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Foundation Of Your Body

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William M. Austin, DC, CCSP, CCRD

Figure 1. Foot conditions and age

Figure 1. Foot conditions and age

Most chronic low back pain is the result of some form of structural weakness or failure.1–2 The cause of chronic lumbar spine breakdown is microtrauma, which is produced by biomechanical errors, structural asymmetries, tissue weaknesses and excessive external loads. The source of these conditions must be recognized and addressed in order to prevent further breakdown and chronicity. That source is often an imbalance/condition in one or both of the feet.

Why the Pedal Foundation Is Important

The feet are the foundation of the body. While 99% of all feet are normal at birth, 8% develop troubles by the first year of age, 41% at age 5 and 80% by age 20 (Fig. 1).3 By age 40, nearly everyone has a foot condition of some sort. Many foot conditions eventually contribute to health concerns farther up the Kinetic Chain, especially the generalized condition of ‘back pain’ (Fig. 2). Therefore, it’s in the best interest of your patients for you to be able to spot a potential low back problem originating in the foot/feet before it is allowed to affect a patient’s health and/or lifestyle.

Foot anatomy. Comprised of one-quarter of the body’s bones, the feet are vulnerable to structural deficits, such as misalignment of bones and connective tissues leading to excessive pronation or supination.4–6

Figure 2. Foot conditions contribute to health concerns above the ankle

Figure 2. Foot conditions contribute to health concerns above the ankle

The foot is constructed with three arches (Fig. 3) which, when properly aligned, give exceptional supportive strength—what is known as the ‘plantar vault.’ The medial longitudinal arch (A to C) extends from the calcaneus through the first three metatarsals. It is the longest and highest arch, and is the most important during static support, movement, and shock absorption. The keystone of the medial arch is the navicular bone. The lateral longitudinal arch (B to C) extends from the calcaneus through the last two metatarsals. It is shorter and lower than the medial arch. Its keystone is the cuboid. Subluxation of the cuboid is a common cause of lateral foot pain. The metatarsal or anterior transverse arch (A to B) is the hollow in the inner part of the sole just proximal to the tarso-metatarsal articulation. Precise placement of metatarsal pads under this arch is one of the most effective programs of care for metatarsalgia, the most common pain syndrome of the forefoot.7–8

Foot Abnormalities and their Relation to Back Pain

The following is a sampling of conditions in which the feet and lower extremities can have a major impact on lumbar spine function:

  • Metatarsalgia. Metatarsalgia is foot pain that involves the metatarsal bones in the forefoot. The patient complains of pain on the bottom of the ball of the foot. Metatarsalgia may be due to a number of factors, from overuse of the foot during sports, to improper footwear, excessive weight or foot subluxations. Pain in the forefoot often leads to altered gait, which in turn can produce stress/pain in the pelvis and low back.
  • Excessive pronation and/or arch collapse. Figure 4 illustrates a typical case of a pronated, flat foot. When either of these conditions is present, a torque force produces internal rotation stresses to the leg, hip, pelvis, and low back (Fig. 5).9 The result is recurring subluxations and eventual ligament instability affecting the sacroiliac and lumbar spine joints.
    Figure 3. Arches of the foot.

    Figure 3. Arches of the foot.

  • Fixed supination and/or high-arched foot. Figure 6 illustrates a typical supinated, high-arched foot. The foot which is ‘fixed’ into excessive supination—or which has a very high-arched (‘cavus’) foot—is unable to move into pronation at heel strike. This results in a foot that is more rigid and hits the ground harder. The supinated foot is also a tighter, stiffer foot that doesn’t flex and bend to accommodate variations in terrain. The poor absorption of shock and lack of flexibility cause biomechanical disorders, such as sacroiliac joint and lumbar facet irritation.10
  • Heel pad atrophy. As the human body ages, the fat pad that cushions the heel gets thinner. The central portion of the heel is most painful to palpation. The heel pad no longer feels thick and rubbery when palpated, and it may have a flat appearance. Atrophied heel pads provide less protection from heel-strike shock. This shock can aggravate and perpetuate low back pain, especially in patients with degenerative changes in the lumbar discs and facets.
  • Heel spurs. A heel spur is a degenerative outgrowth of bone (a type of osteophyte) on the calcaneus. A heel spur demonstrates that there has been chronic tension on the plantar fascia at the calcaneal insertion. Whether it is currently symptomatic must be closely investigated, since some heel spurs are not associated with pain. However, we must realize that this is an indicator of abnormal biomechanical function.
    Figure 4. Pronated, flat foot

