Is Your Patient’s Lower Back Pain Stemming From Their Feet (Part 3)

Happy Friday everyone and welcome to the next episode. Today we’re going to just really hop right in and talk more about how your patient’s feet may be causing their lower back pain.

So, up to this point, we’ve talked about a forefoot valgus, which turns into a Pes cavus foot. We’ve talked about an uncompensated rearfoot varus, how that causes lower back pain and so I’d highly recommend that you tune into those podcasts.

Today we’re going to talk about a compensated rearfoot varus and a compensated forefoot varus.

So, these two types of feet are pretty similar except one’s more extreme. A compensated rearfoot varus foot is a foot that is flat and so is a compensated forefoot varus.

The big thing to note about this is the first foot, the compensated rearfoot varus. They do not have a forefoot issue. They have a rearfoot issue.

They are stuck in rearfoot eversion or inversion, but they have enough mobility at the subtalar joint to compensate.

Now, conversely, the foot I talked about the other day in part two, are stuck in a rearfoot varus, but they do not have the ability to pronate.

They don’t have the mobility, the subtalar joint from the axis in the rotation of that joint. It’s just, you’re not going to get much pronation there.

So, the big difference is, with this compensated rearfoot varus foot can pronate. It’s going to try to get its foot flat as compensation.

So, they’re going to protonate naturally excessively and they’re going to typically pronate through midstance and terminal stance. Now the other end of the spectrum is this forefoot varus or compensated forefoot varus foot.

So if you were to put them in subtalar neutral and look at the forefoot to rearfoot angle, you’ll see that the forefoot is in a varus position.

Because of this varus, this foot can compensate because they have enough motion at the rearfoot. They will actually, again, pronate, but it’s a little bit more excessive.

So this is what we call typically an F foot or failed foot, although they create similar manifestations up the chain with the lower back.

Let’s break it down as far as what happens and then we can go from there.

The first one, when we take a step in the normal gate, we want to have a heel strike where a foot is relatively inverted and as you go into that loading response, then that foot should prone it to the ground to stimulate tibial rotation, femoral internal rotation.

If you’re going to get then the pelvis rotating and get an opposite side trunk rotation.

But what happens with this, typically, if the foot is not controlled, it’s going to be excessive.

Unless you’ve got some stability up the chain, whether it be the muscles, neuromuscular control to help control this. In both cases, the foot is going to go through these patterns.

Now conversely, when I go to midstance and terminal stance when my foot should start to lock up and start to supinate, they either don’t or they don’t get enough.

What that does is, it doesn’t create the rigid lever that we’re needing for propulsion. So you typically see a toed out gate a little bit, because of the splaying of the foot and their foot staying in the eversion.

So you’re not going to get potentially true dorsiflexion, they’re going to get it because the rear foot is staying everted, you are going to get a lot of it at the midtarsal joint still.

So the dorsiflexion really isn’t going to happen. Because of that, you’re not really going to get that windlass mechanism.

So then, the big toes are going to get chewed up here and eventually have hallux rigidus or limitus.But then the big thing is, again, you’re not going to be able to get that internal rotation at terminal stance because the pelvis isn’t going to be able to rotate around.

The knee is going to stay relatively flex. You’re going to get knee extension. On top of it, you’re not going to be able to get hip extension.

This type of patient, again, is going to have a lot of lower back pain because they’re not able to extend the abductor in front and rotate during the propulsion phase, and nor are they going to have the strength typically in the glute to propel off.

So again, they’re getting more than lumbar extension moment that is going to just chew up their back over time.

In the same token to that, just from a postural standpoint, if this person is just standing. So in the opposite, posture has its time and place. It’s big, it’s highly debated.

Does posture cause back pain and I would argue it does with certain people and other people not? But typically we’re moving from posture to posture.

We don’t typically want to think about pathology in a static realm per se, but it does influence function. When someone is in this type of foot, again, you’re going to be in more of the pronated feet.

You’re going to see tibial internal rotation, femoral internal rotation. You’re going to have the pelvis and that’s going to anteriorly rotate and that’s going to then really lock up L four, five, and S one and more the extended position.

So this person is typically going to be more lordotic and if you have, potentially, someone who has stenosis or facet dysfunction, these are things you want to correct potentially because it’s going to change muscle imbalances around the pelvis.

It’s going to mutate the sacrum, which then is going to compensate and get an extension of the lumbar spine, which is going to compress the facet joints.

It’s going to limit rotation of the lower back at those lower segments because the facets are locked up and you may even have some foraminal narrowing for a patient that may be older.

So needless to say, you’re going to have some dysfunction there at those segments. But even then above that, because those segments are locked up, you’re going to maybe have some hypermobility at the other segments.

You’re going to have thoracolumbar dysfunction, you may have painful irritation there.

As you can see, the foot gait is very powerful and it can create an array of problems, up or down the chain.

If you’re not clearing up some of these patients’ back pain, I would advise you to review these past podcasts and look at how the foot is affecting, potentially, that lower back.

So if you’re usually missing something, that’s usually down with the feet, because I think as clinicians we think it’s too far away and it’s too far-fetched and it’s really not.

It starts with the feet.

They set the normal reaction up and down the chain. They provide the stability or mobility for the shank to do its part. So if that’s not doing its job, then how do you expect the lower back to do its job in regards to function?

So, there you have it. Use these techniques in clinical reasoning to help your patients.