By Kent S. Greenawalt
“What would you do if you knew you could not fail?”
I have posed this question for years to groups I’ve spoken to across the country and across the world. I want Chiropractors, Chiropractic assistants (CAs), and students to think about what they want in life and then work toward that goal. If you feel like you or your office has gotten into a rut, stop what you’re doing right now and read this article. My first piece of advice is, “Your practice won’t change until you change the way you practice.”
Success, to me, is doing exactly what you want to do in life. It could be your job, your practice, your family, or anything that makes you happy. As long as you are doing what you love, then you have achieved the first—and most important—step of being successful.
This is an important lesson that I learned early in life as I watched my late father, Dr. Monte Greenawalt, help his chiropractic patients while starting the orthotic company, Foot Levelers. It was easy to see that he loved what he did, which made work not seem like a chore. It was his passion. I have learned 10 lessons in my life that have helped me and are universal steps to success. If you apply these, you can help your practice grow while serving your patients to the best of your ability.
- Think big. Pretty much every success story in history has started when someone thought on a grand scale. It’s easy to get bogged down in the day-to-day details of your practice. While it’s important to be involved in those seemingly mundane decisions, it’s also important to take some time to think of the big picture. What would you want to do for your practice if there was NO WAY YOU COULD FAIL? Get rid of the “no” that keeps coming back in your head, and brainstorm what you could do if there was no way it could fail.
- Learn from your mistakes. Failure is sort of like fertilizer—if you use it, then you grow bigger and stronger. If not, then you’re just standing in a pile of…fertilizer. Look at what hasn’t worked for you and your practice, and assess why and what you could do differently to get a better outcome. Sometimes, you don’t need to throw out a huge process or idea because it didn’t work—maybe it just needs some small tweaks to make it a success.
- Keep on pushing. This applies to the eighth-grade law of physics that an object in motion stays in motion. If you want to make your practice change or continue to grow, you are the person who needs to make that change happen. You have to keep pushing to drive your practice the way you want it to go. If you sit still long enough, even a great practice will become stagnant and stop growing. You have to continuously help your current patients while reaching out to former patients and new patients.
- Payoff is not immediate. What you do today will affect your life three months from now. Not seeing a reward today, tomorrow or even next week can be difficult, but it will happen. You have to keep your eyes on your end goal and realize that sometimes it takes time to get the ball rolling. You will see results based on what you do today, so make each day—and each decision—count.
- Continue doing the things that made you successful. You already have had some success? Great! Don’t start from scratch and reinvent the wheel. However you got to this successful place, continue to do it. You have worked hard to find what works best in your area with your patients and staff. If you have found a rhythm that works well for you, then continue to do it.
- A little better makes a HUGE difference. My father used to tell me that it doesn’t take much to be successful because all you have to be is a little bit better than average—and average isn’t that high. Just going a little bit above the call can be a huge difference between you and the practice down the street.
- Think right. You’ve got to get your mind on your side. So, be positive and committed to your goal and believe you can do it. Henry Ford famously said, “If you think you can or you can’t, you’re right.” You will do what you believe you can do—for better or for worse. Think positively, and you will achieve more.
- Write it down. Try writing down your top three goals, and then put them somewhere you will see them every day (maybe on your bathroom mirror or on your closet door). Now read them every day and be committed. You can’t be committed half-way. You’re either committed or you’re not. Writing these down gives you a clear expectation of what you want to happen—and if you’re committed, you can make it happen.
- Treat every patient/customer as if they are your only one. One of the biggest lessons I can tell someone new to practice is this statistic: 68% of patients leave because of the feeling of indifference. Only 14% actually leave because they are unhappy. If you make your patients feel appreciated and valued, then they are much more likely to want to come back and tell their friends about this great Chiropractor they should go see. This lesson applies to practice or business. We can’t forget about our longtime customers—just to try to get new ones. We need to take the time to make each one feel special, because they are!
- Don’t sell yourself short. This is the final lesson, and it combines everything we’ve talked about. Whatever you think you can do, you can. So think big, keep on pushing, write it down, and don’t get complacent.
Apply these 10 lessons to yourself and your practice, and give yourself 90 days. You’ll be amazed at what you can accomplish, and your patients and staff will thank you for the positive changes.
About the Author
Kent S. Greenawalt, Chairman and CEO of Foot Levelers, is also the founder of The Foundation for Chiropractic Progress. This Foundation generates positive messages about the benefits of chiropractic and shares it with the public. As the Foundation gains more support, the general public and media will advance both their acceptance and knowledge of chiropractic. Help spread awareness by supporting the Foundation for Chiropractic Progress. Visit www.f4cp.com or call the Foundation’s number at 866.901.F4CP (3427) to join today.
by Kim D. Christensen, DC, DACRB, CCSP
Patients who exhibit postural imbalances resulting from an underlying foot dysfunction often require both appropriate Chiropractic adjustments and long-term supportive therapy. For these patients, the “quick fix” is often not a realistic option, and a recommendation of an adjunctive procedure (such as orthotic therapy) frequently raises questions in their minds.
