ARTICLE: Pronation – How a Simple Biomechanical Dysfunction Accelerates the Aging Process: The Most Effective Diagnosis, Treatment, and Prevention

Pronation – How a Simple Biomechanical Dysfunction Accelerates the Aging Process: 
The Most Effective Diagnosis, Treatment, and Prevention

By Dr James Stoxen, DC.

ABSTRACT:

Because the feet are the very foundation from which all other joints align, it is easy to understand why even subtle faulty biomechanics of the lower extremities – principally, I maintain, excessive pronation of the feet – can cause a domino effect of stresses and strains on every joint of the body, literally from toe to head. This in turn will predispose a patient to an acceleration of the aging process that can include advanced arthritis, and can affect myriad muscles, tendons, ligaments and joints. What this means is that treatment of a great number of musculoskeletal problems is simply not complete unless the practitioner has considered faulty biomechanics of the feet, ankles and lower leg as the root cause. In many cases where medicine is prescribed to cover pain, the practitioner has not looked at lower-extremity biomechanics.

Keywords: Foot Pronation – Windlass Effect – Biomechanics – Excessive Pronation Syndrome

Foot Pronation – How a Simple Biomechanical Dysfunction Accelerates the Aging Process: 
The Most Effective Diagnosis, Treatment, and Prevention

INTRODUCTION

Because the feet are the very foundation from which all other joints align, it is easy to understand why even subtle faulty biomechanics of the lower extremities – principally, I maintain, excessive pronation of the feet (Figure 1) – can cause a domino effect of stresses and strains on every joint of the body, literally from toe to head. This in turn will predispose a patient to an acceleration of the aging process that can include advanced arthritis, and can affect myriad muscles, tendons, ligaments and joints. Also not fully realized or understood by many health practitioners is that overall health can be seriously affected by this condition via reduced circulation in the lower extremities, reduced venous return to the heart, and chronic fatigue.

What this means is that treatment of a great number of musculoskeletal problems is simply not complete unless the practitioner has considered faulty biomechanics of the feet, ankles and lower leg as the root cause. In many cases where medicine is prescribed to cover pain, the practitioner has not looked at lower-extremity biomechanics. We at Team Doctors Treatment Centers have come to this conclusion after treating thousands of patients in the manner I will describe below. We believe our treatment method is more complete and inclusive than any you are likely to have seen, reflecting the extremely wide effects of faulty lower-extremity biomechanics on the whole body.

Figure 1. Simple Foot Pronation

An Important Example
Let me suggest just one example at the outset. Low-back pain is quite common in our patients, but we have found that low-back pain almost never stems from a problem originating in the lower back itself. We estimate that 90% of lower-back-pain cases have a related pronation syndrome that was left uncorrected. We have found that the foot, pronation to be exact, has more to do with the onset of lower-back pain than the lower back itself. In our practice when we see any of the following symptoms accompanied by a lack of trauma to explain the cause, we immediately look for excessive pronation syndrome:

• Feet or Ankle: foot or ankle pain, plantar fasciitis, and heel spur.
• Knee: cracking knees, chondromalacia patella.
• Hips: hip pain.
• Lower Back: lower back pain related to a lifting injury or not related to a lifting injury, disc syndrome, facet syndrome, and sciatica.
• Mid Back Pain.
• Upper Back Pain.
• Chronic Fatigue.
• Varicose Veins or other Circulatory conditions.

Lower Back Pain and Lower Back Surgery 
Clinically, we see numerous patients who have been recommended to have lower-back surgery. After evaluation reveals that the patient has faulty biomechanics of the lower extremities that is causing irritation and pressure on the discs and other joints of the lower back, we begin the correction of these faulty biomechanics. Typically, we see a 60% to 100% reduction in pain, and a significant increase in function of the patient within a period of three weeks of aggressive care, which we consider as six days treatment a week. Practitioners should note that we have an excellent record of success with patients – in other words, the avoidance of surgery.

