Is Your Pelvis the Cause of Your Pain?

What happens with a man spends more time thinking about a triangle-shaped bone at the bottom of our back than a teenage boy spends thinking about sex?

The answer is, he discovers a remarkably simple solution to alleviate low back pain and quite possibly, a way to help lessen or completely eliminate other painful bone, muscle and ligament ailments.

Richard DonTigny has spent 40 plus years puzzling out the intricacies of our pelvic ring: the bones, ligaments and muscles that comprise our waist, buttocks and hips.

“Pelvis” is Latin for “basin,” which is what our pelvic ring resembles. In medical-speak the pelvic ring is made up of the hipbones and the sacrum (the triangle-shaped bone at the bottom of your back). The joint between the hipbone and the sacrum is the sacroiliac joint, and that is the linchpin of DonTigny’s work: it is where the secret to pain-relief lies.

DonTigny is a physical therapist who has published over 25 journal articles, written chapters for medical textbooks, lectured extensively, and treated over 8000 patients with sacroiliac joint problems. He is also the author of the Powerpoint CD, “Pelvic Dynamics for the Professional.”

In “Pelvic Dynamics for the Professional,” DonTigny explains how the sacroiliac joint (and the pelvic ring) is prone to becoming out of alignment, setting up a chain reaction of tension and strain on the surrounding muscles, ligaments and other soft-tissue structures. Dysfunction of the sacroiliac joint, DonTigny says, is responsible for at least 85% of low back complaints. Beside the back, he says that a malfunctioning or misaligned sacroiliac joint may also be the culprit in sciatica, piriformis syndrome, and knee, hip, pelvic, or stomach pain, and indirectly cause neck, shoulder or foot problems.

Just one detailed illustration from "Pelvic Dynamics"

DonTigny states: “In 1992 at the First World Congress on the Sacroiliac Joint Dr. Joseph Shaw of the Topeka Bank and Neck Pain Clinic reported that in a series of 1000 consecutive patients he examined for low back pain (LBP) and sacroiliac joint he found that 98% had an SIJ problem. When he addressed that problem, his surgical incidence for herniated disks dropped to 0.2%.”

Once one delves into DonTigny’s CD—a whooping 600 plus slides—you begin to understand how the pelvic ring is the linchpin of our skeleton. It supports our spine, allows us to walk and do other activities by serving as a powerful fulcrum for our body.

DonTigny shows that even small sacroiliac problems can have far-reaching effects on the body, even altering normal function of the feet.

For example, a misalignment of the pelvis can increase the inward curve of the low back (increase lordosis) while increasing the outward curve of our back at the level of our chest (kyphosis). These actions can cause our hips to rotate outward and our shoulders to hunch inward and lead to our head jutting forward (causing neck pain). Sacroilliac joint dysfunction can also cause a curve of our spine in the frontal plane (scoliosis) and ultimately create what appears to be a leg-length discrepancy (one leg longer than the other). Clearly, the sacroiliac joint is the keystone for good, healthy walking, standing and even sitting.

On his CD, DonTigny brilliantly dissects the complex inner details of sacroiliac joint and through his hundreds of beautifully illustrated slides, he makes understanding this complex joint easy.

The crowning jewel of DonTigny’s CD is a series of adjustments – The DonTigny Method – that a physical therapist (or a patient can do themselves) to properly realign the sacroiliac joint.

One has to wonder why DonTigny’s method is not known more widely and more accepted. Clearly, having a patient do some adjustments prior to seeing an orthopedic man for a back fusion is preferable. Part of the answer may lie in the fact that adjustments to solve back pain (and other bone and muscle problems), are so simple that individuals with a financial stake in back pain may feel their livelihood threatened.

Or perhaps, and much more likely, it may be difficult for those health practitioners who have spent their life doing sophisticated back surgeries, injections and/or a myriad of therapy modalities, to open their minds to such an easy solution.

Beyond the health practitioners, patients themselves still, for the most part, believe the medical system has all the answers. Until people begin thinking for themselves, begin asking questions–both to themselves and to their doctors, the system will feed them what it always has.

