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Hip Pain in a Soccer Star
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Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Wednesday, 22 June 2005 16:54

History and Presenting Symptoms

The patient is a 14-year-old soccer player who reports frequent pain in her right hip and posterior thigh region for the past several months.  This is most noticeable the day after a strenuous soccer competition or scrimmage when she has obvious tightness and tension in the back of her upper right thigh.  She denies any specific injury but admits that she has been playing especially hard since being named team captain.  She finds that lying down and putting warm towels around her hip helps the most.

Exam Findings

Vitals. This athletic girl weighs 120 lbs., which, at 5’4", results in a BMI of 21—she is very active and fit.  She is a non-smoker, and her blood pressure and pulse rate are well within the normal range.

Posture and gait. Standing postural evaluation finds generally good alignment with intact spinal curves and no evidence of scoliosis.  Closer inspection identifies a higher left iliac crest, mild bilateral knee valgus, and static pronation of the right foot (calcaneal eversion with low medial arch).  The navicular drop test (Brody’s) finds 7 mm of excursion of the right navicular prominence between sitting and standing, compared to 3 mm of drop on the left.  Gait screening is negative for limp or noticeable asymmetry.

Chiropractic evaluation. Motion palpation identifies a right sacroiliac fixation, with moderate tenderness and loss of endrange mobility.  Straight leg raise is limited to 80° on the right by pain at the hamstring origin.

Primary complaint. The right hamstring is weaker than the left on manual muscle testing, and palpation finds tenderness at the right ischial tuberosity and increased tension in the proximal hamstring muscle.  All knee and ankle ranges of motion are full and pain free.

Imaging

Standing AP lumbopelvic view shows a leg length discrepancy with the right femur head 6 mm lower.  Frog-leg views of both hips are negative for ischemic necrosis (Legg-Calve-Perthes) and slipped femoral capital epiphysis.

Clinical Impression

Chronic hamstring strain, with leg length discrepancy (right short leg) and asymmetric foot pronation.

Treatment

Adjustments. Adjustments of the right SI joint and right foot and ankle were provided as needed.  The adjustments were supplemented by contract-relax stretches for the right hamstring muscle.

Stabilization. Flexible, shock-attenuating orthotics were fitted into her soccer shoes, and another pair was provided for daily wear.  Both were custom made for her individual postural needs.

Rehabilitation. Daily strengthening exercises for the right hamstring were progressed from light to strenuous resistance using elastic exercise tubing in a standing position.

Response to Care

This young athlete responded rapidly to the adjustments and strengthening exercises. She adapted to the custom-made stabilizing orthotics with little difficulty and reported that her ankles and knees felt more secure when on the field. Within three weeks of receiving the orthotics, she had no post-exercise pain or tenderness. She was released from care after a total of eight visits over two months.

Discussion

Hip, upper leg and, even, knee pain in a young person with an immature skeleton always raises concerns of ischemic necrosis (Legg-Calve-Perthes) and slipped femoral capital epiphysis. This star athlete had no X-ray evidence of either condition, but did have a biomechanical asymmetry in the lower extremities which caused a functional short leg.  Appropriate, focused treatment consisting of adjustments and stabilizing orthotics, along with stretching and strengthening exercises, brought about a rapid response.

While this patient had initial concerns about wearing orthotics in her well-fitting soccer shoes, she found them to be effective in helping reduce her hip symptoms and enhancing her athletic performance.  To get the right fit in her specialized athletic shoes, tracings of the inside of her soccer shoes were sent to the orthotics lab along with her foam-casted weightbearing foot images.

Studies have found a significant decrease in electromyographic activity of the hamstring muscles during running while wearing orthotics.  This is thought to be due to the increased stability of the ankles and knee joints, which allows greater relaxation of the hamstrings during gait, especially when running. 

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 .

 
Morning Heel Pain
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Sunday, 22 May 2005 15:37

History and Presenting Symptoms

The patient is a 56-year-old male who reports severe pain on the bottom of his right foot when he begins to walk in the morning.  He also notices pain under his right heel when he has been standing for a long time (greater than one-half hour).  Over-the-counter pain medications help somewhat; but his condition does not seem to be improving, even though he has been avoiding extensive walking and standing.  He has not played racquetball for the past couple of months, due to his heel pain.  There is no history of prior injury to his right foot or ankle.

Exam Findings

orthoticblueVitals: This 5’11’’ financial consultant weighs 195 lbs. which means that he is overweight (BMI of 27).  He demonstrates a thickened waist (43 in.), confirming that his excess weight is due to abdominal fat deposition.  He is a non-smoker, and his blood pressure and pulse rate are within the normal range, probably due to his history of regular vigorous exercise during racquetball.

