Monday, February 25, 2008

Case of the Week - Acute Plantar Fasciitis

Case of the Week – Acute Plantar Fasciitis

Patient: 24 year old female college student complaining of bilateral sharp, stabbing foot pain increasing in severity in the last three weeks. The patient recently took a trip to Paris where she walked the city for one week. Upon her return, she began experiencing occasional sharp pain on the soles of her feet. The symptoms have progressed in intensity and frequency. She currently has the most severe symptoms upon waking, and in the shower in the morning. The pain is severe enough that it causes her to “try to walk without putting my feet on the ground”. Relief position is lying on her back with a pillow under her Achilles tendons, allowing her feet to hang in plantar flexion.

Examination: Plantar fascia of both feet is tight and very tender to the touch. Tight and tender bilateral calf muscles (gastrocnemius and soleus). Tender calcaneous on lateral margins. No significant tenderness at the medial tubercle of the calcaneous. Joint dysfunction of the metatarsophalangeal joints and the calcaenocuneiform joints. The tibialis anterior was weak bilaterally. Orthopedic testing for a sprain or strain, nerve irritation or circulatory problem was negative. Muscle testing of the calf was within normal limits.

Discussion: This case is a fairly common presentation for plantar fasciitis. The patient is female, relatively inactive and recently had and increase in physical activity. In addition, she has weak tibilalis anterior muscles and tight calf muscles. The action of the tibialis anterior is to bring the foot up to a 90 degree angle, allowing us to walk without our toes dragging on the ground. The calf muscles do to opposite, helping to point the toes. It is important that these muscles have equal strength and pull on the ankle. If, as in this case, they are unbalanced, joints are unstable and problems ensue.

In plantar fasciitis, the calf muscles pull on the Achilles tendon, which pulls across the calcaneous on the plantar fascia. The fascia becomes very tight, pulling the ball of the foot closer to the heel. When this tight fascia is suddenly stretched, as in the case of our patient standing in the concave basin of her shower, the patient experiences a sharp pain.

Outcome: In a case of acute plantar fasciitis, the key is to remove the tension on the plantar fascia and then focus on correcting the imbalance. In this case, the patient wore a small heel lift which slackened the fascia. During her treatment, she received massage on the tight fascia and calf muscles, as well as adjusting to ensure proper motion of the feet and knees. At home, she was trained to stretch the calves and strengthen the tibialis anterior muscles. In chronic cases of plantar fasciitis, recovery is a longer process and may even require specialized footwear or custom orthotics. Night splints are also a common treatment method.

For more in-depth information into plantar fasciitis, especially in athletes, visit This is an article written by a chiropractor who is also a track coach. He goes into much more depth on all the complicated factors that predispose someone to plantar fasciitis.

Suggestion: Ice bottle
During a flare-up of plantar fasciitis, or any time your feet have been over-worked, try using an ice bottle to reduce pain and inflammation. Keep a plastic water bottle (like Arrowhead or Evian) in the freezer. When you foot is bothering you, place the bottle on the floor and roll your foot on the bottle. The ice will help decrease pain and inflammation, and the pressure of your foot on the bottle will help to stretch tight tissues. Just remember that water expands as it freezes, so make sure there is some extra room in the top of your water bottle before you freeze it.
Remember never to engage in an exercise without first consulting your chiropractic physician to see if it is safe for you and your unique conditions.

Exercise: Calf and toe stretches

One of the best ways to prevent plantar fasciitis is to maintain muscle balance across the ankle. Try adding stretching of the calves and toe flexors to your daily routine. For the calves, stand in a lunge with your hands bracing you on the wall. The back leg calf is being stretched. Now bend the back knee to bring the stretch down toward the ankle. For the toes, sit and hold your foot in your lap. Pull the toes back in a gentle stretch. Hold each of these positions for 10 seconds on each leg for a great stretching series.

Remember never to engage in an exercise without first consulting your chiropractic physician to see if it is safe for you and your unique conditions.

Tuesday, February 19, 2008

Case of the week - Sacroiliac Tension

Patient: 30 year old female office worker complains of right sacroiliac pain of several years duration. Pain has increased recently with increased time spent sitting at work and increased stress level. Pain is worst in the morning, feeling as though pressure needs to be released. Patient has tried massage and exercise, but the pressure remains. These treatments helped alleviate pain, but did not affect the “pressure”.

Examination: Significant bilateral sacroiliac joint dysfunction and lumbar joint dysfunction at L4 and L5 levels. Fortin Finger Sign. Tight and tender muscles in the right piriformis, right lumbar paraspinal muscles. Tight and tender right upper thoracic spine with right rib joint dysfunction. Range of motion, muscle testing and nerve testing were within normal.