I am reminded of a great quote from the film The Matrix:

“The Matrix is a system, Neo. That system is our enemy. But when you’re inside, you look around, what do you see? Businessmen, teachers, lawyers, carpenters. The very minds of the people we are trying to save. But until we do, these people are still a part of that system and that makes them our enemy. You have to understand, most of these people are not ready to be unplugged. And many of them are so inured, so hopelessly dependent on the system, that they will fight to protect it.”

On a personal note, I VIGOROUSLY applaud DonTigny for not only puzzling-out the mysteries of one our body’s most complex muscle-skeletal structures, but for having the COURAGE to put his theories into the public domain. Often, when someone proposes a new, revolutionary theory or solution—especially one that patients can do themselves—they will quickly experience the sharp pang of the medical community’s arrows in their back.

Final thoughts on DonTigny’s Pelvic Dynamics CD

If you are ready to open your mind to what is often the real cause of our muscle-skeletal problems, this CD is worth a look. Be aware: The sacroiliac joint is complicated and I found myself needing to re-read several of the slides, but the effort is worth it and again, the illustrations make understanding the sacroiliac joint much easier. I highly recommend Pelvic Dynamics for the Professional.

For more information on DonTigny’s work (or to purchase his CD), you should visit his site, The Sacroiliac Joint.

Links:

Interview with Richard DonTigny

The Sacroiliac Joint

Sacroiliac Joint on Wikipedia

Sacroiliac Joint Resources

Related Posts

Can Changing How We Walk Alleviate Our Aches and Pains?

We all want good health. . .   We want to be lean, strong, and free from pain, especially pain in our back, neck, hips, knees, shoulders, legs, ankles, and feet. Beyond good health, we want to live life with energy, confidence, and exuding youth. At one time in our lives, we had this pain-free vitality and more. For many of us, the day-to-day grind wore down our bodies, leading to sore, achy and perhaps arthritic joints, weak muscles, more fat, greater fatigue, and even depression. 

Walking—when done optimally and correctly—can give you all this. But, before we discuss that, we need to understand how we came to walk poorly and how improper walking patterns can lead to pain, disability, increased risk of injury, lack of fitness and muscle strength, and most importantly, a lack of spiritual vitality.    

“You Walked Into Pain” — Sherry Brourman, PT, Walking Instructor

Humans have always walked. With the recent discovery of the oldest known human skeleton, Ardipithecus ramidus, nicknamed “Ardi,” we now know we have been walking for at least 4.4 millions years. It is our most natural and most common physical activity.

Yet, walking is not innate. It is learned, through trial and error, in a haphazard way. The infant, toddler, and young child learns to walk by watching his or her parents or caretakers. The child’s ”adult pattern” of walking locks into place by age 8. Don’t believe me, go to the local shopping mall and watch children walk with their parents. More often than not, the child will walk like one parent or a combination of both.

(As a podiatrist, I recently saw a 10-year-old girl who limped for no apparent reason. In talking with her mother, the mother related that she had the same limp due to a hip that she injured in a car accident a decade earlier. The child had taken on her mother’s limp, even though she had no pain or injury.)

Herein we find the first problem with walking: we may be learning to walk by mimicking parents who are not walking correctly. I can hear some of you now: Wait a minute, Dr. Nirenberg, my parents walk just fine! They may, but it is much more likely they do not. Optimal walking is a combination of proper positioning of our joints, correct breathing, coordinated movement of our extremities, torso and pelvis, and good posture. 

The fact is, most people walk wrong. Yes, they get from point A to point B, but they are moving their joints and muscles in a way that will likely exacerbate or eventually lead to muscle-skeletal pain somewhere in their body (i.e. knee, hip, back, neck or shoulder pain). Likely, they have poor posture, and more likely, their body will be asymmetrical. That is, one shoulder may be lower than the other, one hip higher than the other, one hip more anterior, one foot flatter etc. 

Every Step We Take

So we learn to walk by picking up the bad habits of one or both parents. As youngsters, we can run, jump, even bungee jump, and we feel invincible. Slowly though, due to poor walking patterns or an outright injury, or our activities (or much more often our lack of activity), or habits, aches develop. We may strain a muscle here, twist an ankle there, or just get a slow gnawing discomfort in our back, neck, knee, hip, ankle, foot, or shoulder. 

