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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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Friday, 22 April 2005 13:30 |
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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
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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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Tuesday, 15 March 2005 03:00 |
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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
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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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Tuesday, 15 February 2005 01:34 |
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 History 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
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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, 15 January 2005 00:23 |
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History and subjective complaints
The patient has suffered from a postural imbalance most of her life, causing stress and strain to the pelvic and spinal areas. The patient states that she has received chiropractic care “on and off” most of her life.
As the patient has grown older, she has experienced more frequent and intense pain in her lower back, right leg, and feet. She was 52, when she learned that some of the problems she was experiencing when standing or walking were the result of flat feet (pes planus), lack of arch support, heel spurs, and a neuroma. There are other contributing factors to her overall health and well-being: fibromyalgia, diverticulitis, and excess weight.
Upon her first office visit, the patient was experiencing problems walking at a slow, strolling pace. She reported having constant lower back pain and a great deal of right leg and right thigh pain. She particularly noticed the pain in her right thigh when she climbed stairs, bearing weight on that leg. She also had severe pain in her feet that included numbness in her toes, at times.
Objective findings
The patient is a medium-framed, slightly overweight Caucasian female, 53 years of age. She is a full-time customer service representative, a position which requires her to be seated most of her workday. In addition to working full-time, she is also a certified massage therapist and is on her feet for long periods during evenings and on weekends, to treat her clients.
Vital index
Height: 5 ft. 2 in.
Weight: 146 pounds
Blood pressure: Systolic, 132; Diastolic, 86
Objective and neurological findings
- Gaenslen’s test positive with right leg.
- Nachlas’ test positive, with radiation down the right thigh.
- Morton’s squeeze test positive for chronic onset of interdigital neuroma in both feet.
- Positive pain indicators in 13 of the 18 tender points for fibromyalgia.
Clinical impression and working diagnosis
The patient’s lower back pain was rooted in the lower lumbar area, where she has a curve. She also experienced pain from the ilium, torquing forward. Additionally, her right leg is shorter than the left, and the tightening of the muscles that is part of fibromyalgia also intensified her pain. The patient had a neuroma, or entrapment of the nerve, in her left metatarsal.
Postural imbalances in the pedal foundation were also contributing to her musculoskeletal conditions, as well as obstructing the efficacy of chiropractic adjustments received prior to current care.
Treatment
The patient received a program of specific lumbosacral and lower extremity adjustments. She also regularly received routine checks of her leg length, routine manipulation of vertebrae, and did hip rotator exercises—hip flexors and extenders. Muscle trigger point therapy was also initiated to help manage her fibromyalgia symptoms.
The patient was also fitted for custom-made stabilizing orthotics, to address her spinal/pelvic instability and foot conditions. She had begun wearing well-known name brand sandals at the time she learned of her flat feet, lack of arch support, heel spurs, and neuroma. The sandals offered some stability to her low back, but did not correct her postural imbalances. They also didn’t provide adequate arch support.
The patient currently receives chiropractic care every two weeks, minimum, gets a massage every two weeks, and wears her custom-made stabilizing orthotics every day.
Results
After only eight weeks of receiving adjustments and wearing the orthotics, the patient was no longer experiencing pain in the SI joint area. In addition, the neuroma was corrected without surgery. She no longer has numbness in her toes. And, within a few days of doing hip rotator exercises, she found relief from her leg pain.
Adjustments, orthotic support, and hip rotator exercises proved to be very successful for this patient, as did the muscle trigger point therapy. Additionally, the myofascial release for legs and hips was very beneficial.
Discussion
This case is interesting because there were several contributing factors to the patient’s constant pain. For her, the use of custom-made stabilizing orthotics is not just a method for correcting one thing—it’s an overall approach to improved health and wellness.
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
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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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Sunday, 14 November 2004 22:38 |
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A close evaluation of the anatomy and structure of the foot reveals three arches that form the plantar vault.1 This architectural design provides substantial strength, while still permitting sufficient flexibility to accommodate changes in terrain, and to provide propulsion. The foot’s arched structure is not present at birth, but develops during childhood, by age 6 or 7 in most people.2 Breakdown in any of these three arches can result in abnormal gait and transmission of asymmetrical forces into the pelvis and spine.
