Doctorate of Chiropractic degree (D.C.) in 1977 from the Canadian Memorial Chiropractic College in Toronto.
Definition of chiropractic
Anatomy
First Visit
Chiropractic Treatment
Chiropractic Treatment & Management of Headaches
Conditions Treated At Dr. Fuller's Clinic
Motor Vehicle Accidents (MVAs)
Weight Training Injuries & Management
Nutrition Corner
Orthotics
Origins
Research & Other Updates
When To Consult A Chiropractor
Laser Therapy & Phototherapy
Research confirming value of orthotics
Nawoczenski et al in Archives of Physical Medicine Rehabilitation 1999;80;540 reported that custom shoe orthotics can decrease the high incidence of overuse lower extremity injuries by reducing the stress and strain of running and preventing re-injury. These conclusions were drawn from electromyographic activity testing in the biceps femoris, tibialis anterior and medial gastrocnemius muscles.
 
D’Amico et al in  the Journal of the American Podiatric Medical Association 1986;76:337 contended that custom flexible orthotics prevent excessive pronation and improve tracking of the patella (kneecap).
 
Kuhn et al in JMPT 2002;24;465 reported that orthotics support all three arches of the foot.
 
Eng et al in Physical Therapeutics 1993;73;62 found that orthotics are more effective in reducing knee pain and preventing recurrence than a traditional exercise programme as the orthotics decreased foot pronation and tibial internal rotation.
 
The tibialis posterior lower leg muscle (T.P.) weakness leads to collapse of longitudinal arch (gets longer) resulting in valgus heel and bowed Achilles tendon. These can lead to tendonitis which can lead to T.P dysfunction, disabling weight-bearing symptoms associated with pes planus deformity (test strength of T.P during resisted foot adduction + plantar flexion.
 
The use of orthotics permits selective and more effective tibialis posterior activation during exercise.
 
Tibialis posterior muscle is an essential foot stabilizer during walk and stand. Eccentric activity of a healthy, strong T.P. permits controlled foot pronation and assist with shock absorption during loading.
 
ref. Kulig et al in Medicine & Science in Sports & Exercises Jan. 2005; Vol.37, No.1 24.
 
Orthotics help patellofemoral syndrome of the knee (cause of much knee pain) by:
 
  1. limit internal tibial rotation
  2. constrain femoral internal rotation
  3. decrease magnitude of Q angle
  4. reduce laterally-directed soft tissue forces & excessive patellofemoral contact pressures
  5. reduce foot pronation
 
TX
 
– strengthen quads, especially the vastus medialis obliquus inner thigh muscle by sitting with hand under knee, straighten leg (quads) with toes pointed outward.
- stand with strap over knee, knee slightly flexed, then stand up straightening knee.
- seated quads wt lifting with leg in internal rotation.
 
Research references :
 
Gross et al in Journal of Orthopaedic & Sports Therapy Nov.2005; Vol.33, No.11.
Khun et al in JMPT Sep.2002; 465.
Juhn in American Family Physician, Vol.60, no7, Nov.1, 1999.
Cornwall et al in Journal of Orthopaedic & Sports Physical Therapy, June 1995;21(6):337.
Ekenman et al in American Journal of Sports Medicine Nov.2002(6):866.
Couture et al in The Physician and Sports Medicine, June 2002; Vol.30, No.6.
Yoshitaka et al in Archives of Physical Medicine and Rehabilitation April 2004; Vol.85:673.
Hodgon in Journal of Sport & Rehabilitation 2006;15;33.
Munuera in Prosthet. Orthot. Int. 2011;35;342.
Mills in British Journal Sports Medicine 2010;44:1035.
 
Tight Achilles tendon causes plantar flexion and calcaneal eversion, forces translate medially on talus and medially and down on navicular, causing loss of height of medial longitudinal arch… orthotics stabilize hindfoot and medial longit arch.
 
Research ref:
 
Imhauser et al in Foot And Ankle International Aug.2002; Vol.23(#8);737.
Stovitz et al in Physician and Sports Medicine Aug.2004; Vol.32, No.8.
Shannon & Butler in “Standard of Care: Achilles Tendonopathy” 2004.
Vicenzino in Manual Therapy 2004(9):185.
 