By the way, when I say habits, I am talking about such things as repetitive strain activities (carrying a knapsack, purse, briefcase, or baby or a specific activity that creates wear and tear on the body), diet (obesity or in rare cases malnutrition), and worse of all, poor footwear, which can put the whole body in poor alignment and/or distort and alter foot function (and altered foot function will alter our entire body!).

It Only Takes One Injury. . .

It only takes one injury to one joint, muscle, or ligament to worsen our walking pattern. Our body is a incredibly inter-related functioning unit and a simple knee problem can quickly lead to back, neck and foot problems.Even if the painful knee subsides after a few weeks, problems with your alignment and the way you walk can remain. For example, let’s say you hurt your knee and for a few days you are miserable. So you begin putting most of your weight on the other leg. When our body makes these kinds of adjustments, we call it a compensation. However, shifting our weight in this manner will often lead to additional compensations throughout your body, and these will further alter the way you walk. Over time, the knee pain may go away, but now, your walking pattern has changed—for the worse—and it is unlikely you are going to return completely to the old pattern.  

We Break Down Slowly (aka You Don’t Know What You’ve Got Until It’s Gone)

As we age, we may start having a pain here and there, and as a result, we may avoid certain activities, perhaps we stop skiing, or playing racquetball or even just stop taking the stairs. We soon find ourselves moving less, sitting more and quickly gaining weight. More weight strains our body more, leading to more aches and pains and even less exercise. Our walk might become further limited and stiff because we are worried about another fall or injury, and in effect we begin walking worse. Ironically, for many of us, lack of exercise and movement was probably one of the big factors that contributed to our problems in the first place. Yet, REST is touted as a good treatment for what ails us. Perhaps it is for an acute injury, but 6 months after an ankle sprain, if you’re still resting, you’re in big trouble!  

Worse, when your body isn’t moving as well as it should it is at even more risk for injury. People often think injuries are random. But, when a person has a poor walking pattern, they are much more likely to become injured. The person may slip on the ice, twist an ankle on the front lawn, or even throw out their back bending down to pick up a quarter. When this happens, they may blame the injury, but the injury is just the symptom of an underlying problem: the person’s misaligned, weak, worn out body.    

Keep in mind: The part of the body that hurts may not be the problem.

For example, in my practice I see many people with back pain due to severly flat feet. Once we get these people into orthotics (custom made, medical grade arch supports) their back pain goes away. 

Some people in pain seek help: they may see their doctor, or a chiropractor, or some cases, a surgeon. But even if they have a back fusion, knee replacement or pop pills to mask the pain, if their poor walking pattern continues, their problems will continue, or worse, new problems or injuries will occur. By now, some of you might be saying, I know how to walk. Of course you do, and if I gave you a golf club and no instructions on how to tee off, you could probably manage to hit the ball. But, your swing would be average to horrible.  Perhaps, your walk is too?

There is poor walking and there is walking well—walking optimally. Correct walking positions your bones and joints in their best alignment, which in turn stimulates muscles that were not moving much to not only move but work well.   

Further, if we are not walking correctly, over time we will see an increased strain on our joints, muscles, and ligaments. This strain is actually micro-trauma.  Microtrauma is very insidious, but when it goes on step after step, mile after mile, its damaging effects can add up.

Are You in Symmetry?

Regardless of the mechanism of injury, our body will lose symmetry. Lack of symmetry or lack of alignment, will lead to some muscles contracting or tightening and others weakening or shortening. That is, every joint in our body is able to function or move because the muscles around joints oppose and balance each other. For example, in simplistic terms, our middle toe can bend upward (extend) or bend downward (flex), the muscle that flexes the toe is opposed or balanced by the muscle that extends (these muscles are for obvious reasons called extensor and flexor muscles).

When a joint in our body is out of alignment or out of its correct anatomical position, there is a lack of equal and balanced muscle tension on the joint. Thus, one or more muscles will become looser and weakened and their opposing muscles will become tense and tighter.  Muscles under tension, become tired and may go into spasm, and at some point pain sets in. Further, these muscles–already strained–are at risk for injury as soon as you they try to do an activity out of their normal routine. This is often how people end up with the good old “pulled muscle.”

The activity that pushes these already tensed, tired muscles to the breaking point does not have to be something radical like suddenly going for a run on the treadmill or doing a kick-boxing class. It could be as simple as bending down to pick up the newspaper or reaching high up to clean a window.

