Musculoskeletal Problems and Orthotic Support

By Mark Charrette, DC

Normal biomechanics of the foot and ankle include moving from supination to pronation and back during the gait cycle. This transition is necessary for proper shock absorption at heel strike, stability when the foot is flat and leverage for an efficient toe-off. The most common problem that interferes with effective foot biomechanics is excessive pronation. Since the timing of the change from pronation to supination is critical during walking and running, another term for this is "prolonged pronation." This condition occurs as a result of several factors, including loss of the medial longitudinal arch, eversion (tilting) of the calcaneus, or excessive dropping of the talus and/or navicular bones.

In addition to interfering with gait and decreasing athletic performance, excessive pronation is important for two major reasons. There is the likelihood of developing painful foot and ankle disability over time, and (especially important for doctors of chiropractic) the probability of transferring abnormal stresses up the lower extremity and into the pelvis and spine. Athletes may suffer from a number of "overuse injuries," which actually are caused by excessive pronation. Many times the developing problems go unnoticed for months or years, and it's only when a new walking or recreational program is begun that symptoms arise. Other times it is the painful end-stage of abnormal biomechanics which brings a patient in for care. Here's a review of the conditions and pathologies associated with excessive pronation.

Table 1: Foot pathologies linked to excessive pronation. Hammer toes Calcaneal periostitis (heel spur) Hallux valgus Spring ligament sprain Sesamoiditis Longitudinal arch collapse Tailor's bunions Medial calcaneal compartment syndrome Metatarsal calluses Tarsal tunnel syndrome Metatarsalgia Navicular stress fracture Interdigital neuroma Toe extensor muscle spasms Plantar fasciitis

Table 2: Lower leg conditions linked to excessive pronation. Achilles tendinitis Flexor hallucis longus strain/tendinitis Peroneal tendinitis Tibial periostitis Tibialis posterior muscle strain/tendinitis Tibial stress fracture Flexor digitorum longus strain/tendinitis Fibula stress fracture

Table 3: Knee problems linked to excessive pronation. Patellofemoral pain syndrome Pes anserine bursitis Chondromalacia patellae Anterior cruciate injuries Knee joint capsulitis

Table 4: Hip, pelvis, spine conditions linked to excessive pronation. Iliotibial band syndrome Piriformis muscle strain Tensor fascia lata strain Anterior pelvic tilt Trochanteric bursitis Sacroiliac problems Hip joint capsulitis Excessive lumbar lordosis Hip flexor muscle strain Functional scoliosis Hip adductor muscle strain

Foot Conditions

It's reasonable to assume that abnormal foot biomechanics can lead to foot problems. What is unusual is the number of conditions which have been reported to be linked with excessive pronation. Table 1 is a list of the foot pathologies that have been identified.

Lower Leg Problems

Many of the muscles that move the foot and ankle and provide support during walking, running and jumping arise in the lower leg. Therefore, it makes sense that excessive pronation can result in various strains and tendinitis conditions of the lower leg. When abnormal biomechanics are combined with the higher forces of sports activities, even stress fractures can develop. Table 2 is a list of the commonly encountered conditions in the lower leg, associated with excessive pronation.

Knee Pathology

The knee is a hinge (ginglymus) joint, moving primarily in one plane. When excessive pronation at the foot and ankle causes increased medial rotation to transmit up the leg, this rotary motion eventually results in knee symptoms. Knee problems frequently develop in athletes who experience greater rotational forces. Some studies have even indicated that this can happen on an acute basis, causing rupture of the anterior cruciate ligament. Table 3 is a list of knee problems which can develop from excessive pronation.

Hip/Pelvis/Spine

Regretfully, there is much less written about the specific conditions of the hip, pelvis and spine caused by excessive pronation. Because the foot is not nearby, correlation of poor foot biomechanics with pelvic and spine problems requires additional research. The most important condition for doctors of chiropractic is the functional short leg, created by arch collapse and medial rotation of the ankle and leg. This results in a pelvic tilt to the shorter side and usually is accompanied by a spinal rotoconvexity (scoliosis). This is sometimes known as "functional scoliosis," since it is flexible and present only while in the standing position. Table 4 is a list of the pathologies which may be seen in the hip, pelvis and spine with excessive pronation.

Support From Toe to Head

Excessive pronation is associated with many musculoskeletal complaints - from the foot itself, up the leg to the knee, hip and even the pelvis and spine. The good news is that all of these conditions can be helped with flexible, custom-made orthotics. Investigation of foot biomechanics is a good idea in all patients, but especially for those who are recreationally active. Many times, correction of recurring subluxations can only be accomplished when an excessively pronating foot is provided with appropriate orthotic support. Competitive athletes must have regular evaluation of the alignment and function of their feet in order to avoid potentially disabling injuries. Preventive measures include wearing well-designed and constructed shoes and considering orthotic support in those patients at risk for developing excessive pronation.

References

1. Busseuil C, et al. Rearfoot-forefoot orientation and traumatic risk for runners. Foot&Ankle Intl 1998;19:32-7.
2. Hartley A. Practical Joint Assessment: A Sports Medicine Manual. St. Louis: Mosby Year Book, 1991:571.
3. Schweitzer ME, White LM. Does altered biomechanics cause marrow edema? Radiology, 1996;198:851-3.
4. Dahle LK, et al. Visual assessment of foot type and relationship of foot type to lower extremity injury. J Orthop Sports Phys Ther, 1991;14:70-4.
5. Beckett ME, et al. Incidence of hyperpronation in the ACL injured knee: a clinical perspective. J Athl Train, 1992;27:58-62.

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Arizona Custom Orthotics for Plantar fasciitis Mesa AZ

 

Posted 01:58 PM October 21, 2010

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Protecting Runners With Orthotic Support

By Mark Charrette, DC

Running injuries are caused by a variety of factors. In addition to spinal and lower extremity subluxations, contributory elements often include footwear problems, gait asymmetries, muscle imbalances and training errors. During my nearly 30-year chiropractic career, I have had the opportunity to treat many patients for injuries related to running. I have found that one of the most effective forms of adjunctive care, especially when gait biomechanics are altered, is custom-made, flexible orthotics.

Orthotics are an excellent adjunct to successful chiropractic care of runners' injuries. Here is a brief overview of three common injuries experienced by runners, along with selected treatment considerations.

Achilles Tendinitis

The Achilles tendon insertion on the calcaneus is medial to the axis of the subtalar joint, making the calf muscles the most powerful supinators of the subtalar joint. Therefore, when excessive pronation occurs, the tendon eventually undergoes overuse degeneration and inflammation.

This was described by Clement, et al. They discussed how "pronation generates an obligatory internal tibial rotation, which tends to draw the Achilles tendon medially. Through slow-motion, high-speed cinematography, we have seen that pronation produces a whipping action or bowstring effect in the Achilles tendon." This whipping action, when exaggerated, may contribute to microtears in the tendon, particularly in its medial aspect and initiate an inflammatory response. These investigators expressed their belief that controlling functional overpronation with corrective orthotic devices is a necessary treatment for most patients with Achilles tendinitis.

Patellofemoral Pain

Many factors can contribute to improper tracking of the patella during running, such as genu valgus, tibial torsion, tight hamstrings, weakness of the vastus medialis and training errors (e.g., excessive hill running). In my experience, however, the most common biomechanical fault associated with patellofemoral pain in runners is an increased Q angle. Whenever the measurement of this angle is above normal limits, the probability of developing tracking disorders, patellofemoral pain and chondromalacia patellae greatly increases.

The most effective way to decrease a high Q angle and improve the tracking of the patella is to prevent excessive pronation by the use of flexible, custom-made foot orthotics. Flexible orthotics that support all three arches of the foot have been found to reduce the Q angle immediately. Another study reported that soft orthotics are more effective in reducing knee pain and preventing recurrence than a traditional therapeutic exercise program. My experience is that specific chiropractic adjustments, combined with custom-made, flexible orthotics and a simple, at-home rehabilitative program, provide the most effective and most comprehensive level of care for patients with patellofemoral pain.

