The Practitioner's Corner
Essays By and About Practitioners

THE DE-EVOLUTION OF FOOTWEAR

By John Marchese Jr., DC. CCSP. CSCS, RKS and Kristin McCormick, Strength and Conditioning Coach

Over the past decade the trend of both athletic and non-athletic footwear has turned towards the micro-management of foot mechanics.  These pseudo-orthotics have been created for the purpose of specific motion control, and designed by numerous companies for the general public.  The question to be raised regarding these pseudo-orthotics is, do they create more problems than they were designed to relinquish? Also, do they prevent and manage lower extremity ailments, or create more havoc throughout the entire kinetic chain than originally thought?

Instead of addressing the entire collection of motion control footwear, let’s specifically investigate pronation control footwear. Normal pronation, or "turning inward" of the foot is necessary as the foot adapts to the ground. However, pronation control footwear is currently being prescribed for everything from foot pain to headaches.  Footwear prescriptions are being given out by a vast myriad of professionals and paraprofessionals, ranging from orthopedic physicians and podiatrists to shoe and sneaker salespersons.  Oftentimes the prescription or sale is made following nothing more than watching the subject walk on either a "real life" surface (the ground or floor), or on a false surface like a treadmill.  The patient or customer’s gait is observed and then a recommendation is made.  If a flattened arch is noted during the time between initial heel contact to the toe off, then an assumption of pes planus (flat foot) is made and control of excessive pronation is made a priority  and  footwear or orthotics are prescribed.

How fierce is this enemy, known as pronation, that so many have dedicated their careers to eliminating it?  Put simply, it is the control mechanism by which the body attenuates the collapsing forces from above, and the ground reaction forces from below.  Sounds pretty important doesn't it?  Pronation works with the earth’s gravity, creating eccentric stability for the purpose of shock absorption, and the storage of the resultant elastic energy within the involved soft tissues.  The two gross movements which occur in the foot and ankle during pronation are rear foot eversion, occurring within the frontal plane in the subtalar joint, and forefoot inversion, occurring within the frontal plane in the metatarsal joints.  Additional movement in the subtalar joint in the transverse plane of motion includes abduction.  Additional movements in the metatarsal joints include dorsiflexion in the sagittal plane and abduction in the transverse plane.

Taking the above information into consideration, would it seem logical to block the movement system of pronation?  If the basic premise of treating pain at the foot, knee, hip, etc. using pronation control with footwear and orthotics is prudent then there must be a component of pronation at other joints besides the foot and ankle throughout the kinetic chain. 

Specifically, the following movements occur above the foot and ankle during the act of pronation;

      1. Internal rotation of the tibia with respect to the talus

      2. Knee flexion with genu valgus

      3. Internal rotation of the femur with respect to the ilia

      4. Flexion at the hip

      5. Anterior iliac rocking

      6. Posterior sacral base translation

      7. Lumbar flexion

      8. Thoracic extension

      9. Cervical flexion

    10. Scapular protraction

    11. Internal rotation of the humerus

At this point, let's hypothesize together.  As health care professionals and paraprofessionals we can effectively change the mechanics of the whole kinetic chain, from foot to fingers by blocking pronation.  But is change good?  Let’s visit the hypothetical rantings of a lunatic mind.  Who is smarter (pronounced sma-ta')... the healthcare professionals and paraprofessionals or the human neuromusculoskeletal system?  For those of you who guessed the former, I humbly suggest that it’s time for you to get out of healthcare and start a new career.  For those of you who guessed the latter, let's look into a possible mechanism by which large scale compensations may occur.

The process begins with a trauma mechanism.  This trauma can be either repetitive or singular in nature.  This trauma could take the form of an inversion ankle sprain, turf toe, or even a hang nail which may alter the gait to achieve avoidance of pain; the key being the avoidance of pain.  The human body will avoid pain at all costs.  Just as we pull our hand away from the hot burner to save the hand from being burned, we will avoid the range of motion with a joint or joint system that causes the greatest degree of noxious stimulation or pain. 

With the inversion sprain mechanism, for example, inversion at the rear foot during supination will no longer be possible because of the avoidance behavior.  If there is no supination occurring at the foot due to this protective mechanism, what are the treatment options available?  Well, if no supination is occurring at the foot, then the movement has to be "made up for" at other joints in the body.  Initial increase in supination at the knee will occur followed by the inevitable decreased supination there due to muscle splinting decreasing the excessive joint motion, and increased supination at the next joint system...the hip, and so on and so on until the body can no longer compensate on the same side.  Then it begins to pick on the contralateral side, (a subject for another essay).

So where does that lead us with treatment options?  With the lack of supination occurring at the foot due to the avoidance behavior of the oh-so-smart central nervous system controlling the neuromusculoskeletal system, the foot will assume a predominantly pronated appearance.  The typical observer would label that foot an excessive pronator.  The typical treatment would be to limit the pronation available to the foot using either pronation control footwear, or orthotics.  Let's think about this.  The foot is already trying to avoid going into the movement pattern of rearfoot inversion right?  Then why would we want to push the foot into further supination by blocking pronation?  We would subsequently cause the further pronation at the joint systems above the foot!

In this case, the first thing to occur would be excessive pronation at the knee, followed by limited pronation at the knee, and excessive pronation at the hip, etc., etc., etc.   In short, instability into both pronation and supination, at multiple joint systems occurs.  Limiting pronation, therefore, is not a good treatment choice. 

So what do we do?  The answer is nothing new.  In 1951 the importance of muscular stability was brought up by a famous hockey guru named Lloyd Percival in his book The Hockey Handbook.  In the section on training he specifically targets the feet, ankles, and lower legs stating that they should be "strong and flexible because they have to do the majority of the work".   Never was there a truer statement in athletics or everyday life.  He further outlines the specific exercises for players to do in order to achieve muscular stability.  These principles and procedures have not wavered in their importance for athletes as well as the non-athletic population.  They are in fact essential for the proper function of the entire kinetic chain as we have outlined in the first parts of this article. 

The re-instatement of proper range of motion, with stability, is the key to prudent rehabilitation of the foot, ankle and subsequently the entire kinetic chain; not the blocking of essential movement patterns resulting in further instability and inevitable disability.  The techniques and procedures that the skilled rehabilitative personnel use to go about achieving this goal are very individualized and will not be visited in this article.  The key point to take away from this article for health care professionals: DO NOT BE LAZY!  Fix the cause of the patient’s dysfunction and the future compensatory disability will be avoided and prevented. 

In conclusion, I urge all health care personnel to think outside the proverbial box when caring for these types of injuries.  By doing so you will not only save your patients from a future full of pain and disability, you will also set yourself apart from other health care practitioners as a truly caring and effective health care practitioner instead of a sick care management technician.     

John Marchese Jr., DC, CCSP, CSCS, RKC is a graduate of the University of Rhode Island and Palmer College of Chiropractic.  His practice incorporates multiple techniques, including Muscle Activation, Active Release, ChiroMAT, Janda muscle length assessment, chiropractic adjusting and therapeutic exercise.  He can be reached at Marchese Sports Therapy in Melrose and Winchester at 781-665-9800, or at ProSport Orthopedics in Waltham at 781-487-9444.

Kristin McCormick, Strength and Conditioning Coach is a former strength and conditioning coach for the Boston Breakers Soccer team and has coached many professional and Olympic athletes. A graduate of the University of Maine in Kinesiology, she can be contacted at Mike Boyle’s Strength and Conditioning, 781-729-1333.