It does not always have to be a misaligned joint that starts the cycle of muscle imbalance. Muscle imbalances can cause the joints to BECOME misaligned. For example, a body builder may work his abdominal muscles more than their opposing back muscles. This would lead to imbalance affecting numerous joints, including the spine and pelvis.  

Even one joint out of balance (out of position) can potentionally lead to pain and problems anywhere else in the body.   

Modern medicine likes to break up the human body into its component parts or pieces. There are back doctors, foot doctors, hand doctors etc. The reality is the human body functions as a whole unit. For example, a foot that is out of position can affect the hips as easily as a hip joint that is malaligned can affect the feet. Cause and effect go up and down the body, and to an extent in other directions, too.

Now, you might be saying, I feel fine—I don’t have any hip, knee or back pain. And you may not. But, if you are walking incorrectly, you are likely heading toward some kind of loss of function, decreased flexibility and ultimately, pain. Your body just isn’t at the breaking point yet.

Even if your body never reaches the point of giving you pain, incorrect walking diminishes the effect of walking on many of your muscles, leaving them weaker and flabbier.   

Can We Walk Better?

Yes! Walking is a skill, just like golfing, but even better: recall that walking is our most common and most NATURAL activity. Because it is natural, we can improve on it–easily–to the point where it can be extremely beneficial.

I can hear some of you now going through all the reasons that you cannot change the way you walk: “it runs in my family”, “I’m too old to change”, “I have bad genes”, “I was born with curve in my back” and on and on.

Listen up! Your body and its muscles are under YOUR control. You can change the way you walk once you understand how to do it. You learned how to walk wrong without any help; now, with proper instruction, you can learn how to walk correctly.  

Right now, there are only a few people in the world teaching correct walking. One of the foremost experts on walking correctly is Sherry Brourman. Recently, I spent a three days studying with her at her Santa Monica studio.  Brourman, or “Sherry” as she likes to be called by her patients,  is author of the book Walk Yourself Well. She is also a Physical Therapist and Registered Yoga Teacher, and super dedicated to helping people walk better. 

When treating a new patient, Sherry will take a thorough history, observe how the patient stands and then she will watch them walk. Often, within seconds of the patient taking a few steps, she will point out the patient’s main walking problem. 

At that point, she would recommend ways for the patient to make small adjustments and often some basic exercises and stretches that will target the patient’s specific walking problem.  

Essentially, walking correctly involves a combination of optimal, unique joint and muscle movement, body posture, and breathing, and most importantly, a new and heightened awareness of your body.   

Developing an awareness of your body is key, and this is why it is  important to work with a good teacher. Often, we can’t see our abnormal walking pattern or our compensations because we are so use to them.  For example, when I first  met Sherry, she immediately spotted my left knee hyperextending. Despite having read her book and studying the science of walking and biomechanics for years, I had never noticed my knee hyperextending until she pointed it out.

Now, I am much more tuned into listening to my body, and I have learned that our bodies, in a sense, “talk” to us.  We just have to listen.

Many of the people who I saw going to Sherry for help were at the end of their medical rope. They had tried everything else modern medicine has to offer, and then–out of desperation–went to her. Sadly, some of these patients went through surgery or even surgeries, and they are still in pain.  As I watched Sherry work with them, I often found myself wondering how much better shape many of them would have been in, had they come to her earlier, perhaps, even before they had surgery.

In fact, from observing Sherry work with her patients, I have come to believe that there are few people who cannot be helped with these walking techniques. Further, I believe millions of surgeries could be avoided, if people first tried to walk correctly.  

Lastly, having spent a lifetime trying to alleviate pain for patients, I want to emphasize how impressed I was with Sherry. She brings an intuitive brilliance to training people to walk. Perhaps, this is because of her understanding of traditional medicine and yoga—a great mix! If you have structural pain and can get to the Santa Monica area, I would highly recommend seeing her for a few walking sessions.  

“Walking is man’s best medicine.” — Hippocrates

After studying with Sherry, I slowly began using her techniques with a handful of my patients who had muscle-skeletal pain and problems throughout their body.   

My most successful walking patient to date is a woman who complained of back pain to the point that every morning she needed to use a heating pad for 30 minutes. She also had another unusual problem: the seam of her pants or skirts always rode up on her left butt cheek.  