Plantar Fascitis

This condition causes heel pain in the area of the medial calcaneal tubercle, which is the insertion point for the plantar fascia. This aponeurosis is made of strong yet flexible connective tissue that functions as a bowstring to hold up the medial longitudinal arch. Since the plantar fascia is the major structure that supports and maintains the arched alignment of the foot, it is placed under considerable stress during running.

Excessive pronation has been identified as the most common biomechanical finding associated with plantar fascitis, although a weight-bearing evaluation sometimes finds rigid supination. In either case, custom-made orthotics that provide shock absorption and support for the medial longitudinal arch are needed, along with adjustments of the foot and ankle.

Orthotics Help Protect Runners

Whenever a runner has an injury, it is important to assess the extrinsic contributors, as well as the intrinsic biomechanical faults. Custom-made orthotics have been shown to significantly decrease foot pronation velocity and tibial internal rotation. Wearing orthotics while running also reduces the electromyographic activity in the biceps femoris, tibialis anterior and medial gastrocnemius. Appropriate use of custom-made orthotics can help decrease the high incidence of overuse lower extremity injuries. By reducing the stress and strain of running, a well-designed orthotic can speed a full return to running activities, while also helping prevent re-injury.

References

1. Subotnick SI. Sports Medicine of the Lower Extremity. New York: Churchill Livingstone, 1989:475.
2. Clement DB, Taunton JE, Smart GW. Achilles tendinitis and peritendinitis: etiology and treatment. Am J Sports Med,1984;12:179-84.
3. D'Amico JC, Rubin M. The influence of foot orthotics on the quadriceps angle. J Am Podiatr Med Assoc, 1986;76:337-40.
4. Kuhn DR, Yochum TR, Cherry AR, Rodgers SS. Immediate changes in the quadriceps femoris angle after insertion of an orthotic device. J Manip Physiol Ther, 2002;24:465-70.
5. Eng JJ, Pierrynowski MR. Evaluation of soft foot orthotics in the treatment of patellofemoral pain syndrome. Phys Ther,1993;73:62-70.
6. Huang CK, Kitaoka HB, An KN, Chao EYS. Biomechanical evaluation of longitudinal arch stability. Foot Ankle,1993;14:353-7.
7. Kwong PK, Kay D, Voner RT, White MW. Plantar fasciitis: mechanics and pathomechanics of treatment. Clin Sports Med, 1988;7:119-26.
8. Eng JJ, Pierrynowski MR. The effect of soft foot orthotics on three-dimensional lower limb kinematics during walking and running. Phys Ther, 1994;74:836-44.
9. Nawoczenski DA, Cook TM, Saltzman CL. The effect of foot orthotics on three-dimensional kinematics of the leg and rearfoot during running. J Orthop Sports Phys Ther, 1995;21:317-27.
10. Nawoczenski DA, Ludewig PM. Electromyographic effects of foot orthotics on selected lower extremity muscles during running. Arch Phys Med Rehabil, 1999;80:540-4.

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Arizona Custom Orthotics for Plantar fasciitis Mesa AZ

 

Posted 01:54 PM October 21, 2010

www.CUSTOM-FOOT-ORTHOTICS-AZ.COM

Heel Pain: Fasciitis or Nerve Entrapment?

By Warren Hammer, MS, DC, DABCO

Have you ever treated a plantar fasciitis that did not respond? It might be a nerve entrapment. The symptoms between these two conditions often are strikingly similar. There might not be any paraethesiae on nerve compression, Tinel sign or even a loss of sensation in the area. Both may exhibit symptoms of heel pain upon arising, possibly lessening during the day, with localized pain at the medial process of the calcaneal tuberosity.

The tibial nerve runs posterior to the medial malleolus under the flexor retinaculum (Tarsal canal) and divides into the medial plantar nerve (MPN), the lateral plantar nerve (LPN) and the medial calcaneal branches. Compression at the tarsal canal (tarsal tunnel syndrome) could be responsible for heel pain. Half the time, the cause is idiopathic, but a synovial cyst, ganglion protruding from a tendon sheath, a lipoma, severe pronation, valgus hindfoot or severe ankle sprain might be the cause.

Most patients with a tarsal tunnel complain of a burning, tingling or numb feeling on the plantar portion of the foot. Sometimes the pain is localized to one of the three terminal branches, emulating a plantar fasciitis. A possible differentiation from plantar fasciitis is that while in both diagnoses, the pain is aggravated by activity and relieved by rest, with entrapment, there might be relief by getting up, moving around and even massaging the foot. It is possible there might be fluid accumulation around the nerve during rest and during the first steps. The fluid pressure causes pain, but with walking, the venous pooling and intracompartmental pressures reduce. This might be a reason that pain of neural origin may decrease with walking. However, pain on walking also might decrease in plantar fasciitis.

With entrapment, pain also could occur with rest and in nonweight-bearing positions not common in fasciitis. Tapping the posterior tibial nerve first above the malleolus, and then distally to the terminal branches, might elicit tingling.

The entrapment site thought to be the most common cause of plantar heel pain is the first branch of the LPN. This nerve can get trapped where it passes at the sharp edge of the deep fascia of the abductor hallucis, just distal to the medial edge of the calcaneous, and especially when there is a calcaneal spur or even an association with a plantar fasciitis. Maximal tenderness should be over the nerve, although there might be tenderness over the heel and proximal plantar fascia.

Coppieters, et al., evaluated a modified straight-leg-raising test (SLR) that helps to differentiate plantar fasciitis from a neural problem. The clinician first dorsiflexes and everts the ankle, and then flexes the hip with a SLR. The addition of hip flexion further increased the mechanical forces acting on the tibial nerve in the tarsal tunnel. Hip flexion in the SLR test increased strain and excursion of the tibial nerve around the ankle about two-thirds that of the strain created by ankle dorsiflexion.

The investigators determined that the addition of hip flexion has no effect on the plantar fascia, but it does on the tibial nerve. They stated: "The cumulative effect of ankle dorsiflexion and hip flexion on strain in the tibial nerve in the tarsal tunnel demonstrates that elongation of a larger segment of the nerve bedding places larger mechanical forces on the tibial nerve in the tarsal tunnel than ankle dorsiflexion alone."

 The tibial nerve runs posterior to the medial malleolus and divides into the medial plantar and lateral plantar nerves. Butler examines the tibial nerve by putting pressure or tapping the tibial nerve by the malleolus to see if it radiates along the tibial track. If the medial plantar nerve is involved, a neural response may occur in the big toe. He uses the SLR test and adds pronation of the foot to stress the LPN, and uses abduction and pronation to stress the MPN. He exerts more tension to both of these areas by dorsiflexing the toes, and abducts the heel further to place more tension on the calcaneal branch.

To determine if a heel spur is causing local pain, put pressure on the local spur area. Hold this pressure and do an SLR test. If there is a neural response, the pain will alter compared to the local spur pain. Butler treats the tibial nerve by attempting to gradually mobilize its neuronal attachments. He might start with gentle ranges of motion out of tension, such as ankle dorsiflexion in knee and hip flexion. He then progresses to greater tension with the SLR with the foot in dorsiflexion and eversion, adding hip abduction and lateral rotation. Repetitive stretching to create neural mobilization is used.

In the office and at home, neural mobilization may be used during the slump position. The sitting patient flexes the neck and back with the ankle positioned into end-range dorsiflexion and eversion. The patient then extends the leg to apply more tension to the tibial nerve. The clinician can hold this foot position as the patient extends the leg.

Stretching the gastrocsoleus complex, Achilles tendon, foot muscles such as the abductor halucis and quadratus plantae, correcting pronation, and strengthening weak areas are important. Techniques such as ART and Graston Technique should be beneficial to all related areas.

