--Divider--
The Role of Biomechanics and Chinese Medicine
in the Treatment of Lower Extremity Conditions --Divider--
By
Michael Harman
Diagnosis and Evaluation 3
Pacific College of Oriental Medicine
San Diego, California
April 8, 1997

 

 

Acknowledgements
I am deeply indebted to my family, friends, and associates for the great support and faith they have given me to do this work. I am especially grateful to Adventure 16, Inc. (A-16) for hiring me and giving me the opportunity to become highly educated in the outdoor industry field, as well as to grow personally. If it wasn't for A-16 and Phil Oren, I would not be as interested in foot biomechanics or lower extremity conditions. I also thank Pacific College of Oriental Medicine and Greg Bantick for giving me the education and opportunity to publish this needed information so that acupuncturists, alternative healthcare practitioners or other non-foot care specialists can treat patients that suffer with these types of conditions.

 

Preface
The Role of Biomechanics and Chinese Medicine in the Treatment of Lower Extremity Conditions provides important information about biomechanics, and how it, along with Chinese medicine, can be used to help people with lower extremity conditions such as pain and weakness, etc. Many people walk around with some type of foot or leg problem and feel that there's not much they can do about it other than just put up with it. Others may go to specialists, or other Western doctors, only to find out they "need" surgery or other type of invasive procedure. Until we know what it's like to be somewhat pain-or problem-free, we just seem to go on with our lives each day in pain, and don't do anything about it. Hopefully, this paper will enlighten others, giving rise to a greater awareness of the importance of this material, so that more and more people can have comfort while walking, working, and playing, etc.

 

This paper discusses the different Chinese medical protocols for the treatment of lower extremity conditions that may be used in conjunction with orthotic devices in order to stabilize the foot for better biomechanics, and thus, hopefully allow us to have fewer problems so we might be able to enjoy our lives a little more each day.

 

Writing this paper has been very educational for me, and I hope that the readers will be able to share this same experience, will learn how important this material is for the entire bipedal population, and will share it with their patients, etc.
Michael Harman, L.Ac.

 

Disclaimer
People are like snowflakes: no two are alike. What works for one person doesn't necessarily have to work for another and can, at times, do damage. This information is presented to you as information only and is not designed for self-assessment or self-treatment. Never go it alone. Find a professional to help you on your way to perfect health. The material in this paper is not meant to be a substitute for sound medical advice. If you have an acute or chronic condition, it is my advice to consult a professional healthcare practitioner. The author makes no claims about the effectiveness of the products or treatment procedures described in this manuscript.

Table of Contents

Ch. 1. Introduction
Ch. 2. Biomechanics and Orthoses
Ch. 3. Superfeet Non-prescription Orthoses
Ch. 4. Lower Extremity Conditions that may be helped by Superfeet
Ch. 5. The Knee:
        Red Flags
        Causes of Pain and Other Conditions
        Painful Obstruction Syndrome (POS)
        Orthopedic Neuro-Evaluation (O.N.E.)
        Treatment of Knee Conditions Using Acupuncture
        Rheumatoid Arthritis (case study)

Ch.6. The Lower Leg
Ch. 7. The Ankle
        Strains/Sprains and their Treatments
        O.N.E.
        Other Conditions and their Treatments
Ch. 8. The Treatment of Lower Extremity Conditions Using Ear Acupuncture
Ch. 9. The Treatment of Lower Extremity Conditions Using Chinese Herbs and Other         Substances
Ch. 10. The Treatment of Lower Extremity Conditions Using Dietary Recommendations
Ch. 11. The Treatment of Lower Extremity Conditions Using Exercise
Conclusion
Superfeet Break-in Guidelines
References
Bibliography

Chapter 1

Each day the average person takes approximately 9,000 steps, adding up to a lifetime equivalent of about 3.5 trips around the world [1]. And many, if not most, of these people probably never venture out further than their own hometowns, cities, or states. Just think how much more cultured and educated these people might be if they used part of their time walking to explore these different places, people, and cultures that they would come across in their walking adventures, etc. But that's another topic we'll have to save for another time.

I'm an avid hiker / backpacker, and have been backpacking for more than 25 years. So, I know about foot and leg pain, and how important it is, or can be, to have comfortable feet and shoes. I first became interested in feet about 8 years ago when I started fitting hiking boots at Adventure 16, a specialty retail-backpacking store in Southern California. I went through a very intensive boot fit clinic (Phil Oren's Boot Camp), which was the first of its kind up until that point, back in 1989. So, I was sort of a pioneer back then. There were already some rudimentary (more like primitive) methods used, that, at the time, seemed superior to what other shoe / boot fitters were doing; and they were definitely a far cry from what was about to take shape in the following few years, which is still becoming more and more refined today. I was so interested in this new way of looking at feet and fit that I seriously thought about becoming a podiatrist (DPM). However, I finally decided on becoming an acupuncturist instead, but will most likely continue to specialize in foot and leg problems that don't require more professional help.

I think one of the reasons I became interested in acupuncture was I wanted to help people. I probably also wanted to be in a fairly unique profession (kind of off the beaten path, like cross-country or telemark skiing is in California). But helping people is at the top of the list; and, since most people walk, are on their feet most of the day, like to hike, bike, skate, ski, run, jump, etc., having knowledge about how to keep them comfortable, on their feet, and in relatively little pain, etc., could be helpful for millions (even billions). I hope I don't get them all in my first year of practice!

Chapter 2

I feel that the most important aspect of getting people to become more comfortable and relatively pain free (and keep them there) is to change the way they walk, run, etc. (i.e., to change, or help improve, their biomechanics). Foot biomechanics is a very involved and complex topic, but I would like to talk about it in a way that is hopefully more understandable, so that practicing acupuncturists, other non-foot specialists or healthcare practitioners, etc. can understand it. In addition to biomechanics, I would also like to discuss some foot & leg problems that can be helped by acupuncture and traditional Chinese medicine (TCM), along with the help of a device, most commonly referred to as an orthotic (orthosis is the proper term which is defined as "any device added to the body to stabilize or immobilize a body part, prevent deformity, protect against injury, or assist with function" [2]). These devices change the biomechanics of the foot, which help to alleviate present problems, or to prevent future problems.

There are many different reasons that orthotic devices are made. However, I feel the most important reason should be to support the subtalar joint. This will help to provide support and shock absorption, correct misaligned gait, relieve foot and heel pain, and promote safer and more efficient biomechanics.

The subtalar joint (STJ) is literally the joint "below the talus bone." In Europe, it is known as the "lower ankle joint." This joint is located between the talus and calcaneus bone, and is a very complicated joint that moves in all 3-body planes (tri-plane motion). This motion is referred to as pronation and supination [3]. When the foot is weight bearing, certain motions occur: when the STJ pronates, the calcaneus everts while the talus adducts and plantar flexes, and the leg internally rotates; and when the STJ supinates, the calcaneus inverts while the talus abducts and dorsiflexes, and the leg externally rotates [4]. One of the functions of the STJ is an "integrator of the foot to the leg and visa versa" [5]. It also is a torque translator: 120% of the body impacts the floor when the heel makes contact, and the STJ allows for a softer, more shock absorbed landing at heel contact [6].

