Educational Chiropractic Resource Articles

by Mark Charrette, DC

Children's feet undergo marked developmental changes throughout the first six or seven years of life. Incidence of flat feet, knock knees, or other abnormality in a young patient does not always signal the need for therapeutic intervention, as is recommended for adult subjects. Yet these conditions, along with gait abnormalities, pigeon toes, and bow legs, are the more common signs that cause parents to seek biomechanical evaluation of their children.¹

Young feet have not experienced the years of standing, walking, wearing shoes, or other stresses that exact a high price from the adult foot. Prolonged and repeated stress to pedal soft tissues can create deformation that interferes with structural mechanical interactions.² This explains why an estimated four out of five people older than 20 experience some form of foot dysfunction.³

Architecture of the Foot

The mature foot displays a sound architectural structure that provides for balanced disbursement of body weight in response to gravity. Weight travels through the ankle, where about half the load is borne at the heel. The remainder is divided between anterior medial and lateral supports, which, with the heel, define a plantar vault.⁴

The developing foot of a child displays no distinct architecture for about the first 18 months of life. Soft tissue and adipose tissue are its main components. From 18 months until about age six, rapid development occurs in bony structures and the longitudinal arch.

Weight distribution patterns change as this pedal development progresses. The toddler sways in learning to walk because the foot has limited weight-bearing abilities. Higher loading values are recorded in the midfoot region, and metatarsal loading is roughly equal. As the musculoskeletal frame continues to grow, the pedal foundation seems to shape itself to provide better support. Loading of the midfoot decreases, and the third and fifth metatarsals begin to bear more weight.⁵

Normal Foot Function

The feet serve the body in three ways: bearing weight, assisting locomotion, and receiving the impact of gravitational force, also known as heel strike shock. In the adult foot, these functions occur in the stance phase of gait, which can be broken down into three major components⁶:

1. Contact. As the heel touches the ground, a natural inroll of the subtalar joint begins. This is known as pronation. The tibia also rolls inward, and the knee flexes, causing response in the femur, pelvis, and spine. This kinetic sequence activates the body's natural shock absorbers to reduce forces that, left unchecked, could have pathological influences on the spine and other upper body structures.⁷
2. Midstance. Body weight shifts from the heel to the forefoot, causing an outroll or supination in pedal structures. The tibia and femur also turn outward as the knee unflexes.
3. Toeing off. This propulsion phase sees the foot acting as a rigid lever to shift, beginning the swing phase of stance, when the foot loses ground contact. Leg bones remain externally rotated until the next heel strike, when this three-part cycle is repeated.

The underdeveloped foot of a child accomplishes gait without displaying this kind of synchronized process. Before independent stance is possible, it is typical to observe bowed legs and feet that point inward. Uterine crowding and a normal fetal positioning with one leg crossed over the other are contributing factors.¹

As the child begins to walk and the lower extremities bear weight, the bowing and toe positions normalize. Then skeletal growth begins to accelerate, and genu varum (or toeing in) may reappear for the next few years. By age six or seven, when growth rates begin to stabilize, a return to normal healthy alignment should be observed.

This is the stage when concern for the child's pedal integrity is appropriately pursued. A musculoskeletal examination can be conducted, because ossification of bony structures is usually complete, even if the epiphyses are not entirely closed.8

Pedal Dysfunction

In children, the effects of pedal dysfunction may not be readily apparent, waiting until the subject is well into the adult years to manifest. Cases of low back, knee, and hip problems; postural fatigue; scoliotic deviations; and plantar fascitis in adults have all been linked to untreated childhood pedal imbalance.^7,9

Hyperpronation again may be the culprit in these cases. It is one of the leading foot problems detected among children in the elementary school years, ages six through 12. Three separate studies conducted at 20-year intervals found the condition in 29%, 28%, and 35% of the test populations.¹⁰

The immediate effect of hyperpronation on young feet is an abnormal abduction during gait. Body weight shifts over the foot before stance-phase muscles are prepared to provide adequate support.¹¹ The effect becomes even more pronounced in running, because body weight shifts more to the medial aspect of the feet.⁵

Examining Children's Feet

The same "five red flags" used to identify potential problems in adult feet can be applied to patients aged 6 or older.

1. Toe position. As the child walks, look for signs of toeing out or inward. If possible, gait should be observed before the child is aware that an examination is under way, to obtain the most natural results. The parent might also be able to provide information on the child's normal walking patterns.
2. Dropped arches. As the child stands barefoot, slide an index finger beneath the longitudinal arches. Abnormally low arches will not comfortably accommodate the finger past the first knuckle. Pain on palpation and tissue tightness that is relieved by shifting weight outward are other indicators of imbalance.
3. Tendon bowing. Observation of the Achilles tendons will usually reveal bowing in the presence of hyperpronation. Measure the distance from the navicular to the floor when the child is in a normal resting stance. Next, manipulate the subtalar joint to a neutral position and repeat the measurement. The average limit for all ages is about three-eighths of one inch.¹
4. Patellar displacement. The normal inroll of pronation causes an inward movement of the patella. Excessive pronation might be accompanied by perpetuation of this patellar displacement. Comparative measurements of the distance between two marks on the knees, taken with the feet in normal stance and then manipulated to a subtalar neutral position as described above, can be revealing.
5. Shoe condition. Foot imbalance will cause excessive wear on the lateral aspect of shoe heels. Check the condition of shoes for more clues to the health of a child's feet.

Use of a tread mat or similar surface that records foot patterns during gait is another useful diagnostic tool. Key indicators that can be observed include gait angles, step length, base of step, stance angle, and scuffing.¹

Therapeutic Orthotic Support

The use of functional orthotics to enhance the supportive and biomechanical properties of the pedal foundation—and the kinetic interaction of upper-body structures—has been validated in numerous studies and clinical experience.^6,12,13,14 Functional orthotics offer the developing foot a degree of control in motion that need not disrupt complex structural interrelationships.

The goal of orthotic therapy is to control, not restrict, motion. By enhancing support of the longitudinal arch, orthotics can reduce deformation of pedal tissues.¹³ This, in turn, encourages joint stability, which provides optimal support of the lower extremities and, ultimately, greater postural integrity of pelvic and spinal structures.

