The lumbar spine and pelvis balance on the lower extremities during standing, walking, and running.
If leg or foot asymmetries or misalignments exist, abnormal forces transmitted along the closed kinetic chain can interfere with spinal function.1
Most chronic low-back pain is the result of some form of structural weakness or failure.2 The cause of chronic lumbar spine breakdown is micro-trauma, which is produced by the following conditions:
- Biomechanical errors
- Structural asymmetries
- Tissue weaknesses
- Excessive external loads
The source of these conditions must be determined and treated to prevent further breakdown and chronicity. And that source is often found to be an imbalance condition in one or both of the feet.
The pedal foundation
The feet are the foundation of the body. Statistical evidence shows that, at birth, most people have perfect feet. By age 20, 80 percent of those “perfect feet” have developed some type of problem, and by age 40 nearly everyone has a foot condition of some sort.
Many foot conditions eventually contribute to health concerns farther up the kinetic chain, especially the generalized condition of “back pain.” Therefore, it’s in the best interest of both you and your patient to spot a potential low-back problem before it is allowed to negatively affect health and lifestyle.
A significant factor in reducing excessive biomechanical forces on the lumbar spine is frequently overlooked by practitioners: the use of external supports (orthotics, heel lifts) to decrease external forces. The following are commonly seen conditions in which the lower extremity can have a major impact on lumbar spine function and, in each situation, orthotic support can contribute to an effective treatment outcome:
- When excessive pronation or arch collapse of the foot is present, a torque force produces internal rotation stresses to the leg, hip, pelvis, and low back.3 This results in recurring subluxations and eventual ligament instability affecting the sacroiliac and lumbar spine joints. These forces can be decreased significantly with the use of custom- made orthotics.
- In patients with degenerative changes in the lumbar discs and facets, the external force of heel strike may aggravate and perpetuate low-back pain. This can be readily reduced with the use of shock-absorbing shoe inserts or orthotics that contain viscoelastic compounds.4 The reduction in symptoms is often dramatic.
- An anatomical difference in leg length produces abnormal structural strains on the pelvis and low back. These can cause not only chronic pain, but also have been shown to result in specific degenerative changes.5-7
The use of lifts and orthotics has been shown to reduce these structural strains and bring about significant improvement. 8
Terry Yochum, DC, demonstrated how a 0.6 inch (15.5 mm) leg-length inequality in a patient could be reduced to just 0.15 inch (4 mm) with the use of a custom-made orthotic.9 Not only had the pelvic deficiency been markedly reduced, but the right compensatory listing of the lower lumbar spine had also diminished.
Asking your patients a few simple questions can gain insight into the cause(s) of their back pains. When the back acts up, look at the feet.
- Do you stand or walk on hard surfaces for more than four hours a day?
- Do you participate regularly in any physical sport (e.g., basketball, baseball, tennis, golf, or running)?
- Are you age 40 or older?
- Have you ever had a prior injury to your knee, back, or neck?
- Do your shoes wear unevenly?
- Do you have joint pain while standing, walking, or running?
- Is one of your legs shorter than the other?
- Do you have knock-knees or bowlegs?
- Do you have any obvious foot problems (bunions, corns, flat feet, etc.)?
- Do your feet “toe out” when you’re walking?
If your patient gives an affirmative answer to any of the above, consider him or her a likely candidate for custom-made orthotics.
Mark N. Charrette, DC, is a 1980 summa cum laude graduate of Palmer college. He is a frequent guest speaker at chiropractic colleges worldwide and has taught more than 1,400 seminars worldwide on extremity adjusting, biomechanics, and spinal adjusting techniques. He can be contacted at firstname.lastname@example.org or through footlevelers.com.
1 Keane GP. (1991). Back pain complicated by an associated disability. In: White AH, Anderson eds. Conservative Care of Low Back Pain. Baltimore: Williams & Wilkins: 307.
2 Fulton M. Lower back pain: new protocols for diagnosis and treatment. Rehab Management. 1988;Nov/Dec:39-42.
3 Hammer WI. Hyperpronation: causes and effects. Chiro Sports Med. 1992;6:97-101.
4 Light LH, et al. Skeletal transients on heel strike in normal walking with different footwear. J Biomechanics. 1980;13:477-480.
5 Giles LGF, Taylor JR. Low-back pain associated with leg length inequality. Spine. 1981;6:510- 521.
6 Friberg O. Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality. Spine. 1983;8:643-651.
7 Giles LGF, Taylor JR. Lumbar spine structural changes associated with leg length inequality. Spine. 1982;7:159-162.
8 Hoffman KS, Hoffman LL. Effects of adding sacral base leveling to osteopathic manipulative treatment of back pain: a pilot study. JAOA. 1994;94:217-226.
9 Yochum TR, Barry MS. The short leg (rev. ed.). Practical Research Studies. 1994;4(5).