Identify patient biomechanical problems that start on the ground with foot instability
Athletes and active lifestyle individuals of all levels will touch our practice in some form or another during our careers as chiropractors. Even if one does not specialize in treating sports injuries, it never fails that the opportunity to treat someone in this category will arise frequently.
These days athletes come in all ages, shapes and walks of life. Young children often begin sports at an early age, and we see people staying active well into their elderly years. Most of these patients begin playing sports without realizing the extent of the physical demands that will be placed on their bodies.
Caring for patients engaged in sports and athletic performance does not have to be complicated or even convoluted. Most of the time these individuals can have a unifying theme where we see patterns exist in the biomechanics or movement patterns of their bodies. These observations can offer not only an explanation of how they injure themselves but how we as chiropractors can treat them and help prevent future ailments as well.
The role of the arches
Let’s start by examining what starts to happen to most of us when we are young. The 26 bones constituting the feet are the foundation of our human house. The feet not only support the weight of the body but also perform vital biomechanical functions during all weight-bearing activities like standing, walking and running.
The three functional arches, forming the plantar vault under each foot, are fully formed by ages 6-7. No matter how much longer the foot grows as we mature, the arch support is set by age 7. The existence of the three arches is often unknown by the general public because it is simply not taught by the medical professionals from whom people generally seek care.
As chiropractors we are trained to look outside the proverbial box for the cause of a patient’s pain and dysfunction and not just chase symptoms. Bearing that in mind, let’s investigate a situation I have observed in my practice for upwards of 87% of the population whose arches have fallen to some degree.
This is referred to as excessive or overpronation, and this phenomenon will initiate the collapse of all three arches in a mild, moderate or severe state. After age 7, factors like genetics, activities/sports, injuries, types of shoes worn, etc., play a role in how quickly and how severely the arches fall. Keep in mind that the arch collapse occurs slowly over time, so patients usually don’t realize it is happening until years later.
Foot instability and its effects
To keep this in perspective, let’s look at the numbers. In my experience, I have seen that 85-87% of people excessively pronate; 3-5% supinate (feet roll out instead of in); and 10% have healthy arches and weight-bearing function. This means at least 8 out of 10 people walking into your clinic, including those playing sports, have flat feet to varying degrees.
That is a lot of patients exhibiting excessive foot pronation for us to identify. Since most of the patients seeking care in our clinics have flatter feet, we also see common clinical problems that present with them. Are you looking for this in your patients? Why should you?
Look at the diagram shown here (Fig. 1) and start with the feet. This diagram is referred to as the Crooked Person because it symbolizes and describes many of the athletes who are playing sports. Notice how the picture indicates this person has a left foot that is overpronating worse than the right. Normally, excessive foot pronation is bilateral (both feet) but asymmetrical (one foot is flatter than the other). Now use your logic and follow what is occurring from the foot/ankle upwards. Don’t forget, this process starts from the bottom up. Yes, when scanning the picture, one can observe effects all the way up to the head and jaw.
Start with the left foot and notice how it has dropped toward the floor because all three arches are collapsed. The dropped foot puts stress on the inner ankle and turns the tibia bone medially (inward). The medial tibial rotation pulls the patella in a medial direction as well. The femur bone follows suit and as it rotates medially it also puts lateral stress on the hip joint. The medial stress on the left hip pulls and tilts the left pelvis down lower than the right hip. Left lateral curvature of the lumbar spine along with a compensatory slight curvature of the thoracic spine can also be seen. The biomechanical pattern finally ends up un-leveling the shoulders. So, what does this explanation mean to us chiropractors?
Going up the chain
The effects of excessive pronation alter normal, healthy movement patterns. The patient is now experiencing increased stress and biomechanical wear and tear at the medial ankle, knee, kneecap, lateral hip, pelvis, spine, shoulders, neck and jaw.
In essence, every time they are performing weight-bearing activities, a shock wave will shoot up from their heel to their head and put increased stress on all the joints and their related soft tissues.
This has ramifications for athletes who often put repetitive and sustained physical demands on their bodies. The wear and tear created by the flat feet will eventually cause stress on the bones and soft tissues and they give way to injuries. It’s only a matter of time for our patients. Look at where the red hash marks are on Fig. 2. Do you know of any common injuries you see occurring in these areas?
Some of the more common ailments we see from athletes or physically active patients are:
- Plantar fasciitis
- Achilles tendonitis
- Shin splints (anterior/posterior)
- Osgood-Schlatter disease
- ACL tears
- Meniscus injuries (medial more than lateral)
- Iliotibial band pain
- Hip pain
- SI joint pain
- Lower back pain
- Mid/upper back pain
- Shoulder/rib pain
- Neck pain
- Jaw pain
If you are wondering where I got any of these areas from, then go back up to the first diagram of the Crooked Person and follow the progression of the excessively pronated feet that eight in 10 of the patients presenting to your clinic have. These are conditions you see frequently in athletes and non-athletes alike, so the foot instability principles we are talking about apply to many patients you are and will be helping.
Treating foot instability for improved function and performance
Aside from chiropractic care that includes adjustments, appropriate physiotherapy modalities, exercises and home care, please do not forget to determine needs for the arches of the patient’s feet. A custom-made, three-arch, flexible foot orthotic will make a huge difference in the feet as the foundation of their house.
Properly made custom foot orthotics from a weight-bearing scan or foam mold will help athletes and active-lifestyle individuals. In this case, specific measurements are taken from the scan or cast and factored in along with the height, age, weight and sex of the patient. This ensures a custom product. We are not talking about the store-bought, off-the-shelf orthotics, as those tend to have only one (maybe two) non-custom arch supports.
Reducing stress and strain
When the three arches of each foot are supported properly, the forces starting with the feet and moving through the axial kinematic chain are symmetric. The body will be under less stress and strain.
Athletes can perform at their maximum level and we can also greatly reduce the incidence of sports injuries. When one understands the “Crooked Person” is a high frequency of the patients we see, we essentially have a picture that is a road map to success. Just start from the feet, follow the stress pattern up the body and it gives you understanding of not only how to treat the patient, but how to help protect them in the future as well.
KEVIN M. WONG, DC, is a graduate of the University of California-Davis and a 1996 graduate of Palmer College of Chiropractic West. He has been a practicing chiropractor and continuing education instructor for over 24 years and is the owner of Orinda Chiropractic & Laser Center in Orinda, Calif. His practice has an evolving influence on the course material he teaches chiropractors, chiropractic assistants and students. As a member of the Foot Levelers Speakers Bureau since 2004, he is a frequently-requested speaker on the topics of extremity/spinal adjusting, foot biomechanics, orthotics and ergonomics, and teaches over 120 hours per year in the U.S. and internationally. See continuing education seminar opportunities with Foot Levelers speakers at footlevelers.com/continuing-education-seminars.