Evaluation Strategies When Dealing with Foot Pain and Dysfunction
By Jeffrey Tucker, DC, DACRB
I think we all agree that any dysfunction of the foot and ankle complex can cause problems into the knees, lumbo-pelvic-hip complex, spine and upper extremities. Because of this, people must wear proper footwear to protect the foot and prevent injuries. Do you recommend shoe brands to patients? How do you determine if a patient needs orthotics or if a particular orthotic is helping? I am often asked by patients, "What type of shoes should I buy?" Or, "What about orthotics?" There are specific shoe designs for people with pes cavus (high arches), pes planus (flat feet) and relatively normal feet. The thought with orthotics is to assist the foot and body in performing a more natural and optimal movement pattern. I have concerns about asking patients to spend money on products that I am uncertain will help so I'm going to share my foot evaluation process and the simple device that has helped me say "Yes" or "No" to orthotic use and type.
Whole Body Effect
My experience is that most adults seem to know if they have calluses, bunions, flat feet or high arches. They don't always put together the story (history) behind their foot deformity that we are seeing today. Nor do they realize what effect it has on there whole body or performance. When I tell patients they have flat feet, they respond by saying, "It's always been that way." For many years, I simply evaluated my patients lower extremities with their shoes and socks off and I'd perform a static visual posture analysis. In those days, I thought that was pretty good because most doctors don't even take patients shoes and socks off. Visual analysis can reveal these telltale signs of abnormal biomechanics such as:
Next, I learned to couple my visual analysis with having the patient perform small squats (knees bent about 30 degrees). This alone can reveal the movement tendency of the arches in the feet and help you see if the knees are tracking inward or outward. Even though patients are standing in front of a mirror, this method of evaluation is difficult for patient's to see what I am seeing.
More than a year ago, I added the use of a foot and lower extremity evaluation device with a laser guided light aimed upward along the second toe, up the center of the leg, the patella, thigh and ASIS. With the patient standing on the device in front of a mirror, we are able to visually assess the left and right alignment and movement tendencies of the foot and lower extremity. The simple process helps practitioners to quickly determine the combination of products (shoe type, orthotics, bracing, etc) and services (tape, manipulation, exercise, etc.) needed to help enable biomechanically correct foot transitioning. This evaluation system allows my patients to participate in the determination of whether or not orthotics would be necessary and beneficial.
The recognition of what the arches are doing during movement is essential. Williams et al. measured arch height and then followed participants to see what types of injuries would develop. These researchers showed that people with high arches got more ankle sprains, iliotibial band friction syndrome and stress fractures. This suggests that shock can be absorbed in less efficient places to compensate for a high arch. Pes Cavus, or high arches, is not as common as flat feet, but it is a problem with some people. The people with low arches got more medial injuries like plantar fasciitis and medial knee syndromes. Williams shows that arch height predicts motion and injury patterns. Other studies have demonstrated that higher-arched people hit the ground harder and pronate through smaller, more rapid ranges of motion. It is the velocity of pronation that causes problems.
A high arch in the sole of the foot is definitely less common than a flat foot. Burns, Crosbie, Hunt and Ouvrier found seventy subjects to participate in a study that included 30 subjects with pes cavus of unknown etiology (idiopathic), 10 subjects with pes cavus of neurological etiology (neurogenic) and 30 subjects with a normal foot type. The presence and location of foot pain were recorded and barefoot plantar pressures were measured using the EMED-SF platform for the whole foot, back of the foot, middle foot and front of the foot.
The study found that subjects with pes cavus of either idiopathic or neurogenic origins reported a higher proportion of foot pain (60%) compared to subjects with a normal foot type (23%) (P=0.009). Pressure-time integrals under the whole foot, back of the foot and front of the foot regions in pes cavus, of both idiopathic and neurogenic origin, were higher than in the normal foot type (P<0.01). Pressure-time integrals in subjects reporting foot pain were higher than for pain- free subjects (P<0.001).
Another study done by Burns, Landford, Ryan, Crosbie and Ouvrier found that people who present with pes cavus have tendencies toward lateral ankle instability, lower limb fractures, knee pain, IT band friction syndrome and osteoarthritis of the hip. They suggested that a conservative solution to pes cavus would be to reduce and redistribute plantar pressure loading through the use of foot orthotics. Other strategies include stretching and strengthening the tight and weak muscles and to focus on improving balance.
Regardless of the cause of pes cavus, it is characterized by abnormally high pressure-time integrals, which are significantly related to foot pain. By understanding the kinetic relationship of pes cavus, this will help us to improve the management of our clients who present with excessive arches in their feet and will help determine a corrective action for them to reduce their pain.
After 30 plus years of trying different electronic foot scan devices and stepping into foam devices, it has never been easier for the patient and myself to decide on orthotics.
In summary, I use this device to visually assess the effects of most foot interfacing products and services I perform. The process is to assess on the device – provide an intervention – and then retest to demonstrate improvement or lack of improvement. The majority of foot alignment and movement dysfunctions can be quickly assessed and eliminated with chiropractic care and rehabilitation exercises because improving the foot/ankle complex helps improve movement tendencies.
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