The Doctor Is a Detective

By: Monte H. Greenawalt, DC, DABCO

The well-disciplined Doctor of Chiropractic has learned to look at the patient as a whole person. Humans are inseparable, and each part is dependent upon the related parts. We are a group of integrated and interrelated components. In Chiropractic college we concentrated on the spine and justly so. We concentrated on the discovery and correction of subluxations. Isn’t that what Chiropractic is all about? Of course it is. No one has to tell us of the importance of correction of the subluxation, and no one has to tell us subluxations cause multitudes of problems for the patient. However, the one thing we must do is recognize the danger of “tunnel vision.” We must look at the big picture if we are to find the most complete answer to solve the problem presented in many cases.

Picture if you will for a moment—Mrs. John Doe presents herself in your office; her history encompasses so many symptoms you wonder where to start—headaches, nervous stomach, backache, and nerves. Being the good doctor of Chiropractic that you are, you know that you must be like a detective. The careful history will give you many clues. You’ll know the eating habits, the family relationship, the work, and why the patient feels these problems have developed. You’ll even know what doctors have been visited before coming to you and what procedures they followed. You will know for certain that the doctors who were previously visited failed to accomplish their mission. The patient still has problems. Knowing what has been done in the past is very helpful, because it will tell you what didn’t work out in this particular case.

Chances are the doctors previously visited were good doctors—but not good enough for this patient. For many patients you are their last hope. Some friend has most likely talked them into making an appointment – because you helped them, or a friend of theirs. We as doctors of Chiropractic have a responsibility that is even greater than many other doctors, because so many of our patients seek us out only after all else has failed.

This is the case Mrs. John Doe presents. She has been to the so-called best, but now she’s coming to you. This is not the time to start her Chiropractic education. This is the time to conduct yourself as the astute doctor of Chiropractic. Your friendly, sincere attitude projects the “I care” image. This is further substantiated by the fact that you have taken the time to listen and inquire into her past and present history. The history in many instances will reveal a great deal of information that will prove valuable in making your diagnosis.

After completion of a careful history the physical examination is conducted. The examination will lay the foundation for determining the procedures to follow. X-rays will be necessary in almost all instances, and there is no need to sell the patient on the need for X-ray examination. Simply order the X-rays, taking whatever views are necessary for the particular case.

The most important part of handling the patient in this manner lies in the logic of the course of events. Never try to do anything to a patient that you wouldn’t want done to you. Remember, the patient really isn’t any different than you and won’t accept things that you would not accept.

Your examination will also reveal to the patient and yourself the need for other examinations when indicated. Blood tests, cardiographs as well as checks of the peripheral vascular circulation may become necessary. Once your examination has been completed and the findings have been thoroughly evaluated, it is a simple matter to dictate exactly what the patient should do.

You will find that the patient has very little concern about money. Generally it is the doctor who is “hung up” on money. The patient knows that service must be paid for and will not hesitate to do so… provided he or she understands the importance of that service.

Your physical and X-ray examination give you the reason why other procedures must be followed. For example, when you study the X-rays and find factors of instability—such as unequal facets, lumbarization, sacralization, spondylolisthesis, disk generation, and increase of Ferguson’s angle—you know you must look to the feet.

True, the feet are not the cause of all low back problems; however, when the feet pronate they can contribute to the continued instability of an already unstable area, and your adjustments will not hold as well if they are not properly balanced. Your physical examination should have included testing the strength of the “iliopsoas,” the “abductors of the thigh,” and the neck flexors. Weakness of these muscles will be a deterrent to your patient’s recovery.

A test that is very dramatic and, also, very informative to the doctor is the “figure 8” tape test. Apply the figure “8” tape strapping to the foot and ankle of the weaker muscle side and have the patient walk around the adjusting or examination table twice. Retest the muscles. If you find them stronger, remove the tape and have the patient walk around the table once. Retest again. If the muscles are once again weak the feet should be balanced. Functional orthotics have proven very beneficial in restoring balance to the pronated feet. Casting the patient at this time and ordering the functional orthotics is logical to the patient and to the doctor. Foot manipulation is beneficial in many instances. Restoring mobility to the joints of the feet and correcting any subluxations will do much to help the patient

Muscle Balance

However, it is important to realize that when the foot is pronated, foot adjusting cannot correct the pronation. As you remember, the function of ligaments is to prevent the joint from moving beyond its normal range of motion. When the foot pronates, the bones have moved beyond their normal range of motion; therefore, the ligaments have been injured.

Ligaments are avascular and nonelastic, making it virtually impossible for the ligaments to heal sufficiently to restore and maintain the integrity of the joint. In the case of pronation the primary ligament to be concerned with is the talo-navicular ligament. It is this crucial area (talonavicular) that allows the foot to drop down. Once this has been accomplished the entire foot becomes involved and a series of changes takes place in the knee, hip, pelvis, and entire spine.