Overall, it’s hard to rationalize how mechanical lower back syndromes can exist without a pre-existing mechanical dysfunction lower down in the musculoskeletal system. Given the closed kinematic chain, it is almost impossible to have a mechanical dysfunction in the lower back without some prior or subsequent ramification of the lower extremities. It is a “chicken-and-egg” proposition to some degree, but the practitioner must try to solve it, for the sake of the back and, naturally, to prevent premature aging in the patient.

Fatigue and Depression 
The arthritic effect of excessive pronation isn’t the only aging effect noted in patients with the condition. Since the muscles are stressed and strained to resist the collapse of the kinematic chain, a chronic fatigue sets in from the constant resistance of the postural muscles. Also, since multiple joints are strained and irritated, tonic protective reflexes are activated, further fatiguing the patient. Many patients visit our office complaining of chronic fatigue have tried numerous practitioners and nutritionists with poor results, only to find that they have excessive pronation syndrome and myriad muscle spasms, stresses, and strains. When you reverse the pronation and the stresses and strains are lifted, the patient notes a surge of energy within a few weeks of care, and an increase of approximately 3 to 4 additional hours a day of productive time.

Circulatory and Heart Conditions 
Proper and regular contraction of the muscles of the calf can improve venous return to the heart. Because excessive pronation of the foot causes spastic activity of the muscles of the calf, venous return is compromised. The reduced venous return puts stress on the heart. These muscle spasms and tonic protective reflex spasms are active 24 hours a day even when the patient is asleep, sapping energy, and interfering with the normal recovery process necessary after a productive day. This can contribute to tiredness upon waking, throughout the day, and especially when returning home from work. The patient confuses the fatigue this to the difficulty of the job when it is due to physical factors and oftentimes feels they are just getting “old”. Many of these patients turn to stimulants, which put them at further risk for cardiovascular complications and potential irreversible damage with use.

Depression 
The patient can feel run down day after day, and unable to see any light at the end of the tunnel if this syndrome isn’t discovered soon. All of this pain, inactivity, and chronic fatigue can predispose the patient to depression, leaving the patient feeling that same feeling that they are just getting old.

This quick summary is enough to suggest that when the vital activity of walking is compromised by pronation in one or both feet, aging in many forms – physical and mental – is likely to occur. I intend to show here that any medical practitioner who is committed to preventing aging in his or her patients must be aware of pronation, understand it, and know how it can be treated.

WHEN TO SUSPECT PRONATION 
For the practitioner, when a patient presents with any of the following symptoms, pronation should be suspected:

• Foot and ankle: pain, especially under the big toe and successive toes, lessening with each successive toe; plantar fascitis; a history of heel spurs, and even complete tear of the Achilles tendon.
• Calf and knee: pain (especially after sitting for long periods); crepitus (especially when walking upstairs); peripatellar pain; calf cramps; poor circulation in the calves; cold feet.
• Hip and thigh: aching and/or tired legs; leg cramps; illiotibial band pain; crepitus in the hip; a history of hip arthritis and pain.
• Lower back: insidious pain, disc injury or pain from a lifting injury.
• Systemic: chronic fatigue accompanied by a negative laboratory work-up and other negative tests for pathology.

Objective findings, from orthopedic tests and radiographic investigation, can be one or more of the following:

• Foot and calf: tenderness on deep palpitation of the plantar media aspect of the foot; tenderness on deep palpitation of the lateral aspect of the calf; heel spur seen on radiographs.
• Knee: the presence of Clarks crepitus on extension of the knee; the presence of Waldron’s; knee instability, peri-patellar pain syndrome (patellofemoral arthralgia); chondromalacia patella.
• Hip and thigh: weak and painful biceps femoris on deep palpitation; weak and painful tensor fascia latae on deep palpitation; a positive Modified Obers Test; positive Nobles Test.
• Hip musculature: weak and painful gluteus maximus upon deep palpitation; weak and painful gluteus minimus or gluteus medius, weak and painful piriformis, and difficulty with internal rotation of the hips; tensor fascia latae and/or illiotibial band syndrome, piriformis syndrome, and hip arthritis. We also see difficulty in internal rotation of the hip.
• Trendellenburg test: the patient may display poor balance; he or she may also display difficulty getting up from a seated position. A positive result in the Patrick Fabres test is also possible indicator of the pathology of over-pronation.
• Lower back: there may be positive results in Hibs and Elys tests, chronic idiopathic paraspinal muscle spasms, bilateral or unilateral flexion fixation or subluxation and/or herniated disc(s). Anteriorly tilted pelvis, unilaterally or bilaterally, will also be present.