The role of the foot as shock absorber is also enhanced when pedal imbalance is alleviated with flexible orthotics. Young bones and immature joints are especially vulnerable to the effects of pathological heel strike shock. By normalizing subtalar pronation and accompanying internal leg motion, orthotics help the body's shock absorbers to function most effectively.⁶

The special concerns of young patients are addressed in a functional custom orthotic made of leather bottoms with shock-absorbent heel pads, topped by a moisture-resistant synthetic material to withstand active wear. Leather is preferred for its moderate rigidity while allowing lateral compression and expansion for optimal integration of orthotic, shoe, and foot.⁹

Orthotics for children must take into account the rapid growth rates of this patient group. The best results can be obtained when the shoe, foot, and orthotic function as an integrated unit. Therefore, refit children with new orthotics for every increase of one and a half sizes in shoes.¹²

About the Author
Dr. Mark N. Charrette is a 1980 summa cum laude graduate of Palmer College of Chiropractic. Over the past 15 years, he has lectured extensively on spinal and extremity adjusting throughout the United States, Europe, the Far East, and Australia. Dr. Charrette received a Bachelor’s degree from Illinois State University (summa cum laude) in 1976 where he was an NCAA All-American in 1974.

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¹ Schuster RO, Skliar JD. Outgrowing trends in the lower extremities of children. J Am Pod Med Assoc 1991;81(3):131-135.

² Cailliet R. Soft Tissue Pain and Disability. Philadelphia: FA Davis, 1988.

³ Schafer RC. Clinical Biomechanics. Baltimore: Williams & Wilkins, 1987.

⁴ Kapandji IA. Physiology of Joints, Vol. 2, Lower Limb, 5th ed. New York: Churchill Livingstone, 1987.

⁵ Hennig EM, Rosenbaum D. Pressure distribution patterns under the feet of children in comparison with adults. Foot & Ankle 1991;11(5):306-311.

⁶ Root ML, William PO, Weed JH. Normal and Abnormal Function of the Foot, Vol. II. Los Angeles: Clinical Biomechanics Corp., 1977.

⁷ Steindler A: Kinesiology of the Human Body under Normal and Abnormal Conditions, 3rd ed. Springfield: Charles C. Thomas, 1970.

⁸ Greenawalt MH. Children and orthotics. Amer Chiro 1989;4:46

⁹ Caselli MA, et al. Biomechanical management of children and adolescents with down syndrome. J Am Pod Med Assoc 1991;81(3):119-127.

¹⁰ Notari MA, Mittler BE. Study of the incidence of pedal pathology in children. J Am Pod Med Assoc 1988;78(10):518-521.

¹¹ Valmassy R, Stanton B. Tibial torsion: normal values in children. J Am Pod Med Assoc 1989;79(9):432-435.

¹² Greenawalt MH. Spinal Pelvic Stabilization, 4th ed. Roanoke: Foot Levelers, Inc., 1990.

¹³ Christensen KD. Orthotics: do they really help a chiropractic patient? ACA J of Chiro 1990;27(4):63-71.

¹⁴ Gross ML, Davlin LB, Evanski PL. Effectiveness of orthotic shoe inserts in the long distance runner. Am J Spts Med 1991;19(4):409-412.

by Chris Akey, DC

I was discussing lifestyle choices the other night with a few colleagues, and how so many people come to think that the more expensive a product is, the more it enhances a person’s status, reputation, or overall well-being. The conclusion we came to was that, while most people who thought the things they were buying would help them have a healthier, happier lifestyle, none really focused on health, prevention, and wellness.

I fell into this category when it came to shoes—as many of you probably do, too. As Chiropractors, we spend the majority of our time on our feet, so we want the best shoes and are willing to pay premium for them. I did just that; and while my feet were a little more comfortable during the day, at night they were sore and tired. My expensive shoes looked great (which is what they were designed to do), but they weren’t giving me the support I really needed to get through my daily “stand-up routine.”

If high-priced shoes weren’t the answer, what was? What about shoe inserts? I knew there were many different styles, but I wasn’t sure at first which (if any) was right for my needs. I needed more information in order to reach a decision.

After studying the literature of many different manufacturers, I decided to try a pair of custom-made functional orthotics that were designed to help stabilize and support my entire body, starting with the three arches in each foot. The company that made these custom orthotics offered impressive research published in peer-reviewed Chiropractic journals showing how their products helped to improve structural alignment and dynamic function, as well as reduce fatigue.

The custom-made products arrived, and they were truly amazing. My feet felt like they were on clouds from the time I put my shoes on in the morning until they came off at night. The satisfaction and stress reduction I experienced led me to the next step in my thought process: Could I recommend these products to my patients?

I was hesitant at first because I am a subluxation-based Chiropractor. But the more I thought about it, the more it made perfect sense to me. “Invest now for the future”—that is what we call prevention and wellness. It’s what we preach to our patients every day. I chose to walk the talk as I feel we should all do, and custom-made functional orthotics are a simple, effective, and very affordable investment for you and your patients. They totally belong in a subluxation-based office.

One of the major benefits I have experienced since recommending these products to my patients has been the holding of the adjustment longer. Have you ever had a patient who was “even” when he or she got off the table, walked around, and then was “uneven”? Then you got discouraged about yourself, your technique, or—worse—Chiropractic as a whole? What really happened was the asymmetry that the patient walked in with is the same one he or she will leave with if the asymmetry in the feet is not addressed.

An easy way to tell if there is asymmetry is to look for uneven shoe wear. Many times, I will point this out to a patient and he will say, “Oh, yeah—that’s been uneven for years.” And they still wonder why their feet, knees, hips, and back still hurt or are misaligned! Some other tests are low medial arches, bowed Achilles tendon, and foot flare during gait. One test I particularly like is, when scanning my patients with a surface-EMG and thermography, at the end it will tell me to examine the feet if significant asymmetry is detected.

As Chiropractors, our goal is to adjust the spine to remove and prevent subluxations and the ill effects they cause to our body. Another goal is providing your family, staff, and patients with tools that enhance what we do and provide that added “step” toward a healthier lifestyle. The right orthotic—the kind that supports the Chiropractic adjustment—fits into our vision of what Chiropractic can and ought to do. Benefits and results are what everyone wants, and one of the easiest and most affordable is custom-made functional orthotics.

About the Author
Dr. Akey has a practice, Life Family Chiropractic, in Farmington, Arkansas.

by John Hyland, DC

Sprains of the ankle are common injuries, since this joint 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 treatment, significant improvements in function and stability can be achieved, even in patients with long-standing ankle problems.

Acute Care

Initial treatment of ankle sprains follows the standard RICE protocol, which has recently been adapted to PRICE. This major change in the treatment of acute injuries affects most all soft-tissue traumas. Even with severe ankle sprains, using these procedures has been shown to speed recovery and return to sports.

