If you can identify a need for orthotics early in a patient's treatment, you're well on your way to boosting positive response to adjustments. After all, a balanced body starts with the feet. Early orthotics intervention helps prevent frustration in both doctor and patient. Here is a list of commonly seen characteristics, which indicate the need for orthotics. History 1) Back problems are worse with stand ing, walking, running. When a patient reports a link between locomotor activities and their spine symptoms, this clearly calls for orthotics to minimize the stress being transmitted from the lower extremities to the spine. 2) Recurrent ankle sprains. A history of previous sprain injuries to one or both ankles indicates biome-chanical instability and probable permanent ligament damage. Orthotics provide the support and mechanical advantage needed to prevent re-iniurv. 3) Family history of foot problems or sur gery. Since we inherit many health tendencies, a patient who has family members with foot problems and/or surgery has a much higher probability of the same. Fitting for orthotics may prevent these problems from developing, and could avoid surgery. 4) Strenuous athletic activities. Those who engage in upright, weight- bearing sports need both shock absorp- tion and foot/ankle stability. Orthotic support can increase performance and prevent injuries in a long list of individual and team sports, such as running, tennis, skiing, skating, soccer, baseball, football, and basketball. 5) History of lower extremity stress fractures, recurring shin splints, hamstring strains. Whenever an athlete, whether recreational or competitive, reports symptoms of overuse injury (microtrauma) in the lower extremities, orthotics must be provided. These conditions are closely correlated with bio-mechanical asymmetries, and require better support and shock absorption. 6) Chronic knee pain, patellofemoral arthralgia, ACL injury. The knee joint is a sensitive indicator of abnormal biomechanical stress, and these conditions have all been shown to indicate the need for orthotics. Controlling pronation decreases the rotational forces, improving patellar tracking and protecting the anterior cruciate ligament. Exam Findings 1) Posture imbalances—pelvis tilt, scoliosis, forward head. When a standing structural evaluation discloses a pelvic tilt (whether forward, backward, or low on one side), a lower extremity asymmetry requiring orthotics for proper correction is likely. Both functional and idiopathic types of spinal curvatures can benefit from the foot stabilization and neurological stimulus provided by orthotics. Many postural complexes (forward head is one of the most common) are secondary to poor standing balance and proprioccption from the feet. 2) Gait asymmetry, calcaneal eversion, excessive pronation, foot flare. Watching a patient walk, and looking for indicators of biomechanical asymmetry will often demonstrate the need for orthotics. If the foot and ankle complex is not functioning correctly during the stance phase of gait, this stress is transmitted to the pelvis and spine with every step. Chiropractic care must address this factor, usually through custom-fitted orthotics. 3) Foot calluses, bunions, hallux valgus. A careful examination of the foot will often show evidence of abnormal or poorly tolerated forces during walking. Heavy callousing, bunion development, and abnormal alignment all indicate the need for improved biomechanics and orthotics. 4) Lack of an arch—especially unilat eral. This is seen during the weight-bearing portion of the exam—when a foot collapses under the weight of the body. An even better method is the Navicular Drop Test, which measures the change in height of the medial longitudinal arch at the navicular prominence from sitting to standing. A foot without an arch will not function properly, and needs orthotic support. 5) Knee instability, high Q-angle, poor patellar tracking. When the knee does not align properly or track correctly, degenerative wear-and-tear and chronic symptoms will follow. Orthotic alignment is required to reduce the abnormal forces on this complex joint, which must be able to sustain frequent high forces during walking and running. X-ray Findings 1) Scoliosis (functional or idiopathic), widespread disc degeneration. The spine will demonstrate poor support from one of the lower extremities by developing a lateral curvature. Some studies indicate that gait disturbances may be one of the causative factors for idiopathic scoliosis. Significant interverte-bral disc degeneration is proof of poor spinal shock absorption, and orthotics with viscoelastic properties often reduce symptoms dramatically. 2) Unlevel sacral base, sacroiliac joint degeneration. The pelvis shows evidence of inadequate support by the appearance of a tilted sacral base when standing. This is often due to a functional short leg requiring orthotic support. Sacroiliac degeneration is unusual; when found it indicates significant abnormal stresses, needing orthotics. 3) Low femur head, coxafemoral DJD. These conditions are due to either an anatomical or a functional short leg. Degenerative changes in the hip joint have been correlated with the stress of a longer leg. Both will benefit from the improved balance and support provided by orthotics. 4) Heel spur, DJD in knees, metatarsals. X-rays of the feet and knees may re veal evidence of long-standing regional stress, such as degenerative changes in weight-bearing joints, and connective tis sue calcification. Calcium deposited in the calcaneal attachment of the plantar fascia specifically indicates the need for support of the arches of the foot. Orthot ics reduce shock and symptoms in de generated joints, and provide arch stabi lization. Treatment Response 1) Recurrent subluxations. Making the same adjustment to a patient's spine again and again suggests poor structural support for the region. Orthotics have been used for decades by chiropractors who don't want to continue adjusting the same area, and want to sec the adjustment "hold" better. 2) Unresolving muscle strain, myalgia. Myofascial symptoms that don't re spond to treatment often are a clue to an underlying biomechanical imbalance. Many chronic muscle spasms and strains can be corrected by providing orthotics to support and stabilize. 3) Flare-ups, exacerbations. A patient who is feeling better, returns to daily activities, and then suffers a return of symptoms, probably needs orthotics. Without proper biomechanical support these patients find that every attempt to establish normal routines causes a recurrence of their symptoms. Conclusion Foot symptoms are only one of the many reasons for supplying a patient with orthotics. In fact, the feet are seldom painful in most of the conditions that are clear indicators of the need for orthotics! All doctors of chiropractic must be alert for signs of lower extremity involvement in spinal conditions. The good news is that all of these conditions can be helped with custom-fitted orthotics. Investigation and correction of foot bio-mechanics is a good idea in all patients, and especially for the recreationally active and the elderly. Dr. John J. Danchik is the seventh inductee to the American Chiropractic Association Sports Hall of Fame. He is the current chairperson of the United States Olympic Committees Chiropractic Selection Program. He lectures extensively in the United States and abroad on current trends in sports chiropractic and rehabilitation. Dr. Danchik is associate editor of the Journal of the Neuromusculoskeletal System and the Journal of Chiropractic Sports Injuries and Rehabilitation. He has been in private practice in Massachusetts for 23 years.