Some concerns typically expressed include: “How long will I need to wear supports?” and “Do I need to use them in all my shoes?” Often, a patient will also ask, “Can't I just do some exercises, or have an adjustment, that will fix my foot problems?” Such questions indicate the need for you to spend a little time explaining the concept of plastic deformation (connective tissue overstretch). Taking the time to respond and explain can help prevent many future problems and questions.
The value of discussing the concept of plastic deformation is the carryover into other topics, such as sustained work postures and unrecognized (and unconnected) subluxations. When patients understand that custom-made functional orthotics have been shown to help reduce fatigue1 and improve neuromusculoskeletal complaints in the lower extremities, pelvis, and spine,2 they usually accept and value their postural supports. What’s important is to keep the terminology as nontechnical as possible (not always easy with this subject), while making sure that certain key concepts are understood.
Except for the few people with inherited normal variances or bony anomalies, most of us develop strong, flexible arches in childhood. Our feet and ankles survive the various recreational stresses into adulthood. One of the problems facing our modern society is the constant walking and standing on flat, rigid, man-made surfaces, rather than on soft, variable ground. Over a period of years and decades, the repetitive, abnormal stresses and forces result in a slow breakdown of normal 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 bring 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 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.3 If the stress placed on a ligament is within its elastic range, it can spring back after loading. The more elastic the collagen is, the better the ligament is at returning to its original length when a load stress is removed. When a ligament is loaded beyond its elastic range, it enters the plastic (viscous) range. Plasticity is the tendency of a material (or tissue) to permanently deform when the load goes beyond the elastic range.
The relative proportion of elasticity and plastic deformation varies with the stretching conditions, especially the amount and duration of applied force. A constant low load applied to soft tissues over a prolonged period demonstrates the phenomenon called creep. This is the steady deformation that occurs over a period of time. One example of this is the loss of an individual’s height, which occurs during the day due to temporary deformation of the spinal discs.4 When creep goes beyond the tissue's elastic capability into its plastic range, permanent plastic deformation is the result.
Aging of Collagen
The physical properties of collagen are closely tied to the number and quality of the cross links between fibers. During growth and maturation (up to 20 years of age), the cross-links increase, resulting in increased tensile strength of tendons and ligaments.5 As aging progresses, cross-linking activity plateaus and the collagen content of ligaments begins to decrease. This causes a gradual decline in the elastic capability, facilitating creep and the development of permanent plastic deformation. The process is tremendously variable and occurs at a wide range of ages and activity levels.
Sports and Recreation
Another factor to be reckoned with is the greater amount of force that is applied to the connective tissues during strenuous recreational activities. When running, the forces applied to the ligaments of the foot and ankle are multiplied by at least a factor of three.6 This means that the elastic range of the connective tissues is much more easily exceeded during any athletic activity that includes running. With more patients trying to increase their activity and fitness levels, at the same time the population is aging, it’s a safe bet that we'll be seeing more episodes of plastic deformation becoming permanent.
When your patients spend long periods of time on their feet, perform athletic activities that place higher forces on the lower extremities, or are beyond the age of growth, the likelihood of permanent plastic deformation is great. These patients will best respond to Chiropractic care for their musculoskeletal systems when supplied with appropriate styles of custom-made functional orthotics for all their shoes and levels of activity. When patients understand the concept of permanent plastic deformation, they will realize the importance of wearing their orthotics at least 75% to 80% of the time, and they will accept this as a permanent form of treatment and support. They will also appreciate your caring, expertise, and interest in their long-term health. Such concern and attention helps to build a long-lasting, solid practice.
1 Stude DE, Brink DK. Effects of nine holes of simulated golf and orthotic intervention on balance and proprioception in experienced golfers. J Manipul Physiol Ther 1997; 20(9):590-601.
2 Austin WM. Shin splints with underlying posterior tibial tendinitis: A case report. J Sports Chiro Rehab 1996; 10(4):163-168.
3 White AA, Panjabi MM. Clinical Biomechanics of the Spine, 2nd Ed. Philadelphia: Lippincott, 1990:692.
4 Schafer RC. Clinical Biomechanics, 2nd Ed. Baltimore: Williams and Wilkins, 1987:83.
5 Nordin M, Frankel VH. Basic Biomechanics of the Musculoskeletal System, 2nd Ed. Philadelphia: Lea & Febiger, 1989:68.
6 Subotnick SI, Ed. Sports Medicine of the Lower Extremity. New York: Churchill Livingstone, 1989:67.
by John Danchik, DC, FICC, CCSP
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 these requirements is the role that pedal stability can play in the maintenance of proper posture. Faulty foot biomechanics can have a negative impact on all supporting joints above the foot/ankle complex. For maximum effectiveness, the chiropractor seeking to treat a postural deviation needs to evaluate the potential involvement of the pedal foundation and correct postural foot problems.
