Help your patients maintain proper cervical posture by adding this important information to your protocol.
In this issue... The body is an interconnected chain of segments, with its base in the feet. Pedal instability may contribute to observable postural distortions as far up the chain as the cervical spine. For the most effective adjustments and optimal treatment options, examining for and treating any detectable foot conditions should be an integral part of pain management.
Ideal cervical spine posture in the standing position requires the coordination of skeletal structure, soft tissue integrity, and neurological control to resist adverse gravitational loading forces. An often overlooked factor of the above requirements is the role that pedal stability can play in the maintenance of proper cervical posture. Faulty foot biomechanics can have a negative impact on all supporting joints above the foot/ankle complex. In particular, an unbalanced pedal foundation may contribute to a postural anterior translation in the head and neck over time. For maximum effectiveness, the healthcare professional seeking to treat a postural deviation in the cervical spine needs to evaluate the potential involvement of the pedal foundation, and to correct postural foot problems.
The development of the unique human bipedal upright posture and resultant movement created a more optimum and functional form of ambulation, but with it developed a different variety of potential stressful forces on the connective tissues of the body. The original biomechanical human profile, directed by survival, was primarily a dynamic one. “The ligamentous skeleton is built for mobility rather than stability.”1 Yet over time, human beings have assumed a less consistent, less dynamically optimum biomechanical physical stature on a daily basis. “Compared to primitive man living an outdoor life, civilized man has become a standing-around and a sitting-down animal rather than a running-around one.”2
The relatively sedentary lifestyles and/or altered/compromising postures that a vast majority of human beings assume on a daily basis have placed maladapted strains on the ligaments, tendons, muscle fibers, fasciae, cartilage, and bone in an attempt to maintain equilibrium of the mechanical body. Cailliet reports that many “painful disabling conditions of the soft tissues of the musculoskeletal system are directly or indirectly related to posture in standing, walking, moving, lying, sitting, bending, or lifting.”3 It has been found that up to one third of workers in the United States are required to perform manual activities on a daily basis that are damaging to the musculoskeletal system.1 Many times these potentially harmful tasks involve stationary imbalanced postures as well as dynamically uncoordinated movements.
For preventative healthcare, or specifically neuromusculoskeletal health maintenance, it is basic and imperative that health care specialists take into account an evaluation of an individual's habitual posture and its potential role in pain and disability and include it in their exam. If postural faults were only of aesthetic consequence, the concern about them might be limited to appearance. But this does not appear to be the case, in that postural abnormalities may cause discomfort, pain, or deformity.3,5,6
The Biostatic Chain
During walking and running, the spine is one link in a biomechanical Kinetic Chain, where movement at one joint influences movement at other joints in the chain.7 This concept of a chain also applies to the body in a motionless, standing posture; however, the terms biomechanical static chain or biostatic chain are more appropriate, since directed movement is not involved. In either case, the chain extends from the feet through the ankle, tibia, knee, femur, hip joint, pelvis, and spine.
The biostatic chain depends upon the balance of body alignment and muscle restraining activity at each joint against gravitational pull downward. Passive stability is achieved when the center of gravity of each segment is aligned directly over the center of the supporting joint (see Fig. 1). When the body is erect and weight is evenly distributed between the feet, there are minimal demands for muscle action, because there is no forward motion. While in theory, stability of the biostatic chain should be realized without any muscle action at all, the fact that none of the supporting joints (pelvis downward through feet) are locked means that the slightest sway (the beating of the heart, for example) can create an unstable alignment.1 Therefore, postural balance means a continuous involvement of the supporting skeletal structure and muscles.
Pedal Foundation Deficit
In ideal standing posture, the feet evert to form an angle of 30 degrees, and a plumb line dropped from the sacral promontory falls midway between the feet onto a line between the navicular bones (see Fig. 2).8
Pronation occurs when the superior aspect of the calcaneus tilts and rolls inward, bringing the talus with it. This releases the navicular from its arthrodial articulation with the talus and jeopardizes the medial longitudinal arch. When collapsed, it causes an anterior shift in weightbearing, and begins a serial distortion that may extend to the occiput (see Fig. 3).9
Because pronation involves the talus, it can draw the adjacent tibia into rotation. The movement extends further to the femur, bringing the greater trochanter forward and out. The piriformis muscle at the apex of the trochanter is then subjected to a windlass-type stretch. Due to its connection with second, third and fourth sacral segments, the sacrum at its articulation with the ilium on the involved side may be pulled into a subluxated anterior and inferior position.
When this occurs, the gluteus maximus muscle compensates by contracting to resist the downward and forward disposition of the pelvis. At its origin on the posterior third of the iliac crest, the gluteus maximus contraction may force the ilia portion of the innominate to rotate posteriorly. Thus begins a typical basic distortion.
Likewise, with the sacrum in an anterior and inferior position, the fifth lumbar vertebrate is mobile. Following Lovett's Law, it will rotate toward the low side and introduce a functional scoliosis.
According to Free, the trapezius muscle “may tighten on the same side as the hypertonic hamstring, creating an inferior occiput and an atlas laterality. Subluxations may occur at the atlanto-occipital or the atlanto-axial area, with cervical pain on the side of the tight hamstring. If this cervical compensation occurs, the patient will have pain on the entire side (cervical, thoracic, lumbar) and many times the leg and arm.”10 Porterfield writes that “the cervical spine may be only one component of neck pain complaints. Structures related to the upper extremity and head often are involved with the painful syndrome, and an examination of these structures reveals alteration in function.”1
Clinical evaluation of the standing posture using relatively low-tech tools has been confirmed as valid and reliable by several studies.12,13,14 The original device used to evaluate posture was the plumb line, which served as a reference line for the effects of gravity on body alignment.
A valuable procedure in postural evaluation is the assessment in the frontal and sagittal planes of the balance and alignment of the three major regional masses of the body (cervical, torso, pelvis), and their relationship to their base of support— the feet and legs. This method permits a rapid yet standardized determination of postural deviation from the optimal alignment and can be used in prescribing specific corrective exercises.
When assessing cervical postural distortions in the sagittal plane, the most common is identified as anterior translation. Translation is the motion of a rigid body in which a straight line in the body always remains parallel to itself. “For example, if a boat is pushed smoothly in a straight line from position 1 to position 2 without pitching or rolling, it moves in pure translation” (see Fig. 4).16
In anterior translation, the ear is forward of the AC joint and the bite line is level, creating the so called “dowager's hump”.17 In addition to the forward head, the evaluating clinician may also note a distortion of normal cervical lordosis, round shoulders, internally rotated humerus, and kyphotic posture. These deviations have been identified as “mainly a result of the integrity of the abdominal wall and hip joints” (see Fig. 5).
