JOHN ZHANG, PHD, MDa

Introduction

Foot pain and discomfort are common in workers whose job requiring long hours on their feet due to weight bearing and complexity of its structure and function¹. It has been reported that approximately three-fourths of Americans experience foot problems in their life². Foot pain and discomfort often lead to other complications above the level of the foot. The most common problems associated with foot pain and discomfort are ankle, leg, knee, hip and spinal disorders in people who spend many hours standing.^3,4 Foot orthotics have been used as a non-invasive treatment for conditions involving the feet and other parts of lower extremities. Many researchers believe that foot orthotics are effective in solving problems of the feet and other parts of lower extremities, and low back pain⁵. A study of postal workers performed by Carley (1998) revealed a 67% reduction in foot, knee, or back pain as measured by the Borg scale⁶. Sobel et al (2001) reported in a foot orthotics survey of 122 policemen, that 68% of subjects had decreased foot discomfort but had no improvement in back or leg discomfort⁷. However, these studies on foot orthotics remain inconclusive because they lack controls. Furthermore, different patient conditions, orthotics casting, and outcome assessments also contribute to the evaluation of effectiveness incosistent⁸. Therefore, a newly designed study with controls is necessary to determine the effectiveness of orthotics.

Chiropractic care, as the largest non-drug, non-surgery, non-invasive and holistic health care profession, has been demonstrated to be an excellent choice to treat neuromusculoskeletal and visceral problems with its effectiveness and safety⁹. More chiropractors have been using foot orthotics as part of their practice. However, there are no studies examining the combination o chiropractic care and orthotics for relieving foot and foot-associated pain and discomfort.

Part 2: Research Reshapes Long-Standing Theory

Kevin Arthur Ball, PhD, ^a and Margaret J. Afheidt^b

Abstract

Objective: To challenge casual understanding of the causal mechanisms of foot orthotics. Although the classic orthotic paradigm of Merton L. Root and his colleagues is often acknowledged, the research attempting to explain and validate these mechanisms is far less clear in its appraisal.

Data Sources: Studies evaluating the relationship ·of foot type (medial arch height) and use of foot orthoses to the motions of the foot and ankle were compared and contrasted. A search \Vas conducted to evaluate other possible mechanisms of orthotic intervention.

Results: Although Root's methods of foot evaluation (subtalar neutral position) and casting (rton­weight-bearing) are well referenced, these methods have poor reliability, unproven validity, and are. in fact, seldom strictly followed. We challenge 2 widely held concepts: that excessive foot eversion leads to excessive pronation and that orthotics provide beneficial effects by controlling rearfoot inversion/eversion. Numerous studies show that patterns of rearfoot inversion/eversion cannot be characterized either by foot type or by orthotics use. Rather, subtle control of internal/external tibial rotation appears to be the most significant factor in maintaining proper sup!nation/pronation mechanics. Recent evidence also suggests that proprioceptive influences play a large, and perhaps largely unexplored, role.

Conclusions: Considerable evidence supports the exploration of new theories and paradigms of orthotics use. Investigations of flexible orthotic designs, proprioceptive influences, and the 3-dimensional effects of subtalar joint motion on the entire kinetic chain are areas of research that show great promise. (J Manipulative Physiol Ther 2002;25:125-34)

Chiropractic Response

By William Austin, DC, CCSP, CCRD

As most chiropractors know, orthotics are special shoe inserts that stabilize the spine and pelvis by correcting imbalances in the feet. Orthotics help support chiropractic adjustments, resulting in better clinical outcomes.

Many of your patients are already familiar with off-the-rack shoe inserts, but those inserts and custom-made flexible orthotics are very different in terms of quality and effectiveness. Off-the-rack shoe inserts cannot give patients the unique support and placement that their feet need to maintain proper, stable alignment. Custom-made orthotics ore specifically made to lit each individual's foot. A custom-made orthotic allows for the patient's condition and the chiropractor's instructions to be taken into account when the orthotic is created.

The feet are the foundation of the skeletal system. When the feet are imbalanced, misalign­ments and pain can occur in areas throughout the body-even ii the feet do not hurt. The feet, which play an integral role in biomechanics, perform better when all their muscles, arches, and bones are stable and in ideal positions.

