Help Your Patients, Help Your Practice
BIOMECHANICS
Hone Your Skills as a Feet and Footwear Expert
Kevin Wong
In most of my articles, I am addressing those of you who have never considered using orthotics for your patients or those who use them very infrequently. I sometimes neglect to address those of you who do use them. This article is to help you hone some skills in talking even more expertly to patients about the importance of orthotics, the types of shoes they are wearing, and bridging the gap between allowing patients to wear the shoes they like while still having great arch support.
I need to make sure we do a quick review. Remember, we have three functional arches under the feet: the medial longitudinal, the lateral longitudinal, and the transverse arches. These arches form a triangle of support under the three weight-bearing points of the foot: the first metatarsal head, the fifth metatarsal head, and the calcaneus bone.
The arches absorb shock, support the weight of the body, and allow for transference of energy during walking (the gait cycle). You will also recall that the force from the heel is partially dissipated by the foot, and then it continues up the body through the ankle, knee, hips, pelvis, and spine. The gait cycle is a wonderful symphony of movement in which the feet are the conductors.
More than 80% of the time, the patients we see in our office are excessively pronating, or their feet aie rolling inwards and flattening toward the floor. In this case, all three arches are flatter. Even in the case of a supinator, which we see in about 5% of cases, they may have a high medial longitudinal arch, but their lateral longitudinal and transverse arches are flatter. Either of these types of patients would benefit from custom, three-arch, flexible orthotic support.
“Even though you are not judging them for their footwear choices, they may feel that you are. J J
Once you start talking about the feet, the arches, and how they affect the biomechanical stability of the body, conversation will invariably move toward shoes. It is very important that you feel comfortable talking to patients about their shoes. You also must understand that this topic can be very sensitive and emotional depending upon the patient. As you talk to patients and get to know them, figure out how you will broach this topic. Even though you are not judging them for their footwear choices, they may feel that you are.
In general, shoes sold these days are not that supportive because there is a general misunderstanding in the shoe industry about the existence of the three functional arches. Also, the more arch support a shoe company puts in any shoe, the harder it is for most of the general population to wear it. If you have never really thought about this, then think about the shoes you find in any store. Just pick one up, look inside the shoe at the footbed, and see how flat it really is. If you understand the arches, foot pronation, and the effects they can have on the axial kinematic chain of the body, you see why bad shoes can hurt our patients.
I tend to stay simple when talking to patients about their shoes. I use three categories so they can understand what we are dealing with. You may categorize your shoes differently, and these three may seem very general, but this keeps it simple for the patients.
1. Dress: Dress shoes can cover heels of more than two inches down to flats. It is their appearance and often cost that can place them in this category. Shoes like this usually have a flat footbed with no arches. I have seen some companies that do have a bit of an instep, but most of the time there is nothing. Don’t let the price fool you here. An expensive pair of Italian heels may have comfortable leather, but leather won’t save your patients from walking in them when there is no arch support.
2. Casual: These can include shoes such as flats, boots, UGGs, flip-flops, sandals, and rubber-soled shoes (i.e., Keds, Converse, Tom’s, etc.). Some of these shoes can have arch support for the instep. A few, such as Dansko, Mephisto, Birkenstock, and a few others, can have significant arch support. With more arch support, though, it narrows the population of people who can comfortably wear the shoe.
3. Athletic: Shoes here can range from the minimal running shoes (i.e., Nike Free, Vibram FiveFingers, etc.) to tennis/ court shoes, cleats, and even the heavier basketball shoes. Some of these shoes have very technical terms to describe the technological advances put into the shoe. Some even say they offer motion control, pronation control, and other neat, impressive terminology to amaze you.
Remember, a shoe is a shoe is a shoe. You need to realize that although some of these shoes are made for pronators, supinators, or those with neutral feet, arch support is the key to long-term biomechanical stability of your patient. Very few shoes will ever inherently stabilize someone enough on their own.
Heels, loafers, flats, or any type of shoes with a tight toe box put chronic and repetitive pressure around the metatarsal
heads. This compression and stress on the ball of the foot will lead to collapse of the transverse arch. As this arch flattens, it gets wider and will eventually cause the first and fifth metatarsal heads to rub against the edges of shoes. Bunions, callousing of the metatarsal heads, corns, and metatarsalgia can be a result.
Something else to be aware of is when the medial and lateral longitudinal arches collapse. This causes the feet to get longer. In fact, many women talk about this phenomenon occurring when they are pregnant. The added weight of the child causes the foot to flatten and for their feet to “grow a whole size.” For the average person, the foot flattening happens more as the years progress. We need to be vigilant for our patients so that they have the support they need.
Patients are never taught about the three arches of the feet, the dangers of modern footwear, and the effects that poor shoes truly have on the body. Most women know that heels or certain shoes are “bad,” but they often do not fully understand why. As a chiropractor with a comprehensive knowledge of the bones and biomechanics, coupled with training in understanding the feet, arches, and footwear, you are poised to be the expert for your patients. Have the confidence to engage your patients in discussions about their footwear.
I leave you with this: Don’t let some inexperienced shoe salesperson give your patient the only advice for footwear.
Dr. Kevin Wong is an expert on foot analysis, walking and standing postures and orthotics. Teaching patients and chiropractors is a passion for him, and he travels the country speaking about spinal and extremity adjusting. Dr. Wong practices full-time in Orinda, California. Contact Dr. Wong at 925-254-4040 or [email protected].