A MORE DETAILED LOOK AT PRONATION

Part I

The literature states that rear foot varus deformity is greater than 4 degrees in more than 98% of individuals measured. To compensate, the subtalar joint must pronate excessively to bring the medial condyle of the calcaneus to the ground. This takes place primarily during the period of the foot’s contact with the ground, and research has shown that the angular velocity of the pronation can lead to a range of injuries up the kinematic chain. For instance, the tibia can be forced to rotate internally by 20 degrees in less than a tenth of a second. The work done by the muscles and tendons of the foot to dampen this torque, thousands of times a day, can lead to pain (via tonic protective spasm), and tissue abnormalities in the foot, such as heel spurs and plantar fasciitis. As the lower leg compensates for these problems, shin splints and tibial stress fractures are possible, according to the literature. In our practice, we have found that other maladies, involving the knees, hips, and back, stem from pronation, and these will be covered in this article.

First, however, some examples, we find that almost all non-traumatic lower-back patients have some degree of faulty mechanics in the foot. Apart from trauma, how could the lower back “trick,” unless from a concomitant chain of bad biomechanics? Traumatic back injuries can also stem from faulty biomechanics emanating from the foot, especially in lifting or twisting injuries, where the body’s proprioceptors have been deluded by the sub-optimal functioning of the foot.

The literature states that rear foot varus deformity, which stems from failure of the tibia and/or calcaneus to straighten during infancy, is the prime cause of simple foot pronation. However, this is abetted by shoes with weak heal counters – the stiff component of a shoe that wraps around the heal – especially when combined with improper lacing of shoes or no lacing at all. As our shoes have become more soft and comfortable, often with poor heel counters or no heel counters at all (such as “flip-flops”), the problem is even more likely to occur. When a patient comes to my office in particularly bad shoes, I can almost predict the patient has this syndrome.

We disagree with some practitioners who recommend flexible counters for individuals who have no apparent pronation problems. As most people do pronate somewhat, there’s a chance pronation can become excessive in anyone. A strong counter component can prevent the initial weakening and detrimental compensation characteristic of excessive pronation. If a patient has a stiff heel counter, the risk of excessive pronation and excessive supination will be reduced. What is the downside to stiff heal counters? We see none.

Part II 
Some pronation is natural, and necessary for the proper functioning of a human foot. This takes place around two mid-tarsal joint axes, the oblique mid-tarsal joint axis, which enables dorsiflexion and plantarflexion, and the longitudinal mid-tarsal joint axis, which enables pure inversion and eversion. Metatarsal pronation is limited when the cuboids bone in its forward movement comes into contact with the calcaneus’s bone, as long as the calcaneus is not in a valgus position. If the calcaneus is in a valgus position, the entire complex will collapse in overpronation.

Also key to keeping the calcaneous in the neutral position are several restraining ligaments of the foot, the long and short plantar ligaments, the calcaneonavicular ligament and the bifurcate ligament. If these ligaments are chronically stressed or damaged, possibly through inadequate footwear support, they will not assist in limiting pronation. We manipulate the bones of the foot and work on the intrinsic muscles of the foot to increase the natural strength of the arch. When the arch collapses these ligaments stretch and elicit pain. The bones that make up the arch will lock in the collapsed position and there is a limitation to plantar flexion. The joints which have fixated due to the collapse must be manipulated to bring mobility back to the area for proper biomechanics to be reestablished and the muscles that dorsiflex must be stretched with static or PNF stretching to allow for additional plantar flexion of the foot area.