Another aspect that's affected by the STJ is its effect on the midtarsal joint (MTJ). This is the joint between the talus and navicular, and the talus and cuboid bone (mostly the talo-navicular joint). The STJ determines the total range of motion (ROM) of the MTJ [7]. When the STJ is pronated, the ROM of the MTJ is increased, and when the STJ is supinated, the ROM of the MTJ is decreased [8]. What's important here is that when the STJ is not kept stable (i.e., not placed into a neutral / vertical position), it pronates or supinates, making the MTJ unstable, which causes less control and less efficiency of the foot [9]. Thus, the foot is not as able to adapt to the irregularities in the changing terrain, and because the MTJ doesn't lock, it loses its ability to become a solid unit (or rigid lever), thus, losing its efficiency to propel itself forward [10]. Therefore, the body needs to use more effort to attain the same stride length. It is the unlocking of the MTJ that also causes the foot to become flat (collapsed medial longitudinal arch), unstable, and prone to foot pathology such as arch strain, bunions, calluses, corns, hammer toes, heel spurs, and tailor's bunions, etc. [11] which are due to the elongation  (or splaying) of the foot. So, this, plus the excessive movement of the STJ can lead to injury [12]. The foot just becomes "a loose bag of bones" [13].

  Orthotic devices, in general, also help to narrow the angle and base of gait, reduce shock, and increase stride length in another way. A narrowed base of gait is when our body is more centered and has less side-to-side motion or lateral oscillations. This requires less muscle activity, and thus, less energy to decelerate and stop the extremity, as well as to keep the side-to-side displacement at a minimum [14]. The more we have to try to control this motion, the more energy we expend. In terms of reducing shock, orthoses keep the STJ from pronating at heel contact, which results in a "softer landing" [15]. And, because the STJ is supported, the MTJ is more stable, and when the MTJ is stable, there is more shock absorption due to the contracting posterior tibial muscle [16]. So, not only is stride length increased due to the MTJ locking which makes for a more rigid lever so there is more power coming off the first ray (the first cuneiform and first metatarsal segment) and the great toe, as discussed above, the decrease in lateral oscillations or narrower gait also helps. In addition, there is a decreased tendency to form a bunion (Hallux Valgus), which is the "Inflammation and thickening of the bursa of the joint of the great toe, usually associated with marked enlargement of the joint and lateral displacement of the toe" [17]. This usually occurs because the metatarsal head is not angled more toward the floor, and the unstable first ray accepts less weight [18]. There are other actions that take place here as well, but too complex to get into here.

I also feel there is a slight reduction of shock due to the placing of the knee in a better tracking position so that there are equal amounts of pressure on the sides of the patella joint and its corresponding meniscus, cartilage, etc. In addition, when the patella is in a better position, there is less potential for rubbing which can decrease the amount of inflammation and pain in the knee, etc.

When the STJ is in an neutral position, it indirectly affects the rest of the joints in the body (especially major joints), placing them in a more correct position. Therefore, the body can work more efficiently, and have a decreased potential for pain. And isn't that what we all want in life? It appears that way to me by the number of painkillers that are purchased over-the-counter (OTC) every year. How long (or should I say, short) has it been since you saw an advertisement for aspirin or other like substance? This is why we need to focus on other alternative (less harmful) ways of dealing with pain, etc.; and I see orthoses as a very benign way of dealing with this matter, especially since you don't have to ingest them. (Even some "natural" Chinese herbs can have negative effects on the body).

Here's something I find interesting, if an neutral position is the most "correct" position, then wouldn't you expect the channels that flow through that area to be the most open, with the least amount of constraint or impingement, thus allowing the greatest ease of flow through the channels, leading to the least amount of obstruction in the channels, and thus, less stagnation in the ankle joint as well as the other joints in the body, particularly the knee, hip, and back? Moreover, because a more neutral position has increased our balance and distributed our weight more equally, giving us a more direct contact with our supporting surface (earth), I believe we have greater access to the Qi that flows up from earth which passes through us and into our patients we're healing via the needle or our hands, depending on whether we're acupuncturists, massage therapists, or other energy healers, etc., giving us a much stronger or more efficient healing (therapeutic) touch. And maybe being barefoot is even better. Just don't step on any needles!

Chapter 3  

So, the best way to obtain a more neutral position, and prevent foot instability is to support the medial longitudinal arch in order to prevent it from collapsing and thus pronating; and, the best way I have found to accomplish this is by wearing good supporting shoes along with orthoses (It is important not to place new orthoses in fairly worn shoes). In addition, one must be careful not to take up too much room with the orthosis in order not to create more unwanted pressure on the foot which can lead to more problems, doing more harm than good [19]. Also, the stiffer the midsole of the shoe, the more prevention of rear foot pronation. And this, along with good support, also helps prevent the femur from externally rotating which reduces stress on the knee joint, allowing the patella to track better [20].

There are many different types of inserts on the market that we can choose from to place in our shoes. Many are purchased OTC for a small price, usually under $20, and at the other end of the spectrum can cost over $500, including consultation, x-rays, and other fees [21]. These more expensive orthoses are custom molded in a variety of different ways, using a variety of different materials, for a variety of different reasons. However, I believe that Superfeet (a non-prescription, custom orthotic device from the ski boot industry which replaces the removable insoles from most shoes) are every bit as good (and maybe even better in certain instances) than many of the more expensive, professionally made orthoses on the market today.

First of all, in my experience (and again, I am not a podiatrist), most orthoses that I come in contact with are made out of an extremely rigid and hard material. This, I feel, doesn't give the cushion or flexibility I feel is necessary. With the extreme pressures exerted on the bottom of the foot, you would think a certain amount of cushion would increase comfort.

Second, the foot is flexible. So why would you restrict this flexibility with something rigid? A semi-rigid orthosis, like Superfeet, is more accommodative to the foot. They are designed to support the foot in its most neutral and locked (ideally functional) position, and are not "corrective" devices, but rather "accommodative" devices that support the foot, keeping the STJ more neutral and the MTJ more locked [22]. Thus, they do not attempt to "correct" the foot like most of the orthoses designed by podiatrists and other specialists [23]. However, they do align the foot more and make it function better [24] (i.e., make it more efficient).

Third, professional orthoses, unlike Superfeet, don't seem to be posted very much for the medial longitudinal arch. Or, if they are, the support is usually located more anterior, and therefore doesn't offer as much support or stability for the STJ or rear foot which keeps the calcaneus from everting during the first 25% of stance [25].

Fourth, some of the more expensive professional orthotic devices are made with a weight bearing method of casting which molds the device when the foot is deformed into its collapsed shape where it is longer and fatter, compared to the non-weight bearing method which is much more like the foot [26]. When making Superfeet in this un-weighted position, it is very easy to position the STJ into the neutral position and lock the MTJ.

