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Foot Dysfunction as a Stress Factor in Chronic Lower Back Pain

Rick: Welcome to the Tuesday webinar series “Chiropractic Economics Webinars for Doctors of Chiropractic.” I’m Rick Vach, editor in chief of “Chiropractic Economics.” Today’s webinar, “Foot Dysfunction as a Stress Factor in Chronic Lower Back Pain” is sponsored by Vasyli Medical. As always, our program is being recorded and will be archived at “Chiropractic Economics” website, for one year. Our expert is on board here today to speak with you, and when his presentation is complete, we’ll follow with a Q&A period if we have time. You can submit questions throughout the presentation by clicking on the appropriate chat icon.

Our presenter today is Dr. Howard J. Dananberg, DPM, a podiatrist who practiced in Manchester, in Bedford, New Hampshire for more than 40 years. He has lectured to podiatry, medical, chiropractic, and physical therapy audiences around the globe and has received numerous awards regarding his novel approach to PTO Biomechanics. Dr. Dananberg, thank you for taking the time to participate in our webinar and for sharing your expertise with foot dysfunction and lower back pain. Before we get started, is there anything you wanted to add about your work with Vasyli Medical or foot dysfunction and lower back pain?

Dr. Dananberg: No, but just a brief comment that I’ve been a big fan of Chiropractic for a very long time. I was friends with George Goodhart for many years, and learned from Kevin Herron and others about extremity manipulation and it became a major part of my practice. I will only allude to it briefly today. Today will be all about how gait impacts the back and hopefully, different than what everybody saw. So I’m going to get started and see if I can get this to work and share the right screen. And there we go. Okay. Well, welcome, everybody. I’m glad you’re here. I’d like to thank Vasyli Medical, and they could be reached at, for sponsoring this. The lecture is about how foot dysfunction is a stress factor in chronic lower back pain.

The first thing to ask is what is really the most physically stressful time of the step? You know, if you look at shoe companies and shoes in general, it’s all about impact shock, and impact shock attenuation. But consider that impact shock occurs with the force of gravity. However, heel lift, the time when we raised bodyweight and advanced forward is restricted to it. It is restricted by it. So think about, like, going downstairs or going upstairs and which one’s more difficult. It’s always going up. Fighting gravity is a difficult time. And pronation, the dirty P-word, actually coordinates with…pronation itself is not bad. Actually, it’s a normal motion. It’s when it occurs. And when it’s pathologic, it’s at the late phase of the step. So that’s interesting because that’s the time when you raise your body weight.

There was an anthropologist from Harvard named Stephen J Gould, who wrote a book called, “The Panda’s Thumb.” And in it, he had a concept which is for any theory to be acceptable, the exception must prove the rule. Well, this is sort of a pretty pronated foot. I think everybody would agree with that. You can see the arcs dropping. However, this is their shoe, and the shoe is worn out on the outside. That’s not an error in photography because it’s not even the back of the heel, it’s the front of the shoe too. So even though the arch seems to lower when they stand, when they walk, they walk on the outside of their foot. Well, how’s pronation and not coordinate? And here’s another one. There’s a pretty heavy guy who clearly stands with his feet pronated, but look at his shoe. It’s completely worn out on the outside, not on the inside. What is that? And how could a foot invert and pronate simultaneously?

And so, the question to ask is pronation really an active movement, or is it a reactive movement? A lot in podiatry has focused on the subtalar joint. What is the subtalar joint? Well, it’s really a differential gear and it converts internal and external rotation of the lower limb, which happens every time you take a step because one leg kicks out and the other one has to respond to that, the one that’s weight-bearing. And so, it will externally rotate, and then later in the step, when it hits the ground, it will internally rotate. Well, if your foot didn’t have this differential gear at the subtalar joint, it would sort of grind itself into the ground. And to accommodate this differential approach to thinking about the subtalar joint, the talus has no muscular attachments, which gives it a very interesting freedom of motion.

