1. Faulty Biomechanics of the Lower Extremities: A presentation of
how a simple biomechanical dysfunction accelerates the aging
process. The most effective diagnosis, treatment and prevention.
James Stoxen, D.C. President, Team Doctors Treatment
Centers
Discussion of anti- aging issues with lack of care and how the
body ages more rapidly with the cascading domino effect of
this syndrome. We will discuss the risks and complications of
the development of more life threatening diseases, which can
manifest from the lack of treatment of inappropriate care to
this simple biomechanical dysfunction. The dysfunction is
easily treated with the care cycle outlined if caught early,
given effective treatment and prevented, the biomarkers affect
the aging process.

2. Faulty Biomechanics of the Lower
Extremities Related to Simple Foot
Pronation and its Effects on the Aging
Process
By Dr James Stoxen DC
President
Team Doctors PC
Chicago
(773) 735-5200
Teamdoctors.org
Teamdoctors@aol.com
Drstoxen@teamdoctors.org

3. How Common
10,000 -15,000 average steps per day
640 metric tons of stress on the joints
Even subtle faulty biomechanics can easily yield a chronic
condition or predispose a patient to serious injury
How common are conditions related to faulty
biomechanics of the lower extremities related
to simple foot pronation?

4. What are the long term effects to
the aging process?
The abnormal strain effects the entire
kinematic chain effecting all muscles,
tendons, ligaments and joints.
Tonic/chronic protective spasm, pain and
arthritis
Inactivity due to pain
Chronic fatigue
Depression “I’m just getting old”

5. Long term effects of faulty biomechanics
of the lower extremities
Chronic Arthritis
The most common cause of disability in the
elderly
43 million cases in 1997
Heart Disease
Genetic Factors
Diet
Lack of proper exercise

6. Simple Foot Pronation
One of the most
common examples of
faulty biomechanics of
the lower extremities is
simple foot pronation

7. Simple Foot pronation causes
collapse of the kinematic chain
Pronation of the foot causes a
collapse of the kinematic chain
causing pain, arthritic changes
in multiple joints in the
kinematic chain leading to
inactivity, fatigue and possible
depression. When the foot
pronation becomes chronic this
condition can lead to chronic
fatigue and subsequent heart
conditions due to inactivity.

8. The leading cause of
simple foot pronation is...
Shoes with weak counters
Improper lacing of shoes
Not lacing shoes at all!

9. Foot & Ankle Symptoms
Foot and or ankle pain
Plantar Fascitis
History of a heel spur
Shin splints

10. Knee and Calf
Pain (especially after sitting for long
periods)
Crepitus (especially when walking upstairs)
Peripatellar pain
Calf cramps
Poor circulation in calves
Cold feet

11. Hip and Thigh
The legs ache
Leg cramps
Illiotibial band pain
Crepitus in the hip
History of hip arthritis pain
Tired legs

12. Lower Back Pain
Insidious lower back pain
Lower back pain from a lifting
injury

13. Chronic Fatigue
Patient is fatigued all the time
Negative laboratory work-up
All other tests for pathology are
negative

14. Objective Findings
Orthopedic Tests and
Radiographic Findings

15. Orthopedic Findings
Foot & Calf
Tenderness on deep
palpation of Plantar
Media Aspect of the
Foot
Tenderness on deep
palpation of the
(lateral aspect) of the
Calf
Heel Spur

16. Knee
(+) Clarks - crepitus
on extension of the
knee
(+) Waldron’s
Chondromalacia
patella radiographic
findings

17. Hip and Thigh
Weak and painful
biceps femoris (on
deep palpation)
Weak and painful
tensor fascia latae (on
deep palpation)
(+) Modified Obers
Test (TFL)
(+) Nobles Test (TFL)

18. Hip Muscle testing
Weak & painful
gluteus maximus
(upon deep palpation)

19. Hip muscle testing
Weak & painful
gluteus minimus and
medius
Weak & painful
piriformis
Difficulty with
internal rotation of the
hips

20. Hip
Orthopedic Tests
(+) Trendellenburg
Test (poor balance)
Difficulty getting
up from seated
position
(+) Patrick Fabres
test

