If there’s one thing I have learned in practice, it’s this: Don’t be fooled by not checking the feet. Remember that as a profession, we understand the axial kinematic chain. Joints down below can definitely have an effect on joints up above, either positively or negatively. I have found in the past when I’ve skipped over the feet thinking they had no bearing, I have had to go back later and evaluate them since there was a relationship to the patient’s complaint. For many of us, the feet are not the first place that we think about looking, especially if a patient comes in complaining about hip or lower back pain. “Why would you bother checking the feet when someone isn’t complaining about pain in the feet?” Not only are you asking me this question, but the patients ask it of me as well.
For most of the patients that walk through your door, the reason you should be checking their feet lies in the concept of excessive foot pronation. Eight out of 10 people pronate excessively when they are performing any type of weight bearing activity. Eighty percent of all people coming into our office, from children to the elderly, have feet that roll inward due to some degree of arch collapse. This is a common theme with runners.
Think about the power of that previous statement. This means that regardless of where a chiropractor practices in the world or what techniques they use to remove subluxations or misalignments, 80 percent of the people will have excessive pronation. The kicker is, the patients usually don’t even realize it. Here’s ?another interesting fact: often, the chiropractor doesn’t realize there is excessive foot pronation either. The altered biomechanics that result can lead to pain in the feet, ankles, knees, hips, lower back or higher.
Foot pronation is a normal occurrence when the foot flattens out during the gait cycle. At the subtalar joint, we should observe a healthy amount of foot/ankle inversion, dorsiflexion and abduction. In fact, foot pronation is necessary in order to have normal foot biomechanics. What we are looking at now is the problem of excessive foot pronation; where the foot is dropping or flattening out too much.
Now we have a situation where the foot rolls in so much that the connective tissue and the three arches on the bottom of the foot cannot provide the proper support. When the three arches of the feet begin to collapse due to any number of reasons, we can start to observe the effects of over-pronation as signs and symptoms in the patient.
Excessive foot pronation affects both feet, one usually worse than the other. Since our feet are not as springy and resilient as they were previously, the connective tissue on the underside of the foot (mainly the plantar fascia) becomes stretched permanently. Elastic tissues now become more plastic and deformed. Shock transmission is increased each time the heel strikes the ground because the foot is less biomechanically stable. Thus the foot is not able to absorb the ground shock and it moves into the ankle and up the kinematic chain with more force.
Over-pronation begins at the feet and spreads northward like the domino effect. If you stand up and roll your feet inward as far as you can, it recreates what happens to people who are experiencing excessive foot pronation. You can actually follow along with your own body to find out what happens.
As the arches fall toward the ground and become flatter, more stress is placed on the medial ankles. The tibia and femur bones inwardly or medially rotate, placing stress on the medial knee. The patellae also move medially as a result of the physical forces, thus affecting the Q angle negatively. The femoral head is pulled laterally, placing a lot of pressure on that particular joint. The pelvic effects are equally as significant. There is dropping of the pelvis and posterior movement of the ilium bones. Excessive pronation continues its march up the spine by affecting the thoracic area and shoulder levels. It even affects the pull of the muscles of the neck and skull.
So what is the significance of excessive pronation for your practice? It can be a significant contributor or cause of many ailments that patients present within your office. Sprained ankles, plantar fascitis, achilles tendonitis, shin splints, Osgood schlatter disease, ACL/meniscal/knee pain, patellar tendonitis, hip pain, lower back pain, neck pain and headaches are some examples of what excessive pronation causes. We treat these conditions on a daily basis, no matter what technique you use.
When dealing with treatment we want to adjust the feet and extremities and the spine where appropriate. The use of physical therapy modalities and exercises are helpful as well, but they are not enough. Once the patient stands up and walks out to your front desk to pay your receptionist, the body goes right back into its’ over-pronated state. Essentially all of your work will be shortly undone with each subsequent step they take. So what else might you do to fortify all of the excellent chiropractic care you have just administered?
One of the key concepts in treating the feet focuses around the permanent stretching of the plantar fascia that has occurred. The muscles of the foot can be exercised, but they are not the primary stabilizers of the arch. Exercises will help in strengthening the foot, but they alone will not bring back the arches. The permanent stretching of the plantar fascia must be addressed.
Thus some type of custom molded orthotic must be prescribed for the patient. Does that mean the patient will always have to wear ?orthotics for the rest of their lives? Yes, but it is better than experiencing progressively worsening pain and watching their feet go through arthritic changes. Flexible, custom molded, three-arch orthotics have been documented to be extremely effective for helping the many conditions and joint stresses described earlier. Traditionally, flexible orthotics have been made using foam impression casting. This method is rapidly being replaced by digital scanning technology that reduces error rates by the doctor and gives the patient a “technology show” that impresses them.
Make sure that you assess the feet on as many of your patients as necessary. There may be a few exceptions to this piece of advice. However, if you routinely check the feet of your new patients and even go back and reassess some of your long-time patients, you will be surprised at what you will find. Once you determine there is a relationship between the feet and the body, you can implement an effective, specific treatment plan that will greatly enhance the positive results from your care.
For many athletes, the feet are the most frequently injured anatomical feature. The following stretches and exercises will strengthen the muscles in your feet and calves. In turn, you’ll be giving your body a better foundation.
Golf Ball Exercise Sit with a golf ball under your bare foot. Roll the ball with as much pressure as is comfortable from the front of your foot to the back, and along the arches and outer edges. Do this for up to five minutes per foot, twice a day. This exercise loosens and relaxes your foot.
Sit in a chair and place a bath towel flat on the floor. With your bare foot, reach for the edge of the towel and scrunch it up toward yourself. This exercise helps condition your arches and strengthen your foot. Try performing this exercise up to six times a day.
Sit in a chair with your foot crossed over your opposite knee. Grasp your foot with your hand and slowly bend your toes toward your knee. Hold the stretch for 10 to 15 seconds.
On a set of stairs, stand with both feet on the same step. Position your feet so that your heels hang off of the step. Bend your left knee and move your hips forward until you feel a stretch in your calf. Switch legs and repeat.
Facing a wall, place your hands on the wall for support and position one leg in front of the other. With your back leg straight, your heel flat on the floor, and your foot pointed straight ahead, lean slowly forward, bending your front leg. You should feel the stretch in the middle of your calf. Hold for 10 to 15 seconds.
Stand facing a wall with one leg in front of the other. Place your hands on the wall for support. Keeping your heels flat on the floor, slowly bend both knees. You should feel the stretch in the lower part of your leg. Hold for 10 to 15 seconds.
Next, with your left foot, bend your toes up against the wall, so the ball of your foot is on the ground. Bend your knee toward the wall, keeping it in line with your foot. The stretch should be felt in the arch of your foot. Hold for 30 seconds, switch legs and repeat.
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