture and gait. Standing postural evaluation fi nds a lower right iliac crest, and a low right greater trochanter. The left shoulder is somewhat lower than the right, but the spine demonstrates no signifi cant lateral curvature. Her knees are well aligned, but there is obvious medial bowing of the right Achilles tendon, with a lower medial arch on the right foot. During gait, the right foot toes-out and pronates excessively. Inspection of her shoes finds scuffing and wearing at the lateral aspect of the right heel.
Chiropractic evaluation. Motion palpation identifi es limitations in segmental motion at the right SI joint, with localized tenderness and loss of endrange mobility. Gaenslen’s and Yeoman’s tests for SI joint dysfunction both cause increased pain when the right side is stressed. Lumbar ranges of motion are within expected norms, and neurologic testing is negative for sensory, motor, and refl exive disorders.
Imaging
A lumbopelvic series (AP and lateral lumbopelvic views) is taken in the upright position during relaxed standing. An obvious discrepancy in femur head heights is noted, with the right side 6mm lower. A moderate lumbar curvature (5°) is convex to the right side, and the sacral base angle and measured lumbar lordosis are somewhat increased, but within normal limits. No loss of joint spacing or osteophyte formation is seen in the hip joints.
Clinical Impression
Chronic lumbopelvic misalignment, with mechanical dysfunction of the right sacroiliac joint complicated by leg length discrepancy. The difference in leg lengths is “functional,” since it is due to asymmetry of support in the lower extremities. The inequality results in a pelvic tilt and a slight lumbar curvature.
Treatment Plan
Adjustments. Specifi c chiropractic adjustments for the right sacroiliac joint and lumbar spine were provided as indicated. Manipulation of the right foot, including the navicular, cuboid, and calcaneal bones, was also performed. Support. Flexible, stabilizing orthotics were custom-made, and a pronation correction was added to the right side. The inserts provided support for her arches and included viscoelastic shock-absorbing material to decrease the biomechanical stress on her pelvis and sacroiliac joints.
Rehabilitation. She was shown a lumbopelvic muscle-training program to do in addition to her regular workouts. The “easy eight” exercises were performed daily at home using elastic exercise tubing.
Response to Care
The pelvis and foot adjustments were well tolerated, and the orthotics signifi cantly improved her postural alignment. After fi ve weeks of adjustments (eight visits) and daily home exercises, including wearing the orthotics, she was released to a self-directed maintenance program.
Discussion
This healthy and fi t young woman had a chronic pelvic misalignment caused by a prior injury. It was associated with pronation and biomechanical dysfunction in the right lower extremity. This asymmetry perpetuated her pelvic imbalance, in spite of a well-rounded fi tness program. She responded well to an appropriate combination of chiropractic adjustments, stabilization and support from custom-made orthotics, and specific exercises for the lumbopelvic support musculature.
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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Orthotics
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Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.
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Friday, 06 July 2007 10:32 |
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History and Presenting Symptoms
A 28-year-old male presents with recurring episodes of moderate low-back pain which always respond well to chiropractic adjustments, but eventually return. He recalls no specific back injuries, and cannot identify any triggering activities. On a Visual Analog Scale, he rates his low back pain currently at about 50mm. He has been able to avoid taking pain medication by getting regular chiropractic adjustments.
Exam Findings
Vitals. This active young man is 6 feet tall and weighs 176 lbs, resulting in a BMI of 24; his muscle definition indicates that he is not at risk of overweight. He doesn’t smoke, and his blood pressure is 116/78 mmHg with a pulse rate of 68 bpm. These findings are within the healthy range.
Posture and gait. Standing postural evaluation finds a lower right iliac crest and a low right greater trochanter. His knees are well aligned, but there is obvious medial bowing of the right Achilles tendon, and no medial arch on the right foot. When this is mentioned, he recalls a "bad sprain" injury to his right foot and ankle during high school football. He denies any persisting symptoms or current problems with the right foot or ankle.
Chiropractic evaluation. All active spinal ranges of motion are full and pain free, except that "aching stiffness" restricts left lateral flexion by 10°. Active palpation identifies a motion limitation in the right SI joint, which is also tender to direct pressure. Lumbosacral joint motion is restricted in left lateral flexion, with the feeling of generalized paraspinal muscle tightness. Provocative orthopedic and neurological tests for nerve root impingement and disc involvement are all negative.
Lower extremities. Closer examination reveals that he has no right medial arch when standing. His right calcaneus is noticeably everted when bearing weight. When seated and non-weightbearing, his right arch appears equal to the left, and manual testing finds no evidence of muscle weakness of the fibular or tibial muscles. The Navicular Drop test measures substantial asymmetry in excursion of the navicular bones when moving from sitting to standing (R = 3 mm of drop, L = 8 mm of drop from non-weight bearing to weight bearing). Palpation finds no significant tenderness in the right medial arch or plantar fascia.
Imaging
A lumbopelvic series (AP and lateral lumbopelvic views) reveals an obvious discrepancy in femur head heights, with a measured difference of 5 mm (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
Asymmetrical pronation likely due to previous injury, with associated pelvic tilt and lumbar curvature resulting in chronic biomechanical stress and recurring subluxations in the lumbopelvic region.
Treatment Plan
Adjustments. Specific, corrective adjustments for the SI and lumbosacral joints were provided—with good response, as previously. Manipulation of the right foot, including the navicular, cuboid, and calcaneal bones, was also performed.
Support. Custom-made, flexible stabilizing orthotics were supplied, with a pronation correction added to the right side. He had no problems in wearing the orthotics, finding them "very comfortable."
Rehabilitation. He was shown a series of lumbopelvic mobility exercises, using elastic exercise tubing at home. He was encouraged to continue his twice-weekly workouts at the local gym.
Response to Care
The lumbopelvic and foot adjustments were well tolerated, and the orthotics made a noticeable improvement in his postural alignment, both at the feet and the lumbopelvic region. After 6 weeks of adjustments (12 visits) and daily home exercises, including wearing the orthotics, he was released to a self-directed maintenance program.
Discussion
Excessive pronation and biomechanical asymmetries in the foot and ankle are often locally asymptomatic. In this active patient, the constant weightbearing stress to his SI and lumbosacral joints resulted in recurring spinal symptoms. Preventing chronicity is a vital aspect of chiropractic, and correction of this patient’s underlying pronation asymmetry was necessary. Having had no foot or ankle symptoms, he had not recognized that a previous lower-extremity sports injury could be a significant causative factor in his back problem. Fortunately, this was identified before any substantial degenerative changes developed.
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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