21. Treatment training tip for weak
gluteus medius
Hip Abductor training
Restrict Spinal motion
Short arch
No Hip External
Rotation
10 x 3 (reps x sets)

22. Lower Back
(+) Hibs
(+) Elys
Chronic idiopathic
paraspinal muscle
spasms
Bilateral or unilateral
(SI) flexion fixation
subluxation
Herniated disc or discs

23. Lower Back (Continued)
Anterior Tilted Pelvis Unilateral or Bilateral

24. Lower Extremity Anatomy Review
Foot
– 28 bones
– 55 articulations
Joints
Ankle Joint
– Bones
Tibia
Fibula
Talus

25. Mid Tarsal Joint
– Bones
Talus
Navicular
Calcaneus
Cuboid
Subtalar Joint
– Bones
Talus
Calcaneus
– Subtalar Joint Primary
Motions
Eversion/Inversion
Abduction/Adduction
Lower Extremity Anatomy Review

26. Mid Tarsal Joint Axis
The mid tarsal joint has 2 axis which function as a
unit to allow for triplanar motion around these 2 axis

27. Mid Tarsal Joint Axis
Oblique Mid Tarsal Joint Axis
– Primary Motions
– Dorsiflexion Plantarflexion
– Abduction Adduction
Longitudinal Midtarsal Joint Axis
– Primary Motions
– Pure inversion and eversion

28. Foot pronation occurs at the mid
tarsal joint axis
Midtarsal pronation is limited when the
cuboid comes in contact with the
calcaneus
As long as the calcaneus is not in a
valgus position
If the calcaneus is in a valgus
position then the entire complex
will collapse

29. The Leading Cause of
Simple Foot Pronation
Shoes with
weak counters
(sides)
Shoes which are
tied weak
not tied at all

30. The Leading Cause of
Simple Foot Pronation

31. The Leading Cause of
Simple Foot Pronation

32. The Leading Cause of
Simple Foot Pronation

33. The Leading Cause of
Simple Foot Pronation

34. The Leading Cause of
Simple Foot Pronation

35. The Leading Cause of
Simple Foot Pronation

36. Key to our Treatment Program
Maintaining the
calcaneous in the
neutral position is one
of the key points to
our treatment
program. This
demands excellent
footwear selection
with motion control.
Use shoes with strong
counters both for
treatment and
prevention purposes

37. Ligaments that Restrict Foot
Pronation
Mid tarsal pronation is
restricted by various
restraining ligaments of the
foot
– Ligaments (See Figure)
Long and short Plantar
Ligaments
Calcaneonavicular Ligament
Bifurcate Ligament

38. Key to our treatment program
If these ligaments are damaged or chronically
stressed they will not assist in limiting pronation.
We manipulate the bones of the foot and work on
the intrinsic muscles of the foot to increase the
natural strength of the arch.
– Midtarsal pronation is further limited in excessive
pronation in various stages of the gait cycle by the
pronation/supinator cuff muscles

39. Key to our treatment program
Similar to the premise of treatment of
rotator cuff musculature, we find that
treatment of tonic protective spastic activity
in Phase I and active strengthening of these
muscles in Phase II, III and IV is a key
component of our treatment program

40. Calf Muscles
Primary Movers Tibialis anterior
– Soleus
– Gastrocnemius

41. Pronator/Supinator Cuff
These muscles can act to
prevent excessive
pronation and supination
of the foot (analogous to
the rotator cuff muscles
of the shoulder)
Flexor Hallucis
Longus (See Figure)
Strong plantar flexor
of the ankle joint
Weak Sub Talar Joint
supinator

42. Pronator/Supinator Cuff
Peroneus Longus
– Strong Plantar
Flexor of the
First ray
– Pronator of the
forefoot arouond
the Longitudinal
Midtarsal Joint
Axis

43. Pronator/Supinator Cuff
Flexor Digitorum
Longus (See Figure)
– Strong ankle joint
plantar Flexor
– Moderate subtalar
joint supinator
– Very strong
supinator of the
forefoot around the
midtarsal joint

44. Pronator/Supinator Cuff
Extensor Digitorum
Longus (See Figure)
– Strong plantar flexor
Of the ankle joint
– Moderate pronator of
the forefoot

