Integrate structural and neurological approaches to care

Chiropractic care has long emphasized spinal alignment as a cornerstone of musculoskeletal health.

Emerging research and clinical insights also reveal the lower extremities, feet, knees and hips play an equally critical role in maintaining structural integrity and neurological balance. This article explores the interplay between structural misalignments, gait mechanics and dysafferentation (abnormal neurological signaling)^1,2 and illustrates why neurological approaches and extremity adjustments are not adjuncts but foundational to sustainable chiropractic care.

Structural foundations of lower limb stability

Biomechanics of the foot and gait cycle

The human foot is a marvel of engineering, comprising 26 bones, 33 joints and more than 100 ligaments.^3,4 During gait, it transitions from a flexible shock absorber at heel strike to a rigid lever at toe-off. A critical phase is midstance, when the foot bears full body weight. Excessive pronation, a triplanar motion involving eversion, dorsiflexion and abduction, disrupts the medial longitudinal, lateral longitudinal and anterior transverse arches. Over time, repetitive stress (7,000–10,000 daily steps) stretches the plantar fascia and spring ligament, causing plastic deformation. This collapse elongates the foot, flattens the arches and shifts weight distribution, creating a domino effect up the kinetic chain.

Clinical implications

• Pelvic tilt: Asymmetrical pronation often correlates with a superior ilium (high hip) on the longer leg side, unleveling the pelvis.
• Knee internal rotation: The tibia and femur rotate medially, straining the medial meniscus and ACL.
• Hip compensation: Restricted external hip rotation forces the lumbar spine to overcompensate, exacerbating disc and facet joint stress.

Orthotic intervention: Beyond arch support

Functional foot orthotics are not mere arch supports; they are precision tools designed to:

• Restore triplanar motion: Control excessive pronation/supination while permitting natural midfoot flexibility.
• Optimize ground reaction forces: Redistribute pressure away from overloaded structures (e.g., metatarsal heads).
• Enhance proprioception: Stimulate mechanoreceptors in the plantar fascia to improve balance.

Neurological approaches, neurological mechanisms: Dysafferentation and systemic impact

Joint dysfunction and afferent signaling

Joints are rich in mechanoreceptors (Types I–III) and nociceptors (Type IV). Hypomobility from misalignment silences mechanoreceptors, reducing inhibitory signals to the dorsal horn of the spinal cord. Concurrently, nociceptors fire excessively, creating a state of dysafferentation—a pathological imbalance in sensory input.^5,6,7

Consequences of dysafferentation

• Sympathetic overdrive: Nociceptive surges activate the sympathetic nervous system, elevating cortisol, heart rate and blood pressure.⁸
• Central sensitization: Chronic nociception lowers pain thresholds, amplifying perceived discomfort (e.g., allodynia).⁸
• Visceral-somatic reflexes: Aberrant signals from extremities can mimic visceral pathologies (e.g., pseudo-angina from T4 dysfunction).

Case study: Resolving chronic low back pain

A 45-year-old marathon runner presented with recurrent lumbar pain, unresponsive to spinal adjustments alone.⁹ Gait analysis revealed severe bilateral pronation and limited hip external rotation (-15° left, -10° right). Treatment included:

• Adjustments: Navicular/cuboid mobilization, tibial internal rotation correction and SI joint manipulation
• Orthotics: Custom three-arch supports with lateral heel wedges
• Rehab: Hip external rotation strengthening and proprioceptive drills
• Outcome: 80% pain reduction at six weeks, restored running capacity

Historical evolution, neurological approaches and modern applications of extremity adjusting

From DD Palmer to evidence-based practice

In 1910, DD Palmer asserted, “The chiropractor’s duty is to adjust all displaced bones—vertebral or peripheral.^10,11 Yet, for decades, extremity adjusting was overshadowed by spinal-focused paradigms. Recent advances in neurological approaches like, neuroimaging and gait analysis have revived interest in Palmer’s original vision, validating:

• Peripheral joints influence spinal health: A pronated foot increases lumbar disc compressive forces by 20%.
• Extremity adjustments modulate CNS function: Adjusting a dysfunctional ankle enhances cerebellar processing of balance.^12,13

Innovative techniques for the 21st century

• Instrument-assisted adjusting: Drop-table mechanisms and handheld devices improve precision in complex joints (e.g., midfoot).
• Dynamic taping: Kinesiology tape complements adjustments by providing proprioceptive feedback without restricting motion.
• Sensorimotor retraining: Wobble boards and single-leg stance exercises rewire dysfunctional movement patterns.

Integrative protocols for active patients

Stepwise management of low back pain

Assessment

• Static: Pelvic tilt, leg-length discrepancy, arch collapse
• Dynamic: Treadmill gait analysis, hip range-of-motion screening

Intervention

• Acute phase: Adjustments plus low-dye taping for temporary stabilization
• Long-term: Orthotics plus eccentric strengthening (e.g., tibialis posterior)
• Prevention: Educate patients on footwear choices and workplace ergonomics.

The role of collaboration

DCs must collaborate with podiatrists, physiotherapists and orthopedists to address multifactorial cases (e.g., congenital tibial torsion or femoral anteversion).

Final thoughts

Chiropractic care must evolve beyond a spinal-centric model to embrace the lower extremities as pivotal structural and neurological health determinants. DCs can resolve compensatory patterns at their source by integrating biomechanical corrections (e.g., orthotics, joint adjustments) with neuromodulatory strategies (e.g., dysafferentation reduction). Future research should explore how extremity-focused protocols impact systemic conditions, such as migraines and fibromyalgia, further solidifying chiropractic’s role in holistic healthcare.

Mark Charrette, DC, is a 1980 summa cum laude graduate of Palmer College of Chiropractic and a former All-American swimmer. He is a frequent guest speaker at chiropractic colleges and has taught more than 2,200 seminars worldwide on extremity adjusting, biomechanics and spinal adjusting techniques. He has authored a book on extremity adjusting and produced an instructional video series. His lively seminars emphasize a practical, hands-on approach. Learn more at footlevelers.com.

References

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6. Guyton AC. Basic Neuroscience. 2nd ed. WB Saunders;1991. https://archive.org/details/basicneuroscienc00guyt. Accessed June 20, 2025.
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9. Cambron JA et al. Shoe orthotics for chronic low back pain. Arch Phys Med Rehabil. 2017;98(9):1752-1762. https://www.archives-pmr.org/article/S0003-9993%2817%2930262-9/pdf. Accessed June 20, 2025.
10. Palmer DD. The Chiropractor’s Adjustor. Portland Printing House;1910. https://www.bknychiro.com/images/DDPalmer_booklet.pdf. Accessed June 20, 2025.
11. Palmer DD, Palmer BJ. The Science of Chiropractic. Palmer School;1906. https://search.worldcat.org/title/36930079. Accessed June 20, 2025.
12. Furman JM, Gallo PG. The Neurophysics of Human Behavior. 2000. https://archive.org/details/neurophysicsofhu0000furm. Accessed June 20, 2025.
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