The Biokinetic 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.1 The chain extends from the feet through the ankle, tibia, knee, femur, hip joint, pelvis, and spine.
The biokinetic chain depends upon the balance of body alignment and muscle restraining activity at each joint against gravitational pull. Passive stability is achieved when the center of gravity of each segment is aligned directly over the center of the supporting joint. 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 stability of the biokinetic chain should, in theory, 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.2 Therefore, postural balance means a continuous involvement of the supporting skeletal structure and muscles.
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.3 Pronation occurs when the superior aspect of the calcaneus tilts and rolls inward, bringing the talus with it. This releases the navicular from arthrodial articulation with the talus and jeopardizes the medial longitudinal arch. When collapsed, it can begin serial distortion that may extend to the occiput.4
Common Postural Distortions
Lack of stability in the pedal foundation can lead to serial distortions and muscular stretching all the way up the spine:
Pedal conditions. Excessive pronation causes an abnormal instability in weightbearing mode, creating hypermobility in the foot joints and leading to microtrauma in the soft tissues.4 Over time, even with only normal foot use, symptomatic conditions may develop—such as arch strain and fatigue, plantar fascitis, heel spurs, bunions, or metatarsal stress fractures.
Lower extremity distortions. Once the pedal foundation has been compromised, the effects of this instability will be manifested farther up the leg as conditions such as shin splints, posterior tibial myositis, or Achilles tendinitis. The knees, especially, provide a telltale signal of postural distortions. In normal posture, each patella should point directly ahead and be centered evenly over the foot and ankle. In the patient whose posture is compromised by pronation, an inward rotation of one or both kneecaps can usually be detected visually. In addition, the tibia will be internally rotated relative to the foot and externally rotated in relation to the femur.
Depending on the amount of pronation, the movement extends 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.
Spinal distortions. As each subsequent part of the body’s chain is affected, additional postural conditions may develop, setting off a reaction similar to dominoes falling. As the base point of the body’s center of gravity shifts forward, the pelvis begins to translate, which produces a thoracic extension. As this point, the head attempts to maintain its position over the vertical center of gravity, and therefore slides into anterior translation.
In anterior translation, the ear is forward of the AC joint and the bite line is level, creating the so-called “dowager’s hump.”5 In addition, the evaluating doctor will also note an increased cervical lordosis, rounded 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.”6
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.7
Functional scoliosis is another relatively common spinal condition that can result from overpronation. The internal rotation of the femur causes the pelvis to tilt forward, leading to external subluxation. The resulting limitation of hip rotation and compensatory subluxations can cause scoliotic curvatures.
Effects of pronation are also evident in adjacent tissues. The increased anterior pelvic tilt elevates the posteroinferior portion of the pelvis, resulting in abnormal stretching and tension on the hamstring musculature. Tension on the piriformis muscle increases, often giving rise to sciatic pain.
Corrective Orthotic Support
The Kinetic Chain plays a key role in understanding the biomechanics of a patient’s postural condition. Structural imbalance in the feet can impact on other body parts, all the way up through the spine.
The use of orthotics is frequently indicated to restore balance and provide a level pedal foundation. Orthotics are of special value in cases where foot pronation and arch ligament laxity have been observed. Custom-made functional orthotics address excessive pronation and provide support for the collapsed structures in the feet, creating a sturdy base for the rest of the biokinetic chain.
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.
1 Steindler A. Kinesiology of the Human Body Under Normal and Pathological Conditions (3rd ed.). Springfield, IL: Charles C. Thomas, 1970.
2 Perry, J. Gait Analysis: Normal and Pathological Function. Thorofare, NJ: SLACK, Inc., 1992.
3 Cailliet R. Foot and Ankle Pain (2nd ed.). Philadelphia: F.A. Davis, 1983.
4 Greenawalt MH. Spinal Pelvic Stabilization (4th ed.). Roanoke, VA: Foot Levelers, Inc. 1990.
5 Christensen KD. Chiropractic Rehabilitation, Vol. 2: Cervical Spine. Ridgefield, WA: C.R.A. Publication Division, 1991.
6 Porterfield JA, DeRosa C. Mechanical Neck Pain: Perspectives in Functional Anatomy. Philadelphia: W.B. Saunders Co., 1995.7 Cailliet R. Neck and Arm Pain. Philadelphia: F.A. Davis, 1981.
by Mark N. Charrette, DC
Excessive foot pronation is one of the most common conditions affecting the human frame. This is a condition where the foot rolls inward, creating a foot that is flatter, wider, and longer. A subluxation pattern of the various tarsals and metatarsals results.
