Lower Extremity Subluxations and Supportive Orthotics

Whether due to sports injuries, recreational overuse or just a gradual buildup of biomechanical stress, most foot, ankle and knee joint subluxations will need custom-made, stabilizing orthotics in addition to the extremity and spinal adjustments and corrective exercises doctors of chiropractic provide. And while the connection is less obvious, supportive foot orthotics play a vital role in the proper care of several conditions of the pelvis and spine.

Since the pelvis and spine are at the end of a closed kinetic chain from the lower extremities, abnormal biomechanical forces are transmitted in both directions - upward and downward. Fortunately, the use of well-designed foot orthotics can balance and stabilize the lower extremities, and significantly reduce the deleterious effects of lower extremity subluxations on the spine.

Foot and Ankle

It's not surprising abnormal biomechanics of the foot and ankle can cause local symptoms that need support from a stabilizing orthotic. In fact, almost any subluxation in this region will respond much better with a combination of custom-made shoe inserts and adjustments. The specific problems identified most commonly in chiropractic practice include: plantar fascitis, hallux valgus, pain under the metatarsal joints, interdigital neuroma, heel spur, arch collapse, Achilles tendinitis, recurrent ankle sprain and shin splints (i.e., strain of the anterior or posterior tibialis muscle).

Often, patients will seek treatment for spinal problems, and their foot or ankle symptoms will be mentioned only in passing. Once they have experienced relief of their lower extremity subluxation (which often has been quite chronic) with adjustments and orthotics, they can understand much better the whole-body treatment philosophy of chiropractic.

Knee

Many patients with anterior knee pain (whether it is called patellofemoral pain, chondromalacia patellae or retropatellar arthralgia) report almost-immediate relief from a combination of adjustments and custom-made, stabilizing orthotics. That is because the orthotics reduce the extent of foot pronation, thereby decreasing internal rotation of the tibia and improving the tracking of the patella in the femoral groove. Especially when there is a high Q angle, correction of excessive pronation is necessary for a complete response. Other knee conditions, such as iliotibial band syndrome in runners, popliteus tendinitis and recurring fibular head subluxations, indicate the need for orthotic support throughout the gait cycle.

Hip

When a patient presents with a trochanteric bursitis or evidence of hip joint degeneration, casting for orthotic support should become almost automatic. The hip joint develops symptoms only when there is a biomechanical asymmetry of the lower extremity. A strain or chronic tightness of the tensor fascia lata, recurrent groin pulls in an athlete or a piriformis syndrome all require close evaluation in determining the need for custom foot support.

Sacroiliac Joints

When each foot pronates during the stance phase of the gait cycle, there is a normal inward (medial) rotation of the entire limb and pelvis on that side. In patients with excessive pronation, this twisting movement is accentuated (on one or both sides), and is transmitted to the pelvis, especially the sacroiliac (SI) joints. A chronic SI subluxation complex develops, one that can only be treated with a combination of chiropractic adjustments and stabilizing orthotics. Particularly when a patient describes the pain in the region of the sacroiliac joint as being made worse with standing, walking and/or running, the need for orthotics must be considered. Whenever a strenuous sport or recreational activity also is reported, I immediately look to the lower extremities for the source of biomechanical stress.

Pelvis/Short Leg

The pelvis is the structural foundation for the spine. If there is leg asymmetry anywhere from the feet to the femurs, the pelvis and the spine will suffer. Anterior tilting, rotations and lateral tilts of the pelvis all interfere with chiropractic spinal care and must be addressed. All of these pelvic distortions are frequently caused by foot and leg imbalances, which require stabilizing orthotics and occasionally permanent heel lifts.

When there is an anatomical difference in leg length, any permanent buildup should be attached to an orthotic to ensure balanced foot and ankle function. If the discrepancy is functional, it will most commonly be caused by a lower arch on one foot, producing a lowering of the femur head during standing and walking (positions of function). To treat the current spinal problems and to prevent the development of recurring subluxations, stabilizing orthotics should be fitted immediately upon determination of a structural short leg.

Spine/Disc Degeneration

The long-term result of the microtrauma caused by poor structural support from the lower extremities is degeneration of the spinal discs. Of course, frank trauma and a history of overuse also can damage the intervertebral discs. Once this has occurred, reducing the forces transmitted to the less elastic and less flexible joints is necessary. I find that foot orthotics constructed with extra shock-absorbing materials are often the only way to provide long-lasting relief for patients with disc and/or sciatica symptoms.

A significant decrease in the pounding stress on the joints from the feet to the knees, hips, pelvis, and spine during walking and exercising can be a godsend to elderly patients. Flexible, shock-absorbing orthotics are always included in my treatment recommendations when X-rays demonstrate substantial spinal joint degeneration.

Locate the Source of the Problem

When chiropractic patients report lower extremity symptoms, or when their spinal problems are chronic and become worse with standing and walking, I always look carefully for lower extremity subluxations. Excessive pronation or supination, if not addressed, will interfere with even the best chiropractic care. Degenerated joints will magnify the forces transmitted to the spine during normal activities. Identifying those patients who need custom-made, stabilizing orthotics and/or shock absorption right from the beginning gives chiropractic adjustments the best chance for success.