In posture (the distribution of body mass with respect to gravity), the lowermost joints in the musculoskeletal system are of fundamental significance.
These include both the feet and ankles, which support the entirety of the musculoskeletal system and the sacral base buttressing the vertebral spine. There are four elements that are capable of reducing more than two-thirds of common pain occurrences:
- Manual manipulation to reduce somatic dysfunction,
- Foot orthotics to optimize the amplitude of the arches of the feet as well as vertically aligning the ankle,
- A heel lift to level the sacral base, and
- A set of therapeutic postures designed to minimize the restrictions of peripheral soft tissue reflective of the earlier posture.1
Most often in musculoskeletal pain, there is no objective evidence of trauma or disease. Rather, one must consider mechanical stress as a contributing factor—the stress often brought on by spinal lesions and improper posture.2-4 In light of the points stated above, the activity of the foot and its management merit further consideration.
A successful solution
Foot orthotic devices have been found to successfully modify selected aspects of lower extremity mechanics and enhance foot stability, as seen in the support phase of gait. The hypothesis was that the use of orthotics would relieve excessive strain on the ankle ligaments and reduce postural sway.
Indeed, recent investigations have demonstrated that custom-fit orthotics may restrict undesirable motion of the foot and ankle, enhancing joint mechanoreceptors to detect perturbations and providing structural support for detecting and controlling postural sway in ankle- injured subjects.5
A more thorough and recent systematic review concluded that foot orthotics increased activation of the tibialis anterior and peroneus longus and might have altered lower limb and back muscle activation.
Changes in electromyographic (EMG) activation were reported as well, although standards for reporting these were found wanting when confidence intervals were calculated.6,7 Attenuations of the gain of the gastrocnemius H-reflex when subjects balance on a stable surface shifting to an unstable surface have been positively correlated with perceptions of the comfort of foot orthotics.8
The effectiveness of custom-fit foot orthotics in alleviating back, foot, ankle, and leg pain in addition to promoting ankle stability is attested to by the findings of 33 randomized and unrandomized clinical trials, case series, and case studies involving 2,674 patients suffering from foot and lower limb pain, juvenile idiopathic arthritis, rheumatoid arthritis, plantar fasciitis, cavus (high arch pain), inversion ankle sprain, Morton’s neuroma, Hallux valgus, and patellofemoral pain..9-39
In some instances orthotics are used in combination with other conservative, noninvasive therapies, often involving spinal manipulation.9,12-42
Better in combination
Regarding the relationship of back pain to foot orthotics, six studies involving 211 patients suggest that pain and disability scales associated with low back pain resolve with the use of orthotics; in fact, one case series reports that the application of orthotics produces a twofold extension of the duration of improvements produced by traditional back pain treatment.10
Of even greater significance is the finding that lumbar disk rupture can occur as the result of a low force repeatedly applied over a long period of time, particularly stress that is applied by rotation and lateral bending.43
One study related this to the utility of foot orthotics by explaining how the pivotal activity of shifting one’s weight from behind,over, and then in front of the weight- bearing foot in normal gait activity requires that the center of mass revolve around the foot as though it were the rim of a wheel. To allow this to occur, a series of three “rockers” (the round underside of the calcaneus, the ankle joint, and the metatarsophalangeal joints) exist within the foot.44
A failure of any of these sites to allow this revolution (called sagittal phase motion) in a timely fashion can cause a sagittal plane blockage that tends to extend the hip such that the psoas muscle has difficulty in lifting a leg not already moving forward before entering the swing phase of gait.45
Because patients often display low-back pain symptoms at the sacroiliac joint on the same side as the sagittal plane blockage, and because the aforementioned studies have shown orthotics to improve the course of back pain, it is easy to see how custom-made orthotics may encourage the weight-bearing foot to revolve properly around its axis and thus allow the hip to avoid the sagittal plane blockage that can lead to some forms of back pain.10-12
The fact that a shoe orthotic that improves both pain and disability contains a spongy polymer to assist in the toe-off portion of gait is consistent with this model.42
A kind of reflexology
There may be mechanisms in addition to the biomechanical model that describe how other parts of the body might be affected by foot orthotics. The nerve impulse or automatic somatic integration theory takes advantage of the fact that feet are conspicuously sensitive to pressure, stretch, and movement.
Indeed, feet play a central role in reflexology—the technique of applying pressure to the reflex areas of the feet or hands to produce a state of deep relaxation and to stimulate healing throughout the body.46
Accordingly, it has been suggested that pressure applied to the feet during reflexology compresses cellular receptors, opening ionic channels in the plasma membrane that triggers local action potentials and conveys messages to the spinal cord and brain. The result is the processing of these signals to produce motor output to the muscles and organs.47
A broader analysis of these principles is reflected in the acupressure and acupuncture literature.
Enter the adjustment
A major question lying ahead that needs to be resolved by further research is whether custom-made orthotics can prolong the beneficial effects seen with chiropractic adjustments. Multiple maintenance care studies relating to spinal manipulation, for instance, have shown that disability or both pain and disability scores of low-back pain patients regress to baseline levels after 9 to 10 months if intervening chiropractic adjustments are not administered each month following the first series of treatments terminating at one month.
With more research to be conducted, there remains an impressive body of literature supporting the clinical utility of using foot orthotics—not only for the relief of back pain, but possibly also creating additional beneficial effects throughout the body.
Depending on the validity of reflexology, the suggestion could be made to the effect that stimulation of the foot through the proper use of custom made orthotics, recognized by the brain, could result in salutary effects through resulting motor-neuron transmissions to the muscles and organs.
Simply demonstrating that orthotics can reduce the number of interventions (pharmacologic as well as nonpharmacologic) needed to produce a sustained relief from back pain would be immeasurably valuable.
Anthony Rosner , PhD, is a champion of interdisciplinary research methodology in the health sciences, having previously served as director of research and education at the Foundation for Chiropractic Education and Research. He was designated Humanitarian of the Year in 2000 by the American Chiropractic Association and holds an honorary degree from the National University of Health Sciences. He obtained his PhD from Harvard in medical sciences and biochemistry. He can be contacted at firstname.lastname@example.org.
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