As Chiropractors, we understand that the foundation of the spine is the pelvis, and any pelvic misalignment can affect the biomechanics of the lumbar, thoracic, and cervical sections of the spine. What we must remember is that the pelvis is itself dependent upon the status of balance in the lower extremities and the pedal foundation.
Effects of Imbalance
Any structural imbalance—such as an anatomical leg length inequality, pes planus, etc.—requires compensating movements in the lower extremities and pelvis in order to minimize as much as possible stresses and strains that would affect the spinal column. Over time, however, specific muscle imbalances and shortenings will develop. Eventually, both the soft tissues and bones are damaged by microtrauma, which can eventually lead to pain and discomfort.1 2 3 4 5
A functional imbalance, such as collapse of the arches of the foot, also results in excessive motion during the various phases of gait. With excessive pronation, the leg spends too much time in internal rotation, placing twisting stresses on the pelvis with each step. In time, this results in overstretching of the hip and pelvic support ligaments and may also cause chronic pain and dysfunction.
Evaluation for Imbalance
An evaluation to check for lower extremity imbalance should be performed on every patient who presents with chronic musculoskeletal conditions of the spine or lower extremities. This can be done with a quick and easy screening procedure, such as a weightbearing examination. The following is a recommended series of observations to make while the patient is barefoot and standing:
Foot flare. Toeing out while walking indicates hyperpronation. Weight falls on the medial longitudinal arch, leading to plastic deformation that weakens the foot’s supportive qualities.
Knee rotation. Hyperpronation forces the patella to rotate medially, indicating excessive leg movement. The tibia and femur rotate medially, increasing the risk of abnormal hip rotation.
Bowed Achilles tendon(s). The Achilles tendon bows in on the side of hyperpronation. The calcaneus tilts inward, bringing the talus with it. Stress may extend to the tibia and along the entire Kinetic Chain.
Low medial longitudinal arches. With the patient in a normal, relaxed stance, insert two fingers beneath each medial longitudinal arch. Tight plantar fasciae, with possible pain or pressure, indicate foot imbalance. As the patient shifts weight outward, note tissue relaxation and absence of pain.
Shoe wear. With hyperpronation, excessive heel wear on the outer edges occurs. Check also for lateral distortion in the counter and/or shoe vamp.6
The 20 to 30 seconds required to perform the above exam is time well spent in avoiding treatment frustration and improving patient outcome. The information that you gather about the feet will be very helpful in dealing with postural distortions and pain farther up the body. For example, positive findings often indicate a need for individually designed stabilizing orthotics to help stabilize the spine and pelvis and absorb heel-strike shock.
Typical Subluxation Pattern of the Pronated Foot
When the foot pronates, creating a longer, wider, and flatter foot, the tarsal bones subluxate in a predictable pattern. The first, second, and third cuneiforms will subluxate in an inferior direction.
Adjustment for Inferior Cuneiforms 1-2-3
The doctor stands on the involved foot side, facing the opposite foot. The superior, or headward, hand makes a U-shaped contact over the talus-navicular-cuboid area on the dorsal surface of the foot. The doctor applies inferior traction with this hand while keeping the forearm as parallel as possible to the tibia.
The medial-anterior border of the doctor’s inferior or thrusting hand contacts the plantar surface of the foot. A dynamic thrust is given in a superior line of drive while the superior/headward hand applies inferior traction.
Rotating the foot slightly internally or externally can bring about relaxation, making this adjustment more effective.
About the Author
Dr. Mark N. Charrette is a 1980 summa cum laude graduate of Palmer College of Chiropractic. He has lectured extensively on spinal and extremity adjusting throughout the United States, Europe, the Far East, and Australia.
1 Chambless KM, Knudtson J, Eck JC, Covington LA. Rate of injury in minor league baseball by level of play. Am J Orthop 2000; 29(11):869-872.
2 Kibler WB, Safran MR. Musculoskeletal injuries in the young tennis player. Clin Sports Med 2000; 19(4):781-792.
3 Kavanaugh J, Yu JS. Too much of a good thing: overuse injuries of the knee. Magn Reson Imaging Clin N Am 2000; 8(2):321-334.
4 Gabbett TJ. Incidence, site, and nature of injuries in amateur rugby league over three consecutive seasons. Br J Sports Med 2000; 34(2):98-103.
5 Hyland J, Yochum T, Barry M. Posture and weightbearing biomechanics: unproved theory or clinically important concept? Dynamic Chiropractic 1996; 14(16):21-24.
6 Charrette MN. Examination of the foot and ankle: non-weightbearing and weightbearing procedures. Success Express 1996; 16(3):20-22.
