Educational Chiropractic Resource Articles

By John K. Hyland, DC, MPH, DACBR, DABCO, CSCS

Achilles tendon problems are common injuries in athletes, and they are also found frequently among aging and active individuals. Those who run and/or climb stairs are particularly at risk of injury, but problems are also frequent in anyone who participates in activities such as racquet sports, volleyball, and soccer. ¹ Injuries are usually secondary to biomechanical deficits, ² and most will eventually respond well to conservative care, including exercise and Chiropractic adjustment procedures. Pain and dysfunction of the Achilles tendon can be a disabling factor that inhibits the effort to persist in regular fitness exercise for wellness.

Functional Anatomy

The Achilles is the combined tendon of the gastrocnemius and soleus muscles. It is surrounded by a paratenon (rather than a synovial sheath), which is continuous with the fascia of the gastrocnemius and soleus muscles and the periosteum of the calcaneus. Tendinopathy usually occurs within that part of the tendon that is 2 to 6 cm proximal to the calcaneal insertion at a site of decreased vascularization. ³

Poor blood flow may be a contributing factor to Achilles tendon overuse injuries, and especially for tendon tears. Clement and his fellow authors speculate that “in individuals who overpronate, the conflicting internal and external rotatory forces imparted to the tibia by simultaneous pronation and knee extension may blanch or wring out vessels in the tendon and peritendon causing vascular impairment and subsequent degenerative changes in the Achilles tendon.” This “region of relative avascularity” extends from 2 to 6 cm above the insertion into the calcaneus, and is the common site for a rupture of the Achilles tendon. This makes it especially important to ensure very good blood flow as the body attempts to heal this condition.

Achilles “tendinopathy”

The most common cause of functional breakdown of the Achilles tendon is a biomechanical deficit that places excess stress on the tendon. Inflexibilities, weakness, and imbalances are noted throughout the lower extremity Kinetic Chain, into the pelvis and spine. In a study of 455 athletes with Achilles tendon injuries, Kvist discovered obvious biomechanical deficits in 60% of subjects. ⁴ In many cases, the major biomechanical problem underlying an Achilles tendon problem is excessive pronation.

Most injuries of the Achilles tendon are not due to a recent acute injury—they have actually developed gradually, over a period of weeks or months. These are “overuse” or “misuse” conditions and are caused by excessive and/or repetitive motion, often with poor biomechanics. The end result is a microtrauma injury—the body is unable to keep up with the repair and re-strengthening needs, so the tissue begins to fail and becomes symptomatic. If it is not very painful (or when the pain is eliminated by pain-killing drugs), continued stress can lead eventually to complete failure, with a resulting acute tear of the tendon.

Because the Achilles tendon insertion on the calcaneus is medial to the axis of the subtalar joint, the calf muscles are powerful supinators of the subtalar joint. Therefore, when excessive pronation occurs, the Achilles tendon is overstressed, and it eventually undergoes overuse degeneration and inflammation. This was described by Clement and his fellow investigators at the University of British Columbia in Vancouver, Canada. They explained how “pronation generates an obligatory internal tibial rotation which tends to draw the Achilles tendon medially. Through slow motion, high-speed cinematography we have seen that pronation produces a whipping action or bowstring effect in the Achilles tendon. This whipping action, when exaggerated, may contribute to microtears in the tendon, particularly in its medial aspect, and initiate an inflammatory response.” ⁵ These investigators believe that the control of functional overpronation with corrective orthotic devices is a necessary treatment for most patients with Achilles tendinitis.

Achilles Tendinitis/Tendinosis

It’s not surprising that abnormal biomechanics of the foot and ankle can cause problems with the largest tendon in the leg. Symptoms are usually described as diffuse pain in or around the back of the ankle (from the calf to the heel). The pain is aggravated by activity, especially uphill running or climbing stairs, and relieved somewhat by wearing higher-heeled shoes or boots. Palpation will find a tender thickening of the peritendon, and there could be crepitus during plantar and dorsiflexion. Often, a recent increase in activity levels (such as more stair-climbing) or a change in footwear is reported by the patient. The most useful (and highly predictive) clinical test is to find a tender area of intratendinous swelling that moves with the tendon and disappears when the tendon is put under tension.⁶

Macroscopically, overused Achilles tendon tissues examined at surgery are dull, slightly brown, and soft, in comparison to normal tendon tissue, which is white, glistening, and firm.⁷ There is a loss of collagen continuity and an increase in ground substance and cellularity, which is due to fibroblasts and myofibroblasts, and not inflammatory cells.⁸ This is the reason that anti-inflammatory strategies (such as NSAIDS drugs and corticosteroid injections) are not indicated for these conditions, and actually may interfere with tendon repair.⁹ We now know that the condition we usually have described as “tendinitis” is actually better understood as “tendinosis”, and is not due to inflammation, but an underlying degeneration of collagen tissues in response to mechanical overuse.¹⁰ This “new paradigm” will help to guide our management of all tendon problems, and provide more effective rehabilitation for Achilles tendons.

Two other factors have been recently reported—and they deal with drug side effects. Doctors of Chiropractic should be aware that the use of statin medications (cholesterol-lowering drugs)¹¹ and fluoroquinolones (a class of antibiotic drugs) ¹² have been reported to cause Achilles tendinopathy and rupture. Patients with Achilles tendon problems must always be asked about their drug regimens.

Conclusion

A combination of a change in activities and the use of custom-made functional orthotics has been found to be effective in most cases of Achilles tendinopathy. ¹³ Achilles tendinitis can be easily treated conservatively, and steroid injections, surgery, and casting are seldom used these days. 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 which provide good heel stability with a small amount of additional heel lift. This will help to prevent Achilles tendon problems and is especially important in athletes running for more than a few miles at a time. Once any local inflammation that is present has been controlled, treatments to improve the blood flow to the region of relative avascularity are necessary.

The use of corrective orthotics can prevent many overuse problems from developing in the lower extremities. Investigation of foot and ankle biomechanics is a good idea in all patients, but especially for those who are recreationally active. Competitive athletes, in particular, must have regular evaluation of the alignment and function of their feet, in order to avoid potentially disabling injuries. As described above, most Achilles tendon problems develop from poor foot and ankle biomechanics, and control of pronation is needed to prevent recurrent injuries. ¹⁴ Custom-made functional orthotics are now available that can support the hindfoot, midfoot, and forefoot, thereby providing biomechanical control throughout the entire gait cycle.

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¹ Paavola M, Kannus P, Jarvinen TA, et al. Achilles tendinopathy. J Bone Joint Surg Am 2002; 84:2026-76.

² Maffuli N, Kader D. Tendinopathy of tendo achillis. J Bone Joint Surg Br 2002; 84:1-8.

³ Carr AJ, Norris SH. The blood supply of the calcaneal tendon. J Bone Joint Surg Br 1989; 71:100-01.

⁴ Kvist M. Achilles tendon injuries in athletes. Ann Chir Gynaecol 1991:80:188-201.

⁵ Clement DB, et al. Achilles tendinitis and peritendinitis: etiology and treatment. Am J Sports Med 1984; 12:179-84.

⁶ Maffuli N, Kenward MG, Testa V, et al. Clinical diagnosis of Achilles tendinopathy with tendinosis. Clin J Sports Med 2003; 13:11-5.

⁷ Astrom M, Rausing A. Chronic Achilles tendinopathy: survey of surgical and histopathologic findings. Clin Orthop 1995; 316:151-64.

⁸ Khan KM, Cook JL, Bonar F, Harcourt P, Astrom M. Histopathology of common tendinopathies: update and implications for clinical management. Sports Med 1999; 27:393-408.

⁹ Almekinders LC, Temple JD. Etiology, diagnosis, and treatment of tendonitis: an analysis of the literature. Med Sci Sports Exerc 1998; 30:1183-90.

¹⁰ Khan KM, et al. Overuse tendinosis, not tendinitis. Part 1: a new paradigm for a difficult clinical problem. Phys Sportsmed 2000; 28:38-48.

¹¹ Chazerain P, Hayem G, Hamza S, et al. Four cases of tendinopathy in patients on statin therapy. Joint Bone Spine 2001; 68:430-3.

¹² Vanek D, Sexena A, Boggs JM. Fluoroquinolone therapy and achilles tendon rupture. J Am Podiatr Med Assoc 2003; 93:333-5.

¹³ Sorosky B, Press J, Plastaras C, Rittenberg J. The practical management of Achilles tendinopathy. Clin J Sport Med 2004; 14:40-4.

