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Adolescent Ideopathic Scliosis linked to Abnormal Pronation

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Brian A. Rothbart, May 7, 2021.

  1. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member


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    In 2013 I published a preliminary research study that statistically linked Adolescent Ideopathic Scoliosis to abnormal foot function (gravity drive pronation).
    1. Pelvic instability was linked to abnormal foot function (outcome of my 2014 research project)
    2. Spinal cord instability (excessive curves in the spinal cord) was linked to pelvic instability (A basic tenant in Chiropractic medicine)
    In 2017, Kim et al published a paper consistent with my findings in 2013. Below is a copy of their abstract:

    "Severe calcaneus misalignment is correlated with low back pain, and affects pelvic alignment. However, little has been published with regard to the influence of pronation and supination on trunk alignment. Therefore, the present study aimed to investigate the influence of calcaneal inversion on pelvic and trunk alignment. [Subjects and Methods] A 3-dimensional motion analysis system was used to assess pelvic and trunk alignment in 10 healthy male subjects with unilateral and bilateral calcaneus inversion. [Results] Medial and anterior tilting of the pelvis, and posterior tilting and lateral rotation of the trunk were observed. [Conclusion] Calcaneal inversion induces changes in the alignment of the pelvis and trunk. These changes may induce lumbar lordosis and body misalignment, leading to back pain."

    What are your clinical experiences in this area.
     
  2. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    I would be very interested in hearing from Chiropractors on this subject:
    • In your clinical practice, do you see a link between AIS and foot function
    • If so, have you used anything underneath the feet to reduce the scoliotic curves
    • Do you link AIS to pelvic instability
    • Do you link pelvic instability to abnormal foot function
    • What is your opinion regarding spinal bracing to treat AIS
    • What is your opinion regarding surgical intervention in reducing AIS
    Or any other thoughts you have. This is a subject, that we as Podiatrists need to look at.
     
  3. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Adolescent Ideopathic Scoliosis has escaped etiological determination ever since it was first diagnosed. It has been treated symptomatically: physical therapy, bracing and then surgery (in that order). Until recently, the foot has never been in the protocol of therapy.

    For years, chiropractors and osteopaths have written on the link between pelvic /spinal column instability: where goes the pelvis, so goes the spine.

    In 1988 I published a statistical study linking frontal plane pelvic instability to foot instability (gravity drive pronation).

    The rationale for using orthotics/proprioceptive insoles to stabilize the spine:
    • By decreasing the foot instability (gravity drive pronation)
    • The pelvis levels, which, in turn
    • Attenuates the abnormal spinal curves
    However, using orthotics to stabilize the foot is also a double edge sword: if the wrong type of orthotic is used, it can increase the instability in the foot (increase the gravity drive pronation).

    In prior posts I presented visual documentation: an orthotic incorporating a rearfoot varus post and an arch support was fabricated for a patient later diagnosed as having a PreClinical Clubfoot Deformity. Result: the foot instability (gravity drive pronation) increased.

    Any comments on the above, particularly from Chiros, Osteopaths or Physical Therapists?
     
  4. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Below is a capsular summation of the frontal plane chain of events (foot to spine), viewed posterior to anterior, that can result in AIS. This is an Ascending Model of AIS. Osteopaths and Dentists describe a Descending Model of AIS, not to be confused with the Ascending Model.

    1. Gravity drive pronation (gdP) unlevels the sacral base. More specifically, it is the degree of asymmetry in the gdP (AgdP) that determines the degree of sacral base unleveling. As the degree of AgdP increases, the degree of sacral base unleveling increases.
    • If the AgdP is right >left, the sacral base drops downward towards the right foot (low right pelvic crest, high left pelvic crest). The greater the degree of AgdP, the greater the degree of sacral base unleveling.
    • If the AgdP is left>right, the sacral base drops downward towards the left foot (low left pelvic crest, high right pelvic crest). The greater the degree of AgdP, the greater the degree of sacral base unleveling.

    2. Sacral base unleveling, if severe enough, can result in a lateral (scoliotic) shift in the lumbar vertebrae.
    • If the Sacral base is tilted downward towards the right foot, the lumbar vertebrae compensate by shifting toward the left leg (e.g., left lumbar scoliosis).
    • If the Sacral base is tilted downward towards the left foot, the lumbar vertebrae compensate by shifting toward the right leg (e.g., right lumbar scoliosis).
    3. Lumbar scoliosis, if severe enough, can result in a lateral (scoliotic) shift in the thoracic vertebrae.
    • If the lumbar vertebrae have shifted towards the left leg, the thoracic vertebrae compensate by shifting towards the right leg (e.g., right thoracic scoliosis)
    • If the lumbar vertebrae have shifted towards the right leg, the thoracic vertebrae compensate by shifting towards the left leg (e.g., left thoracic scoliosis)
    The data collected in my 2013 publication (Preliminary Study: Adolescent Ideopathic Scoliosis Linked to Abnormal Foot Pronation) is consistent with the above descriptors. To recapitulate:
    • AgdP right>left is linked to a right thoracic scoliosis
    • AgdP left> right is linked to a left thoracic scoliosis

    Clinically I have seen a preponderance of AIS in patients diagnosed as having the PreClinical Clubfoot Deformity.
    AIS is less frequent in patients diagnosed as having Primus Metatarsus Supinatus.

