Visual Indicators in a Digital World
BIOMECHANICS
Brian Jensen
DC
In our ever-changing world, new technology appears every day. We’re often overwhelmed with the latest and greatest innovation. It’s certainly helpful, but let’s not forget to use one of the basics when examining patients—our eyes. It sounds so simplistic and rudimentary, but our eyes can tell us so much.
When examining patients, visual indicators contribute to your overall impression of the cause of their condition. Patients don’t typically mention these issues in the consultation because they don’t always cause obvious symptoms. When present, five red flags indicate instability that is effectively addressed with a flexible, custom-made orthotic.
The five red flags are foot flare during gait, internal knee rotation, bowed Achilles tendon, low medial arches, and excessive shoe wear. If you see any of these red flags during your evaluation, your patient is exhibiting structural imbalances that will contribute to premature degeneration over time and will benefit from wearing custom-made orthotics.
The Five Red Flags
The five red flags are a tremendous tool to visually evaluate your patients for structural instabilities. Here is how to use these visual clues during evaluation:
1. Foot Flare During Gait - As your patient is walking down the hall toward the exam or treatment room, look at what is going on with his or her feet. Ideally, the toes should point straight forward while walking, but during the swing phase of the gait cycle, you will often see the toe of your patient’s foot point laterally away from the midline. What does it mean? It could be several things. It’s primarily an indication that we need to investigate further, but there are a few things to consider.
The toeing out of the foot is one of the compensation mechanisms for a functional leg length inequality,
1.e., the notorious short leg. It could also be hip or knee involvement. We need to continue looking, so file that information away and move on to the next red flag.
2. Internal Knee Rotation - Standing in front of your patient with his or her knees and lower legs exposed, observe the position of the patellae. If you had a plumb line positioned at the center of the kneecap, the line should fall vertically to a point over the second metatarsal bone. Often we see an internal deviation of the knees with the patellar line falling medial to the second metatarsal bone. Another thing to take notice of is whether the knee rotation is symmetrical. Asymmetries of this nature are the cause of accelerated degenerative changes.
3. Bowed Achilles Tendon - Have the patient stand facing away from you with his or her lower legs exposed. Look at the medial aspect of the Achilles tendons. If the Achilles bows medially, it indicates that the calcaneus is rolling to the inside, which is a strong indication that the foot is pronating excessively. This distortion is often present with foot flare and the next red flag.
4. Low Medial Arches - If you look at the medial aspect of the foot from big toe to the heel, the center of the foot should be higher than the front and rear of the foot. You should be able to slide your fingers under the arch up to the distal interphalangeal joint of your middle finger. If you can’t, we have a positive finding for this red flag.
Remember, the medial arch is the last arch to collapse, and even if it appears to be well maintained, the lateral and transverse arch may be compromised, affecting the biomechanics of the lower extremity.
5. Excessive Shoe Wear - The key is simply to see if the shoes wear evenly on the heel area. If they don’t, we have an indication of asymmetry or imbalance. Also, look for a broken-down heel counter. This is a common finding and is usually worse on one side.
Study the Clues
As you begin to study these five visual clues, you’ll see recurring patterns that are associated with some very predictable findings, such as low back pain, knee pain, and restricted movement patterns associated with joint fixation of the hips and pelvis. Such compensation mechanisms may or may not result in aches or pain, at least not yet. There are postural changes that translate all the way up to the cervical spine, often in the absence of trauma, which are not random circumstances that just happen to befall the poor and unsuspecting but result in biomechanical changes that start inside your patients’ shoes. Yes, that’s right, the feet— the foundation of all biomechanical function. The more you look at the feet, the more you’ll be able to make the connection between the kinetic chain—foot, ankle, knee, hip, pelvis, and spine.
As I studied these five red flags and used them in my practice, I made two basic conclusions about the human body; balance is better than imbalance, and mobility is better than immobility. When I started paying attention to the details, I was able to see the imbalances that led to premature wear and tear, chronic degeneration, and intermittent flare-ups. If we only concentrate on relieving pain, we miss many of the preventable causes of permanent degenerative changes.
Stabilizing the Feet
The most effective way to address instability, as indicated by the five red flags, is to stabilize the feet. Custom-made, flexible, stabilizing orthotics affect the entire kinetic chain. They enhance neuromuscular response, reduce harmful shock forces absorbed by the articular cartilage, and create a symmetrical, balanced foundation. If structural imbalances accelerate degeneration, it makes sense that structural balance slows that process down.
If it isn’t already a part of your routine exam procedure, add a new evaluation tool and look for the five red flags of postural instability. These visual clues will open up a new world of understanding about biomechanics, spinal instability, and the potential cause of degenerative arthritis, pain, and joint instability. If you identify the presence of any of these five red flags early enough in a patient’s life, you have a chance to prevent a great deal of unnecessary suffering. It sets the stage for you to make recommendations that will have a positive, long-lasting influence on your patients’ overall health and well-being.
Dr. Brian Jensen, a graduate of Palm er College of Chiro practic, is the owner of Cave Spring Chi ropractic in Roanoke, Virginia. In practice for over 30 years, Dr. Jensen is a highly sought-after Chiropractic lecturer and educator. When he's not practicing, Dr. Jensen speaks on behalf of Foot Levelers on a regular basis.
