By Brian Jensen, DC
If a patient is unable to walk stably, the treatments you provide will have less than enduring results. As you examine new patients, watch for five signs that may indicate structural instability, which can be corrected with orthotics.
The five signs are foot flare while walking, internal knee rotation, bowed Achilles tendon, low medial arches, and excessive shoe wear.
Here is how to use these visual clues during evaluation:
• Foot flare while walking. As your patient walks down the hall toward the exam or treatment room, look and watch his feet.
Ideally, the toes should point straight forward while walking. But, during the swing phase of the gait cycle, you often see the toe of the patient’s foot point laterally away from the mid line.
This is an indication that there is a need for further investigation. Toeing out could, for example, indicate a compensation mechanism for a functional leg-length inequality — a short leg. Or, it could be an indication of hip or knee involvement.
• Internal knee rotation. Stand in front of your patient with her knees and lower legs exposed and observe the position of the patellae.
If you were to position a plumb line at the center of the knee cap, the line should fall vertically to a point over the second metatarsal bone. A common condition is an internal deviation of the knees with the patellar line falling medial to the second metatarsal bone.
Notice if the knee rotation is symmetrical. Asymmetries are the cause of accelerated degenerative changes.
• Bowed Achilles tendon. Ask the patient to stand facing away from you with his lower legs exposed. Look at the medial aspect of the Achilles tendons.
If the Achilles bows medially, it indicates the calcaneus is rolling to the inside, which is a strong indication that the foot is pronating excessively. This distortion is often present with foot flare and low medial arches.
• Low medial arches. Look at the medial aspect of the foot from the big toe to the heel. The center of the foot should be higher than the front and rear of the foot. You should be able to slide your fingers under the arch up to the distal interphalangeal joint of your middle finger. If you can’t, you have a positive finding for low medial arches.
Remember: The medial arch is the last arch to collapse. Even if it appears to be well maintained, the lateral and transverse arches may be compromised and affecting the biomechanics of the lower extremity.
• Excessive shoe wear. If the shoes are not worn down evenly or there is a broken heel counter, this excessive wear indicates asymmetry or imbalance.
Study the clues
As you begin to study these five visual clues, you’ll see recurring patterns associated with some very predictable findings: Low back pain, knee pain, and restricted movement patterns associated with joint fixation of the hips and pelvis; and compensation mechanisms that may or may not result in aches or pain — at least not yet.
Postural changes translate all the way up to the cervical spine, often in the absence of trauma. These are not random circumstances that just happen to befall the poor and unsuspecting; these are the result of biomechanical changes that start inside your patients’ shoes. The kinetic chain includes foot, ankle, knee, hip and pelvis, and spine.
Imbalances lead to premature wear and tear, chronic degeneration, and intermittent flare ups.
The most effective way to address the instability, as indicated, is to support the feet. Orthotics affect the entire kinetic chain. They enhance neuromuscular response, reduce the harmful shock forces absorbed by the articular cartilage, and create a symmetrical, balanced foundation. If structural imbalances accelerate degeneration, it makes sense that structural balance slows that process down.
If it isn’t already part of your routine exam procedure, add a new evaluation tool and look for these five signs of postural instability. These visual clues will open up a whole new world of understanding about biomechanics, spinal instability and the potential cause of degenerative arthritis, pain, and joint instability.
If you identify any of these signs early enough in a patient’s life, you have a chance to prevent a great deal of unnecessary suffering.
Brian Jensen, DC, is associate director of education at Foot Levelers Inc. (www.footlevelers.com). He can be reached by e-mail at bjensen@footlevelers.com.
