Effective spinal care requires a combination of adjustments, stabilization and neuromuscular rehabilitation. Abnormal lower-extremity biomechanics represent a primary source of structural weakness that promotes chronic forms of back pain.1 Custom-made orthotics are designed to make caring for spinal joints and supporting musculature easier and more effective.
Assessing the Feet
Excessive pronation is the most common lower-extremity structural misalignment. Each foot has three natural arches, and the functioning of this postural foundation depends on the proper alignment of all three arches. Any compromise of arch structure or supporting soft tissue adversely affects the whole body. A whole range of conditions, from knee pains to TMJ disorders, can be linked to poorly supported feet.
The hyperpronated foot pulls the tibia and femur into excessive internal rotation during weight-bearing. Leg rotation affects patellar tracking, pelvic rotation and muscular tonicity. On the same side of hyperpronation, you can expect to find knee pain, piriformis irritation, weak psoas, visual foot flaring in non-weight-bearing, and the combination of AI sacrum and AS pelvis. The anterior shift of the pelvis is accompanied by an increase of the thoracic kyphosis, rounding of the shoulders and anterior head translation.
As your care reverses patterns of distortion, fixations and muscular imbalance, overall health generally improves. There is no substitute for adjusting the spine and balancing paraspinal muscle tonus, but it's essential to provide the same level of expertise for the extremities.
Postural Distortion
Slight deviations from normal posture can cause the body to work harder to stay in balance. For example, when the head is centered over the cervical lordosis, minimal muscle effort is required to maintain this position. However, a 1-inch translation from neutral results in a tenfold increase in effort required by the supporting musculature. Anterior head translation is a very common postural distortion, so show your patients how the cervical spine affects the feet and vice versa.
You can make a graphic demonstration of increased anterior head translation with your patient in front of a full-length mirror. Have them jut their head forward and do the following:
- Report where they feel the shift in weight on their feet. The weight will shift forward onto the more sensitive structures of the forefoot.
- Abduct their arms toward their ears. In the translated posture, they will be unable to touch their arms to the side of the head.
- Take a deep breath. Thoracic expansion and depth of inspiration are decreased.
- Attempt to keep the mouth closed. Anterior translation increases tension on the anterior neck muscles of mastication and the TMJ.
Until the feet are properly supported and the muscular imbalances and fixations that accompany this presentation are removed, any treatment approach will be incomplete.
Adapting to Orthotic Support
Supporting the feet with custom-made orthotics is the first step toward postural stabilization and rehabilitation, but the lower extremities also require a combination of adjustments and neuromuscular rehabilitation. Orthotics can isolate hidden fixations in the feet and lower extremities that become irritated as joint alignment improves. You can help patients through this adaptation process so they get the most from their orthotics.
For analysis and care, the general rule is that joints will be fixated in the direction of the distortion pattern, and muscles will be hypertonic and irritated opposite the direction of fixation. Whatever your preferred technique, the following suggestions will help:
| Segmental Fixation | Segmental Adjustment | Rehab Exercise |
| Navicular bone fixation, inferior and medial | Superior and lateral | For navicular or cuboid fixations: Resisted lower-extremity internal-rotation and golf-ball exercises |
| Cuboid bone fixation, inferior* | Superior and medial | Same as above |
| Metatarsals 2-4 will drop straight inferior | Metatarsals 2-4 straight superior, 1 and 5 inferior relative to 2-4 | Towel-scrunch exercises |
| Proximal tibia with internal rotation fixation hamstring-muscle | External rotation with anterior glide | Resisted-quadriceps and hamstring-muscle strengthening |
| Pelvis and proximal femur AI sacrum and AS innominate | Sacropelvic adjustment of choice with superior/medial femur adjustment in direction of femoral neck | Passive and active stretching of piriformis muscle with resisted strengthening of the psoas and gluteus medius/maximus |
| *With Hx of inversion sprain, evaluate cuboid for superior and lateral fixation. | ||
Promoting a Stable Relationship
As you improve posture and support the feet, you stabilize the relationship between the lower extremity, the pelvis and spine. Repeatedly adjusting the same spinal segments without long-term improvements suggests poor postural support for that region. Providing patients with custom-made orthotics early in their care is an effective way to break up patterns of fixation, misalignment and muscular irritation - and maintain healthier spinal conditions.
Reference
- Fulton M. Lower back pain: New protocols for diagnosis and treatment. Rehab Management, Nov/Dec 1988:39-42.
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