Naturally assisting to prevent pronation are several “pronation/supinator cuff” muscles. Similar to the premise of treatment of the rotator cuff musculature of the shoulder, we find that treatment of tonic protective spastic activity in Phase I of the treatment, and active strengthening of these muscles in Phases II through IV is key.

It will be helpful to summarize the components of the pronator/supinator cuff muscles of the foot and their functions (Figures 2-4). In general, these can act to prevent excessive pronation and supination of the foot, analogous to the rotator cuff muscles of the shoulder. They reach down from the calf area, looping around the arch of the foot. They act as a supportive system for the arch. Comprising the pronator/supinator cuff are:

• The flexor hallucis longus, which is a strong plantar flexor of the ankle joint and a weak subtalar joint supinator (Figure 2).
• The peroneus longus, which is a strong plantar flexor of the first ray and a pronator of the forefoot around the longitudinal midtarsal joint axis.
• The flexor digitorum longus, which is a strong ankle joint plantar flexor, a moderate subtalar joint supinator, and a very strong supinator of the forefoot around the midtarsal joint (Figure 3).
• The extensor digitorum longus, which is a strong plantar flexor of the ankle joint and a moderate pronator of the forefoot.
• The tibialis anterior, which does not affect the midtarsal joint axis, a moderately strong supinator of the forefoot and a slightly weaker supinator of the subtalar joint.
• The tibialis posterior, which acts to plantarflex the ankle and invert the foot. Thus, it maintains the medial longitudinal arch and controls pronation eccentrically (Figure 4).

Figure 4. Pronator/Supinator Cuff Muscles – Tibialis Posterior

It may also be helpful to summarize the muscular anatomy of the hip and lower back:

• Muscles to consider are the gluteus maximus, medius, minimus, and piriformis, which are external rotators of the legs and adductors.
• Muscles to review in the lumbar and pelvic area are the iliopsoas, extensors, and abdominal muscles, which are important in this syndrome.

EXCESSIVE PRONATION

Prime Cause

It is our clinical opinion that the main cause of excessive pronation is weak muscles which support the arch, fixation in the arch and wearing poorly constructed footwear, improperly laced shoes or not lacing the shoes at all. When our patients present with chronic conditions related to excessive pronation of the foot or feet, we find that they have one thing in common. They wear shoes that have weak counters. Counters are the sides of the shoe that surround the calcaneous or heel. We find that a majority of these maladies can be prevented if patients select a strong-sided shoe that has motion-control properties. The restriction of heel motion with a shoe with a strong heal counter can control excessive pronation and the concomitant collapse of the arch and the subsequent domino effect up the lower extremities and into the lower back.

Prevention

The first step in the correction of the improper biomechanics of the lower extremities related to excessive pronation is to support the heel in order to inhibit the excessive pronation, and then “clean up” all the muscular tension and mechanical joint fixations resulting from the abnormal stresses and strains caused by the previous improper biomechanics. After that, we strengthen the weakened areas to “lock in” the positive changes made.

When we are trying to prevent excessive pronation, we stress the importance of these factors:

• Footwear that is tight-fitting on the heel from the sides.
• Footwear made of a strong material, preferably leather, two or three layers thick.
• Footwear that has material that is fairly resistant to moisture.
• Footwear with laces.

Pick shoes as you would fruit: squeeze the heel counter with your palm and fingers and pick a pair that gives only slightly. Relatively, more leather and less padding is best in all shoes, for athletics or work. Further, the shoes should be laced to effect more support, by looping the laces below and out through the outlets, not over and into them.

We have experimented with arch support devices, and have found that patient compliance is poor with arch support devices that are inserted into the footwear. Patients do not like to continually transfer the support devices into each pair of shoes. The other problem with these devices is that they “hike up” the arch, which can “jam” the instep into the shoe, causing a jamming of the already rigid and poorly moving bones of the arch into the shoe causing pain and further compliance problems. Furthermore, these devices are easily undermined by flimsy, unsatisfactory footwear, which will encourage continued pronation and work against the device. We never use arch supports in our office; we get excellent, repeatable results with the treatment outlined below.