This patient constantly would have to pull the seam back into place. Now, after only working with her for 4 sessions, she no longer has a problem with the seam of her pants and more importantly, her morning back pain is gone!  

Further, all the patients who I have been working with are doing better to varying degrees. Of course, a handful of patients walking well and getting well is not scientific proof that walking better makes your body better, but it is very encouraging.   

(By the way, if you step into my common sense chamber for a moment, you would have to admit that it seems logical that walking better will make your mind and body feel better.)   

For now, I am continuing to study, explore, and learn new ways to help people walk better. I am meeting with various holistic and biomechanic experts and seeing what I can learn from them. Ultimately, I believe if  people walk better, they will not only experience increased weight loss and fitness and pain relief, but spiritual vitality. That is, beyond the physical effects that walking well bring, people often find that good, whole-body walking has a very beneficial effect on their emotional state. It can lessen anxiety, alleviate depression or just clear their minds–briefly–of psychological woes.

We should never forget that our mind and our body are tightly linked. Each  affects the other, and walking well will lift your spirits and when done regularly can become meditative and rejuvenating.   

“It is impossible to walk rapidly and be unhappy.” — Mother Theresa

“Everyday I walk myself into a state of well-being and walk away from every illness.” — Soren Kierkegaard

If you are in the Chicagoland or Northwest Indiana area and are interested in learning to walk better, please contact my office – Friendly Foot Care.     

Final Thoughts on Walking Better

Most exercise and fitness programs require a conscious decision to do them each day. When it comes to walking, you already are doing it. The average person walks 10,000 steps a day. Now, you can just do it better.

How do you walk? Do you walk well? Or poorly? I would love to hear your comments on walking!      

References:

Brourman S. Walk Yourself Well. Santa Monica, CA. 1998.  

Kendal FP. Muscles: Testing and Function, with Posture and Pain (5 ed). Philidelphia, PA: Lippincott Williams & Wilkins, 2005. Klenerman L, Wood B. The Human Foot. London: Springer, 2006.  

Kirtley C. Clinical Gait Analysis: Theory and Practice. London: Churchill Livingston, 2006.  

Kou AD, Donelan JM. Dynamic Principles of Gait and Their Clinical Implications. Phys Ther. 2010 Feb;90(2):157-74. 

Neumann DA. Kinesiology of the Musculoskeletal System: foundations for rehabilitation (2nd ed). St. Louis: Mosby, 2010.   

Oatis CA. Kinesiology: The Mechanics and Pathomechanics of Human Movement (2nd ed). Philadelphia, PA: Lippincott Williams & Wilkins, 2009.  

Perry J, Burnfield JM. Gait Analysis: Normal and Pathological Function (2nd ed). Danvers, MA: Slack Incorporated, 2010.  

Rose J, Gamble JG. Human Walking. Philadelphia, PA: Lippincott Williams and Wilkins, 2006.  

Sahrmann S. Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis: Mosby, 2001.  

Subotnick SI. Sportsmedicine of the Lower Extremity (2nd ed). Philadelphia:Churchill Livingstone, 1999.  

Zajac FE, Neptune RR, Kautz SA. Biomechanics and muscle coordination of human walking. Part I: Introduction to concepts, power transfer, dynamics and simulations. Gait Posture 2002; 16: 215-232.  

Links:

Sherry Brourman 

About.com Walking  

The Walking Site  

Walking on Wikipedia  

AARP – The Numerous Benefits of Walking  

Active.com – Walking  

Walk About Magazine

EroFit 

Marathon Walkers 

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Recently, EmpowHer invited me to write a column – here it is!

Pain and problems in the female foot are common—four times greater than for men. One study found that eighty-two percent of U.S. women report having foot pain, seventy-two percent have a foot deformity, and of all foot surgeries in the U.S., women undergo ninety percent of them.

Incredibly, it isn’t just the woman’s foot that leads in pain and problems. Females suffer with more ankle, leg, knee, hip, back, and neck problems. Clearly, when it comes to pain, this is one place women have too much equality!

Don’t despair! You can do simple things to prevent and alleviate pain now. Before I get to that, I want to explain why women are more prone than men to experience muscle-skeletal pain and ailments.