While 99% of all feet are normal at birth, 8% develop troubles by the first year of age, 41 % by age 5, and 80% by age 20. ¹ By age 40, nearly everyone has a foot condition of some sort. By supporting and balancing the feet, custom-made orthotics enhance the body's performance and efficiency, reduce pain, and contribute to total overall wellness.

The Foot and Problems of the Foot
The feet support the whole weight of the body, they provide balance, they safely absorb heel­strike shock, and they adapt to walking stresses. Most importantly, feet provide the foundation of support for the spine and the pelvis.

Part 1: Coherent Theory or Coherent Practice?

Kevin Arthur Ball, PhD, ^a and Margaret J. Afheidt^b

Abstract

Objective: To present a critical review of the evolution of foot orthotics theory and clinical practice. Data Sources: Several classic publications were consulted because of their overwhelming influence. The work of Merton L Root and his colleagues in the 1970s was carefully examined. Careful evaluations were performed to determine how faithfully Root's central concepts were subsequently followed, Studies attempting to validate this and other orthotic paradigms were also reviewed.

Results: Epidemiologic studies provide strong support for the clinical advantages of orthoses, yet explanations of foot orthotic mechanisms remain elusive, Considerable variability has crept into the literature with respect to Root's core theoretical concepts of how and why to determine the neutral position of the subtalar joint (weight-bearing vs non-weight-bearing, palpation vs range-checking). Numerous studies document poor clinical reliability and validity; indeed, this paradigm appears to favor supination, thereby violating its "neutral" premise. Mechanisms other than those of the classic Root theory must be at work, Accordingly, successes have been achieved with alternate paradigms that use much simpler casting techniques. Although less frequently cited, successes have been gained with various viscoelastic materials that enhance shock-absorption and proprioception, as well as custom-made flexible orthotic designs that emphasize the 3 natural arches of the foot

Conclusions: The use of foot orthoses is \:veil documented for the treatment of many maladies, yet clinical successes have been achieved both inside and outside of the classic Root paradigm, Clearly, a more complete theoretical understanding of the mechanisms of foot orthotics awaits discovery. (J Manipulative Physiol Ther 2002;25:116-24)

Chiropractic Response

W.M. Austin

In addition to the type of service offered, individuals seeking care have essential three wants: 1) to be listened to; 2) a thorough examination/evaluation with a simple explanation; and 3) to be empowered - how you can help them help themselves.

It will be imperative to sit down with Kerry and let him thoroughly vent his feelings, his diagnosis, and his treatment programme. His feelings are the most important and may shed some light on his condition. His diagnosis and the diagnosis of the other health care providers should not be accepted as final. Perform your own thorough examination/evaluation and draw your own conclusion. Providing this patient with specific therapeutic activities will help hi1n actively participate in his treatment programme. He may be helpful in developing this programme; however, the activities must produce specific results based on functional need, the outcomes being progressive and measurable.

It will be important to establish a baseline assessment using a Pain Drawing for location and type of pain, a Visual Analogue Scale for intensity, and the Oswestry Low Back Pain Scale for lifestyle/ function limitations. These tools are important not only to monitor progress, but to help Kerry set goals and 'complete' with himself toward their resolution or improvement.

From immobilization to controlled mobility

The primary stabilization for the foot's three arches comes from proper bony alignment, supported by the plantar fascia and other ligaments. Secondary stabilization depends on healthy, coordinated muscular control. When the ability of these structures to respond to stress is overwhelmed, pain often develops in the foot or lower extremity.

Some providers have found that immobilizing the foot and ankle can effectively allow the body to heal at a rate that keeps up with the trauma. However, just as a cast, crutch, collar, or brace is only helpful while the body heals, a rigid orthotic used beyond the recovery period can create a new set of problems. This information will help you determine when to upgrade a patient to flexible orthotic support and help you make this transition a smooth one. Rigid orthotics are often prescribed for the acute phase of plantar fasciitis, achilles tendonitis, and shin splint therapy. In addition to providing the foot with a "crutch", the provider will likely give activity or lifestyle modifications. Unfortunately, when the pain is relieved, patients are often less inclined to return for continued care or to comply with the doctor's orders. Furthermore, rigid orthotic systems can cost between $350-$500. As a result, many patients are hesitant to discontinue wearing the rigid orthotics in which they have invested and risk having the pain return. Unfortunately, the body will often experience disuse atrophy and structural compensations, as the patient becomes truly dependent on the rigid orthotics.