¹⁴ Busseuil C. et al. Rearfoot-forefoot orientation and traumatic risk for runners. Foot & Ankle Intl 1998; 19:32-7.

The Q angle is a very important indicator of biomechanical function in the lower extremity. This measurement reflects the effect of the quadriceps mechanism on the knee (hence the “Q” angle). When assessed correctly, it supplies very useful information concerning the alignment of the pelvis, leg, and foot. Determination of the Q angle is particularly important for patients who are athletically active, both in competitive and recreational sports. It is also necessary to measure this angle in female patients who walk for health or who climb stairs frequently. The effects of excessive pronation on the Q angle also deserve attention, since controlling foot pronation can often reduce the detrimental effects of an abnormal Q angle.

Determining the Q Angle

Definition and procedure. The Q angle is the angle between the quadriceps muscle (primarily the rectus femoris) and the patellar tendon.¹ It provides useful information regarding the alignment of the knee in the frontal plane. A measurement is made of the angle formed by the quadriceps muscle’s pull from the pelvis to the patella, and the patellar tendon’s pull on the tibia. Since large forces are transmitted through the patella during extension, misalignment will cause problems with knee function.

To measure the Q angle, start with the patient’s knee and hip in extension, and the quadriceps muscle relaxed. First, place the center axis of a long-arm goniometer over the center of the patella. Next, palpate the proximal tibia and align the lower goniometer arm along the patellar tendon to the tibial tubercle. Take the upper arm of the goniometer and point it directly at the anterior superior iliac spine (ASIS). The small angle measured by the goniometer is the Q angle.

Patient position. Slight variations in patient positioning have a significant effect on the measurement of the Q angle, and measurement reliability in the supine position is only moderate.^{2, 3} The best way to perform this test is with the patient standing. This has the advantage of measuring the Q angle in the patient’s usual upright posture, so that the normal weightbearing stresses are included. This means that additional valgus stresses on the knee and internal rotation forces due to excessive foot pronation are included in the measurement. Since we are most concerned with assessing how the knee functions during daily and sports activities, it certainly makes sense to obtain this important measurement while in a weightbearing position.

Normal ranges. When measured standing, the Q angle should fall between 18° and 22°.⁴ Males are usually at the low end of this range, while females (because of their wider pelvis) tend to have higher measurements. One author considers standing Q angles greater than 25° in females and 20° in males to be abnormal.⁵ When measured in the supine position, the values will be lower, and the normal range ends at 15° in males and 20° in females.⁶ Generally speaking, when it comes to the quadriceps angle, less is better than more.

Problems Associated with the Q Angle

Increased measurements. A Q angle measured at the higher end of the normal range indicates a tendency for added biomechanical stress during strenuous or repetitive activities using the knee. When the measurement is above the normal limits, the probability of developing knee joint symptoms increases rapidly. These problems are dependent on a number of factors, including habitual forces on the knee and other alignment abnormalities.

Patellar tracking. A high Q angle interferes with the smooth movement of the patella in the femoral groove. Over time, and especially with sports activities and/or stair-climbing, this microtrauma causes a non-specific anterior knee pain. Patellofemoral pain syndrome develops when abnormal tracking continues, and causes muscle imbalance.⁷ Eventually, wearing away of the cartilage on the underside of the patella (chondromalacia patellae) and degeneration of the articular surfaces of the knee (DJD) is found. At this point, permanent damage has been done, and complete recovery is usually not possible.

Excessive foot pronation. Whenever a patient has excessive pronation of the foot, Q angle stresses are magnified. Prolonged time in pronation causes excessive internal rotation of the tibia, impeding its normal external rotation during gait progression in the stance phase. This excessive internal tibial rotation transmits abnormal forces upward in the Kinetic Chain and produces medial knee stresses, force vector changes of the quadriceps mechanism, and lateral tracking of the patella.⁸ The combination of a higher Q angle with excessive pronation causes a more rapid progression from knee dysfunction to patellofemoral arthralgia to degenerative joint disease.

Decreasing the Q Angle

Orthotic supports. The most effective way to decrease a high Q angle and to lower the biomechanical stresses on the knee joint is to prevent excessive pronation with custom-made functional orthotics.⁹ One study found that using soft corrective orthotics was more effective in reducing knee pain than was a traditional exercise program.¹⁰ A more recent study shows that Q angle asymmetries, secondary to excessive pronation affecting knee alignment, can be effectively controlled or corrected utilizing custom-made functional orthotics.¹¹

Adjustments and exercises. While no adjustment has been reported to reduce the Q angle, a search for pelvic and knee misalignments should be part of care. It is important that good biomechanical function be restored to all joints of both lower extremities.

Stretching of tight muscles and strengthening of weak areas should be included. Muscles commonly found to be tight include: quadriceps, hamstrings, iliotibial band, and gastrocnemius. The vastus medialis obliquus (VMO) is usually weaker than the opposing vastus lateralis muscle. Sometimes it is the coordination of these muscles that has become abnormal. Strengthening may require a special focus on the timing of muscle contractions. Closed chain exercises (such as wall squats) done only to 30° of flexion are currently recommended.¹²

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¹ Magee DJ. Orthopedic Physical Assessment. Philadelphia: WB Saunders, 1987:296.
² Olerud C, Berg P. The variation of the Q angle with different positions of the foot. Clin Orthop 1984; 191:162-165.
³ Tomsich DA et al. Patellofemoral alignment: reliability. J Ortho Sports Phys Ther 1996; 23:200-208.
⁴ Loudon JK, Jenkins W, Loudon KL. The relationship between static posture and ACL injury in female athletes. J Ortho Sports Phys Ther 1996; 24:91-97.
⁵ Post WR. Patellofemoral pain: let the physical exam define treatment. Phys Sports Med 1998; 26.
⁶ Hvid I, Anderson LB, Schmidt H. Chondromalacia patellae: the relation to abnormal patellofemoral joint mechanics. Acta Orthop Scand 1981; 52:661-669.
⁷ Galea AM, Albers JM. Patellofemoral pain: targeting the cause. Phys Sports Med 1994; 22.
⁸ Tiberio D. The effect of excessive subtalar joint pronation on patellofemoral mechanics: a theoretical model. J Ortho Sports Phys Ther 1987; 9:160-165.
⁹ D’Amico JC, Rubin M. The influence of foot orthotics on the quadriceps angle. J Am Podiatr Med Assoc 1986; 76:337-340.
¹⁰ Eng JJ, Pierrynowski MR. Evaluation of soft foot orthotics in the treatment of patellofemoral pain syndrome. Phys Ther 1993; 73:62-70.
¹¹ Kuhn DR, Yochum TR, Cherry AR, Rodgers SS. Immediate changes in the quadriceps femoris angle after insertion of an orthotic device. J Manip Physiol Ther 2002; 25(7):465-470.
¹² Johnson RM, Poppe TR. Considering patellofemoral pain: exercise prescription. Strength Condition J 1999; 21:73-75.

I’m thrilled to inform you that the Foundation for Chiropractic Progress (FCP) has just announced a record-breaking event! Following publication of “Outcomes-Based Contracting™: The Value-Based Approach for Optimal Health with Chiropractic Services”—a pro-Chiropractic report by The Center for Health Value Innovation—the FCP generated unprecedented exposure to this major document in high-profile media. CNBC.com, Forbes.com, MarketWatch.com, Newsday.com and WSJ.com all carried coverage of the report, which has since resulted in over 22,000 headline impressions and hundreds of release views, including a feature on FierceHealthcare.com, the premier source of healthcare management news for executives in the healthcare industry.

As national exposure to the Foundation’s message continues to increase at a record pace, more contributors are pledging their support, membership in the FCP is growing daily, a new public service announcement (PSA) is in the works right now—and that’s only a fraction of the activities that are currently underway to promote Chiropractic to a nationwide audience! Here are just some of the other numerous efforts that the FCP is taking on behalf of your profession:

PSA, Advertorial Numbers Climb

The advertorials, TV, and radio spots created and produced by the Foundation continue to generate mass exposure nationwide. Below is a listing of the most recent materials and their audience numbers:

• General Halstead TV PSA: As of Oct. 6, 2010, this spot had been broadcast 138 times in 29 different states, with an audience of 146,422,681.
• Jerry Rice Radio PSA: As of Oct. 7, 2010, this spot had been broadcast 179 times in 38 different states, with an audience of 14,489,326.
• Jerry Rice TV PSA: As of Oct. 6, 2010, this spot had been broadcast 141 times in 34 different states, with an audience of 157,963,116.
• Jerry Rice Advertorial: As of Oct. 12, 2010, this release generated 360 news articles in 24 different states, with a readership of 10,730,208.
• Obesity Advertorial: As of Oct. 12, 2010, this release generated 124 news articles in 17 different states, with a readership of 4,655,008.
• Headache Advertorial: As of Oct. 12, 2010, this release generated 268 news articles in 23 different states, with a readership of 10,137,792.