And so it’s best to think of the subtalar joint not as creating pronation and having all this effect on feet, but more that it’s acted upon by the structures that are both proximal and distal to it. So let’s look at force application and when it times and how that addresses to pathologic pronation. That’s where the center of body mass is, somewhere between the spine and the belly button. And when the body, when the center of mass is behind the foot like it is at heel strike, the ability of the body weight to lower the arch is rather minimal. In fact, it almost doesn’t exist. And it doesn’t exist until the center of mass moves just over the foot and then passes all the way anterior to it by the end of single support phase. So at the end, that’s the time when the physical force that would lower the arch actually exists. And that’s the time when we talk about pathologic pronation.

We also know from intrude [SP] pressure testing that forefoot loads are far higher than rearfoot loads, forefoot loads are applied over much longer duration than rearfoot loads, and that pathologic pronation times with the increase and the peaking of the loads on the forefoot, and the reduction on the removal of rearfoot loads. In fact, if you go back, there are actually times when the heel is off the ground. So the idea of rearfoot pronation having this major impact may not be the right approach. So let’s put that in a little pocket for a while and we’ll come back to it later, and let’s look at how we model the body. A lot of theory on how the body works has been based on beams and trusses. But beams and trusses are static and the skeletal is anything but that. And as chiropractors, you know that mobility, if it’s restricted at one spot, needs to be accommodated in another spot. I mean, that’s the tenant of chiropractic. It became a tenant of my practice. And I think it’s something that’s very important in understanding how the body actually works and what it’s about.

Well, the body is clearly not a stack of blocks placed one on top of the other, because it has to support itself in a wide variety of positions that are other than vertical. Like a high jumper, or a professional football player, or even a gymnast. Now, if any of you ever meet me and you see me in this position, something is dramatically wrong, so I’m going to need help. But I don’t think you’ll ever see me in that position. Just joking. And so, how is it that we support the body? Well, the bones, the ligaments, the muscles, the tendons, the fascia is very important, combine to create a structure that’s capable of flexing and twisting and bending, yet maintain full support of all its components. Buckminster Fuller coined a term called tensegrity.

In tensegrity, he combined two terms, tension, and integrity, to describe the biologic process of structural soundness and full flexibility. Tensegrity structures share the following characteristics. They are a continuous tension network. They have discontinuous compression components, and that flexible hinges connect all the joints. Just get your head around tensegrity. Let’s use an example of a kite. Kites are constructed of vinyl, a couple of pieces of balsa wood, and some string. It can have a tail to keep it some weight. But you need the string tied across the back of the kite to create tension within the vinyl. And it’s not until the tension is added that the kite is capable of withstanding the forces of the wind. Balloons are an example of tensegrity in their own way.

Balloons, when you tie the end and fill them with air, the air molecules press in a million different directions all against the plastic of a balloon. And the balloon, interestingly enough, can be changed into many different shapes without breaking. You squeeze one end, the other end pops out. So it maintains its integrity even though the shape can change. Until, of course, you take a pen and prick the covering, and all of a sudden, because the continuous tension is lost, now the entire system breaks down. Well, if we take feet, for instance, although the whole body works the same way. Feet are covered by the plantar fascia. And the plantar fascia covers four layers of arch muscles on the bottom.

Now, we know that when you exercise a muscle, it doesn’t gain more fibers. It doesn’t twitch faster or slower. What it does is it increases its volume. It gets larger. What’s the effect of a larger muscle? It could create more tension against the fascia, improving the strength of the structure. Hold on a second. I need a drink of water. Tensegrity structures have been modeled throughout the whole body. On the far right, you can see the one that models the lower leg and foot, and in the center, there’s a spine and on the left, there’s the spine that you’re all familiar with. But certainly, with the ligaments and the muscles that run both sides in the back and front of the spine, It’s quite interesting to see how you could think about this as a tensegrity structure. But the key, as you all know, is mobility of the parts.

Well, how do we mechanize a tensegrity structure? This is a four-bar mechanism. And a four-bar mechanism is the simplest structure of mechanical engineering capable of weight-bearing and movement simultaneously. One bar is fixed while the others are able to move around it, but all the joints must be flexible in order for this to work. So you need four rigid bars. And rigid’s a funny term because it can actually be, muscles can act that way too, they can add their rigidity. But the key component of these systems is having mobile joints. Failure of any one joint can impact the function of all the joints. Failure of any one joint can disable the entire mechanism. At least one bar must be fixed while the others can be mobile. And the sixth component could change as motion requirements change.