Fifth, the ambient pressure created by the vacuum, compresses the soft tissue, enhancing the curved shape of the footbed, thus allowing for a more intimate relationship with the foot [27].

Sixth, Superfeet devices have a very deep heel cup. This adds to the stability of the device by stabilizing the heel, which prevents the foot from pronating off of the device, as well as preventing inversion injuries of the foot [28]. It also contains the fatty tissue under the heel, keeping it from splaying outward, which keeps it thicker, and thus offers more padding and shock absorption. This is the body's natural shock absorber, (in addition to the STJ), which is better than any other shock absorber on the market [29].

Last, but not least, Superfeet are much less expensive. The Custom Sport High Profile style costs $85.00 per pair, which includes labor. Now I'm really sounding like a sales rep. for Superfeet!

Chapter 4

Wearing Superfeet can help many different types of foot and leg problems: Patello-Femoral Syndrome is helped by stabilizing the rear foot, helping the foot and lower extremity dissipate and dampen excessive shock; Chondromalacia Patellae is helped by controlling excessive internal rotation of the leg which pulls the patella off alignment to the femur; Metatarsalgia is helped by locking the MTJ which stabilizes the forefoot on the rear foot; Iliotibial Band (ITB) Syndrome is helped by stabilizing the foot and reducing the tibial and femoral torsion by reducing excessive internal hip rotation, thereby taking the stress off the ITB, as well as reducing the friction and trauma that occurs at the distal portion of the band; and over-pronation is helped by promoting stability of the foot by keeping the STJ in a more neutral position and the MTJ locked which prevents arch / foot collapse [30].

There are many other types of conditions that can occur in which Superfeet may or may not help, depending on the severity: (1) Bunion: discussed above; (2) Hammertoe (AKA claw toe): "a toe with dorsal flexion of the first phalanx and plantar flexion of the second and third phalanges" [31]; (3) Morton's Neuralgia (AKA Morton's Neuroma or Morton's Metatarsalgia): "pain in the metatarsal area due to a fallen transverse arch with pressure on the lateral planar nerve" [32]; (4) joint pain in the ankle or foot: pain in the MTJ, STJ, or other joints; (5) Heel pain: pain in the heel ("the rounded posterior portion of the foot under and behind the ankle -- AKA the calx") [33]; (6) Arch pain / strain / fatigue: usually the medial longitudinal arch; (7) Calluses: "hypertrophied thickening of circumscribed area of horny layer of skin" [34]; and (8) other conditions: Sesamoiditis, Turf Toe, Hallux Rigidus or Hallux Valgus, Metatarsal Stress Fractures, Dorsal Subluxation of the Fourth Metatarsocuboid Joint, Abductor Hallucis Myositis, Midfoot Plantar Fasciitis, Accessory Navicular Bone, Plantar Fasciitis, Anterior or Posterior Tibial Tendonitis, Flexor Hallucis Longus Tendonitis, Tarsal Tunnel Syndrome, Achilles Tendonitis, Calcaneal Apophysitis, Global Foot Conditions, Lateral Soft Tissue Ankle Impingement, Transchondral Fractures / Osteochondritis Dissecans of the Talus, Shin Splints, Flexor Digitorum Longus Myositis, Pes Anserine Bursitis, Unicompartmental Knee Arthritis, Popliteal Tendonitis, Leg Length Inequality, Trochanteric Bursitis, and Gluteus Medius Syndrome, etc. [35]. (My grandma, what great big words you use...!).

Later on, I will discuss some of these problems and how acupuncture and Chinese medicine can help. And even though I won't cover everything, you can experiment with some of the points discussed in order to treat different types of lower extremity conditions with just a little bit of thought and imagination.

As explained above, there are many reasons that I have chosen Superfeet footbeds over other custom orthotic devices. Of course, there are times that Superfeet are possibly not the best product for the patient. It is important to note that nothing works for everyone, and that we're not trying to take the place of foot specialists here. Similarly, just as acupuncture is very beneficial for many people, it's not for everyone or every situation, and also shouldn't be practiced by untrained professionals like podiatrists, etc. Just as I would choose a Western medical doctor over an acupuncturist in an emergency appendicitis, severe laceration, or other trauma needing immediate medical attention, etc., I would similarly choose an acupuncturist over a Western doctor for many other non-life-threatening conditions.

So, there are times when you should refer out to a DPM, orthopedic surgeon / specialist, etc. For instance, when any deformity is noticeably very severe, or the complaints are out of proportion to its appearance, this is probably time to refer out [36]. Also, the elderly, or patients with arthritis, should most likely be referred to a DPM first [37]. In addition, patients with such severe conditions (e.g., tarsal coalition and serious arthritis, etc.) that cannot tolerate a rigid neutral device should also be referred out. And here is where a weight bearing mold or cast should be made [38].

Remember, it is important not to prescribe footbeds as "cures" for particular problems, and, in general, we should be careful about using this word "cure" anytime with our patients. It's best to just "recommend" them and use your experience to guide you as to what you feel their effectiveness might be, etc., and share this with your patients. JUST BE HONEST!!

I know I said I wouldn't get too complicated, but I did leave out a tremendous amount of information that is much more complex and difficult to understand. The bottom line is that Superfeet give great support, balance, and shock absorption for the price. And this can help to decrease foot and leg problems (including the knee) as well as other upper body problems such as hip, back, neck (and even jaw and headache pain, [39]), etc. However, I will only be focusing on the problems of the lower extremities, starting with the knees first and moving down.

Chapter 5

Before discussing particular protocols for the knee, I need to first warn you about particular situations in which extreme precautions should be taken when dealing with knee pain. These are referred to as "red flags." First, beware of knee pain with fever where the area gets hot and red. This may be an infection that could be very serious; and second, if, after a trauma, the knee swells up immediately, it can indicate a ruptured blood vessel. Normal swelling should take about 20 minutes [40]. Now I can continue with a better conscience.

Figure 1 shows the specific areas of pain, tenderness, and swelling, for various knee conditions. It also names the points in these areas, which can subsequently be needled, as local points to treat the corresponding problems in the area. Needling local points can have a tremendous therapeutic effect on local pain as well as other types of conditions in the area. However, this should not take the place of having a good diagnosis of the condition at hand (TCM as well as Western).

The following are some of the causes of knee pain as recognized by TCM: (1) Trauma / Overuse: this can be local Qi or Xue Yu. For example, joggers, brick layers, housemaids, or accidents, etc; (2) External Pathogens: this is usually unilateral (worse on one side), has a sudden onset, is affected by weather changes like Wind, Cold, and Damp, and there may be swelling due to Dampness; (3) Kidney Xu: this is usually bilateral pain and occurs over a long period of time. The knees can be weak and cold, especially if there's Kidney Yang Xu; and (4) Bi / Painful Obstruction Syndrome (POS): this is usually due to Qi Zhi or an old injury, etc. [41].