Posture and gait: Standing postural evaluation finds generally good alignment, but a decreased lumbar lordosis.  He has bilateral pes planus (flat foot), with no medial arches and bilateral calcaneal eversion.  These findings are somewhat more pronounced on the right side.  Both feet toe out during walking.

Chiropractic evaluation: The lumbar spine is moderately tender throughout, and he demonstrates a generalized loss of vertebral mobility, with few specific subluxations.  Orthopedic and neurological provocative testing of the spine and pelvis is negative.

Primary complaint: Examination of the right foot finds exquisite tenderness to palpation over the antero-medial aspect of the calcaneus.  All right foot ranges of motion are full and pain-free, and manual muscle testing finds no evidence of weakness when compared to the left side.

Imaging

A lateral X-ray of the right foot demonstrates a small bony outgrowth from the anterior aspect of the calcaneus.

Clinical Impression

Chronic irritation of the point of insertion of the plantar fascia into the calcaneus, with radiographic evidence of a heel spur.  This appears to be secondary to long-standing biomechanical stress associated with poor foot function, and excessive loading from strenuous exercise activity and too much body weight.

Treatment Plan

Adjustments: Mobilization and adjustments were provided to the lumbopelvic region.  The right calcaneus was adjusted anteriorly and both navicular bones were adjusted superiorly.

Stabilization: Orthotics with viscoelastic, shock-absorbing materials were custom-made and fitted to support his arches and to reduce calcaneal eversion.  In addition, a calcaneal “divot” was ordered for the area under the right heel, in order to decrease the pressure on the bone spur.

Rehabilitation: The patient was shown a series of foot exercises (marble pick-up and towel-scrunching) to improve the coordination and strength of his foot intrinsic muscles.  Once he had his orthotics, he also performed standing Achilles tendon stretches, keeping his feet in forward alignment. 

Response to Care

While his heel pain was initially somewhat slow in responding, this patient was diligent with his exercises and, after five weeks, he was able to walk in the morning with no foot pain.  At that point, he was advised to return to his regular racquetball exercise program and he had no recurrence of heel pain.  He was released to a self-directed maintenance program after a total of sixteen visits over three months.

Discussion

Radiographic evidence of a heel spur does not always correlate with heel pain.  However, it is frequently an indication of chronic biomechanical stress to the insertion of the plantar fascia.  Symptomatic heel spurs are difficult case presentations, and they require appropriate patient education.

If this overweight 56-year-old man had been less active (or had been a swimmer), or if he had inherited feet with better arches, he would have been less susceptible.  And, if he is able to follow through on his decision to drop twenty pounds of abdominal adipose tissue (which is necessary for him to be considered in the normal weight range for his height), he will be less likely to suffer future recurrences.

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 .

 
Case Study: Functional Scoliosis
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Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Friday, 22 April 2005 13:30

History and presenting symptoms

The patient is a 12 year-old girl, who was identified at a school screening as having a discrepancy in her shoulder heights.  Her parents were advised to seek further evaluation by an orthopedic surgeon.  They reported that the orthopedist found evidence of a scoliosis, but recommended a “watch and wait” approach.  He offered no treatment, but said that, if her spinal curve increased, he would be available to perform spinal corrective surgery.

The girl’s parents are requesting a second opinion, and any recommendations for conservative care.  The patient has no back symptoms, and she recalls no back injury.  Her delivery was relatively easy and uncomplicated, as reported by the parents.  She is regularly active in several physical activities, including soccer and softball.

Exam Findings

Vitals.  This 5’0’’ tall, athletic 12 year-old girl weighs 105 lbs, which results in a BMI of 20—she is not overweight.

Postural examination.  Standing postural evaluation identifies a right low pelvis, and a left low shoulder.  Her knees are well-aligned, but she has an obvious medial bowing of the right Achilles tendon, with a lower medial arch on the right foot.

Chiropractic evaluation.  Motion palpation identifies several mild limitations in spinal motion: The right SI joint, the lumbosacral junction, T11/12, and at the cervicothoracic junction.  Palpation finds no local tenderness in these regions, and she has full and pain-free active spinal ranges of motion.  Thoracolumbar lateral bending is equal to both sides, and Adams test finds no evidence of rib hump or persisting curve.

Lower extremities.  Closer examination finds that the right medial arch of the foot is lower than the left when standing.  When she is seated and non-weightbearing, the right arch appears equal to the left.  And when she performs a toe-raise while standing, the right arch returns.  Manual muscle testing finds no evidence of muscle weakness in the peroneal or anterior tibial muscles.

