A Resting of the Soul
In my pursuit of being a skilled health care provider, I focus on reading journals, attending classes, staying current on medicinal research, and choosing the correct billing codes. However, most of us would never have started down this career path if there wasn't something more.
End of Life Treatment
TCM looks death in the face. We do not camouflage it as if it were poisonous. "We must allow our patients to die but we cannot allow them to perish," was my first lesson the day I met my teacher as a teenager.
The Secondary Insurance Plan
I have a patient that has Medicare, but also has a secondary insurance plan that does cover acupuncture. How do I bill Medicare to get a denial so that I may bill this secondary payer?
Blockchain Health Records?
Keeping data secure has become a nightmare for the average consumer. Just consider general user account hacks on Yahoo (3 billion records compromised), eBay (145 million records compromised) and Facebook (87 million records compromised), to health record breaches involving Anthem Blue Cross (78 million records compromised) and TRICARE (almost 5 million records compromised).
Art of the Associateship: It's OK to Trust, But Verify
Trust is a valuable part of any business relationship. It serves as the foundation for all business operations and ultimately long-term success for owners, employees and customers. This is especially true in the world of health care.
Reducing Hip, Knee & Shoulder Replacements (Part 2)
In the first article in this series, "Early Detection Reduces Hip, Knee, & Shoulder Replacements," I described time tested screening procedures and perspectives as indicators of when to encourage your patients to seek further medical evaluation.
Autoimmunity, Gut Health and Diet: Connect the Dots
According to the National Institute of Health (NIH), autoimmune disease is recognized in approximately 24 million individuals in the U.S., consisting of more than 80 various disorders that contribute to the top 10 causes of death in female children and women of all age groups.
Doc, Are You a Social Media Holdout? Your Future Is Now
Whether you like it or not, to compete in any business, even chiropractic, you really should know and consider using social media. It is no longer a small, sleepy, local world we live in; it has become a far-reaching community.
Confessions of a Former Drug Rep: Statins Are Endangering Your Overweight Patients
As I sit at my desk on the sixth anniversary of my successful liver transplant, I can't help but reflect on what caused that life-threatening ordeal. Looking back on my personal situation, I want to offer my insight into what is happening routinely to many patients.
Why Take X-Rays When You Already Have an MRI?
Let's clear up the issue regarding the efficacy of plain-film studies when an MRI study has already been performed. I review imaging studies primarily for chiropractors, and often their patients have been to other health care providers before finding their way to a DC.
#TechPain: Causes, Solutions
For the past several decades, the science of ergonomics has blossomed. The workplace is much safer and life is generally more pleasant thanks to the application of ergonomic principles.
The Certified Practitioner
Certified Chinese herb practitioners often identify themselves with the credentials "LAc" (Licensed acupuncturist).
Help Shape the New Neck Pain Best Practices Guideline
The Clinical Compass (originally the Council on Guidelines and Practice Parameters – CCGPP) has issued a call for interested chiropractic clinicians to help shape a new best practices guideline for chiropractic care of neck pain.
News in Brief
WFC Among Founding Members of Global Rehab Alliance; HealthSource Selects GoChiroTV as Exclusive Digital Signage Partner; Western States' Online Degree Programs Among Best in the Nation; Logan University, University of Missouri-St. Louis Forge Partnership.
Facebook Marketing 101
Many of the health care practitioners we work with have smaller practices. The provider tends to wear many hats – office manager, salesperson and healer.
It's All About That Ki
As an industry are we shifting too much toward a Western mind set? We strive to understand how acupuncture works using imaging and extensive studies. We spend numerous hours of our training learning Western medicine and learning to speak their language. What happened to our core though?
A Bold Strategy to Take Chiropractic to New Heights
Building public awareness of an entire profession requires strategic planning – especially when it pertains to the exploration of ground-breaking marketing tactics that target new audiences with key messaging about the value of chiropractic care.
NCCAOM: A Route to National Certification
The National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) is offering a route to achieve national certification—without having to take any of the NCCAOM exams. This is specifically for California licensed acupuncturists that meet the eligibility requirements.
Trending: CBD / Hemp Oil
A recent survey of DCs regarding cannabidiol (CBD) / hemp oil provides food for thought as to the viability of CBD-based products as a component of chiropractic patient care. Here are some observations from the executive summary of the survey:
"Community Care" for Vets: It's Really a Big Deal!
As a preamble, while I regrettably never served in the military, I have the highest respect for those who did and those who currently serve.
Why the Automatic Denials for Modifiers 25 and 59?
Your experience is one shared by many chiropractic providers who bill through those plans. It appears to be the national trend, but by far is more prominent in Texas and Illinois.