Giovanni discusses POS fairly thoroughly in his book The Practice of Chinese Medicine, in which he talks about the etiology of POS as being an affliction of the channels alone due to external pathogens such as Wind, Cold, or Damp, etc., solely due to particular weather conditions [42]. However, there are other predisposing factors to POS such as excessive sports, repetitive- or over-use, and accidents (as mentioned above) which cause Qi Zhi (when mild) or Xue Yu (when serious); underlying [Qi], Xue and Yin Xu which cause malnourishment of the channels so that they become more prone to external pathogenic attack; emotional factors, like anger or resentment, which cause Qi Zhi, and thus, Qi and Xue depletion, leading to malnourishment of the channels [43]. When POS is chronic, it usually involves Liver and Kidney Xu. This can lead to the retention of Phlegm, and Xue Yu. And because the Liver nourishes the tendons and sinews, and the Kidneys nourish bone, when there are deficiencies of these organs there can be corresponding problems with their associated tissues (Phlegm can build up in the joints leading to swelling when the bones are deprived of nourishment) [44]. These etiologies may also carryover to other conditions below the knee as well.

The treatment for the different types of Bi Syndromes (POS) can be found in many Chinese medical texts including Chinese Acupuncture and Moxibustion (CMX) and PCM (cited previously). The following are some general point prescriptions for these different types of Bi Syndromes: There is Wandering, Fixed, Hot, Painful, Tendon, and Bone Bi, etc. For Wandering Bi, use UB 17 and Sp 10 to nourish Xue in order to smooth its flow to reduce wind (can combine with GB20); for Painful Bi, use UB 23 and Ren 4 to strengthen the Kidneys; for Fixed Bi, use ST 36 and SP 5 to relieve Dampness by strengthening the Spleen and Stomach; for Hot Bi, use Du 14 and LI 11; for Tendon Bi, use GB 34, the Influential point of the tendons; and for Bone Bi, use UB 11 and GB 39, the Influential point of bone and marrow, respectively [45]. In addition, you may also want to differentiate which soft tissue injuries, if any, may be causing the problem. One way to do this is using Orthopedic Neuro Evaluation (O.N.E.) testing.

O.N.E. tests are very important and should be used if you want to differentiate between the many causes of knee pain or other knee problems (as well as other lower extremity conditions). The following are the more common tests used and the conditions they diagnose (a review of each test may be warranted since test procedures will not be discussed in detail here): (1) Apley's Distraction and Compression: screen test - prone, knee flexed 90 degrees, press down (pain = meniscus problem), pull up (pain = ligament problem); (2) One-Plane Medial Instability: extension pain = PCL (Posterior Cruciate Ligament) problem, and flexion pain = MCoL (Medial Collateral Ligament) or ACL (Anterior Cruciate Ligament) problem; (3) One-Plane Lateral Instability: extension pain = LCoL (Lateral Collateral Ligament), or PCL problem, and flexion pain = LCoL problem; (4) Drawer Sign: greater than 6mm movement - straight foot - pull = ACL, MCoL, or Posterior Capsule damage; push = PCL or ACL problem; (5) Slocum Test: excessive movement - 30 degree medial rotation - pull = Anterolateral Rotary Instability; 15 degree lateral rotation - pull = Anteromedial Rotary Instability; (6) Hughston's Posterolateral Sign: push = PCL, Posterolateral Rotary Instability, or LCoL problem; (7) Posteromedial Drawer Sign: push = PCL, ACL, or MCoL problem; (8) McMurray's Test: flex-to-extend - medially rotated - pain and clicking = lateral meniscus damage; laterally rotated - pain & clicking = medial meniscus damage; (9) Clarke's Sign: for Chondromalacia patella; (10) Wilson's Test: pain = Osteochondritis Dissecans; and (11) Noble Compression Test: pain = ITB Friction Syndrome [46].

After you have a good diagnosis of the condition, you may proceed with your acupuncture (which may include Moxibustion)treatment. The following are local and distal (or proximal) points that treat knee pain and other conditions of the knee: ST 34, 35, 36, 40, 44, SP 9, 10, Ki 10, LV 7, 8, 10, GB 29, 31, 33, 34, 37, 39, UB 38, 39, 40, 58, Dalun, Heding, Jianxi, Kuangu, Lanweixue, Liaoliao, Xixia, Xiyan (medial), and any local ah shi points.

ST 44 and Xixia (located in the patellar ligament, at the middle of the inferior margin of the patella) are used for clearing inflammation; ST 35 and medial Xiyan, SP 9, LV 7 and 10 are for treating medial knee pain (SP 9 can remove fluid from the knee), ITB Syndrome, and strengthening other muscles like the vastis medialis to help the knee track better; deep insertion into knee joint via Xiyan (medial or lateral), or LV 8 (or lateral equivalent) for arthritis or meniscus problems; electro-stim into the joint has also been very effective; and for Baker's cyst, use UB 40 to drain the cyst and decrease inflammation and swelling [47].

In addition, the following points and prescriptions were compiled from Acupuncture: A Comprehensive Text (Shanghai): individual points used for knee arthritis = ST 31 and UB 40; combinations = GB 31, 33, 34; or SP 9, GB 33, 34, LV 8; or ST 34, 35, and GB 34; individual points for knee swelling = ST 34 and GB 33; individual points for knee pain or soreness = ST 34, Sp 9, UB 58, GB 37, and LV 8; individual points for any condition of the knee = ST 34, GB 39, and LV 8; and a combination for soft tissue damage to the knee = ST35, UB 40, medial Xiyan, plus any local ah shi point [48]. Points used for general pain in the knee joint are ST 35, SP 9, GB 34, medial Xiyan, and Heding [49].

In Case Studies from China, there is a case of Rheumatoid Arthritis of the knee that was treated with good success. The points used were as follows: UB 11, the meeting point of bone which is good for treating joint conditions; UB 17 to tonify and move the Blood to enhance the circulation to the affected areas, and disperse Cold and Damp; UB 23, Du 4, and Ren 6 to regulate the Kidneys, supplement the Yang, and disperse Cold and Damp (when the Kidneys are strong, the bones and joints heal more quickly); local points were used to move Qi and Blood in order to decrease pain and swelling; SI 3 and UB 62 to open the Du or Yang Qiao channels in order to treat the legs, muscles, tendons, and bone; and SP 21 and UB 17 to treat pain in general [50].

Chapter 6

Moving distally from the knee, we get to the lower leg. Here we can develop what are known as shin splints. This is defined as "pain in the anterior compartment of the tibia" which "usually follows strenuous exercise" which causes "ischemia of the muscles and minute tears in the tissue" [51]. The pain usually occurs in both legs and can be due to improper stretching, or poor shoes, poor fit, or both [52]. For lateral problems use ST 36, 41, GB 34, and 40; for medial problems, use SP 6 and 9; either can be helped by massaging the muscle away from the tibia; also tonifying Liver Blood with LV 3 and SP 6, tonifying Kidney Yin with Ki 3 and decreasing inflammation and heat with ST 44 can be very beneficial [53].