William M. Austin, DC, CCSP, CCRD
Director of Professional Education
When a doctor of chiropractic encounters a patient with low back pain, a careful examination of the spine is necessary. Often overlooked, though, is the importance of the feet to the normal function of the lower back. When patients don’t respond as well as expected to their chiropractic care, frequently there is a source of interference found in the pedal foundation. A recent study concluded that “there are small, but important, inter-segmental movements of the spine during gait.”1 An abnormal gait, no matter what the source, will eventually interfere with these important movements, and eventually back pain develops.
The foundation provided by the feet and legs must bear the weight of the entire body (and considerably more during running and other sports). If there is insufficient or inadequate support from the pedal foundation, the spine will be exposed to abnormal stresses and strains that eventually develop into low back pain. Excessive stresses on the spine can be the result of abnormal foot biomechanics, poor function of the foot/ankle complex, excessive shock transmission, or leg length asymmetry. Recognizing and then responding appropriately to these factors separates the doctors of Chiropractic from the spinal technicians.
When some part of the foot is not moving properly (either insufficient or excessive joint motion), the resulting forces produce effects all along the Kinetic Chain. Investigators have found that “Alteration of normal foot mechanics can adversely influence the normal functions of the ankle, knee, hip, and even the back.”2 Following are some examples of common foot problems that have been found to interfere with spinal function.
First MTP Joint. When the metatarsophalangeal joint of the first toe is stiff and doesn’t flex properly, the transition from midstance to toe off is restricted (Fig. 1). Studies have found that this movement limitation (called “functional hallux limitus”) is a “major gait abnormality that causes lumbar stress.”3 The best treatment for this condition is custom-made functional orthotics that support the medial arch and yet still encourage motion at the first MTP joint.
Plantar Fascitis. When a patient complains of “a sharp heel pain that radiates along the bottom of the inside of the foot,” and especially when the pain is worse when getting out of bed in the morning, inflammation of the connective tissue that supports the underside of the foot must be considered.4 This causes a significant problem with comfortable walking, often resulting in a painful limp. An orthotic with a heel spur cut-out will improve gait and lessen the impact of this condition on the pelvis and spine.
Dropped Metatarsal Heads. If there is no anterior arch to the foot, excessive weight-bearing on the metatarsal heads will cause the transition from foot flat to toe-off to be painful. This alters the timing of the gait cycle, resulting in a rushed propulsion phase. The effects are felt in the pelvis and spine, which are not able to move smoothly through the phases of gait. Orthotic support for the metatarsal arch can improve both the local and biomechanics.5
Foot and Ankle Function
The biomechanics of the foot and ankle are complex, and this region must handle repetitive physical forces. There is normally a smooth transition from pronation following heel strike to supination at toe off. However, when there is excessive pronation or fixed supination, gait is affected, and the entire musculoskeletal system is less efficient. In the case of excessive pronation, the entire lower extremity undergoes excessive medial (internal) rotation, which can cause a range of effects on the pelvis, sacroiliac joints, and spine. Custom-made functional orthotics work to restore and support proper foot function.
Whether a foot tends toward hyperpronation or excessive supination, excessive shock may be transmitted into the spinal joints. “A high-arched (cavus) foot with limited range of motion attenuates shock poorly, and a hypermobile flat foot also does poorly on shock attenuation because of its function near the end of the range of motion.”6 In either case, the forces are felt in the joints of the pelvis and spine. In their classic investigation of skeletal transients on heel strike, Light and his colleagues found a significant stress that could be reduced by using viscoelastic heel pads. Regarding the spine, they warned that “while the transients will load the majority of joints primarily in compression, shear stress will predominate in others, such as the spinal facet and sacroiliac joints.”7 This explains the rapid response of lumbosacral and sacroiliac pain to the use of orthotics that contain viscoelastic materials such as Zorbacel® and TechCel™ (Fig. 2).
Leg Length Asymmetry
When there is a discrepancy in the length of the legs (whether anatomical or functional), the pelvis will tilt to one side. This asymmetry will cause vertebral rotation and recurrent subluxation, and possibly even a functional scoliosis (Fig. 3). The correct use of orthotics (occasionally with an added heel lift) can provide substantial correction for structural short legs.
When a good patient exam reveals any of the deficits in the pedal foundation listed above, the astute doctor of Chiropractic will recognize the need for supplementary treatment. This frequently requires the use of custom-fitted orthotics for long-term stabilization. Flexible orthotics made from viscoelastic materials have now been shown to be the most useful approach. As one investigator has commented, “the full rehabilitation of the back patient with chronic back pain, must include reeducation in the optimal use of the spine in walking.”8 Even expertly applied spinal corrections will often be only partially successful until the lower extremity problems are addressed and corrected.
