Pain and dysfunction in the lower back, hips, and knees can come from one or several biomechanical anomalies in the feet and ankles. Recent evidence supports the use of custom orthotics in patients with acute and chronic conditions of the lower extremities. There is value in assessing the feet and ankles when patients with a chief complaint of lower extremity conditions exist. Assessment through starting distal (or proximal) to the area of questionable pathology is essential in understanding if there is a possible interference within the kinetic chain (kinetic referring to motion and chain being an analogy for the interdependent link between systems).
This concept of the kinetic chain was originally adapted from the work of a mechanical engineer named Franz Reuleaux (Kinematics of Machinery 1875) in 1955 by orthopedic surgeon Dr. Arthur Steindler. This is the idea that the human body is an arrangement of connecting sections associated with a progression of joints. The lower active chain is comprised of your toes, feet, lower legs, knees, upper legs, hips, pelvis, and spine. Basic foot issues that can add to back, hip, and leg dysfunction include non-neutral subtalar joint, pes planus, pes cavus, and deconditioning of the deep intrinsic foot muscles. According to Karasawidis et al. (2020), approximately 24% of adults have foot ailments, and the prevalence increases with age. These foot conditions can go up the kinetic chain to then produce possible knee, hip, and lower back conditions.
How Foot Positioning Affects the Lower Extremities
When bilateral overpronation is present in the feet, it can translate up the kinetic chain through biomechanical and somatic changes. In this particular case, the tibia and femurs will internally rotate, placing excessive and unnecessary medial knee strain and genu valgum. Continuing up the chain, the internally rotated femur will create internal rotation at the femoroacetabular joint and external rotation of the sacroiliac joint. The sacroiliac joint positioning bilaterally can produce a gapping of this joint, and stretching the posterior interosseous ligament at this joint can cause pain. This can also create an anterior pelvic tilt, which will simply perpetuate the problem. Notice the chain response? It begins with a skewed foot stance and influences each joint as far as possible up to the lower back. Anecdotally, it could be assumed the kinetic chain response continues up the chain, but we do not have any evidence with strength level I (Johns Hopkins evidence-based tool) to support this. The simplest way to evaluate the lower extremities is as follows:
"...Notice the chain response? It begins with a skewed foot stance and influences each joint as far as possible up to the lower back..."
If You Talk the Talk, Time to Walk the Walk: Recent Findings
With custom orthotics, we can help our patients deal with the effects of musculoskeletal conditions and prevent many of the muscle and joint degenerative problems that are improperly called “normal aging.” Once their lower extremities are properly aligned, muscles are strengthened and lengthened, and hip joints work smoothly, our patients will enjoy the benefits of independent mobility well into their elder years. Despite the major focus of structure and alignment in arthritis, remarkably little work has focused on the foot and nonsurgical foot interventions that might affect lower extremity joint alignment, structure, and pain in rheumatic diseases. Emerging research suggests that there may be a significant role for foot orthotics and footwear in the treatment of rheumatoid arthritis and osteoarthritis of the hip, knee, and foot (Riskowski et al., 2011)1. In addition, a recent article by Karasavvidis et al. (2020) provided evidence-based recommendations for patients with severe knee osteoarthritis (OA) who’d had their knee surgery postponed due to the COVID-19 pandemic. Obese patients are encouraged to set weight loss goals and adopt a healthy diet. Their studies concluded that there were benefits with foot orthotics as well as the use of knee braces and sleeves2.
With regards to a common foot condition called plantar fasciitis, many studies suggest that using custom orthotics will help decrease the pain by supporting the medial longitudinal arch of the foot. Plantar fasciitis, characterized by the degeneration of the plantar fascia, leads to heel pain. In a study conducted by Çaglar Okur (2019), they compared the effectiveness of extracorporeal shock wave therapy (ESWT) and custom foot orthotics (CFO) for plantar fasciitis. They concluded that ESWT and CFO could be used interchangeably. Moreover, neither method was superior in treating plantar fasciitis.3 Custom orthotics have been and continue to be a successful treatment option for those with foot pain and show much promise with all other lower extremity conditions.
Conclusions
Lower extremity evaluation is crucial by using critical thinking analysis of the findings to understand the patient’s condition. It is not enough to simply correct for overpronation of the foot but to find the problem causing the overpronation. In addition, emerging evidence continues to support the use of custom foot orthotics in the use of lower extremity injuries and systemic conditions in adults. The author of this article encourages the chiropractor to contact their local academic institutions in attempts to publish or transfer patient data in this particular field to add to our peer-reviewed literature.
Dr. Jennifer llles is a graduate of New York Chiropractic College in Seneca Falls, New York, and earned a master's degree in applied clinical practice from the National University of Health Sciences in Lombard, Illinois. She is an associate professor at Keiser University's College of Chiropractic Medicine in West Palm Beach, Florida. In addition to teaching, Dr. llles speaks on behalf of Foot Levelers on a regular basis.
References
1. Riskowski, Dufour, A. B., & Hannan, M. T. (2011). Arthritis, foot pain and shoe wear: current musculoskeletal research on feet. Current opinion in rheumatology, 23(2), 148-155. https:// doi.org/10.1097/BOR. 0b013e3283422cf5.
2. Karasavvidis, Hirschmann, M. T., Kort, N. R, Terzidis, I., & Totlis, T. (2020). Home-based management of knee osteoarthritis during COVID-19 pandemic: literature review and evidence-based recommendations. Journal of experimental orthopedics, 7(1), 52. https://doi.org/10.1186/s40634-020-00271-5.
3. Çaglar Okur, S., & Ay din, A. (2019). Comparison of extracorporeal shockwave therapy with custom foot orthotics in plantar fasciitis treatment: a prospective randomized one-year follow-up study. Journal of musculoskeletal & neuronal interactions, 19(2), 178-186.