References

1. Mann RA. Entrapment Neuropathies of the Foot. In: Orthopaedic Sports Medicine Vol. 2, 2. ed. DeLee JC, Drez D, Eds. Philadelphia: Saunders, 2003:2474-82.
2. Alshami AM, Souvlis T, Coppieters MW. A review of plantar heel pain of neural origin: differential diagnosis and management. Manual Therapy, 2008;13:103-11.
3. Coppieters MW, Alshami AM, Babri AS, et al. Strain and excursion of the sciatic, tibial and plantar nerves during a modified straight leg raising test. J Orthop Res, 2006;24(9):1883-9.
4. Butler DS. Mobilization of the Nervous System. New York: Churchill-Livingston, 1991:213-30.
5. Meyer J, Kulig K, Landel R. Differential diagnosis and treatment of subcalcaneal heel pain: a case report. J Orthop Sports Phys Ther, 2002;32(3):114-22.

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Arizona Custom Orthotics for Plantar fasciitis Mesa AZ

 

Posted 01:52 PM October 21, 2010

www.CUSTOM-FOOT-ORTHOTICS-AZ.COM

The Influence of the Windlass Mechanism on Plantar Fasciitis

By Manuel Duarte, DC, DABCO, DACBSP, CSCS

Plantar fasciitis, inflammation of the plantar fascia and perifascial structures, is a common problem requiring treatment by chiropractors. Chandler and Kibler reported a 10 percent occurrence rate in runners, while Kwong classified plantar fasciitis as a syndrome resulting from repeated trauma to the plantar fascia at its origin on the medial tubercle of the calcaneus.

A literature review attributes plantar fasciitis to faulty biomechanics, including excessive pronation. Excessive pronation can result from structural deformities such as a forefoot varus that can contribute to excessive foot mobility. The resulting stresses are absorbed by muscle, fascia and other soft-tissue structures as fascia elongates and tissue stresses increase.

Increased stress along the medial joint capsule and ligamentous structures causes the foot joints to be strained beyond their normal motion. The tibialis posterior muscle becomes lengthened, which results in excessive muscle fatigue as it tries to control the excessive motion. It has been determined that plantar fasciitis can be attributed to thedisproportionate duration of motion, as opposed to the motion itself. To appreciate the effect different biomechanical stresses have on the foot, one must understand and appreciate the function of the windlass mechanism as it applies to foot mechanics and gait. The windlass mechanism is a model that explains biomechanical factors and stresses as they relate to foot pronation and plantar fasciitis.

A windlass is a device designed to lift a heavy object by tightening a rope or cable. The plantar fascia simulates a cable attached to the calcaneus and the metatarsophalangeal joints. Dorsiflexion during the propulsive phase of gait winds the plantar fascia around the head of the metatarsals. This shortens the distance between the calcaneus and the metatarsals, and results in elevation of the medial longitudinal arch.

The crux of the windlass mechanism principle is the shortening of the plantar fascia resulting from hallux dorsiflexion. The medial longitudinal arch raising is synchronous with subtalar joint supination and external leg rotation. Without correct windlass function, the foot will not act as an efficient lever and effective push-off power cannot be achieved.

A reverse windlass mechanism has also been proposed. During the early single-support phase of gait, the leg internally rotates and the subtalar joint pronates. This unwinds the windlass, and the arch lowers as the foot elongates. In this situation, the plantar fascia becomes tight and applies a plantar flexion moment to the phalanges, stabilizing them against the ground. This applies a compressive force longitudinally and resists excessive pronation movements.

Prolonged reverse windlass occurs as a result of excessive pronation at the subtalar joint. This movement impedes hallux dorsiflexion, prevents the arch from rising and reduces the ability of the foot to efficiently move the body forward, resulting in inefficient propulsion. Understanding this mechanism will enhance the decision-making process in theevaluation and treatment of patients with plantar fasciitis.

Hicks originally described the foot and its ligaments as an arch-like triangular structure. The calcaneus, midtarsal joints and metatarsals, including the medial longitudinal arch, form the truss' arch. The plantar fascia form the tie-rod that runs from the calcaneus to the phalanges. Vertical forces from the body weight travel downward along the tibia and have a tendency to flatten the medial longitudinal arch. At the same time, ground-reaction forces push up on the calcaneus and metatarsal heads, which further the flattening effect because these forces fall both anterior and posterior to the tibia.

The plantar fascia prevents foot collapse due to its anatomic location and tensile strength as it runs from the base of the calcaneus to the phalanges. Stretch tension from the plantar fascia prevents spreading of the calcaneus and the metatarsals, which maintains the medial longitudinal arch.

There are several phases of gait, as described by Donatelli. The stance phase of gait includes heel contact, weight acceptance, midstance, push-off, propulsion and toe-off. The gait cycle begins with the foot in a supinated position at heel strike. The subtalar joint then immediately pronates when going from heel strike to weight acceptance. This period of pronation results in the increased foot mobility needed to absorb ground-reaction forces and adapt to uneven terrain.

The foot reaches maximum pronation following the weight-acceptance phase, and the subtalar joint supinates the foot from midstance through toe-off. Supination transforms the foot into a rigid lever necessary for propulsion. Without a mechanism to maintain the arch, we would not be capable of overcoming the many forces that stress the foot and result in disruption of the medial longitudinal arch. This results in inefficient and nonsystematic gait patterns. The orientation of the plantar fascia helps maintain the arch throughout gait and significantly contributes to appropriate timing of pronation and supination during the gait cycle.

From heel strike to weight acceptance, pronation increases the relative distance between the calcaneus and the metatarsals, and applies a tension stress to the plantar fascia. From midstance through the propulsive phase, supination occurs so the foot can become a rigid lever using the windlass mechanism to propel the body forward. Forces that are generated during supination also apply tension to the plantar fascia, just as in pronation. The forces generated during pronation and supination increase plantar fascia tension. Inefficient foot function can lead to increased tissue stress.

The foot must have a balance between pronation and supination. Too much or too little of either motion at the wrong time of gait in a prolonged fashion leads to foot dysfunction. The previous discussion illustrates how vertical and ground-reaction forces stress the plantar fascia tissues. Plantar fascia pain results from increased tension and excessive traction forces applied to the calcaneus. High tension in the fascia can result in periosteal lifting at its insertion on the calcaneus, and bone healing could cause growth of a spur commonly seen at the calcaneus. The explanation of traction stress describes why bone spur growth occurs horizontal to the ground. It should also be clear that fascial stretching causes pain either to the fascia itself or to its bony attachment on the calcaneus.

There are a number of studies that support the belief that heel pain does not occur from the bone spur itself, but from excessive tension applied to the plantar fascia. Excessive tension causes tissue irritation to the plantar fascia, as well as to its origin at the medial calcaneal tubercle. Clinicians can reproduce the symptom by applying the windlass test.

In a weight-bearing position, the clinician forcefully extends the great toe. A positive test reproduces pain at the medial calcaneal tubercle. Researchers have reported 100 percent specificity, but only 31.8 percent sensitivity with this test. However, clinicians may find it useful in determining plantar-fascial tissue irritation. Decreasing tension in the plantar fascia will decrease the pain. Therefore, successful management depends on the clinician's ability to reverse the forces that lead to excessive strain and the resulting pain and discomfort that bring patients in for management.

Patients with pronation problems have a more flexible, lower-arched foot. Factors that contribute to excessive pronation include muscle weakness, heel-cord tightness and structural foot deformities.Thordarson found that the posterior tibialis muscle provided the most significant dynamic arch support during the stance phase of gait. This muscle eccentrically lengthens to control pronation and reduces tension applied to the plantar fascia during weight acceptance. With excessive pronation, the plantar fascia elongates and weakens the tibialis posterior muscle. This reduces the effectiveness of the foot's windlass mechanism because of instability during the propulsive phase of gait. Subsequently, controlled pronation provides for the appropriate timing of supination during gait.