So now let’s take the information that I’ve given you so far and understand pathologic pronation as a failure of effectively lifting and advancing body weight at the time when that action is occurring the most. When we walk, we’re not level. We go up and we go down and that’s a very, very, very important component of walking. Because when we’re in our peak, as you can see the head at the highest here, the bodyweight force graph at the bottom shows that that’s the major dip in the curve. That’s when the weight is the lowest because we rise up. But then we’re going to continue to go forward, so we’re going to lift our weight and advance at the same time, reaching the second peak in the curve. That’s the time when thrust occurs and that’s the time when we advance.

How do we lift and move at the same time? Well, second class levers are a very interesting example of that. You have the lift and the handle, the load and the barrel, and a rolling fulcrum point, which is the wheel. And this is really how they work. And it’s rather simple. Second class levers are well known in physics. How could you model a foot that way? Fairly simple. The lift comes through the Achilles tendon to the back of the heel, the load is borne by the tibia, and the rolling fulcrum point is the hingable MTP joint. MTP joint is exclusively human. It’s a fascinating part of the body. It allows the heel to be lifted as the body passes over it and maintains structural integrity of the entire foot at the same time. I’ll show you.

The windlass effect was described by J.H. Hicks in 1954 in “The Journal of Anatomy.” He wrote four articles, well, parts one to four, interestingly enough, and he described certain aspects of the windlass that were pretty interesting. Number one, when you bend the toe, the arch raises. It’s automatic. And not only does the arch raise, but the load leg externally rotates at exactly the same time, which is interesting because that’s the time when the upper thigh is being externally rotated by the swing limb, which is kicking out. So you have external rotation from above, timed with external rotation from below, and all you have to do is bend your toe to make that happen. And Hicks also said that the motion was not resistible, that once it began, it was impossible to resist it. That the arch raising an external rotation would happen automatically. All you had to do is walk.

So for the windlass to function, the hallux must dorsiflex. However, this is not a given. Actually, the question really to ask is do feet excessively pronate, or instead, is it a failure of the windlass to function resupinate them? Well, this is a video that I made quite a long time ago. This is a very flat-footed young woman, but you could see that when she rises up on her toe, her arch raises. I’ll show you again, and you can see quite flat, but look how the arch raises just by hinging at the toe joint. It’s a rather remarkable system and functions pretty much every time. This is the same young woman, except now she’s walking. And watch what happens. That as she steps forward and the swing limb pulls the body forward as we’ll talk about later, the heel lifts, but at what price? Because the MTP joint doesn’t move at all.

And so, the arch breaks down in the middle because the motion at the MTP joint fails to occur. Certainly, the midfoot is obvious here, but other site is much more proximal, including the low back, hips, knees, neck, all are affected by the same process. I’m sure you’ve all seen these. This is one of those pools that you can swim in, you don’t really go anywhere, you’re swimming against the current. And the swimmer stays stationary because she’s swimming forward at the same speed that the current is flowing backwards. And if she stopped swimming, she’d get rammed into the back of the pool, but if she stays at her same pace, she’ll just stay in the middle. Well, what does this suggest when we look at how feet move during that heel lift process? This is the same video that I just showed you, but now we’re looking head-on and from the side at the same time. And you’ll see a bar come across the weight bearing the left foot and it’s right at the level of the ankle.

Now, the medial malleolus is the tibia. So what you’re really watching is the movement of the tibia as the step is taking place. And watch what happens. The bar comes in and instead of going up, it moves medially. It doesn’t rise. But if you look in the upper left-hand corner of the video, the heel’s already off the ground. So what’s happened is the heel has come up, but the tibia has not. Well, it’s exactly the same as the current pool analogy. That if the tibia doesn’t go up at the time that the heel raises, it has to be dropping at the same rate of speed that the heel is rising. What is the implication of that on the rest of the body? Falling rather than raising weight now impacts an elegant neurology that’s used for stability and walking itself. And this is actually the etiology to many lower extremity and postural elements.