The change from RICE to PRICE consists of adding some form of biomechanically appropriate protection to the injured joint (see Table 1). This then allows the R to be updated from rest to restricted activity. With the injured joint protected, patients can be encouraged to continue their activities (rather than using the now-discredited bedrest), 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.

TABLE 1

Treatment of Acute Injuries
P	protection of the injured joint (brace or support)
R	restricted activity (contralateral exercising)
I	ice (cryotherapy)
C	compression (elastic)
E	elevation (above heart level)

A study by Konradsen, et al. found that even in severe, Grade III lateral ankle sprains (with joint instability), encouraging early activation and walking in an Aircast^® functional brace produced a more rapid return to full work and sports activities than use of a cast.¹ The long-term results were equally good, with a minimum of chronic instability. This is consistent with the reports from studies of injuries to other joints, which demonstrate generally better results by encouraging early activity of injured joints while providing restrictions and protection from further damage.

Exercises

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).² Additionally, vigorous exercise of the contralateral joint’s muscles has been shown to provide a healing stimulus and a more rapid return to activities.³ This is called cross-over or cross education and is based on the neurological interconnections between extremities. In the case of lateral ankle (inversion) sprains, the peroneus muscles should be targeted. The patient can begin the rehabilitation process by frequently exercising the peroneus muscles of the uninjured ankle, using elastic tubing (such as a Thera-Ciser™) to perform eversion exercises. Since a recent study of cross education of the quadriceps found better results when the lengthening (eccentric) muscle action was emphasized, I want patients to focus more attention and spend more time on the returning part of the exercise.⁴

In the early sub-acute phase, as healing progresses, patients should begin to perform non-resistive active exercises, concentrating on mobility of the injured ankle. This usually takes the form of writing the alphabet with the foot while seated. The entire alphabet should be performed several times a day. This may be accompanied by isometric exercises for the peroneus muscles. The seated patient pushes the foot outwards (laterally) against an unmovable object, holding each contraction for five seconds or longer.

Once the joint can be passively moved through a normal range, isotonic resistance exercising of the peroneal muscles using elastic tubing should be started.⁵ 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 to participate in sports. Examples include rope jumping, which progresses to side-to-side jumps, carioca steps, figure eight runs, and even backwards running. Plyometric procedures should be introduced only when all other capabilities have returned to pre-injury capacity.

Proprioception

One reason that 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.⁶ An easy test for this type of problem 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 might be required to regain normal proprioceptive coordination. Subotnick recommends that an athlete should be able to demonstrate a “stork stand” for a least one minute on the injured leg before being allowed to return to full competition.⁷

Orthotics

In many patients, a custom-made functional orthotic 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 a stabilizing, custom-made orthotic 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.⁸

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, including the use of contralateral exercising, isotonic exercises with elastic tubing, and proprioceptive training techniques, most doctors of Chiropractic can manage acute ankle sprain injuries very well. In some patients, custom orthotics will be needed to help prevent future problems and joint degeneration.

About the Author
A 1980 graduate of Logan College of Chiropractic, Dr. John Hyland has practiced for more than 20 years in Colorado. 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 Chiropractors in the concepts and procedures of spinal rehabilitation and wellness exercise.

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¹ Konradsen L, Holmer P, Sondergaard L. Early mobilizing treatment for grade III ankle ligament injuries. Foot & Ankle 1991; 12:69-73.

² Roy S, Irvin R. Sports Medicine: Prevention, Evaluation, Management and Rehabilitation. Englewood Cliffs: Prentice-Hall, 1983:394.

³ Stromberg BV. Contralateral therapy in upper extremity rehabilitation. Am J Phys Med 1988; 65:135-143.

⁴ Hortobagyi T, Lambert NJ, Hill JP. Greater cross education following training with muscle lengthening than shortening. Med Sci Sports Exerc 1997; 29:107-112.

⁵ Roy S, Irvin R. Sports Medicine: Prevention, Evaluation, Management and Rehabilitation. Englewood Cliffs: Prentice-Hall, 1983:397.

⁶ Lentell GL, Katzman LL, Walters MR. The relationship between muscle function and ankle stability. J Orth Sports Phy Ther 1990; 11:605-611.

⁷ Subotnick SI. Sports Medicine of the Lower Extremity. New York: Churchill Livingstone, 1989: 284.

⁸ Heiser JR. Rehabilitation of lower extremity athletic injuries. Contemp Podiat Phys 1992; Aug:20-27.

Orthotics for leg length discrepancy is an effective treatment.

by John Danchik, DC, FICC, CCSP

The presence of a short leg might initially be suspected from a patient’s clinical exam, spinal X-rays, or from a history of recurrent subluxations. The first step is an accurate examination to determine the amount of difference and the influence this discrepancy has on the patient’s spine and gait. Next, the source of the inequality must be determined so that the correct treatment can be provided. And finally, the treatment must be evaluated to determine if it has sufficiently addressed the problem.

This process cannot be performed without examining the patient in the upright, weightbearing position. Whenever a patient is checked on the treatment table, whether prone or supine, errors of positioning are introduced (and are very difficult to exclude). Measurements of leg length discrepancy obtained in non-weightbearing positions have been found to be very unreliable.¹ In the upright posture, these errors and confusions are no longer a factor. Accurate clinical and radiographic determinations are then possible,² and effective Chiropractic care can proceed. Since the lower extremities provide the foundation and support for the pelvis during standing and walking, it is not surprising that they can have a profound effect on the alignment of the pelvis (and the spine, as well).

Effects and Causes

When one leg is shorter, there is often pelvic unleveling with a compensatory lumbar curve to the short side.³ Gait will be altered somewhat in an attempt to make up for the difference, and eventually, specific degenerative changes will be seen in the spine⁴ and hip joints.⁵ Studies have found that a difference in leg length (measured while standing) between 5mm to 9 mm or more results in a higher incidence of low back pain.^6,7 Athletes and those who spend a lot of time on their feet could develop chronic symptoms with just 3 mm of discrepancy.⁸ There are two possible causes of a short leg, and each cause needs different treatment. Therefore, a successful outcome is dependent upon differentiating whether a patient has an anatomical asymmetry or a functional imbalance.

An anatomical short leg is caused by a difference in the length and/or size of the structures between the femur head and the ground. This is sometimes found after a fracture or surgery, but it is most often the result of asymmetrical growth. A functional short leg develops secondary to a difference in the supporting structural alignment between the femur head and the ground. The most common cause is excessive pronation on one side, but knee valgus could also be a causative factor. Pelvic subluxations and/or lumbar muscle imbalances cannot be the cause, since these problems do not alter leg length while standing or walking.