    This is makes sense because AgdP is greater in the PreClinical Clubfoot Deformity, and much less in the Primus Metatarsus Supinatus (Rothbarts Foot). To understand why this is so, I would suggest you read the following 2010 publication:
     
  5. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Cobb Angle Pre vs Post PI.jpg

    Above is an example of the effectiveness of using the appropriate Proprioceptive Insole to stabilize a very unstable spine.

    This adolescent was scheduled for surgery (Harrington Rods), but the parents were reticent about proceeding with the surgery.
    • This adolescent was diagnosed as having a PreClinical Clubfoot Deformity.
    • Proprioceptive Insoles were prescribed as an alternative therapy
    The above radiographs show the result of this non-invasive intervention.
     
  6. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Right Thoracic Left Lumbar Curve Skeletal View.gif

    Above is an animation of the picture I used (Rothbart 2013), describing, segment by segment, the chain of biomechanical events that inchoates with gravity drive pronation and results in a thoracic scoliosis. In the below animation, only the right foot is rotated into gravity drive pronation:
    1. Gravity Drive Pronation Right foot (triplane motion)
    2. Anterior (sagittal plane) rotation of right innominate (right acetabulum cephaladly displaced relative to the left acetabulum which results in a FLLD right)
    3. Right leg functions shorter than left leg which forces a frontal plane displacement of the pelvis (downward unleveling towards the right foot)
    4. The unleveling of the pelvis (which includes the sacral base) is compensated for by a left lumbar scoliosis
    5. The left lumbar scoliosis is compensated for by a right thoracic scoliosis
    • Rothbart BA 2013. Preliminary Study: Adolescent Idiopathic Scoliosis Linked to Abnormal Foot Pronation. Podiatry Review Vol 72, No 2:8-11.
     
  7. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Heel Lift (or full length platform) must not be used when the AIS is the result of either the PreClinical Clubfoot Deformity or the Primus Metatarsus Supinatus foot structure:
    • Placing a heel lift (or platform) underneath the short leg will lock the pelvic tilt in place.
    • The patient may feel more balanced, but the scoliosis will increase.
    Therapy should be directed towards leveling the pelvis:
    • Attenuate the abnormal (gravity drive) pronation by prescribing the appropriate proprioceptive insole.
    • Prescribe adjunct therapy judiciously
     
  8. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    In summation, AIS, in many cases inchoate from the feet:
    • The pathomechanics, foot to thoracic spine, step by step, resulting in AIS
    • Avoid heel lifts, instead, direct intervention towards stabilizing the abnormal foot structure using appropriate insoles
     
  9. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Interesting study by Raoof et al that links abnormal pronation (2nd degree flatfoot) to increased curvatures in the spine. Below is their conclusions:

    "This study provided evidence for the effects of bilateral, flexible, second-degree flatfoot on pelvic mechanics and spinal curvatures. It revealed that subjects with bilateral, flexible, second-degree flatfoot had an increase of ante-rior pelvic tilt, and increased lumbar and tho-racic curvatures compared to healthy subjects. We recommend further research to assess the biomechanic foot alterations in females who have developed pelvic organ prolapse.
    (PDF) Influence of second-degree flatfoot on spinal and pelvic mechanics in young females. "

    In 1988 I reported on a previously unreported link between abnormal foot motion and pelvic mechanics. Specifically, I reported a statistical correlation between abnormal (gravity drive) pronation and an anterior rotation of the innominates. Since that time, numerous published studies have reported similar results. And it is this anterior rotation of the innominates that unlevel the pelvis, resulting in increased curvatures in the spine.

    Their study also concluded that a biomechanical link between foot alternation and pelvic organ prolapse (a cause of infertility in women) required further research. When I made this same observation approximately 15 years ago, on this forum, you can read how it was received.

    • Rothbart BA, Esterbrook L, 1988. Excessive Pronation: A Major Biomechanical Determinant in the Development of Chondromalacia and Pelvic Lists. Journal Manipulative Physiologic Therapeutics 11(5): 373-379.
     
  10. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Kim et al reported a link between calcaneal posture and changes in the thoracolumbar alignment. They observed a paucity in published studies regarding the influence of foot function on trunk alignment.

    Hence, their study was aimed to investigate the influence of calcaneal inversion (hallmark of the PreClinical Clubfoot Deformity) on pelvic and trunk alignment.

    A 3 dimensional motion analysis system was used to assess pelvic and trunk alignment in 10 healthy male subjects.
    They reported an anterior tilting of the pelvis and a lateral rotation of the trunk. They concluded that these changes may induce lumbar lordosis and body misalignment leading to back pain.

    • Kim SC, Yi JH, Jung SW, 2017. The effects of calcaneal posture on thoracolumbar alignment in a standing position. Journal Physical Therapy Science 29(11):1993-1995.
     
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