45. Pronator/Supinator Cuff
Tibialis Anterior
(See Figures)
– Does not effect the
midtarsal joint axis
– Strong supinator
of the forefoot
– Slightly weaker
supinator of the
subtalar joint

46. Pronator/Supinator Cuff
Tibialis Posterior

47. Anatomy of the Leg and Knee
Knee Anatomy
– Bones
Tibia
Fibula
Femur
Knee Joint Motions
– Flexion
– Extension
– Rotation
Muscles which control the knee
– Quads
Rectus Femoris
Vastus Medialis
Vastus Lateralis
Intermedius
– Hamstrings
Biceps Femoris
Semimimbranosis Semitendinosis
– Tensor Fascia Larae - Illiotbial
Band (Figures on next slide)

48. Gluteus Maximus, Medius and Minimus
Muscular Anatomy of the
Hip and Lower Back

49. External Rotators (See
Figure)
Adductors
Lower Back Muscles
Illiopsoas
Extensors
Abdominal Muscles
MuscularAnatomy of the
1Hip and Lower Back

50. Correct the Foot Pronation with Deep
Tissue Work to the Intinsic Muscles of
the Foot and Lateral Calf

51. Pronation Treatment
and Prevention takes
place when supination
is aided by reduced
weakness of and
increased strength of
the intrinsic muscles of
the foot (See Figures)
Training Rehab Tip
correct through training
not through orthodics
Correct the Foot Pronation

52. Foot Pronation Correction
Treatment Tip
Motion Control stabilizing foot wear
Pick you shoes like you pick your fruit

53. Foot Pronation Correction
Treatment Tip
Alternative shoe
lacing for added
counter stability
(start under)

54. Pronator/Supinator Cuff Treatment
Phase I - Passive Treatment:
Reduce weakness via deep
tissue work or EMS
– Abductor Hallucis
– Flexor Hallucis Brevis
– Flexor Digitorum
Phase II, III, and IV - Active
Strength Training
– Abductor Hallucis
– Flexor Hallucis
– Flexor Digitorum Brevis
Pronation, treatment and prevention takes place when
supination is aided by reduced weakness and increased
strength of the extrinsic supinators of the foot (AKA
supinator Cuff Muscles)

55. Pronator Supinator Chronic
Weakness
With chronic pronator
supinator cuff
weakness the body
shifts the weight to
other muscles and
serious injuries can
occur

56. Calf Training
Training/Rehab
demands joint
motion in flexion
extension be
along the
metatarsal joint
axis

57. Phase I - Passive Treatment
Phase II, III and IV - Active
Strength Training
Reduce weakness via deep
tissue work or EMS
– Flexor Hallucis Longus
– Flexor Digitorum Longus
– Tibialis Posterior
Treatment of the Faulty Biomechanics of
the Lower Extremity Related to Simple
Foot Pronation

58. Pronation
Treatment/Training/Rehab Tip
Stretch these muscles
– Extensor Hallucis Longus
– Extensor Longus & Brevis
– Tibialis Anterior

59. During the push off phase of gait, pronation is reduced
when the peroneus longus is strengthened to insure that
toe off will occur with a stable first, second and third
digit. Joint motion is lost and must be regained through
manipulation of the joints of the foot.

60. Improve toe off and Stride Length
“Windlass Effect”
Excessive pronation is reduced with the “Windlass Effect”.
When the toes dorsiflex, the heel lift draws the plantar fascia
around the metatarsal heads which acts to pull the pillars of
the longitudinal arch together thus decreasing the fore foot
rear foot distance or strengthening the arch. This only
happens when the patient steps off with reasonable toe off
force.

61. Pronation Correction
Phase I - Passive Treatment - Reduce weakness via deep tissue
work or EMS (See Figures)
Peroneus longus
Phase II, III and IV - Active Strength Training (See Figures)

62. Peroneus Training Tip

63. Reduce Tibial Torsion
Increase stride length to reduce tibial
torsion
The sub talar joint acts as a directional torque transmitter
converter frontal plane motion of the calcaneus into axial
rotation torque or torsion of the tibia/fibula (shank). This can
cause considerable internal rotational stresses on the tibia,
femur and thus hip and lower back. When in the swing phase
the opposite side, when swinging a reasonable distance or a
longer stride which causes the effected side to reduce in
torsion.