As has been previously discussed, the spine is one link in a chain, with the feet as the base. Lack of stability in the pedal foundation can lead to serial distortions and muscular stretching all the way up the spine. With foot pronation and the associated collapse of the anterior transverse arch, the base point of the body's center of gravity shifts forward. This shifting causes a pelvic translation, which in turn produces a thoracic extension. At this point the head attempts to maintain its position over the vertical center of gravity, and therefore slides into anterior translation. The body's overall stabilization efficiency is greatly reduced, and it must work harder to maintain a standing posture. Cailliet concluded that for every one inch of anterior translation, there is a ten-fold increase in muscular effort on the part of the supporting muscles of the cervical spine. This inefficiency results in a constant firing of these muscles.18
Given the above sequence of events, it is not surprising that there are literally hundreds of clinical observations which suggest that a mutually detectable relationship appears to exist between a cervical anterior translation and a deviated pedal foundation (pronated feet). Although quantifiable literature on this subject is lacking at present, clinical observations of this phenomenon are common. Therefore, in order to provide your patient with optimal balance and stability, it is critical that you evaluate and treat all the areas involved - feet, pelvis, torso, and cervical spine.
Treatment of cervical anterior translation requires manipulation, the prescription of the appropriate conditioning exercise regimen, and if indicated, corrective orthotic support. Often, both muscle and joint dysfunction require correction19, and appropriate strength should be developed to help minimize the potential of future injury.20
For isotonic exercise of the cervical spine, the NECKSYS® Cervical Rehab System is a unique combination of a versatile, simple-to-use neck exerciser, cervical collar, and a series of biomechanical exercises. In minutes, you can instruct the patient to use the System and perform the prescribed exercise of posterior translation from home (see Fig. 6). Combining the chiropractic adjustment with the NECKSYS exercise will speed recovery due to the benefits of the NECKSYS Home Care System.
As mentioned in Porterfield, cervical anterior translation can be linked to weakness in the thoracic spine.11 The BACKSYS® System provides an easy-to use, effective way to condition and strengthen back muscles affected by injury, illness, or postural deficits. In the case of thoracic extension, the appropriate exercise would be thoracic flexion.21
In the case of anterior pelvic translation, the corrective exercise with the BACKSYS is posterior pelvic translation, (see Fig. 7)
The NECKSYS® and BACKSYS® Systems are based on postural distortions and the proper corrective exercise as published by the Chiropractic Rehab Association and developed by Donald Harrison, M.S., D.C., which allow patients to perform very posture-specific asymmetric exercise maneuvers against resistance.13 The result is a stretching of shortened connective tissues while strengthening and re-training imbalanced spinal support muscles.
The Crucial Role of Custom Orthotics
Custom flexible orthotics that support all three arches of the feet are of special value in cervical anterior translation cases where foot pronation and arch ligament laxity have been observed. A flexible, custom-made orthotic addresses the excessive pronation and provides support for collapsed structures in the feet, and should be added to every patient’s treatment plan.
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Explore orthotic and rehab tool recommendations for common conditions, rehab exercise videos, helpful articles, and much more, visit footlevelers.com/rehabilitation.
1. Perry J. Gait Analysis: Normal and Pathological Function. Thorofare, NJ: SLACK, Inc., 1992.
2. Zacharkow D. Posture: Sitting, Standing, Chair Design and Exercise. Springfield, IL: Charles C. Thomas, 1988.
3. Caillet R. Soft Tissue Pain and Disability (2nd ed.). Philadelphia: F.A. Davis, 1988.
4. Chaffin DB. The value of biomechanical assessments of problems of load handling, workplace layouts, and task demands. In: Hayes KC et al. (eds.) Biomechanics IX-B. Champaign, IL: Human Kinetics Pub., 1983.
5. Kendall HO et al. Posture and Pain. Malabar, FL: Robert E. Krieger Pub. Co., Inc., 1992.
6. Travell JG, Simons IDG. Myofascial Pam and Dysfunction, The Trigger Point Manual, Vol. 2. Baltimore: Williams and Wilkins, 1992.
7. Steindler A. Kinesiology of the Human Body Under Normal and Pathological Conditions (3rd ed.). Springfield, IL: Charles C. Thomas, 1970.
8. Cailliet R. Foot and Ankle Pain (2nd ed.) Philadelphia: F.A. Davis, 1983.
9. Greenawalt MH. Spinal Pelvic Stabilization (4th ed ). Roanoke, VA: Foot Levelers, Inc. 1990.
10. Free RV. Some common denominators in spinal misalignments, part 2. Digest Chiro Econ 1988; 30(6): 128-129.
11. Porterfield JA, DeRosa C. Mechanical Neck Pain: Perspectives in Functional Anatomy. Philadelphia: W.B. Saunders Co., 1995.
12. Garrett TR, Youdas JW, Madson TJ. Reliability of measuring forward head posture in a clinical setting. JOSPT1993; 17:155-160.
13. Raine S, Twomey L. Posture of the head, shoulders and thoracic spine in comfortable erect standing. Austr J Physiolher 1994; 40:25-32.
14. Bullock-Saxton J. Postural alignment in standing: a repeatability study. Austr/ Physiolher 1993; 39:25-29.
15. Harrison DD, ed. Spinal Biomechanics- A Chiropractic Perspective. Harrison Pubs. 1992.
16. White AA, Panjabi MM. Clinical Biomechanics of the Spine (2nd ed.). Philadelphia: J.B. Lippincott Co., 1990.
17. Christensen KD. Chiropractic Rehabilitation, Vol. 2. Cervical Spine. Ridgefield, WA: C.R.A. Publication Division, 1991.
18. Cailliet R. Neck and Arm Pain. Philadelphia: F.A. Davis, 1981.
19 Cibulka MT. Evaluation and treatment of cervical spine injuries. Clin Spts Med 1989; 8(4): 691-701.
20. Cole AJ, et al. Cervical spine athletic injuries. Sports Med 1994; 5(1): 37-68.
21. Christensen KD The big three. Success Express 1994; 15(1)- 4-5.
Doctor-reviewed by Christine Foss, DC, MD, MS. Ed, ATC, DACBSP, DACRB, ICSC
by Mark N. Charrette, DC
Research studies confirm the importance of postural balance to effective bio-mechanical results. In a study on the effects of orthotic intervention on balance and proprioception among experienced golfers, data suggested a relationship between exercise and changes in standing balance and proprioception. Custom-made functional orthotics positively influenced balance and proprioceptive symmetry and likely reduced the relative effects of fatigue associated with playing nine holes of simulated golf.1
In a second study, this one on the effects of orthotic intervention on club head velocity (CHV), results showed an approximate 3 to 5 mph increase in CHV, or a relative increase in CHV by up to 7% after experienced golfers wore custom-made functional orthotics daily for six weeks. The effects of fatigue associated with playing golf (relative to CHV) were eliminated, therefore improving the likelihood for more consistent golf performance.2
In addition to the research findings, the three steps discussed below will likely help most of your patients who use them. The key to the last sentence is “use them.” Without application, the best idea will never come to fruition. If you’re a golfer, I recommend that you try these techniques yourself. If you aren’t a golfer, try them out on one of your patients. If you do them exactly as I recommend, you’ll generate some excitement—and very likely some new patients.
Step 1: Stabilize the foundation
Stabilize and balance the foundation with custom-made functional orthotics. This will help both structurally and functionally. If there is a structural imbalance, the pulley system of the muscles will be adversely affected, and the muscles won’t be able to work as efficiently.