Discussion: This patient displayed a classic finding in sacroiliac joint cases: the Fortin Finger Sign. Elegant in its simplicity, the Fortin Finger Sign indicates that the patient points directly to the sacroiliac joint when describing their pain. This sign is highly specific for the diagnosis of a sacroiliac joint problem. Lest you think Fortin to be moronic, it is actually very common for a patient to complain of pain in one location, while the source of that pain is located elsewhere. In this case, the patient’s pain and feeling of pressure were due to a chronic joint dysfunction of the sacroiliac joints. This dysfunction was so longstanding, it began to affect other areas of the spine, including the lumbar and thoracic spines. The patient’s long hours using a mouse at a computer were contributory to the thoracic pain.

Outcome: The patient underwent a series of treatments involving adjusting of the sacroiliac joints, the lumbar spine and the thoracic spine and ribs. Treatment also involved significant ergonomic corrections to the patient’s workstation and included postural re-training exercises to help the patient maintain the effects of her care.

Exercise: Knees to Chest – A great way to reduce tension on your sacroiliac joint is to stretch it in a flexed position. To achieve this, lay on your back on a comfortable surface. Slowly bring both knees to your chest and hug them with your arms. Take a deep breath, and, as you exhale, sue your arms to pull your knees closer to your chest. Repeat until you feel a stretch in your low back, just above your buttocks. Hold the stretch for 10 seconds, and then release very slowly, returning your legs to the ground. Do this once in the morning and once at night to help maintain your sacroiliac joint flexibility.

Remember never to engage in an exercise without first consulting your chiropractic physician to see if it is safe for you and your unique conditions.

Suggestion: Ergonomic Support – For all the hours we spend seated, we need to make sure our spines are supported. Evaluate your chair to make sure it allows your spine to be supported, with a lumbar curve and arm rests at the proper height. Ask your chiropractor to help you fix your chair for your specific needs, and watch your productivity soar!

Remember never to engage in an exercise without first consulting your chiropractic physician to see if it is safe for you and your unique conditions.

Monday, February 11, 2008

Case of the Week - Tension Headache

Image by Getty Images

Case: 26 year old female complaining of headaches several times per week, always in the afternoon or at the end of the day. The pain starts at the base of the neck and slowly moves up until it is at her forehead. The movement from neck to forehead takes about a hour. The patient has tried eating more regularly and drinking more water and decreasing or increasing caffeine intake, but none of these is effective. When she has a headache, the only thing that helps is to lie down and close her eyes. The headaches seem to be worse with increased time at the computer.

The muscles of the neck, especially the sub-occipital muscle group, are very tight and tender. There are multiple trigger points in the sub-occipital muscles and in the sternocleidomastoid on the right. Pressure on the sub-occipital trigger points reproduces the headache. Range of motion is decreased in neck flexion and right rotation. Other orthopedic testing for nerve, muscle and joint involvement was negative. The temporomandibular joint (TMJ) was not contributory.

This is a classic tension headache case. As the patient works at her desk, poor posture and fatigue cause her to slump in her chair. This causes excess tension in the posterior neck muscles, especially those at the base or the skull (the sub-occipital muscle group). Treatment involves massage to release the muscle tension, adjusting of the thoracic and cervical spine (mid back and neck) to achieve good joint motion, and then training the patient on proper posture and ergonomics. The patient education is key in this case. Without good posture, her headaches will continue to develop. Our goal in the office is to ensure her spine is able to provide that posture.

The patient feels fully in control of her headaches. She continues to receive regular chiropractic check-ups to maintain her spinal health. She maintains healthly posture by exercising at her desk and taking regular breaks. Now, on the rare occassion that she does get a headache, she knows why and she knows what to do about it.

Posture pod – check out this link for a great 2 minute posture re-fresher. Once at the page, click on Posture Pod. These were designed to be done by anyone, regardless of their physical fitness. Have fun!

Remember never to engage in an exercise without first consulting your chiropractic physician to see if it is safe for you and your unique conditions.


Take a posture break! – Every hour you are at work, take 5 seconds to do the opposite of what you have been doing. If you are at a desk, stand up and walk around. If you are standing, sit down and relax. Roll your shoulders back. Stretch your neck. Get moving! Your muscles need to be reminded that they have a job to do: holding you up! Take a few seconds every hour to get refreshed.

Remember never to engage in an exercise without first consulting your chiropractic physician to see if it is safe for you and your unique conditions.

