Orthotics


Case Study: Pedal Imbalance With Associated Conditions
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Saturday, 15 January 2005 00:23

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 This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

 
Orthotic Support for All Three Arches
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Sunday, 14 November 2004 22:38

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 This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

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.

 
Ankle Sprains and Active Support
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Tuesday, 14 September 2004 21:57

Ankle sprains are common injuries, because the ankle is required to perform complex movements under high forces during normal walking.  This can be particularly important for patients who participate in recreational activities and sports that require running and jumping.  Proper evaluation and management in the early stages of an ankle sprain are very important in preventing chronic instabilities.  With appropriate care, including orthotic support and exercise, significant improvements in function and stability can be achieved, even in patients with long-standing ankle problems.

Acute Care

Initial treatment of ankle sprains is the standard “PRICE” formula (Protection, Rest, Ice, Compression, Elevation).  Even with severe ankle sprains, using these procedures has been shown to speed recovery and return to sports (see Table 1).  With the injured joint protected, patients can be encouraged to continue their activities (rather than using the now-discredited bed rest), with some restrictions.

In the case of ankle sprains, this entails the use of a lightweight, but laterally rigid brace, which protects against inversion and eversion.  If a patient has been placed in a walking cast rather than a mobilizing brace, frequent prolonged stretching of the Achilles tendon must be performed in order to prevent shortening.

Conditioning and Exercise

During the initial acute stage, exercises for the damaged ankle are not appropriate.  However, general full-body conditioning should be continued, using methods that do not place undue stress on the healing ankle (a stationary cycle with pedal straps is recommended).1  Additionally, vigorous exercise of the opposite ankle’s muscles (“cross education” or “cross-over”) has been shown to provide a healing stimulus and result in more rapid return to activities.2,3

As healing progresses, patients should begin to perform non-resistive active exercises concentrating on mobility of the injured ankle.  Once the joint can be passively moved through a normal range, isotonic resistance exercising of the peroneal muscles using elastic tubing should be started.4  Initially, these exercises should be performed from a sitting position, with the heel resting on the floor, to reduce the forces on the ankle joint while still maintaining the functional alignment.

As strength builds, the patient should progress to standing during the exercises, in order to re-train the ankle support muscles in a closed-chain position.  Further sport-specific exercises should be introduced to ensure that an athlete has all the strength and mobility required to participate in sports.

Proprioception

One reason some ankle injuries become chronic or recur appears to be the loss of the normal coordination of the muscles about the ankle, rather than simply their strength.5  An easy test is to have the patient stand on each leg, with the eyes open and then closed.  Check to see if there is less capability of the injured leg.  Practice of the one-legged stance, and use of “wobble” boards may be required to regain normal proprioceptive coordination.  An athlete should be able to demonstrate a “stork stand” for at least one minute on the injured leg before being allowed to return to full competition.6

Orthotic Support

In many patients, custom-made orthotics can also be helpful in preventing future (and often more disabling) damage to the injured ankle.  A careful evaluation of the biomechanics of the foot and ankle will find some patients who have underlying anatomical or functional problems.  Particularly in the case of athletes, use of stabilizing, custom-made orthotics with good torsional rigidity should be considered.  Orthotic support and control of inversion/eversion is necessary and highly recommended whenever there is a deficit in biomechanical function.7

Summary

Recent studies demonstrate that, even in severe ankle injuries, a well-informed conservative and active treatment approach will result in good outcomes.  Using active rehabilitation concepts, most doctors of chiropractic can manage acute ankle sprain injuries very well.  In many patients, custom-made orthotics will be needed to help prevent future problems and joint degeneration.

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 This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

References

1. Roy S, Irvin R. Sports Medicine: Prevention, Evaluation, Management and Rehabilitation. Englewood Cliffs: Prentice-Hall, 1983:394.

2. Stromberg BV. Contralateral therapy in upper extremity rehabilitation. Am J Phys Med 1988; 65:135-143.

3. Hortobagyi T, Lambert NJ, Hill JP. Greater cross education following training with muscle lengthening than shortening. Med Sci Sports Exerc 1997; 29:107-112.

4. Roy S, Irvin R. Sports Medicine: Prevention, Evaluation, Management and Rehabilitation. Englewood Cliffs: Prentice-Hall, 1983:397.