Postural Examination

The first step in treatment of a patient with a short leg is the clinical weight-bearing postural examination of the pelvis and lower extremities. Start by positioning the patient in bare (or stocking) feet on an unyielding, level surface. Tell the patient to stand relaxed in a “normal upright posture.”⁹ Now palpate the iliac crests and the lumbar spine to determine if there is any pelvic unleveling and a compensatory lateral curvature. If either of these is found, see if the greater trochanters and knee joints are level, and evaluate the knee alignment for valgus and the feet for asymmetrical hyperpronation. If there is evidence of a functional short leg, check to see if the pelvis and spinal imbalances can be temporarily corrected. This is done by asking the patient to roll onto the outsides of both feet. As you palpate the levels of the iliac crests and greater trochanters, ask the patient to relax and return to normal, relaxed stance. If the pelvis dips down or rotates forward on the side of greater foot pronation, this shows the effect of the foot imbalance on the pelvis and lumbar spine. A lack of significant asymmetry in the lower extremity alignment reveals the difference to be anatomical.

Radiographic Procedures

The only acceptable method for obtaining an exact measurement of leg length discrepancy is with properly positioned standing X-ray images.¹⁰ To do this, we must limit sources of projectional distortion and magnification distortion, while carefully controlling equipment alignment and patient positioning. This entails the use of either an AP lumbopelvis view taken at a distance of 72 inches or 80 inches (instead of 40 inches) or a tightly collimated spot view of the femur heads from 40 inches. With both of these methods, the patient must be standing in bare feet on an unyielding, level surface. Body weight is borne equally through both legs, with the knees extended. Heels are placed directly under the femur heads (the “parallelogram” stance), which ensures accurate measurements even with lateral displacement of the pelvis. All X-ray equipment components must be installed level and square, especially the bucky. The film must be placed along the bottom of the cassette, and the cassette must rest squarely in the bucky. If all factors are controlled, then accurate measurements of true femur head heights can be obtained from the standing films, and the effect of any discrepancy on the spine and pelvis can be determined.

Orthotic Treatment

When there is evidence of a difference in lower extremity alignment (such as excessive pronation), the most effective treatment is to provide symmetrical support. This is accomplished by supplying custom-made corrective orthotics for both feet. It is very important to recognize the functional short leg, since providing a lift instead of an orthotic is likely to perpetuate the associated sacroiliac subluxations.¹¹ There is no reliable information on the radiographs to make this differentiation—it is only the standing postural exam with careful evaluation of lower extremity alignment that permits this determination. If there is any doubt, the safest approach is to fit the patient with custom-made orthotics, initially. If there is a persisting leg length discrepancy after wearing the orthotics for several weeks and receiving Chiropractic adjustments, a heel lift can then easily be added to the orthotic for complete correction.

Heel Lifts

When an anatomical difference in leg length affects the alignment of the pelvis and spine, Chiropractic care should include the recommendation of an appropriate amount of lift under the heel. Since some asymmetry is tolerated by the body (most good studies find that about 5 mm is the limit),¹² an exact correction of the difference measured at the femur heads is not needed. The exception to this might be athletes (such as long-distance runners) who spend many hours a day exercising and competing on their feet. For most patients, undercorrection (to within about 3 mm) is the best way to ensure a good response while avoiding any negative reactions. If the amount of lift needed exceeds 6 mm (the difference measured at the femur heads is more than 10 mm), the additional lift must be built onto the shoe, since a lift in excess of 6 mm will push the foot out of most shoes. This is done by adding half of the heel lift amount to the sole of the shoe, so the foot is not excessively plantarflexed during stance and gait.

Conclusion

Once a patient with a short leg has been properly examined, the source of the lower extremity shortening can be identified, and effective treatment can be provided. In many cases, orthotic support for foot pronation, knee rotation, or femur angulation is needed. Those few patients with a true anatomical leg length discrepancy will need to be supplied with an appropriate lift. The additional time required to determine the source of the short leg will be repaid in more effective Chiropractic care and adjustments that last.

About the Author
Dr. John J. Danchik is the seventh inductee to the American Chiropractic Association Sports Hall of Fame. He was the chairperson of the United States Olympic Committee’s Sports Medicine Physician Selection Program. He lectures extensively in the United States and abroad on current trends in sports chiropractic and rehabilitation. Dr. Danchik has served as an associate editor to the Journal of the Neuromusculoskeletal System and the Journal of Chiropractic Sports Injuries and Rehabilitation. He is in private practice in Massachusetts.

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¹ Woerman AL, Binder-MacLeod SA. Leg length discrepancy assessment: accuracy and precision in five clinical methods of evaluation. J Orthop Sports Phys Therap 1984; 5:230-238.

² Friberg O et al. Accuracy and precision of clinical estimation of leg length inequality and lumbar scoliosis: comparison of clinical and radiological measurements. Int Disabil Studies 1988; 10:49-53.

³ Friberg O. The statics of postural pelvic tilt scoliosis; a radiographic study of 288 consecutive chronic LBP patients. Clin Biomech 1987; 2:212-219.

⁴ Giles LGF, Taylor JR. Lumbar spine structural changes associated with leg length inequality. Spine 1982; 7(2):159-162.

⁵ Friberg O. Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality. Spine 1983; 8:643-651.

⁶ Giles LGF, Taylor JR. Low back pain associated with leg length inequality. Spine 1981; 6:510-511.

⁷ Friberg O. The statics of postural pelvic tilt scoliosis; a radiographic study of 288 consecutive chronic LBP patients. Clin Biomech 1987; 2:212-219.

⁸ Subotnick SI. Limb length discrepancies of the lower extremity; the short leg syndrome. J Orthop Sports Phys Therap 1981; 3:11-16.

⁹ Bullock-Saxton J. Postural alignment in standing: a repeatability study. Austral J Phys Ther 1993; 39:25-29.

¹⁰ Friberg O. Accuracy and precision of clinical estimation of leg length inequality and lumbar scoliosis: comparison of clinical and radiological measurements. Int Disabil Studies 1988; 10:49-53.

¹¹ Rothbart BA, Estabrook L. Excessive pronation: a major biomechanical determinant in the development of chondromalacia and pelvic lists. J Manip Physiol Therap 1988; 11:373-379.

¹² Travell JG, Simons DG. Myofascial Pain and Dysfunction: the Trigger Point Manual. Vol. 2. Baltimore: Williams & Wilkins, 1992: 55.

by Jeffrey D. Olsen, DC

With any new treatment or therapy, there is an adjustment period while the body adapts to the improvements being made. Whenever I present a treatment plan to a new patient, I like to use an orthodontic analogy. Most patients can relate to the always-uncomfortable changes associated with moving teeth. However, everyone realizes that the temporary discomfort results in a healthier bite and improved smile. If the orthodontist were to remove the appliances at the first hint of pain, patients would never achieve these benefits. Similarly, Chiropractic treatments make significant structural changes, and the patient must have patience.