There is a direct correlation between the medial arch and the iliopsoas muscle, the lateral arch and the hip abductor (gluteus medius/minimus) muscles, and the transverse arch and the quadriceps/hamstring balance. All the muscles inserting into the pelvic bowl should be working to their optimal ability and be approximately equal in strength and function. You will find that when there is asymmetry in the pedal foundation, there is muscular imbalance as well. Custom-made functional orthotics were created not only to stabilize the bones of the foot, but also to enhance muscle function throughout the lower legs and spine.
Try these simple manual muscle tests:
- Perform a manual muscle tests of the iliopsoas, gluteus medius/minimus, and quadriceps/hamstring muscles before inserting the orthotics.
- Insert the orthotics into the patient’s shoes, then have the patient walk around the table.
- Re-test the above muscles. They will appear stronger, as they are now working more efficiently.
By stabilizing the pedal foundation, you will be creating better structural alignment and enhancing muscular function. The pelvis, though moving throughout the swing, must be stable and balanced.
Step 2: Strengthen the lumbar extensor muscles
The most important muscle group for low back stabilization is the extensor group. Studies clearly demonstrate that if you only strengthened one muscle group in the low back region, it should be the extensors.
Many golfers, like just about everyone else, have lumbar extensor muscles that are not as strong as they should be. Adding to this, the nature of their golf stance further stresses these muscles. The constant bent-over position creates a postural distortion, further weakening these muscles.
According to Weishaupt et al., when golfers who did not experience back pain were examined relative to isometric strength of trunk muscles, they showed highly significant stronger lumbar extensors, but also “muscular dysbalance in lateral flexors and rotators of the spine.” This finding supports the recommendation of specific physical training for well-balanced strengthening of muscle groups involved in the maintenance of spinal stability, including the lumbar extensor muscles and the muscles of the mid-back region.3
Simple surgical tubing stretching exercises will definitely strengthen the lumbar extensors. The protocol to start off with is three sets of six reps performed slowly, to benefit both the concentric and eccentric muscle contractions. The number of reps can be increased as the golfer gets stronger. The number of sets remains the same and can be alternated with the next key exercise.
Step 3: Strengthen the mid-back region
Just as with the lumbar extensor muscles, the mid-back region—especially the mid-trapezius, rhomboids, teres minor, and infraspinatus muscles—are notoriously weak. This is true for the general population and particularly for golfers (look at the stance posture).
Simple surgical tubing stretching exercise works wonders for stabilizing the mid and upper torso. The protocol for this is slightly different: three sets to fatigue at a fast but controlled pace. Again, these can be alternated with the above extensor exercises.
These exercises can be performed daily and can be done in five minutes or less. The cardinal rule is “no pain for maximum gain.” This is not an intense bodybuilding program—rather, it is designed to facilitate the nervous system to enhance muscular co-ordination to stabilize the golf swing.
As simple as this approach appears, it gets great results quickly. Most golfers will notice the difference immediately—and all will notice it within two weeks. What will they notice? A smoother, more controlled swing that produces greater distance with each club they use.
About the author
Dr. Mark N. Charrette is a 1980 summa cum laude graduate of Palmer College of Chiropractic. He is a world-renowned expert in extremity adjusting. Over the past 20 years Dr. Charrette has lectured extensively on spinal and extremity adjusting throughout the United States, Europe, the Far East, and Australia – performing over 1,000 seminars. Dr. Charrette is a featured speaker in Foot Levelers’ 2010 Seminar Series.
1Stude DE, Brink DK. Effects of nine holes of simulated golf and orthotic intervention on balance and proprioception in experienced golfers. J Manip Physiol Ther 1997; 20(9):590-601.
2 Stude DE, Gullickson J. Effects of orthotic intervention and nine holes of simulated golf on club-head velocity in experienced golfers. J Manip Physiol Ther 2000; 23(3):168-174.
3 Weishaupt P, Obermuller R, Hofmann A. Spine stabilizing muscles in golfers. Sportverletz Sportschaden 2000;14(2):55-58.
by Jeffrey D. Olsen, DC
Warning! If your patient is already lying on the treatment table before you enter the room, you could be missing important clues. Evaluating your patient’s gait can provide valuable information, especially in slowly responding cases or other special cases. Many of the chronic or recurring cases of pelvic, hip, or low back complaints are directly associated with gait imbalances. Take time to watch your patients walk around.
When patients don’t respond to our Chiropractic care as expected, often there is an underlying collapse in the postural platform formed by the feet. A recent study found that “there are small, but important, inter-segmental movements of the spine during gait.”1 Abnormal motion initiated by excessive or restricted joint interactions of the feet and lower extremities will eventually interfere with the normal inter-segmental motions and lead to pain syndromes.
Specifically, I would like to address the common clinical findings of excessive foot flare, externally rotated femur, and piriformis muscle contracture. This triad of findings is often found in the patient with generalized hip and sacroiliac pain and dysfunction that might even include classic findings of sciatic nerve irritation. The same patient might enjoy temporary relief from symptoms following pelvic adjustments and/or the combination of stretching and massage. However, all too often, the underlying cause of the dysfunction is altered foot biomechanics, especially the hyperpronated foot.
When patients turn to Chiropractic care for pain relief, few, if any, expect an area of their anatomy, distant from the perceived pain, to be at fault. However, in seven of 10 patients with back pain, postural fatigue and spinal strain cause their discomfort.2 We find that the ultimate cause of pain could originate in any tissue or joint involved in the Kinetic Chain. This is the exact scenario that, with time, produces the symptoms we are discussing.
Click here to find a local Healthcare Provider who will help with Piriformis Syndrome.
As you observe your patient walking, take note of unilateral toeing out. Toe-out is an adaptive muscular response to the biomechanics of hyperpronation. Hyperpronation (loss of medial longitudinal arch integrity) during stance phase accentuates walking with foot flare, which should normally be in the range of 10 to 20 degrees. Associated with excessive pronation and foot flare is marked wear along the lateral border of the heel. The excessive lateral heel wear is a good indicator of the chronicity and extent of the deformation. Excessive lateral heel wear also indicates the need to properly support the medial longitudinal arch.
Even with the patient prone, the toe-out or foot flare will remain until corrected. Furthermore, this position gives a great view of any lateral heel wear.
There are three natural arches of the foot. Their strength and function depend on the proper alignment of bones and the support of the ligamentous tissues—plantar fascia and bone-to-bone ligaments. The most common structural misalignment of the lower extremity is excessive pronation, affecting the medial arch primarily. Whenever there is compromise of the arch structures or the supporting soft tissues, the postural foundation is adversely affected.
In addition to the normal degrees of foot pronation during the stance phase of the gait cycle, there are a series of coupled motions that result in medial rotation of the entire lower limb and pelvis. With hyperpronation, this torqueing is accentuated. The increased rotational forces are transmitted into the pelvis and hip region. One of the primary antagonists to this excessive medial rotation is the piriformis muscle.
