The Feet Are The Body's Foundation
Chiropractors are an interesting bunch of people, much like our patients. Two DCs who went to the same school and were in the same graduating class can treat the same patient two completely different ways to get results. I am still astonished to this day by the multitude of techniques and philosophies Chiropractors have for healing their patients. Regardless of your technique, the concept I want to discuss transcends all of the different beliefs on how you should get your patients well.
It has become a routine part of my new patient exam procedure to analyze and assess patients’ feet when they come to my office for care. Problems in the feet can lead to many ailments, like knee pain, hip pain and axial spine pain, to name just a few. Now for someone who is coming in for headaches, TMJ problems or neck pain, the feet are not the most obvious things that jump out at you as being a possible cause – but you will be surprised.
One recurring theme you will find throughout this article is: don’t be fooled by not checking the feet. Remember that as a profession, we understand the axial kinematic chain. Joints down below can definitely have an effect on joints up above, either positively or negatively. In the past I have found that when I skipped over the feet, thinking they had no bearing, I had to go back later and evaluate them because there was a relationship to the patient’s complaint.
For many of us the feet are not the first place we think about looking, especially if a patient comes in complaining about hip or lower back pain. Why would you bother checking the feet, when someone isn’t complaining about pain in the feet? Not only are you asking me this question, so are my patients.
For most of the patients that walk through your door, the reason you should be checking their feet lies in the concept of excessive foot pronation. Eight out of ten people pronate excessively when they are performing any type of weight-bearing activity. Eighty percent of all people coming into our offices, from children to the elderly, have feet that roll inwards due to some degree of arch collapse. Think about the power of that statement. This means that regardless of where a Chiropractor practices in the world or what techniques they use to remove subluxations or misalignments, 80 percent of people will have excessive pronation. The kicker is patients usually don’t even realize it. Here’s another interesting fact: the Chiropractor often times doesn’t realize there is excessive foot pronation either. The altered biomechanics that result can lead to pain in the feet, ankles, knees, hips, lower back or higher.
I will mention for the sake of completeness that 10 percent of the world’s population excessively supinates (rolls outward on the feet) and 10 percent of the population has adequately supported feet that neither roll in to over-pronation or out to over-supination.
Foot pronation is a normal occurrence when the foot flattens out during the gait cycle. At the subtalar joint, we should observe a healthy amount of foot/ankle inversion, dorsiflexion and abduction. In fact, foot pronation is necessary in order to have normal foot biomechanics. What we are looking at now is the problem of excessive foot pronation, where the foot is dropping or flattening out too much.
Now we have a situation where the foot rolls in so much that the connective tissue and the three arches on the bottom of the foot cannot provide the proper support. When the three arches of the foot begin to collapse, due to any number of reasons, we can start to observe the effects of over-pronation as signs and symptoms in the patient.
Excessive foot pronation affects both feet, one usually worse than the other. Since our feet are not as springy and resilient as they were previously, the connective tissue on the underside of the foot (mainly the plantar fascia) become stretched permanently. Elastic tissues now become more plastic and deformed. Shock transmission is increased each time the heel strikes the ground because the foot is less biomechanically stable. Thus, the foot is not able to absorb the ground shock and it moves into the ankle and up the kinematic chain with more force.
Over-pronation begins at the feet and spreads northward like a domino effect. If you stand up and roll your feet inwards as far as you can, it recreates what happens to people who are experiencing excessive foot pronation. You can actually follow along with your own body to find out what happens.
As the arches fall towards the ground and become flatter, more stress is placed on the medial ankles. The tibia and femur bones inwardly or medially rotate, placing stress on the medial knee. The patellae also move medially as a result of the physical forces, affecting the Q-angle negatively. The femoral head is pulled laterally, placing a lot of pressure on that particular joint. The pelvic effects are equally as significant. There is dropping of the pelvis and posterior movement of the ilium bones. Excessive pronation continues its march up the spine by affecting the thoracic area and shoulder levels. It even affects the pull of the muscles of the neck and skull.
So what is the significance of excessive pronation for your practice? It can be a significant contributor or cause of many ailments that patients present with in your office. Sprained ankles, plantar fascitis, achilles tendonitis, shin splints, Osgood schlatter disease, ACL/meniscal/knee pain, patellar tendonitis, hip pain, lower back pain, neck pain and headaches are some examples of what excessive pronation causes. We treat these conditions on a daily basis, no matter what technique you use.
