By: John Palo, BS, DC, DABCO
The Collapsed Longitudinal Arch
Hyperpronation, the collapse of the longitudinal arch of the foot, has received the greatest attention in the field of foot orthotics. And justly so. It has been of particular concern to the Chiropractic physician. Why? The collapsed longitudinal arch lowers the sacral table on the side of the arch collapse. This produces a lumbar scoliotic convexity at the lowered side. This forces compensating scoliosis at the thoracic and cervical spine. Scoliosis stenose intervertebral foramina (IVF) at the concave side and enlarge the IVFs at the convex side. In either case, especially at the stenosed IVF, the emitting nerves may be comprised by the joint subluxations.
Further, abnormal superstructure body weight is placed upon the facets of the vertebrae at the concave side of the scoliosis. This does not make for the most efficient spinal column. It is, too often, a spine waiting for an accident to happen. It is more apt to present back pain than a spine with a level sacral table. A major aim of Chiropractic is to level the sacral table to reduce or eliminate the short leg, low sacral table, causing the scoliosis. When the cause is due to foot hyperpronation, orthotics are indicated to prevent the subsequent leg shortening. When the shorter leg is due to a shorter tibia or femur, a heel lift should be added to the orthotic commensurate with the amount of leg shortage.
Old, worn-out shoes, in cases of significant leg length difference, may reveal more wear of the heel on the longer leg side and more sole wear on the shorter leg side. It seems there is a subconscious attempt to level the sacral table by walking more on the heel of the longer leg and by walking more on the sole of the shorter leg. The heel with the greater wear is an attempt not to raise that longer leg; the sole with the greater wear shows an attempt to raise that shorter leg. Heightening the shorter leg is an attempt to balance the lowered side of the sacral table. This balancing of the sacral table may well be nature’s way of creating a more efficient spine and preventing back pains.
Cause of the Cause
Certainly, the use of orthotics may prevent subluxations due to sacral table inequity. Their use makes us more efficient doctors. It shows more concern with our patient’s best body mechanics. If the subluxation is considered the cause of a patient’s condition, it behooves the doctor of Chiropractic to seek out and correct the cause of the subluxations. We cannot change the flat level of the streets and floors we walk upon. However, we can, through orthotics, correct the way we meet that street and floor.
The Collapsed Metatarsal Arch
Less commonly found than the longitudinal arch collapse is the collapse of the metatarsal arch (MTA). This usually comes with pain at the second, third, and fourth balls of the foot. In an attempt to relieve the pain, the toes are enlisted to bear some of the forefoot weight. This is a cause of claw toes, hammer toes, and mallet toes.
Further, in an attempt to relieve the pain at the bottom of the sunken MTA, a protective callous may form. This is a failed attempt at pain relief. As the callous builds, more of the body weight is directed to the mid metatarsal heads (MTH). The obese are particularly prone to MTA collapse. Sufferers tend to avoid walking on the forefoot and assume a heel walking gait. A common cause of MTA collapse is the use of high heels. This forces more body weight to the forefeet.
The Short Leg
Forefoot MTA collapse is more apt to be found at the foot of the shorter leg. In an attempt to compensate for a short leg, and to level the sacral table, there is the tendency to diminish the use of the heightening lift from the forefoot of the longer leg by walking more upon the heel. This can be substantiated by examining sole and heel wear in well-used older shoes. This office finds the greater the leg length differential, the greater the heel wear on the side of the longer leg, and the greater the sole wear on the sole of the shorter leg. Correcting the leg length discrepancy with a shorter-leg heel lift may help correct a compensating walking pattern and relieve MTA pain.
In MTA pain, there is an immediate tendency to place soft padding under the area of the pain at the MTHs. However, as in the self-defeating callous formations, such padding brings more weight upon the painful MTHs.
The MTA may be permanently collapsed. The pain may not be completely relieved by 1) lower-heeled shoes; 2) weight loss; and 3) foot adjustments. In these cases, the incorporation in the orthotics of an arch support behind the MTHs may afford relief. Most orthotics provide such a lift of the MTA, behind the MTHs. This helps raise the arch that has fallen and leads to a better distribution of body weight upon all five MTHs rather than mostly MTH 2, 3, and 4.
In cases of painful MTA collapse, full-length orthotics should be ordered. This allows you to not only build further (if necessary) upon the MTA padding. It also (if necessary) allows you to add incremental padding under the 1st and 5th MTH.
This office finds (when standard MTA padding is insufficient) raising the MTA padding further usually brings the sought-for pain relief. In stubborn cases, especially in the obese patient, padding under the 1st and 5th MTH may finally bring welcome MTH pain relief. These paddings force body weight upon the little-used 1st and 5th MTHs. Such padding is particularly effective under the 1st MTH. It has been estimated that in a 160 pound body, 20 pounds should be carried at the 1st MTH. The remaining four MTHs are estimated to carry 5 pounds each. The heel is estimated to carry 40 pounds of body weight. Fifth MTH padding directs it to carry its proper load. This relieves the abnormal stress upon the 2nd, 3rd, and 4th MTHs.
Padding at the strategic areas outlined above should be done incrementally. Round, squared or rectangular leather cut-outs from an old thin belt should suffice. The appropriate padding should be glued under the orthotic. Start with the heightening MTA and then, if necessary, pad under the 1st and 5th MTH. Give a week or two before adding further paddings. The time will permit pain and inflammation to dissipate.
Feet as Base of Spine
A patient’s painful fallen MTA will warp his or her gait. This affects the integrity of the spine. For years, Chiropractic has sought the causes of ailments in subluxations at the intervertebral foramina (IVF) through which nerves exit. We should go further in our quest. We should seek out those many things that may prove to be causes behind causes, especially as they compromise spinal integrity. The fallen MTA, longitudinal arch, and a shorter leg are such causes.
Are we not professionally negligent when we do not seek to find and correct the cause behind the cause? We expand our profession, and service to our patients, when we look fully to the bottom of things in our attempt to get to the bottom of things.
About the Author
Dr. John Palo is a diplomate Chiropractic orthopedist and certified Chiropractic sports physician. He is a former instructor for the diplomate orthopedist program and guest speaker for the Sports Injury program at New York Chiropractic College (NYCC). He is a graduate of the National College of Chiropractic and former assistant director of the Chiropractic Division of the New York City Department of Health. He has been listed in Who’s Who in America, with a biography in Who’s Who in the East. Dr. Palo is the author of the text Orthopedic and Neurological Tests for the Office.