Presentation
A 35-year-old female presented to our office with left-ankle pain following a long period of recovery from a foot-fracture surgery. The patient was generally fit and healthy. Other signs and symptoms were developing as the patient was decidedly using the right leg more than the left. As a result of becoming right-leg dominant, her low back hurt, her gait was noticeably off balance, and increases in activity amounted to an increase in all of her symptoms. The surgery was successful, but the patient was getting progressively worse.

Following an examination of the foot, ankle, and lower leg, many areas of tissue-texture changes were noted. These tissue-texture changes occur in varying degrees depending on several factors all related to blood flow and, ultimately, oxygen flow to the injured cells and surrounding tissues. Time is the key factor in the equation that demonstrates how tissues worsen when left untreated. When soft tissues are deprived of oxygen, a reaction is triggered in the liver.   The liver produces substances that make those cells fibrous and much less elastic. Several adhesions were also identified. Adhesions are areas where the fascia of one muscle becomes adhered to the fascia of its neighbor.

In the final portion of the exam, the patient’s spine was examined for subluxation, and several were noted.

Diagnoses
Structures that contain tissue texture change:
• achilles tendon;
• soleus muscle;
• plantaris tendon;
• gastrocnemius muscle; and
• peroneus longus muscle.

Adhesions:
• flexor digitorum Longus tendon at the flexor retinaculum;
• tibialis posterior tendon at the flexor retinaculum;
• peroneus brevis muscle at the inferior peroneal retinaculum; and
• tibialis anterior tendon at the superior extensor retinaculum.

Subluxations:
• sacroiliac joint ( left); and
• T11, T12, L1

All of the chiropractors at Whole Health Partners (WHP) are dedicated to addressing soft-tissue structures related to subluxation prior to adjusting. WHP team members work under the assumption that if we can improve blood flow to any tissue, the healing properties of that tissue will help correct the problem.

Treatment
Our first visit consisted of examining more than 60 soft and bony tissue structures (joints, muscles, tendons, ligaments, and fascia) to determine the number of structures and to what extent each structure has been affected. This is how we arrive at our initial diagnosis. The process can take up to 1 hour. We also tested the patient’s biomechanics as they were related to the kinetic chain of muscles and joints of her gait. A motion-palpation exam of the lower limbs, pelvis, and the spine was conducted. Finally, we took two opposing x-ray views of the foot and ankle to complete the picture. In this case, surgical screws were installed. The x-rays gave us the answer to some questions and guided our treatment in many ways.

The examining team in this case reviewed the findings and prepared a plan to treat the affected soft tissue. The plan is designed to address the most superficial tissues first. Allow time for the treated area to rest and heal before retreating. The plan is also designed to test the biomechanics (joint function) of the affected joints as treatment is on-going. Once the integrity of the soft tissues nears normal, specific exercises will be designed to establish normal muscle memory.

Active-release specialists base their diagnosis in part on the outcome following the treatment rendered at the exam. Our patients guide us to the diagnosis when they report back a successful treatment. Specifically targeting the areas that matter is at the heart of quick and complete resolution. Our report of findings in this case has been targeted for a time when we can gauge how our patient is coming along. We have prescheduled that visit for visit No. 4 in 8 to 10 days. In the meantime, we reviewed the x-rays, initial-exam findings, and outcome of our initial treatment with our patient. We established that in two visits, we should be able to fully understand what is ahead of us and how we should proceed.

Patient comments: “My leg below my knee felt much, much lighter. I was quite sore the following day, but that has since gone away. Overall, I have a significant decrease in pain and a huge improvement in how much motion has returned to my ankle. Also, the tightness on the top of my foot is gone. As a matter of fact, I didn’t realize the top of my foot was so tight until it went away. I don’t have as much pain when I plant my foot on the ground and push off.”

Treatment on the second visit began with one of our therapists reviewing our patient’s overall active range of motion. Next, an active release specialist sifted through the muscles and other soft tissues that were treated in the initial visit and then determined a change from the initial visit. An appropriate game plan for this day’s visit was established and executed in the following 20 minutes. Visit No. 2 consisted of 15 minutes of active release technique. Just prior to ending the second visit, we adjusted our patient’s left sacroiliac joint. A 10- to 15-minute icing period ended the session.

In the days prior to visit No. 3, we were contacted by our patient’s foot surgeon. This surgeon was genuinely interested in learning more about what we do. I was honored to speak with this doctor. It was refreshing to talk and work cooperatively with a medical man. Before we ended our conversation, I invited him to visit our office in the future.

The patient’s subjective comments: “I am so pleased with the results so far. Each day I feel stronger and stronger. I went for a walk yesterday. It was my first workout since my surgery. I was a little sore afterward. My soreness was as much the rest of my body as it was my left leg. I feel like it’s going to be OK.”

Treatment on the third visit was very much like visit No. 2. We begin with observing our patient’s range of motion while nonweight bearing. Then we observed weightbearing during a normal walking gait. It was clear that our patient had made a dramatic improvement since her second visit. Next, an ART specialist took a more critical review of the tissues involved. As the tissue texture changes, active-release technique protocols remain the same; however, tension and pressure modulate. As in the prior visit, a treatment strategy for this visit was defined and completed. This time, the active-release portion of the visit was approximately 10 minutes. The left sacroiliac joint was readjusted, following motion-palpation analysis. Ice was applied for 10 to 15 minutes, and the visit ended.

Visit No. 4, the report of findings (5 days later): In the days preceding visit No.4, our team laid out a light exercise plan for our patient that included five exercises. We also outlined relevant passages of a copy of Release Your Pain,¹ an educational publication that hits the target in a case like this.

The patient’s subjective comments: “I feel remarkably better. I have actually been able to use my treadmill. I know it’s not perfect, but I don’t feel any pain anymore. Two weeks ago, I could barely walk. I knew after the first visit that you guys were on to something. Well, I guess you found it.”

We performed a detailed exam reviewing all tissues involved. Remarkably, nearly all the tissues’ textures had returned to normal. I admire the human body’s healing prowess every time I see it. Oddly, the final treating day had come in just four visits. Our recommendation was to let our team put the finishing touches on her problem while she was there in the office that day. We went through each of the five exercises. The prior-mentioned book was given to our patient when she checked out.

A 1-month follow-up was also recommended.

At the time of the follow-up, our patient did not require continued treatment.

Our patient has recently informed me that her surgeon is going to remove the screws in her foot in September. It looks like there might be more to come.

Francis Xavier Murphy, DC, has operated a practice in Dallas for 11 years. Contact him at www.wholehealthpartners.com

Reference
1. Abelson B, Abelson K. Release Your Pain. Calgary, AB, Canada: Rowan Tree Books Ltd; 2003.