Orthotics


Chronic Facet Syndrome
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Monday, 26 December 2005 23:43

History and Presenting Symptoms

A 46-year-old female presents with recurrent, sharp pain in her low back.  These episodes usually resolve within a few days, but she is concerned that they are becoming more frequent.  Using a Visual Analog Scale, she describes the usual pain level in her lower back as around 35mm.  She doesn’t recall any injury to her back, and can’t identify any specific cause for her pain.  She states that she just “takes it easy” for a few days, and the pain resolves.

Exam Findings

Vitals.  This patient is 5’5’’ tall, and she weighs 138 lbs, which is a BMI of 23; she is not overweight.  Her blood pressure is 124/76 mmHg, with a pulse rate of 76 bpm.  She reports that she has never used tobacco products, and averages 4-5 glasses of wine per week.

Posture and gait.  Standing postural evaluation finds generally good alignment throughout her pelvis and spine, except for an accentuated lumbar lordosis.  She has a mild bilateral knee valgus and moderate calcaneal eversion, with hyperpronation bilaterally.  During gait, both feet demonstrate a tendency to toe-out.  Inspection of her shoes finds scuffing and wearing of the lateral aspect of both heels.  She states that she usually wears shoes with higher heels for work, and that she has noticed that all her shoes wear out quickly.

Chiropractic evaluation. Kemp’s testing produces sharp pain localized to the lumbar spine when performed to both sides.  Motion palpation identifies functional limitations in extension at the L3/L4 and L4/L5 levels, with moderate tenderness and loss of endrange mobility.  Neurological tests are negative for nerve root impingement.

Imaging

A-P and lateral lumbopelvic X-rays in the upright position are taken during relaxed standing.  The sacral base angle is 48°, the lumbar lordosis measures 62°, and the lumbar gravity line (from L3) falls anterior to the sacrum.  There is evidence of chronic facet imbrication, with sclerosis seen at L3/L4 and L4/L5.  There is no discrepancy in femur head or iliac crest heights, and no lateral listing or lateral curvature is noted.

Clinical Impression: Chronic facet syndrome with lumbar hyperlordosis and increased sacral base angle.  This postural stress is being exacerbated by her choice of heel heights, and by her tendency to overpronate during gait.

Treatment Plan

Adjustments.  Flexion distraction and side posture adjustments for the lower lumbar region were provided, as needed, with good response.
Stabilization.  Custom-made, flexible orthotics were supplied, and she was told to limit her heel height to 1” maximum.  She was found to be wearing shoes that were too small for her feet, and needed to increase one full size for proper fit.

Rehabilitation.  She was instructed in a daily core strengthening program, to be done at home, using elastic exercise tubing.  The focus was on activation of her transverse abdominis musculature, for improved spinal stability.

Response to Care

This patient responded rapidly to her spinal adjustments.  She had very little difficulty in adapting to the custom-made, flexible orthotics, and she reported that the slightly larger shoes with lower heels were much more comfortable.  She was consistent with her home exercise program, as demonstrated by her exercise log.  After six weeks of adjustments (10 visits) and daily home exercises, including wearing the orthotics in properly fitted shoes with lower heels, she was released to a self-directed maintenance program.

Discussion

This case demonstrates the importance of investigating all sources of underlying biomechanical stress, especially when a spinal condition is chronic or recurrent.  Shoe-related postural problems are not uncommon, particularly in women.  Many women don’t check their shoe size for many years, and they often wear shoes that are too small for their feet.  Heel height can complicate spinal facet syndromes, resulting in a poor response to chiropractic care.

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 can be reached by e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

 
A Non-Surgical Approach to Chronic Knee Pain
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Saturday, 26 November 2005 22:43

History and Presenting Symptoms

The patient is a 41-year-old male, who describes persistent pain and occasional stiffness in his left knee, which is not associated with any specific activity.  He reports several 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 172 lbs., which, at 5’10’’, results in a BMI of 24; he is not overweight, but getting close.  He is a long-time moderate cigarette smoker (10/day), and 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 left side.  A tendency for the left foot to toe out (foot flare) is noted during gait screening.

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

Primary complaint: Examination of his left knee finds no ligament instability and no limitation, pain, or “click” on McMurray testing.  Moderate pain and crepitus is 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 left sartorius muscle, when compared to the right side.

Imaging

No X-rays or other forms of musculoskeletal imaging were requested, since multiple X-rays and an MRI of the knee had previously been performed.

Clinical Impression

Biomechanical asymmetry of the lower extremities, with probable meniscal irritation at the left 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 left proximal tibia was adjusted into internal rotation, with additional medial pressure for the valgus malposition.