    Figure 4. Pronated, flat foot

  • Leg length inequality (LLI). A functional or anatomical difference in leg length produces abnormal structural strains on the pelvis and low back. These strains can cause not only chronic pain, but have also been shown to result in specific degenerative changes.11,12

Pedal Support

A significant factor in reducing excessive biomechanical forces on the lumbar spine is frequently overlooked by practitioners: the use of orthotics to decrease external forces. For each of the abnormalities mentioned above, Foot Levelers’ custom-made functional orthotics are not only appropriate, they will contribute significantly to a cost-effective program of care.

Custom-made orthotics are used to align and support the foot/ankle complex in a more near-normal physiologic position for a weightbearing foot, to prevent dysfunction, and/or improve function of movable body parts.13 Fig. 7 is a practical guide of key indicators (‘red flags’) to be considered when making your clinical decision if a patient would benefit from custom-made orthotics.

Custom-made functional orthotics are indicated to:

  • Create a symmetrical foundation by blocking pronation or supporting supination. An asymmetrical pedal foundation is a contributing factor in pelvic unleveling and flexible scoliosis.14-17 Yochum demonstrated how a 15.5 mm LLI in a patient could be reduced to just 4mm with the use of Foot Levelers’ custom-made orthotics (Figs. 8A & 8B).18 Not only had the pelvic deficiency been markedly reduced, but the right compensatory listing of the lower lumbar spine had also diminished.
    Figure 5. Effects of excessive pronation

    Figure 5. Effects of excessive pronation

  • Provide heel strike shock absorption—the natural shock absorption capacity of the foot/ankle complex is reduced with either pronation or supination.17,19 Pronated feet are more susceptible to metatarsal stress fractures, whereas the tibia is more susceptible with supination.
  • Inhibit serial biomechanical stress up the Kinetic Chain—the inward rotation of the foot/ankle complex, tibia, and fibula is a contributing factor in frequent ankle sprains, lower leg compartment syndromes, patello-femoral dysfunction, medial knee DJD, stress fractures, ilio-tibial band inflammation and pelvic unleveling. Foot mechanics affect all joint complexes above, including the sacroiliac joints, up to the occiput.20,21
  • Enhance neuromuscular re-education—the sensory information from the mechanoreceptors of the foot play a major role in balance, gait, reciprocal inhibition and innervation of muscles, and posture.22–24 Orthopedic manual muscle is an indicator of enhanced function, and is becoming an active area of research.

What to Do

The responsible practitioner will evaluate the impact of patient lifestyle, physiology, and clinical condition to define the individual stress level acting upon the Kinetic Chain. When orthotic care is indicated, Foot Levelers’ custom-made, flexible functional orthotics are recommended because of their state-of-the-art, individualized design and proven effectiveness.25–30 The most advanced of these custom-made orthotics ‘families’—the InMotion® line—boasts the patented Extreme Gait Cycle System® with 75% more shock-absorbing Zorbacel® at heel-strike; StanceGuard™ for midstance support; and 50% more Propacel™ for a propulsive ‘boost’ at toe-off (Fig. 9).

Figure 6. Supinated, high-arched foot

Figure 6. Supinated, high-arched foot

[Figure 9. Foot Levelers’ InMotion® with Celliant® and silver-infused top cover, which increases tissue oxygen by up to 10.2% and reduces foot odor]

In Summary

Foot abnormalities can have a significant impact on the proper functioning of the low back. Orthotic care has been shown to reduce structural strains and bring about significant clinical response.31–32 Correcting foot problems with Foot Levelers’ custom-made functional orthotics helps to reduce lumbosacral discomfort and helps enhance pelvic and spinal stability.