Monday, February 4, 2008

Case of the Week - Medial Epicondylitis

Patient: 40 year old male, office worker

Complains of bilateral medial elbow pain with a duration of the last several weeks. Pain has steadily increased with increased time spent bicycling. All symptoms are greater on the right. Patient is right-handed. Some bilateral medial tingling in the forearms. No reported loss of grip strength. No shoulder or neck pain. Ice, tiger balm and OTC anti-inflammatories relieve only temporarily. Patient is concerned he will not be able to continue his exercise program and compete in an upcoming event due to pain.


All findings greater on right than left. Bilateral mild edema at the medial elbows. Tight and tender medial and anterior forearm muscles (Flexor carpi radialis and ulnaris, palmaris longus, pronator teres) especially at the common flexor tendon insertion. Mild tight and tender distal triceps tendons. Active range of motion within normal limits, but painful if stressed in extension and supination (elbow straight with hand facing out). Neurological testing for deep tendon reflexes, muscle strength and sensation were within normal limits. Palpation of the elbow joints was impeded by regional swelling. The shoulder and wrist joints were within normal limits bilaterally.


Here is a website that may be helpful in visualising the area. Bear in mind that this is an orthopedic website and typically recommends less conservative treatments than we perform. The picture in this post is from this website also and is provided by the Mayo Foundation.

This patient is suffering from a unique form of medial epicondylitis, commonly known as golfer's elbow. As you can see, there is no mention of the patient playing golf. Also, golfer's elbow is usually only present on the dominant swinging arm, not both arms. In this case, the inside of the patient’s elbow, the medial epicondyle, is irritated and inflamed because the muscles that attach to the area are being over-stressed. The patient has increased the amount of time he spends bicycling. With increased time on a bicycle, the wrists fatigue and the elbows are forced to absorb the shock to the arms from the handlebars. Due to a lack of fore-arm-specific strength training, the muscles of the patient’s wrist and forearm have become over-tight and swollen, causing pulling on the bone of the elbow, the ulna. This causes significant pain, especially during activities where these muscles are used, such as during the swing of a golf club. Because the patient needs to maintain a rigorous training schedule on the bicycle, our treatment will focus on pain-management until after his up-coming event. After the irritation of training rides is removed, the patient will be ready for the focal strength training and muscle re-balancing he needs to prevent this injury in the future. It should be noted that his examination showed the tingling he was feeling to be non-neurologic in origin. This means that he feels tingling, but it is not caused by a nerve problem. Often this sort of symptom is caused by the tension in the surrounding muscles and is relieved when the muscles relax.


After several weeks of therapeutic massage and chiropractic manipulation for the elbows, the patient experienced a significant reduction in symptoms and was able to continue training for and to eventually participate in his event. Since then, the patient continues to experience mild discomfort in his forearms, but only a few days per week, and only when he has performed an irritating activity. He is working on strengthening his forearms and stretching the over-tight muscles in his arms. When he over-stresses the area, ice relieves the symptoms. He continues to improve and our hope is that he will be in great condition for next year’s event.

Exercise of the week:
Soup Can Exercises - Hold the arm at the side of the body, with the elbow bent at 90o and the thumb facing the ceiling. Hold a can of soup in the hand. Move the wrist into flexion, that is bending the wrist to bring the can closer to your stomach. Now move the wrist into extension, that is bending the wrist back as far as it can go. These flexion/extension exercises are a great way to start re-strengthening your fore-arm after an injury. If you are strong enough, add gravity to your exercise: for flexion, hold the arm in the same position, but palm-up. Bend the wrist to bring the can closer to the stomach. For extension, turn the hand over so the palm is facing down. Bend the wrist back. Try starting with 10 reps on each side and see how your arm muscles feel!Remember never to engage in an exercise without first consulting your chiropractic physician to see if it is safe for you and your unique conditions.
Suggestion of the week:
Stretch at your Desk! Most of us work with our hands in one way or another. Whether you are working as a laborer and use a shovel, or work at a desk and use a keyboard, your arms are busy. The muscles that keep your hands doing what they do are anchored in the forearm, mostly at your elbow. With that in mind, take a 40 second break every hour or so. Hold your right arm straight out in front of you and use your left hand to bend your right wrist down. Feel the stretch across the top of the forearm. Then turn the right arm over and use the left hand to pull the right hand back. Feel the stretch in the forearm. Repeat this on the left arm. Hold each position for 10 seconds, and breathe while you hold. This takes a total of 40 seconds. You CAN find time for stretching! And you’ll feel better and more productive to boot!Remember never to engage in an exercise without first consulting your chiropractic physician to see if it is safe for you and your unique conditions.
See the following pictures for explanations of the exercises and suggestions of the week:

Stretching the forearms - Beginner

Stretching the forearms - Advanced

Strenghtening the forearms