Always Think Feet First

By Dr. Tim Maggs

“Oh, everyone doesn’t need orthotics.” This was the response I got from a top chiropractic researcher after reading an article authored by me and Dr. Terry Yochum in 2011, “100% of My Patients Get Orthotics. What About Yours?”

In 2011, this article was the by-product of Dr. Yochum, a leading chiropractic radiologist, and me lecturing together many times, and him hearing my reasoning, case studies and experience with orthotics and patients. At breakfast one morning, he suggested we write the article. Evidently, it made sense to him.

Today, with much advanced technology, I can now show with evidence-based research that in fact, everyone does need orthotics. That is, if the goal is to reduce the likelihood of injuries and delay degeneration of the musculoskeletal system.

2023 Research Study – Over a period of three years, I accumulated digital laser foot scans of 1,001 patients (Maggs, 2023). This is study number five and can be found online: drtimmaggs.com. The scan detects pixels, and pixels become red when that portion of the foot makes direct contact with the scanner. The optimal foot is somewhat like a suspension bridge, and the three arches (medial, transverse, lateral) prevent the entire foot from making direct contact with the ground.

The scan attaches a specific number to the degree of collapse of the feet, ranging from the optimal foot (0) to the most collapsed foot (200). There are five categories a patient’s feet can fall into, optimal (0), mild pronation (1-34), moderate pronation (35-84), severe pronation (85-124), and total pronation (125+).

These scans were the scans I formerly did on all patients who came into my office as part of our biomechanical exam. Some of the patients had no symptoms, while some had either acute or chronic symptoms. Scans were only done on patients who could stand with their normal posture. Patients with severe spasms in the low back or significant pain that would cause them to stand guarded or with any degree of antalgia (abnormal pattern of walking) were not scanned until their symptoms were reduced and they could stand with their normal posture.

Everyone is “Crooked Man” – The above study plus multiple other studies that have been published in the past five years have proven that everyone has some degree of foot collapse, and more people have unlevel femoral head height difference (FHHD) greater than 3mm (64%) than people whose FHHD is less than 3mm while barefoot. A staggering 42% have FHHD greater than 5mm while barefoot. The conclusion is, everyone is Crooked Man.

Some authorities claim that the inclusion of orthotics in the shoes will level femoral head height difference. Actually, that only happens 21% of the time (Maggs, 2023). When orthotics are put into shoes, 61% of people have FHHD greater than 3mm while 40% have FHHD greater than 5mm. The fact that everyone has some degree of collapse of the feet and more have unlevel FHHD than level FHHD, the importance of knowing the feet/hip relationship on every patient cannot be overstated. The standing anterior-posterior lumbo-sacral (APLS) x-ray is necessary for this information.

Case History – A 41-year-old healthy and athletic male came into my office with chronic low back pain that was getting worse with time. This patient is a semi-pro golfer who golfed four to five times per week. His ability to play without pain was becoming more difficult.

Our research study of the 1,001 patients concluded that FHHD was really the critical variance when attempting to get the low back healthy. Abnormal loading was the underlying cause of most low back conditions, so an APLS x-ray while barefoot was compared to an APLS x-ray while wearing orthotics. Research has proven there is no need for custom orthotics (Maggs, 2023), as the most important purpose for orthotics is to create symmetry of both feet while supporting the arches of the feet. Both goals can be addressed with high quality over-the-counter orthotics. Once in the shoe, the most important test to be done is now the second APLS x-ray.

Earlier studies have shown there are five versions of Crooked Man (Siozos, 2020). Due to the fact the FHHD worsened once orthotics were put in the shoes, and the patient’s FHHD was abnormal while barefoot, this would categorize this patient as a Crooked Man 2. Anecdotally, Crooked Man 2 usually produces the worst injuries.

On the patient’s lateral lumbar spine, there is much information. His Ferguson’s gravity (weightbearing) line and sacral base angle are both normal, however, there is advanced narrowing of the L4/L5 disc space. All other disc spaces appear to be normal, which could suggest some form of injury and loss of normal motion some years ago accelerating the degeneration of the L4 disc.

Conclusion – The human architecture in many ways is no different than the building (home) you reside in. If the foundation is off balance, there will be many secondary issues that will occur over the years. In the above patient, he’s had 41 years of some degree of collapse of his feet and uneven leg lengths. This is in combination with the many slips, falls and repetitive activities we all go through. While his L4 disc shows signs of premature wear and tear, and while his symptomatic picture is getting worse with each day, we can’t ignore his foundation if our goal is to help his low back.

Orthotics must be the first step in helping this patient to heal. Once the second x-ray is taken, a 7mm lift is put under the right orthotic to help level the hips as much as possible. Then, once the structure is supported and leveled, a treatment program can begin. Our office provides chiropractic adjustments, cold laser therapy and spinal decompression. We set this patient up for 10 visits to see how he responds at which time we’ll do a re-exam. 

The real conclusion is, if you’re confused as to where to begin with preventing and solving injuries, always think feet first. Even if you’re a chiropractic researcher.

References – Maggs, B. a. (2023). “Each Person’s Collapse of the Arches of the Foot May Be Unique but its Correction is Standard. A Large Study Explains Why.” Orthopedics and Rheumatology Open Access Journal, 6. Siozos, B. a. (2020). “When Correcting the Collapse of Arches of the Feet with Custom Orthotics, are Other Areas of the Body Effected? A Revolutionary Approach towards Reduced Injuries and Better Outcomes.” Orthopedic and Rheumatology Open Access Journal, 001-008.

Dr. Tim Maggs (drt@drtimmaggs.com) is a chiropractor in private practice for 45 years in upstate NY. He has specialized in the diagnosis, treatment, and investigation of sports injuries throughout his career, some of it from his own injury experience. Tim, his wife Trudy, and four sons are runners, bikers, and actively involved in fitness and a healthy lifestyle.