The piriformis has its origin on the second through fourth anterior segments of the sacrum and on the sacrotuberous ligament. The muscle travels anterior and inferior, through the greater sciatic foramen, as it passes superior and posterior to the femoral head. The muscle inserts on the greater trochanter, allowing the muscle to laterally rotate the thigh and assist in the tracking of the femoral head within the acetabulum.3
The following have been proposed as possible mechanisms in which irritation of the piriformis muscle leads to apparent or actual sciatic neuritis. First, in many cases, branches forming the sciatic nerve first pass through the belly of the piriformis muscle. Spasm and hypertrophy can physically irritate the nerve.4 Second, when irritated, the piriformis can release inflammation byproducts that have been shown to be chemical irritants.5
With the patient prone, efforts to place the thigh into internal rotation will be limited both by the contracture of the muscle and by reproduction of the patient’s symptoms. Externally rotating the femur accentuates the subluxated position of the femur and should result in shortening of the reactive leg, during functional leg checks.
Treatment involves contacting the posterior aspect of the greater trochanter and adjusting with an anterior and slightly inferior line of drive.
Obviously, the long-term solution is to remove the underlying irritation by supporting the feet. Foot Levelers’ Gait Cycle System™ (GCS) is the appropriate solution. This is the only system designed to absorb the shock of the foot striking the ground, to specifically support the three arches within normal ranges of motion, and to facilitate neuromuscular control for coordinated gait.
Our discussion of hyperpronation leading to a piriformis syndrome is only one example of the possible consequences of poorly supported arches. Remember that excessive motion in the feet will irritate the weak links further up the Kinetic Chain. A custom orthotic will help your patient’s foot adapt to its environment, regardless the circumstances.
Not only does the orthotic support the arches of the foot, but it also reduces the transmission of shock into the spine. Pathological shock occurs when normal walking on ridged surfaces exacerbates irritated structures. Force generated at heel strike can reach five to seven times body weight, with the musculoskeletal system itself absorbing a significant percentage of the total, under normal conditions.6 With Zorbacel® in the heel and Propacel™ in the forefoot, orthotics with GCS contain unique viscoelastic materials to absorb shock and provide a boost, whatever part of the foot first strikes the ground.
Chiropractic adjustments of the spine improve proprioceptive input by normalizing joint alignment and muscle tonus. Furthermore, because the feet contain approximately one quarter of all the body’s joints and, therefore, a concentration of proprioceptive fibers, it becomes logical to conclude that support of the postural foundation using custom-made orthotics will enhance the balance of our patients who need it most. In fact, this was the basis for recent research involving Foot Levelers’ custom orthotics, published in JMPT.
Drs. Stude and Brink showed that experienced golfers, after wearing Foot Levelers orthotics daily for a period of six weeks, showed improvements in balance and proprioception. This becomes significant given the fact that experienced golfers would be expected to have maximized their coordination and balance abilities as it relates to the game of golf, and yet they did show improvement. The results were obtained through functional tests involving single and double-leg stances, with and without the use of sight.7
Obviously, not every one of our patients is a candidate for orthotic therapy, but about four out of five adult patients older than 40 can benefit from orthotics. By this time, the effects of walking and standing on hard surfaces, ligament laxity (age-related or post-partum), and repetitive microtraumas have often contributed to significant plastic deformation in the feet. Prescribing the orthotics with GCS provides highly dynamic and adaptive responses for an increase level of mobility and stability. If you are watching your patients come and go, you’ll know when they need it.
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.
1 Sychewska M, Oberg T, Karlsson D. Segmental movements of the spine during treadmill walking with normal speed. Clin Biomech 1999; 14:384-388.
2 Brunarski DJ. Chiropractic biomechanical evaluations; validity in myofascial low back pain. J Manip Physiol Ther 1982; 5(4):155-161.
3 Moore KL. Clinically Oriented Anatomy. Baltimore: Williams & Wilkins, 1982:346.
4 Cox JM. Low Back Pain: Mechanism, Diagnosis and Treatment, 5th ed. Baltimore: Williams & Wilkins, 1990.
5 Steiner C et al. Piriformis syndrome: pathogenesis, diagnosis, and treatment. J Am Osteopath Assoc 1987; 87:318.
6 Voloshin AS, Burger CP. Interaction of Orthotic Devices and Heel Generated Force Waves. 9th International Congress on Applied Mechanics, Canada, 1983.
7 Stude DE, Brink DK. Effects of nine holes of simulated golf and orthotic intervention on balance and proprioception in experienced golfers. J Manip Physiol Ther 1997; 20:590-601.
There are Healthy Alternatives to Corticosteroid for Plantar Fasciitis Relief
by Mark N. Charrette, DC
The classic presentation of plantar fasciitis is “a sharp heel pain that radiates along the bottom of the inside of the foot. The pain is often worse when getting out of bed in the morning.”  This can occur in runners or other athletes who repetitively land on the foot. Another susceptible group is middle-aged persons who have spent much time on their feet. More rarely, the fascia becomes inflamed after a single traumatic event, such as landing wrong after a jump, or running a long hill.
The vast majority (95%) will respond to conservative care, and not require or surgery.  Many other invasive methods of treatment, such as corticosteroid injections, can also be avoided. Proper treatment is necessary to both ensure continued participation in sports and daily activities and avoid chronic damage. The plantar fascia is the major structure that supports and maintains the arched alignment of the foot.  This aponeurosis functions as a ‘bowstring’ to hold up the longitudinal arch.
Plantar fasciitis develops when repetitive weightbearing stress irritates and inflames the tough connective tissues along the bottom of the foot. High levels of strain stimulate the aponeurosis to try to heal and strengthen. If the biomechanical strain continues, it overwhelms the body’s repair capacity, and the ligaments begin to fail. It is this tear/repair process that causes the chronic, variable symptoms that can eventually become unbearable in some patients.
Since the plantar fascia inserts into the base of the calcaneus, the chronic pull and inflammation can stimulate the deposition of calcium, resulting in a classic heel spur seen on a lateral radiograph. Unfortunately, there is no correlation between the presence of a heel spur and plantar fasciitis; many heel spurs are clinically silent, and most cases of plantar fasciitis do not demonstrate a calcaneal spur. 
Biomechanical evaluation may find either excessive pronation or supination. The flatter, hyperpronating foot overstretches the bowstring function of the plantar fascia, while the high-arched, rigid foot places excessive tension on the plantar aponeurosis. In either case, it is the combination of improper foot biomechanics and excessive strain that causes the connective tissue to become inflamed. A careful assessment of the weightbearing alignment of the lower extremities is helpful, since many patients will have functional imbalances up the kinetic chain, into the pelvis and spine.
Direct palpation of the plantar fascia will demonstrate discrete painful areas, most commonly at the insertion on the antero-medial calcaneus.  Fibrotic thickenings are frequently felt – these are remnants of the repetitive ‘tear and repair’ process. With the foot relaxed, grasp the toes and gently pull them up into passive dorsiflexion. Since this maneuver stretches the irritated plantar aponeurosis, it is frequently quite painful, and is an obviously positive objective sign.
- Taping. Temporary support for the strained plantar fascia can be provided with figure-8 taping.
- Restricted activity. Repetitive and straining activities should be strictly limited, initially. Immobilization is not recommended.