It also explains how feet can invert and pronate simultaneously. So what happens is that as they rise up and they are avoiding a first MTP joint that doesn’t move as I just showed you, the most common method of avoidance is inversion. Turning the arch inward so that you walk on the outside of the foot. But when the heel raises and the foot’s in that position and the toe is not bending, there’s no windlass effect. So now, you can have pronation occurring simultaneously with inversion. Now, this affects not only the foot, but the entire body that’s proximal to it at the same time. Well, there’s a strong link between gait style and lower back pain. And it’s not pronation specifically, but rather the effect of the sagittal plane restriction on hip extension during single support phase, as well as its impact on postural alignment.

Humans walk by pulling. The swing limb pulls the body over the standing limb. And the amount of extension of the trailing leg is directly proportional to the pull of the swing leg. Muscle action on the stance side is eccentric, not concentric. So it resists motion and supports the body as it advances. And that, it allows for efficient muscle action rather than inefficient muscle action. And the most important thing about swing phase, it’s a neurologic constant. That infants when they’re born, if you pick them up by their arms, they have what’s called a kick place reflex. They know how to kick the leg out. It’s automatic. Everything else, stance, bounce, support, that’s all learned.

And so what happens is, as we kick out with one side, the trailing leg extends out from under the hip joint. The knee moves out from under the backside as you stride, then from the extended position, when the opposite limb hits the ground, the limb collapses into pre-swing. In other words, it uses its own weight to accelerate forward at the time just before toe-off. And then at toe-off, the limb comes off the ground and pulls that side over the standing side. And that happens back and forth, and back and forth. So trailing limb extension reverses deflection at the moment single support and double support begins. And limb extension during single support phase is really the potential energy storage mechanism for the next swing phase. If you don’t extend, it’s very, very hard to kick the leg out again.

Another drink of water, excuse me. To maintain upright stance while we walk, both the hip and the foot must permit forward, sagitally plane-based motion. It’s rather simple. It’s a ball and socket. It’s easy to understand how it extends and it flexes. The foot, however, is rather complex. The first pivot is around on the side of the heel. That’s what allows you to get the foot flat on the ground. The next level is the leg over the foot, which is ankles during dorsiflexion, which is a rather interesting motion. And then that reverses to plantarflexion. The heel rises off the ground and all the motion [inaudible 00:26:04]

When full hip extension occurs, that again, as I said, is the preload to the next swing phase. And if you can see that that’s what you want to get, you want to get the knee out from under the backside when they walk. However, what’s much more common is what you see here where the knee itself is flexed. The thigh is directly beneath the hip. And you see the sequelae of years and years of doing that with the lumbar spine scrape not curved ahead of this forward posture. And the lumbar spine is actually flexed to create the straight spine position. And that this is very difficult walking and requires a lot more muscle activity, and which is what creates fatigue.

So think about it this way, that there are many, many postural issues that can be related to this concept of functional hallux limitus. That the joint can bend freely and smoothly at the time of examination, but during a load, it doesn’t move at all, which is what you saw in the previous videos. You can end up with a forward head posture. You can have a hunched gait. You can have limited hip extension, mid-step knee flexion, and late phase foot pronation. And what these really are, are all the same motion at different locations at the same time. Think about it this way. If you’re walking down a hallway and you trip, you’re going to fall forward because momentum acts on the body and has a continuum. A body in motion tends to stay in motion. So that’s an easy picture to understand when you’re falling.

However, when we look out at flexion response over decades, so the upper picture shows somebody walking and being highly efficient. The lower one is a different picture where they kind of flex forward, the head’s forward. The knee is really not out from under the backside. There’s actually an absence of heel lift during single support phase, which is a very, very interesting way to look at walking. Does the heel lift before the opposite limb hits the ground, or does it lift after the opposite limb hits the ground? Because when functional hallux limitus is present, remember this motion happens thousands and thousands and thousands of times a day. Average people take about 7,000 to 8,000 steps a day. Postman, mailman, waitresses, they take 20,000 steps a day. People take 3,000 to 4,000 steps a day. So the numbers are staggering and over a year, it’s millions and millions of these cycles a year. And so form always follows function. The shape of the body results because of how it’s used.