[Captions for illustrations]
Fig. 1. First MTP Joint at Toe Off [“toe off” panel from gait cycle pic]
Fig. 2. FirmFlex Plus® orthotic with Zorbacel® and TechCel™
Fig. 3. Functional short leg, showing pelvic tilt and spinal curvature [PRS Vol. 8 #5, Fig. 2]
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 Katoh Y et al. Biomechanical analysis of foot function during gait and clinical applications. Clin Orthop Rel Res 1983; 177:23-33.
3 Dannanberg HJ, Guiliano M. Chronic low-back pain and its response to custom-made foot orthoses. J Am Podiatr Med Assoc 1999; 89:109-117.
4 Sousa TA. Differential Diagnosis for the Chiropractor. Gaithersburg: Aspen Pubs., 1997; 354.
5 Hayda R et al. Effect of metatarsal pads and their positioning: a quantitative assessment. Foot Ankle Int 1994; 15:561-566.
6 Subotnick SI. Forces acting on the lower extremity. In: Sports Medicine of the Lower Extremity. New York: Churchill Livingstone, 1989; 189.
7 Light LH, McLellan GE, Klenerman L. Skeletal transients on heel strike in normal walking with different footwear. J Biomech 1980; 13:477-480.
8 Yekutiel MP. The role of vertebral movement in gait: implication for manual therapy. J Man Manip Therap 1994; 2:22-27.
by William M. Austin, DC, CCSP, CCRD
How can orthotics designed for the feet improve the function and stability of the entire musculoskeletal system? The list of conditions that have been attributed to biomechanical imbalances in the feet is extensive. While it is obvious that foot hypermobility can affect the lower extremities, problems in the pelvis and spine can also be helped with the use of foot orthotics. Over the past few decades, research investigations have contributed to our understanding of this phenomenon.
Normal gait causes predictable, repetitive motions to occur from the feet to the head. One recent study concluded that “there are small, but important, inter-segmental movements of the spine during gait.”1 The accurate timing of the many muscle contractions required to control these fine spinal movements during walking and running depends on stimuli from a symmetrical gait.
Pedal imbalances, such as excessive foot pronation (whether in one foot or bilaterally) will interfere with these carefully orchestrated movements and cause problems throughout the musculoskeletal system. In fact, investigators have found that “Alteration of normal foot mechanics can adversely influence the normal functions of the ankle, knee, hip, and even the back.”2 This is how biomechanical problems, such as excessive pronation in the feet, can be the cause of recurrent spinal subluxations, back pain, and degeneration.
Effects of Pedal Instability
Whenever the necessary structural support for the spine is lacking, chiropractic care suffers. The foundation provided by the feet and legs must bear the weight of the entire body. If there is either too much pronation or excessive supination in the feet, the spine is repeatedly exposed to abnormal stresses and strains that will eventually develop into low back pain.
These biomechanical excesses will affect musculoskeletal function in four specific ways: abnormal rotational stress, chronic sacroiliac joint dysfunction, excessive shock transmission, and pelvic unleveling. The use of custom-made functional orthotics will improve gait symmetry and help relieve these negative effects.
Abnormal Rotational Stress
As the foot pronates during the stance phase of gait, there is a normal inward (medial) rotation of the entire leg, into the pelvis. When the foot and ankle complex on one side stays too long in pronation (hyperpronation), the entire lower extremity undergoes excessive medial rotation. This can cause stress on the knee and hip joints, as well as into the pelvis, sacroiliac joints, and spine. The increased rotational forces are transmitted up the leg into the pelvis, and especially the sacroiliac joint.3
In response, various compensatory pelvic subluxation complexes develop. These include pelvic tilts (usually anterior or to one side), innominate rotations (usually postero-inferior), and other complex adaptations. Asymmetrical pronation also results in abnormal firing of muscles during the rotational component of gait. This causes inaccurate proprioceptive nerve impulses and mechanoreceptor responses, affecting skeletal muscle coordination and balance.
“Based on excessive internal femoral rotation due to hyperpronation,” Hammer writes, “there may develop compensatory shortening of the iliopsoas, which would draw the spinal column downward, forward, and rotate it contralaterally. Unilateral iliopsoas involvement would cause a unilateral anterior pelvic tilt, while bilateral hyperpronation may result in an increased lordosis.”4
Chronic Sacroiliac Joint Dysfunction
Because of their complex anatomy and unique axis of joint motion, the movement pattern of the sacroiliac joints is called “nutation.”5 With each step, one leg swings forward and the pelvis twists forward on that side. At heel strike, the leg is externally rotated and the ilium is posterior (PI).