The combined effects of the flexor digitorum longus, flexor hallucis longus, peroneus longus and Achilles tendons permit the supination needed to enhance the windlass mechanism. The plantar flexors enhance supination so the cuboid pulley system can plantar-flex the first ray and promote efficient use of the windlass mechanism. Proximal muscle weakness from the gluteus medius, gluteus minimus, tensor, fascia latae or quadriceps muscle can contribute to plantar fascia abnormalities. Weakness in these muscles inhibits their ability to assist with the lower-extremity load response, which results in greater transmission of shock to the supporting foot structures. Furthermore, gluteus medius, gluteus minimus, tensor fascia latae weakness can accelerate lower-extremity pronation.

A tight Achilles tendon limits the amount of dorsiflexion available during gait. A person with a flexible foot can compensate for this by unlocking the midtarsal joint, because dorsiflexion and abduction are movements allowed at the midtarsal joints axis. This increased motion results in excessive pronation that can lead to stress of the plantar fascia. Structural deformities such as an excessive subtalar or forefoot varus can contribute to plantar fascia problems. When the heel hits the ground, the foot must pronate excessively to allow the forefoot to contact the ground. This excessive pronation stresses the plantar fascia and inhibits efficient use of the windlass mechanism. A subtalar varus deformity of more than 10 degrees can also contribute to excessive pronation.

A rehabilitation plan should relieve inflammation and correct the mechanical factors. Treatment goals should focus on restoring normal muscle strength, improving muscle flexibility and normalizing biomechanical influences. Strengthening should center on muscles involved in controlling pronation and facilitating the windlass mechanism. This should encompass tibialis posterior, ankle plantar flexors, the peroneus muscles as well as proximal hip and knee musculature. Rehabilitation should also include calf stretching, chiropractic manipulative therapy for the foot and ankle and biomechanical control of excessive pronation.

Orthotics are commonly prescribed to control pronation. An orthotic device applies a supinatory moment at the subtalar joint. Orthotics allow an appropriately timed windlass mechanism and initiation of autosupportive mechanisms. Thisfacilitates supination in coordination with external leg rotation and stabilizes the foot, leading to efficient toe-off. Plantar fasciitis is the most common musculoskeletal injury presenting to the podiatrist for treatment with orthotics.

Functional hallux limitus has been restored by the use of foot orthoses. The orthoses controlled abnormal subtalar pronation by restoring dorsiflexion at the first metatarsal phalangeal joint, thereby eliciting a more functional windlass mechanism. This led to decreased stress, increased healing and a more efficient gait pattern.

References

1. Chandler TJ, Kibler WB. A biomechanical approach to the prevention, treatment and rehabilitation of plantar fasciitis.Sports Med, 1993;15:344-52.
2. Kwong PK, Kay D, Voner PT, White MW. Plantar fasciitis: mechanics and pathomechanics of treatment. Clin Sports Med, 1988;7:119-26.
3. Whiting WC, Zernicke RF. "Lower-Extremity Injuries." In Biomechanics of Musculoskeletal Injury. Champaign, Ill.: Human Kinetics; 1998:172-3.
4. Cornwall MW, McPoil TG. Plantar fasciitis: etiology and treatment. J Orthop Sports Phys Ther, 1999;29:756-60.
5. Bolgla LA, Malone TR. Plantar fasciitis and the windlass mechanism: a biomechanical link to clinical practice. J Athl Train, 2004;39(1):77-82.
6. Hicks JH. The mechanics of the foot, II: the plantar aponeurosis and the arch. J Anat, 1954;88:25-30.
7. Kim W, Voloshin AS. Role of plantar fascia in the load-bearing capacity of the human foot. J Biomech, 1995;28:1025-33.
8. Fuller EA. The windlass mechanism of the foot: a mechanical model to explain pathology. J Am Podiatr Med Assoc, 2000;90:35-46.
9. Viel E, Esnault M. The effect of increased tension in the plantar fascia: a biomechanical analysis. Physiother Pract, 1989;5:69-73.
10. Donatelli RA. Abnormal biomechanics. In Donatelli RA, Ed: Biomechanics of the Foot and Ankle. 2nd ed. Philadelphia: FA Davis;1996:34-72.
11. Karr SD. Subcalcaneal heel pain. Orthop Clin North Am, 1994;25:161-75.
12. Norkin CC, Levangie PK. Joint Structure and Function. A Comprehensive Analysis. 4th ed. Philadelphia: FA Davis; 2001.
13. Onwuanyi ON. Calcaneal spurs and plantar heel pad pain. Foot, 2000;10:182-5.
14. Brown C. A review of subcalcaneal heel pain and plantar fasciitis. Aust Fam Physician, 1996;25:875-85.
15. Thordarson DB, Schmotzer H, Chon J, Peters J. Dynamic support of the human longitudinal arch: a biomechanical evaluation. Clin Orthop, 1995;316:165-72.
16. Kappel-Bargas A, Woolf RD, Cornwall MW, McPoil TG. The windlass mechanism during normal walking and passive first metatarsalphalangeal joint extension. Clin Biomech (Bristol, Avon), 1998;13:190-4.
17. Sahrmann SA. "Movement Impairment Syndromes at the Hip." In Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis: Mosby; 2002:121-93.
18. Johanson MA, Donatelli RA, Wooden MJ, et al. Effects of three different posting methods on controlling abnormal subtalar pronation. Phys Ther, 1994;74:149-61.
19. Hoke BR. Biomechanics of the Foot, Ankle and Lower Extremity. Aiken, SC: Motivations, Inc;2002.
20. Turlik MA, Donatelli TJ, Veremis MG. A comparison of shoe inserts in relieving mechanical heel pain. Foot, 1999;19:352-6.
21. Aquino A, Payne C. The role of the reverse windlass mechanism in foot pathology. Australasian J Podiatr Medicine, 2000;34(1):32-4.
22. Harradine PD, Bevasn LS, Carter N. Gait dysfunction and podiatric therapy - part 1: foot-based models and orthotic management. Br J Podiatry, Feb 2003;6(1):5-11.
23. Lynch DM, Goforth W, Martin JE, et al. Conservative treatment of plantar fasciitis. A prospective study. J Am Podiatr Med Assoc,1998;88(5):375-83.
24. Munuera PV, Dominguez G, Palomo IC, Lafuente G. Effects of rearfoot-controlling orthotic treatment on dorsiflexion of the hallux in feet with abnormal subtalar pronation. J Am Podiatr Med Assoc, 2006;96(4):283-98.

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Dr. Manuel Duarte is a graduate of National College of Chiropractic and a diplomate of the American Chiropractic Board of Sports Physicians and the American Board of Chiropractic Orthopedics. He has extensive teaching experience and lectures on a variety of topics, including manual treatment procedures, rehabilitation, orthopedics, and sports medicine.

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Arizona Custom Orthotics for Plantar fasciitis Mesa AZ

 

Posted 01:49 PM October 21, 2010

www.CUSTOM-FOOT-ORTHOTICS-AZ.COM Dynamic Chiropractic – March 6, 2000, Vol. 18, Issue 06

Clinical Considerations: Plantar Fasciitis

By Mark A. King, DC

Heel pain is a common presenting complaint in chiropractic, podiatric, orthopedic and family-practice offices. Heel pain can be helped most of the time with quality conservative management. A common cause of heel pain is plantar fasciitis. This can occur in the athlete or nonathlete. This short article will not cover biomechanics of the foot and ankle complex. I would recommend Dr. Michaud's Foot Orthosis as an excellent text on foot biomechanics.

Plantar fasciitis patients commonly complain of pain, particularly upon rising in the morning, after sitting for an extended time, or with the onset of exercise. The patient will have pinpoint tenderness to deep palpation of the calcaneus, particularly at the medial tuberosity. Dorsiflexion (active or passive) of the foot and toes often causes pain with plantar fasciitis, but not always.

