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When first starting to practice I felt I had a great deal of tools to use to help my patients. However, I feel very fortunate to have continued to pursue knowledge and skills to better serve my patients. One of the areas that I have gravitated towards expanding my knowledge is foot and ankle conditions, along with a variety of treatment options for those conditions. Much of the focus while in school was how to treat the condition, with little attention on prevention. About five years ago and was introduced to Dr. Ray McClanahan, a sports medicine podiatrist with a focus on natural foot health.
Ray has been a great resource for my patients and has exposed me to concepts and ideas on how to treat foot and ankle conditions that I had not been exposed in my formal training. Ray exposed me to the importance of allowing the foot to function the way it was designed and how it functioned as a young child, which helped change my thoughts on how to manage foot and ankle conditions. My background with these came from spending my breaks in college working at a specialty running store in which we would try to correct over-pronation related conditions, such as plantar fasciosis, shin splints, runners’ knee, ITB syndrome, hip tendonopathy and others with a stability shoe or orthotics. I had been a strong believer in that concept until I was made aware of the ability to correct those problems with another approach. It is very evident that our feet are designed to function; there are 26 bones with 33 joints and over 100 muscles, ligaments and tendons.
The approach that I now take to the management of foot and ankle conditions involves the following. First, identify the insults that are occurring -- footwear, exercise demand -- and checking the kinetic chain in the lower extremity. Second, identify the injured structures and provide a catalyst to helping those structures heal. Third, retrain the foot and lower extremity to function properly with rehabilitation exercises to reduce the likelihood of recurrence.
The first step of the management is to identify insults, one of which is footwear, which in my practice accounts for the majority of the conditions I see. There are three major faults in most of the footwear on our feet today, tapper in the toe box, elevated heel with toe spring, and lack of flexibility in the shoe. The best way to illustrate the need for a wider toe boxes in our shoes it to look at infants’ feet when they are born. The widest part of a newborn’s foot is between the first and fifth toe, so when looking for a shoe the toe box should be shaped to have the widest point between the first and fifth toe. To account for the elevated heel and toe spring, shoes should have the heel and the forefoot parallel to the ground. Toe spring can be evaluated by placing the shoe on a stable surface and while anchoring the heel to the surface and applying pressure to the toe. If the toe of the shoe does not flex enough to touch the surface the toe spring is problematic (see pictures).
We need to have the big toe anchored to the ground for “rooting” of the foot to occur (editors note). Shoes that are rigid in structure function like a brace and don't require the foot to function as it is designed. A commonly accepted principle in the field of physical medicine is the SAID principle, which is specific adaptation to imposed demand; if the foot does not have the demand to function properly, it will not. However, with the correct imposed demand it will adapt. Once we have corrected the footwear component, we can move on to the demands being placed on the foot, check the kinetic chain in the lower extremity, and identify the injured structures and provide treatment for these. These can be addressed with a good history and physical exam performed by a trained physical medicine provider. The last part of the management of these conditions focuses on retraining the foot, ankle and lower extremity to function as a whole.
I have incorporated ideas, exercises and philosophy from many different providers and seminars that I have attended over the past several years to help provide my patients with a complete approach to this area. Obviously, I can’t provide all of the information I have learned, but I feel it would be appropriate to share the sources to allow for further exploration. Dr. Ray McClanahan has a wealth of resources about natural foot function on his website Correct Toes. Another resource I have used is the Evidence Based Fitness Academy Youtube channel of Dr. Emily Splichal, a podiatrist in New York City. Dr. Perry Nickelston, a chiropractor, has a website and Facebook page Stop Chasing Pain that focuses looking for areas in the body that are dysfunctional to help treat the area of pain.
Patient centered treatment should focus on a variety of treatment modalities and approaches; I hope to have exposed you to another way of thinking about the foot and ankle. Shoe_Selection_Guide
Dr. Adam Mohr DC, DACBSP®
Dr. Mohr owns and operates Acceleration Sports Medicine in Tigard, Oregon and is a Diplomate of the American Chiropractic Board of Sports Physicians.
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