Heel Pain:
– shoe orthoses often effective (and add to benefits of hands-on therapy):
Reference:
Rome in Journal of American Podiatric Medical Assn May 2004; Vol.94, No.3; 229.
 
Prevention of injuries :
- military recruits had 50% less lower extremity injuries due to orthotics.
Reference:
Aaltonen et al in Archives of Internal Medicine Aug.13/2007; Vol,167;No.15.
 
Plantar fasciitis research 2006 from Foot and Ankle International 2006;27:606-611
Roos et al researched plantar fasciits and concluded that there were "significant decreases in plantar fasciitis pain at 3 and 12 months post study with use of custom orthotics alone." They reported "clinically significant benefits of foot orthotics compared to using only night splints" and that there was no additive benefit to using night splints in combination with orthotics.
It is estimated that 80% of the population has foot problems or at least foot-related problems. Hyland in Spinal Pelvic Stabilization: A Practical Approach to Orthotics 2002 reported that feet can be free of pain yet be the cause of pains and problems in other parts of the body, especially in the legs, knees. The average person walks about 250,000 miles in their lifetime. Your two feet have 52 bones (25% of all of the bones in the entire body!), 132 joints, 214 ligaments, and 398 muscles and tendons. Each day 1,280 metric tons of pressure affect your feet. Perhaps as many people who require eyeglasses to see better also require orthotic devices (“orthotics” or “orthoses”) in order to feel and function better in the foot, ankle, legs, hips, and spine. A good fitting shoe should have lots of room by the toes, the heels should be stable within the heel counter, and new shoes should feel comfortable the moment you try them on.

Orthotics control abnormal motion without restricting normal motion and also eliminate the jarring effect so commonly associated with no supports. Not all people who may benefit from orthotics have foot pains, since abnormal alignments and imbalances can cause symptoms higher up in the legs, knees, hips, and back with or without foot pains.

Orthotics can be ordered by your chiropractor to suit the special needs of older patients as well as those who are overweight or diabetic. Alterations from the normal of gait patterns (how we walk) create shifting onto either the inside (“pronation” or “flat foot”) or outside (“supination”) of the foot.
In the case of a “pronated” foot, the inner aspect of the ankle will appear to roll inward to the ground.

The most essential joint involved is the “subtalar” joint which is composed of the talus foot bone and the calcaneus (heel) bone. In abnormal pronation, the subtalar joint rolls inward to compensate for the rear part of the foot twisting outward.(termed varus rearfoot). The talus foot bone is forced to adduct (move toward the middle) and to plantarflex an excessive amount while the calcaneus simultaneously everts (twists outward).

 

These abnormal forces create long term sprain of the calcaneonavicular ligament between those bones as well as of the joint capsule between the navicular and talus foot bones.

 
Over time, these exaggerated movements can lead to a pathological laxity (abnormal loosening) of these supporting structures, creating instability.
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This excessive pronation can also damage the plantar fascia (under the long arch of the foot) which connects the bottom of the heel bone to the toes. This results in “plantar fasciitis” (inflammation of the fascia connecting the heel to the toes) which in time can lead to “heel spurs” as the talus bone is displaced forward 1.5mm for every 10 degrees of abnormal calcaneus eversion.

 

In turn, the forward displacement of the navicular bone causes the 1st three metatarsal bones (toes) to abduct (bend outward).

Bursitis (inflammation of bursae) and neuritis (inflammation of nerves) are other possible results, such as bunions nad Achilles tendonitis.

Pronation means collapse of the front  or transverse arch and angulation of the metatarsophalangeal joints (various toe joints) into extension (upward), increasing pressure on the already angulated plantar digital nerves by the edges of the deep transverse metatarsal ligaments, which together with the superficial ligaments underneath, sandwich the nerves here causing more pain.

 

Pronation also causes stress pressure higher up of the knee’s medial collateral ligament, the medial plica, and medial collateral ankle ligament.