Print Campaign Pushes Forward

In my last column, I related how the FCP had placed positive testimonials in three major national publications: The Wall Street Journal, Sports Illustrated, and Working Mother. Here are five additional magazines or newspapers that have carried our professionally created advertisements:

• Woman’s Day: September. Circulation: 3,966,414.
• Pro Football Hall of Fame Yearbook: August (p. 73). Circulation: 550,000.
• San Francisco Chronicle: Aug. 16, 2010 (Bus. p. 5). Circulation: 254,932.
• USA Today (Florida): Aug. 27, 2010 (p. 7). Circulation: 127,684.
• Quad City Times: Aug. 11, 2010 (p. A8). Circulation: 51,035.

Fundraising Update

In addition to the Foundation's successful campaign during the Florida Chiropractic Association Convention in August, there are a number of new supporters, as well as some established ones, who made recent noteworthy contributions:

• Multi Radiance Medical: Pledged $25,000.
• Hygenic/Performance Health: Pledged $50,000—bringing their total contribution to over $100,000.
• Northwestern Health Sciences University: Pledged $30,000—bringing their total contribution to $85,000.
• Parker College of Chiropractic: Pledged $15,000 and promised an additional $20,000 in 2011.
• Chiro One Wellness Center (COWC): Submitted a check for $500 in the name of Dr. Fab Mancini. This is in addition to COWC's contribution of $10,000 made earlier in the year.
• Chiropractic Association of Louisiana: Pledged $6,000—bringing their total contribution to $32,000.
• Southern California University of Health Sciences: Pledged $4,200—bringing their total contribution to $20,400.
• Texas Chiropractic College (TCC): Pledged $3,000—bringing their total contribution to $14,000. In addition, TCC President Richard G. Brassard, DC, pledged $5,000 individually.
• Western States Chiropractic College: Pledged $6,000—bringing their total contributions to $12,000.
• International Chiropractic Pediatric Association: Endorsed the Foundation and became a supporter.
• World Congress of Chiropractic Students: Endorsed the Foundation and made a contribution of $500.
• Foot Levelers, Inc.: Total funds contributed to date now exceed $1,000,000.

Car Raffle Continues

Don’t forget that, if you donate to the FCP today, you could soon be driving away in a 2011 Ford Mustang! Here’s how it works: Every 2010 contributor will be given a chance to win. Each dollar you donate counts as an additional entry, so more dollars means more chances to win! You can make a pledge on the FCP Web site, fill out a pledge sheet, or contact the foundation office (866-901-3427). The winner, to be announced at the 2011 Parker Las Vegas conference, will receive a two-year pre-paid lease of a new Mustang convertible. (Visit www.foundation4cp.com for complete contest rules).

Make a Difference—Join Today

We need your help to reach more people and tell them about the many benefits of chiropractic care. Take a look at what you are doing to help your profession. Evaluate what you can do and then join the cause. No donation is too small, because every new contribution means one more Chiropractor has decided to help his or her profession. Just think what we could accomplish together if every Chiropractor joined the fight to get more positive press for the profession! Become a monthly contributor to have an impact on the public’s perception of chiropractic. With your support, we can do so much more in 2011 to spread the good news to the general public.

To learn more about the Foundation for Chiropractic Progress or to arrange an automatic monthly donation, visit www.foundation4CP.com or call (866) 901-3427. Support the FCP today.

Contact Information:
The Foundation for Chiropractic Progress
PO Box 560
Carmichael, CA 95609-0560

By John Hyland, DC

Whenever a patient or an athlete reports problems with Achilles tendinitis, a close examination of foot and ankle function must be performed. In addition to treating the inflamed tendon of the gastrocnemius-soleus muscle complex, long-term prevention has to be considered. Recurring injuries to this tendon can significantly affect sports enjoyment and performance levels. A rupture of the tendon will likely require surgery, and occasionally ends participation in competitive and recreational sports completely.

Inflammation of the Achilles Tendon

All forms of tendinitis are due to microtrauma, either from excessive or abnormal activity on a normal tendon, or from normal stresses on an abnormal tendon. Inflammation develops in and around the tendon (peritendinitis). Symptoms are usually described as diffuse pain in or around the back of the ankle (from the calf to the heel).

The pain is aggravated by activity, especially uphill running or climbing stairs. Palpation will find a tender thickening of the peritendon, and there may be crepitus during plantar and dorsiflexion. Patients usually present with the complaint of being unable to participate in sports activities due to pain at their heel and lower calf. Often, a recent increase in activity levels or change in footwear is reported.

Hyperpronation and the Achilles Tendon

The Achilles tendon insertion on the calcaneus is medial to the axis of the subtalar joint, making the calf muscles the most powerful supinators of the subtalar joint.¹ Therefore, when excessive pronation occurs, eventually the tendon undergoes overuse degeneration and inflammation. This was well-described by Clement and his fellow investigators at the University of British Columbia in Vancouver, Canada. They describe how “pronation generates an obligatory internal tibial rotation which tends to draw the Achilles tendon medially. Through slow motion, high-speed cinematography we have seen that pronation produces a whipping action or bowstring effect in the Achilles tendon. This whipping action, when exaggerated, may contribute to microtears in the tendon, particularly in its medial aspect, and initiate an inflammatory response.”² These investigators believe that the control of functional overpronation with corrective orthotic devices is a necessary treatment for most patients with Achilles tendinitis.

Poor blood flow may be a contributing factor to Achilles tendon overuse injuries, and especially with tendon tears. Clement and his fellow authors speculate that “in individuals who overpronate, the conflicting internal and external rotatory forces imparted to the tibia by simultaneous pronation and knee extension may blanch or wring out vessels in the tendon and peritendon causing vascular impairment and subsequent degenerative changes in the Achilles tendon.” This “region of relative avascularity” extends from 2 to 6 cm above the insertion into the calcaneus, and is a common site of rupture of the Achilles tendon. This makes it especially important to ensure good blood flow during the healing of this condition.

Treatment Methods

Anti-inflammation

• Restricted activity: jumping, running, and other activities which stress the tendon are eliminated, while easy walking is still encouraged. Bicycling is allowed, as long as the pedals are pushed with the heels, and not with the forefeet. Immobilization is not recommended.
• Temporary heel lifts: bilateral higher heels reduce the tensile loading on the tendon, and permit the patient to continue to be ambulatory.
• Cryotherapy: frequent (hourly) ice massage and/or cold packs help reduce inflammation.
• Vitamin C with bioflavonoids: a natural anti-inflammatory that will speed healing.

Better Bloodflow

• Ultrasound: initially pulsed, then constant and direct (once inflammation has subsided).
• Deep friction massage: to stimulate healing deep in the tendon and prevent adhesions.³

Improved Biomechanics

• Orthotics for pronation: to reduce the stresses on the tendon due to “whipping action.”
• Shock absorption: viscoelastic inserts will decrease the amount of shock at heel strike.

Rehabilitation

• Heel cord stretching: “runner’s stretch” against a wall. All exercises should be performed with corrective orthotics in place.⁴
• Eccentric strengthening: standing on the edge of a stair, do a toe raise up, then rapidly drop the involved heel as far as possible, returning by pushing back up with the uninvolved leg.⁵
• Wobble board training: to stimulate proprioception and neuromuscular control.⁶

Conclusion

Achilles tendinitis can be easily treated conservatively. Steroid injections and casting are seldom used these days. 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 which provide good heel stability with a small amount of additional heel lift. This helps prevent Achilles tendon problems, and is especially important in athletes running for more than a few miles at a time. Once the local inflammation has been controlled, improved blood flow to the region of relative avascularity is necessary.

The use of corrective 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. Competitive athletes must have regular evaluation of the alignment and function of their feet, in order to avoid potentially disabling injuries.

About the Author
Dr. John Hyland has practiced for more than 20 years in Colorado and was the developer and director of four Chiropractic rehabilitation practices for more than eight years. He is a postgraduate faculty member for several Chiropractic colleges. In addition to his specialty board certifications in Chiropractic orthopedics (DABCO) and radiology (DACBR), Dr. Hyland is nationally certified as a strength and conditioning specialist (CSCS) and a health education specialist (CHES). He now consults, advises, and trains doctors of Chiropractic in the concepts and procedures of spinal rehabilitation and wellness exercise.