Well, this is a muscle I’m sure you’re all quite aware of, the iliopsoas complex. This muscle originates from the lumbar spine, from the discs, from the intervertebral septa, and it runs with the iliacus, which originates from the iliac crest, directly through the pelvis, into the lesser trochanter of the femur. And its action is to flex the thigh on the hip at toe-off. Well, think about all the things I’ve been talking to you about. When you walk, as you advance, the body needs to get that trailing limb extended so that when the opposite side hits the ground, the limb accelerates, and then the psoas only needs to produce a burst of activity on a limb that’s already in motion.

However, if that limb is falling, as I showed you on the video, the psoas now has to catch that limb and lift it in motion in the opposite direction that it’s going. And it has to do that thousands upon thousands of times a day. And looking at where it comes from and where it inserts, you start to realize how these impact, the thousands of cycles a day, impact the structures of the lower back. It’s not impact shock that is damaging, the body’s actually very strong to impact shock. But it’s weak to our rotational forces. And since this happens on one side at a time, think of the rotations that are going to occur while the lumbar spine is flexing forward, because you’ve now hinged in that direction because you couldn’t step over your feet.

The other thing that happens is there is a very interesting reflexive motion that occurs within the body known as lateral trunk bending. And it leads to overuse of the quadratus lumborum and the iliotibial band too at the same time, and it’s actually reflexive. And I’ll show you, and this is a video off the internet. I hope this plays. Let’s see. It should. And what you’re going to see is a silverback gorilla, the one on the left, and it’ll come into focus. And watch how they walk. And watch how he bends from left to right, left to right, left to right. Constantly doing that as he’s walking. I mean, they can certainly walk erect, but it’s uncomfortable to them. And so, they stop and they go back to all fours, like you see in the other one.

I’m gonna stop this, go to the next slide if I can, there we go. Well, primates have adaphistic thumbs. Their great toe on a primate is opposing because they’re still arboreal. They climb trees and they use the gripping motion of the foot in order to grasp and hold. Well, if you take a look at your own hand and you try and dorsiflex your thumb on the hand, you can’t. Because it has to lock in place in order to be an effective opposing digit. Well, as we evolved, that changed in the foot and its ability to flex became very, very important in allowing us to be upright. Because when you look at a force plate analysis of a primate walking, it’s very different than a human walking. As I showed you earlier, when we raise and lower our body weight, that what happens is that you can see the graph, the peak at heel strike, the lowering in the middle, and the second peak, but on the graph on the right, that’s the primate walking. Look at it, it’s flat.

There is no bodyweight moving. They really don’t fall forward and in fact, you can almost see on the graph the picture at the top of the monkey walking that he’s trunk bending. Why is this so important? Because the trunk bending motion is reflexive in the ape and it’s also reflexive in the human. If you look at this picture, which is a picture of an amputee walking, and the classic explanation has to do with the position of the center of mass and how they have to balance it. That’s not really true. I don’t buy that, and I’ve worked with amputees. My partner was an amputee and we were able to solve this actually pretty regularly. Because the motion and the trunk bend is always away from the viable side to the prosthetic side. And when you watch amputees walk, it’s the prosthetic side that extends, not the viable side.

The viable side never extends when you walk because the weight of the prosthetic is unable to pull them over the viable side when they kick out. And so, without any limb extension on the viable side, the only way they can get them into swing phase is to trunk bend. You’re literally dragging it with one side of your body to drag the other side into motion. And that is always through the quadratus lumborum and the iliotibial band. I’ve seen this so many times, I stopped counting a long time ago. Because when hip extension fails, and this is a fellow with a normal hip, when they don’t get the limb in motion by extending it first, now what happens is they have to drag it with the other side of their body. As I said before, this is repeated thousands upon thousands upon thousands of cycles a day, and it becomes the ultimate repetitive strain injury.