References

  1. Plantar Pressure Distribution Pattern during Mid-Stance Phase of the Gait in Patients with Chronic Non-Specific Low Back Pain.Anukoolkarn K, Vongsirinavarat M, Bovonsunthonchai S, Vachalathiti R. J Med Assoc Thai. 2015 Sep; 98(9):896-901.
  2. Association between foot type and lower extremity injuries: Tong JW, Kong PW. J Orthop Sports Phys Ther. 2013 Oct; 43(10):700-14. doi: 10.2519/jospt.2013.4225. Epub 2013 Aug 3
  3. Gatterman MI. Chiropractic Management of Spine Related Disorders. Ed. Gatterman MI et al. Baltimore: Williams and Wilkins, 1990. 413.
  4. Influence of Step Rate on Shin Injury and Anterior Knee Pain in High School Runners. Luedke LE, Heiderscheit BC, Williams DS, Rauh MJ. Med Sci Sports Exerc. 2016 Jan 26.
    Figure 7. Five key indicators ("red flags")

    Figure 7. Five key indicators (“red flags”)

  5. Risk Factors and Protective Factors for Lower-Extremity Running Injuries A Systematic Review. Gijon-Nogueron G, Fernandez-Villarejo M. J Am Podiatr Med Assoc. 2015 Nov; 105(6):532-40.
  6. High-intensity running and plantar-flexor fatigability and plantar-pressure distribution in adolescent runners. Fourchet F, Kelly L, Horobeanu C, Loepelt H, Taiar R, Millet G. J Athl Train. 2015 Feb; 50(2):117-25.
  7. Effect of a metatarsal pad on the forefoot during gait. Koenraadt KL, Stolwijk NM, van den Wildenberg D, Duysens J, Keijsers NL. J Am Podiatr Med Assoc. 2012 Jan-Feb; 102(1):18-24.
  8. The effect of 3 foot pads on plantar pressure of pes planus foot type. Nordsiden L, Van Lunen BL, Walker ML, Cortes N, Pasquale M, Onate JA. J Sport Rehabil. 2010 Feb; 19(1):71-85.
  9. Effect of foot hyperpronation on lumbar lordosis and thoracic kyphosis in standing position using 3-dimensional ultrasound-based motion analysis system. Farokhmanesh K, Shirzadian T, Mahboubi M, Shahri MN. Glob J Health Sci. 2014 Jun 17; 6(5):254-60.
  10. Hartley A. Practical Joint Assessment: A Sports Medicine Manual. St Louis: Mosby Year Book, 1991:573.
  11. Foot posture, leg length discrepancy and low back pain–their relationship and clinical management using foot orthoses–an overview. Kendall JC, Bird AR, Azari MF. Foot (Edinb). 2014 Jun; 24(2):75-80.
  12. Leg-length discrepancy is associated with low back pain among those who must stand while working. Rannisto S, Okuloff A, Uitti J, Paananen M, Rannisto PH, Malmivaara A, Karppinen J. BMC Musculoskelet Disord. 2015 May 7; 16:110. doi: 10.1186/s12891-015-0571-9.
  13. Levitz SJ. Biomechanical foot therapy. Clinics in Podiatr Med and Surg 1988.
    Figure 8. Before (A) and after (B) the use of Foot Levelers custom-made orthotics

    Figure 8. Before (A) and after (B) the use of Foot Levelers custom-made orthotics