- Cryotherapy. Ice massage and/or cold packs help reduce pain and inflammation.
- Ultrasound. Initially pulsed, then constant and direct (once inflammation has subsided).
- Transverse friction massage. To stimulate blood flow and collagen deposition. 
- Vitamin C with bioflavonoids. A natural anti-inflammatory that can speed healing.
- Calcaneus. Reduction of calcaneus posteriority to relieve sagittal stress. Kell’s technique uses a posterior to anterior thrust on a table with a pelvic drop piece. 
- Other foot joints. Brantingham found various areas of joint dysfunction in the tarsal and metatarsal joints in patients with plantar fasciitis.  The navicular and first metatarsophalangeal joints are often involved.
- Orthotics for pronation. To support the arches and reduce the stress on the plantar fascia.
- Orthotics for supination. Arch support with added viscoelastic material to cushion the foot and decrease the amount of shock at heel strike.
- Heel spur correction. A ‘divot’ in the surface of the material under the heel to spread pressure away from the fascial insertion.
- Heel and foot stretching. ‘Runner’s stretch’ for the calf and the bottom of the foot.
- Intrinsic muscle strengthening. Toe curl exercises (sitting, gather a towel on the floor up under the arch – repeat three times).
- Extrinsic muscle strengthening. Toe raises (standing on the edge of a stair, slowly raise up on balls of feet), ankle stabilizing series with exercise tubing.
Plantar fasciitis usually responds well to focused, conservative treatment. Corticosteroid injections and surgical release are seldom necessary, and are best avoided. One of the most important treatment methods is to reduce any tendency to pronate excessively. In addition to custom-made orthotics, runners should wear well-designed shoes that provide good heel stability.
The use of custom-made orthotics can prevent many overuse problems from developing in the lower extremities. Investigation of foot biomechanics is a good idea in all patients, but especially for those who are recreationally active.
- Souza TA. Differential Diagnosis for the Chiropractor. Gaithersburg, MD: Aspen Publications, 1997:354.
- Baxter DE. The heel in sport. Clin Sports Med 1994; 13:685-693.
- Huang CK et al. Biomechanical evaluation of longitudinal arch stability. Foot Ankle 1993; 14:353-357.
- Lapidus PW, Guidotti FP. Painful heel: report of 323 patients with 364 painful heels. Clin Orthop 1965; 39:178.
- Subotnick SI. Sports Medicine of the Lower Extremity. New York: Churchill-Livingstone, 1989:237.
- Lear L. Transverse friction massage. Sports Med Update 1996; 10:18-25.
- Kell PM. A comparative radiologic examination for unresponsive plantar fasciitis. J Manip Physiol Ther 1994; 17:329-334.
- Brantingham JW. Examination and treatment of plantar fasciitis. Chiro Technique 1992; 4:75-82.
- Kibler WB et al. Functional Rehabilitation of Sports and Musculoskeletal Injuries. Gaithersburg, MD: Aspen Publishers, 1998:280.
by Mark N. Charrette, DC
Orthotic therapy represents an integrated approach to Chiropractic case management. Effectively addressing problems of the spine requires considering the musculoskeletal structure as a series of interrelated components, with the feet as its foundation.
In seven out of 10 cases of back pain, postural fatigue and spinal strain are frequent causes of discomfort.1 The stress can often be traced to altered foot biomechanics that lead to pelvic and spinal distortion.2 Custom-made functional orthotics are useful in correcting abnormal biomechanics in the lower extremities and enhancing the effectiveness of Chiropractic care.
The spine is one link in a biomechanical Kinetic Chain, where movement at one joint influences movement at other joints in the chain,3 extending from the feet to the spine. Locomotion demonstrates the complexities of biokinetic interaction and the risk of imbalance or structural deficiency that leaves the spine vulnerable to destructive torque, bending, and shearing stresses.4,5,6
Locomotion is composed of two phases: stance, when the foot bears weight; and swing, when no weight is borne. When the foot hits the ground, changes occur that can have detrimental effects if pedal imbalance is present.
The stance phase is divided into three sub-phases:
- Contact. A natural inward rotation of the subtalar joint produces pronation. The tibia rotates internally, with the femur moving slightly.
- Midstance. Forefoot loading occurs as the foot supinates, accompanied by external rotation of the tibia and femur while the knee unflexes.
- Propulsion. For toeing off, the foot remains in supination and leg bones rotate externally.
If pronation is maintained into the midstance phase of gait, the tibia and femur will remain in the inward rotational configuration. This places the patello-femoral complex in immediate jeopardy—the structure that is the most frequent source of knee disorders.7
Rotation of the lower extremity transmits to the pelvis, causing an inward hip rotation commonly associated with myofascial back pain.8 Inward rotation of the femur brings the greater trochanter forward and outward, stretching the piriformis muscle. The sacrum may be pulled into a subluxated anterior and inferior position.2
The gluteus maximus muscle contracts to compensate for the downward and forward pelvic tilt. The innominate at its iliac portion rotates to the posterior, producing a typical pelvic distortion. The sacrum’s anteroinferior position causes the L5 vertebral body to gravitate and rotate toward the low side, initiating structural scoliosis.2
Excessive pronation results in abnormal firing of muscles and inaccurate proprioceptive nerve impulses. This also interferes with the toe-off phase, resulting in less-efficient propulsion.
Correcting Postural Imbalance
When the gait is affected by excessive pronation, the pelvis and spine must compensate. The specific way in which each patient adapts to abnormal support from the lower limbs is very individualized. This explains why patients often notice so many areas of improvement when their pronation is corrected with orthotics.
Custom-made functional orthotics help enhance biomechanics of the lower extremity and modify minor deficits that inhibit the integrity of the pedal foundation.9 Orthotic therapy seeks to control—not restrict—motion within the pedal structure, particularly of the subtalar joint.10 Restricted subtalar joint pronation affects the knees, hips, and back.11 Custom-made orthotics can also improve back pain caused by walking with an abnormal gait and poor toe-off.12
Postural instability is a direct result of imbalance in the pedal foundation. As the arch rolls inward, the tibia twists, the knee strains, the femur rotates, and spinal curves are affected.
Custom-made functional orthotics address problems of pedal imbalance and related postural instability. When used as an adjunct to Chiropractic care, orthotics enhance postural stability and protect the integrity of musculoskeletal structures.
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.
1 Brunarski DJ. Chiropractic biomechanical evaluations: validity in myofascial low back pain. JMPT 1982; 5(4):155-161.
2 Schafer RC. Clinical Biomechanics: Musculoskeletal Actions and Reactions. Baltimore: Williams & Wilkins; 1983.
3 Gross MD, Davlin LB, Evanski PL. Effectiveness of orthotic shoe inserts in the long-distance runner. American Journal of Sports Medicine 1991; 19(4):409-444.
4 Farfan HF. Muscular mechanisms of the lumbar spine and the position of power and efficiency. Orthop Clin North Am 1975; 6(1):135-144.
5 Cappozzo A. Compressive loads in the lumbar vertebral column during normal level walking. J Orthop Res 1984; 1(3):292-301.