Stabilization. Custom-made, flexible orthotics were provided to support the arches, to decrease the medial pressure on his left 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 left sartorius muscle for improved medial knee support.  He also worked to strengthen internal rotation action of his left 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 two weeks.  He reported no difficulty in wearing the orthotics in all of his shoes.  Over the next two months, 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 maintenance program after a total of 15 visits over three months.

Discussion

This patient had received the “learned 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 custom-made 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 health potential.  He has made a commitment and a plan to quit his smoking.  He has already improved his diet, and is exercising regularly now for fitness.

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 .

 
Arch Collapse in an Active Woman
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Wednesday, 26 October 2005 21:52

flatfeetHistory and Presenting Symptoms

A 62-year-old female presents with a recent history of moderate pain in her lower back.  Her back pain responds well to chiropractic adjustments, but recurs within a couple of days.  There are no specific triggering activities, although being up and active seems to bring on the pain more rapidly.  She describes her current level of low back pain as usually around 30mm to occasionally 40mm on a Visual Analog Scale.

Exam Findings

Vitals:  This aging, but physically active woman (she plays golf at least twice each week, and walks about a mile every day) weighs 148 lbs., which, at 5’ 7”, results in a BMI of 23; she is not overweight.  She reports that she has been a non-smoker since she quit 22 years ago, and she is a social drinker of alcohol, with an average of one glass of wine each day.  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 a lower iliac crest on the right, and a low right greater trochanter.  The left shoulder is slightly lower than the right, with no history of fracture or surgery.  She has a mild bilateral knee valgus and moderate calcaneal eversion and hyperpronation on the right side, with a noticeable outward flare of her right foot.  Palpation of the right arch, when standing, finds it significantly lower than the left, but it is not tender to direct pressure.  The Navicular Drop test demonstrates greater excursion of the right navicular bone when moving from sitting to standing (non-weight bearing to weight bearing).

Chiropractic evaluation:  Motion palpation identifies limitations in segmental motion at L4/L5 and L5/S1, with some local tenderness.  These segmental dysfunctions demonstrate loss of end range mobility in all directions.  Additional subluxations are noted at T9/T10, C5/6, and C2/3.  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 moderate loss of intervertebral disc height at L4/L5 and L5/S1, with small osteophyte formation at those levels.  A discrepancy in femur head heights is seen, with a measured difference of 6mm (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

Moderate lumbosacral osteoarthrosis and disc degeneration, with mechanical dysfunction associated with poor biomechanical support from the lower extremities.  There is a functional short leg on the right side.  The asymmetry in the lower extremities is clearly demonstrated by the loss of right arch stability seen on the Navicular Drop test.  There is noticeable hyperpronation, arch collapse, and foot flare consistent with right arch collapse, with the expected effects in the pelvis and spine.

Treatment Plan

Adjustments:  Specific chiropractic adjustments for the lower extremities and the involved spinal regions were provided as needed.

Support:  Custom-made, stabilizing orthotics were provided to support the right arch and calcaneus (pronation correction) and decrease the asymmetrical stress on the knees and back.

Rehabilitation:  This patient was instructed to perform an at-home series of back exercises using elastic tubing to develop and maintain coordinated strength in her spinal stabilizers (paraspinal musculature) and core (trunk and pelvic) musculature.

Response to Care

She responded well to the adjustments and exercise, and reported a rapid decrease in symptoms.  Within two weeks of receiving her orthotics, she related that she had more energy and no longer had the previous nagging low back pain.  She was released to a self-directed maintenance program after a total of 10 treatment sessions over two months.

Discussion

This patient had no foot or arch pain, but was undergoing plastic deformation of her arches.  For unknown reasons, the deformation was accelerated in the right foot, producing a chronic asymmetrical strain on her pelvis and spine.  Her condition was documented with a test for stability of the arches—the Navicular Drop test.  This highlighted the asymmetry in her lower extremities and provided for an easy discussion of the benefits of long-term orthotic support.

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 .

 
Shin Splints in an Amateur Runner
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Friday, 26 August 2005 19:45

shinsplintrunnerHistory 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 .

 
Leg Length Inequality
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Tuesday, 26 July 2005 17:41

shortlegexamHistory 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 .

 
«StartPrev111213141516NextEnd»

Page 12 of 16
 

requestmagazinebutton


Advertisement

Recent Comments


Advertisement

 

TAC Publications

The American Chiropractor Magazine: Digital Issues | Past Issues | Buyer's Guide

 

More Information

TAC Editorial: About | Circulation | Contact

Sales: Advertising | Subscriptions | Media Kit