By: William M. Austin, DC, CCSP, CCRD
During standing, walking, and running the lumbar spine and pelvis balance on the lower extremities. As shown in Fig. 1, leg or foot asymmetries send abnormal forces along the closed Kinetic/Kinematic Chain, interfering with spinal function.1 And interfering with spinal function can result in a number of bodily malfunctions. Many foot conditions eventually contribute to health concerns farther up the Kinetic Chain, especially the generalized condition of chronic back pain (or even neck pain).
The major source of most chronic low back pain is structural weakness or failure caused by repetitive microtraumas.2 Structural weaknesses and the resulting microtrauma effects can be seen in the bones and joints, and also in the connective tissues.
Low Back Pain and the A-S-R Program
For most cases of chronic low back pain, Foot Levelers recommends the ‘A-S-R’ program: Adjustments, Support, and Rehabilitation. The adjustments to the affected bones and joints are determined by the Chiropractic professional. Support comes from custom-made, flexible functional orthotics which are scientifically designed for the individual’s unique postural problems. Rehabilitation is provided by Foot Levelers’ BACKSYS® system for low back exercise.
Bones and joints. There are two types of bone and joint asymmetries: a) Functional misalignments and joint dysfunction; and b) Anatomical discrepancies. Functional asymmetries develop over time in response to repetitive microtraumas, resulting in greater susceptibility to injury and breakdown. This condition often responds well to specific adjustments of the offending joint(s). Custom-made, flexible orthotics are effective in helping your adjustments last longer and hold stronger.
However, a structural asymmetry due to discrepancy in the anatomical shape or size of the bones cannot be adjusted into alignment. In such a situation, comprehensive care requires the
use of some type of compensatory support. Frequently an orthotic orthotic with an adjustable heel lift, or an orthotic with a built-in heel lift, must be properly fitted and permanently used in order to normalize leverage forces and provide bony stability to the lumbar spine.
Tendons and ligaments. When imposed forces exceed the level of structural strength, something always fails. The result is symptomatic breakdown of tissues, and often permanent degenerative changes.
Due to their specialized viscoelastic (stretching) properties, connective tissues are particularly susceptible to repetitive microtrauma (Fig. 2). This type of insidious injury causes permanent plastic deformation, which is the underlying factor in most overuse and repetitive trauma conditions, as well as many job-related spinal injuries. The end result is ligament laxity and/or disc degeneration, with excessive joint mobility (instability). These are both conditions which are very difficult to treat directly or reverse, and treatment usually requires compensation by muscle over-development and/or orthotic support.
A significant factor in reducing excessive biomechanical forces on the lumbar spine is frequently overlooked: the use of external supports (orthotics with or without heel lifts) to decrease external forces. The following are commonly seen conditions in which the lower extremity can have a major impact on lumbar spine function. In each of these situations, orthotic supports are not only appropriate, they contribute significantly to a cost-effective care program:
Stress forces. When excessive pronation and/or arch collapse of the foot is present, a torque force produces internal rotation stresses to the leg, hip, pelvis, and low back (Fig. 3).3 The result is recurring subluxations and eventual ligament instability affecting the sacroiliac and lumbar spine joints. These forces can be decreased significantly with the use of flexible, custom-made orthotics.
Heel-strike shock. In patients with degenerative changes in the lumbar discs and facets, the external force of heel strike may aggravate and perpetuate low back pain. This force is easily reduced with the use of shock-absorbing shoe inserts4 or Foot Levelers’ functional orthotics which contain Zorbacel®. The reduction in symptoms is often dramatic due to the decrease in low-level inflammation of the affected joints.
Leg length inequality. An anatomical difference in leg length produces abnormal structural strains on the pelvis and low back. These strains can cause not only chronic pain,5,6 but also have been shown to result in specific degenerative changes.7 The use of lifts and orthotics has been shown to reduce these structural strains and bring about significant response.8,9 Lifts can be more effective when used in conjunction with spinal manipulation.5 Research on leg length inequality (LLI) patients revealed a greater reduction in pain scores when orthotic therapy was combined with spinal manipulation, as compared to orthotic therapy or spinal manipulation alone.