6 Adams MA, Hutton WC. Mechanical factors in the etiology of low back pain. Orthopedics 1982; 5(11):1461-1465.
7 Foot Levelers Educational Division. Clinical Chiropractic Biomechanics. Roanoke: Foot Levelers, Inc., 1984.
8 Greenawalt MH. Spinal Pelvic Stabilization, 4th Ed. Roanoke: Foot Levelers, Inc., 1990.
9 Steindler A. Kinesiology of the Human Body Under Normal and Pathological Conditions, 3rd Ed. Springfield: Charles C. Thomas, 1970.
10 Christensen KD. Orthotics: do they really help a chiropractic patient? ACA Journal 1990; 27(4):63-71.
11 Gastwirth KD et al. Electrodynographic study of foot functions in shoes of varying heel heights. J Am Podiatr Med Assoc 1990; 81(9):463-472.
12 Dananberg HJ, Giuliani M. Chronic low-back pain and its response to custom-made foot orthoses. J Am Podiatr Med Assoc 1999; 89:109-117.
by David Fletcher, DC, FCCSS
Imagine a practice organized around the principles of Chiropractic that had developed efficient patient flow. Now, imagine this practice inspired its patients to choose ongoing wellness care and had provided the necessary information and services to support this process. The uniqueness of the Chiropractic message allows each practitioner to meet the needs of patients as they enter into the practice and to support their overall health and healing with individualized services and products. The key to this ideal setting is to create an organized and efficient template that can be adapted to each patient.
Orderly and Congruent Procedures
The foundation for all Chiropractic care is the adjustment. This distinctive procedure not only highlights our message and style of care from the other health disciplines but also allows the patients to see beyond their symptoms. All efficient procedures can be based upon the delivery of the adjustment and the ancillary services that support the changes associated with this process. Each procedure, service, or product needs to be congruent with the philosophy of care within the office, and each must be used in an orderly manner. A practice quickly meets its capacity if systems are inefficient or poorly thought out. Sadly, this capacity can fall short of the doctor’s and staff’s ideal practice situation. The solution begins with a clear understanding of the unique nature of Chiropractic and a passion for service and productivity.
The Chiropractic model and philosophy of care is based upon the understanding of natural healing and restoration of function. The adjustment is the centerpiece of the Chiropractic protocol and in itself awakens new potential within the individual. The goal of success in patient care and in practice success is to provide value and congruency to each procedure, service, and product.
Chiropractic uses the structural balance of the spine and its components to reset the tone of the entire nervous system. Evaluating and rebuilding the structural alignments alter the tension at a neurological level. The importance of maintaining this natural balance is paramount in the success of long-term postural and tonal retraining.
Orthotic usage has long been an adjunctive procedure in practice. Again, the Chiropractic goal is to use these devices to assist in the alteration of postural control. Better dynamic balance, beginning at the foot and ankle level, reduces the noxious stress into the structure and the nervous system. The purpose of the adjustment is to arouse the inner wisdom and control of the bodily systems while helping to restore better tone to the structure and nervous system. The goal of orthotic placement is to supplement this Chiropractic approach and to enlist a passive device that can challenge the structure and nervous system to hold a healthier pattern.
To many doctors and patients, orthotics are used in a reactive manner. If the patient begins to exhibit foot or back pain symptoms, there is a need to examine the foot and ankle posture. However, the Chiropractic paradigm is a proactive one. When posture is viewed from a tonal perspective, orthotic placement is a part of the hygienic regimen in addressing forces that can affect and damage the integrity of neural input and outflow.
The Value Added Service
If adjustments arouse and reset the tone of the spine and nervous system, orthotics support and challenge this process. Orthotics become a value-added service from your office. In the alignment of community health services, Chiropractors are viewed as the natural alternative to the medical model. Patients look to the Chiropractor as their portal to natural health services. As doctors, we operate under “vis medicatrix naturae.” The extensive education and training in human health and wellness allows us to extend the scope of practice far beyond the confines of being a spinal technician. We can become the patients’ gateway into a wellness model that not only maintains good spinal health but also encourages them to explore their potential and creativity. As such, practice members look for congruent advice and services to be discussed or provided by the office. Typically, these wellness-based services range from exercise protocols and hygienic nutrition to postural support devices.
Whole communities are searching for a wellness provider. There is a shift in the realization that medical services are not designed to support performance and well-being. Medical management and the insurances that fund them are primarily directed to addressing and treating disease states. Tissue pathology is the end stage of the adaptation and dis-ease process. A gradual awakening and acceptance of a more responsible approach to healthcare has occurred. Given access and opportunity, the public has demonstrated that they will shift toward making healthier choices.
The importance of the adjustment within the office can never be diminished. Releasing subluxations is the starting point to feeling alive and being well. Subluxations represent a persistent disturbance along the central neuraxis, which interferes with the interpretation and response to environmental challenges. This maladaptive process impedes the free-flowing, organizing impulses that are known as innate intelligence. The adjustments “arouse innate,” while other procedures support the healing process. The challenge for the Chiropractic team, then, is to be clear about their mission and to have a system that allows a timely application of congruent services.
Taking a New Path
Patient care plans are traditionally based upon a spinal rehabilitation model. After assessment and diagnosis, a three-step protocol is usually advised. This transits the patient from acute to corrective care, and finally maintenance check-ups are recommended. This style of patient treatment is ultimately shortsighted, as it focuses on the management of symptoms and the restoration of function. A missing dimension is the lifelong exploration of potential and well-being. These stages of living far exceed the parameters of this rehabilitation model.
A more natural method of guiding and leading the patient is known as the Path to Wellness©. This patient care and scheduling continuum can be used in any style of practice with any technique. Instead of a rehabilitative, three-step model, this is a wellness orientation for the Chiropractic team and the practice member.
The Path to Wellness follows three stages that are referred to as Release, Rebuild, and Revitalize. The stages represent a seamless flow that supports the release of persistent subluxations with the rebuilding of newer lifestyle habits. Finally, it offers the opportunity to choose Chiropractic care with the goal constantly revitalizing the natural flow of innate intelligence.
On the practical side, The Path to Wellness is an orderly method of delivering watchful and progressive care. Strategies for managing each stage of care can be discussed with the patient. A “roadmap” can be displayed that clearly defines when other services, beyond the adjustment, are to be applied. For instance, the Rebuilding stage is an ideal time to provide restorative exercises and to explore the use of orthotics to enhance stability and motion. Structural integrity and balance are an integral component in this stage of care. The Rebuilding phase is a time to create more flexible and stable support in the spinal system. This enhances the effectiveness of the adjustments and empowers patients toward more personal control of their health. This time in care is typically longer in duration than the Release stage. It provides a focus for the patient to address long-standing health and postural habits.
Conversely, the early Release stage has different goals, as it represents the initial unwinding of the subluxation process. Here, the practitioner might choose to use simple movement strategies rather than rehabilitative exercises to begin the process. Progressive strategies can easily be layered in as healing evolves. By dividing the care into different stages, the Chiropractic team and the patient can be focused on their immediate needs, while continuing to look toward the future. The intent of the Chiropractic paradigm is imbedded in the communication and procedures every step of the way. Wherever the patient is along this continuum, the central theme of adjusting the subluxation and supporting the process is never diminished.
