There are a number of components doctors of chiropractic need to consider when examining the foot for biomechanical concerns.
Foremost is the need to screen new patients for the requirement for foot support and correction. This is important, because many (if not most) people have lower extremity and foot imbalances, which may be causing or complicating their spinal complaints.1
Often, though, patients don’t report foot problems; they only notice their back or pelvic symptoms. This means that you must frequently search for the underlying causes of the reported problem.
Sometimes, of course, a patient will report a history of foot, ankle, or knee problems that indicates the need for a more in-depth foot examination.2
When either the history or a screening examination indicates a further evaluation of the foot and ankle complex is necessary, it’s helpful to have a standard foot exam procedure. Technology can help; it also gives patients the “wow” factor, and can be a effective educational tool.
A 3D digital foot scanner has become integral to the intake process in many practices, whose staff know that every new patient gets scanned, and by talking through the results on- screen, patients begin to understand the concept of body imbalances, and how the feet can play an important role in whole-body posture.
Even if you don’t have a scanner yet, a well-designed exam will ensure that important factors aren’t forgotten or skipped in a busy practice. An evaluation protocol should include both static and functional evaluations of the foot and ankle complex, as well as the impact of this region on the pelvis and spine.
An evaluation of the foot when it is bearing weight—but not moving—is the easiest starting point. Many foot problems can be identified by examining the feet and ankles in their postural, weight-bearing position and then also while non-weight-bearing.
The first assessment of the feet and ankles takes place while they are bearing the weight of the pelvis and spine. In fact, this should be a standard part of the postural evaluation of every new patient.
As the patient’s usual standing posture is examined, check the pelvis, knees, lower legs, each ankle and calcaneus, and finally the feet and toes. Look carefully for the following indicators while the patient is standing:
- Pelvis: Is there a tilt or a twist; is either SI joint tender?
- Knees: Is one patella (or both) facing inward or outward; is there valgus or varus?
- Achilles tendons: Does one (or both) of the tendons bow medially?
- Calcaneus: Does the heel look tilted (everted)?
- Medial arch: Can a finger fit under each arch; is there pain with upward pressure?
- Navicular: Is the navicular bone prominent or dropped on the medial side?
- Forefoot: Are the toes misaligned, deformed, or is there a hallux valgus?
- Foot angle: Does one foot (or both) point out to the side (foot flare)?
With the patient sitting on the table, palpate and examine each foot individually.
Look for the following indicators of biomechanical problems:
- Limited mobility: Are any motions restricted during passive or active foot movements?
- Calluses: Is the body building up tissue in response to friction and abnormal motion?
- Weakness: Do manual muscle tests find an imbalance (front or back, medial or lateral)?
- Tenderness: Are any joints or insertions swollen or painful upon direct pressure?
- Bunions: Is joint alignment obviously abnormal, with remodeling and deformity?
While a static exam provides a lot of information about the posture and alignment of the feet, more information regarding foot function is often necessary. You want to get an idea of how the foot operates during daily activities.
Three quick evaluations can give a good snapshot of usual foot function: inspecting the wear patterns on shoes; watching patients while they walk; and measuring how much the arch drops when standing.
Shoe wear patterns
A few seconds spent evaluating the shoes for wear patterns can provide a wealth of information regarding abnormal foot biomechanics. Look for the following problems:
- Heel wear: Is there excessive wear or asymmetry at the lateral heel?
- Sole wear: Do the soles have different wear patterns?
- Heel counter: Is there an obvious tilt (usually inward) of the heel counter(s)?
- Upper bulging or scuffing: Is there abnormal wear or stretching of the shoe?
- Metatarsal crease: Does the shoe flex unevenly at the forefoot during toe-off?
Watching a patient walk provides information regarding biomechanical asymmetries and the body’s compensations. A visual inspection will include the following factors:
- Rhythm: Is there a limp or abnormal gait (due to pain or avoidance)?
- Cross-crawl: Do the arms and legs coordinate properly?
- In-toeing: Does one (or both) of the feet turn in while walking?
- Foot flare: Does one (or both) of the feet point outward while walking?
Digital foot scan
If you have a 3D digital foot scanner, every patient should be screened with it for foot imbalances. It only takes a minute, and with the right software you can analyze important factors such as degree of arch drop; left and right foot imbalance; and, most crucially, whether orthotics would be beneficial to the patient. Clear, compelling, and colorful screen images and reports of findings help the patient understand the importance of a balancing the pedal foundation.
Navicular drop test
Another useful and easy test to document the extent of excessive pronation is the navicular drop test.3, 4
This simple procedure measures the change in the position of the navicular bone from sitting to standing.
The test helps verify the existence of poor spinal support from the arches and demonstrates the need for orthotics to the patient. It requires no additional space or testing equipment—just a chair, a pen, and a file card. Here are the things to look for:
- Drop amount: A drop of 7 mm or more indicates a high risk, while 4 to 6 mm is a moderate risk, and is a problem for athletes or those on their feet for long periods.
- Foot asymmetry: A 4 mm or more difference from left to right is a high risk, and a 3 mm discrepancy is a moderate risk.
Putting it together
When a patient shows evidence of lower extremity asymmetry on a screening exam or reports lower extremity symptoms, a more in-depth examination of the feet and ankles is warranted. The combination of static and functional evaluations, in both postural and non-weight-bearing positions can quickly provide the information needed to determine the correct treatment approaches.
Orthotic support for biomechanical, postural, and functional abnormalities is an important part of chiropractic care. Foot asymmetries are associated with many musculoskeletal complaints—not just in the foot, but also up the leg to the knee, the hip, and even the pelvis and spine. Many times, correction of recurring pelvic and spinal subluxations can only be accomplished when the feet are provided with appropriate orthotic support.
Kevin Wong, DC, is an expert on foot analysis, walking and standing postures, and orthotics. He discusses spinal and extremity adjusting at speaking engagements. He can be contacted through orindachiropractic.com.
1 “Ask the Expert.” American Podiatric Medical Association (APMA). https://www.apma.org/ learn/AskTheExpertList.cfm?navItemNumber=4 Updated Jan. 2017. Accessed Jan. 2017.
2 Kirby KA. Biomechanics of the normal and abnormal foot. J Am Podiatr Med Assoc.2000;90:30-34.
3 Brody D. Techniques in the evaluation and treatment of the injured runner. Orthop Clin North Am. 1982;13:541-558.
4 Gould N. Evaluation of hyperpronation and pes planus in adults. Clin Orthop. 1983;181:37-45.