Thursday
Jan142010
The Foot-Back Connection
Thursday, January 14, 2010 at 2:59AM Stuart Currie DC,
Director of Research, Sole Supports.
www.solesupports.com
Do foot biomechanics play a role in your clinical practice? This is a question that is answered very differently depending on your point of view. For some the answer is, “Not at all” while for others, the answer may be “Yes, with every patient”. As with many evaluation strategies, neither answer is incorrect but as is often the case the answer to this question prompts another: When should one look to the foot in a clinical situation involving the low back?
As chiropractors, we are well aware of the high prevalence and cost of low back pain. What is less obvious sometimes is the exact cause of that pain. The decision of when to look to the foot in a clinical situation can be one with philosophical consequences. It is often a question that prompts a “chicken or the egg” debate, or more specifically a “foot or back debate”. What came first, the low back problem, or the foot pathology? Is your patient limping because he has back pain, or does he have back pain because he’s limping? Many times the answer to that debate is irrelevant as a comprehensive treatment plan will encompass aspects of both areas, but often times a search to find the underlying cause of a disorder leads to a better understanding of lower extremity involvement.
A review of some relevant literature helps the discerning clinician determine if and when to look to the foot. From a structural or postural standpoint, it has been demonstrated that the severity of pes planus correlates with the prevalence of anterior keen pain and intermittent low back pain, and therefore foot screening has been recommended for patients with intermittent low back pain.1
There is also evidence that treatment of the foot with various wedges can produce measureable changes in the timing of low back and pelvic muscle activity2. This should be of particular interest to those who treat muscle imbalances. Significant postural improvements including reduction in scoliotic curves in subjects with low back pain and a measured leg length deficiency have been obtained by using wedges underfoot 3. Again, these studies lend credence to the conclusion that the foot posture affects the back.
As for how to treat a perceived abnormality, the importance of custom foot orthoses in the management of low back pain is supported by Dananberg’s work. He concluded that the treatment of chronic or acute recurrent low back pain with custom made foot orthoses is more effective than standard methods of care (at PT clinics, a physiatry center and family group practices), and that the symptoms remained improved for a longer period of time.4 Interestingly, the custom orthotic group in this study also received selective manipulation of the first MPJ, ankle and fibular head when appropriate. Furthermore, the crucial role of foot biomechanics in the management of the low back patient is illustrated by the use of foot orthoses to change abnormal lower extremity biomechanics in relation to low back pain.4-7
With the evidence in support of the foot-back connection it might seem as though treatment of the foot is a given. While this may be the case a solid knowledge of the treatment effect is required. It is not advisable to prescribe a foot orthotic in the absence of a biomechanical goal and expected objective result. The consequences for patients can be dire. For example, investigators have shown that different types of foot orthotics can affect plantar pressures differently, even causing a pressure shift that is counter to the goals of foot biomechanics8 with resultant potential consequences to the kinetic chain. This underscores the notion that any intervention that can have a positive effect, can also have a negative effect if administered improperly.
Some foot related pathologies that might prompt a practitioner to consider biomechanical etiologies include plantar fasciitis, hallux valgus deformity, morton’s neuromas, and hallux limitus. Other clinical indicators of a possible lower extremity connection include a signficiant leg length discrepancy, significant genu valgum, tibial or femoral internal rotation, and asymmetrical pronation. If you can see it, then it might be causing problems in the kinetic chain.
The obvious answer to the question posed at the beginning of this article, is that the foot should be evaluated whenever there is a suspected contribution of the foot to the clinical picture. Knowledge of the key components of foot function and their relation to the low back is crucial to a comprehensive understanding of the kinetic chain. The next step in the process is honing specific clinical evaluation skills in order to recognize the foot’s contribution. This will be discussed in a subsequent article.
Reference List
1. Kosashvili Y. Foot Ankle Int 2008 September; 29(9): 910-3.
2. Bird AR. Gait Posture 2003 October; 18(2): 81-91.
3. Bellomo RG. Gait Posture 2009;29(Supplement 1: SIAMOC 2008):e6-e7.
4. Dananberg HJ. J Am Podiatr Med Assoc 1999 March;89(3):109-17.
5. Wosk J. Arch Phys Med Rehabil 1985 March; 66(3):145-8.
6. Botte RR. J Am Podiatry Assoc 1981 May;71(5):243-53.
7. Rothbart BA. Am J Pain Manage 1995;5:84-90.
8. Hodgson B, Tis L, Cobb S. J Sport Rehab 2006;15(1):33-44.
www.solesupports.com
Do foot biomechanics play a role in your clinical practice? This is a question that is answered very differently depending on your point of view. For some the answer is, “Not at all” while for others, the answer may be “Yes, with every patient”. As with many evaluation strategies, neither answer is incorrect but as is often the case the answer to this question prompts another: When should one look to the foot in a clinical situation involving the low back?