Imaging

A P-A full-spine film demonstrates a C-curve scoliosis, which encompasses the lumbar and thoracic regions.  The sacral base is lower on the right by 3 mm, and the Cobb angle is 12°.  A collimated pelvis view with the femur heads centered finds a difference of 6 mm in the heights of the femur heads, with the right side lower.

Clinical Impression

This is a classic case of a functional scoliosis associated with a unilateral flexible flat foot (pes planus).  By definition, this eliminates the concern of a progressive idiopathic scoliosis, which had caused the parents so much concern.  The condition is accompanied by multiple areas of mild joint motion restriction and compensatory spinal subluxations.

Treatment Plan

Adjustments.  Specific adjustments for the lumbopelvic and thoracolumbar spinal regions were provided as needed.  Manipulation of the right foot, including the navicular and cuboid bones, was performed.

Support.  Custom-made stabilizing orthotics were provided to ensure balanced support for both arches and to reduce weight-bearing asymmetry.  Particular emphasis was placed on wearing the supports in her athletic shoes.

Rehabilitation.  Because of her age and athletic pursuits, no specific rehabilitation exercises were provided.  She was able to continue in her sports activities without difficulty.

Response to Care

The spinal and foot adjustments were well tolerated, since she was young and symptom-free.  The orthotics improved her postural alignment and eliminated the shoulder discrepancy.  After three months of care, repeat full-spine X-rays with her orthotics in place found only a minimal (3 mm) leg length discrepancy, a level sacral base, and a 5° Cobb angle (which is considered non-scoliotic).  She was released to a self-directed maintenance program after a total of 10 treatment sessions over three months.

Discussion

This active 12 year-old girl responded well to a combination of spinal adjustments and custom-made orthotics.  Although she was asymptomatic, her parents considered her at risk for spinal surgery, based on the specialist’s opinion.  Chiropractic evaluation found her scoliosis to be functional, and her flat foot was found to be flexible.  Appropriate conservative care was initiated, and was ultimately very successful.  In most cases, a functional scoliosis responds well to chiropractic care, and is unlikely to require surgery.

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 .

 
Case Study: Knee Pain in a Tennis Player
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Tuesday, 15 March 2005 03:00

History and Presenting Symptoms

The patient is a 48-year-old real estate broker, who is also the president of the local Chamber of Commerce.  She reports pain in the front of her right knee, over the past several months, especially when playing tennis.  She denies any specific injury, and has no obvious swelling or discoloration.  She reports that she takes ibuprofen for relief, but is worried that she has to take this drug in order to play tennis.

Exam Findings

Vitals.  This active, middle-aged woman weighs 140 lbs, which, at 5’5’’, results in a body mass index (BMI) of 23—she is 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 pelvis and spine.  She has a mild bilateral knee valgus and moderate calcaneal eversion and hyperpronation on the right side.  Measurement finds a standing Q-angle of 28° on the right and 24° on the left (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 right at L5/S1.  A compensatory subluxation is also noted at T10/T11.  Neurologic testing is negative.

Primary complaint.  Examination of the right knee finds 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 (previously chondromalacia patellae) on the right, associated with an elevated Q-angle and foot pronation.  This is accompanied by lumbosacral joint motion restriction and compensatory lower thoracic subluxation.

Treatment Plan

Adjustments.  Specific, corrective adjustments for the lumbosacral joint and the lower thoracic region were provided as needed.  Manipulation of the right knee into external rotation was performed to decrease the internal rotation associated with hyperpronation and her elevated Q-angle.

Support.  Custom-made stabilizing orthotics were provided to support the arches and decrease the Q-angles.  Two pairs of stabilizing orthotics were ordered, one designed specifically for her tennis 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 tennis playing.

Response to Care

The spinal and knee adjustments were well tolerated, and she reported a rapid decrease in symptoms. Once she began wearing her orthotics regularly, she noted a substantial decrease in knee irritation with use, and a firmer foot plant during tennis playing.  Within two weeks of receiving her orthotics, she related that she had successfully completed a round-robin tournament with absolutely no knee pain or limitation.  She was released to a self-directed maintenance program after a total of eight treatment sessions over two months.

Discussion

Several interesting factors are present in this case.  This high-powered businesswoman used her tennis games as both a form of business interaction and a recreational relaxation.  As her knee began to bother her more, she was driven to using anti-inflammatory drugs.  She was wearing supportive shoes, but the underlying biomechanical problem had not been sufficiently addressed.