The Feet Are Our Body’s Foundation

Feet are your foundation—whether you are man, woman or child. Strong, well-functioning feet and ankles are essential for support and balance. Working in unison with the body, your feet rapidly adapt to maintain balance over a variety of surface, whether you are running, walking, jogging, carrying a backpack, baby, purse, or all three, or even recovering from a sudden stumble. Feet do it all.

Having incredibly dynamic feet is great until something with them goes wrong. The smallest imbalance in your feet shows up as larger problems up above—in your knees, hips, back, and/or neck. Thus, a misaligned foot leads to a misaligned hip and/or back and/or neck.

Our body depends on agonist-antagonist muscles pulling against each other around our dozens of joints, and any joint imbalance will cause weakness of the muscles on one side of the joint and tension and strain of the muscles on the other side. The result is pain.

Further, these muscle-skeletal misalignments are more likely to occur due to the unique shape of the woman’s “normal” foot.

How is Woman’s Foot Unique?

Compared with males, the female’s foot is generally shorter, narrower, and the length of instep is not as long. The average woman wears a size 8.5 (her foot is approximately twenty-four centimeters or 9.5 inches in length, about an inch shorter than the foot of the average male). The woman’s heel is narrower when compared to the ball of foot, which is wider and has a larger girth relative to the rest of the foot. 

Overall, the woman’s foot is flatter than the male foot. This lower (or more pronated) foot is the root cause of the many of the body’s structural problems.

When feet flatten more than necessary (or over-pronate), the legs compensate by rotating excessively inward. This increased internal rotation creates abnormal stress on the knees causing them to become painful and deteriorate (osteoarthritis). With the knees now strained and out of alignment, a “ripple effect” can occur, causing imbalances, pain and arthritis in the hips, back and neck  Since a woman’s foot is already on the flat-side, she is more predisposed to this painful cascade of events. (For those people whose feet are high arched (or supinated), a similar cascade of joint misalignment occurs leading to pain, imbalance and osteoarthritis.)

To make this chain-of-events even worse, a foot—male or female—that is on the flat side (excessively pronated) is more prone to become even weaker through a vicious downward foot-flattening cycle. Ultimately, this progressive flattening of the foot results in even more foot problems and more muscle-skeletal problems throughout the body.

What You Can Do About Foot, Knee, Hip, Back and Neck Pain

To restore normal alignment to your body, you need to restore balance. The best way to do this is by strengthening agonist and antagonist muscles around your major joints with the goal of improving posture.

This sounds complicated, but there is a very simple way to start: walk barefoot. Shoes act as braces for your feet, altering the alignment of your body and negating the need for many muscles to work at all. Walking barefoot or in minimalist footwear (very flexible shoes such Terra Plana’s Vivo Barefoot), allows your body to “feel” the ground. Do as much walking barefoot as safely possible.

Barefoot activity allows your body’s muscles to develop and remarkably, an innate biofeedback system kicks in that tells your body how to make subtle, unconscious adjustments in the way you walk (your gait). To walk correctly takes a lot of work and study, and is beyond this article, but barefoot walking is a great way to start.

When you must wear shoes, less is more. As mentioned, wear minimalist shoes or very flexible, thin shoes that provide basic protection but still let your feet sense the ground beneath them.

Final Thoughts on Muscle-Skeletal Pain

Now, you can begin to understand the effect of foot misalignment and other joint imbalances on your body. The simplest way to start to strengthen your muscles and rebalance your body is through your feet, and how by losing your shoes, you will be on your way to losing the pain.

If you have any questions or foot, ankle or walking-related topics you would like to learn about, please post in our Forum Section.

References:

Bingefors K, Isacson D. Epidemiology, co-morbidity, and impact on health-related quality of life of self-reported headache and musculoskeletal pain–a gender perspective. Eur J Pain. 2004 Oct;8(5):435-50.

Stubbs D, Krebs E, Bair M, Damush T, Wu J, Sutherland J, Kroenke K.Sex Differences in Pain and Pain-Related Disability among Primary Care Patients with Chronic Musculoskeletal Pain.

Khang YH, Kim HR. Gender differences in self-rated health and mortality association: role of pain-inducing musculoskeletal disorders. J Womens Health (Larchmt). 2010 Jan;19(1):109-16.