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¹ Subotnick SI. Sports medicine of the lower extremity. New York: Churchill Livingstone; 1989:475.

² Clement DB, et al. Achilles tendinitis and peritendinitis: etiology and treatment. Am J Sports Med 1984; 12:179-84.

³ Lear L. Transverse friction massage. Sports Med Update 1996; 10:18-25.

⁴ Hertling D, Kessler RM. Management of common musculoskeletal disorders. 2nd ed. Philadelphia: JB Lippincott; 1990:405.

⁵ Standish WD, et al. Tendinitis: analysis and treatment for running. Clin Sports Med 1985; 4:593-609.

⁶ Kibler WB, et al. Functional rehabilitation of sports and musculoskeletal injuries. Gaithersburg, MA: Aspen Publishers; 1998:282.

People have differing views on continuing education. Some rarely, if ever, set foot in a classroom again. Others will take specialized or “hobby” classes based on what interests them, while others will actively pursue their continued education to benefit their careers.

Chiropractors have options similar to this. State license renewal guidelines give doctors the opportunity to take brief “focus” classes with topics or techniques they would like to implement. They also have the option to actively continue their wellness education through certifications and diplomates in a wide variety of topics.

Why be certified?

Receiving a certification or diplomate can be a considerable investment in both time and money. In most cases, classes are held on weekends, and not necessarily at an easy distance. So why be certified? One of the biggest advantages of a diplomate or certification is specialization and what that brings to a doctor’s practice.

Diplomates in radiology can allow doctors to serve as references to peers in particularly complicated or challenging patient cases. A doctor with a specialization in sports injury or rehabilitation can more effectively develop a sports practice, including becoming a team Chiropractor locally or even nationally. A certification in spinal trauma or neurology can allow a doctor to develop a stronger knowledge base on acute injuries and associated spinal conditions.

The number of available certifications and diplomates also allows one to select a focus or specialty that fits specific interests and passions. From readily available information on the web, here are a look at some of the opportunities available and what’s involved:

• Certified Chiropractic Sports Physician (CCSP) is a 100-hour certification program aimed at achieving a focus in patient care in sports and their associated injuries. Doctors obtaining this certification can better treat their patients by knowing the mechanism of the sports-related injury, degree of injury, and rehabilitative techniques to stabilize and strengthen the biomechanics of the involved area. This program can also act as a stepping stone to a full diplomate (DACBSP).
• Certified Chiropractor in Spinal Trauma (CCST) is designed to improve clinical results through thorough case management and professional communication. The certification involves 10 modules and final examination, resulting in a strong background on whiplash, spinal trauma, and soft tissue injury.
• Certified Strength and Conditioning Specialist (CSCS) allows a doctor to recommend safe and effective programs of physical activity to his or her patients, improving the overall wellness of those individuals. Chiropractors are by their educational background able to sit for the CSCS examinations without additional classroom time beyond their current degree. Several guides and reference materials are available for those who would like to sit for this exam in order to review materials contained in the CSCS exam.
• Diplomate of the American Board of Chiropractic Orthopedics (DABCO) places focus on the examination, diagnosis and treatment of the human body from an orthopedic perspective. The program encompasses 400 hours of class time with a minimum completion of 360 hours, along with successful completion of all course examinations.
• Diplomate of the American Chiropractic Board of Radiology (DACBR) is a residency program for becoming a Chiropractic radiologist. The doctor will have a referral specialty and can provide consultation services to other doctors and their patients. Many diplomates perform research and can be expert witnesses in litigation. Seven schools in the United States currently offer residencies for becoming a Chiropractic radiologist.
• Diplomate in Philosophical Chiropractic Standards (DPhCS) is a program designed to span five years and includes 320 hours divided among 13 live weekends, an online segment, self-study, and a thesis. The doctor’s thesis is then defended at Palmer Lyceum, witnessed by those in Lyceum attendance. Doctors achieving this diplomate are given a strong background in the founding principles of Chiropractic that serve as the “backbone” of the profession.
• Diplomate of the American Chiropractic Board of Sports Physicians (DACBSP) is the next step of specialized education after a doctor receives certification as a sports practitioner. In addition to the CCSP prerequisites, the doctor must attend 200 additional hours of class, complete a written and practical examination, be published in a peer-reviewed journal, and have 100 hours of hands-on treatment outside the regular clinic setting. Receipt of a doctor’s DACBSP demonstrates a strong commitment and specialization in sports medicine as well as physical fitness.
• Diplomate of the American Chiropractic Board of Occupational Health (DACBOH) is designed to broaden a doctor’s background through a focus on occupational health, the work environment, and safety relating to injury prevention and worker treatment. Doctors pursuing a diplomate in occupational health must complete 300 of the 360 total class hours as well as pass several examinations and complete a paper focusing on an aspect of occupational health.
• Diplomate of the American Chiropractic Neurology Board (DACNB) is a 300-hour program for “specialist level” training in neurology. The program is offered at several colleges as well as through other dedicated institutions. Written and practical examinations are given upon completion of the program’s hours, and yearly recertification is part of this diplomate.
• Diplomate of the American Chiropractic Rehabilitation Board (DACRB) focuses on the use of rehabilitation in the doctor’s office to speed recovery from injury and improvement in overall patient wellness. The program includes 300 hours divided into a three-year study program with examinations at the conclusion of study.
• Diplomate of the American Chiropractic Board of Nutrition (DACBN) is for doctors who seek a focus on nutrition and its application in the clinic. The program comprises 360 hours of class, followed by examination for certification.

Getting started

Since many programs require time and attention, it is important to first decide to make the commitment to the specialty you are interested in. The continuing education departments of the colleges can provide you with the information on where and when each certification or diplomate will be offered. The internet is also an excellent option if you’re not certain a particular school offers your program.

Numerous continuing education seminars dot the Chiropractic landscape and can be a worthwhile experience, even though a certification or diplomate is not achieved. For example, Dr. Mark N. Charrette, a member of the Foot Levelers, Inc. Speaker Bureau, does a 12-hour course on extremity adjusting, which is useful knowledge and something that can be immediately used in the practice on Monday.

Broadening your education benefits your patients, your practice, and yourself. Once you have found a certification or diplomate that holds your interest, you’ll be on your way to personal and professional growth that may not have been possible before.

About the author

An enthusiastic speaker, Dr. William Austin provides an energetic approach to learning. He draws from more than 35 years of healthcare experience, which includes Athletic Training, Emergency Medicine, English Bonesetting, and Chiropractic. Dr. Austin has developed two successful practices. His patients range from newborns to centenarians, couch potatoes to professional athletes. Dr. Austin is a 1986 graduate of Logan College of Chiropractic.

To see the proof of how effective the Foundation for Chiropractic Progress (FCP) is at spreading positive press about the benefits of chiropractic, all you have to do is look at the numbers:

• The Foundation estimates that—in 2009 alone—from its ads and public service announcements, the FCP generated 500 million positive messages!
• In 2010, the Foundation estimated it would easily exceed another 500 million positive messages before the end of the year.

From award-winning work to ground-breaking research to inspirational appearances by a retired brigadier general, the FCP continues to work toward its goal of creating more positive press about Chiropractic. Take a look at what the FCP has accomplished recently, and then make a decision today to join this national effort for positive press!

Search for New Spokesperson

Thanks to our overwhelmingly positive response to our current spokespeople, including NFL legend Jerry Rice and retired Brig. Gen. Becky Halstead, the Foundation is currently seeking another spokesperson to help us reach even more people. We are looking for someone with an excellent reputation and who is a strong supporter of the profession.

Jerry Rice TV PSA Wins Media Award

The original Jerry Rice 60-second PSA created in 2009 won the North American Precis Syndicate (NAPS) award for extraordinary achievement in media relations, broadcasting 197 times in 33 different states. The television spot promoting Chiropractic care reached an audience of more than 122 million viewers!

An updated Jerry Rice PSA (including both a 30 and 60 second version) is available exclusively for members contributing to the Foundation.

Foundation Reaches Out to Employer Community

You may be aware of the Foundation-sponsored Mercer Report, which was prepared by two prominent medical researchers and reconfirmed the effectiveness and cost savings of Chiropractic care compared to other procedures for the treatment of neck pain and low back pain. To expand on the reach of this study, the Foundation is now working with the Center for Health Value Innovation, a prominent healthcare think tank.