These in turn generate tightness and tenderness and pain of the tibilais posterior muscle (inside lower leg giving power for inversion) and irritates the tibial nerve. This in turn causes the tibia (the larger of the 2 lower leg bones) to rotate (twist) internally (inwardly) and displaces the patella (kneecap) upward by increased tension of the quadriceps (front of thigh) muscle. The kneecap also then is pulled laterally (to the outside) by external rotation of the femur (thigh bone).

 

This increased pressure with which the kneecap is forced onto the underlying groove and condyles (surfaces of the lower femur like knuckles) causes a “tracking pattern” sideways during knee extension (straightening) instead of the normal straight upward direction.

Pronation can also cause the fibula (smaller of the 2 leg bones) to be pushed upward against the outflare of the tibia and is often associated with tight biceps femoris (part of the hamstrings muscles on the back of the thigh) and sideways compression forces can affect the sural nerve which can reduce sensation to the outside of the foot and 4th, 5th toes. 

 

The abnormal excessive twisting of the femur thigh bone increases strain on the gluteus maximus buttock muscle.

Also the greater trochanteric bursa (side of hip) is more prone to injury due to the upper femur rotating too much, resulting sometimes in “trochanteric bursitis.”

Since pronation and overpronation are most common, it is helpful to explain that the foregoing abnormalities further lead to abnormal pulling and tightening of the psoas muscle which connects the lumbar spine to the femur (upper leg bone) resulting in increased low back lordosis (“swayback”), jamming of the spine’s delicate facet joints, and if only on one side, also causes twisting of the lower spine.

 

Supinated footis the opposite of pronation and is a much less common problem.

It causes the lower leg to turn outward and increases traction of the lateral collateral ligament on the outside of the knee, affecting the common peroneal and sural nerves (pain felt in the front and outside of lower leg). It also increases tightness of the inside part of the knee (medial compartment) causing inner knee pain and weakness of the peroneus longus muscle of lower leg.

This in turn stresses the ligament on the outside of the knee and causes abnormal tightening of the side of thigh muscles (“iliotibial band” or “tensor fascia lata”) which can restrict proper knee movement and reduce ability to move the thigh across to the middle of the body.

If a person doing a squat exercise cannot keep their heels flat on the ground, this represents tightness of the Achilles tendon, calf muscles and plantar fascia.

Therefore the heels lift up and weight is transferred to the forefoot and metatarsal heads, potentially impinging or pinching the joints and nerves of the rear part of the foot.

 

The foregoing can be generally classified as ‘malalignment syndrome’ which is corrected usually by the combination of orthotics, specific chiropractic treatment involving possibly joint adjustments of the feet, ankles, knee, hips, low back, muscle treatment in any of these areas as indicated by examination findings, and advice on exercises. The mechanical basis of malalignment syndromes is often given other more common diagnoses such as plantar fasciitis, Achilles tendonitis, shin splints, bursitis of the knee or hip, iliotibial band syndrome, chondromalacia patellae, sinus tarsi syndrome, heel spur, metatarsalgia, tarsal tunnel syndrome, BUT one should be more interested in methods that serve to correct and maintain good function and good feeling rather than what name to call it.

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What about callouses?

When the skin is exposed repeatedly to shearing or friction stress, a protective layer of keratin (a “callous” or “keratoma”) is laid down. This is the body’s way to prevent damage to the skin and prepares it to handle further pressure and abrasion. These keratomsa or callouses frequently develop under weight-bearing areas of the foot as a result of abnormal loading. If these callouses continue to get bigger, they can contribute to elevated foot pressures (according to Whiting in Common Foot Disorders 1993). Unfortunately callouses are quite common in the adult population. Since callouses form in response to sustained pressure patterns, they provide helpful clues to an examining practitioner regarding abnormalities in foot function.

Most commonly, these are in the forefoot under the metatarsal arch or under the heel (Magee in Orthopaedic Physical Assessment 1987).

More specifically, callouses are associated with a lower longitudinal arch and too much pornation as well as with restricted movement of the ankle in dorsiflexion. (also due to tight calf muscles) and reduced dorsiflexion of the big toe (Bevans in The Foot 1999).

If one foot has more callouses, this can be due to asymmetry of the feet, ankles, and/or leg length difference.