Terrier P, Dériaz O, Meichtry A, Luthi F. Prescription footwear for severe injuries of foot and ankle: effect on regularity and symmetry of the gait assessed by trunk accelerometry. Gait Posture. 2009 Nov;30(4):492-6. Epub 2009 Aug 25.

Related Posts

There is a new buzzword in foot care: Orthotics. The science of treating deformities and abnormalities in the musculo-skeletal system – traditionally associated with ungainly corrective footwear – has been given a high-tech makeover.

Now, off-the-shelf or custom-made insoles worn in shoes to correct the gait (walking style) and support weakness in the foot are created using the latest in computer scanning technology. Available from £15 at High Street foot clinics, the great thing about them is no one can tell you’re wearing them.

Experts also say that orthotics could be the answer to curing leg, knee and even lower back pain.

Delicate: Damage in the feet can make itself felt in other parts of the body

Do you need orthotics?

Some estimate that the distance we travel on our feet every ten years is equivalent to the Earth’s circumference. So the 26 bones and 33 joints that make up each foot take a pounding over the course of a lifetime.

And given that between one and two times a person’s entire body weight is

absorbed to as much as three-and-a-half times when running, it is hardly surprising they are susceptible to injury.

‘Feet are fairly delicate structures,’ says consultant podiatrist Simon Costain of the Gait & Posture Centre in Harley Street. ‘Damage may be painless in the foot but felt elsewhere in the body.’

For instance, collapsed foot arches – also known as flat feet – which can be inherited or brought on by weakening of the muscles in the feet through sustained strain caused by wearing high heels, ageing and weight gain, are a common cause for knee pain.

‘The condition can cause the heel to turn outwards at the ankle,’ says Costain. ‘This misalignment can result in painful grinding of the knee. We can track even further up the body, to lower back pain caused by the feet.

‘For example, leg length inequality can cause a tilt in the pelvis – if the legs are functionally different because of a collapsed arch in one of the feet, we can use orthotics.’

Therapy often centres on treating pain caused by walking with high or flattened arches, and problems caused by overpronation or oversupination – the way the foot rolls inwards or outwards through a step to distribute impact throughout the foot.

‘Our feet are like shock absorbers, and the ability to roll inward or outward is essential,’ says Costain.

Difficulties begin when there is too much or too little pronation or supination, or if it happens at the wrong time when walking.

By creating extra support underneath specific parts of the feet – lifting the ankle a few millimetres, for example – insoles, made of foam rubber or carbon fibre, rebalance the action of the foot and correct other mechanics of the gait.

Walk away from your sore feet

Orthotics are frequently used by footballers, rugby players and runners – but their uses go beyond the playing field. They can be used to treat a range of common medical problems, experienced by one in five of the population.

These include metatarsalgia (pain in the ball of the foot, sometimes caused by dropped metatarsals where the bones we use to push off when we walk become misaligned) achilles tendonitis (soreness of the large tendon that connects the back of the ankle to the calves) and plantar fasciitis (a painful condition caused by tearing and inflammation of the tissues around the ligaments that connect the heel to the front of the foot).

Tibialis posterior pain, also known as acquired flat feet, causes pain on the inside of the ankle as a result of the collapse or rupturing of the muscles that hold up the arches.

Costain says: ‘Moving from high heels to flat shoes often provokes this kind of pain but an orthotic can be worn in either or both type of shoe to help alleviate the problem.’

Costain says that about 70 to 80 per cent of patients referred to his clinic by GPs can benefit from orthotics and estimates that they could also help up to 70 per cent of the general population to treat or prevent injuries or improve the efficiency of the gait.

‘Not enough people use them,’ he says. ‘The analogy we use is with racehorses – most have orthoses put on before each race and they would not run without them.’

Screen test: A scan can reveal feet are the cause of many problems

Pinpointing the problem

While gait analysis is increasingly available in sports shops and gyms, Michael O’Neill, from the Society for Chiropodists & Podiatrists, says prospective wearers should undergo a full gait analysis with a trained podiatrist or other medical expert (see below).

‘A full analysis will include watching how someone walks, from their neck and shoulder to arm swing, knee function and leg swing, rather than just the foot,’ says O’Neill. ‘From there, we make a temporary device and subsequently make improvements once we know we are on the right track.