We are sponsoring an "Innovator Summit," a panel discussion with benefits leaders and chief medical officers from a number of large corporations as well as Chiropractors, to explore the role of Chiropractic care and its inclusion in value-based benefit design. The first meeting with the Center for Health Value included robust discussions of Chiropractic, presentation of relevant research, and a strategy/timeline for next steps.

The Center will be issuing a white paper on this discussion, issuing a press release, and will submit the paper for presentation at an industry conference of business and health care leaders scheduled in September.

Monthly Contributors Honored in Chiropractic Economics and Dynamic Chiropractic
The doctors, students, and others who contribute monthly to the Foundation for Chiropractic Progress were recently recognized in print. The June 3 issue of Dynamic Chiropractic and the June issue of Chiropractic Economics included a F4CP appreciation ad featuring the names of monthly contributors. The Foundation plans to continue to regularly thank its monthly contributors in both publications. I would like to give one more sincere “Thank you!” to those who support the Foundation in its mission of positive press. Our success is YOUR success.

Local Marketing: How-to Guide

Besides national media attention about the value and benefits of Chiropractic care, the Foundation offers its contributors full use of our resources for their local use. Once you become a member of the Foundation for Chiropractic Progress, you will have access to ALL our marketing materials for local use.

The Foundation has developed a "How-to Guide" on local marketing for contributing doctors who wish to use the Foundation's plethora of ads, public service announcements, advertorials, and press releases in their community. The guide includes step-by-step directions on how to properly use the Foundation as a marketing tool.

General Halstead Speaks at the Michigan Association of Chiropractors

Foundation spokesperson and retired Brig. Gen. Becky Halstead was a featured speaker at the Michigan Association of Chiropractors (MAC) spring convention held in Traverse City, Michigan. The highly successful association, which recently passed a significant scope of practice law, welcomed more than 1,000 doctors and students to their annual conference. Gen. Halstead shared her inspiring words on how Chiropractic care changed her life for the better.

New and Renewed Contributors

• 123Chirorpactors: Renewed its financial support to the Foundation in 2010 for $6,000. 123Chiropractors has now contributed a total of $11,000 to the Foundation.
• National University of Health Sciences: NUHS has joined other chiropractic colleges in supporting the Foundation with a donation of $6,000, bringing their total contribution to $12,000.
• North Carolina Chiropractic Association: NCCA has pledged another $2,500 to the Foundation.
• Missouri State Chiropractic Association: MSCA confirmed its support to the Foundation and became a monthly contributor.

Obesity PSA Hits the Airwaves

The Foundation issued a 60-second radio PSA highlighting the life-threatening risks and musculoskeletal problems associated with obesity. The PSA advises patients suffering from obesity to consider contacting their local Chiropractors for safe, cost-effective treatment and advice on how to live a healthier lifestyle. To listen to the radio spot, please visit the Foundation's website: www.foundation4CP.com.

How You Can Help

We need your help to reach more people and tell them about the many benefits of Chiropractic care. Take a look at what you are doing to help your profession. Evaluate what you can do and then join the cause. No donation is too small, because every new contribution means one more Chiropractor has decided to help his/her profession. Just think what we could accomplish together if every Chiropractor joined the fight to get more positive press for the profession! Become a monthly contributor to have an impact on the public’s perception of Chiropractic. With your support, we can do so much more to spread the good news to the general public.

To learn more about the Foundation for Chiropractic Progress or to arrange an automatic monthly donation, visit www.foundation4CP.com or call 1.866.901.3427. Support the FCP today!

Contact Information:
The Foundation for Chiropractic Progress
PO Box 560
Carmichael, CA 95609-0560

by Steve Agocs, DC, K. Jeffrey Miller, DC, DABCO, and Steve Troyanovich, DC

Care of the extremities, including extravertebral adjusting, can be traced back to the founder of Chiropractic, D.D. Palmer, and many other Chiropractic pioneers. Extremity care is part of almost every major technique system in Chiropractic, and extremity adjusting enjoyed a major resurgence in the profession in the 1970s and 1980s. In addition to spinal adjusting, extremity care is at the core of the Chiropractic profession, and it is a legacy not to be soon forgotten.

Introduction

In the 1910 text The Chiropractor’s Adjuster, the founder of Chiropractic, D.D. Palmer, wrote: “Chiropractic is not a system of healing. Chiropractors do not treat disease; they do not manipulate the spinal column. Chiropractors adjust any or all of the 300 joints of the body, more particularly those of the spinal column.”¹

Although Chiropractic extremity adjusting can be traced back to the founder and many early practitioners, extremity care has taken a back seat to spinal-pelvic adjusting. In fact, some suggest extremity adjusting is not and should not be a part of Chiropractic. In recent history, Chiropractors in Michigan and New Jersey have battled to maintain extremity care in their scope of practice, making this a timely and relevant topic as other states revise their own scope of practice laws. This writing is intended to remind the reader of the role extremity care has played in the profession and to urge the continuation of what is truly a legacy.

Manipulation in History and Chiropractic

Chiropractors were not the first group to manipulate the extremities. Virtually every culture that has existed has employed some form of manipulative art or “bonesetting” tradition. The earliest written records of Asia, Egypt, and Greece all clearly document manipulation traditions, as do drawings and artwork from ancient cultures. In Western culture, manipulation survived throughout the Middle Ages and Renaissance periods. It was largely a peasant practice, passed down from master to apprentice.²

As people from all over the world immigrated to the United States, they brought these traditions with them. Prior to the last quarter of the nineteenth century, there were no formal schools or professional organizations for these practitioners. The skills were practiced by independent-minded individuals throughout the American frontier, and some of the early art of Chiropractic can be traced to these bonesetters.

Since its inception, the Chiropractic profession has been focused on the spine, with extravertebral adjusting taking secondary importance. The focus, though secondary, does not reduce the effectiveness and importance of extremity care.

The earliest of Palmer’s theories dealt with the human body as a machine. Palmer theorized that the human body was like a fine watch. If all of the parts of the watch were in perfect alignment, there would be little or no friction and the watch would function normally.³ By analogy, if the parts of the human frame were in perfect alignment, friction and inflammation would be kept in check and the human body could function normally. Naturally, in this analogy of alignment, friction and inflammation would extend to the joints of the extremities.

The Chiropractor’s Adjuster, Palmer wrote, “I emphatically affirm, as I did 13 years ago, that about 95% of diseases are caused by displaced vertebrae; the other 5%, including corns and bunions, come from luxated joints other than those of the backbone”⁴ (p. 100). This quote echoes Palmer’s early statements regarding the role of extremity adjusting in Chiropractic and links it to Palmer’s analogy of a watch and the human body.

Many of Palmer’s writings about extremity adjusting focused on the feet. Corns and bunions were mentioned numerous times. Hard manual labor, walking long distances, and the poor quality of shoes were the likely culprits here. Palmer practiced in the Midwest, where farming provided the majority of jobs. Transportation was limited, resulting in walking relatively long distances by today’s standards.

Most shoes in the late 1800s were still made with straight lasts for women and girls. Only shoes for men and boys were made specifically for the right and left feet. Shoes for women and children had to mold to the wearer’s feet, a process that was aided when the shoes were wet (Curator of the Arabia Steamboat Museum, personal communication with K.J. Miller, October 2009). This leaves little wonder why corns, bunions, subluxations, and other conditions of the feet were common and a concern of Palmer’s. In 1910, Palmer wrote: “I have never found it beneath my dignity to do anything to relieve human suffering. The relief given bunions and corns by adjusting is proof positive that subluxated joints do cause disease” (p. 322). And, also, “Why adjust in the lumbar for displacements in the joints of the foot?”⁴ (p. 322).

In the Beginning

Chiropractic began with Palmer’s adjustment of Harvey Lillard. This also marked the beginning of the Palmer School. From this beginning in 1896⁵ (not 1895, as legend goes), the school was run by Palmer, who espoused a philosophy of adjusting any subluxated joint in the body.

The Palmer School of Chiropractic taught extravertebral adjusting. In 1910, the Palmers wrote: “Were we to know of a dislocated shoulder, hip, or of any one of the 52 articulations of the vertebral column being luxated…and did not replace the dislocation…it would show to our patients and students that we were not doing our duty and were criminally negligent”⁴ (p. 78).

The Palmers studied and wrote of bone-setting techniques for the extremities. They were also acutely aware of the techniques of various European bonesetters as well as techniques from New England. Palmer mentions the Sweet family of “natural bone-setters” as well as others in his 1910 text⁴ (p. 543).