When dealing with treatment we want to adjust the feet, extremities and the spine where appropriate. The use of physical therapy modalities and exercises are helpful as well, but they are not enough. Once the patient stands up and walks out to your front desk to pay, the body goes right back into its’ over-pronated state. Essentially all of your work will be shortly undone with each subsequent step they take. So what else might you do to fortify all of the excellent Chiropractic care you have just administered?
One of the key concepts in treating the feet focuses around the permanent stretching of the plantar fascia that has occurred. I’ll put it another way: the muscles of the foot can be exercised, but they are not the primary stabilizers of the arch. Exercises will help in strengthening the foot, but they alone will not bring back the arches. The permanent stretching of the plantar fascia must be addressed.
Some type of custom-made orthotic must be prescribed for the patient. This will prevent the patient from experiencing progressively worse pain and having the feet go through arthritic changes over time. Flexible, custom-made orthotics that support all three arches of the foot have been documented to be extremely effective for helping the many conditions and joint stresses described earlier. Traditionally, flexible orthotics have been made using foam impression casting. This method is rapidly being replaced by digital scanning technology that reduces error rate by the doctor and gives the patient a high-tech visual that impresses them.
There is an easy exercise that shows your patient how the feet and spine are connected. Have the patient stand with the legs hip-width apart, hands placed on the hips (greater trochanters). Now have the patient roll the feet inwards (into pronation) as far as possible. In this position, the patient will start to feel strain and stress on the inner ankles and knees, lateral hips, and the lower back. The pain tends to worsen the more the feet roll inwards.
Now have the patient roll their feet outwards (into supination). In this position, the stress is in the same joints but in different, almost opposite areas. If you have the patient stand in front of a mirror while doing this test, he/she can visually see the movement of the feet and lower extremities. Watch his/her face as they understand the effect the feet can have on the body. You are teaching powerful information!
The moral of my story is to make sure that you assess the feet of as many patients as possible. If you routinely check the feet of your new patients and even go back and re-assess some of your long-time patients, you will be surprised at what you will find. Once you determine there is a relationship between the feet and the body, you can implement an effective, specific treatment plan that will greatly enhance the positive results from your care.
About the Author
Dr. Kevin Wong is a 1996 summa cum laude graduate of Palmer College of Chiropractic West in San Jose, California. In 1997, Dr. Wong was named Clinician of the Year by Palmer College of Chiropractic West. He has served as a past instructor of Chiropractic Technique for the college and is currently part of the adjunct faculty. Dr. Wong is also a past Lecturer/Instructor for the International Chiropractic Association of California. Currently he is in full-time practice in Orinda, California and has been a Foot Levelers Speaker for over two years.
It has become a routine part of my new patient exam procedure to analyze and assess patients’ feet when they come to my office for care. Problems in the feet can lead to many ailments, like knee pain, hip pain and axial spine pain, to name just a few. Now for someone who is coming in for headaches, TMJ problems or neck pain, the feet are not the most obvious things that jump out at you as being a possible cause – but you will be surprised.
One recurring theme you will find throughout this article is: don’t be fooled by not checking the feet. Remember that as a profession, we understand the axial kinematic chain. Joints down below can definitely have an effect on joints up above, either positively or negatively. In the past I have found that when I skipped over the feet, thinking they had no bearing, I had to go back later and evaluate them because there was a relationship to the patient’s complaint.
For many of us the feet are not the first place we think about looking, especially if a patient comes in complaining about hip or lower back pain. Why would you bother checking the feet, when someone isn’t complaining about pain in the feet? Not only are you asking me this question, so are my patients.
For most of the patients that walk through your door, the reason you should be checking their feet lies in the concept of excessive foot pronation. Eight out of ten people pronate excessively when they are performing any type of weight-bearing activity. Eighty percent of all people coming into our offices, from children to the elderly, have feet that roll inwards due to some degree of arch collapse. Think about the power of that statement. This means that regardless of where a Chiropractor practices in the world or what techniques they use to remove subluxations or misalignments, 80 percent of people will have excessive pronation. The kicker is patients usually don’t even realize it. Here’s another interesting fact: the Chiropractor often times doesn’t realize there is excessive foot pronation either. The altered biomechanics that result can lead to pain in the feet, ankles, knees, hips, lower back or higher.
I will mention for the sake of completeness that 10 percent of the world’s population excessively supinates (rolls outward on the feet) and 10 percent of the population has adequately supported feet that neither roll in to over-pronation or out to over-supination.
Foot pronation is a normal occurrence when the foot flattens out during the gait cycle. At the subtalar joint, we should observe a healthy amount of foot/ankle inversion, dorsiflexion and abduction. In fact, foot pronation is necessary in order to have normal foot biomechanics. What we are looking at now is the problem of excessive foot pronation, where the foot is dropping or flattening out too much.