‘We can use orthotics to control problems, improve the way the foot works and change its mechanics.’

Custom-made orthoses are created by taking plaster casts of the foot, but specialist clinics increasingly use cameras and lasers to map a three-dimensional image.

Ready-made insoles can also be bought. However, Jimmy Walsh, of fitness chain Runners Need, says: ‘Off-the-shelf insoles can help sportsmen and women who have already been diagnosed with overpronation or supination, but prescribing orthotics really requires a trained medical professional.

‘There are some trainers that help remedy these problems and some off-the-shelf insoles such as Sorbothane, Sofsole and Spenco have an orthotic function and will take more impact out of the foot when running, but they won’t correct the gait.’

So, what’s the next step?

Your GP can refer you to NHS podiatry services, however simple orthotic insoles are available from chiropodists, with more specialised appliances costing from £75 to several hundred pounds from clinics.

‘I’d never say orthotics are the magic bullet,’ says Costain, ‘but very often they prove to be extremely helpful in a range of ways.’

And O’Neill argues that orthotic therapy will work only as part of a wider package.

‘A person’s mobility, stretching regime and muscle balance are all as important. Orthotics on their own won’t work.’

Scan that reveals secrets of the sole

During gait analysis, a practitioner – usually a podiatrist, osteopath or chiropractor – takes a detailed medical history, including any specific complaints such as pain in the foot or elsewhere in the body. This is followed by a physical examination of the foot to check for any abnormalities.

‘The GaitScan pad has thousands of pressure sensors linked to a computer which shows on a screen the distribution of pressure across the feet,’ says Dr Roger Reid, a chiropractor at London’s Body 4 Life Healthcare.

‘Red shows most pressure, and blue the least. Pressure should be evenly distributed across the sole. The patient first stands still on the pad, where an uneven distribution of pressure could indicate a musculo-skeletal problem such as different leg lengths or misaligned hips.

‘After this, the patient walks across the pad a number of times. Problems with pronation – the rotation of the foot – would show up as uneven pressure during this part of the scan.’

If needed, the scans, above, can be used alongside a mould of the foot which is sent to a specialist orthotic manufacturer that uses CadCam technology.

‘This uses cameras and lasers to scan the surface of the mould and is the most accurate way of capturing the anatomy of the foot,’ says Pat McGonigle, of Pegasus Orthoses, who create orthotics for Chelsea Football Club and the Royal Family.

‘This is then used together with patient-specific information about sex, age, weight, height and medical problems, to create a 3-D computer model of an orthosis, which can then be manufactured.’

Running insoles cured my painful shins

Relief: Katharine Vile wears orthotics for high arches

Literary agent Katharine Vile began using orthoses after experiencing severe shin pain.

‘I was suffering from soreness in the lower leg, and found I was in pain just standing up and walking. It was even stopping me wearing my favourite heels. I enjoy running but it got so bad in February this year that I had to stop exercising. Friends suggested I look at orthotics,’ says the 38-year-old.

Katharine visited a physiotherapist who discovered that she had high arches, a common inherited condition in which the arch of the foot is higher than average, often requiring supporting insoles.

‘High arches often mean the feet are very poor shock absorbers and they can lead to pain in the knee, lower back and the arches themselves,’ says Simon Costain.

The orthosis is built up under the arch of the foot to help take the weight of each step as it is distributed through the foot. Treatment was simple – the physiotherapist prescribed orthoses to use in her running shoes. They cost about £70.

Katharine says she noticed an improvement almost immediately.

‘Within a couple of days I could feel the difference. Now, when I’m standing, my feet are flat rather than falling in on themselves,’ she says.

She was able to return to running and has found that she no longer suffers leg pain when wearing her everyday shoes.

‘The physio suggested I should wear them in my other shoes.

‘I like wearing high heels and I know it would help, but just wearing them in my running shoes has helped and the pain has gone, so I think I can get away with it.

Dr. Nirenberg’s Comment:

This is an excellent article. Numerous scientific studies have shown poor foot structure can cause not only back pain and problems, but also ankle, leg, knee and hip pain. In patients where these problems are related to weak, unstable, or flat feet, I have had good success alleviating their pain with custom made arch supports (orthotics).

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