While Palmer wrote about the importance of adjusting the extraspinal joints, there is no record of Palmer’s specific extremity approach. The earliest written record of a systematic approach to extremity adjusting in Chiropractic comes from Palmer’s first rival, Dr. Solon Langworthy. Langworthy and his co-authors, Minora Paxson and Oakley Smith, published the first textbook on Chiropractic, Modernized Chiropractic, in 1906. The book contains detailed instruction in extremity adjusting and was used in the curriculum of the American School of Chiropractic, located in Cedar Rapids, Iowa⁶ (p. 257-272).

Palmer’s son, Bartlett Joshua (“B.J.”) Palmer, took over the operations of the Palmer School of Chiropractic in 1906.⁷ From 1906 until 1924, B.J. was inarguably the most influential leader in Chiropractic. While his influence waned after 1924, B.J.’s opinions continued to exert themselves in the profession through his leadership of the Palmer School of Chiropractic until his death in 1961.

In 1907, B.J. and his cohorts in the Universal Chiropractors Association helped defend his friend and colleague Shegetaro Morikubo in a landmark trial held in LaCrosse. The Wisconsin case was the first successful defense of Chiropractic as a separate and distinct profession from osteopathy and the practice of medicine. The defense was based partly on the premise that Chiropractors were exclusively engaged in reducing vertebral subluxations. This is in stark contrast to Palmer’s initial teachings of “all of the 300 joints of the body.”⁸

Following the trial and for the next few decades, thousands of trials ensued for Chiropractors accused of practicing medicine or osteopathy without a license. The defense always fell back to the precedent set by the Morikubo ruling of 1907.

B.J. maintained the spine-only philosophy in the Palmer School and used his influence to attempt to exert the philosophy on the profession. In the early 1930s, B.J. narrowed his focus even further by almost exclusively limiting Chiropractic adjusting to the upper cervical spine. In 1956, B.J. relaxed his upper cervical stance by allowing full-spine adjusting in the clinic and classroom of the Palmer School.⁹ Extremity adjusting, however, remained in exclusion.

Langworthy and Others

While the control and philosophy of the Palmer School changed over the years, the influence of the profession’s largest institution and its leader did not prevent other Chiropractic practitioners from carrying the flag for extremity care in Chiropractic.

Solon Langworthy led the way. Langworthy was an osteopath who received his diploma in Chiropractic from the Palmer School of Chiropractic and Cure in 1901. Langworthy founded the American School of Chiropractic and Nature Cure, the first real rival to Palmer’s school, in 1903. Langworthy co-authored the first textbook on Chiropractic, Modernized Chiropractic, along with two other early graduates of Palmer’s school, Minora Paxson and Oakley Smith.¹⁰

Modernized Chiropractic was published in 1906 as two volumes. Volume II contains specific descriptions and photographs for adjustments of the clavicle, hand, fibula, scaphoid, cuboid, tarsals and metatarsals, calcaneus, talus, cuneiforms, metacarpals, and phalanges. On page 271-272, the authors wrote:

The idea which we have been advancing in regard to the foot is not that disease in the foot (and perchance subluxation of the bones of the foot themselves), is not in many instances the result of subluxations of the spine or pelvis. We know from many cases of trouble in the foot successfully treated by adjustments given to the spine and pelvis, that such is many times the case.

But we say emphatically that when the primary cause in the shape of a subluxation exists in the foot itself, that it is logical and scientific to make direct correction of these conditions and that it is extremely illogical, unscientific, and anti-modern not to do so.⁶

In addition to Langworthy and his associates, hundreds of other Chiropractic technique developers included extremity care in their systems. Diversified Technique began as a “proto-technique” of “non-Palmer” adjustments used by many Chiropractors who refused to fall into step with B.J.’s upper cervical philosophy.¹¹

In 1947, National College of Chiropractic published Chiropractic Principles and Technique, accepted as the “textbook” on Diversified techniques. Janse et al.’s book contains adjustments of the spine as well as the extremities, viscera, and cranium, contrary to the “spine-only” focus that the Palmer School embraced.¹²

Other technique developers who branched out from the spine with their instruction of adjusting extremities included Leo Spears (Spear’s Painless System), Major Bertrand DeJarnette (Sacro-Occipital Technique), Clarence Gonstead (Gonstead Chiropractic Technique), Hugh Logan (Logan Basic), and Raymond Nimmo (Receptor Tonus Technique). Many other shorter-lived techniques instructed doctors in extraspinal adjusting, as evidence by the myriad books and manuals one may find from the 1920s and onward in a Chiropractic library.

A common link among these techniques is the premise that the extremities were being addressed to influence the spine. This was achieved through heel lifts, braces of various types, or direct adjustment.

In the late 1940s and early 1950s, Monte Greenawalt noticed that patients he referred to a podiatrist returned with increased lower-back pain. The patients had been fitted with rigid orthotics. He concluded that if the orthotic’s effect on the feet could influence the spine in a negative manner, it was logical that they may also affect the spine in a positive manner.

Greenawalt also felt that part of the orthotic problem stemmed from the rigid materials used by the podiatrist. So began a process of tinkering with flexible materials to develop an orthotic that would enhance spinal care. The resulting product of Greenawalt’s experimentation was called the Spinal Pelvic Stabilizer, and in 1952 he founded Foot Levelers, Inc. to market his product to other Chiropractors.

Greenawalt’s invention was initially met with great criticism. In 2002, Greenawalt, reflecting on his career and invention, said, “In the early years, my ideas and work were scoffed at by some of the best minds of the time. Today, all the major Chiropractic techniques recognize that stabilization of the feet is an integral part of care and recommend orthotics with foot imbalances.”¹³

Another development in the 1950s was the publishing of Athletic and Industrial Injuries of the Ankle and Foot in 1958 by August Schultz. Schultz later published The Shoulder, Arm and Hand Syndrome in 1969 and The Knee, Femur and Pelvis in 1979. Like Greenawalt, Schultz was an inventor. His first book included an order form for products he invented, including the Schultz Shinsplint Easer, Schultz Elbow Easer, and the Schultz Osgood-Schlatter Support.

In the 1970s and 1980s, extremity adjusting as a standalone procedure seemed to really come into its own. D.D. Stierwalt published Extremity Adjusting in 1975.¹⁴ Kim Christensen published the Illustrated Manual of Common Extremity Adjustments in 1980¹⁵, and in 1981, Kevin Hearon published, What You Should Know About Extremity Adjusting.¹⁶ That same year, Motion Palpation Institute founder Leonard Faye published Motion Palpation and Manipulation of the Extremities.¹⁷

In 1982, R.C. Shafer wrote Chiropractic Management of Sports and Recreational Injuries.¹⁸ In 1985, National College of Chiropractic published the States Manual of Spinal, Pelvic and Extravertebral Techniques, largely thought of as the modern “Diversified textbook.”¹⁹

These authors and instructors were looking at the extremities beyond their relationship to the spine. The concept of a subluxation was quickly moving away from a “bone out of place and nerve pressure.” Recognition of the extremities as part of a complex biomechanical and neurological model was coming to light. Investigations into movement, the gait cycle, exercise physiology, and how Chiropractic plays a role in athletics showed that healthy extremity function went far beyond a sore elbow or a fallen arch, and the effects were wide-ranging.

This trend continued with the founding of the Council on Extremity Adjusting in 1995. The council offers a 105-hour post-graduate program on extremity care leading to a certification as a Chiropractic Extremity Practitioner, and post-graduate education in extremity care remains popular in the Chiropractic profession.

Conclusion

Despite rather humble beginnings in the late nineteenth century, by the mid-1990s evaluation and adjusting of extremity conditions were part of the core curriculum of every Chiropractic college, and they remain so today. Recent evaluation of the websites of all 16 Chiropractic educational institutions that are members of the Association of Chiropractic Colleges confirms extremity care in their curricula. With few exceptions, extremity care is within the scope of licensed Chiropractors in almost every state and country where Chiropractors practice.

A 2003 survey included in the Job Analysis of Chiropractic 2005 showed that 95.4% of respondents used extremity adjusting techniques in their practices. The survey also showed 69.3% of Chiropractors use heel lifts and 81.8% use foot orthotics in their practices.²⁰ Extremity care in Chiropractic has a long, rich history, and it is a history that continues to be written.

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¹ Palmer, D.D. (1910). The Chiropractor’s adjuster, the science, art, and philosophy of Chiropractic. Portland, OR: Portland Printing House, 228.

² Breasted, J.H. (1930). The Edwin Smith Surgical Papyrus, Volume 1: Hieroglyphic Transliteration, Translation, and Commentary. Chicago, IL: University of Chicago Press, 303-304.