Other conditions of the lower leg can also be treated with good success: (1) leg pain: GB 31, ST 34, 37, UB 57 or 58 (calf), 62, or Ki 9 (for pain in the medial aspect of the leg); combinations = Sp 9 and GB 34; (2) leg paralysis: GB 29, 31, ST 31, 32, UB 37, 40, 57, 60, Ki 1, 3 (turned up foot), and Dannangxue; combinations = GB 30, 34, 39, or GB 31, 33, 34; (3) leg numbness: ST 31, 32, GB 29, 31, 37; (4) leg stiffness: GB 31; (5) leg Qi (edema of the leg): ST 32, GB 29, 33, 39; combinations = ST 41, SP 4, GB 40, or ST 36, SP 6 and GB 39; (6) leg swelling: ST 40; combinations = SP 9, GB 34; and (7) spasm of the leg muscle: UB 57 (twisted calf), UB 40 and Ki 9 (gastrocnemius) [54].

Chapter 7

Moving right along, we now come to the ankle. Ankle strain / sprain, usually from a twisting trauma (inversion sprain occurs approximately 90% of the time [55]), is probably the most common injury of the ankle and is defined as "a trauma to a joint that causes pain and disability depending upon degree of injury to ligaments" [56]. There is pain, swelling, and decreased ROM in the area that is usually due to injury of the sinews which causes Qi and Xue Yu in the channels, and can be treated by corresponding ah shi / local, and distal points to move Qi and Blood to decrease swelling and pain. These points are ST 41, GB 40, and UB 60 (can combo with moxibustion) [57]. The treatment principles are to decrease inflammation and re-tighten the tendons by surrounding the area of swelling with needles, bleeding with lancets, and then cupping with very small cups (glass cups are best for use in autoclaves, but you can buy a complete kit which includes 3 different sizes of plastic cups with the vacuum for under $15 in most backpacking stores. It's called The Extractor, and is used for snake and insect bites). In most cases of ankle strains, especially severe ones, I recommend seeing a Chiropractor as quickly as possible. However, you can see a Chiropractor many years after the trauma occurs with still good results. Of course, the sooner it's treated, the better the prognosis, due to the development of scar tissue as well as the natural deviations of the tendons and ligaments that develop in order to compensate for the deformity; and this can lead to a joint that will not be as strong or flexible as it was prior to the injury. Therefore, the patient will most always have a greater propensity towards twisting or re-injuring this joint.

There are, I believe, as many as 7 bones that can become out of alignment after an ankle sprain, and the adjustment of these bones is what takes place in the Chiropractor's office, which help to relieve much of the immediate pain. The adjustment can be a very painful, but usually gets the patient back on their feet immediately, and walking with less discomfort, etc. Now the healing process can take place with a structurally sound joint.

O.N.E. tests can also be done with the ankle in order to make a more correct diagnosis: (1) Anterior Drawer Sign: lateral movement = medial ligament problem; medial movement = lateral ligament problem; (2) Talar Tilt: pain = calcaneofibular ligament damage; (3) Kleiger Test: pain = deltoid ligament damage; (4) Thompson's Test: absence of plantar flexion = ruptured Achilles tendon [58]. Once you've made a good diagnosis, you can begin your treatments.

The specific points used for lateral ankle problems are UB 60, GB 40, 41, ST 41, ST 36 and GB 34. For medial ankle problems, use Ki 3, LV 3, 4, SP 6 and 9 [59]. Other points and combinations for the ankle (and the foot in general) are as follows: for ankle joint diseases use Sp 5, UB 60, GB 39 and 40; for soft tissue injuries of the ankle: ah shi points + GB 39 (lateral injury) or SP 6 (medial injury); for soreness of the joints of the extremities, combine LI 4, 11, ST 36 and LV 3; for general swelling of the foot or ankle: GB 41, or combine UB 60, 62 and Ki 3; for ankle pain, combine UB 60, GB 39 and 40; for pain in the foot or ankle use ST 41, SP 4 or Ki 3 (for soles); for pain or difficulty walking use ST 36, LV 3 and 4; for general foot pain, combine ST 41, SP 5 and GB 40; for foot arthritis use UB 62; for pain at the soles of the foot use ah shi points + UB 57, 60, Ki 3 + Qi and Xue Yu points; for numb feet (neuritis), combine UB 60, GB 35, 38, 39, 40 and LV 2; for inflammation of the dorsum of the foot or toes use Bafeng points; for pain in the toes, combine Ki 1 (for tips), 2 and LV 3 [60].

CMX discusses a few points that can also be used. For numbness / pain in the leg: UB 57 and 58; for ankle pain: ST 41, SP 5, UB 60, Ki 3 and GB 40; for numbness / pain in the toes: SP 4, UB 65, Bafeng points; and for pain in general: SI 3 / UB 62, LI 4, 11, 15, ST 41, SP 21, UB 17, SJ 4, GB 30, 34 and 39 [61].

For more specific foot conditions use the following points: for heel spurs and plantar fasciitis use UB 61, Ki 5, and Bafeng points; for bone spurs, treat at the sight of the pain and needle right to the bone and electro-stimulation to Ki 5 (prognosis = 5-6 treatments); for sesamoid bone problems use SP 3 and needle under the bone; for pain in the ball of the foot (Metatarsophalangeal joint), such as bunions, you can tonify Liver and Kidney, surround the bunion with needles at SP 2, 3 and LV 2, 3, and electro-stimulation between these points [62]. Bunions have also been treated with success (decreasing pain, muscle spasms, and swelling in the joint), as noted in the American Journal of Acupuncture, using SP 4 and 5, plus three painful points above the bunion on the lateral, medial, and proximal sides, into which the needles are inserted through the periosteum directly into the bunion for 7-16 treatments (once a week) [63].

Chapter 8

This concludes the treatment of thedifferent types of lower leg conditions using the regular channels / points. However, there are other micro systems that you may incorporate into your treatment plan for these (and other) conditions. The ear, for example, is a great complimentary system that can be used for the previously discussed conditions. Some of the points you might use are ankle, knee, knee joint, heel, toe, gastrocnemius, popliteal fossa, Kidney, Liver, bone, relax muscles or sympathetic for an analgesic / anesthetic effect, or hormone or sub cortex for inflammatory problems, etc. There are other micro systems on the hands and feet, etc. that may be beneficial. However, at this time, I am not knowledgeable enough to discuss their use.

Chapter 9

There are many different individual herbs and formulas that can be used for the treatment of lower extremity conditions, especially those involving pain. The herbal information below is very brief and fairly basic, but should give the reader enough information to get started in the treatment of these conditions. Dosages will not be included here due to the large discrepancies between the different authors, as well as the individual needs of each patient. You may find this information in the PCM text, as well as other herbal texts like Materia Medica and Formulas and Strategies by Dan Bensky, et al, etc.

Herbs can be used for both acute or chronic conditions, and especially when there is chronic pain. There are many different individual herbs or formulas that can be used depending on what is causing the pain. Is it Wind, Cold, Damp, Heat Bi, Qi or Xue Xu or Yu, Phlegm in the joints, or Liver / Kidney Xu, etc.? When there's chronic pain, you may want to resolve Phlegm, move Xue, or nourish the Liver / Kidney [64]. There will be an overlap with some of the following herbs, which have many important functions.

