Beginning a successful exercise regimen requires an understanding of how to avoid injury and ensure you are properly prepared for the increased stress that this will play on your body. To take the stress out of your work out, this article will showcase why the engines of locomotion are firmly planted on the ground and why they are so important. 

Foot and Ankle Anatomy 

The human foot is a complex machine consisting of a flexible network of structures including: bones, joints, muscles, tendons and ligaments. Each foot consists of 26 bones, 30 joints and more than 100 muscles/tendons/ligaments all of which work together to provide support, balance and mobility. Sections of the foot are divided into three recognized areas:

• The Forefoot: includes the bones of your toes (phalanges) and the five longer bones that attach to them, called metatarsals.
• The Midfoot: consists of a puzzle-like pyramid of bones that contribute to the arches of the feet. These include three cuneiform bones (meaning wedge-shaped), the cuboid bone (square) and the navicular bone which gets its name from being boat-shaped.
• The Hindfoot: contains structures to form the heel and ankle. The talus bone supports the bones of the lower leg (fibula and tibia) to create the ankle. The calcaneus (heel bone) is the largest bone in the foot.

What many people don’t realize is that each foot also contains three arches, not just one. When functioning properly, they work the same way as a spring, allowing the feet to bear the weight of the body and absorb the shock produced during activities like walking, running and jumping.

• The Medial Longitudinal Arch: Stretches from the ball of the foot (under the big toe) to the heel. This is what most people think of when discussing ‘the arch of the foot’ because it is the highest and most noticeable arch.
• The Lateral Longitudinal Arch: Spans from the ‘ball’ under the pinky toe to the heel. Note that what we think of as the balls of our feet are actually the heads of the metatarsal long bones where they meet the toes. 
• The Anterior Transverse Arch: Crosses the width of the foot from the ball of the foot under the big toe to the ‘ball’ under the pinky toe and represents the arc of the metatarsal heads.

All of these structures form an association of moveable parts that work synergistically. As experts in optimizing joint function and alignment, doctors of chiropractic (DCs) not only address joints in the spine, they also work with the many joints of the upper and lower extremities and have a detailed understanding of the complexities of the foot and its many supporting structures.

Understanding the Kinetic Chain

Feet are the body’s foundation. Our feet provide the groundwork for our upright weight-bearing posture. This makes them a primary influence when we talk about the kinetic chain in the body. ‘Kinetic chain’ is actually an engineering concept used to describe human movement. It refers to the interconnectedness of the body and how our body areas work together, compensate for or affect one another to perform movements. When choosing footwear, the importance of having proper support to promote functional stability for the many joints and arches of the feet cannot be undervalued. 

It has been estimated that every pound of body weight exerts up to three pounds of force that the feet have to absorb when walking. If a person weighs 200 lbs., the force on the feet will be up to 600 lbs. When running, that number grows exponentially with up to seven pounds of force per pound of body weight being exerted which would translate to 1,400 pounds of pressure per footfall for our 200 lb. example. 

Foot and ankle biomechanics influence motion and function throughout our skeletal structure. Improper gait, foot strike or subtle differences in functionality from one foot to the other can all translate stresses up through the knees and into the hips, pelvis and spine. Anyone who has ever broken a toe, been in a leg cast or sprained an ankle will inherently relate to this concept of how a change in gait can cause pain in other areas. However, an injury does not have to be the primary cause of compensatory pain. Pain can also manifest simply from the way you are walking.

Watching your Step

Over-pronation, for example, is a very common finding in patients. It means you are walking more on the inside arch of your foot. Walking this way actually creates an unnatural internal rotation in the lower leg, which when combined with typical joint positions needed to simply walk, translates to stress in the knee joint and has been shown to increase the risk for knee injuries and back pain.

Internal rotation of the lower leg from over-pronation has also been correlated with an increased Q-angle (Q for quadriceps). The Q-angle is a valuable indicator when evaluating biomechanical function in the lower extremity. The assessment of it provides useful information about the alignment of the hips, pelvis, leg and foot. Increased Q-angle measurements have been associated with higher incidence of ACL injuries.

As we continue up the body, we find multiple studies have also linked over-pronation in the foot to unspecified low back pain. In 2017, a randomized controlled trial was published in the journal Archives of Physical Medicine and Rehabilitation which concluded that over 40% of patient participants had a significant reduction in low back pain and an increase in function with a combination of custom foot orthotics and chiropractic care. This exemplifies how much impact a well-functioning foundation can have on our musculoskeletal system as a whole.