 

A thick callous at the inside of the big toe or occasionally the 5th toe signifies abnormal “toe-off” and excessive propulsion forces, often in combination with poor shoe fit (Subotnick in Sports Medicine of the Lower Extremity 1989).

Callouses can also be caused by diabetes and plantar wart, both of which require the expertise of health professionals other than a chiropractor.

Plantar warts are caused by a virus infection and are unlikely to respond to a solely mechanical approach (plantar warts are usually not tender to pressure but are painful upon pinching and can be separated from surrounding tissues upon palpation.

 

Some patients require podiatric surgical removal of callouses.

Not uncommonly, patients also require chiropractic adjustments to restore normal flexibility of any of the 66 possible fixated (stiff) joints between foot bones and/or the mortise joint (the joint between the 2 lower leg bones, tibia and fibula with the talus foot bone).

Chiropractic management also often includes hands-on myofascial massage-type therapy and advice on stretching exercises for the foot, ankle and leg.

 
What about excessive foot moisture and perspiration?

The feet have 250,000 sweat glands which excrete half a pint of water daily.

An infection, overactive thyroid, anxiety, and autonomic nervous system imbalances can raise metabolic rate and cause increased sweating. These require a medical physician to differentiate. Most people have “idiopathic hyperhydrosis” meaning that no definite medical cause is usually found. Work and personal stress may be all that one needs in order to generate overactivity of the nervous system. When the feet are exposed to excessive moisture on a regular basis, there is a local effect on the skin followed by microbes that multiply in this local Environment causing rashes, blisters, infections and more serious medical problems, callouses, smells (bromhidrosis) , fungus, and warts.

Solutions include medical diagnosis, keeping feet dry, addressing true causes (eg. nervousness, medical conditions), soaking in tee tree oil, antibacterial soaps, topical medications, cotton or wool socks (avoid polyester or nylon), and walking in bare feet or sandals where possible. For patients who would benefit from orthotics, these should be constructed of viscoelastic but not leather materials.

 

What about people whose feet “toe-in” when walking?

Orthotics are NOT a corrective approach for this, but rather one should be instructed on exercises and possibly treatment that emphasize “external rotation” or turning out of the hip muscles

 
What about children and orthotics?

Generally, it is believed that children will not require orthotics until after age 6.

Therefore, one can better understand how foot alignment problems can cause pains and problems higher up including the spine. We are more familiar with how misalignment of wheels on a car cause premature wear of tires and pulling to one side when braking.

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What does an orthotic do?

After careful static and functional assessment by your chiropractor, an impression of your feet is carefully cast by your chiropractor and after being manufactured in a lab, your chiropractor ensures that your new orthotics fit comfortably into your footwear and provides additional advice at that time.

Depending on your age, weight, and usage, one should typically consider new ones every 2-3 years.

They fit inside one’s shoes and restore normal alignment of the subtalar and midtarsal (midfoot) joints, controlling excessive pronation or supination, and reducing the abnormal forces up into the leg, knee, hip, spine. The orthotic is attempting to support the subtalar joint as close as possible to neutral position. Sometimes a “posting” is prescribed for an orthotic.  A medial posting is used to correct a forefoot varus and to control the heel bone from rolling into a valgus or outward position.

Orthotics also reduce “dysafferentation.”  This refers to overstimulation of the nervous system, particularly the sensory receptors (nerves) that innervate or supply energy to joints. Restricted joint movement causes an increase in nociceptive sensory axons (A-delta & C fibres) of nerves and a decreased firing of large diameter mechanoreceptos axons (A-beta fibres) as per Hooshmand Chronic Pain: Reflex Sympathetic Dystrophy, Prevention & Management 1993.

 

Orthotics serve to 1. Improve the proprioceptive response of the lower extremities,
                           2. Support the three arches of the foot within normal ranges of motion.
                           3. Allow for flexible movement.

 
Research confirming the value of orthotics
 

Sutlive et al in the journal Physical Therapuetics 2004;84:279 examined 50 military personnel with chondromalacia patellae knee pain and concluded that only the  group which was given custom orthotics had a reduction of pain by 75%.

Saxena in Journal of American Podiatric Medicine Assn, 2003;93:264 studied 102 patients with chondromalacia patellae who had no benefits from non-steroidal anti-inflammatory drugs and physiotherapy and found that with orthotics after 2-4 weeks 2% were pain-free, and 77% had large improvements.