5. Lentell GL, Katzman LL, Walters MR. The relationship between muscle function and ankle stability. J Orth Sports Phy Ther 1990; 11:605-611.

6. Subotnick SI. Sports Medicine of the Lower Extremity. New York: Churchill Livingstone, 1989:284.

7. Heiser JR. Rehabilitation of lower extremity athletic injuries. Contemp Podiat Phys 1992; Aug 20-27.

 
Metatarsalgia and Orthotic Support
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Thursday, 08 July 2004 21:29

Foot pain can interfere significantly with normal activities, and severely limit participation in sports.  Metatarsalgia is foot pain involving the metatarsal bones in the forefoot—the complaint of pain on the bottom of the ball of the foot.

Metatarsalgia may be due to overuse of the foot during sports, improper footwear,1 excessive weight, foot subluxations, or other factors.  The underlying cause is often faulty foot mechanics; the most common problem is excessive pronation.  Blake and Ferguson found that joint pain and capsulitis of the metatarsals were common foot problems reported by recreational walkers and hikers.2  The second and third metatarsophalangeal joints were the most frequently involved joints.  Since the vast majority of foot problems in recreational walkers and hikers were unilateral, rather than bilateral, these researchers concluded that, “Structural anomalies and faulty biomechanics, i.e., limb length discrepancy or abnormal pronation, may be the cause or additional cause in many injuries.”

Arch Problems

The anterior transverse arch is located immediately behind the metatarsal heads.3  When non-weightbearing, the first and fifth metatarsal heads are most prominent, and initially bear the weight of the body during gait.  As weightbearing progresses, pressure is distributed across the arch to the other three heads.  As with all arches, the ligaments and connective tissues support the anterior transverse arch,4 not muscular strength.5  Arch problems will develop when supportive tissues are put under excessive stress—either from high loads for sudden, brief periods, or from more moderate, but repetitive stresses over longer periods.  In most cases, it appears that chronic overstretching of the transverse ligaments is the underlying cause of metatarsal problems.6

Metatarsalgia

Callus Formation

One sign of abnormal transverse arch biomechanics is callus build-up.  Since plantar callosities form in response to sustained pressure patterns, they provide helpful clues regarding altered foot function.  These are commonly seen in either the forefoot (under the metatarsal heads), or under the anterior aspect of the heel.7  This pattern (under the transverse arch and at each end of the medial longitudinal arch) has always been taken to indicate that most calluses are caused primarily by arch collapse and/or excessive pronation.  A 1999 study confirmed that callus formation is closely associated with several specific “abnormal foot weightbearing patterns.”  These are a lower medial arch with greater pronation, reduced dorsiflexion of the first metatarsal joint, and limited ankle dorsiflexion (due to calf muscle tightness).8  All three factors can contribute to abnormal biomechanics of the metatarsal arch.

Relief and Control

Helping a patient with pain at the metatarsal region requires a phased approach.  Immediate care can reduce the acute pain and inflammation.  Long-term control of the problem usually requires custom-made orthotics.

Acute relief.  Any aggravating activity must stop, and shoes should be evaluated and changed, if necessary.  A temporary metatarsal pad should be placed just proximal to the metatarsal heads to support the anterior transverse arch.9  This will relieve the weightbearing pressure on the sensitive metatarsophalangeal joints.  Anti-inflammatory and pain-relieving modalities can be considered.  Any subluxations, such as “dropped” or fixated metatarsal heads should be adjusted, as necessary.  Multiple foot subluxations, arch collapse, and excessive pronation are frequently found, so the navicular and the cuboid must be carefully evaluated.

Permanent control.  Patients should avoid shoes with a tight toe and forefoot region and reduce high heels to 1½ inches.  These instructions must be followed for best results.  Patients with tight Achilles tendons and diminished foot dorsiflexion should perform calf stretches.  In order to improve foot biomechanics and provide permanent support for the transverse arch, most patients will need custom-made orthotics.  Flexible orthotics are the most beneficial, especially for people who must be on their feet for many hours each day.  The orthotics need to support all three arches of the foot and provide cushioning and shock absorption.  Additional forefoot padding also appears to be very helpful. TAC

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 27 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 .