  14. Management of adolescent idiopathic scoliosis. Peelle MW, Luhmann SJ. Neurosurg Clin N Am. 2007 Oct; 18(4):575-83.
  15. The relationship between foot motion and lumbopelvic-hip function: a review of the literature. Barwick A, Smith J, Chuter V.
  16. The correlation between calcaneal valgus angle and asymmetrical thoracic-lumbar rotation angles in patients with adolescent scoliosis. Park J, Lee SG, Bae J, Lee JC. J Phys Ther Sci. 2015 Dec; 27(12):3895-9. doi: 10.1589/jpts.27.3895. Epub 2015 Dec 28.
  17. Adults with flexible pes planus and the approach to the prescription of customised foot orthoses in clinical practice: A clinical records audit. Banwell HA, Thewlis D, Mackintosh S. Foot (Edinb). 2015 Jun; 25(2):101-9. doi: 10.1016/j.foot.2015.03.005. Epub 2015 Mar 25.
  18. Yochum TR, Barry MS. The short leg (revised edition). Practical Research Studies 1994; 4(5):1-4.
  19. Effect of soft and semirigid ankle orthoses on Star Excursion Balance Test performance in patients with functional ankle instability. Hadadi M, Mousavi ME, Fardipour S, Vameghi R, Mazaheri M. J Sci Med Sport. 2014 Jul; 17(4):430-3. doi: 10.1016/j.jsams.2013.05.017. Epub 2013 Jun 28.
  20. Harries M et al. Oxford Textbook of Sports Medicine. Oxford University Press, 1994.
  21. Association between foot type and lower extremity injuries: systematic literature review with meta-analysis. Tong JW, Kong PW. J Orthop Sports Phys Ther. 2013 Oct; 43(10):700-14. doi: 10.2519/jospt.2013.4225. Epub 2013 Aug 30.
  22. Guyton AC. Textbook of Medical Physiology. Philadelphia: WB Saunders Co., 1981.
  23. Evaluation of autonomic dysfunction in familial dysautonomia by power spectral analysis. Maayan C, Axelrod FB, Akselrod S, Carley DW, Shannon DC. J Auton Nerv Syst. 1987 Nov ;21(1):51-8. Erratum in: J Auton Nerv Syst 1988 Mar; 22(2):174. Shannon CD.
    Figure 9. Foot Levelers’ InMotion® with Celliant® and silver-infused top cover, which increases tissue oxygen by up to 10.2% and reduces foot odor

    Figure 9. Foot Levelers’ InMotion® with Celliant® and silver-infused top cover, which increases tissue oxygen by up to 10.2% and reduces foot odor

  24. Plantar Pressure Distribution Pattern during Mid-Stance Phase of the Gait in Patients with Chronic Non-Specific Low Back Pain.Anukoolkarn K, Vongsirinavarat M, Bovonsunthonchai S, Vachalathiti R. J Med Assoc Thai. 2015 Sep; 98(9):896-901.
  25. Kuhn DR, Shibley NJ, Austin WM, Yochum TR. Radiographic evaluation of weight-bearing orthotics and their effect on flexible pes planus. J Manip Physiol Ther 1999; 22(4):221-226.
  26. Kuhn DR, Yochum TR, Cherry AR, Rodgers SS. Immediate changes in the quadriceps femoris angle after insertion of an orthotic device. J Manip Physiol Ther 2002; 25(7):465-470.
  27. Stude DE, Brink DK. Effects of nine holes of simulated golf and orthotics intervention on balance and proprioception in experienced golfers. J Manip Physiol Ther 1997; 20(9):590-601.
  28. Stude DE, Gullickson J. Effects of orthotic intervention and nine holes of simulated golf on gait in experienced golfers. J Manip Physiol Ther 2001; 24(4):279-287.
  29. 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.
  30. Fraser DM. Whiplash: a total body approach. J Neurol Orthop Med Surg 1994; 15:10-12.
  31. Targeting Patient Subgroups With Chronic Low Back Pain for Osteopathic Manipulative Treatment: Responder Analyses From a Randomized Controlled Trial. Licciardone JC, Gatchel RJ, Aryal S. J Am Osteopath Assoc. 2016 Mar 1; 116(3):156-68.
  32. Recovery From Chronic Low Back Pain After Osteopathic Manipulative Treatment: A Randomized Controlled Trial. Licciardone JC, Gatchel RJ, Aryal S. J Am Osteopath Assoc. 2016 Mar 1; 116(3):144-55.

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