The individual herbs that are used to treat acute conditions due to Wind-Dampness can be broken up into warm and cold categories. The warm ones are Du Huo, Wu Shao She, Hai Feng Teng, Wu Jia Pi, Can Sha, Mu Gu, Song Jie, Tian Xian Teng, and Wei Ling Xian. The cold ones include Xi Xian Cao, Fang Ji, Qin Jiao, Sang Zhi, Hai Tong Pi, Si Gua Luo, Kuan Jin Teng, Luo Shi Teng, and Ren Dong Teng (AKA Yin Hua Teng) [65].

There are herbs that can generally be used to nourish the tendons or bone, which will help some of these lower extremity conditions. These include Wu Jia Pi, Ji Xue Teng, Sang Ji Sheng, Du Zhong, Nui Xi, Xu Duan, Bu Gu Zhi, Gu Sui Bu, and Yin Yang Huo; Cang Zhu and Huang Bai treat the legs and knees more specifically [66]. Gou Pi Gao (Dog skin Plaster), patent #86, has been used with good success for ligament, tendon, and meniscus tears or damage, etc. It has been suggested by Alex Tiberi, one of my teachers at PCOM, to not apply Dog skin for more than 12 hours at first, to see if there is any skin reaction, etc. [67]. (Jake Frakin's Patent Guide says only to wear for 10-20 minutes).

Other herbs can be used specifically for POS, whether acute or chronic. These are Ji Xue Teng, to nourish Blood, for chronic POS with underlying Xue Xu; Fang Feng, to resolve Damp, for Damp POS; Du Zhong, to tonify Yang, for Cold POS, especially in the lower extremities; Niu Xi, to move Blood, for chronic POS of the lower back and knees; Dang Gui, to nourish Blood, for chronic POS with underlying Xue Xu; Sang Ji Sheng, to nourish Liver Blood, for chronic POS with underlying Xue Xu; Bai Zhu, to tonify Qi and dry Damp, for Damp POS; Cang Zhu, to dry Damp, for Damp POS; Ru Xiang, to move Blood, for chronic POS with underlying Xue Yu and very painful and stiff joints; Yi Yi Ren, to drain Damp, for Damp POS with swollen joints; Mu Tong, to invigorate the Connecting channels, for hot POS with numbness of the limbs; and Lu Jiao, to tonify Kidney Yang and strengthen the Du Vessel, for chronic POS with underlying (Kidney) Yang Xu and internal Cold [68].

Some herbs specifically affect the limbs and are used for POS in the fingers, wrist, elbow, knee, ankle, and toes. These are Sang Zhi, Ji Xue Teng, Luo Shi Teng, Tian Xian Teng, Kuan Jin Teng, Hai feng Teng, and Ren Dong Teng (or Yin Hua Teng); "most vines (recognizable by the term Teng in their Chinese name) affect the limbs" [69].

Other herbs (insects and animal substances, as well) also have an important role in the treatment of chronic POS, especially in the elderly. For Cold-Dampness, use Wu Shao She and Can Sha, combined with Fu Zi and Cang Zhu; for heat patterns, use Di Long combined with Shi Gao; for phlegm, use Jiang Can, combined with Dan Nan Xing and Ban Xia; for Xue Yu, use Di Bie Chong, combined with Hong Hua and Tao Ren; for severe pain, use Quan Xie and Wu Gong, combined with Yan Huo Suo; and for joint swelling, use Fang Feng and Jiang Can, combined with Yi Yi Ren [70]. These herbs give the ability to modify or fine-tune a base formula in order to make it even more individual or personal for each of the different patients that we treat. This is one of the reasons, which makes herbal therapy so versatile and powerful.

The following are some of the more important basic raw herb formulas that may be used for these lower extremity conditions: for Wind POS, expel Wind and remove obstructions from the channels (ROTC) using Fang Feng Tang or the Empirical Prescription from Dr. Jiao Shu De (see Giovanni for the different types of herbs used according to the different patterns); for Cold POS, warm the channels, scatter Cold, expel Wind and eliminate Dampness using Wu Tou Tang, Wu Fu Ma Xin Gui Jiang Tang, or Gui Zhi Fu Zi Tang; for Damp POS, drain Damp, ROTC, expel Wind, and scatter Cold using Yi Yi Ren Tang, Chuan Bi Tang, Ma Huang Lian Qiao Chi Xiao Dou Tang, Gui Shao Xi Cao Tang, or San Miao San; and for Hot POS, clear heat, ROTC, expel Wind, and drain Damp using Bai Hu Jia Gui Zhi Tang, Xuan Bi Tang, Xi Jiao San, etc. [71].

These particular heat patterns can also be looked at using the 4-Level theory, which includes the Wei, Qi, Ying and Xue Levels. For Wei Level conditions you can use Yin Qiao San + Luo Shi Teng and Si Gua Luo (for lower extremity conditions, add Nui Xi); for Qi Level (Heat) use Bai Hu Tang + Huang Qin, Zhi Zi, Lian Qiao, Qin Jiao, Si Gua Luo, and Ren Dong Teng; for Qi Level (Damp-Heat) conditions use Lian Po Yin + Huang Qin, Huang Bo, Yi Yi Ren, Fu Ling, Zhu Ling, Xi Xian Cao and Ren Dong Teng (for lower extremity conditions, add Cang Zhu, Niu Xi and Fang Ji); for Ying Level conditions use Qing Ying Tang + Dang Gui, Sang Zhi, Ji Xue Teng, Xi Xian Cao and Dan Shen; and for Xue Level conditions use the prescription of Dang Gui, Chi Shao, Dan Shen, Di Gu Pi, Qing Hao, Chai Hu, Dang Shen, Bai Zhu, Huang Qi, Sang Zhi, Qin Jiao, Bie Jia and Wu Shao She (if Xue Yu, add Hong Hua and Tao Ren) [72].

Many of these above formulas are usually used for acute POS conditions. However, many of the POS conditions seen in clinic are usually of a more chronic nature, and therefore usually involve both channels and organs, and usually stem from an external pathogenic invasion of Wind-Cold-Damp [73]. I have already discussed the factors that are involved in chronic POS, so the following formulas will be used depending on the pattern that is involved.

For Qi, Xue, or Liver / Kidney Xu, expel the pathogenic factors, tonify Qi and Xue, and nourish the Liver / Kidney using Du Huo Ji Sheng Tang, Qin Jiao Si Wu Tang, or the formulas by Jiao Shu De or Zhu Dan Xi (see Giovanni); for Phlegm stagnation in the joints, resolve phlegm, eliminate stasis, expel Wind, and ROTC using Tao Hong Yin (modification); and for Xue Yu in the joints, use Huo Luo Xiao Ling Dan; etc. [74].