³ Palmer, D.D. (1899). The key to Chiropractic work. The Chiropractic, No. 26, 1.

⁴ Palmer, D.D. (1910). The Chiropractor’s Adjuster. Davenport, IA: D.D. Palmer, 100.

⁵ Palmer, D.D. (1897). Deaf seventeen years. The Chiropractic, 17(3).

^6] Smith, O., Langworthy, S.M., & Paxson, M. (1906). Modernized Chiropractic (Vol. II). Cedar Rapids, IA: S.M. Langworthy, 257-272.

⁷ Troyanovich, S.J. & Keating, J.C. (2005). Wisconsin versus Chiropractic: The trials at LaCrosse and the birth of a Chiropractic champion. Chiropractic History, 25(2), 37-45.

⁸ Rehm, W.S. (1986). Legally defensible: Chiropractic in the courtroom and after 1907. Chiropractic History, 6, 50-55.

⁹ Himes, H.M. (Speaker). (1956). Policy talk delivered to the PSC student body.

¹⁰ Troyanovich, S.J. & Gibbons, R.W. (2003). Finding Langworthy: The last years of a Chiropractic pioneer. Chiropractic History, 23, 9-17.

¹¹ Cooperstein, R. (1995). Diversified technique: Core of Chiropractic or ‘just another technique system?’. Journal of Chiropractic Humanities, 5(1), 50-55.

¹² Janse, J., Houser, R.H., & Wells, B.F. (1947). Chiropractic principles and technic. Chicago, IL: National College of Chiropractic.

¹³ Greenawalt, M.H. Introduction. In: Hyland, J.K. (2002). Spinal pelvic stabilization: A practical approach to orthotic application. Roanoke, VA: Foot Levelers, Inc.

¹⁴ Stierwalt, D.D. (1975). Extremity adjusting. Davenport, IA: D.D. Stierwalt.

¹⁵ Christensen, K.D. (1980). Illustrated manual of common extremity adjustments.

¹⁶ Hearon, K.G. (1981). What you should know about extremity adjusting (5th ed.). K.G. Hearon.

¹⁷ Faye, L.J. (1981). Motion palpation and manipulation of the extremities. Huntington Beach, CA: Motion Palpation Institute.

¹⁸ Shafer, R.C. (1982). Chiropractic management of sports and recreational injuries. Baltimore, MD: Williams & Wilkins.

¹⁹ Kirk, C.R., Lawrence, D.J., & Valvo, N.L. (Eds.). (1985). States manual of spinal, pelvic and extravertebral techniques (2nd ed.). Lombard, IL: National College of Chiropractic.

²⁰ Christensen, M.G. (2005). Job analysis of Chiropractic 2005. Greeley, CO: National Board of Chiropractic Examiners, 135.

Research tells us that the average American consumer is exposed to more than 3,000 advertising messages a day.¹ With that many messages going out every day, how will you make sure your message stands out from the crowd? When you get out of school and start your work either in your own practice or as part of a group practice, you will need to think about your message. You’ll need to make sure someone sees your ad, hears your message, and takes action. It’s up to you to take charge of your advertisements, and there are some important principles to consider before placing an ad.

Everyone wants the same thing—to get noticed (leading to more patients, sales, etc.) Advertising is just one component of a marketing strategy designed to drive business. Advertising for health-related services (such as Chiropractic) can be even more frustrating than that of typical companies because the consumer may not need the service when they are exposed to the marketing message. Therefore, the intent of many marketing campaigns in healthcare is to build and maintain awareness in the mind of the consumer until they are in need of the service being offered.

Sometimes media works best when used together

A recent study found that “the Web increased the reach of television by a remarkable 51% in the morning, 39% in the middle of the day, and 42% in the afternoon.”² So if you place an ad designed to air on television that sends consumers to your website to take advantage of a sale or special promotion, they are more likely to do this because they are using both forms of media at the same time.

If you have a website for your practice, try to incorporate it into your ads. Driving consumers and potential patients to your website can only improve the chances that they will remember you when they need Chiropractic care. It’s going that extra step that will give you the most return on investment (ROI) for your advertising budget.

Be targeted with your message

It is better to send out a message to 10 people who are listening than to 100 people who are not. For example, if your practice works primarily with sports injuries, setting up a booth at a 5K race will get your name in front of more athletes who could use your services than if you just placed an ad in a newspaper. While more people might read the newspaper, it is likely that the athletes at the 5K could directly benefit from your specific knowledge of sports injuries.

Try to find creative ways to target your audience, and you’ll be surprised how quickly you see results. Pregnancy magazines are the perfect place to place an ad about how your practice can relieve tension or pain for the mom-to-be and help her during her pregnancy. Contact local hospitals or women’s groups to see if you can speak to a childbirth class where women could use Chiropractic to help with their body changes.

Consumers trust other consumers more than they trust you

Most successful Chiropractors know that referrals are not only one of the best ways to grow a practice, but they are also extremely cost effective and help to develop the overall brand of the practice. One of the most popular ways referrals are generated is by satisfied people talking to other people. Consumers tend to trust the word of other consumers more than they trust that of companies when considering a product or service.

One way to take this concept to the next level is to utilize various online resources. You can actually have your patients go to work for you by talking about you and your practice using blogs, message boards, forums, and chat services. Word of mouth travels fast, and people are more likely to tell others about a bad experience than rave about a good one. Ask your patients how they are feeling during the exam, and get plenty of feedback about what you could do to make their visit better. Common courtesy can extend further than any ad you place.

Standing out from the crowd isn’t easy, but if you apply these principles you will be surprised how effective your advertising will be. Knowing where to spend your money and how to plan your message are important components in a successful marketing strategy. Be aware of your audience when making advertising decisions, and follow these guidelines to watch your practice grow!

About the Author

Dr. Mark Charrette has taught over 1,000 seminars worldwide on extremity adjusting, biomechanics, and spinal adjusting techniques. His seminars emphasize a practical, hands-on approach. Having developed successful practices in California, Nevada, and Iowa, Dr. Charrette currently resides in Irving, Texas.

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¹ http://www.inc.com/magazine/20050801/future-of-advertising.html. Inc. Magazine: August 2005. Page: David H. Freedman. Accessed 2/08/08.
² http://www.online-publishers.org/?pg=press&dt=060606. Accessed 2/08/08.

By Drs. Terry Yochum and Tim Maggs

We all are victims, in many ways, of the existing healthcare crisis.

The auto industry is addressing their crisis through new laws for improved mileage per gallon and stricter pollution controls. The energy crisis continues to drive searches for more efficient and alternative means to produce renewable energy. The healthcare crisis, unlike the above two, is merely shifting responsibilities with regard to who will pay for it. This “system” will continue until it can no longer sustain itself.

Chiropractic’s Role

As Chiropractors, we are interested in the neuro-musculoskeletal system (NMS). The current healthcare system has three major flaws in addressing NMS disorders:

1. We wait until someone breaks,
2. We only look at the site of the break, and
3. Our goal is to only remove the pain or symptoms.

This approach costs exponentially more, as we all know it is less expensive to “pay now” vs. “pay later”—especially when the proactive approach will produce slower aging, delayed degeneration, and a much greater quality of life.

Joint replacement surgery is a growth industry. Between 2000 and 2009, the incidence of total knee replacements increased by 120%. Osteoarthritis, the leading arthritis (better known as the “wear and tear” arthritis), led to 21.7 million ambulatory care visits and more than 3 million inpatient hospitalizations, and medical expenditures most likely attributed to osteoarthritis cost $62.1 billion in each year between 2008 and 2011.

As Chiropractors, we know that a joint that has lost mobility is predisposed to a more rapid degeneration. We know that joints will fixate when under greater stress (abnormal mechanical loading), such as with traumas or biomechanical imbalances. These fixations prevent people from moving or exercising, which is the breeding ground for obesity, elevated blood pressure, increased anxieties, elevated cholesterol, and much more. We know that we, as a profession, are the most equipped to both detect and improve biomechanical fixations and imbalances. This approach will make a dramatic impact on the “fixing” of this healthcare crisis.

Altered Biomechanics and Bone Marrow Edema?

According to an article published in the journal Radiology 1996 by Mark E. Schweitzer, M.D. and Lawrence M. White, M.D. from Thomas Jefferson University Hospital in Philadelphia, a unique study was performed to evaluate the effects of altered biomechanical stress on the human skeleton.