Optimum Foot Strike and Support

The way you walk contributes to significant outcomes. Years of improper walking can lead to joint stress, pain, degeneration, spurs, fallen arches, and in the shorter term, can translate to compensation and resulting pain in your ankles, knees, hips and spine. 

Most people will demonstrate a better foot strike when barefoot. This is because the nerves in your feet can feel the ground and adjust the way your steps hit the floor. Being barefoot on the beach isn’t just a daydream, it also takes more effort than walking on a hard surface and strengthens your foot and ankle while you burn more calories!

With shoes, people are more prone to developing bad walking habits such as dragging the feet, heavy impact steps and limiting natural movement in the joints of the foot. Most of us, however, need to wear shoes the majority of our waking hours. Watch the soles of your shoes, if the outer sole wears down unevenly it can be a strong clue that you need to adjust your foot strike/gait. 

To best support your feet, keep the following considerations in mind to help optimize the way that you walk:

• Proper Posture: Stand up straight/shoulders back/head supported by your spine. Do not look down (such as at your feet or your phone), look forward. Feet should be shoulder width apart/chest forward and abdominals/core muscles engaged.
• Foot Strike: Should begin with the heel landing squarely on the floor. As you roll onto the entire ball of your foot the heel should begin to slightly lift and toes should be flexed. The step should spread to each toe, beginning with the small toe hitting the floor and lifting up off the ground as you complete the step. Mindfully watch to see if your step has you rolling inward or outward.
• Gait: Ensure your toes face forward to keep the ankles in a neutral position. If toes are in a ‘V’ outward or inward it creates strain on soft tissues of the ankle and heel.
• Shoe Fit: Ensure that your shoes are supportive for all areas of the foot and that they are flexible and provide ample width. Also note if they are causing blisters. Custom orthotics may be indicated for many patients that require extra support to ensure that foot strike is optimized. 

Urban exercise myths like ‘no pain, no gain’ certainly do not apply to the foot. Your feet should not feel pain during normal walking or with exercise activities. In the chiropractic office, DCs can analyze and advise on your foot strike/gait, evaluate the complexities of the foot and kinetic chain, adjust affected areas to optimize joint function and mobility, offer strengthening exercises and many offices are also equipped to take foot molds and have custom orthotics created for patients that need to augment foot support. 

For more information on the benefits of walking and running read the Next Step Walking Guide and tune into our ‘Adjusted Reality’ podcast interview with elite endurance athlete, author and adventurer, Colin O’Brady, as he discusses the benefits of walking and how shifts in mindset can enhance our time on the trail.      

Embracing a Menopause Mindset

Every single day, millions of women all around the world are experiencing a natural mid-life progression called menopause. Mindsets about it, however, can be very different. In the Western world, for example, the menopause event seems to carry with it a lot of stigma and may be viewed negatively with aspects of aging. Loss of menses and mid-life hormonal changes are treated as a medical event vs. a natural conversion that our bodies were made to undertake. 

In China, the process of menopause is much different, described as a ‘rebirth’; a time when energy that was once used for fertility/child-bearing and rearing can be saved and repurposed. Many other cultures see the process as one of liberation and ‘being set free.’ In Japan, menopause is viewed as an expected stage of life and the term for it, konenki, actually means renewal, season and energy. For many cultures, the time of menopause is one for celebration and postmenopausal women are revered in the community as mentors with experience and wisdom. Embrace menopause with a positive mindset.

Defining the Process

Menopause is a term loosely used to describe the cessation of menses. Though it sounds like a simple instant change, it is actually a multi-stage process. These stages include:

• Perimenopause: The time (often years) leading up to menopause. During this time hormones change/decline and menstrual cycles may become inconsistent. Women may begin to feel side effects of these subtle hormonal shifts such as hot flashes, vaginal dryness, mood changes, sleep issues and menstrual irregularity. 
• Menopause: The body stops producing the hormones that cause your menstrual period. After going without a period for 12 consecutive months, you are medically considered to be in menopause. If you go without a period and after 10 months you get one, it is not official and you begin the count again. After the 12 consecutive month benchmark, you enter postmenopause.
• Postmenopause: Once menopause has occurred, women are in a postmenopausal state for the rest of their lives.

It is important to note that the process of menopause should not be associated with a specific age. It is a change in physiology, and for some women, perimenopause can begin as early as in their 30s. Other women don’t go through the change until their late 40s or 50s. The menopausal experience is a process specific to each individual. Some women breeze through the progression and others may experience symptoms such as: hot flashes, mood issues, urinary/bladder symptoms, vaginal dryness or sleep disruption. Musculoskeletal and joint pain are also correlated with age and hormonal changes.