Both acupuncture and Chinese herbs can be extremely effective in the treatment of POS (and other conditions involving the lower extremities, etc.). Acupuncture, in general, is usually better for the more acute conditions, and herbs are generally more applicable with chronic conditions, especially when Phlegm or bone deformities are involved, or there is Xue Yu or Liver / Kidney Xu. As far as prevention goes, since POS can be due to the weakening of Qi and Blood, as well as a Liver / Kidney Xu as we get older, diet and exercise can minimize or prevent these conditions altogether [75].

Chapter 10  

The following are brief dietary recommendations that may be incorporated into ones lifestyle, depending on the particular pattern. If the POS is due to Cold, don't eat cold foods like raw vegetables or fruits. In addition, avoid cold or iced drinks because these cold substances can create internal Cold, which can increase pain, especially in the joints [76]. So, eat more warming foods like ginger, garlic, warm spices (moderate amounts), or small amounts of alcohol like brandy, wine (grape or rice), or cognac (approx. 5-15 ml / 1/6 - 1/2 oz.), etc. This can help to stimulate the circulation in the channels and expel cold [77]. If POS is due to Damp, avoid dairy products such as milk, cheese, butter, ice cream, peanuts, and bananas, as well as greasy / fried foods, etc.; if POS is due to Xue Xu, eat foods that tonify the Blood like carrots, rice, chicken soup, & beets, etc.; if POS is due to Heat, avoid hot or spicy foods such as beef, lamb, game meat, alcohol, garlic, ginger, and other spices; for general POS, avoid sour foods like yogurt, pickles, vinegar, rhubarb, goose berries, oranges, and other citrus, etc. since these tastes can upset the Liver which may cause constraint leading to pain [78].

These are just some general dietary guidelines that can be used for POS or other lower extremity conditions. If the reader is interested in more specific information, they might consult Paul Pitchford's extensive work on nutrition from a Far Eastern perspective: Healing with Whole Foods (see Bibliography). His work discusses the properties of specific foods, healing methods to treat particular TCM patterns, as well as how to eat with the seasons, etc. Just as diet is important in keeping healthy, so too is exercise. An old Chinese saying says a moving door hinge gathers no worms (paraphrase).

Chapter 11

Regular exercise has been known for many years to be very important in the preservation of good health and to keep one flexible and mobile. Exercise (like certain warming foods, etc.) helps to stimulate the circulation of Qi and Blood and keep the sinews supple, helping to keep the different types of external pathogenic invasions to a minimum [79]. Tai Ji Quan, Qi Gong, and even Yoga, are good because they're not high impact (external) exercises like weight lifting, jogging, racquetball, tennis, or aerobics, etc. These are more internal exercise which help to develop Qi as well as to stimulate the internal organs with breathing, massage, and other movements, etc., as well as to help calm the mind which can also play a role in the health of the organs and channels, etc. [80].

The combination of both of these types of exercises is probably the most beneficial. However, jogging, racquetball, weight-lifting, and high-impact aerobics should probably be avoided since they can put stresses and strains on the knees, ankles, and back, etc., weaken Kidney Qi (heavy lifting), and create stress and tension (e.g., a fast-paced game like racquetball or squash, etc.) [81]. Walking, swimming, tennis, and bicycling are some exercises you might choose to do that have less impact. Just remember not to overdo it, especially at first. And more important, do what you like to do, not what you think you should be doing. In other words, HAVE FUN!!

Conclusion

In conclusion, I feel that foot biomechanics plays an important role in the prevention and treatment of many lower extremity conditions, and the way to attain this, especially with minimal cost, is with Superfeet footbeds. I basically feel that Superfeet should be worn in every shoe that they will fit into, and be worn as much as possible. I also feel that the Custom Sport High Profile type would be best for everybody, but the trim-to-fit inserts, bought right off the shelf, are probably better than any other pre-fabricated insert on the market. I think they will help decrease, or eventually eliminate, problems such as knee pain, heel spurs, shin splints, bunions, plantar fasciitis, hip pain, back pain, and neck pain, etc. However, the main thing that I want the reader to get from this paper is that having good support can not only help to alleviate pain and discomfort in the feet and lower extremities, etc., but also give us more comfort, as well as more energy and efficiency in our stride, so that it takes less work to get around. And doesn't everyone want to work less, be more comfortable, have more energy, and be in less pain? I think so!

Superfeet Break-in Guidelines

The following is important break-in information that I give to new Superfeet owners:

You have just purchased the world's best non-prescription footbed. In order to ensure that you get the best experience from your Superfeet, we have some recommendations:

First, do not wear your Superfeet for more than 2 hours per day for the first week. Then, if you don't have any significant problems, you can increase 1-2 hours every few days or so until you're wearing them all day long, every day, in any shoe you can get them to fit into. This break-in procedure is important not because you're going to have a problem, but if you do, you won't freak out and want to trash your Superfeet because you now know it can take some time getting accustomed to them, allowing your bones, muscles, tendons and ligaments to slowly get use to being in a different (better) position than they're normally in. You may need to adjust your break-in time to a longer one if you have low or fallen arches, or feet that heavily pronate (turn to the inside). These possible negative effects can be anything from slight or early foot fatigue to sharp pain. Usually significant pain doesn't occur. Some people can wear them all day, right away, and never have problems (we don't recommend this); and others may need a month or more to adjust fully. Just be patient!

Second, try to wear your Superfeet as much as you can because it's not just getting your footwear to fit better, it's giving your foot better support, and this will help you biomechanically so you have a more efficient stride, increased lower extremity strength, and your subtalar (ankle) joint will be in a more correct position, forcing the rest of your joints (knee, hip, back, neck, etc.) into a better position, preventing potential stresses and pains in these areas. Also, by wearing them in your other shoes, you won't have to keep going through the break-in procedure; and your Superfeet aren't doing your feet any good in the closet! If you follow these simple guidelines and are still not satisfied with your Superfeet, you can return them for a full refund.