Combining custom-made orthotics with Chiropractic treatment will often shorten the adaptation period, but nothing will eliminate this natural process. I frequently remind my patients about the changes they might experience. Because supporting the feet affects the whole body, it is not uncommon to experience mild but temporary discomfort as the knees, hips, pelvis, and spine adjust to the improvements. This article will provide some tips to minimize the discomfort your patients feel and help you reassure them throughout care.

First, let me share an observation I have made about Chiropractic care in general and with supportive products specifically. People seem to believe that custom-made products must also be indestructible. By their nature, custom-made products actually might not be as durable as mass-produced products because the attention in their design is on “customization.”

An example might help make my point. A good friend was not happy with the standard 15-inch tires that came on his sports car, so he purchased customized, 16-inch tires to tweak the performance. Unlike production tires, each custom tire was unidirectional and could only be used at one corner of the car and, therefore, could not be rotated. The car gripped the road like nothing I have ever seen, but the tires, which cost five times a normal tire, lasted only 20,000 miles.

I like to remind my patients about performance enhancement whenever I hear concerns about price, number of visits, or the fact that “adjustments don’t last.”

The first hurdle we must overcome is common to every purchase. It is well understood that following any purchase (adjustments, orthotics, or tires), the purchaser must be reassured that the purchase was wise and valuable. This period of “post-buyer depression” could manifest as anything from apprehension to unrealistic expectations. Simply be aware of this fact so that you don’t overreact to patients’ concerns—reassurance and education are key. Your confidence in your treatment will be the number-one help to getting them through their “buying blues.”

“You break it, you buy it!” and “you scuff it, you own it!” are common policies our patients are familiar with. However, in our office, we let our patients know that after a treatment, if they want to return that same day to be re-examined or even adjusted, we will do it at no charge. A follow-up is reasonable, because no matter how well we adjust, we may need a second chance, occasionally. When it comes to orthotics and custom-made shoes and sandals, patients must understand that, during the adaptation period, it is not only acceptable to wear their shoes and get them dirty, but it is also critical that they do so!

The normal adaptation period could last from two to four weeks, or longer with patients in special circumstances. It is only after the proper break-in period that the patient will feel how truly wonderful these prescription products are. And if, during the warranty period, the product requires any “tailoring,” Foot Levelers is happy to do it, regardless of any normal wear and tear.

Follow these steps to help your patients through the adaptation process:

1. Have the patient bring the shoes they will wear with their orthotics. It is important to see the kinds of footwear they have. You can quickly spot properly fitting versus worn out shoes.
2. Instruct the patient about and demonstrate the proper orthotic/shoe combination. They should understand that orthotics are specifically designed to work in only certain shoes for maximum support and performance.
3. Physically remove the factory insert so the patient knows the orthotic is designed to sit on a flat surface. The factory insert can also be used as a template. Foot Levelers intentionally sends its full-length orthotics with extra material beyond the toes. This allows the doctor to trim the orthotic to match the factory insert, which eliminates movement of the prescription while in the shoe.
4. If the patient has opted for a custom shoe or sandal, have them tear the tags off and try them on right there. Sandals require additional attention to the straps. Patients’ heels should rest firmly toward the rear with the forefoot secured by the straps. Properly securing the straps ensures the prescription is properly located. Verify with subjective muscle testing-more later.
5. Many patients can tolerate full-time use of their orthotics immediately. However, most patients should limit their use to 1 to 2 hours the first day and then add an additional hour each day.
6. Most importantly, schedule additional visits during the first 2 to 3 weeks while you help your patients adapt to their new supports. Chiropractic adjustments improve the transition and help muscles, ligaments, and joints adjust to their healthier positions. Nothing will help more than having you and your staff offer genuine empathy and reassurance that improved health, performance, and quality of life are just a few steps away.

When your patients are focused on pain during any portion of your care, redirect their attention to functional improvement using muscle testing. If you are unfamiliar with or unsure about doing muscle testing, ask Foot Levelers for their free educational materials on the subject (e.g., “Enhanced structure and muscle function”). Muscle testing is an effective way to get immediate, objective feedback from your patients. Muscle testing is based on the fact that joints, ligaments, and tendons have mechanoreceptors, which are constantly modulating neuromuscular tonus and reactivity. This allows the practitioner to supply a stimulus and measure the body’s response. General muscle tests will allow you to go beyond pain and reassure yourself and your patient that performance is improving.

Here are a few examples. Before performing a lumbar adjustment, muscle test the psoas muscle bilaterally for relative strength and the ability to “lock in” resistance to the examiner’s pressure. Make your adjustment and immediately retest the muscle. When joints are misaligned or ligaments are stretched, mechanoreceptors fire and inhibit muscle activity. Adjustments restore joints and supporting soft tissues and reset mechanoreceptors. Your patients will feel the difference, even though they may still have low back pain! Similar procedures can demonstrate improved proprioception and coordination using orthotics versus going without.

Fortunately for us, Chiropractic care is nothing like wearing braces—Chiropractic feels great! Because we are “selling” health performance, we are faced with many of the same challenges any retailer is. Understanding patients’ needs for reassurance about their healthcare purchases should influence every interaction with our patients. This is especially important for our new patients or for established patients changing some aspect of their care—converting from acute care to maintenance care, beginning a nutrition program, or starting custom orthotic therapy. Your ability to confidently demonstrate improvement will help your patients overcome their natural resistance to change, even when it’s for the better!

About the Author
Dr. Jeffrey D. Olsen is a 1996 Presidential Scholar and summa cum laude graduate of Palmer College of Chiropractic. He has been in private practice with his two brothers/partners since 1997, in Roanoke, Virginia. In addition to his practice, Dr. Olsen has instructed as an adjunct faculty member at the College of Health Sciences in Roanoke, teaching Anatomy and Physiology in the Physician Assistant department.

By John Hyland, DC, DACBR, DABCO, CSCS, CHES

Research into ruptures of the anterior cruciate ligament (ACL) is now helping us understand and treat this unfortunate and much-too-common athletic injury. As a result of the newly understood concepts, we as Chiropractors might now be able to prevent (or at least minimize) many of these injuries. From a sports injury perspective, this is the best approach—prevent the problem, rather than try to salvage the knee after the damage is done. If certain predisposing postural factors can be identified in athletes, preventive actions can be taken.