As the foot and ankle pronate, the leg rotates inward, and the sacroiliac joint “contranutates.”6 The ilium moves anterior (AS) during mid-stance. As the foot and ankle supinate and the leg rotates outward, the opposite movement (“nutation”) brings the ilium posterior. If this complex movement pattern is disrupted by one foot pronating more than the other, recurring sacroiliac joint subluxations and pelvic region pain develop.
Excessive Shock Transmission
A foot in supination doesn’t absorb shock well. Interestingly, a foot that stays in pronation too long will also transmit excessive shock into the pelvis and spine. “A hypermobile flat foot does poorly on shock attenuation,” Subotnick writes, “because of its function near the end of the range of motion.”7 In both of these cases, shock forces are felt first in the lower extremities, and then in the pelvis and spine.
Light and his colleagues studied the “brief but sizeable deceleration transient which travels up the human skeleton on heel strike during normal walking.”8 They found this shock wave to be a significant stress that could be reduced by the use of viscoelastic heel pads. Regarding the spine, they warned that, “while the transients will load the majority of joints primarily in compression, shear stress will predominate in others, such as the spinal facet and sacroiliac joints.” This explains the rapid response of lumbosacral and sacroiliac pain to the use of orthotics that control pronation and also contain viscoelastic materials.
The loss of arch height that occurs with excessive pronation allows the pelvis to drop to the more pronated side during stance and gait. Rothbart and Estabrook found a correlation factor of 0.97 between asymmetrical pronation and a pelvic tilt to the same side.(9) The resulting pelvic tilt lowers the sacral base and drops the lowest freely moveable vertebra.
A lateral spinal curvature develops in response to the lack of solid support for the base of the spine. This “functional” scoliosis starts in the lumbar region, but can affect the entire spine. When uncorrected for a period of years, the leg asymmetry and pelvic misalignment produce sustained stress on the spinal joints, resulting in classical patterns of microtrauma, cartilage wear, and osteophytes.9
The most common cause of leg length discrepancy is a lowered medial arch and excessive pronation. In such cases, there is no possibility of eliminating the pelvic or spinal subluxations without correcting pedal imbalance. Using orthotics to reduce pronation can provide substantial correction for most short legs. It is very important to recognize the functional short leg, since providing a lift instead of an orthotic is likely to perpetuate the associated sacroiliac subluxations.10
Reducing Musculoskeletal Stress
A properly designed custom-made orthotic will provide the following corrections throughout the day and during all locomotor activities:
- Decreases the extent and speed of pronation (reduces the medial rotation force that is transmitted up the leg into the pelvis and spine)
- Improves alignment of the arches (permits smoother nutation of the sacroiliac joints during gait)
- Absorbs shock from viscoelastic materials (eases the impact at heel strike and reduces the abnormal forces on degenerated joints)
- Reduces calcaneal eversion with a “pronation wedge” and support the medial arch (limits the dropping of the pelvis during gait and the effects of a functional short leg)
Look to the Feet
While the feet are located at the far end of the musculoskeletal system, they are a vital part of overall stability. Both structural and neurological factors form this inter-related and integrated system. Posture, as well as balance, coordination, and efficient musculoskeletal function, depend on the smooth functioning of the foot and ankle complex.
Whenever a patient demonstrates evidence of musculoskeletal instability, we must always consider the importance of the lower extremities, and the feet in particular. Even expertly applied chiropractic adjustments to the musculoskeletal system will often be only partially successful until lack of stability from the feet has been addressed with custom-made orthotics.
About the Author
An enthusiastic speaker, Dr. William Austin provides an energetic approach to learning. He draws from over 37 years of healthcare experience, which includes Athletic Training, Chiropractic, and Chiropractic Research. He has developed two successful practices. He is a 1986 graduate of Logan College of Chiropractic.
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 Katoh Y et al. Biomechanical analysis of foot function during gait and clinical applications. Clin Orthop Rel Res 1983; 177:23-33.
3 Botte RR. An interpretation of the pronation syndrome and foot types of patients with low back pain. J Am Podiatr Assoc 1981; 71:243-253.
4 Hammer WI. Hyperpronation: causes and effects. Chiro Sports Med 1992; 6:97-101.
5 Kapandji IA. The Physiology of the Joints, Vol. 3: The Trunk and Vertebral Column. New York: Churchill Livingstone, 1974.
6 Magee DJ. Orthopedic Physical Assessment. Philadelphia: WB Saunders; 1987: 220.
7 Subotnick SI. Forces acting on the lower extremity. In: Sports Medicine of the Lower Extremity. New York: Churchill Livingstone, 1989:189.
8 Light LH, McLellan GE, Klenerman L. Skeletal transients on heel strike in normal walking with different footwear. J Biomech 1980; 13:477-480.
9 Rothbart BA, Estabrook L. Excessive pronation: a major biomechanical determinant in the development of chondromalacia and pelvic lists. J Manip Physiol Ther 1988; 11:373-379.