It’s no wonder why you see patients in the same structures become locked up and tightening because they keep doing it to themselves over and over and over again. You all know the anatomy of the quadratus lumborum. Originates from the last rib to the spine, and into the iliac crest. And it’s clearly capable of side bending, which is what it does. And the iliotibial band, which connects the gluteals, the tensor fasciae lata into the iliotibial band, is the other structure that’s always involved. The other thing that happens in athletes, it’s not uncommon in runners to see iliotibial band syndrome, and it’s highly repetitive once they get it. Check them. It’s the short side. Because the long side is a more difficult vault to step over. So the limb…it doesn’t extend as much as the shorter one. And so they need to trunk bend away from it, and they use the same structures all the time to do it. And that’s how it ends up.

So as far as treatment goes, I’m going to go through this quickly and show you some things. There is a whole section on manipulation. I recommend that you search “Dananberg and manipulation” on YouTube, or go to There are articles and videos there, and you could see how I do these, or you may have your own techniques to do them. That’s fine. I have learned a very, very gentle technique to manipulate the cuboid. I once had an extremity chiropractor come to visit me and he saw how gentle it could be and he was, “Whoa, I’m killing people.” So you can actually do this very gently and be very successful. But the key ingredients are if you’re going to use orthotics, they need to have first-rate cutouts to allow the first metatarsal to plantarflex so the MTP joint can dorsiflex as the heel starts to lift from the ground.

As far as shoe management goes, avoid excessive cushioning. The more you cushion the heel, the longer the heel stays on the ground. The longer the heel stays on the ground, the less hip extension there is, and you’ve already hurt those sequelae. Avoid stiff-soled shoes, wingtips, you know, for men, and thick-soled shoes for women. They don’t flex and they restrict your motion. And there’s even you can alter cleat design. I’ll share that in a few more slides so you get the idea of what that looks like and how we can deal with that. But let me show you this video. I guess there’s no sound here. This is a motion from Vasyli, that’s me, and what I’m showing is how the MTP joint can dorsiflex normally.

However, when you load it like you would do the ground and you press on it, there’s actually no range of motion available to join. And if that happens when you’re walking with all your body weight on it, then the problem can exist. But as soon as you plantarflex it, that allows for normal motion. Now, the Vasyli Dananberg Orthotic, and this is just showing how flexible the foot is when the toe is straight, but when you bend it, all of a sudden, the foot becomes nice and stable because of the action of the windlass effect. You can see the arch actually come up.

Now, the Vasyli Dananberg Orthotic has two plugs on the bottom of it. There’s a proximal and a distal, and is designed for long and short metatarsals. So you hold the device up to the bottom of the foot and then you place it so that the metatarsal head itself, not the toe, but the metatarsal head is over the area. And then you just simply remove the plug. It’s all built for that purpose. And then you could put it in their shoe. These are actually, you can heat mold these, you can add posts, you can add heelies to them, they’re very, very easy to function. But once the plug is removed, there’s plenty of room for the toe to dorsiflex. And we’re going to move the orthotic to show you that if it was a very long first ray, then you’d want to remove the distal plug, which is fairly easy to do. And the same thing as the proximal plug, you just take it out, peels back, and then you could just put it in their shoe and have it fit appropriately.

And there’s even a third way to use this, which you’ll see in a second, which is if it’s sort of in the middle and you don’t know what to do, you can take out the distal plug, take out the proximal plug, flip it over, and put it right directly against the bottom so that you can actually see how this can fit. Okay. Now, this is why I actually was talking about cleat design. That when you look at cleats, there’s always one that’s directly underneath the first metatarsal head. No wonder they get turf toe. It’s a common problem. When patients get turf toe, one of the things you want to look at is the strength of the peroneus longus. The peroneus longus comes down the lateral side of the leg, under the cuboid, and connects into to the base of the first metatarsal. And it holds the first metatarsal against the ground so the joint can dorsiflex.

Following an ankle sprain, following chronic inverted gait, which I’ve shown you many pictures of already, the peroneus longus could become inhibited, and as such, it can actually perpetuate the pain itself. By manipulating the ankle joint, you can immediately return to normal facilitation and resolve turf toe is literally or even ankle sprain pain in one visit. But if I have cleats like these, you can grind this off. You can have this removed by their parents, you can do it. I had a grinding wheel in my office, it was easy to do, and you just grind the cleat down so that you can change the entire dynamic of how they walk and move with cleats on. The last thing I want to show you is a video, you know, I started off by talking about the exception proving the rule. Ankylosing spondylitis, now because of the drugs that are available to treat this sort of thing are disease of the past. But this is an older video, and you can see that this poor guy is walking always looking at the ground.