The Classical Texts & Integrative Medicine
The acupuncture profession has been undergoing many changes in the past years. There has been a shift towards a more integrative approach to medicine as more hospitals include integrative departments.
UnitedHealthcare Can't Seem to Keep Chiropractic Down
AA decade ago, UnitedHealthcare announced changes to its chiropractic services policy that declared manipulative therapy for headache unproven.
Vaccines & Autism (Part 1)
It turns out chronic inflammation is the driver of autism expression. Unfortunately, those who emotionally embrace the vaccine issue rarely, if ever, consider this relationship, which hinders a rational view of the vaccine issue.
Treating Pain With Nutrition
Back in 1910, when D.D. Palmer published The Chiropractor's Adjuster and introduced the world to what he called the "triad of health" – thoughts, trauma and toxins – he explained that the body can only be made optimally healthy if all three aspects of health are addressed.
Does Dairy Cause Dampness?
The topic of dairy consumption was brought up at a scalp acupuncture seminar I recently attended.
CBD for Athletes: The Advantages of Cannibidiol
For athletes, pain is often part of their sport or activity. And to a certain extent, it is to be expected. However, after pushing themselves to the limit, soreness and fatigue set in, hampering their ability to perform and recover.
Valuable Adjunctive Therapies
Based on the latest CDC statistics, more than 795,000 Americans have strokes per year, 140,000 of which are lethal. Approximately 87 percent of all strokes are ischemic with an estimated health care and missed work cost of $34 billion annually.1
May, 2015, Vol. 15, Issue 05
The Hallux Valgus and Lower Extremity Dysfunction
By Whitney Lowe, LMT
What is hallux valgus? No doubt you've seen one, or perhaps many, clients with hallux valgus. Some may not know this common postural deformity by its technical name, but instead refer to as a bunion (Fig. 1). The technical term is important, though, as it gives insight into the key biomechanical causes of the deformity. An improved understanding of hallux valgus helps us design the most appropriate treatment interventions involving massage.
Hallux valgus is a biomechanical description of what occurs with the forefoot and toe in this condition. The great toe is the hallux, and it has a valgus angulation in this condition. A valgus angulation is one in which the distal end of the bony segment deviates in a lateral direction. Hallux valgus is the most common foot deformity in adults.1
Despite its prevalence, there is still debate about what causes hallux valgus. Some advocate that it is purely a structural condition caused by narrow shoes. Others say it is a genetically inherited condition, also aggravated by footwear. Newer biomechanical studies have further clouded the picture by suggesting this condition is not the result of just shoes or genetics, but is in fact influenced by complex dysfunctional foot mechanics.
For some time, the most prevalent cause of hallux valgus was thought to be the wearing of narrow toe box shoes. Epidemiological studies show females in Western countries wearing fashionable shoes with a narrow toe box, especially high heels, are the most likely to develop this deformity.1 Clearly, there is a correlation between certain types of footwear and hallux valgus.
High-heeled shoes cause increased pressure on the metatarsal heads because greater amounts of weight are born by the distal forefoot (balls of the feet). High-heeled shoes cause the foot to be jammed down into the front of the shoe. Because the front of the shoe narrows significantly, it is natural to suggest that the distal end of the toe would be pushed in a lateral direction, giving the hallux a valgus angulation.
Additionally, many (if not most) of our contemporary shoes in North America have narrowed toe boxes. Most shoes narrow to some degree at the toe, not just the high heel. Even athletic shoes have this design (they also go up at the toe, another issue for another article). The issue of shoe wear remains a key issue; however, new research indicates additional factors that could help choose treatment options for this condition.
New studies in foot biomechanics increase suspicions that complex dysfunctional foot mechanics may have a significant role in hallux valgus. Understanding foot mechanics helps the massage practitioner develop beneficial treatment strategies to address the problem.
Deciphering Complex Foot Mechanics
There is evidence that excessive mobility of the first ray plays a dominant role in the development of hallux valgus. The first ray is a structural segment of the foot composed of the first metatarsal and the medial cuneiform bone (Fig. 2). The first ray is more mobile than the other segments of the forefoot and has a crucial role in maintaining the medial longitudinal arch and governing the proper amount of foot pronation.
Many individuals with hallux valgus have excessive mobility at the junction between the first metatarsal and medial cuneiform bone. Increased mobility at this joint also occurs in people having a collapsed or fallen medial longitudinal arch or who overpronate their foot during gait. Individuals having a fallen arch or who overpronate put increased weight on the medial edge of the foot. As the medial edge of the foot bears more weight, the medial cuneiform pushes the base of the first metatarsal in the opposite direction (laterally) forcing the distal head of the metatarsal in a medial direction. As the distal head of the metatarsal is forced medially it causes the base of the hallux to move with it in a medial direction. This movement makes the distal end of the hallux move laterally producing the hallux valgus deformity (Fig. 3).