Common causes of plantar fasciitis include abnormal gait biomechanics, excessive supination or pronation, leg-length inequality, bad shoes, or what is probably the most common cause, shortened gastrocnemius, soleus and Achilles tendon.

A concern with heel pain is a calcaneal stress fracture. Cupping your hand on the medial and lateral sides of the calcaneus, not the plantar side, and squeezing firmly causing an acute increase in pain raises your suspicion of a stress fracture. I spoke with Bryan Hosler,DC,DACBR, about this. He suggested a CT scan to rule out a fracture, as the plain films will usually not reveal a calcaneal stress fracture. The x-rays will reveal a heel spur if present. The spur is the "result" of the problem, it is not the "cause." The spur develops subsequent to the tractioning on the periostal attachment of the fascia to the calcaneus.

Surgery for heel spurs is rare these days because the results are poor, due to the underlying problem not being addressed. Cortisone injections are still commonly used and when they are helpful, it is typically temporary. Dr. Hosler also said if you are looking for nonspecific bone pathology in the area, a bone scan is very sensitive and usually tells you if there is a problem, but it does not identify the problem.

If there is a stress facture, the foot must be put in physiologic rest. This can mean a cast, an air cast, or strong, supportive strapping and taping of the involved foot with no running or extra walking.

If a stress fracture is not a concern, and the diagnosis of plantar fasciitis has been established, then you are ready to help these people. My office protocol varies, and in this age of managed care and cash practices, cost must be considered. I may use any combination of the following: 

• adjustments and mobilization for the foot and ankle as indicated by palpation findings with particular emphasis on the subtalar joint;
• orthotics if indicated, including addressing any leg-length inequality;
• stretching of the hamstrings and gastrocnemius via a contract and relax stretch on the hamstrings. I add passive dorsiflexion of the ankle simultaneously while stretching the hamstring to stretch the gastrocnemius.
• soft-tissue work to the plantar fascia. There are lots of ways to address this component, including cross friction, stripping of the fascia, deep massage, etc.
• modalities, including ultrasound or electrical muscle stimulation.

Remember, if there is a stress fracture, the ultrasound will make it worse.

Home protocol is also very important and may include the following: 

• Stretch the gastrocnemius and soleus on a step, initially 3-4 times per day for one minute each time. If the step is not available, then a slant board is fine. A modified stretch against the wall with the foot flat on the ground and the leg behind you, while leaning into the wall, also is adequate. These stretches can be increased in quantity, or the time can be increased. For example: 1H to 2 minutes per session after a week and then increased again in H or 1-minute increments after another week. This stretching at home is very important, so emphasize it to your patients.
• Ice should be used in 15-minute increments, anywhere from two times a day up to 6-8 times per day.
• Toe curls, especially using a towel on the floor and grabbing it with the toes, help to strengthen the plantar fascia.
• You can do much with nutrition, though this is too large a topic for this article. I keep it simple: supplements directed toward decreasing inflammation and strengthening tendons and ligaments.

You can expand your practice and give yourself some new challenges by addressing extremity problems.

One final recommendation for those of you interested in treating sports injuries: Functional Soft Tissue Examination and Treatment by Manual Methods by Warren Hammer,DC. It is a tremendous resource and reference book that has helped me many times with difficult cases. Good luck with your practice and your patients' health. 

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Arizona Custom Orthotics for Plantar fasciitis Mesa AZ

 

Posted 01:48 PM October 21, 2010

www.CUSTOM-FOOT-ORTHOTICS-AZ.COM Dynamic Chiropractic – November 30, 1998, Vol. 16, Issue 25

Plantar Fasciitis (Heel Spurs)

A Patient's Guide

By Darryl Curl

Chronically painful feet are hard to ignore and sometimes even harder to return to a pain-free state. As a treating chiropractor, I have found that actively involving the patient in their care has made a big improvement in treatment success.

If your practice is similar to mine, you have many patients asking questions about the cause of their chronically painful feet and how to care for them. Surprisingly, it is difficult to find a concise compendium of information on painful feet suitable for patient use. I decided to create a brochure for our office that has become quite a hit with our patients.

Herewith are the important excerpts from our Patient's Guide to Plantar Fasciitis/Heel Spurs. The brochure is too long to print here, but use the following material as a template. Modify it as it suits your practice style and training. Here it is.

What Is Plantar Fasciitis?

Plantar fasciitis (pronounced PLAN-tar fashee-EYE-tiss) is an inflammation of the fascia (also called aponeurosis) on the bottom of the foot. It is often considered the same as, or seen with, heel spur.

(Insert your favorite picture of a heel spur here.)

What Causes Plantar Fasciitis and Heel Spurs?

Plantar fasciitis and heel spurs are conditions caused by such factors as: 

• too much standing;
• unpadded shoes on hard ground;
• poor shoes (see below);
• repetitive stress;
• diets low in vitamin C;
• a change or increase in activities;
• being overweight;
• age-related shrinkage of the heel fat pad (a.k.a. fat ad atrophy);
• an injury.

Bad shoes are those that ... (add your own criteria if you wish) 

• have poor or no arch support;
• do not have a raised heel;
• are worn out
• do not bend at the ball of the foot
• do not have any cushion and are worn on a hard surface

What Are the Symptoms of Plantar Fasciitis and Heel Spurs?

The pain is usually in the front and bottom of the heel. It can also be over the entire bottom area of the foot. The pain can be mild or debilitating. It can last a few months or a lifetime. It can go away by itself, only to return in a few weeks or months.

If you have heel pain at the inside, front and bottom of your heel, especially if it's in the morning or after sitting a long time, then your probably have plantar fasciitis (heel spur). When the pain is severe, it is believed to be the result of bone and/or nerve irritation that is the result of too much tension, inflammation or scar tissue in the fascia. The pain often increases with more walking and standing. The pain is usually where the fascia attaches to the heel, but it can be over the entire bottom area of the foot.

If the heel pain began concurrently with a change or increase in activity, or an increase in weight, then it can be considered more of a cause of plantar fasciitis (heel spur). A stress fracture where the fascia attaches to the heel is sometimes seen in bone scans. Fifty percent of the sufferers say the pain is constant. About 90 percent say it hurts when pressed deeply with a finger.

What Is the Treatment for Plantar Fasciitis and Heel Spurs?

The most successful treatments include gentle stretching of the calf muscles, decreasing or changing activities, losing weight, better fitting shoes (with an arch support and raised heel), shoe inserts that have good arch support (name your favorites), heel pads (1/2" or more when compressed -- many designs like Tuli cups are often too thin), applying ice for five minutes after activities, and anti-inflammatory medication such as aspirin, Aleve or ibuprofen (but not Tylenol).

Many sufferers swear by Birkenstock sandals (which provide good arch support similar to good inserts and custom orthotics). However, arch support is less likely to work if you have a high arch.

When constant foot pain is present, it is caused by inflammation (which may not be visible to the eye). The effects of the inflammatory process may be reduced by keeping the foot raised above the heart and/or compressed by wrapping the foot with ace bandages after long periods of being on your feet. (Add your preferred wrapping instructions here.) Trying to "walk through or ignore the pain" can cause a mild case to become long-term and debilitating.

Home Care Routines (add your favorite advice if you wish) the fascia, daily massage of the feet or ankles, and/or arch support are often the cure for plantar fasciitis. 