Twelve asymptomatic volunteers (six women and six men) ranging between the ages of 19 and 41 were chosen to be evaluated in this biomechanical study. All 12 of these asymptomatic volunteers had MR images of their hips, knees, ankles, and feet performed at the commencement of the study. No evidence of pathology or bone marrow edema was seen affecting any of these 12 volunteers, and the MR imaging was done bilaterally. They were evaluated again two weeks after a pad had been used to achieve altered weight bearing with overpronation of one foot. Three volunteers underwent imaging a third time, two weeks after overpronation was stopped.

The alteration in weight bearing was accomplished by placing an extra-large 9/16 in. (1.4 cm) longitudinal metatarsal arch pad underneath the lateral aspect of one foot to increase pronation. This orthotic was placed in the shoe, but the volunteers did not undergo casting with the foot in this position. Therefore, movement was altered somewhat voluntarily. The volunteers were instructed not to alter their daily or recreational activities in any way other than that caused by the pronation. The volunteers were given an adequate number of pads for all pairs of their shoes. The pads were placed unilaterally to minimize discomfort.

After two weeks of altered weight bearing, MR images of both the lower extremities were obtained in the STIR (short tau inversion recovery) or fluid sensitive (or fat suppression images) imaging sequence. All three sets were done with STIR sequences.

The results of these MR images were that 11 of the 12 volunteers demonstrated changes, and the overpronated side only was affected in 10. One of the volunteers with medial involvement had the findings only on the non-overpronated side. These changes were seen most frequently in the foot, four metatarsals, and calcaneus. Changes were predominately lateral in six volunteers. The tibia was affected in three volunteers—one proximately and one distally—and in an additional three volunteers, the femur was involved—one affecting the proximal femur and two affecting the distal femur. Eleven of these 12 volunteers had pain directly over the areas where bone marrow edema was identified. At MR follow-up, after the pad was removed in two of the three volunteers, the MR images returned completely to normal. But in the third volunteer, MR images demonstrated minimal persistent edema, with approximately 50% having been resolved. All of the volunteers were completely asymptomatic immediately after the pad removal and at clinical follow-up (one week, one month, and one year)¹.

Bone is dynamic, undergoing hypertrophy in response to stress. Alternatively, after immobilization from casting or paralysis or in a gravity free environment, bone atrophy occurs. What was most interesting about this study is that bone marrow edema and symptoms directly over the area of edema were created with only two weeks of altered biomechanical weight bearing with overpronation of one foot.

One wonders if there would be altered biomechanics (subluxation) of the lower extremity and/or the lumbar spine for an extended period, what kind of stress this would place on the human skeleton, and what long-standing effects it could have on premature degenerative changes within the freely moveable joints of the spine and/or pelvis and lower extremities. The results of this study clearly show that increased signal intensity on fluid sensitive images or STIR images (fat suppression images) can occur and may represent a bone contusion or bone bruise. The results of this study indicate that the increased signal intensity is the result of a bony response to the stress created upon it without actual fracture occurring. On the basis of Schweitzer’s study, I believe that the altered biomechanics should be added to the list of causes of increased intramedullary signal intensity on T2 and/or STIR weighted images.

It is of interest to note that I (Dr. Yochum) personally interviewed Dr. Mark Schweitzer and asked him if any of these 12 volunteers had lower back pain and/or sacroiliac pain. He told me that those questions were never asked of these volunteers. From my Chiropractic perspective, I would have to believe that many these patients would have had sacroiliac and/or lower lumbar pain. It would have been interesting to perform pre- and post-MRI images of the bones adjacent to the sacroiliac joint and/or the lumbar facets to determine whether bone marrow edema could have been identified there as a result of the altered biomechanical stress from the disturbance of the lower kinetic chain.

Imaging Bone Marrow Edema

Imaging stress to the human skeleton may be done by means of plain films, bone scan, CTl, or MRI scan. The most sensitive imaging modality to detect stress to the human skeleton reflected as bone marrow edema is magnetic resonance imaging. While bone scans can certainly reflect an increase in turnover of bone, they are not as sensitive as the 1% sensitivity of marrow change occurring with MRI scans.

Understanding this concept becomes extremely important to evaluating the highly motivated athlete who may or may not have the presence of a spondylolysis and/or spondylolisthesis on plain film radiographs and may only be seen by means of magnetic resonance imaging scans. It is possible that a patient may have normal plain film radiographs, yet have pain on extension and have in fact the early fatigue fracture (stress fracture) of spondylolysis and be hidden or “PENDING.” Since the plain film radiographs may not be sensitive enough to detect the “PENDING” spondylolysis or certainly not see edema adjacent to existing pars defects (spondylolysis), specialized physiologic imaging such as magnetic resonance imaging should be given clinical consideration.

On standard MR imaging with standard T1- and T2-weighted images, it is quite possible that bone marrow edema may be missed on the T2-weighted image in a patient who may be “PENDING” without defect or in a patient with an existing pars defect who may have bone marrow edema adjacent to the pars defect. With that being the case, it is important that an additional imaging series referred to a “short tau inversion recovery” (STIR)—otherwise known as fluid sensitive images or fat suppression images—be performed routinely in patients where there is a high suspicion of the possibility of a hidden or pending pars defect or bone marrow edema adjacent to an existing pars defect. The imaging sequence of choice, which should be added to the standard routine MRI scan is a sagittal STIR imaging sequence, will unequivocally rule in or out the possibility of bone marrow edema in the region of the pars interarticulares with or without a defect.

For further discussion of patient management and evaluation of the problematic cases of spondylolysis and/or spondylolisthesis in the lower lumbar spine and how it relates to the highly motivated athlete, please see chapter 5 of Dr. Yochum’s textbook, “Essentials of Skeletal Radiology.”²

Evidence Based

The industry is pushing for all care to be evidence based. The irony is that under this heading, less imaging is encouraged. Less treatment is encouraged. And in the end, less correction will have been done. The Chiropractic profession would do well to redefine our identity and to associate itself closely with the detection and correction of biomechanical faults—an identity our forefathers fought hard to protect. We would then be the only profession whose goal would be to correct these structural imbalances (even in the absence of symptoms), and not just provide symptomatic care. This identity would enhance the public’s perception of our profession, as the public is begging for someone to help them achieve structural preservation, especially when this approach would improve their long-term quality of life.

To achieve this result, we must look at all people from a biomechanical perspective, as everyone has biomechanical faults and imbalances. Just as the orthodontist improves the alignment of the teeth long before problems occur, it’s easy to understand the benefit of doing this to the NMS system as well. As seen in Figure 1, all people have biomechanical imbalances, and these imbalances always originate in the feet.

If we ignore the imbalances in the feet, we would be ignoring the importance of a balanced foundation. Introductory Architecture teaches the importance of a balanced foundation. This is the very reason our office puts every patient into custom orthotics at the beginning of all correction programs.

Biomechanics of Feet

There are three arches in each foot, with each being critically important for providing foundational balance. Upon scanning of the feet (Figure 2), it is easily detectable if any or all of these arches have fallen. Most patients have multiple fallen arches, when scanned in the standing position. In addition, aging, gravity, and stress over time will encourage further falling of these arches, which will alter centers of gravity in every joint of the body. Abnormal centers of gravity, combined with aging, will further accelerate the degenerative process in joints.

Figure 2

Custom Orthotics

The simple solution to current foot/structural imbalances as well as future structural weaknesses is to put the patient into custom-made functional orthotics at the start of their corrective program. Regardless of whether the patient appears to have pronated, supinated, or even normal arches, the digital foot scan will demonstrate that most people will have some degree of fallen arches, as well as imbalances with body weight distribution. Secondly, although we don’t test for this in our office, a significant percentage of people will overpronate during the gait cycle, and this overpronation is blocked with custom-made functional orthotics. Many injuries, especially sports injuries, occur at or are aggravated during this overpronation phase.

After we digitally scan each patient, along explaining Figure 1 (Crooked Man) and the potential for acceleration of degeneration if left imbalanced, most people will excitedly agree to the inclusion of custom orthotics as soon as possible. All people have a similar lifetime goal—to have a higher quality of life combined with greater activity.

More patients wearing custom orthotics in your office will convert to improved clinical results, improved patient satisfaction, and greater patient compliance. And, if an office can “manage” patients properly, patients will require new orthotics every two years, keeping more people engaged in active care. This truly is the beginning of making your practice more successful and fixing the healthcare crisis.

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¹ Schweitzer, M. E., White, L.M. “Does altered biomechanics cause marrow edema?” Radiology, Mar 1996, Vol. 198:851–853.
² Yochum T. R., Rowe, L. J. Essentials of Skeletal Radiology, 3rd ed., 2005, Chapter 5.