Doctors of chiropractic (DCs) provide care to support women throughout their lifecycle, from the onset of menses, through child-bearing years and as they work through the natural and expected process of menopause.      

21^st Century Considerations

A core contributor to increased symptoms for menses and menopause is stress.  Stress has been well-documented to worsen menstrual symptoms, to affect fertility during childbearing years, and to contribute to menopausal symptoms. Stress is also a growing concern in our modern world. In the body, it is our adrenal glands that respond to stress. These walnut-sized glands that sit on top of our kidneys are also responsible for producing the precursors for our sex hormones including: estrogens, testosterone (androgens and DHEA) and progesterone. This means that high stress can affect all of these other hormones. Optimal adrenal gland function is needed for a smooth menopausal transition and stress reduction is paramount.

Talking to family members (grandmothers, mother and aunts) can help you get a feel for what your menopausal experience may be like. However, if a 21^st century woman is under significantly higher stress than her relatives (or vice-versa), that could change family correlations.

Common medical interventions for menopausal symptoms, such as Hormone Replacement Therapy (HRT), can include significant risks including: breast cancer, endometrial cancer, blood clots in the legs and lungs, heart disease, strokes and an increased risk of dementia and gallbladder problems. For that reason, women all over the world are opting for more natural approaches to address symptoms.

Reducing stress should be at the top of the list. Chiropractic care has a long history of aiding in the alleviation of many of the symptoms of stress. It been demonstrated that as chiropractic optimizes joint function, it contributes to muscle relaxation and pain relief. Studies have also specifically shown that menstrual pain associated with primary dysmenorrhea may be alleviated through lumbosacral joint care. 

Preventing Conditions of Change

Beyond basic symptoms of hormonal change, it is important for women to take a preventative approach to the more critical conditions associated with aging and preventative actions are the best way to combat those conditions.

Osteoporosis is a primary concern after menopause. This is because women lose bone more rapidly due to decreased hormone levels. Research indicates that up to 20% of bone loss can happen during these stages. More than one in ten women over the age of 60 are affected by osteoporosis worldwide. Bone loss increases the risk of developing osteoporosis and bone fractures. The bones of the hip, wrist and spine are most commonly affected.

Cardiovascular disease is another major concern. Decreased hormones make women more prone to cardiovascular disease complications including heart disease, stroke and heart attack. After menopause, many women also become more sedentary which can lead to higher cholesterol levels and ultimately high blood pressure. 

Your Partner on the Menopause Path

Your doctor of chiropractic (DC) can help you navigate a positive path through menopause by helping you monitor osteoporosis and osteopenia (a precursor to osteoporosis) through a referral for bone mineral testing. DCs can also design a program of specific weight-bearing exercises to help keep bones strong, and recommend nutrition (such as calcium and vitamin D3 which supports the absorption of calcium) that will help promote the foundational needs of bone tissue.

Chiropractic care can also help you get moving with exercise plans, promote healthy eating habits, and aid in smoking cessation (if needed) which are all paramount to preventing heart disease. 

On the symptomatic level, chiropractic can offer relief from joint aches and pains by promoting optimal joint function, provide recommendations for stress reduction techniques and advise on nutrition to support adrenal function and hormonal balance to give you the smoothest menopausal experience possible so that you can enjoy the newfound freedom that comes with the season of postmenopause.

From sitcoms to movie depictions, the chiropractic profession has certainly earned its ‘good sport’ award as we’ve watched actors enact what they believe to be a re-creation of a chiropractic adjustment accompanied by a very loud series of noises.      

In reality, though, one of the most commonly asked questions in a chiropractic office is “What is that sound?” Patients are often inquisitive about the ‘popping’ and ‘cracking’ sounds and different types of chiropractic adjustments that can be utilized.      

Many patients have visualized that chiropractic care is ‘one thing’ and done only one way. They may expect back-wrenching positions like they see with sitcom stereotypes. They may expect loud noises. They may think that just anyone can provide an adjustment. These notions, however, are far removed from the actual patient experience in a chiropractic office.

The Science Behind the Sound

Doctors of chiropractic (DCs) adjust diarthrodial joints. These are freely moveable joints created by two bones surrounded by a joint capsule. The capsule is filled with a lubricant called synovial fluid. Synovial fluid also serves as a source of nutrients for the cells that maintain the joint cartilage. Within its contents, synovial fluid also contains dissolved gases of oxygen, nitrogen and carbon dioxide.  