As chiropractors, we are well aware of the high prevalence and cost of low back pain. What is less obvious sometimes is the exact cause of that pain. The decision of when to look to the foot in a clinical situation can be one with philosophical consequences. It is often a question that prompts a “chicken or the egg” debate, or more specifically a “foot or back debate”. What came first, the low back problem, or the foot pathology? Is your patient limping because he has back pain, or does he have back pain because he’s limping? Many times the answer to that debate is irrelevant as a comprehensive treatment plan will encompass aspects of both areas, but often times a search to find the underlying cause of a disorder leads to a better understanding of lower extremity involvement.
A review of some relevant literature helps the discerning clinician determine if and when to look to the foot. From a structural or postural standpoint, it has been demonstrated that the severity of pes planus correlates with the prevalence of anterior keen pain and intermittent low back pain, and therefore foot screening has been recommended for patients with intermittent low back pain.1
There is also evidence that treatment of the foot with various wedges can produce measureable changes in the timing of low back and pelvic muscle activity2. This should be of particular interest to those who treat muscle imbalances. Significant postural improvements including reduction in scoliotic curves in subjects with low back pain and a measured leg length deficiency have been obtained by using wedges underfoot 3. Again, these studies lend credence to the conclusion that the foot posture affects the back.
As for how to treat a perceived abnormality, the importance of custom foot orthoses in the management of low back pain is supported by Dananberg’s work. He concluded that the treatment of chronic or acute recurrent low back pain with custom made foot orthoses is more effective than standard methods of care (at PT clinics, a physiatry center and family group practices), and that the symptoms remained improved for a longer period of time.4 Interestingly, the custom orthotic group in this study also received selective manipulation of the first MPJ, ankle and fibular head when appropriate. Furthermore, the crucial role of foot biomechanics in the management of the low back patient is illustrated by the use of foot orthoses to change abnormal lower extremity biomechanics in relation to low back pain.4-7
With the evidence in support of the foot-back connection it might seem as though treatment of the foot is a given. While this may be the case a solid knowledge of the treatment effect is required. It is not advisable to prescribe a foot orthotic in the absence of a biomechanical goal and expected objective result. The consequences for patients can be dire. For example, investigators have shown that different types of foot orthotics can affect plantar pressures differently, even causing a pressure shift that is counter to the goals of foot biomechanics8 with resultant potential consequences to the kinetic chain. This underscores the notion that any intervention that can have a positive effect, can also have a negative effect if administered improperly.
Some foot related pathologies that might prompt a practitioner to consider biomechanical etiologies include plantar fasciitis, hallux valgus deformity, morton’s neuromas, and hallux limitus. Other clinical indicators of a possible lower extremity connection include a signficiant leg length discrepancy, significant genu valgum, tibial or femoral internal rotation, and asymmetrical pronation. If you can see it, then it might be causing problems in the kinetic chain.
The obvious answer to the question posed at the beginning of this article, is that the foot should be evaluated whenever there is a suspected contribution of the foot to the clinical picture. Knowledge of the key components of foot function and their relation to the low back is crucial to a comprehensive understanding of the kinetic chain. The next step in the process is honing specific clinical evaluation skills in order to recognize the foot’s contribution. This will be discussed in a subsequent article.
Reference List
1. Kosashvili Y. Foot Ankle Int 2008 September; 29(9): 910-3.
2. Bird AR. Gait Posture 2003 October; 18(2): 81-91.
3. Bellomo RG. Gait Posture 2009;29(Supplement 1: SIAMOC 2008):e6-e7.
4. Dananberg HJ. J Am Podiatr Med Assoc 1999 March;89(3):109-17.
5. Wosk J. Arch Phys Med Rehabil 1985 March; 66(3):145-8.
6. Botte RR. J Am Podiatry Assoc 1981 May;71(5):243-53.
7. Rothbart BA. Am J Pain Manage 1995;5:84-90.
8. Hodgson B, Tis L, Cobb S. J Sport Rehab 2006;15(1):33-44.