Medial Longitudinal Arch
The most obvious arch is seen along the medial aspect of the foot. The navicular bone forms the “keystone” of this large and long arch, which is supported primarily by the plantar fascia and spring ligament.3 Years ago, John Basmajian, MD, (the “father of electromyography”) demonstrated that the muscles of the foot and lower leg do not provide support for the medial arch, except during toe-off when walking or while standing on tip-toe. He said, “From the present study, one may conclude that, in the standing-at-ease posture, muscle activity is not required and the muscles are inactive.…”4 While he believed, in 1963, that he had settled the controversy regarding active (muscular) versus passive (ligamentous) support for the medial arch, there still remains much misinformation and persisting, misguided attempts at “strengthening muscles to rebuild the arch.”
The most effective method for evaluating the function of the connective tissues that support the medial arch is to perform a comparison between its non-weight bearing and weight bearing alignment. This procedure is called the “Navicular Drop Test”, and was first described by Brody. 5 The easy-to-perform clinical test objectively documents the presence (or absence) of collapse of the medial longitudinal arch, and has been used successfully to evaluate the risk of athletes with ACL ruptures.6
Lateral Longitudinal Arch
This arch is located along the outside of each foot. Because the cuboid bone serves as its structural keystone, the lateral arch relies much less on connective tissues for its support. For this reason, proper function of the lateral arch is very dependent on the alignment of the cuboid, which is frequently found to be in need of adjustment. Proper support for this arch is at least as important as for the other two, but is surprisingly absent in many orthotics.
Anterior Transverse (Metatarsal) Arch
This arch extends from the metatarsal heads back to the tarsal bones, and runs from the medial to the lateral sides of the foot. At its most anterior portion, the metatarsal heads contact the ground. Poor function and loss of this arch will often result in a build-up of thick callus underneath the metatarsal heads. Recurrent “dropped” metatarsal heads and/or irritation of one of the interdigital nerves (a “Morton’s neuroma”) are also good indications that this arch is not being supported properly by the plantar fascia.
Helping the Faulty Vault
The structural design of the three-arched plantar vault is very good at supporting weight and carrying high loads, while remaining flexible. During normal standing, the load of the body is balanced over the center of the foot, anterior to the ankle. This places the greatest amount of load at the apex of the three arches. This force is then distributed along the “buttresses” of the arches to the heel (which bears 50% to 60% of body weight) and the metatarsal heads (which bear 40% to 50% of body weight). Loss of this configuration will result in abnormal force concentrations, which will eventually cause degenerative and symptomatic clinical conditions.
Collapse or dysfunction of any of the arches needs to be addressed with custom-made orthotics that will support the patient’s foot throughout the gait cycle, while controlling the impact forces. Particularly when there is asymmetry between the feet, arch problems can cause abnormal rotational forces to be transmitted into the pelvis and spine, resulting in chronic spinal symptoms. For this reason alone, doctors of chiropractic need to be aware of the status of their patients’ three arches, since they can have a substantial impact on spinal health.
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 28 years. He can be reached by e-mail at
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References:
1. Kapandji IA. Physiology of the Joints: Lower Limb (2nd ed.). New York: Churchill Livingstone, 1981:154-182.
2. Gould N, Moreland M, Alvarez R et al. Development of the child’s arch. Foot Ankle 1989; 9:241-245.
3. Huang CK, Kitaoka HB, An K-N, Chao EY. Biomechanical evaluation of longitudinal arch stability. Foot Ankle 1993; 14:353-357.
4. Basmajian JV, Stecko G. The role of muscles in arch support of the foot: an electromyographic study. J Bone Joint Surg 1963; 45A:1184-1190.
5. Brody D. Techniques in the evaluation and treatment of the injured runner. Orthop Clin North Am 1982; 13:541-558.
6. Beckett ME et al. Incidence of hyperpronation in the ACL injured knee: a clinical perspective. J Athl Train 1992; 27:58-62.
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