Correction

Correction of pronation – and prevention, for that matter – involves increasing the opposite movement, supination, by the increased strength of the intrinsic muscles of the foot and the supinators that originate in the calf and control movement in the foot. This is achieved through neuromuscular re-education (NMR), which reduces the tonic protective reflexes in these muscles via the use of electrical muscle stimulation, vibrational massage, and ischemic compression. Further strengthening in Phase II III and IV utilize a properly designed rehabilitative and training program with the use of proper footwear and lacing techniques being the key to maintaining the arch stable while this retraining is taking place. We do not recommend the use of orthotic inserts, as these do not promote strengthening of the intrinsic foot muscles, they merely prevent the undesirable movement while offering no remediation of the underlying problem, or, usually, the associated problems throughout the kinematic chain.

Another way to look at the problem of pronation is from the point of view of proprioception, the mind and body’s way of gauging its place in space. Ideally, the body’s proprioceptors detect abnormal musculoskeletal function and faulty mechanics and set off corrective measures. Serious pronation can vex the proprioceptors, and the area can go into protective spasm – for life. Orthotic arch supports will not correct the abnormal reflexes already developed nor will they relieve tonic protective reflexes, or correct fixations of already collapsed joints with fixations in the joints. Instead, as you stand or walk, you remain in the tonic protective state, which uses energy and drains strength from the rest of the musculoskeletal system.

Calf Training – Calf training is also considered. This demands that the area is trained in flexion and extension, but primarily in internal rotation, external rotation, abduction and adduction along the metatarsal joint axis. In Phase I, this can be aided by passive treatment, deep tissue work (Figure 5) or EMS on the flexor hallucis longus, flexor digitorum longus and tibialis posterior. Only in Phases II through IV is active strength training recommended.

Stretching – Stretching of the extensor hallucis longus, extensor longus and brevis, and tibialis anterior is also effective in treating calf weakness and pain. During the push-off phase of gait, pronation is reduced when the peroneus longus is strengthened to insure that toe-off will occur with a stable first, second and third digit. Providing a concomitant strong peroneus lungus and brevis to stabilize the first and second digit is essential. This stretching is vital, as joint motion often is lost during a prolonged state of pronation and must be regained through manipulation of the joints of the foot.

Windlass Effect – Another recommendation is teaching patients the “Windlass Effect” (Figure 6). Excessive pronation is reduced through this technique. When the toes dorsiflex, the heel lift draws the plantar fascia around the metatarsal heads, which acts to pull the pillars of the longitudinal arch together, thus decreasing the forefoot/rearfoot distance and strengthening the arch. This only happens when the patient steps off with reasonable toe-off force and educating the patient to push the body forward at toe off to exercise these muscles so they can assist in supporting the arch.

Increase Stride Length – Still another recommendation is to increase stride length to reduce tibial torsion. The subtalar joint acts as a directional torque transmitter, converting frontal plane motion of the calcaneus into axial rotation, torque or torsion of the tibia/fibula. This can cause considerable internal rotational stresses on the tibia, femur, and thus, on the hip and lower back. In its swing phase, when the patient swings the striding leg a reasonably long distance, the other side experiences a reduced torsion.

Strength Training – Strength training is also a good way to reduce tibial torsion. Knee extension exercises strengthen the quadriceps group and help pull the patella into correct alignment. Remember the patella must be in correct alignment before the extensions can begin. The TFL must be free of tonic protective reflex spasms before initiating the leg extensions. Knee flexion exercises (hamstring curls) strengthens the biceps femoris and helps pull the shank into proper alignment. Hamstring curls will be the exercise of choice with the leg in a neutral position. Finally, hip abduction will strengthen the gluteus medius. When the gluteus medius is stronger the body will have more balance. In addition, when this muscle is stronger more of the weight transferred from the weak gluteal area onto the lower back will be retransferred back off the overloaded lumbar area back to the hips to allow more equal distribution of loads, and reduced stress on the lumbar spine.