Facet joints (also called zygapophyseal joints) are synovial joints that are found between vertebral bones along the length of the spine, on both sides and at the top and bottom of each vertebral segment. They allow for the variety of bending, arching and twisting motions that come from our spine. Facet joints are the most common joint type adjusted in the chiropractic office.

The formal term for noise when moving a joint is ‘joint cavitation.’ When a joint capsule is stretched to a point of resistance, it creates pressure within the fluid that causes the exchange of dissolved gases. Recent studies indicate that the process may actually create a cavity within the capsule fluid allowing this to happen. 

DCs will often explain this to first-time patients so they are not alarmed. It’s important for patients to know that their bones are not literally ‘cracking.’  

Patients may ask questions such as:

• Is the sound from bones grinding together?
• Is the popping sound causing damage?
• There was no sound, did the adjustment happen?
• Can I safely adjust myself or have a friend do it?

As we just described, the sound itself is not bones rubbing together. The sound certainly does not indicate damage or we wouldn’t adjust people. The presence of a noise, or lack of it, in no way indicates the success of an adjustment, it is normal and expected should it occur; and lastly, only a trained provider should attempt the procedures.

Types of Adjustments

Despite common lingo about ‘back-cracking,’ chiropractors do not ‘crack’ the spine. A chiropractic adjustment is a safe, controlled force applied to a joint/joints to restore proper function and mobility. 

Adjustments provided by DCs are very precise corrections that address the way a joint has shifted. Unlike popping your knuckles to simply make a noise, DCs examine and palpate the spine to determine the exact joints involved and the x-y-z axis (three-dimensional space) of how they have moved out of alignment. They are then able to issue a gentle controlled adjustment with a precise line of drive applied to the particular joints that are involved.

Chiropractic is not limited to only the spine. DCs also understand the complex anatomy associated with the joints of the extremities: shoulder, elbow, hand, hips, knees and feet. They are specifically trained to evaluate and adjust all areas of the human skeleton.

To accomplish this goal, there are a wide variety of effective techniques that DCs learn and implement. These include popular hands-on techniques or may utilize special tables with pieces that drop away, and/or instruments. Though joint noise does often occur, different types of adjustments will have different levels of cavitation. Many methods will not have any noise at all but they are as equally as effective in correcting joint alignment. There are many named techniques out there, and your DC will pick one or a combination that they feel is best suited to your individual needs. A broad overview and explanation of what you might experience are given here:

Hands-on Techniques: There are a variety of techniques that go by different names to delineate different hands-on manual adjustment methodologies. With some of them, you may lay on a table, with others you may sit in a chair or use a piece of equipment designed for the low back. Your body will be positioned according to what joints are being addressed and which method is being utilized. With these techniques you may be more apt to hear a cavitation noise, however, it is also not unusual for a bone to silently slip into place during the procedure. 

Special Tables: For certain techniques, special tables may be indicated. Some chiropractic tables will maneuver patients from a standing position, and lower them to a position lying face down. These tables are to maintain the weight-bearing position that a patient had standing, and also to make it more convenient for patients that may have trouble maneuvering positions.

Some tables may have moving pieces that the DC will use to facilitate the adjustment. These require less body positioning. Patients will hear the sound of the moving pieces during the adjustment and may feel a slight shift in the position of a table piece. Other tables may have features that move to provide traction and/or bend to address specific spinal joints or spinal areas. 

Instruments: Small hand-held instruments are used by many DCs. They are spring-loaded mechanisms and provide rapid low-force impulses to targeted areas. The goal is to issue rapid impulses in the direction of correction before the muscles have a chance to tense up. The impulses can be calibrated to be extremely light or heavier depending on the patient and region or joint being addressed. Instrument adjusting is less likely to result in cavitation.

Care vs. Comedy

A diarthrodial joint provides the ability for movement but it also limits movement to prevent injury. It isn’t difficult to pop a knuckle and stretch a joint capsule to make a noise, but a well-meaning friend trying to pop your spine (like on a sitcom) could actually over-stretch the capsule or move joints in the wrong direction and cause more harm. This is why only trained professionals should ever attempt to adjust your spine and extremities.

When care is implemented by a trained provider, such as a DC, specific adjusting affords multiple benefits including:  

• The restoration of optimal range of motion.
• The normalization of local nerve function (or even vascular function) for those structures that might be directly impacted.
• The relaxation of muscles adjacent to the joint as they are able to stop ‘protecting’ the joint through spasm and resume their natural position.
• A decrease in inflammation when the stress on the joint capsule is resolved. 
• A decrease in pain through the release of endorphins at the region of care.