10 Giles LGF, Taylor JR. Lumbar spine structural changes associated with leg length inequality. Spine 1982; 7:159-162.
by Brian D. Jensen, DC
According to the American Academy of Orthopedic Surgeons (AAOS), more than 700,000 knee replacement operations performed each year in the United States. Although the majority of these operations are performed in people over the age of 65, a growing number of knee replacements are being done in younger patients. A study presented at the 2014 AAOS meeting found that the number of surgeries for patients 65 to 84 increased by 89%, while surgeries for patients 45 to 64 increased by 188%.
Most surgeons expect to see the proportion of knee arthroplasties performed in younger patients continue to rise. One reason for this trend is improvements in surgical technique, as well as the design and construction of knee prostheses since the first knee replacement was performed in 1968. Although most knee prostheses are still cemented in place, cementless prostheses were introduced in the 1980s. A second reason for the trend is people's changing attitudes toward aging and their expectations of an active life after retirement. Fewer are willing to endure years of discomfort or to resign themselves to a restricted level of activity.
Why the Higher Numbers?
It is projected that the number of primary total knee replacements will increase to 3.48 million by 2030, compared with a growth in the number of primary total hip replacements to 572,100. Additionally, given the growth in the number of procedures in the younger, more active patients, implant longevity will require further enhancement.
These numbers are staggering, and they have to make you wonder: Why is this such a growing problem? Degeneration of the knees is not a new phenomenon to our society. I think the rate has been accelerated by the obesity epidemic in this country, as well as the fact that knee replacement technology has become advanced to the point that the risk of the surgery has been diminished by the reward of being pain free and active.
I have seen this with patients as well as family members—years of subtle biomechanical dysfunction leading to gradual degradation of the joint, followed by stiffness, swelling, and eventually debilitating pain. A vast majority of them responded favorably to the new hardware and were able to resume a more active and pain-free lifestyle. The results are wonderful, but it still doesn’t make me a big advocate of knee replacement surgery. I am more of an advocate of common sense and conservative management, even going so far as to say that I am a “preventionist.” I am genuinely happy that there exists a technology for replacing damaged and degenerated joints—I just don’t want to participate in that technology. So I am going to take steps to prevent the factors that contribute to that sorry state.
Preventing Asymmetrical Stress Problems
To understand the basic principles of prevention, think back to when you were 6 years old, and remember the old “Dem Bones” song. The ankle bone is connected to the knee bone! It’s simple and a little silly, but truer words have never been spoken. The foot and ankle influence movement and function throughout the entire skeletal structure. If there are subtle differences in function and flexibility from one foot to the other, those differences are translated superiorly through the knees into the hips, pelvis, and spine.
The most common influential factor of the feet is bilateral, asymmetrical excessive pronation. The dropping of the navicular bone and internal rotation of the foot/ankle complex slightly twists the knee—because the ankle bone is connected to the knee bone! The slight internal rotation of the tibia correlates with an increase in the Q angle. An increased Q angle has been associated with increased incidents of ACL injuries, but let’s assume you don’t do anything very athletic that predisposes you to the running and jumping forces associated with a typical ACL tear. The difference is speed of injury. You end up with the slow accumulation of microtrauma as opposed to the sudden onset of macrotrauma. Asymmetrical stress to the cartilage is compounded by the fact that there is a neuromuscular inhibition of the quadriceps femoris muscle with excessive pronation, further contributing to the asymmetrical stresses on the knee.
This is the foundational source of stress that contributes to degenerative changes in the knees, hips, pelvis, and spine. For me, the most basic form of prevention comes from custom-made functional orthotics to block the biomechanical differences in the feet that are transferred up the Kinetic Chain. Creating a symmetrical foundation at the feet with functional orthotics allows the joints above the feet to function more symmetrically. This reduces the effect of unequal forces and angulations on the cartilaginous structures and enhances the neuromuscular response to proprioceptive input.
When the harmful biomechanical stresses are managed efficiently, the result is a reduction in microtrauma. This means that there is less inflammation, scar tissue, and joint space degradation. Addressing the foundation is fundamental to preserving optimal joint function in the presence of an imbalanced foundation.
I realize that prevention is not something that typically falls under the category covered by most insurance policies. There are policies and codes that address specific conditions of the feet and knees that are appropriate for you to submit to an insurance carrier, but I think it is our obligation to patents to point out wellness strategies while they are under our care. I know that I can’t be the only one out there who doesn’t want to participate in the latest joint replacement technology.
About the Author
Dr. Brian Jensen graduated from Palmer College of Chiropractic in 1987. He speaks on a wide variety of topics, including orthotic therapy, posture, structural preservation, breaking free of the medical model of health care, and innovations in nutrition.