References

1. Jarboe NE, Quesada PM. The effects of cycling shoe stiffness on forefoot pressure. Foot Ankle Int 2003; 24(10):784-788.
2. Blake RL, Ferguson HJ. Walking and hiking injuries: a one year follow-up study. J Am Podiatr Med Assn 1993; 83:499-503.
3. Hoppenfeld S. Physical Examination of the Spine and Extremities. New York: Appleton-Century-Crofts, 1976:208.
4. Huang CK et al. Biomechanical evaluation of longitudinal arch stability. Foot & Ankle 1993; 14:353-357.
5. Basmajian JV, Stecko G. The role of muscles in arch support of the foot. J Bone Joint Surg 1963; 45A:1184-1190.
6. Reid DC. Sports Injury Assessment and Rehabilitation. New York: Churchill Livingstone, 1992:129-184.
7. Magee DJ. Orthopedic Physical Assessment. Philadelphia: WB Saunders, 1987:323.
8. Bevans JS, Bowker P. Foot structure and function: etiological risk factors for callus formation in diabetic and non-diabetic subjects. The Foot 1999; 9:120-127.
9. Souza TA. Differential Diagnosis for the Chiropractor: Protocols and Algorithms. Gaithersburg, MD: Aspen Pubs, 1997:351.

 
Plantar Fascitis and Orthotic Support
Orthotics
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Tuesday, 08 June 2004 20:11

The classic presentation of plantar fascitis is “a sharp heel pain that radiates along the bottom of the inside of the foot.  The pain is often worse when getting out of bed in the morning.”1  This can occur in runners or other athletes who repetitively land on the foot.  Another susceptible group is middle-aged persons who have spent much time on their feet.  More rarely, the fascia becomes inflamed after a single traumatic event, such as landing wrong after a jump, or running a long hill. 

The vast majority (95%) will respond to conservative care, and not require surgery.2  Proper treatment is necessary, however, to both ensure continued participation in sports and daily activities and avoid chronic damage.  The plantar fascia is the major structure that supports and maintains the arched alignment of the foot.3  This aponeurosis functions as a “bowstring” to hold up the longitudinal arch.

Pathology
Plantar fascitis develops when repetitive weight bearing stress irritates and inflames the tough connective tissues along the bottom of the foot.  High levels of strain stimulate the aponeurosis to try to heal and strengthen.  If the biomechanical strain continues, it overwhelms the body’s repair capacity, and the ligaments begin to fail.  It is this tear/repair process that causes the chronic, variable symptoms that can eventually become unbearable in some patients.

Since the plantar fascia inserts into the base of the calcaneus, the chronic pull and inflammation can stimulate the deposition of calcium, resulting in a classic heel spur seen on a lateral radiograph.  Unfortunately, there is no correlation between the presence of a heel spur and plantar fascitis; many heel spurs are clinically silent, and most cases of plantar fascitis do not demonstrate a calcaneal spur.4

Examination
Biomechanical evaluation may find either excessive pronation or supination.  The flatter, hyperpronating foot overstretches the bowstring function of the plantar fascia, while the high-arched, rigid foot places excessive tension on the plantar aponeurosis.  In either case, it is the combination of improper foot biomechanics and excessive strain that causes the connective tissue to become inflamed.  A careful assessment of the weight bearing alignment of the lower extremities is helpful, since many patients will have functional imbalances up the kinetic chain, into the pelvis and spine.

Direct palpation of the plantar fascia will demonstrate discrete painful areas, most commonly at the insertion on the antero-medial calcaneus.5  Fibrotic thickenings are frequently felt—these are remnants of the repetitive “tear and repair” process.  With the foot relaxed, grasp the toes and gently pull them up into passive dorsiflexion.  Since this maneuver stretches the irritated plantar aponeurosis, it is frequently quite painful, and is an obviously positive objective sign.

Conclusion
Plantar fascitis usually responds well to focused, conservative treatment.  Steroid injections and surgical release are seldom necessary, and are best avoided.  One of the most important treatment methods is to reduce any tendency to pronate excessively.  In addition to custom-made orthotics, runners should wear well-designed shoes that provide good heel stability. 

The use of custom-made orthotics can prevent many overuse problems from developing in the lower extremities.  Investigation of foot biomechanics is a good idea in all patients, but especially for those who are recreationally active.

 

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 27 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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