We must remember, our body is a group of integrated and interrelated components. It is possible to care for a specific area and gain temporary results. For instance—adjusting the lumbosacral area. The patient gets good results; however, the adjustment fails to hold…..why???

It could be any of a number of things: muscle imbalance, pronated feet, etc. Knee problems respond to adjusting procedure in many instances, but they tend to recur. The feet may be a contributing factor. A new pair of shoes may be all that is necessary to give the proper foundation to relieve the stress. Functional orthotics may prove beneficial in some instances. Adjusting the feet may help. Correction of a lower spinal subluxation may perform an apparent miracle. The real point I’m trying to make involves you as the doctor. You must be like a detective. Find the clues and put them together to solve the problem.

Dr. George Goodheart is well known in the profession. He is constantly stressing the importance of muscles and muscle balance. We all know that muscles move bones. Therefore, restoring balance to the muscles is a very important part of your patient management program. If you haven’t studied Dr. Goodheart’s work…you should.

It is with knowledge we gain enthusiasm. Your patients gain enthusiasm when they know they are going to a doctor who cares. A doctor who cares enough to put forth the effort to find the cause of their problem and then correct it to whatever degree may be possible. Knowledge doesn’t come easily. You must study, and this involves thinking. Time is consumed and the end never seems in sight; for the more we learn, the more there is to learn. There is one ray of light: Once the learning habit, is developed, studying becomes easier and more enthusiasm can be generated.

The Posture

We profess to be posture specialists. We hold posture contests and we talk about posture. Ask yourself: “Do I really make an in-depth study of the patient’s postural attitude?” Chances are you make a partial study. As you know, posture involves the entire body…physical, mental, and chemical. It is, almost, a reflex act to note the position of the head, noting if one ear is higher than the other; one shoulder higher than the other; or one hip higher than the other. Your physical examination most likely includes testing the range of motion of the cervical, dorsal, and lumbar areas of the spine. You should note the changes that take place in the spine when the spine is flexed. Palpation to find subluxations are routine. All of these acts are old hat and need no explanation.

We must give more thought to the structures below the pelvis. The lower extremities are neglected to a great degree unless they are painful; however, a problem above may be aggravated by imbalance below, even though the problem below presents no specific pain syndrome. We do not hang from a sky hook… the forces of gravity are constantly at work.

The intervertebral disk is designed to hold the vertebrae apart and act as a shock absorber as well as allow the spine to move in flexion, extension, and lateral attitudes without bringing undue pressure on the nerves and blood vessels as they course through the intervertebral foramen. The ligaments prevent the vertebrae from moving beyond their normal range of motion. As the spine deviates from plumb, the forces of gravity cause increased pressure and wear and tear on the disk. Tension and pressure are exerted on the disk from muscle contraction or tension.

Now consider if you will the disk. At approximately the age of fifteen, disk degeneration begins. It is at this time the nucleus pulposus begins to seep into the tough fibrous annulus fibrosus. Initially we find what is known as “tears” seeping into the annulus, then gradually there is the formation of “rents,” or larger canals, into the annulus. The annulus gradually undergoes degenerative changes as the nucleus escapes. This action allows the disk to narrow and lose its elasticity because of the dehydration process that results. As the disk narrows, the vertebrae come closer together, allowing a more critical condition to exist in the intervertebral foramen. The nerves and blood vessels are in greater jeopardy of experiencing injury.

To compound the problem we find the ligaments have become lax and cannot efficiently prevent the vertebrae from moving beyond their normal range of motion. The patient can now experience an injury with ever increasing ease. Muscle balance, postural stress, and general body balance become more and more important. Remember, if muscle balance, postural stress, and general body balance had been considered early in life, the degenerative changes in the disk could have been slowed by virtue of the fact gravitational stress and the strain from posture imbalance would have been reduced. Realizing the importance of body balance and striving to maintain the body in the optimum postural attitude, dictate we must not overlook any factor that may have an adverse effect. Therefore, let us consider the very base foundation…the shoe.

The Shoe

Placing the foot into a shoe is much like casting the feet. A poor-fitting shoe acts in much the same manner as a poorly applied cast. We shall not go into great detail concerning the manufacture of shoes; however, it would be well for you to know a few basic points. The point of the shoe that covers the toes and instep is known as the vamp and the part behind and around the heel is the counter. The large toe joint should rest at the widest part of the shoe. When assuming the weightbearing posture you should be able to palpate the large toe joint and find it positioned at the widest part of the shoe. If you find this joint forward of this area, the shoe is too short. Seldom will you find the shoe too long. As a general rule when a shoe is misfitted you find it to be short and wide. Casual shoes are generally fitted short to be certain the foot is wedged into the shoe in such a manner as to avoid heel slippage. It is very important that the shoe worn for everyday wear is properly fitted and of proper construction.