When women are physically active, their naturally higher Q-angles are frequently a source of patello-femoral pain.  This condition was previously called chondromalacia patellae, but it has been recognized that it is actually a biomechanical “tracking” disorder of the kneecap in the femoral groove.  The best treatment is a conservative approach, with a combination of chiropractic adjustments, flexible stabilizing orthotic support, and—when indicated—rehabilitative strengthening sessions using elastic exercise tubing.

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 .

 
Case Study: Ankle Pain in a Young Athlete
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Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Tuesday, 15 February 2005 01:34

orthoticblueHistory and presenting symptoms:

The patient is a 16-year-old athlete who plays football and baseball.  He reports recurrent pain in his left ankle over the past year, especially after lengthy running practices.  Occasionally, the ankle will swell, which he treats with an ice pack and over-the-counter anti-inflammatory drugs.  He recalls no specific injury and has no significant disability, but is concerned for his future sports performance.  Parental advice prompted him to seek chiropractic care.

Exam findings:

Vitals:  The patient weighs 180 lbs, which, at 5’10’’, results in a body mass index (BMI) of 26—at his age, he is considered overweight.  His appearance, however, confirms that excess weight is due to muscular development, not excess fat mass.  He doesn’t smoke, and his blood pressure and pulse rate are well within normal range.

Posture and gait:  Standing postural evaluation finds generally good alignment, with intact spinal curves, and no lateral listing of pelvis or spine.  He demonstrates a mild bilateral knee valgus (more prominent on left), with bilateral pes planus and calcaneal eversion.  These findings cause medial bowing of the Achilles tendons when standing, especially on the left.  A toeing-out tendency (foot flare) is seen during gait screening; this is also somewhat more prominent on left.

Chiropractic evaluation:  Motion palpation identifies a limitation in left sacroiliac motion, with moderate tenderness and loss of end range mobility.  Several compensatory subluxations are identified throughout the thoracolumbar region.  Orthopedic and neurological testing is negative.

Primary complaint:  Left ankle examination reveals slight swelling of entire Achilles tendon, which is moderately tender to palpation. All left ankle ranges of motion are full and pain-free, except dorsiflexion, which is slightly limited by tightness, not pain. Manual muscle testing finds slight weakness in plantar flexion when compared to right side.

Imaging:

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

Clinical impression:

Chronic, recurrent Achilles tendinosis secondary to lower extremity biomechanical stress.  This is accompanied by sacroiliac joint motion restriction and compensatory thoracolumbar subluxations.

Treatment

Adjustment:  Specific, corrective adjustments for the SI joints and thoracolumbar region were provided, as needed.  Manipulation of the left talus during traction was performed to increase the range of ankle dorsiflexion motion.

Stabilization:  Custom-made stabilizing orthotics were provided to support the arches, decrease calcaneal eversion, and reduce the asymmetrical biomechanical forces being transmitted to the spine and pelvis.

Rehabilitation:  Initially, was taught to perform daily self-mobilization to increase left ankle dorsiflexion motion, along with towel-scrunching exercises.  After two weeks, daily strengthening of plantar flexion was introduced, using elastic exercise tubing.

Response to care:

The spinal and pelvic adjustments were well-tolerated, and this young, in-shape athlete required few re-adjustments.  His compliance with the stabilization and exercise recommendations was excellent, since he was motivated to improve his performance and prevent potential sports injuries.  He adapted to and wore the orthotics without difficulty.  He filled out and brought in his exercise log at every visit, which provided an opportunity to support his home-based efforts.

Within four weeks of receiving his orthotics, the patient was able to complete several long running practices without symptoms or swelling in the ankle.  He described a noticeable improvement overall in his athletic performance.  He was released from acute care to a self-directed maintenance program after a total of 12 visits over 2 months.

Discussion:

Using pediatric BMI calculations, this patient was classified as overweight.  This and his high activity level are likely to be significant factors in his ankle problem.  However, it is important to recognize that, in the case of athletes, overweight may be due to greater than usual amounts of lean body mass (muscle and bone), not fatty deposits.  This was readily apparent during examination.

While the traditional term for this condition is “Achilles tendinitis,” the more accurate and contemporary description is “tendinosis.”  As was apparent in this case, the problem is usually not an acute inflammatory event, but rather a long-standing biomechanical irritation that needs to have the underlying problem correctly addressed.

This case demonstrates that young athletes are superior patients.  Most have a great healing potential and are willingly to follow self-care recommendations—particularly when they include the use of orthotics for stabilization, specific exercises for rehabilitation, and a rapid return to full sports function.

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 .

 
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