1. Decrease activity or switch to exercises that keep the weight off of the feet such as stationary bike riding or swimming. Avoid or modify anything that causes an increase in pain. Be patient, it may take months of reduced activity. Increase activities very slowly. Complete rest is not good, as some activity is necessary for recovery. 
2. Stretching. Stretching is often recommended. In the few cases where it is caused by a sudden injury, stretching and strengthening may not be necessary. Stretching can reinjure the traumatized fascia. 
3. Taping can help to simply protect the fascia or enable a patient to walk again. The tape should be tight when you stand and the pain is immediately relieved (unless the pain is present 24 hours a day). If not, consider the "other causes" section. 
4. Arch support and medial wedges. Certain shoes, inserts (name the type you recommend) or custom-made orthotics can give more arch support. Heel pads can sometimes be worn under inserts. 
5. Heel pads, 1/2" to 1" thick in both shoes. The waffle-bottomed Tuli cups or viscoelastic designs may not work as well because they are thin when compressed. Playing tennis or similar activity while wearing heel pads can cause a serious ankle injury. 
6. Reduce inflammation with ice, anti-inflammatory medication, compression and elevation. The swelling may not be noticeable, but it is often there and causes pain by putting pressure on tissue in the area. 
7. Ice immediately after activities or injury. Place ice on a towel, step on it and roll it under the feet for five minutes. Repeat every hour until bedtime. 
8. Massage in the morning and evening.

When Will My Feet Get Better?

It is important for you to be active in the treatment of your foot problem. Poor compliance with home care or prescribed treatment means your treatment will take far longer than it should. If there is little improvement after a few weeks or months of proper treatment, our office will refer you to a podiatrist or another appropriate specialist. Those who delay seeking treatment, have it in both feet or are overweight are more likely to have it for a long time before they see improvement.

Enjoy!

Darryl D. Curl, DDS, DC 
La Jolla, California 

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Arizona Custom Orthotics for Plantar fasciitis Mesa AZ

 

Posted 01:45 PM October 21, 2010

www.CUSTOM-FOOT-ORTHOTICS-AZ.COM Dynamic Chiropractic – January 29, 2007, Vol. 25, Issue 03

Rehabilitating Plantar Fasciitis While You Sleep

By Daniel Batchelor, DC

Plantar fasciitis (PF) is a common cause of heel pain in adults. The PF is a fibrous band that holds the arch in your foot, much like the guy wires of a suspension bridge. When it overstretches, the patient will experience pain in the arch or heel, or both. The disorder usually presents itself with arch/heel pain that is severe during the first few steps taken in the morning. Symptoms usually resolve more quickly when the interval between the onset of symptoms and the onset of treatment is shorter. Many treatment options exist, including physiotherapy, rest, special taping, stretching, strengthening, change of shoes, arch supports, orthotics and night splints. Surgical intervention is an extremely rare necessity for those suffering from PF.

Over the past 26 years, I have successfully treated hundreds of patients for plantar fasciitis and heel spurs. Recent advances involving pulsed ultrasound, along with galvanic current to gradually reduce the sharpness of the spur, are very effective. In addition to reducing the cause of the pain, it's also important to address the rehabilitation of the area to prevent future episodes of pain.

One of the most aggravating symptoms of PF is the pain experienced when first stepping out of bed in the morning. One very effective device that helps to improve PF pain is the night splint. Just before going to bed, you strap the special brace to your foot. It places your foot into a dorsiflexed position. This allows your plantar fascia to gradually lengthen. It is the tight PF band that causes a great amount of pain. If the PF continues to be tight, a spur eventually will occur. This is why it's important to reduce the chronic tightness of the PF. After wearing the brace for a few days, most patients state that their initial morning steps, which used to be painful, are pain-free. Wearing the brace every night for a total of six weeks will allow your PF to adapt to its new length.

Pulsed ultrasound is a type of physiotherapy that breaks up the sharpness of the low-density calcium spur. I have used this method with excellent results. Remember, only the sharpness of the spur needs to be dulled. One person might have a huge, dull spur and feel no pain, while another person with a tiny, sharp spur can have severe pain and swelling. Some patients state that this small, sharp spur feels like a piece of ground glass under the heel. Pre- and post-X-rays determine the results.

The patient with chronic PF usually is put on a program of cross-training for two to four weeks. Kayaking, biking, swimming, etc., are excellent activities to take the stress off the PF.

Overuse is the most common cause of plantar fasciitis in athletes. A history of weight-bearing activities is common, especially those involving running, which causes microtrauma to the plantar fascia and exceeds the body's capacity to recover. Plantar fasciitis also occurs in elderly adults. In these patients, the problem usually is more biomechanical, often related to poor intrinsic muscle strength and compounded by a decrease in the body's healing capacity.

On examination, the patient usually has a point of maximal tenderness at the front bottom region of the calcaneus/heel bone. The patient also might have pain along the arch/mid plantar fascia. The pain might be exacerbated by passive dorsiflexion of the toes or by having the patient stand on the tips of the toes.

It's equally important to correct the problems that place individuals at risk for plantar fasciitis, such as increased amount of weight-bearing activity, increased intensity of activity, walking/running on hard surfaces and wearing worn shoes. Early recognition and treatment usually lead to a shorter course of treatment, as well as increased probability of success with conservative treatment measures.

Stretching and Strengthening

Stretching and strengthening programs play an important role in the treatment of plantar fasciitis and can correct functional risk factors such as tightness of the gastrocsoleus complex and weakness of the intrinsic foot muscles. Increasing flexibility of the calf muscles is particularly important. Frequently used stretching techniques include wall stretches.

Strengthening programs should focus on intrinsic muscles of the foot. Exercises used include towel curls and toe taps. Exercises such as picking up marbles and coins with the toes also are useful. To do a towel curl, the patient sits with the foot flat on the end of a towel placed on a smooth surface. Keeping the heel on the floor, the patient pulls the towel toward the body by curling it with the toes. To do toe-taps, all of the toes are lifted off the floor and, keeping the heel on the floor and the outside four toes in the air, the big toe is tapped to the floor repetitively. Next, the process is reversed and the outside four toes are repetitively tapped to the floor while keeping the big toe in the air. Rolling the foot over a soup can or a roller pin also can help to loosen the PF.

Orthotics also might be necessary to correct any biomechanical imbalances in the foot. If the patient wishes to train without pain, there are a number of factors that must be addressed. During examination, I determine the cause and correction of PF pain and devise a specific rehab program to prevent it from occurring in the future.

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Arizona Custom Orthotics for Plantar fasciitis Mesa AZ

 

Posted 01:44 PM October 21, 2010

www.CUSTOM-FOOT-ORTHOTICS-AZ.COM

Care Options for Plantar Fasciitis

By Mark Charrette, DC

Plantar fasciitis generally presents as "a sharp heel pain that radiates along the bottom of the inside of the foot. The pain is often worse when getting out of bed in the morning." Plantar fasciitis can occur in runners or other athletes who repetitively land on the foot. Another susceptible group is middle-aged people who spend much time on their feet. More rarely, the fascia becomes inflamed after a single traumatic event, such as landing wrong after a jump or running a long hill. The vast majority (95 percent) will respond to conservative care and not require surgery. Proper treatment is necessary, however, to allow for continued participation in sports and daily activities and avoid chronic damage.

The plantar fascia is the major structure that supports and maintains the arched alignment of the foot. This aponeurosis functions as a "bowstring" to hold up the longitudinal arch. Plantar fasciitis develops when repetitive weight-bearing stress irritates and inflames the tough connective tissues along the bottom of the foot. High levels of strain stimulate the aponeurosis to try to heal and strengthen. If the biomechanical strain continues, it overwhelms the body's ability to repair, and the ligaments begin to fail. It is this tear/repair process that causes the chronic, variable symptoms that can eventually become unbearable for some patients.

Since the plantar fascia inserts into the base of the calcaneus, the chronic pull and inflammation can stimulate the deposition of calcium, resulting in a classic heel spur seen on a lateral radiograph. Unfortunately, there is no correlation between the presence of a heel spur and plantar fasciitis. Many heel spurs are clinically silent, and most cases of plantar fasciitis do not demonstrate a calcaneal spur.

Biomechanical evaluation may reveal either excessive pronation or supination. The flatter, hyperpronating foot overstretches the bowstring function of the plantar fascia, while the high-arched, rigid foot places excessive tension on the plantar aponeurosis. In either case, it is the combination of improper foot biomechanics and excessive strain that causes the connective tissue to become inflamed. A careful assessment of the weight-bearing alignment of the lower extremities is helpful, since many patients will have functional imbalances up the kinetic chain into the pelvis and spine.

