March 2004

Managing the unstable posture

by Dr. Mark Charrette

Postural instability often occurs because of foot problems. Pedal misalignments that create postural distortions and stress throughout the body can often be effectively managed if the condition is identified early and appropriate care is undertaken.

We rely on proper posture to support our bodies. Maintaining balance helps prevent structural breakdown that can lead to pain in ligaments, tendons, muscle fibers, cartilage, and bone. Many painful, disabling conditions are related to improper posture while standing, walking, lying, sitting, bending, or lifting. [1] Therefore, proper posture is essential in preventing these conditions.

How postural defects develop

Postural stabilization requires proper balance and coordination between movements of the lower extremities and the pelvic and spinal areas. Faults can arise from injury, illness, or imbalance in the pedal region. Posture can also be affected by a sedentary lifestyle. Problems of the feet and lower extremities are often the underlying cause of postural problems of the spinal, pelvic, torso, and cervical areas of the body. Two examples are excessive pronation and/or leg length inequality.

Excessive Pronation. Excessive or prolonged foot pronation can cause an abnormal instability during weightbearing, creating hypermobility in the foot joints and leading to microtrauma in the soft tissues. [2] Increased rotation is forced upon the leg, pelvis, and most especially the sacroiliac joint. Gait is affected with every step; and an unbalanced gait affects body balance, stability, and eventually posture.

To determine if a patient is pronating, look at her gait and posture. Does she toe‑out, or present with low medial arches? Are her shoes worn along the lateral border of the heel? If so, this hyperpronation may be an underlying cause of postural distortions.

Leg Length Inequality (LLI). Leg length inequality is another factor in postural instability. Patients presenting with low back pain or pain in the hips often have a low femur head height, low sacral base, and/or low iliac crest height. Anatomical causes such as unequal growth rates, trauma, congenital deformities, degeneration, infection, and neoplasms may contribute to LLI. There are two main types of LLI. Structural LLI is a true difference in the length of the legs, perhaps due to unequal growth rates, fractures, deformities, or altered joint structure. Functional LLI results from excessive foot pronation (flat feet), muscle contractures, or pelvic distortions. Functional LLI is more common, yet difficult to spot without extensive clinical evaluation.

Determining LLI can be achieved by either visual or radiographic procedures. Utilizing Standing A‑P Pelvis or Standing A‑P Lumbopelvic radiographic views are the preferred method. If the patient presents with a functional short leg or pelvic unleveling, she should also be checked for excessive supination or pronation.

Postural evaluation

Evaluating a patient's standing posture helps to determine whether postural distortions are occurring. Balance and alignment assessment of the frontal and sagittal planes of the three major regional masses of the body (cervical, torso, pelvis) and their relationship to their base of support ‑‑ the feet and the legs ‑‑ is important. Using a commercially available plumb line device is a useful assessment tool. Postural analysis should be part of the patient's initial examination. X‑rays may also be required to determine further postural defects.

Extra care

In addition to chiropractic adjustments, patients can help improve their posture by performing at‑home rehab exercises and by wearing flexible, custom‑made orthotics to help stabilize the spine and pelvis.

Exercises. Correcting both joint and muscle dysfunction will help strengthen the body and minimize the potential for future injury. Posture‑specific, asymmetric exercise maneuvers against resistance are helpful. [3] The result is stretching shortened connective tissues while strengthening and retraining imbalanced spinal support muscles.

It is important for patients to develop and maintain an active lifestyle through exercise. Exercising three days a week for a minimum of half an hour will help keep their bodies in motion and assist in weight management ‑‑ an important factor in keeping feet in line. Swimming, walking, and other low‑impact exercise programs should be recommended.

Orthotic Support. Restoring postural balance can be effectively achieved with flexible, custom‑made orthotics. Orthotic support can also help relieve pain caused by poor body mechanics. If the pelvis tilts forward (causing postural defects), orthotics can shift and align the pelvis back into its normal, balanced position. For patients with excessive pronation or leg length inequality, supporting the feet with custom‑made orthotics will aid in the natural balancing and stabilization of the lower extremities and pelvis. Generic, off‑the‑shelf orthotics are not designed to keep feet in their proper structural positions. Custom‑made orthotics help support the foot's natural posture, absorb shock, reduce fatigue, and help adjustments 'hold' better and longer.

References

1. Cailliet R. "Soft Tissue Pain and Disability" (2nd ed.). Philadelphia: FA Davis, 1988.

2. Greenawalt MH. "Spinal Pelvic Stabilization" (4th ed.) Roanoke, VA: Foot Levelers, Inc., 1990.

3. Harrison DD, ed. "Spinal Biomechanics: A Chiropractic Perspective." Harrison Pubs., 1992.

(Dr. Mark N. Charrette is a 1980 summa cum laude graduate of Palmer College of Chiropractic. Over the past 18 years he has lectured extensively on spinal and extremity adjusting throughout the U.S., Europe, the Far East, and Australia. In 1976, he received a Bachelor's degree from Illinois State University [summa cum laude] where he was an NCAA All‑American in 1974.)