Now we have a situation where the foot rolls in so much that the connective tissue and the three arches on the bottom of the foot cannot provide the proper support. When the three arches of the foot begin to collapse, due to any number of reasons, we can start to observe the effects of over-pronation as signs and symptoms in the patient.
Excessive foot pronation affects both feet, one usually worse than the other. Since our feet are not as springy and resilient as they were previously, the connective tissue on the underside of the foot (mainly the plantar fascia) become stretched permanently. Elastic tissues now become more plastic and deformed. Shock transmission is increased each time the heel strikes the ground because the foot is less biomechanically stable. Thus, the foot is not able to absorb the ground shock and it moves into the ankle and up the kinematic chain with more force.
Over-pronation begins at the feet and spreads northward like a domino effect. If you stand up and roll your feet inwards as far as you can, it recreates what happens to people who are experiencing excessive foot pronation. You can actually follow along with your own body to find out what happens.
As the arches fall towards the ground and become flatter, more stress is placed on the medial ankles. The tibia and femur bones inwardly or medially rotate, placing stress on the medial knee. The patellae also move medially as a result of the physical forces, affecting the Q-angle negatively. The femoral head is pulled laterally, placing a lot of pressure on that particular joint. The pelvic effects are equally as significant. There is dropping of the pelvis and posterior movement of the ilium bones. Excessive pronation continues its march up the spine by affecting the thoracic area and shoulder levels. It even affects the pull of the muscles of the neck and skull.
So what is the significance of excessive pronation for your practice? It can be a significant contributor or cause of many ailments that patients present with in your office. Sprained ankles, plantar fascitis, achilles tendonitis, shin splints, Osgood schlatter disease, ACL/meniscal/knee pain, patellar tendonitis, hip pain, lower back pain, neck pain and headaches are some examples of what excessive pronation causes. We treat these conditions on a daily basis, no matter what technique you use.
When dealing with treatment we want to adjust the feet, extremities and the spine where appropriate. The use of physical therapy modalities and exercises are helpful as well, but they are not enough. Once the patient stands up and walks out to your front desk to pay, the body goes right back into its’ over-pronated state. Essentially all of your work will be shortly undone with each subsequent step they take. So what else might you do to fortify all of the excellent Chiropractic care you have just administered?
One of the key concepts in treating the feet focuses around the permanent stretching of the plantar fascia that has occurred. I’ll put it another way: the muscles of the foot can be exercised, but they are not the primary stabilizers of the arch. Exercises will help in strengthening the foot, but they alone will not bring back the arches. The permanent stretching of the plantar fascia must be addressed.
Some type of custom-made orthotic must be prescribed for the patient. This will prevent the patient from experiencing progressively worse pain and having the feet go through arthritic changes over time. Flexible, custom-made orthotics that support all three arches of the foot have been documented to be extremely effective for helping the many conditions and joint stresses described earlier. Traditionally, flexible orthotics have been made using foam impression casting. This method is rapidly being replaced by digital scanning technology that reduces error rate by the doctor and gives the patient a high-tech visual that impresses them.
There is an easy exercise that shows your patient how the feet and spine are connected. Have the patient stand with the legs hip-width apart, hands placed on the hips (greater trochanters). Now have the patient roll the feet inwards (into pronation) as far as possible. In this position, the patient will start to feel strain and stress on the inner ankles and knees, lateral hips, and the lower back. The pain tends to worsen the more the feet roll inwards.
Now have the patient roll their feet outwards (into supination). In this position, the stress is in the same joints but in different, almost opposite areas. If you have the patient stand in front of a mirror while doing this test, he/she can visually see the movement of the feet and lower extremities. Watch his/her face as they understand the effect the feet can have on the body. You are teaching powerful information!
The moral of my story is to make sure that you assess the feet of as many patients as possible. If you routinely check the feet of your new patients and even go back and re-assess some of your long-time patients, you will be surprised at what you will find. Once you determine there is a relationship between the feet and the body, you can implement an effective, specific treatment plan that will greatly enhance the positive results from your care.
About the Author
Dr. Kevin Wong is a 1996 summa cum laude graduate of Palmer College of Chiropractic West in San Jose, California. In 1997, Dr. Wong was named Clinician of the Year by Palmer College of Chiropractic West. He has served as a past instructor of Chiropractic Technique for the college and is currently part of the adjunct faculty. Dr. Wong is also a past Lecturer/Instructor for the International Chiropractic Association of California. Currently he is in full-time practice in Orinda, California and has been a Foot Levelers Speaker for over two years.
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