Direct palpation of the plantar fascia will demonstrate discrete painful areas, most commonly at the insertion on the anteromedial calcaneus. Fibrotic thickenings are frequently felt - these are remnants of the repetitive "tear and repair" process. With the foot relaxed, grasp the toes and gently pull them up into passive dorsiflexion. Since this maneuver stretches the irritated plantar aponeurosis, it is frequently quite painful and is an obviously positive objective sign.

Standard temporary support procedures for strained plantar fascia can be provided with figure-eight taping and initial restriction of repetitive and straining activities. Immobilization, however, is not recommended. Ice massage and/or cold packs often help to reduce pain and inflammation. Other steps that can be taken include ultrasound (initially pulsed, then constant and direct) once inflammation has subsided, along with the use of vitamin C with bioflavonoids (which is a natural anti-inflammatory that can speed healing). In addition, transverse friction massage helps to stimulate blood flow and collagen deposition.

If the feet are pronated, recommend custom-made, flexible orthotics to support the arches and reduce the stress on the plantar fascia. For the rarer cases of supinated feet, recommend custom-made orthotics that support the arches and offer added viscoelastic material to cushion the feet and decrease the amount of shock at heel strike. When ordering orthotics, ask for a divot in the surface of the material under the heel. This helps to spread pressure away from the fascial insertion.

Recommend the runner's stretch for the calf and the bottom of the foot. Demonstrate toe-curl exercises (while sitting, gather a towel on the floor up under the arch) for intrinsic muscle strengthening. For extrinsic muscle strengthening,have the patient perform toe raises (standing on the edge of a stair, slowly rising up on the balls of the feet) and perform the ankle-stabilizing series with exercise tubing.

Plantar fasciitis usually responds well to focused, conservative treatment. One of the most important treatment methods is to reduce any tendency to pronate excessively. In addition to custom-made orthotics, runners should wear well-designed shoes that provide good heel stability. The use of custom-made orthotics can prevent many overuse problems from developing in the lower extremities. Investigation of foot biomechanics is a good idea for all patients, but especially for those who are recreationally active.

References

1. Souza TA. Differential Diagnosis for the Chiropractor. Gaithersburg, Md.: Aspen Publications, 1997:354.
2. Baxter DE. The heel in sport. Clin Sports Med, 1994; 13:685-93.
3. Huang CK, et al. Biomechanical evaluation of longitudinal arch stability. Foot Ankle, 1993;14:353-7.
4. Lapidus PW, Guidotti FP. Painful heel: report of 323 patients with 364 painful heels. Clin Orthop, 1965;39:178.
5. Subotnick SI. Sports Medicine of the Lower Extremity. New York: Churchill-Livingstone, 1989:237.
6. Lear L. Transverse friction massage. Sports Med Update, 1996;10:18-25.
7. Kibler WB, et al. Functional Rehabilitation of Sports and Musculoskeletal Injuries. Gaithersburg, Md.: Aspen Publishers, 1998:280.

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Custom Orthotics for Plantar fasciitis Mesa AZ

 

Posted 01:41 PM October 21, 2010

www.CUSTOM-FOOT-ORTHOTICS-AZ.COM Dynamic Chiropractic – August 18, 2000, Vol. 18, Issue 18

High-Heeled Shoes and Musculoskeletal Problems

By Kim Christensen, DC, DACRB, CCSP, CSCS

Looking good is what counts most! At least that is what one might conclude, faced with the popularity of high-heeled fashion footwear. A recent survey of 620 women established that the majority was dissatisfied with their dress shoes because they hurt their feet, even though most had paid between $50 and $200 per pair. Not surprisingly, women have about 90 percent of the nearly 800,000 annual surgeries for neuromas, bunions, and "hammer toes." 1 There is a clear link between the types of shoes worn and the development of abnormal foot conditions.

Convincing patients not to wear high heels is another story, however, this information should help you make a strong and logical appeal. Additionally, custom-made shoes - which combine fit, fashion, and the postural support of custom orthotics - are now available, so you can offer a sensible solution.

Forefoot Compression Injuries

A neuroma, also called interdigital neuritis, results from compression of a plantar nerve or a bursa between two metatarsals. The resulting inflammation and fibrosis can diminish both nerve and vascular flow, resulting in a burning sensation that extends into the toes. The most common area involved is between the third and fourth metatarsals but may occur at any site of compression. A three-inch heel was found to create seven times more stress on the forefoot than a one-inch heel."

Brantingham et al. reported the results of a clinical trial involving 29 patients suffering from Morton's neuroma. The average pre-treatment history of foot pain was 19 months. All patients received a series of foot manipulations, with the number of treatments ranging from three to 26. The manipulations included mobilization of the metatarsal and MTP joints, forefoot mobilization relative to the rear foot, ankle mobilization, and specific adjustments of the cuboid and cuneiforms. Additionally, 23 of the patients (80 percent) were fitted with orthotics to control excessive movements and hyperpronation. A follow-up, three months after treatment established that 83 percent reported moderate-to-excellent relief of their pain. Adjustments that restore the articulations, combined with flexible orthotics that maintain the corrections, provide a true long-term solution in many cases, but high heels (higher than two inches) are nearly impossible to properly fit with orthotics.

Shoe Styles and Biomechanics

Although the Brantingham et al. study did not comment on modifying footwear, a long history of research has attempted to link shoe style with altered biomechanics, necessary for the development of these common conditions among women. Some of the earliest studies that compared gait in low-heel and high-heel shoes were performed by Schwartz et al. They reported changes in the distribution of weight in the forefoot with a shift away from the fifth metatarsal head in high-heel shoes. Increased weight distribution over the third and fourth metatarsals, combined with the compressive toe box common to most high-heel shoes, is a logical mechanism for the development of a neuroma. Considering that 59 percent of women surveyed report wearing high-heel shoes at least one to eight hours a day, unless the underlying stress is removed by changing shoe styles, the symptoms associated with neuromas are likely to return.

Loss of Arch Integrity

The same biomechanical derangement responsible for neuroma can cause a hallux valgus and bunion formation. In this condition, one or more of the foot's three arches has often collapsed or lost integrity, which changes normal toeing off and weight transfer in the forefoot. Lateral deviation of the proximal first phalanx changes the direction of muscle attachments on the great toe. Contraction of these muscles leads to abnormal abduction of the phalanx and the cycle of deviation continues.

An early clue that the patient is losing integrity of the transverse arch is excessive callus formation directly under any of the metatarsal heads, but especially two through four. This is the body's attempt to lift and pad the fallen structures. Metatarsal corrections built into flexible, custom orthotics can lift the metatarsals from the bases and remove the pressure from the metatarsal heads.

Rear Foot Conditions

Wearing heels also concentrates abnormal forces on the ankle and rear foot, relative to the forefoot. The tibiotalar joint is a tightly interlocked joint, exposed to extreme mechanical conditions during single limb support, and is susceptible to repetitive, traumatic forces. Anyone who has seen an inexperienced high-heel walker knows exactly what repetitive microtrauma is. The integrity of this joint is ensured by tension produced as the wedge-shaped talus is secured between the malleoli. However, the forced plantarflexion associated with high-heel use decreases the degree of tension, because of the shape of the wedge (wider anteriorly).

Although slight, this loss of tension decreases the optimal biomechanical relationship. According to Kapandji: "There is only a single position of articular congruence for the subtalar joint, i.e. the median position. The foot is then straight without any inversion or eversion and it is the position adopted by a normal foot lying flat on a horizontal plane..." He continues: "This neutral position, where the articular surfaces are kept together by the force of gravity, and not by the ligaments, is stable and can be maintained for a long time owing to the congruence of the articular surfaces. All other positions are unstable and are associated with a variable degree of articular incongruence."