There are indications that heredity plays a role in the development of hallux valgus. Consequently, it is likely that some of these biomechanical stresses are compounded by hereditary structure and tissue composition. One study found evidence of medial collateral ligament weakening at the first metatarsophalangeal joint.2 The weakening of this ligament structure makes it less resistant to the forces pushing the metatarsal head and hallux out of position. This tendency might be passed on genetically and be one factor that increases the condition's incidence within familial lines.
Another study found variations in the insertion points of several lower extremity muscles, including extensor hallucis longus. They found that some of these variations have a high correlation with hallux valgus.3 This may indicate that the pulling forces of muscles inserting on locations slightly different than normal could be a contributing factor to the hallux valgus distortion. It is likely that some of these anatomical variations may also be genetic and play a role in the genetic components of this condition.
Wearing of high-heeled shoes is strongly correlated with the development of hallux valgus. But it may not be just the narrow toe box that's contributing to the disorder. Long periods in high-heeled shoes cause progressive shortening of the plantar flexor muscles and that decreases overall foot dorsiflexion. Loss of flexibility in the plantar flexor muscles adversely affects tension on the plantar fascia and has detrimental effects on mobility of the first ray because of fascial connections between the first ray and plantar fascia.
Other lower extremity disorders are frequently correlated with hallux valgus. In some cases they are contributing to the cause while in others they may result from it. Hallux valgus is strongly correlated with overpronation, and the combination can become a vicious cycle of dysfunction. Not only does overpronation increase the likelihood for hallux valgus development, the loss of hallux alignment increases overpronation even further. One of the primary roles of the hallux is to prevent excessive pronation during the push-off phase of gait. If the distal end of the hallux is deviating laterally, it does not have the force capability to resist increased foot pronation leading to further overpronation.
Losing the hallux as a primary resistor of overpronation can have other detrimental effects. There are strong correlations between hallux valgus deformity and shin splints, plantar fasciitis, tarsal tunnel syndrome, and other lower extremity disorders. The dysfunctional foot mechanics that developed with hallux valgus causes increased force loads in the lower extremity that must be absorbed by other soft tissues, causing them to be overloaded. In many cases symptoms of these other foot disorders may be addressed, but the underlying biomechanics that led to them may frequently go untreated.
Bunions are often a painful, and sometimes debilitating condition. Treatment options are few and surgical intervention is not guaranteed as a solution. We tend to develop treatment approaches based on the most evident postural or biomechanical alteration. Noting in this condition that the distal end of the hallux is deviating in a lateral direction, numerous treatment strategies focus on trying to pull the distal hallux back in a medial direction. Sometimes this is done surgically, but it is also attempted through soft-tissue work such as vigorous stretching, orthotics, or biomechanical interventions.
These approaches may have some degree of effectiveness. If the dysfunctional condition is resulting from genetic weakness in the medial collateral ligament combined with mechanical forces that are pushing the bones out of alignment, simply pulling it back towards neutral might not be sufficient to cause more lasting change.
Correcting overpronation and other problematic foot mechanics is important for long term solutions and orthotics can play an integral therapeutic role. Moving to shoes with a wide toe box, such that the toes can easily spread out all the way to their distal ends is key (clogs often have wide toe boxes). To test appropriate width for the client's toes, remove the liner from their shoe and have them stand on it. If their foot is wider than the liner and/or the toes land outside the liner in the toe box area, the shoes are too narrow. There are toe spacers available that can be used to encourage the toes to spread out (these must be introduced very slowly, a few minutes at a time until the toes adjust (Fig. 4).
The massage therapist can play a helpful role in addressing this condition by managing tensions in the soft tissues throughout this region. Of particular importance is treating the plantar flexor muscles and the other soft tissues on the plantar surface of the foot, which can decrease the detrimental forces that lead to or aggravate this deformity. Working the entire kinetic chain (calf muscles and hip adductors for example) can play critical roles in treating a variety of foot conditions. Stretching and range-of-motion activities performed at home are also important.
Sometimes it's not easy to unravel the complex biomechanical patterns that lead to dysfunction. When you see a client that has a visible alignment problem with hallux valgus, consider the soft tissues and mechanical factors that may be contributing to local problems in the foot and perhaps other disorders that result from the dysfunctional mechanics. Make sure to address all of those factors in your treatment to decrease the likelihood that further complications develop from this common disorder.
Earn CE credit for this article and learn about Whitney Lowe's innovative, engaging, and interactive instructional designs. Whitney's texts and courses have benefited professionals and schools for more than 25 years. For more information, visit www.academyofclinicalmassage.com.
Click here for more information about Whitney Lowe, LMT.
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