Place your thumb and forefinger on either side of the counter and squeeze; it should be very firm with almost no give at all. The counter will do much to lend stability to the feet. As you can see in Fig. 1, when the foot pronates, the calcaneus tilts medialward at the top and tends to kick outward at the bottom. A strong counter is needed to prevent the calcaneus from pushing over the side laterally. When correcting pronation a medial wedging of the calcaneus is utilized to aid in returning the calcaneus to the upright position (Fig. 2). You can readily recognize the importance of counter strength when dealing with the pronated foot.

Next, consider the shank. Set your shoe on a desk or other flat surface. If the shoe has a heel you will find a space between the front of the heel and the point where the sole contacts the surface. The area between these two points is known as the shank of the shoe. Generally the area is re-enforced with steel or bamboo to help prevent breakdown. Feet that are weak, flat, or pronated require support in this area and tend to break down the shank when not properly supported. A steel shank does not always provide the necessary strength to prevent a breakdown. In these instances shank breakdown is readily recognized by the sole wear. Sole wear should stop approximately one-fourth inch behind the widest part of the shoe sole. As the wear continues back towards the heel, the shank has weakened and support for the foot is lost (Fig. 3). To correct this condition your local shoe repairmen can apply what is known as a shank-block.

The block is started one and one fourth inches in front of the heel and fills the area to a point where the sole of the shoe rests on the level surface (Fig. 4). Be certain that the block is smooth as it blends into the sole. The shank-block is not to be confused with “metatarsal bars,” “anterior heels,” or “mayo bars,” all of which elevate the sole behind the metatarsal heads.

The next problem found in the shoe wear involves the sole of the shoe wearing unevenly. Generally the wear is to the lateral border. Many times you have seen shoes with the vamp overhanging the lateral edge of the shoe sole. When viewing the sole you find excessive wear on the lateral border and evidence of sole wear beginning one-fourth or more from the medial side of the sole. Let us review just why the sole wear develops in this manner, and why the heel of the shoe wears excessively on the back lateral corner. Make a mark in the middle of the sole at the level of the widest part of the shoe. An easy way to do this…grasp the sole of the shoe between the thumb and forefinger at the widest part of the shoe. Make a mark midway between your fingers. An easy way to be certain that your mark is in the middle of the sole….place the tip of the pencil or pen on the mark and hold the pencil or pen between your fingers by the sole edge… turn the shoe around and place your finger against the opposite sole edge…if the dot is in the middle, the point should be on the mark. Next, hold the tip of the shoe between your fingers and make a mark midway between your fingers. Now sight from the mark at the tip of the shoe down through the mark in the middle of the sole and project through the heel (Fig. 5). You will find that the line bisects the heel in such manner that only about one-third of the heel shows on the lateral side. Next, make a mark on the middle of the heel on the back bottom side.

Sight from this mark up through the middle of the sole and you will find less sole on the lateral side than on the medial (Fig. 6). It now becomes obvious that most shoes are designed in such manner that there is less sole and heel on the lateral side. There is little wonder that the sole would tend to wear on the lateral side, especially in cases presenting the pronated foot. Hold a shoe in your right hand and place it on the desk with just the heel touching. If the shoe is straight then you will find the heel contact is in the middle back portion. If the shoe is pointed laterally as you find when the patient has pronation, the contact is on the back lateral portion of the heel. You can readily visualize why the patient with pronated feet wears his heels on the back lateral portion. The second phase of gait brings the patient along the lateral side of the foot until plantar contact is made.

In view of the fact most shoes have less sole on the lateral side, as demonstrated earlier, you can understand why many soles tend to run over on the lateral side (Fig. 7). A “Dutchman’s wedge” is utilized to restore even sole wear (Fig. 8). The local shoe repairman can apply the “Dutchman’s wedge.”

You will find that proper foot gear will do much to help your adjustments hold better. Restoring balance to the pedal foundation can be accomplished far more effectively if you take a few moments to instruct the patient as to the type of shoe that will be best for their particular condition. Generally a good lace shoe with five eyelets, firm counters, and steel shanks are best. The heel should not extend one and one-half inches. Dress shoes may be worn for limited periods. Shoes without laces fail to give the patient sufficient support and do not give the proper foundation for spinal pelvic stabilizers.

About the Author

Dr. Monte Greenawalt graduated from Lincoln Chiropractic College in 1948. He received postgraduate training at Northwestern College of Chiropractic in the field of orthopedics, which resulted in his DABCO.