Particularly dramatic results have been achieved by incorporating Foot Levelers’ orthotics in LLI case management. Yochum demonstrated in a set of before-and-after radiographs how a 15.5mm LLI in a patient could be reduced to just 4mm with the use of orthotics (Figs. 4A and 4B).9 Not only had the pelvic deficiency been markedly reduced, but the right compensatory listing of the lower lumbar spine had also diminished.
When the amount of anatomical leg length discrepancy is not definite (or is complicated by functional discrepancy and arch collapse), fit the patient with orthotics without heel lifts initially. After 4–6 weeks of continued Chiropractic care and wearing the orthotics, re-evaluate (clinically and/or radiographically) to determine if a significant difference in femur head height still exists when the patient is standing (5mm or more). If so, then the addition of a permanent heel lift is appropriate.
Corrective exercises done at home to strengthen supporting muscles are recommended as an adjunct to Chiropractic adjustments and orthotic support. Activity should focus on developing strength in the abdominals and supporting pelvic and low-back muscles. This can also enhance the shock-absorbing properties of the tissues. Foot Levelers’ BACKSYS® exercise program is especially suited for low-back rehabilitation.
A-S-R: A Solid Program
Research is increasing our understanding of factors involved in effective lumbar spine treatment. When faced with the complex and costly concern of low back pain and disability, patients are forced to seek out the most effective practitioners. Doctors who use a comprehensive care approach which includes adjustments, the appropriate use of Foot Levelers’ custom-made functional orthotics, and the BACKSYS rehabilitative exercise system are recognized as the most competent experts in the management and rehabilitation of lumbar spine disorders.
Asking your patients a few simple questions can provide valuable insight into the cause(s) of their back pains. When low back pain and spinal instability are present, look to the feet!
During your examination of a patient who expresses the vague complaint, “My back hurts,” make sure to get answers to the following ten questions:
- Do you stand or walk on hard surfaces for more than 4 hours daily?
- Do you participate regularly in any physical sport (basketball, baseball, tennis, golf, bowling, etc.)?
- Are you age 40 or over?
- Have you ever had a prior injury to your knee, back or neck?
- Do your shoes wear unevenly?
- Do you have joint pain while standing, walking or running?
- Is one of your legs shorter than the other?
- Do you have knock-knees or bow legs?
- Do you have any obvious foot problems (bunions, corns, flat feet, etc.)?
- Do your feet ‘toe out’ when you’re walking?
If your patient gives an affirmative answer to any of the above, consider this patient a likely candidate for flexible, custom-made functional orthotics.
- Keane GP. Back pain complicated by an associated disability. In: White AH, Anderson R. eds. Conservative Care of Low Back Pain. Baltimore: Williams & Wilkins, 1991:307.
- Fulton M. Lower back pain: new protocols for diagnosis and treatment. Rehab Management 1988; Nov/Dec:39-42.
- Hammer WI. Hyperpronation: causes and effects. Chiro Sports Med 1992; 6:97-101.
- Light LH, et al. Skeletal transients on heel strike in normal walking with different footwear. J Biomechanics 1980; 13:477-80.
- Giles LGF, Taylor JR. Low-back pain associated with leg length inequality. Spine 1981; 6:510-21.
- Friberg O. Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality. Spine 1983; 8:643-51.
- Giles LGF, Taylor JR. Lumbar spine structural changes associated with leg length inequality. Spine 1982; 7:159-162.
- Hoffman KS, Hoffman LL. Effects of adding sacral base leveling to osteopathic manipulative treatment of back pain: a pilot study. JAOA 1994; 94:217-26.
- Yochum TR, Barry MS. The short leg (revised edition). Practical Research Studies 1994; 4(5).
About the Author
Dr. William Austin, a graduate of Logan College of Chiropractic and Director of Professional Education at Foot Levelers, provides an energetic approach to learning. He draws from over 35 years of healthcare experience, which includes athletic training, emergency medicine, English Bonesetting, and Chiropractic.