Evaluating the feet and the importance of gait analysis in new patients

The initial visit and assessing foot function and the importance of gait analysis can bring life-changing results

Each new patient who walks through the front door of your chiropractic clinic presents an opportunity for you to make a huge impression on their lives. Many of these individuals have already been bounced around to multiple health care practitioners for their ailment(s) with varying degrees of success. It is typical for new patients to exhibit disappointment, confusion and irritation with the type(s) of care they have had thus far. The patient may have received a diagnosis and treatment from a previous health care practitioner, but they are still in pain and are looking to you for different answers with assessing foot function and the importance of gait analysis.

Treatment protocols and foot function

We have been taught since chiropractic college that during a first patient encounter, there are specific steps to take. We must successfully interact with the patient, gather pertinent facts, and then arrive at our specific diagnosis and treatment plan. Observation, history-taking, physical/orthopedic and chiropractic examinations are just some of these important areas to cover.

Assessing the patient’s foot function and the importance of gait analysis should also be part of the initial visit. Not only do these steps provide critical information to help fact-find, but they also convey to the patient that you are very skilled and thorough at your job.

The patients may have seen specialists (podiatrists, orthopedic surgeons, etc.) who treat pain with medication, injections or surgery and tend to focus on symptoms of an issue rather than addressing the root cause, which is often dysfunctional feet. When allopathic medicine focuses on pain points, many acute and chronic conditions are simply prolonged, causing additional stress to other areas of the body. Ultimately, this creates additional frustration and cost for the patient while increasing the risk for surgical complications and/or opioid abuse.

The feet as the body’s foundation

One the most important areas of the body to evaluate on every new patient is ironically glossed over regularly by health practitioners in general. The two feet are the body’s foundation, and they offer powerful information toward understanding the stability and biomechanical state of the patient’s whole body. Most patients do not realize that there are three arches rather than just one on the inside of the foot.

Introducing the concept of how the feet affect the rest of the body on the initial visit sets the framework for future care. This “foot-spine connection” is a powerful tool in helping a patient understand stresses that affect the body from the feet all the way up to the head and jaw.

As chiropractors, we are trained to evaluate the spine and extremities of the body, and we employ these skills depending on the patient’s presenting complaints. When the feet are out of alignment, the entire body is affected and becomes unbalanced. Assessing and correcting foot function and the importance of gait analysis should be an integral part of chiropractic treatment and can help doctors achieve better care outcomes.

Examining the feet

With the patient barefoot and standing in front of you in an anatomical position, look at their feet and observe what state the three arches are in. I have observed that 99% of patients coming to our clinics exhibit excessive foot pronation that is either mild, moderate or severe.

It has been established that overpronation of the feet puts stress and strain on the ankles, knees, hips, pelvis, axial spine, shoulders and jaw. The remaining 1% of the population are excessive supinators or have healthy weight bearing. You will see far more overpronators than oversupinators.

Here is a menu of options on how to identify excessive foot pronation quickly and easily:

Visual changes of the feet: Have the patient stand in front of you and take a look:

Bunions on Metatarsals (MT) 1 and 5 — due to the flattened MT arch, the MTs rub against the edges of the shoes and calcium deposits in response to the stress.
Hallux valgus of the big toe — collapse of the MT/medial arches makes the big toe move laterally.
Hammer toes — collapse of the medial/lateral longitudinal arches makes the foot grow longer, pushing the toes into the edges of the patient’s shoes. This combined with the flattening of the MT arch can lead to hammer toes.
Calluses — ones located on the tops of the toes and on the balls of the feet are due to collapse of the MT arch. The tops of the toes hit the roof of the shoe while the MT heads rub on the sole of the shoe or the ground.

The 5 Red Flags of Overpronation:

External foot flare
Internal knee rotation
Medially bowing Achilles tendons
Flat medial arches
Uneven lateral heel wear

The digital foot scanner

A weight bearing, 3-D, laser digital foot scanner offers accurate assessments of the state of the arches underneath the feet. The scan indicates the severity of the arch collapse.