When we started this video, he said that he could walk for maybe five or six or seven minutes, and that was about it. And that’s all he could do. I’ll show you again. There’s a very limited extension of the limbs, the posture is horrible, and it’s a tough life to always look at the ground. This is the same guy, and this is still long before the drugs to treat ankylosing spondylitis came available. This is still 11 months later. He says when he walks, and this is not meant as a sexist thing, but his wife can’t keep up with him anymore. That his walking had improved so dramatically that he was able to walk and move better. I mean, he still has the effect of the ankylosing. That’s obvious. But look at him, he’s moving. And you can see that he’s got an external fixer. He’d actually fallen down the stairs and broken his wrist, but look at how he moves. Look at the difference just by putting foot orthotics in that mobilized the first MTP joint. That’s the difference.

So the body is not a system of beams and trusses which utilize direct muscle action for functional movement. It’s much more elegant than that. Instead, it uses continuous tension and discontinuous compression network, which has as its most basic requirement, mobile hinge joints, which manage strength, motion, and support. So what appears as excessive or abnormal motion in one spot is actually compensation for functional joint fixations at others. And by recognizing what’s restricted from what’s actually moving or should move, represents the key to understanding chronic and recurrent biomechanical pathology for both the foot and lower back pain symptoms. So that’s pretty much my talk for today. I’m going to stop sharing, come back to the screen. And if there’s any questions and we can share them, I’d be happy to try to answer them for you.

Rick: Dr. Dananberg, we have a question that came in. Many chiropractors don’t start with the feet with patients. They go immediately to the back or spine. How can chiropractors benefit from starting with the feet?

Dr. Dananberg: Well, I think that you’re going to stop a lot of the recurrence. I know that in my practice, which is about 40 years’ worth, I practice in Southern New Hampshire about an hour North of Boston, patients who kept coming back and they always treated the same thing over and over again. It wore on them and it wore on me. And if you go back to the feet and you look at them and say, “Well, let me see if this is contributing to your problem,” people always need chiropractors. They always need to go, something happens, they bend over wrong, whatever it is, but if you could take away the chronic recurrent thing that’s ruining their lives, it makes a big difference. And looking at feet first can do that.

Rick: Thank you. And we have one other question. Can you share any stories where orthotics made a huge difference with your patients or really opened your eyes up to something?

Dr. Dananberg: Sure. Well, I did publish an outcome paper in 1999, which looked at 32 patients at medical endpoint for lower back pain. And we treated them all with custom foot orthotics and ankle manipulation. Those were the two parts of the study, and all the orthotics were very similar in that they all have first-rate cutouts like I showed you on with the Vasyli Orthotic. And that was basically what we did. And we followed them for over a year. The average follow-up time was 13.9 months. And we used the Quebec back pain disability scale to measure the pain before and the pain after. And what we basically came up with was at the end of the year…at the end of, it was actually almost 14 months, we had an 84% cure rate in medical endpoint low back pain patients.

And there were nine patients in the group who were involved in lawsuits and work injuries. And even them, they got better. Because it’s not so much that they have a vested interest, which they might very well have, but they also were hurting and the way they walked may not have caused the problem, but it perpetuated the symptoms. And so, if you’re able to change or intervene in how they repeat thousands of cycles a day, you’re going to have a major change in how they feel.

Rick: Thank you very much. At this time, we’d like to thank our sponsor Vasyli Medical and Dr. Howard J. Dananberg for today’s webinar. And thank you all for attending. We also have a special offer, 20% off the Vasyli Dananberg Orthotic through ScripHessco. So, redeemable via only. The code is “Vasyli120” it is valid for one week, and we’ll also be emailing you this information. Remember, this webinar, including our speaker’s PowerPoint presentation has been recorded. We will alert you via email when the webinar is available online. Thanks for attending, and we look forward to seeing you next time. Have a great day.

Dr. Dananberg: Thank you. Bye, everybody.

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