Non-Traumatic Causes

Epidemiology and frequency studies have now demonstrated that the vast majority of acute tears of the ACL occur without any contact or direct trauma to the athlete’s knee.¹ While this seems contrary to the previous common understanding of this problem, it has been found in several different studies. We now know that it is the torque, or twisting forces imposed on the knee joint that cause some ACLs to rupture. Some athletes have knee joints that seem to be more susceptible to these torque forces, and certain sports activities have been identified as particularly problematic.

Common Causes of ACL Injury

Landing at foot strike with the knee extended or in slight flexion (less than 20 degrees) and internally rotating the tibia in relation to the femur is by far the most commonly described incident which results in tearing of the ACL.² A rapid change in direction during running (or a similar twist of the leg during a fall skiing) can produce just such an episode. This is especially true in sports that use shoe spikes (which fix the lower leg to the ground). Arnold et al. found that 81% of athletes with injury to the ACL recalled the moment of injury as having their tibia in internal rotation combined with a sudden change of direction at foot strike.³

Markolf et al. used cadaver specimens to measure the forces on the ACL with various types of loading. They found that internal rotation of the tibia places a greater force on the ACL than external rotation. The greatest amount of strain occurred when the knee was hyperextended and in internal rotation. Forces were also quite high when the knee was in 10 degrees or less of flexion and internally rotated.⁴

Pre-Disposing Factors

A recent study by Beckett et al. retrospectively reviewed a group of athletes with acute, non-traumatic ACL ruptures (arthroscopically proven) and compared them to a matched control group. These researchers found excessive pronation of the foot and collapse of the arch during weight bearing in the injured subjects, and they proposed this finding as the mechanism of injury.⁵

In their study, Beckett et al. reviewed the biomechanics of the foot and ankle and described how arch collapse and excessive pronation lead to abnormal internal (medial) tibial rotation, which “pre-loads” the anterior cruciate ligament. Normally, subtalar joint pronation and internal rotation of the tibia occur only during the initial, contact phase of gait. If pronation continues beyond the contact phase, the tibia will remain internally rotated. This abnormal tibial rotation transmits excessive forces upward in the Kinetic Chain to the knee joint, producing medial knee stresses, force vector changes in the quadriceps muscle, and lateral tracking of the patella.⁶ This theory is supported by Copland’s work, which found that passive tibial rotation was statistically greater in hyperpronators than in nonpronators.⁷

Another study found that ruptures of the ACL in female athletes (many of whom are at a high risk for ACL rupture) were directly correlated with the amount of arch collapse and hyperpronation.⁸ Beckett et al. conclude that “hyperpronation of the foot and ankle complex may increase the risk of injury to the ACL.”⁵

Prevention of ACL Ruptures

Prevention is the best treatment for athletic injuries. This is particularly true when the injury is one that may lead to permanent joint instability (even with surgical repair) and could end an athlete’s career or limit a middle-aged runner’s fitness program. With our current knowledge regarding the causes and predisposing factors for ruptures of the ACL, we can now work to prevent these devastating injuries. All physically active patients and local athletes should be examined and evaluated for the existence of excessive pronation at the foot and ankle.

When you find an athlete with arch collapse and/or hyperpronation, the next step is to communicate and describe the risk factors for ACL rupture, then recommend the regular use of custom-made orthotics during all sports activities. The critical factors to look for in an orthotic for an athlete are shock absorption, support for all three arches of the foot, moisture resistance, and little added weight. In addition, the athletic orthotic must have enough flexibility to be comfortable during intense activities, and yet have sufficient stability to prevent excessive pronation and tibial rotation.

As doctors of Chiropractic, we might be able to extend the competitive careers and active lifestyles of many in our communities. When we recommend the use of custom-made functional orthotics, we could be preventing not only arch breakdown and biomechanical foot problems, but also acute ruptures of the ACL.

About the Author
A 1980 graduate of Logan College of Chiropractic, Dr. John Hyland has practiced for more than 20 years in Colorado. 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 Chiropractors on the concepts and procedures of spinal rehabilitation and wellness exercise.

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¹ McNair PJ, Marshall RN, Matheson JA. Important features associated with acute anterior cruciate ligament injury. N-Z Medical Journal 1990; 14:537-539.

² Whittington CF, Carlson CA. Anterior cruciate ligament injuries, arthroscopic reconstruction and rehabilitation. Nursing Clin North Am 1991; 26:149-158.

³ Arnold HA, et al. Natural history of the anterior cruciate ligament. Am J Sports Med 1979; 7:305-313.

⁴ Markolf KL, et al. Direct measurement of resultant forces in the anterior cruciate ligament. J Bone Joint Surgery 1990; 72:557-567.

⁵ Beckett ME, et al. Incidence of hyperpronation in the ACL injured knee: a clinical perspective. J Athl Train 1992; 27:58-62.

⁶ Tiberio D. The effect of excessive subtalar joint pronation on patellofemoral mechanics: a theoretical model. JOSPT 1987; 9:160-165.

⁷ Copland JA. Rotation motion of the knee: a comparison of normal and pronating subjects. JOSPT 1989; 10:366-369.

⁸ Ludon A. Posture and ACL injuries in women. JOSPT 1996; 15:204-209.

by Kim D. Christensen, DC, DACRB, CCSP, CSCS

All Chiropractic patients should be given specific exercise recommendations as part of their Chiropractic treatment, and then more exercise guidance as part of their wellness program. Athletes being treated for sports injuries, whether caused by direct trauma or overuse, need to be taught how to correctly stretch and strengthen in order to return to their sports activities and to improve their performance.

Anyone who has been injured in an auto collision, or who has experienced an injury on the job, will need exercise guidance to regain function and prevent weakness and re-injury. And all patients who are interested in wellness can benefit from Chiropractic recommendations regarding spinal fitness exercises, along with specific encouragement to stay active, while using correct body mechanics. This means that essentially all patients will need to receive Chiropractic rehab services at some point in their Chiropractic care.

Exercise Instruction

Most doctors of Chiropractic frequently use some form of exercise instruction in their offices. A large survey done by the National Board of Chiropractic Examiners found that 98% of Chiropractors reported that they use “corrective and/or therapeutic exercise” as part of their treatment of musculoskeletal conditions, and that more than 61% of their patients received exercise recommendations.¹ Unfortunately, many of these doctors are missing a chance to add to their revenue stream, because they don’t ask for or receive any payment for this additional service.