Gait analysis — Patients take walking for granted as it is just something they do to get from place to place. Recall that in the importance of gait analysis the gait cycle has two phases: the Swing Phase (40%) and the Stance Phase (60%). Focusing on the more clinically relevant information, let’s talk about the stance phase where the foot is in contact with the ground.

There are three parts of the Stance Phase:

Heel Strike — the calcaneus hits the ground and supinates while a force of 5 Gs goes from the heel into the ankle. That same force begins moving up the axial kinetic chain until it becomes .5Gs at the jaw after 10 milliseconds.
Foot Flat — the foot pronates at the subtalar joint and the tibia and femur bones internally rotate so the foot can grip the ground and make solid contact.
Toe Off — the MTP joints flex, the plantar fascia tightens, and the foot supinates as it gets ready to swing forward for the next step.

The key takeaway for the Stance Phase is realizing that during the foot flat portion, the tibia and femur bones are internally rotating under normal pronation circumstances. For people who are overpronating, their tibia and femur bones are excessively internally rotating with every step they take. This creates stress at the medial ankle, medial knee, hip, SI, lumbar spine and up the kinetic chain to the neck/head. Excessive pronators can wear down the cartilage and connective tissues in these joints, predisposing their bodies to arthritis, soft tissue injuries and pain.

What the evaluation of the feet reveals is that the feet have a critical role to play in overall body stability and stress. If the arches are flat, the feet cannot absorb shock and distribute forces in a safe manner for the body. Compensation results and problems arise in many areas of the body. To that end, recommending the proper arch support for the feet becomes paramount.

The digital scanner we discussed earlier or the traditional foam casting kits come into play. The scan or mold is analyzed by the lab correlating the patient’s age, height, weight and gender. Sixteen different measurements are then used to create a custom molded, three-arch orthotic to be worn comfortably in the patient’s shoes. So not only do these types of orthotics support the patient’s feet, but they stabilize the whole body from the ground up.

Of interesting note, a conclusive study, “Shoe Orthotics for the Treatment of Chronic Low Back Pain: A Randomized Controlled Trial,” published in the Archives of Physical Medicine and Rehabilitation, shows that three-arch, flexible, custom orthotics, particularly in combination with chiropractic care, significantly reduces low-back pain and improves function.¹

Patients do not often seek chiropractors out for foot-related issues because our current medical model would have them see a specialist instead. These doctors do not have the background and treatment methods that we do in regard to helping the entire body heal itself naturally. This is a point in the treatment path at which chiropractors can provide crucial guidance and information that the patient will not get elsewhere.

The importance of gait analysis and becoming the voice for foot stabilization

Chiropractors can position themselves to really understand the feet and the biomechanics. We can and should be the voice for foot stabilization in our communities as there few ways patients are going to learn this information.

Because of the nature of their care, chiropractors can evaluate and converse with patients regarding the feet, walking and foot stabilization, and impacting the kinetic chain.

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 in practice for over 25 years and is the owner of Orinda Chiropractic & Laser Center in Orinda, Calif. As a member of Foot Levelers Speakers Bureau since 2004, he travels the country speaking on extremity and spinal adjusting. See upcoming continuing education seminars with him and other Foot Levelers speakers at footlevelers.com/continuing-education-seminars.

References

1 Shoe Orthotics for the Treatment of Chronic Low Back Pain: ^ARandomized Controlled Trial. Jerrilyn A. Cambron, DC, MPH, PhD, ^aJennifer M. Dexheimer, BS, LMT, ^aManuel Duarte, DC, MSA, ^cDABCO, DACBSP, ^bSally Freels, MS, PhD ^c From the ^aDepartment of Research, National University of Health Sciences, Lombard, IL; ^bDepartment of Clinical Practice, National University of Health Sciences, Lombard, IL; and ^cSchool of Public Health, Division of Epidemiology and Biostatistics, University of Illinois, Chicago, IL.