Johnston& Gross in Journal of Orthopaedic Sports Physical Therapy 2004;34(8):44 examined 16 patients with patellofemoral knee pains and excessive pronation. After 2 months with orthotics they reported reduced pains and stiffness, and after 3 months reported significantly improved function.

Weimer at the February 2005 American Physical Therapy Assn Conference reported testing 22 patients and found that the group with orthotics reported the greatest improvement.

Hertel in Archives of Physical Medicine & Rehabilitation 2005 studied 30 patients and concluded that orthotics were useful in treating patellofemoral knee pain.

 

Dimou in the Journal of the American Chiropractic Ass. 2004;41(9)32 found that custom orthotics combined with chiropractic adjustments of the foot and ankle plus stretches was effective.

Krohn in Clinical Orthopaedics & Related Research 2000 reviewed research that showed that orthotics reduce varus torque in the knee and reduced symptoms of osteoarthritis.

Krohn in Current Opinions in  Rheumatology 2005 reported that orthotics could reduce knee and leg pain and reduce the progression of osteoarthritis.

Foster at the ASB-ISB Meeting in August 2005 reported studying 11 female runners with knee or iliotibial band syndrome (side of leg) and found that orthotics resulted in significantly lower mean peak ankle inversion and mean peak rearfoot eversion.

In Diabetes Research & Clinical Practice April 2005 it was reported that there was “significant reduction” in the grade of foot callus with orthotic therapy.

The Journal of Joint, Bone, Spine November 2005 reported that patients with metatarsalgia (pains in the underside of the front of the foot) can expect orthotics to reduce forefoot pains.

Martin in the Journal of the American Podiatric Medicine Assn 2001;9(2):55 concluded with a randomized study that 68% of patients using orthotics had good to excellent reduction in pains.

Lynch et al in the Journal of the American Podiatric Assn 1998;88(8):375 concluded 70% success rate with orthotics compared to 33% improvement with steroid injections and 30% with off the shelf heel cups.

Batt et al in Clinical Journal of Sports Medicine 1996;6(3):162 reported that orthotics help reduce plantar fasciitis heel pain.

Navaros in Journal of American Podiatric Assn 1993;83(3) studied 500 long distance runners and found that 76% reported complete resolution of pains in the foot, ankle, knee, hips, shins.

 

What about ankle sprains?

1.The most common type of ankle sprain is the “inversion” sprain where the foot and ankle are suddenly turned inward and the person usually falls onto the outside of their leg. This is classically treated by rest, ice, elevation, and compression as many people already know. Once the acute swelling and pain have subsided, the ankle evaluation should include a chiropractor to determine if any joint dysfunction occurred during the twisting injury as well as to advise on timing and nature of rehabilitative exercise (eg. wobble board, weight lifting).
 
2. A less commonly-known type of ankle sprain is the “high ankle sprain.” Doctors know this as “tibiofibular syndesmosis.” This occurs when the foot is bent upward at the same time as the ankle is turned outward when injured. Sometimes xrays are needed to rule out fracture of the malleolus.
Once again, rest from aggravation is essential while pursuing ice therapy, electrotherapy, possibly cortisone injection, until gentle joint mobilization is feasible if indicated and then progressive resistance exercises, proprioceptive exercises, plyometric exercises, mini trampoline, and sport-specific agility drills.
Your chiropractor may diagnose this by testing the ankle in dorsiflexion combined with turning the foot outward, by palpating the anterior tibiofibular and anterior talonavicular ligaments for tenderness, and possibly by recommending ultrasound diagnostic testing. Also once the condition allows furtherjoint play testing, your chiropractor will assess the flexibility of the “mortise” joint which is between the tibia and fibula leg bones with the talus foot bone.
 

This second type of ankle sprain was described in detail in the Journal of the Canadian Chiropractic Association 2007;Vol.51,No.7,p.42. as well as in the Physician and Sports Medicine 1993;21(12):39, Orthopaedic Clinics of North America 2001;32(1):79 and the Journal of Sports Medicine 2005;33(5):745.

   
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