The Path to Wellness represents a dynamic new opportunity for offices to present a wellness program and to manage the delivery of adjustments and support services in an organized, flowing manner. Orthotic appliances are a natural adjunct to the chiropractic adjustment. They can be easily dispensed at the appropriate time in this patient care system. Imagine a thoroughly trained team that focuses on providing watchful and progressive wellness care for each patient and their family in the community. Hundreds of offices have chosen to practice using this new protocol and are reporting great value in its ease of patient care and management. Now, imagine how you could be this practitioner.
About the Author
David Fletcher, DC, FCCSS is a Fellow of the College of Chiropractic Sport Sciences (Canada). He practices in Pickering, Ontario, Canada. He is recognized internationally for his practical views blending traditional Chiropractic principles with contemporary technologies and is the founder of RippleFX Coaching Methods. Dr. Fletcher can be reached at 905-831-9696 or via email at .
by John K. Hyland, DC, DACBR, DABCO, CSCS
As society ages, the average age of our patients is also increasing. That fact is often overlooked, since we’re getting older at the same time! If you take a moment to review your current practice, I’ll bet that you’re seeing more chronic, age-related conditions than you were 10 or even just five years ago. This should also mean that your use of orthotics has been increasing. If it hasn’t, then you’re missing some critical factors in treatment, and your patients aren’t benefiting from your Chiropractic care as they should.
With aging, a number of important conditions begin to affect the feet. Some of these are not immediately symptomatic, and often the patients are unaware of the deterioration until they develop a loss of functional capacity and independence. Once we begin to pay attention, we will discover a variety of problems in the feet of our aging patients—some biomechanical, others systemic. Many of them can be helped with comprehensive Chiropractic care, along with custom-made functional orthotics.
Overweight and obese
Depending on the specific population studied and the exact definitions used, most researchers have found that somewhat more than half of all adult North Americans are overweight, and from 20% to 30% of our society is defined as obese. As we age, we tend to put on more weight. Since the additional weight load places more stress on the supportive skeletal structures, it’s not surprising that being overweight results in a greater frequency of musculoskeletal and arthritic problems, especially in the knees and feet.
Lower extremity biomechanics are very different in the overweight patient, and many gait changes and abnormalities are commonly seen. During walking, obese individuals take shorter steps, have an increased step width, and walk more slowly. They have increased Q-angles at the knee, more hip abduction, significantly more abducted foot angles, and increased out-toeing (foot flare). Hyperpronation is greatly increased, with a greater touchdown angle, more eversion of the foot, a more flat-footed weight acceptance period in early stance, and a faster maximum eversion velocity being measured. There is also greater ankle dorsiflexion, but less plantar flexion.
Joint degeneration becomes much more prevalent as we age. In the feet, the small joints are exposed to high forces over many years. While the causes of joint degeneration and osteoarthritis are still debated, several studies have clearly demonstrated that repetitive impact loading from a variety of sources results in the development of osteoarthritis.1,2
When a joint is exposed to cyclic impact forces, the appearance of degenerative changes is only a question of time.3 These repetitive forces cause a “fatigue-failure” in the joint tissues, a well-known phenomenon that includes alterations in both the articular cartilage and the cancellous subchondral bone. When this type of intermittent dynamic loading is combined with biomechanical faults, previous injury to a joint, or a rigid, non-yielding walking surface, degenerative changes progress rapidly and symptoms frequently develop.
Plastic deformation and breakdown
Over a period of years and decades, the repetitive stresses and normal forces result in a slow breakdown of support for the bones and joints of the feet. It is the connective tissues (collagen and proteoglycans) that are exposed to these long-term lengthening forces, resulting in a decrease in elasticity and a sagging of the foot’s arch. This breakdown then allows transmission of abnormal strains into the legs, the pelvis, and ultimately the spine. Since it is usually the spinal symptoms that have brought the patient into the Chiropractor’s office, the doctor must be able to identify the underlying foot dysfunction.
The tissues that must withstand this strain for years are the connective tissues (ligaments, tendons, and fascia), which are composed primarily of woven collagen fibers. This arrangement allows for the combination of flexibility and strength that keeps our joints within close alignment, while still allowing for a wide range of movement. The woven collagen fibers demonstrate a very important physical property—viscoelastic behavior. Viscoelasticity is the time-dependent response of tissues to a load.4 The longer a load is imposed on the tissues, the more likely is that there will be enough stretch to result in a permanent lengthening.
The result in many aging patients is a loss of the elastic support for the arches of the foot, and less shock absorption from the heel pads. Providing support for the aging foot’s arches can help prevent problems such as plantar fasciitis and heel spurs, which often develop as the foot ages. An additional recommendation for aging patients with loss of heel pad compliance is the use of a heel cup, which improves heel pad function by preventing lateral and medial bulging, thereby maintaining pad thickness.5
The aging of our population provides us with new challenges. Many of the chronic conditions reported by older patients will respond best when their chiropractic care is augmented by flexible, custom-made orthotics. With new materials and innovative construction techniques, orthotics are now being designed to meet the needs of this growing segment of our communities. When your “more mature” patients get relief from their chronic, degenerative conditions under your care, they’ll help build your practice with referrals. The use of orthotics will often complement and improve the chiropractic adjustment, while assisting the body to return to an improved state of function and health.
About the Author
Dr. Hyland is a 1980 graduate (cum laude) of Logan College of Chiropractic. He is a Diplomate of both the American Board of Chiropractic Orthopedists (DABCO) and the American Chiropractic Board of Radiology (DACBR). A popular speaker, Dr. Hyland is a postgraduate lecturer for several chiropractic colleges and a frequent contributor to Chiropractic publications.
1 Paul JL. Musculoskeletal shock absorption: relative contribution of bone and soft tissues at various frequencies. J Biomech 1978; 11:237-242.
2 Radin EL. Effect of repetitive impulsive loading on the knee joints of rabbits. Clin Orthop 1978; 131:288-291.
3 Radin EL. Effect of prolonged walking on concrete on the knees of sheep. J Biomech 1982; 15:487-494.
4 White AA, Panjabi MM. Clinical Biomechanics of the Spine, 2nd ed. Philadelphia: Lippincott, 1990. 692.
5 Jahss MH. Investigations into the fat pads of the foot: heel pressure studies. Foot & Ankle 1992; 13:227-232.
by John Danchik, DC, FICC, CCSP
Flatfoot (the absence of a medial longitudinal foot arch) is normally found during early human growth and development. During childhood, we all start out with little or no arch. Some people, however, never develop normal feet arches. This situation differs from the collapse of normal arches due to excessive loading and eventual plastic deformation. Are “normally” flattened feet a clinical problem? Are arch supports, special shoes, or orthotics necessary? Chiropractors need to understand the natural history of flatfeet and the clinical presentations associated with this condition.
In childhood, almost every foot has a large medial fat pad which slowly decreases during maturity, resulting in a more prominent medial longitudinal arch.1 A study of the developing arch in children2 has confirmed that 28% to 35% of school children have a flatfoot deformity, 80% of which are classified as “mild.” Without treatment, more than 90% of these children will have normal arches by age 10.1,3 The remaining 10% will grow into adulthood without developing normal longitudinal arches.