As we get joints moving, a chiropractic adjustment is multifold and holds the advantage of not only properly optimizing joint function but also providing patients relief from the many symptoms associated with it.

Balancing the Hype and Harm of High Heels

The appeal of the high heel has spanned centuries, but what is the motivation to strap a 4-inch peg on the back of your foot and try to walk around? Psychological science says that incentives are multi-faceted and can range in a spectrum from utility to vanity and include reasoning such as:

• Wanting to be taller/reach things/feel more powerful in groups.
• The desire to seem more attractive/sexier gait/enhancing the appearance of the calf muscle/the illusion of elongating the legs or looking slimmer.
• Aspiring to be on top of fashion trends/help clothes hang better/status symbol/look more affluent.

Whatever the reason, high heels are big business. The global high heel footwear market is projected to grow by USD $2.39 billon by 2027. But what is the real cost for consumers who regularly buy and wear high heels?

Paying the Physical Price

Each foot is comprised of three arches, 26 bones, 30 joints and more than 100 muscles, tendons and ligaments. When you slip on a pair of heels, the biomechanical changes that occur in the feet and up the kinetic chain are immediate. With gait, changes were found in the rollover function of the foot, ankle, knee joints and lower back. Step length and balance are also compromised which increases the risk for falls, stress fractures and sprain/strain injuries of the ankle.

An increase in heel height forces the foot into more pronounced plantar flexion (pointing the toes toward the ground) which, in turn, affects the knee and the curve in the lower back. Low back and leg pain are common due to compressive forces and as major joints all the way up the kinetic chain become affected from the unnatural shift in heel height. 

In the long term, pain and deformity are very real concerns. When you think of the shape of most high heels, the deformities fit like puzzle pieces as individuals force their feet to adapt to the shape of their shoes:

• Hallux valgus (aka a bunion on the inside of the foot near the big toe) has been noted in heel wearers as is a deformity of the pinky toe creating a similar situation on the outside of the foot. 
• Haglund’s deformity occurs as a lump on the back of the heel(s) near the Achilles tendon attachment which can then lead to pain and bursitis. Since it often develops in people who wear pump-style heels, it is also referred to as ‘pump bump.’
• Wearers are also at higher risk of developing hammer toes, corns, heel spurs, plantar fasciitis, flattened arches, stress fractures, knee damage and low back pain. 

Studies have shown that regular high heel use may compromise muscle efficiency in walking causing wearers to often experience discomfort and muscle fatigue due to structural and functional changes in the muscles of the lower leg. A 2022 study concluded that balance control was affected for regular wearers not only while in the shoes, but also it did not correct itself in a natural barefoot state which is evidence of lasting change.

Because of the stress and wear and tear to the cartilage of joints, osteoarthritis is another concern. High heels cause stress to the entire foot and the change in foot strike translates up the kinetic chain. Knee osteoarthritis in particular has been an ongoing finding due to altered biomechanics.  

In healthcare offices low back pain has also been an ongoing and prevalent finding in women who wear heels. With your toes plantar-flexed, the joint function of the foot is altered, the hips shift forward and your spine has to balance out the weight by overarching backwards, all of these changes start with the unnatural stresses on the foot joints which move all the way up the kinetic chain to the spine.

Tips for Balancing High Heels with Health

It’s clear that high heels are here to stay and you don’t have to give them up altogether. However, there are several strategies that you can take to mitigate the risks involved with wearing them. 

• Choose flexible shoes with a wider toe box.
• Try not to go over two inches. Even a heel as low as 3/4 inch has
  been found to increase the pressure on the forefoot by as much as 22%.
• Select a wider heel base (vs. skinny heels) to disperse weight and increase balance.
• Be mindful of how often you wear heels. Only wear them occasionally/when absolutely necessary. Wear comfortable shoes to and from the office and only put the heels on for meetings, presentations or special occasions.
• Perform exercises to keep the stabilizing muscles of your foot strong and your calf muscles stretched.

Wearers may also find benefit from custom orthotics to maximize the support of the foot while wearing heels. A study published in the Archives of Physical Medicine and Rehabilitation found that 40% of patient participants had increased function and a significant reduction in low back pain through a combination of custom orthotics and chiropractic care. Your doctor of chiropractic (DC) understands the complex structure of the foot and can support healthy foot function through evaluating and adjusting the joints of the foot, knee, hip and low back (up the kinetic chain) to reduce pain and keep joints functioning optimally. DCs can also advise on footwear, demonstrate exercises for foot stability and help you to obtain custom orthotics for your heels so that you can maximize function, balance and strength when wearing them.