In extreme cases, the plantarflexion associated with heels may be responsible for injuries as serious as inversion sprains. Remember also, that because of the lack of muscular attachments, the talus is nourished only by a weak blood supply, accompanying ligaments. "Thus it has a barely adequate arterial supply under normal conditions." This is an unfortunate situation for a bone faced with remodeling in response to repetitive microtraumas.

Conclusion

Whether or not your patient turns an ankle, high heels disrupt gait and posture for the entire body. In their study of varying heel heights, Gastwirth et al. observed: "Proximal symptomatology associated with wearing high heels, such as knee, hip and back problems, may in part be related to (a) restriction of subtalar joint pronation. The subtalar joint pronation that normally occurs at heel strike aids in shock absorption. If this pronation is limited, an increased shock wave must be absorbed by the joints proximal to the foot."

If your female patients continue to wear their high-heeled shoes, despite your best recommendations, it isn't your fault if you cannot "cure" their every ache and pain. However, because fashion is still "in fashion," your patients will want an alternative to high heels. According to at least one study, it is not necessary to wear completely flat shoes. Only heel heights greater than 5 cm (2 inches) significantly influenced lower extremity mechanics and gait. That may be a compromise that many of your fashion-conscious patients could live with.

References 

1. The low down on high heels. AOFAS Online (http://www.aofas.org/highheels.htm). 
2. Brantingham JW et al. Chiropractic management of Morton's metatarsalgia (Morton's neuroma): a review of 29 patients. Chiropractic Technique 1994; 6(2):61-66. 
3. Craigmile DA. Incidence, origin and prevention of certain foot defects. Br Med J 1953; 2:749. 
4. Feinberg H. Women's fashion shoes. JAPA 1969; 59:360. 
5. Gorecki GA. Shoe-related foot problems and public health. JAPA 1978; 68:245. 
6. Schwartz RP, Heath AL, Misiek W. The influence of the shoe on gait. J Bone Joint Surg 1935; 17:406. 
7. The Gallup Organization, Inc. Women's Attitudes and Usage of High Heel Shoes. August, 1986. 
8. Kapandji IA. The Physiology of the Joints (5th ed.). New York: Churchill Livingstone Inc. 1989:148-206. 
9. Gastwirth BW, et al. An electrodynographic study of foot function in shoes of varying heel heights. J Am Podiatric Med Assoc 1991; 81:463-472. 
10. Ebbeling CJ, et al. Lower extremity mechanics and energy cost of walking in high-heeled shoes. JOSPT 1994; 19:190-196.

Kim Christensen,DC,DACRB,CCSP 

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Walking and Orthotic Support

 

Posted 05:17 PM July 28, 2010

Custom foot orthotics Dynamic Chiropractic – March 25, 2002, Vol. 20, Issue 07

By Mark Charrette, DC

People who are concerned about good health are walking a lot more nowadays, and they're doing it to help lower blood pressure, lose weight, look better, and feel better. Many chiropractors are even recommending that their patients begin walking regularly to improve their neuromusculoskeletal health. With so many people participating, it should come as no surprise that many of these regular walkers need orthotic support.

A Popular Activity

Fitness walking is a very popular form of exercise because of its many health benefits and the ease with which it can be accomplished. Research from many fields has proven the value of this form of exercise. Recommendations to "get out and walk" come from any number of health organizations and groups, and as more individuals participate, even more friends and neighbors are joining in. The aging of the "baby boomer" generation is certainly a factor in popularizing the use of walking as a low-stress exercise.

Advantages of Walking

• It can be continued when on business trips and vacations.
• Companionship with friends and/or family is possible.
• It does not require a partner or companion.
• Equipment is relatively inexpensive.
• Indoor locations are readily available in poor weather conditions.
• Little or no commuting is needed.
• No membership or fees required.
• No special coordination or learned skills are required.
• It permits listening to music, radio, or books on tape.
• Routines are simple and can be easily varied.
• Scheduling can be individualized and varied.
• It utilizes large muscle groups for efficient aerobic conditioning.

Health Benefits

Fitness walking is effective in:

• burning calories efficiently, assisting in weight loss;
• decreasing blood pressure and resting heart rate;
• decreasing cholesterol counts and increasing good HDL levels;
• developing heart and lung capacity;
• gradually increasing lean muscle mass;
• helping to reduce all the health risks of obesity;
• improving balance and neurological coordination;
• improving elimination of waste and toxic products;
• improving psychological outlook, reducing stress;
• increasing oxygenation of all tissues in the body;
• lowering the risk for many diseases;
• stimulating strong and dense bones, staving off osteoporosis;
• strengthening hip and back support muscles; and
• strengthening the immune system, thereby reducing cold and flu symptoms.

Spinal Conditions and Walking

Walking is a very beneficial, and is recommended exercise for patients with back problems.

I have found this to be true with my own patients. In most cases, both acute and chronic back conditions improve more rapidly when patients walk at least 20 minutes every day.

Walking at comfortable pace for at least 20 minutes is an achievable level of exercise, even in very busy lives. You can feel the benefits almost immediately, and those benefits continue as the pace is increased. When patients miss work due to a back injury or condition, I have them walk three times a day for at least 20 minutes per session. Most patients are surprised at first by this recommendation; they do not think they can do much walking with sore backs! However, once they start walking, they can feel how it loosens up the back muscles and decreases their pain levels.

Walking is a very useful adjunct to the treatment of most spinal conditions - and patients gain all the benefits and advantages listed above. There is, however, a factor that must be considered. For many patients, a major issue in their spinal condition is inadequate support and faulty alignment from the lower extremities and/or poor shock absorption. These issues must be addressed if your patients are going to enjoy their walking regimens and truly benefit from the activity.

Orthotic Support for Walkers

As fitness walking catches on as a regular exercise routine, there will be walkers who develop back problems, and many will seek chiropractic care. To effectively treat their spinal conditions, most walkers will benefit from custom-made, flexible orthotics - either to decrease the biomechanical stress on the spine caused by arch collapse, foot hyperpronation, or leg length problems, or to help absorb and dissipate the shockwaves transmitted into their spines with each step. This is especially true in middle-aged and elderly walkers who have developed degenerative changes in the joints of the lower extremity and of the spine. The gradual aging of the soft tissues results in a progressive stiffening of the natural shock absorbers. This stiffness eventually leads to clinical symptoms, and will be accentuated by a regular walking program.

The answer, however, is not to cut back on the walking, but to address the issue at its source - by providing well-fitted, custom-made, flexible orthotics that decrease biomechanical asymmetry and excess motion, absorb much of the shock, and fit comfortably into the walker's shoes. Orthotic manufacturers who recognize the value of walking in the treatment of spinal conditions have developed specialized lightweight inserts to address these concerns. This is the type of orthotic to consider whenever you are dealing with a patient who already has an established walking program. Such an orthotic is also appropriate when you recommend that a patient begins a walking program to help a spinal condition and improve general well-being, but the patient has an interfering condition (such as arch collapse, degenerative joint changes, or spondylolisthesis).

Conclusion

The chiropractic patient should be encouraged to engage in a regular fitness and exercise program, and fitness walking should be considered for such a program. While many walkers need only a well-made walking shoe, some patients will need to be fitted with custom orthotics. The orthotics must be designed to be lightweight, shock-absorbing, and comfortable, and yet provide proper biomechanical support and a good fit. These parameters can be achieved through the use of specialized orthotics for walking shoes. The doctor who considers this approach will improve clinical efficacy and outcomes, while being assured of patient satisfaction at the same time.

References

1. Bigos S, Bowyer O, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline, Quick Reference Guide Number 14. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, AHCPR Pub. No. 95-0643. December 1994.
2. Yochum TR, Barry MS. The short leg (revised edition). Practical Research Studies 1994; 4(5).
3. Yochum TR, Rowe LJ. The Essentials of Skeletal Radiology (2nd ed.). Baltimore: Williams&Wilkins, 1996:363.

Mark Charrette,DC 
Las Vegas, Nevada

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