With a few minor changes in office procedures, most Chiropractic practices could be generating more income from the same number of patients. Barring a few exceptions, Chiropractic scopes of practice and insurance regulations permit licensed doctors of Chiropractic to perform, bill for, and be paid for providing rehab services to their patients. A few states do limit Chiropractic rehab to spinal exercises, so it is important to know your individual state’s practice laws, worker’s comp. procedures, and insurance regulations.

Doing Rehab in a Small Office

Very little additional space or equipment is needed when an office adopts the popular “low-tech” rehab approach. Since the patients do their exercises at home, the rehab sessions can often be done in the adjusting room or an exam room. The most space- and cost-efficient method is to have a multi-exercise unit mounted on the wall in one or several rooms. This way, patients can learn to do the exercises using elastic tubing or a cervical resistance bar, and then leave with an at-home version of the office equipment.

The cost of the home exercise equipment is much less than the fee for doing supervised exercises on a machine. In addition, the patient can do the exercises when it’s convenient, and even take it along on travels. Billing for the home exercise equipment is usually by CPT 99070, although some insurance companies will request a more specific HCPCS code.

The codes that are used for the type of rehab services we provide are all based on the 15-minute, direct contact definition. CPT 97110 – Therapeutic Exercise is the broadest and least controversial of the rehab codes. It is the easiest code to use, and the one that most practices should start out with. The reimbursement for 97110 varies considerably with plans and among states, but is usually between $25 and $35.

The definition of CPT 97112 – Neuromuscular Reeducation includes “improving proprioception, coordination, balance, and posture,”² so it is reasonable to use this code to bill for spinal stabilization, posture-changing, and wobble board exercises. Since these are more specialized exercises, this code is often reimbursed a bit higher—$30 to $45. However, because it has often been misused to bill for myofascial release and triggerpoint stimulation, insurance companies often question this code.

And finally, CPT 97530 – Therapeutic Activities, which is defined as “dynamic activities to improve functional performance,” is the most complex procedure of the three, and is usually paid at a higher rate ($40 to $60). Since this service calls for expert skills and knowledge, insurance companies and worker’s comp boards often look for more in-depth documentation, and it’s important to state what function and/or performance is being improved during this session.

The Need to Document

No matter which code is used, the most important factor in documentation of rehab is to separate the rehab notes from the adjustment notes. Since this is going to be billed as a separately identified professional service, the documentation must not be hidden in the adjustment notes—it must stand out as an additional procedure. This can be done in any number of ways, depending on the specific documentation methods used. Then it’s a matter of recording what the patient did, since rehab procedures are active, not passive, treatments, and the patient must do the exercises while the doctor teaches, supervises, and corrects the biomechanics.

Since there are no billing codes for unsupervised exercising, the documentation must demonstrate evidence of supervision. Also, since the codes for rehab services are based on 15 minutes, it must be obvious that somewhere between 8 and 23 minutes of direct supervision occurred.

Two-way Benefits with Rehab

Including exercises as an integral part of Chiropractic care is easy and very beneficial. Not only do patients appreciate the doctor who gives them specific, corrective exercises, they are also willing to pay for this additional service. In fact, most Chiropractors who have added rehab to their practices have seen an influx of new patients referred in specifically because this additional service is now available! Chiropractic rehab can increase the income from current patients, and also stimulate new patients.

Get Started with Foot Levelers »

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¹ Christensen MG, ed. Job Analysis of Chiropractic. Greeley, CO: National Board of Chiropractic Examiners; 2000.

² Current Procedural Terminology. Chicago, IL: American Medical Association; 2004.

by John K. Hyland, D. C., DACBR, DABCO

Research into the cause of ruptures of the anterior cruciate ligament (ACL) is beginning to shed light on this unfortunate and much too common athletic injury. As a result of the newly understood concepts, we might now be able to prevent (or at least minimize) many of these injuries. From a sports injury perspective, this is the best approach—prevent the problem, rather than try to salvage the knee after the damage has been done. Certain predisposing factors can be identified in athletes, and preventive measures can be recommended.

Non-traumatic causes

Epidemiology and frequency studies have now demonstrated that the vast majority of acute tears of the ACL occur without any contact or direct trauma to the athlete’s knee.¹ This seems contrary to the previous common understanding of this problem, but it has now been shown in several different studies. We now know that it is the torque, or twisting forces, imposed on the knee joint that cause some ACLs to rupture. Some athletes have knee joints that seem to be more susceptible to these torque forces, and certain sports activities have been identified as particularly problematic.

Common causes of ACL injury

Landing at foot strike with the knee extended or in slight flexion (less than 20 degrees) and internally rotating the tibia in relation to the femur is by far the most commonly described incident that results in tearing of the ACL.² A rapid change in direction during running (or a similar twist of the leg during a fall skiing) can produce just such an episode. This is especially true in sports that use shoe spikes (which fix the lower leg to the ground). Arnold et al. found that 81% of athletes with injury to the ACL recalled the moment of injury as having their tibia in internal rotation combined with a sudden change of direction at foot strike.³

Markolf et al. used cadaver specimens to measure the forces on the ACL with various types of loading. They found that internal rotation of the tibia places a greater force on the ACL than does external rotation. The greatest amount of strain occurred when the knee was hyperextended and in internal rotation. Forces were also quite high when the knee was in 10 degrees or less of flexion and internally rotated.⁴

Predisposing factors

Numerous theories concerning factors that could predict which athletes would develop acute ruptures of the ACL have been investigated. A large discrepancy in the strength ratio between the quadriceps and hamstring muscles is only sometimes present. Another theory that shows some merit is the greater frequency of internal derangement knee injuries in people who are deconditioned and resume strenuous sports activities without proper conditioning.⁵

A recent study by Beckett et al. retrospectively reviewed a group of athletes with acute, non-traumatic ACL ruptures (arthroscopically-proven) and compared them to a matched control group. These researchers found excessive pronation of the foot and collapse of the arch during weight-bearing in the injured subjects, and they proposed this finding as the mechanism of injury.⁶

Excessive pronation and rupture of the ACL

In their study, Beckett et al. review the biomechanics of the foot and ankle and describe how arch collapse and excessive pronation lead to abnormal internal (medial) tibial rotation that “pre-loads” the anterior cruciate ligament. Normally, subtalar joint pronation and internal rotation of the tibia occur only during the initial, contact phase of gait. If pronation continues beyond the contact phase, the tibia will remain internally rotated. This abnormal tibial rotation transmits excessive forces upward in the Kinetic Chain to the knee joint, producing medial knee stresses, force vector changes in the quadriceps muscle, and lateral tracking of the patella.⁷ This theory is supported by Copland’s work, which found that passive tibial rotation was statistically greater in hyperpronators than in nonpronators.⁸ Beckett et al. conclude that “hyperpronation of the foot and ankle complex may increase the risk of injury to the ACL”.⁶

Prevention of ACL ruptures

The best type of treatment of athletic injuries is prevention. This is particularly true when the injury is one that could lead to permanent joint instability (even with surgical repair) and could end an athlete’s career. With our current knowledge regarding the causes and predisposing factors for ruptures of the anterior cruciate ligament, we can now work to prevent these devastating injuries. All physically active patients and all local athletes should be examined and evaluated for the existence of excessive pronation at the foot and ankle. This is true for young athletes as well as for the weekend warriors.