References

1. Black, Edwin, Biomechanics: Secrets of Body Motion (BSBM), Stride, Vol.1, No.1, 1996, p.1.
2. Clayton, Thomas L., M.D., M.P.H., ed., Taber's Cyclopedic Medical Dictionary, 17th ed., F.A. Davis
Co., Philadelphia, 1993, p.1375.
3. Biomechanical Technical Manual, Superfeet In-Shoe Systems, Inc., 1988, p.4.
4. Smith, Christopher E., D.P.M., Professor of Biomechanics at California College of Podiatric Medicine, Biomechanics, written for Superfeet In-Shoe Systems, Inc., Seattle, WA, 1993, ch.1, pp.1-2.
5. Ibid, p.7.
6. Ibid, p.8.
7. Ibid, p.9.
8. Ibid.
9. Ibid, Ch.1, p.9 and Ch.4, p.2.
10. Ibid, ch.2, p.2.
11. Ibid, p.7.
12. Hamill, Joe, Ph.D., and Derrick, Timothy R., The Mechanics of Foot Orthoses for Runners (MFOR), Biomechanics, Vol.3, No.2, February, 1996.
13. Biomechanics, op. cit., Ch.2, p.8.
14. Ibid, ch.4, p.8.
15. Ibid, p.2.
16. Ibid, p.4.
17. Taber's, op. cit., p.279.
18. Biomechanics, op. cit., ch.10, p.1.
19. Black, Edwin, The Truth About Insoles, Stride, Vol.1, No.1, 1996.
20. MFOR, op. cit.
21. Ibid.
22. Biomechanics, op. cit., Ch.10, p.2
23. Ibid, ch.9, p.2.
24. Ibid, Ch.10, p.2.
25. Ibid.
26. Ibid.
27. Ibid.
28. Ibid, p.5.
29. Mark Sanders, California Superfeet Representative.
30. Biomechanics, op. cit., ch.10, p.3.
31. Taber's, op. cit., p.844.
32. Ibid, p.1239.
33. Ibid, p.863.
34. Ibid, p.293.
35. Reiley, Mark A., M.D., Guidelines for Prescribing Foot Orthotics, SLACK Professional Book Publishing, www.slack, 1996.
36. Biomechanics, op. cit., ch.10, pp.4-5.
37. Ibid, p.4.
38. Ibid.
39. BSBM, op. cit.
40. Tiberi, Alex, Oriental Clinical Medicine (OCM), Class Lecture Notes, Pacific College of Oriental Medicine (PCOM), San Diego, CA., winter, 1996, p.21.
41. Maciocia, Giovanni, The Practice of Chinese Medicine (PCM), Maciocia, Churchill Livingstone, Edinburgh, 1994, p.599.
42. Ibid, p.563.
43. Ibid, pp.563-564.
44. Ibid, p.565.
45. CMX, op. cit., pp.439-442.
46. Lara, Cliff, D.C., Orthopedic Neuro Evaluation, Class Lecture Notes ("Cliff Notes"), PCOM, San Diego, CA., Fall, 1994, pp.90-93.
47. OCM Notes, op. cit., p.20.
48. O'Connor, John, and Bensky, Dan, trans. & ed., Acupuncture: A Comprehensive Text (Shanghai), Shanghai College of Traditional Medicine, Eastland Press, Seattle, 1981, pp.262-305.
49. Xinnong, Cheng, ed., Chinese Acupuncture and Moxibustion (CMX), Foreign Language Press, Beijing, 1987, pp.441-442.
50. Jirui, Chen, M.D., and Wang, Nissi, M.Sc., ed., Acupuncture Case Histories from China, Eastland Press, Seattle, 1988, p.156.
51. Taber's, op. cit., p.1792.
52. Cliff Notes, op. cit., p.105.
53. OCM Notes, op. cit., p.21.
54. Shanghai, op. cit.
55. Cliff Notes, p. 103.
56. Taber's, op. cit., p.1857.
57. CMX, op. cit., p.481.
58. Cliff Notes, op. cit., pp.102-103.
59. OCM Notes, op. cit., p.21.
60. Shanghai, op. cit.
61. CMX, op. cit., pp.441-442.
62. OCM Notes, op. cit., p.22.
63. Sternfeld, M., Finkelstein, Y., Eliraz, A., et al, Symptomatic Improvement and Anatomical Regression of Hallux Valgus Deformity (Bunion), American Journal of Acupuncture, Vol.20, No.1, 1992, p.9.
64. PCM, op. cit., p.565.
65. Ibid, p.572.
66. OCM Notes, op. cit.
67. Tiberi, Alex, Oriental Medicine 6 Class Lecture Notes, PCOM, San Diego, CA., spring, 1995, p.32.
68. PCM, op. cit., p.573-574
69. Ibid, p.573.
70. Ibid, pp.573-574.
71. Ibid, pp.574-580.
72. Ibid, p.581.
73. Ibid, p.582.
74. Ibid, p.582-585.
75. Ibid, p.602.
76. Ibid, p.603-604.
77. Ibid.
78. Ibid.
79. Ibid, p.602-603.
80. Ibid.
81. Ibid.

Bibliography

1. Black, Edwin, Biomechanics: Secrets of Body Motion (BSBM), Stride, Vol.1, No.1, 1996, p.1.
2. Black, Edwin, The Truth About Insoles, Stride, Vol.1, No.1, 1996.
3. Biomechanical Technical Manual, Superfeet In-Shoe Systems, Inc., 1988.
4. Bensky, Dan, and Barolet, Randall, compiled and trans., Chinese Herbal Medicine: Formulas and Strategies, rev. ed., Eastland Press, Seattle, WA, 1990.
5. Bensky, Dan, and Gamble, Andrew, compiled and trans., Chinese Herbal Medicine: Materia Medica, rev. ed., Eastland Press, Seattle, WA, 1993.
6. Clayton, Thomas L., M.D., M.P.H., ed., Taber's Cyclopedic Medical Dictionary, 17th ed., F.A. Davis Co., Philadelphia, 1993.
7. Frakin, Jake, Chinese Herbal Patent Formulas: A Practical Guide, Shya Publications, Boulder, CO., 1986.
8. Hamill, Joe, Ph.D., and Derrick, Timothy R., The Mechanics of Foot Orthoses for Runners, Biomechanics, Vol.3, No.2, February, 1996.
9. Jirui, Chen, M.D., and Wang, Nissi, M.Sc., ed., Acupuncture Case Histories from China, Eastland Press, Seattle, 1988.
10. Lara, Cliff, D.C., Orthopedic Neuro Evaluation, Class Lecture Notes ("Cliff Notes"), PCOM, San Diego, CA., Fall, 1994.
11. Maciocia, Giovanni, The Practice of Chinese Medicine (PCM), Maciocia, Churchill Livingstone, Edinburgh, 1994.
12. O'Connor, John, and Bensky, Dan, trans. & ed., Acupuncture: A Comprehensive Text (Shanghai), Shanghai College of Traditional Medicine, Eastland Press, Seattle, 1981.
13. Pitchford, Paul, Healing with Whole Foods: Oriental Traditions and Modern Nutrition, North Atlantic Books, Berkeley, CA., 1993.
14. Reiley, Mark A., M.D., Guidelines for Prescribing Foot Orthotics, SLACK Professional Book Publishing, www.slack, 1996.
15. Smith, Christopher E., D.P.M., Professor of Biomechanics at California College of Podiatric Medicine, Biomechanics, written for Superfeet In-Shoe Systems, Inc., Seattle, WA., 1993, ch.1, p. 1-2.
16. Sternfeld, M., Finkelstein, Y., Eliraz, A., et.al., Symptomatic Improvement and Anatomical Regression of Hallux Valgus Deformity (Bunion), American Journal of Acupuncture, Vol.20, No.1, 1992.
17. Tiberi, Alex, Oriental Clinical Medicine (OCM) Class Lecture Notes, PCOM, San Diego, CA., Winter, 1996.
18. Xinnong, Cheng, ed., Chinese Acupuncture and Moxibustion (CMX), Foreign Language Press, Beijing, 1987.