Adults with flatfeet demonstrate several biomechanical inefficiencies in the foot and ankle, as well as a variety of gait abnormalities. The development of clinical problems is dependent on the levels of activity and the amount of repetitive stress that the feet must endure. Symptoms and associated pathology arise secondary to excessive pronation of the foot and ankle, and an inability to achieve a rigid foot at toe-off.
A 1988 study assessed the effects of arch supports on oxygen consumption in 20 subjects with flat feet who complained of fatigue and “weariness.”4 These subjects, between 18 and 38 years old, had no specific foot symptoms. Their heart rates, blood pressures, and walking oxygen consumption values were measured on a treadmill—first without, and then with arch-supporting orthotics. The results demonstrated that use of the orthotics significantly improved their gait efficiency, and decreased their oxygen consumption during normal walking.
Flexible or Rigid Arches?
It is important to differentiate a congenital, rigid flatfoot, from the normal, flexible flatfoot, since specialist referral is often necessary for the rigid condition. Here is a simple test to determine the existence of a rigid flatfoot (usually due to an osseous deformity, such as a tarsal coalition): If an arch is present when the patient is sitting with the foot dangling, or when standing up on the toes, then the flatfoot is “supple and is correctable with an arch support.”5 If the foot remains flat and rigid during this test, any attempt to lift or support the arch will be painful and unsuccessful. In these rare cases, specialized treatment is required. Evaluation by a foot specialist is usually necessary to determine the underlying cause of a rigid flatfoot and to develop the proper care.
Recommendations for Adults with Flexible Flatfoot
- Strengthen the lower leg muscles with home exercises (exercise tubing, scrunching up a towel with the toes).
- Stretch the Achilles tendon regularly, which is found to be secondarily tight in many patients with flatfeet.
- Insist on supportive, lacing shoes with a strong, stable heel counter.
- If excessive pronation is present, support from custom-made functional orthotics is indicated.
Body weight is a major factor that can increase the levels of biomechanical stress that the feet must bear. Adults with flatfeet can decrease their potential for developing clinical problems by keeping their weight within recommended norms.
Orthotics provide support for the arches and decrease the tendency for excessive pronation. Fit patients who have flatfeet with comfortable orthotics at an early stage, before deformity develops and symptoms become intractable. Support from custom-made functional orthotics will encourage normal function of the foot and ankle. Further foot deformity can be prevented, along with reduction of abnormal Kinetic Chain stresses on the pelvis and spine.
Adults with flatfeet should be identified early in the examination process. The likelihood of foot biomechanics being involved in their musculoskeletal complaints is high. Corrective support for the arches is often necessary to obtain good clinical results, and custom-made orthotics should be considered from the start. Prevention of future foot, leg, and back problems requires the Chiropractor to discuss the natural history of flatfeet with the patient. A review of the importance of maintaining normal body weight, good strength and flexibility, and the availability of orthotics will provide needed information.
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 Kemp HC. Current Pediatric Diagnosis and Treatment. Norwalk: Appleton and Lange, 1984:614.
2 Notari MA. A study of the incidence of pedal pathology in children. Journ Am Podiatric Med Assn 1988; 78:518-521.
3 Wetton EA. The Harris and Beath footprint: interpretation and clinical value. Foot & Ankle 1992; 13:462-468.
4 Otman S, et al. Energy cost of walking with flatfeet. Prosthets and Orthots Int 1988; 12:73-76.
5 Hoppenfield S. Physical Examination of the Spine and Extremities. New York: Appleton-Century-Crofts, 1976:232.
by Chris Akey, DC
Most of us agree that we do adjust below the atlas. How far below is the question!
Going through college, my philosophy was to adjust the spine only, and that anything else was “mixing.” The notion that subluxations were only in the spine was steadfast and blinders tight. I’m sure I might get remarks still today about this, but I have opened my blinders since then. The nerve system doesn’t stop at the spine, nor do subluxations. I know the subluxation as defined by D.D. and B.J. and Stephenson’s text. I highly respect those individuals—if not for them, I would not be a Chiropractor.
Involvement Beyond the Spine
If we are dealing with a misalignment in the spine that is causing nerve interference, can the bones in the extremities misalign and cause nerve interference too? Let’s consider a knee that is symptomatic. Can adjusting the pelvis help the knee? Yes. Can adjusting the atlas help correct the knee? Right again. So, I put my hands or instrument on the knee to adjust, then the pelvis and atlas (necessary in this case). What would the difference be? You can email me.
My point is, you are adjusting other structures, whether you think so or not. And it’s ok—you are still a Chiropractor.
What about a couple of parts of the nerve system called mechanoreceptors and nociceptors? Mechanoreceptors provide continuous feedback about where the body is in space. They also are sensitive to position, motion, vibration, and pressure—and they inhibit perception of pain. Nociceptors are in every tissue in the body except two small areas in the brain. Excessive firing of nociceptors indicates pain, also called proprioceptive noise. Since these are part of the nerve system—and the nerve system goes everywhere—can we examine these areas if it would better serve our patients?
As Far as the Feet
If the nociceptors are excessively firing in a foot, does adjusting the low back help? Correct. Does adjusting the foot help too? Even better. Adjust both, and this allows the nerve pathway back to the spinal cord and brain to be free of the proprioceptive noise. If I were to adjust the pelvis only, while leaving the excessive firing of nociceptors in the foot, short-term and long-term results would be different.
The most common subluxation pattern of the foot is excessive pronation, and nearly all excessive pronation is bilateral and asymmetrical. When walking or running, the foot goes into a heel-toe strike motion. While walking, two-and-a-half times your body weight is concentrated on the foot (and three-and-a-half times while running). If the foot is misaligned, just imagine the problems that can and will occur. What about a foot that is currently aligned in which we want to prevent future problems?
To help both cases, I suggest custom-made functional orthotics, along with adjusting at least the feet. Since I have been wearing mine, I have noticed a significant improvement in running, walking, or even standing in my office all day. My feet and knees used to hurt, with pain running down my right leg. Now, I get adjusted regularly and wear my functional orthotics every day. And I feel terrific!
For more information on adjusting extremities, I urge you to attend a seminar put on by Dr. Mark Charrette. In my opinion, he is one of the best in our profession.
About the Author
Dr. Chris L. Akey runs a practice in Northwest Arkansas. His focus is educating his community to be subluxation free. He can be contacted at .
- Addressing Pedal Integrity in Growing Children
- Examination and Treatment involve Orthotics for Leg Length Discrepancy
- Adding Rehab to Your Practice
- Adding a ‘Step’ to Your Life
- Adaptation for a Comfortable Fit
- Acute Ruptures of the Anterior Cruciate Ligament: Causes and Prevention
- Active Care for Ankle Sprains
- ACL Ruptures: How We Can Prevent Many Knee Injuries
- Achilles Tendon Rehab Procedures
- Achilles Tendon Problems
- Achilles Tendinitis and Pronation
- An Abridged History of Chiropractic Extremity Care