When you find an athlete with arch collapse and/or hyperpronation, the next step is to communicate and describe the risk factors for ACL rupture, then recommend the regular use of custom orthotics during all sports activities. Prescribe a custom orthotic designed specifically for athletes. The critical factors to look for in an orthotic for an athlete are: shock absorption (without “bottoming out”), support for the arches of the foot, moisture resistance, and little added weight. In addition, the athletic orthotic must have enough flexibility to be comfortable during intense activities, and yet have sufficient stability to prevent excessive pronation and tibial rotation.

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¹ McNair PJ, Marshall RN, Matheson JA. Important features associated with acute anterior cruciate ligament injury. NZ Medical Journal 1990; 14:537-539.

² Whittington CF, Carlson CA. Anterior cruciate ligament injuries, arthroscopic reconstruction and rehabilitation. Nursing Clin North Am 1991; 26:149-158.

³ Arnold HA et al. Natural history of the anterior cruciate ligament. Am J Sports Med 1979; 7:305-313.

⁴ Markolf KL et al. Direct measurement of resultant forces in the anterior cruciate ligament. J Bone Joint Surgery 1990; 72:557-567.

⁵ Smillie IS. Injuries to the Knee Joint, 4th ed. Baltimore: Williams & Wilkins, 1970: 33-38.

⁶ Beckett ME et al. Incidence of hyperpronation in the ACL injured knee: a clinical perspective. J Athl Train 1992; 27:58-62.

⁷ Tiberio D. The effect of excessive subtalar joint pronation on patellofemoral mechanics: a theoretical model. JOSPT 1987; 9:160-165.

⁸ Copland JA. Rotation motion of the knee: a comparison of normal and pronating subjects. JOSPT 1989; 10:366-369.

by Kim D. Christensen, DC, DACRB, CCSP, CSCS

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 they 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 eventually lead to complete failure, with a resulting acute tear of the 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. Clement et al. described 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.

Impaired circulation may be a contributing factor to Achilles tendon overuse injuries, especially with tendon tears. The same researchers 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.”³ 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.

The New Paradigm for Care

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.

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.sup>3 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.⁴ 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.⁵ 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.⁶ This “new paradigm” will help to guide our management of all tendon problems, and provide more effective rehabilitation for Achilles tendons.

Rehab Procedures

When an injury is acute, an initial period of relative rest is needed. Occasionally, the weakened tissues will tear through, resulting in a ruptured Achilles tendon. This may require surgical repair and a period of rest before rehabilitation can begin. During this period, though, exercise of the opposite ankle should be encouraged. Vigorous exercise of the uninvolved contralateral ankle muscles produces a neurological stimulus in the injured muscles (called the “cross-over effect”), and helps to prevent atrophy.⁷ Initial treatment should also include heel lifts to reduce the strain on the Achilles tendon and cross-fiber friction to improve circulation. Complete return to function will then require attention to range of motion, functional strength, and orthotic support.

Range of motion. In addition to appropriate foot and ankle adjustments, stretching of the tight and shortened gastrocnemius/soleus muscle complex is a necessary part of Achilles tendon rehabilitation. Gentle stretching should be started early, putting a linear stress on the tendons and stimulating connective tissue repair. The standard is the “runner’s stretch,” performed against a wall. Patients with tightness and pronation will often allow the foot to flare outwards while stretching, which forces the medial arch to drop. This tendency must be carefully corrected, with the foot positioned straight ahead and the medial arch kept elevated.⁸ Even better is to perform the stretches with corrective orthotics in place.

Functional strength. Isotonic strengthening exercises that focus on the eccentric (negative) component have been shown to improve the healing of tendons and accelerate return to sports participation.⁹ These exercises should be progressed to closed-chain, heavily-loaded eccentric exercises, in order to stimulate collagen fiber re-orientation and strengthening.¹⁰ The patient is instructed to stand 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.

Conclusion

Achilles tendon injuries can be successfully rehabilitated conservatively. Steroid injections and casting are seldom used these days. Once the local inflammation has been controlled, improved blood flow to the region of relative avascularity is necessary. Correct stretching and strengthening exercises can be demonstrated and monitored in the office.

About the Author
Kim Christensen DC, DACRB, CCSP, CSCS directs the Chiropractic Rehab & Wellness program at PeaceHealth Hospital in Longview, Washington. He is a popular speaker, and participates as a team physician and consultant to high school and university athletic programs. Dr. Christensen is currently a postgraduate faculty member of numerous chiropractic colleges and is the past-president of the American Chiropractic Association (ACA) Rehab Council. Christensen is a “Certified Strength and Conditioning Specialist,” certified by the National Strength and Conditioning Association. He is the author of numerous publications and texts on musculoskeletal rehabilitation and nutrition. He can be reached at PeaceHealth Hospital at .

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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; 12:179-184.

³ Astrom M, Rausing A. Chronic achilles tendinopathy: survey of surgical and histopathologic findings. Clin Orthop 1995; 316:151-164.

⁴ Khan KM et al. Histopathology of common tendinopathies: update and implications for clinical management. Sports Med 1999; 27:393-408.

⁵ Almekinders LC, Temple JD. Etiology, diagnosis, and treatment of tendonitis: an analysis of the literature. Med Sci Sports Exerc 1998; 30:1183-1190.

⁶ Khan KM et al. Overuse tendinosis, not tendinitis. Part 1: a new paradigm for a difficult clinical problem. Phys Sportsmed 2000; 28:38-48.

⁷ Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders. 2^nd ed. Philadelphia: JB Lippincott; 1990. 334.

⁸ Ninos J. Chain reaction: a tight gastroc-soleus group. Strength Cond J 2001; 23:60-61.

⁹ Niesen-Vertommen Sl et al. The effect of eccentric versus concentric exercise in the management of Achilles tendinitis. Clin J Sport Med 1992; 2:109-113.

¹⁰ Alfredson H et al. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998; 26:360-366.