A MORE DETAILED OVERVIEW OF TREATMENT

We have covered the basic causes and results of simple foot pronation, but a more detailed overview of the treatment used in each phase on the pronator-supinator cuff is called for here.

Phase I
In Phase I, the goals are reduced inflammation and tonic protective spasms, pain relief, and joint mobility. Therapy (ultrasound and anti-inflammatory’s) can be prescribed to reduce joint swelling. Joint fixation is reduced through manipulation of the articular structures. Motion-control shoes, with strong heel and lateral counter elements, are recommended over orthotics that inhibit the foot’s range of motion and do not foster strengthening. Reduction of the chronic tonic reflex reduction through neuromuscular re-education (NMR) of ischemic compression to the spastic area takes place at this phase. Treatment frequency is daily care for two to three weeks depending on the severity of the condition and any complicating factors. We look for a 10% diminution in spastic activity and pain per visit, and notice that by the sixth or seventh visit, there is an energy surge in the patient that allows for two to three more hours of energetic “up time” in the day. Their desire to exercise will shoot up at this point, which engenders a positive cycle for rehabilitation.

Phase II 
In Phase II, the goals are flexibility, joint alignment, joint strengthening, and overall coordination. Again, fixation is reduced through manipulation of the articular structures. All tonic protective spastic activity along the kinematic chain must be reduced from superficial to deep before phase II can begin. Attention to the calf is introduced into this phase of training. Flexibility training techniques (PNF) Proprioceptive Neurologic Facilitation are used, and light strength training. There is a concentration on joint alignment, form and technique. Treatment frequency is three days a week for three or four weeks or more.

Phase III
Phase III’s goals are the same as Phase II, and involve manipulation of the articular structures, flexibility training (PNF), heavier and faster strength training, and concentration on joint alignment, form and technique, and speed and strength. Treatment frequency is three days a week for three to four weeks.

Phase IV
In Phase IV, the goals are heavier and faster strength training. There is a concentration on joint alignment, form and technique, and speed and strength. For competitive athletes, sports performance training is indicated at this point, although fitness training is indicated for all patients, as it is essential for the purpose of reducing premature aging of the patient.

We feel very strongly about considering biomechanical dysfunction of the lower extremities for every lower back patient. If one prescribes a chemical remedy without having looked for biomechanical dysfunction, at this time we consider this negligence on the part of the practitioner. If the practitioner cannot, does not posses the skills, or have the time to normalize these biomechanics, he or she should refer the patient to a practitioner who does possess these skills. In summary, providing a chemical remedy for a condition caused by faulty biomechanics without addressing the faulty biomechanics is a poorly thought out treatment option. The physician should at least instruct and insist that the patient consider footwear with motion-control properties.

FOOTWEAR SELECTION COMPLIANCE

Compliance with respect to the purchase of footwear is essential. We ask that the patient purchase footwear that is going to support the heel, and we have examples of this type of footwear in our office, for men and women. We wear the same footwear as we consult with the patient. We explain that we are on our feet all day and can’t afford to have the collapse of the arch and the subsequent aches pains and mechanical dysfunctions associated with it, including fatigue. Physicians who wish to get great compliance must lead by example.

We ask the patient to buy proper shoes within the first three visits, as we consider it a medical necessity. We aim to have all biomechanical stresses removed through a carefully planned procedure and treatment plan within ten office visits plus or minus three visits for variants in compliance and other factors. If the patients prolong the purchase of the footwear beyond ten visits, the patient is released as noncompliant. A rule of thumb is the first day that the proper footwear is worn add ten office visits or two weeks as a prediction of when phase I should be complete. The patient is asked to keep the receipt for the footwear and visual and mechanical inspection of the footwear takes place in the office by us, whereupon the patient can begin wearing it. We also ask the patient to discard any old footwear that is not supportive. After approval of the footwear, we ask the patient to purchase a second pair of the approved footwear, so that the pairs can be worn on alternative days, giving them a chance to breathe and dry out, prolonging their life.