64. Treatment of the Knee Disorders Related
to Simple Pronation of the foot
Conditions
– Knee Instability
– Peri-patellar Pain Syndrome - Patellofemoral arthralgia
– Infrapatellar Cartilage Damage - Chondromalicia Patella

65. Phase I - Passive Treatment
Reduce weakness via deep tissue work or EMS
Tensor Fascia Latae Biceps Femoris
(See Figure) (See Figure)

66. Strength training tip to reduce tibial
torsion
Tibial Torsion Treatment and
Prevention takes place when
Reduced Torsion is aided by
reduced weakness and increased
strength of the Tensor Fascia
Latae and the Biceps Femoris of
the thigh. (See Figure)
•Knee extensions - the quad group
pull the patella in the correct
alignment
•Knee Flexion Bicep femoris pulls the
shank back into proper alignment
•Hamstring Curls

67. Strength training tip to reduce tibial
torsion
Train your
patient in hip
abduction
through the
gluteus medius
and indirectly
TFL

68. Treatment of Hip and Thigh Disorders or
Syndromes Related to Simple Pronation
of the foot
Conditions
Tensor Facia Latae and/or
Illiotibial Band Syndrome (See
Bottom Figure)
Piriformis Syndrome (Side Figure)
Hip Arthritis

69. Phase I Reduced Weakness
- Deep Tissue or EMS (See
Figure)
– Tensor Fascia Latae
– Gluteus Maximus
– Gluteus Medius
– Gluteus Minimus
Strength Training
– Tensor Fascia Latae
– Gluteus Maximus
– Gluteus Medius
– Gluteus Minimus
Treatment of Hip and Thigh Disorders or
Syndromes Related to Simple Pronation
of the foot

70. Treatment of Lower Back Disorders
or Syndromes
Non Traumatic Lower Back Pain Disorders or Syndromes
Hyperlordosis
Facet Syndrome
Traumatic Lower Back
Disorders and Syndromes
Herniated Discs etc
We feel that a majority of these injuries are due to a prior predisposition
from abnormal lower extremity biomechanics causing an anterior tilted
pelvis and weight shift from the gluts and lateral thigh to the hamstrings
and lower back causing overload and injury

71. Passive Phase I - Reduced Weakness of these
muscles via deep tissue work or EMS
Hip External Rotators
(See Figure)
Gluteus Medius
Lumbar Extensors

72. Active Phase II - Active Strength
Training in Phase II, III and IV
Midsection Training - This
training must occur in flexion,
extension, lateral flexion and
rotation with the pelvis in a
neutral position with reduced
extensionof the lumbar spine.
The Spine must be trained in
a neutral position.(See
Figure)

73. Phase I - Goals - Reduced Inflamation and
Tonic Protective Spasms, Pain Relief, Joint
Mobility
Joint Swelling Reduced (Therapy)
Joint Fixation Reduced via Manipulation of
Articular Structures
Pronation Supported - Orthodics vs NMRE
and motion control shoe and active training
Chronic Tonic Protective Reflex Reduction
(NMRE)
Treatment Frequency and Duration Daily
care for 2 weeks or 3 days a week for 3
weeks

74. Phase II - Goals Flexibility, Joint Alignment,
Joint Strengthening and Coordination
Joint fixation reduced via Manipulation of
Articular Structures
Flexibility training technique (PNF)
Light Strength Training
Concentration on joint Alignment, Form and
Technique
treatment frequency & duration 3 days a
week for 3 weeks

75. Phase III - Goals - Flexibility, Joint
Alignment, Joint Strengthening and
Coordination
Manipulation of Articular Structures
Flexibility training (PNF)
Heavier and Faster Strength Training
Concentration on Joint Alignment, Form
and Technique, Speed and Strength
Treatment frequency and duration 3 days a
week for 3 - 4 weeks

76. Phase IV Goals - Heavier and Faster
Strength Training
Concentration on Joint Alignment, Form
and Technique, Speed and Strength
Sports Performance Training