Patients who are classified as either overweight (having an excess of body weight compared to set standards) or obese (having an abnormally high proportion of body fat)1 have specific requirements and issues regarding foot orthotics. Their rate of developing lower extremity and spinal problems is higher, as is their requirement for shock absorption. Shoe fit concerns and biomechanical distortions are potential obstructions to achieving a satisfactory response. The following are special considerations that are important in obtaining good results with obese chiropractic patients.
Obesity: A Growing Problem
Most researchers have concluded that Americans are becoming increasingly overweight, with nearly one-quarter of U.S. adults defined as obese.2 Since the additional weight load places more stress on the supportive skeletal structures, it isn't surprising that being overweight contributes to more musculoskeletal and arthritic problems.
Obesity Biomechanics
Lower extremity biomechanics are very different in the overweight patient. Obese individuals walk more slowly, take shorter steps and have an increased step width. They have increased Q-angles at the knee, more hip abduction, significantly more abducted foot angles, and increased out-toeing (foot flare). Overpronation is greatly increased, with a greater contact angle at heel strike, more eversion of the foot, more flat-footed weight acceptance period in midstance, and a faster maximum eversion velocity. There is also greater ankle dorsiflexion, but less plantar flexion.
In a 1996 study,3 Frey determined that overweight patients experience a higher incidence of plantar fascitis, tendinitis, osteoarthritis, and fractures/sprains of their feet and ankles. A more recent study suggested that obesity is "a cause and initiator of heel pain and plantar fasciitis/calcaneal spur, and that improper footwear aggravates the condition."4 A study by Riddiford-Harland, et al., concluded that excess body mass "appears to have a significant effect on the foot structure of prepubescent children, whereby young obese children display structural foot characteristics which may develop into problematic symptoms if excessive weight gain continues."5
Clinical Considerations in the Overweight Patient
Orthotics for the Obese
There is an inherent conflict in the overweight patient's need for orthotics. A relatively rigid, very controlling type of support is needed to counteract the high forces generated by the heavier loads imposed on the lower extremities, but the need for shock absorption to decrease the excessive stress on the articular cartilage and slow the degenerative processes is also critical. Comfort is also a factor, since unworn orthotics aren't useful. So, which is optimal for an overweight patient: a rigid, controlling orthotic or a soft, flexible orthotic?
I recommend an orthotic that provides variable firmness, flexibility and control at midstance, and also protects the foot from heel-strike with a shock-absorbing material in the heel area. When an orthotic with these qualities is combined with advice on shoe fit, strengthening and stretching exercises, and appropriate chiropractic treatments for involved joints, the overweight segment of our population has a much greater opportunity to begin exercising safely and in comfort.
Doctors who treat low back pain and lower extremity problems should consider the benefits of orthotics for their obese patients. For many such patients, well-fitted and appropriately designed custom-made orthotics will help provide a more successful and longer-term clinical outcome.
References
Many relevant diagnostic signs are not performed deliberately by the examiner or by the patient at the examiner’s direction. They are observed as the patient reacts to their condition. Fortin’s finger sign, Minor’s sign, and Vanzetti’s sign are three examples of this principle.
Spearheaded by burgeoning scientific and clinical research literature, psychedelics have reached a level of media coverage and popular interest that has not been seen for over half a century. By “psychedelics,” we are referring to the unique class of substances that includes psilocybin (the active compound found in so-called “magic mushrooms”), LSD, dimethyltryptamine (DMT), ayahuasca, 5-MeO-DMT, and mescaline – each of which occurs in the natural world (except for LSD, which is a semi-synthetic compound).
While working at the Lovelace Medical Center in Albuquerque, N.M., one of the primary care physicians stated that imaging every patient prior to receiving chiropractic was not medically necessary. It was at that point I reconsidered the need for the imaging of every patient to avoid malpractice.