TREATMENT GOALS: PHASE I

Once the arch is supported, we can begin the treatment of the muscular stresses (spasms) and protective muscular stresses (tonic protective reflexes) as well as the joint fixations (joint subluxations) related to the articular collapse and damage incurred to the joints of the kinematic chain. We aim for the removal of the muscular stresses and tonic protective reflexes, and for the reduction of joint inflammation, by the tenth visit, plus or minus three. We call this Phase I. Some patients heal faster than others do, but we have found that this is a reasonable clinical goal. The practitioner has to work hard and be willing to work with his/her hands to reach this goal.

TREATMENT OF TONIC PROTECTIVE REFLEX SPASMS

In order to be effective at removing the tonic protective reflexes you must understand their nature and what treatment is most effective at removing them. First, tonic protective reflex spasms are activated by acute or chronic overload related to fatigue caused by improper biomechanics, direct trauma or chilling. Primary tonic protective reflex spasms develop in muscles subject to excessive repetitive contraction or overload fatigue as in the case of excessive pronation case, when a patient’s arch collapses and the tibia/fibula complex internally rotates an abnormal 20 degrees in less than 0.08 seconds, as described in the literature.

Tonic protective reflexes mainly lie latent and undiscovered by the patient and practitioner in the muscles strained from the collapse of the kinematic chain. These muscles are weakened, and normally have lost their ability to support the frame as intended. The force of their contraction is reduced. By latent, I mean that these muscles are non-symptomatic with respect to pain, except when direct pressure is applied to the belly of the latent tonic protective spasm. When this is done, you and the patient will know right away that the spasm is there because they are very painful. For compliance, it will help to show the patient that the pain caused is out of proportion to the pressure applied, and not simply a result of strong pressure by applying the same equal pressure to muscles, which are not involved in the syndrome as a comparison.

Other factors that are important to note are when these tonic protective reflexes are active and latent or passive or active, stretching of the affected muscle causes pain and the condition will actually regress instead of improve. It is for this reason that the active and passive stretching of musculature in the surrounding area of complaint is reserved for Phase II, after the latent tonic protective reflexes have been removed. With latent tonic protective reflexes, the stretch range of motion is restricted so the joint moves in an aberrant way. This causes irritation to the joint involved, or arthritis.

We don’t suggest that you ever begin active strengthening or rehab in phase I. The weakness found in many muscles as a result of pronation would seem to call for some immediate rehabilitation. This approach usually will backfire on you if you don’t understand the nature of the tonic protective reflexes. Sustained contraction of the muscle with a latent tonic protective reflex spasm will elicit a sharp pain during exercise and pain related to further damage to the area. When you have tonic protective reflexes and faulty biomechanics you don’t want to strain the mechanism because that will accelerate joint irritation and damage to the articular surfaces. The patients energy level and confidence isn’t sufficient for exercise, so for these important reasons we never advocate exercise in Phase I.

How Do You Find The Tonic Protective Spasms?

The active and latent tonic protective reflex spasms associated with pronation syndrome follow a specific pattern of distribution. This pattern of distribution will be discussed in detail in subsequent paragraphs to come. Understanding the pattern of distribution, you will know the specific location. The rest is palpation. You palpate the area and you will find a palpable band that when compressed will elicit a sharp circumscribed spot of exquisite tenderness. Digital pressure applied to an active or latent tonic protective reflex spasm will elicit a “jump sign” at times as well, as if the muscle jumps underneath the pressure.

Neuromuscular Reeducation (NMR) Technique: Ischemic Compression

We at Team Doctors have found the following method is best at relieving tonic protective reflex spasms. First, electrical muscle stimulation is used on all tonic protective reflex spasms in advance of ischemic compression. Note: Ischemic compression is contraindicated in patients who are suspected or at risk of developing clots in the deep veins of the calf or other diseases where the patient could possibly form clots. The next procedure is vibrational massage to the affected musculature, which increases circulation and further relaxes the involved musculature. The final and most important treatment of the tonic spastic musculature is a procedure that utilizes ischemic compression, which is firm digital pressure applied to the tonic protective reflex spasm areas. It has been thought that this technique applied to the muscle spindle and Golgi tendon reflex organ receptors acts to reorganize and/or alter the tonic protective reflex, and we see this occur clinically with the steady reduction of spastic activity when this technique is employed.

When you apply this ischemic compression, the patient will feel pain. When the patient feels the pain, you ask the patient to grade the highest pain a grade of ten. As the pressure is maintained the pain will decrease. Ask the patient to count down the pain from ten to one, until the patient notes feeling no pain, only pressure. At this point, you remove the compression and move methodically inch by inch through the area of the protective reflex spasm adjacent to this point, down the length of the belly of the muscle until the entire area of the muscle spasm is void of spastic activity. This procedure begins at the hip joint in the gluteus medius; through the thigh in the tensor fascia latae and lateral hamstring; in the calf in the supinator muscles; and in the foot in the intrinsic muscles surrounding the heel and first and second toe area. Because the lower extremities have larger muscles, this technique can be exhausting to the practitioner and difficult to complete without experiencing fatigue in the muscles of the forearms and hands. The physician or therapist must have a great deal of power in his or her hands and forearms, therefore the procedure is not for everybody. We take one to two minute breaks as needed to recover after several areas are treated.

Joint Manipulation/Mobilization and Joint Stabilization

Joint manipulation must take place to normalize the motion lost with the collapse of the arch and the subsequent domino effect up the kinematic chain. Foot and ankle manipulation is medically necessary because with the chronic strain on the ligaments created by the collapse of the arch, there are joints that are hypermobile and there are joints that are hypomobile. It is essential to bring motion back to joints that are hypomobile due to subluxations, this can be done using specific joint mobilizations that utilize effective technique to improve the joint play and thus allow for proper biomechanics.

Hypomobile Articulations of the Foot – The hyopomobile articulations that need to be manipulated are:

• Talotibial joint
• Talonavicular joint
• Naviculo cuneiform joint
• Cuneiform 1st metatarsal joint
• Cuneiform 2nd metatarsal joint

Hypermobile Articulations of the Foot – The hypermobile articulation of the foot that needs to be stabilized is the talo calcaneal joint.

Hypomobile Articulations of the Lumbo-pelvic Area – There is usually a bilateral or unilateral (on the side of biomechanical dysfunction) flexion fixation.

TREATMENT FREQUENCY

In Phase I we treat the patient daily for a period of approximately two weeks or ten to twelve office visits with the goals to remove all tonic protective reflexes, reduce all pain related to ischemic compression to zero, reduce all inflammation to zero and nerve root compression to zero. Remember to apply the ischemic compression into the deep muscles. Most patients will make these goals as long as the proper footwear is selected to support the foot and prevent the excessive pronation. At the fifth or sixth visit, if treatment is aggressive, the patient usually feels a noticeable increase in energy. By the tenth to twelfth visit, the patient notes that a majority, if not all, of the pain has subsided and the lower extremities feel more powerful. A quick scan with digital pressure on the involved musculature will note no pain where it once was. The patient is ready for rehabilitation.

Phase II, III, and IV involves training of the frame in all ranges of motion but with particular emphasis on training the weakened areas of tonic protective reflex spasms. Patients flexibility and cardiovascular training can begin after the physicians evaluation to determine the frequency and duration required. Performing the care that is medically necessary to reduce or correct the faulty biomechanics of the lower extremities, and the effects of faulty biomechanics of the lower extremities is important to insurance carriers and patients who wish to have pain relief and reduction of accelerated aging effects of the complicating factors related to faulty biomechanics of the lower extremities.

At Team Doctors, we extend care to the patient into Phase IV in our center we prepare athletes for competitions in regional, national and world championships as well as the Olympic games.

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