When Lower Extremity Dysfunction Contributes To Back Pain

George C. Trachtenberg, DPM

Offering biomechanical insights on how back pain may be triggered by secondary postural changes and altered gait compensations from foot dysfunction, this author emphasizes assessment of the sagittal plane and a better understanding of the impact of lumbar spine flexion.

Consider that individuals walk anywhere from 2,500 to 15,000 steps per day.1 If any one of those individuals has a biomechanical foot dysfunction, the resulting abnormal movement and function can and will alter gait, putting stress and strain on muscles, bones and joints in regions of the body remote to the foot.

   When this altered gait is repeated day after day, week after week and year after year, it ultimately weakens muscles and joints, causing pain, arthritis and increased susceptibility to injury.

   As the decades pass and podiatric biomechanics is seemingly better understood, the significant influence gait abnormalities can have on musculoskeletal symptoms and dysfunctions in the proverbial “kinetic chain,” as a result of secondary postural changes, becomes more apparent. No longer should we isolate our thinking to the pathological effects these gait abnormalities create within the foot. We also need to consider the effects of these gait dysfunctions proximal to the foot.

   Indeed, foot dysfunction may be the etiology or a contributing factor in many pathological conditions, including those affecting the back, hips and knees as well as other joints, bones and muscles. As a result of these postural changes, there is subsequent redistribution of ground reactive forces and the forces altered and redirected via compensations and the repetitive movements involved in gait.

   If a patient has a condition (i.e. a painful lower back) proximal to the foot and it is aggravated during or after walking or standing, that may be a good indicator that foot dysfunction is the cause or a contributor to the problem. If this is the case and there are obvious podiatric biomechanical dysfunctions (even in the absence of pain in the feet), one can prevent serious conditions from developing proximally in the kinetic chain. If these serious conditions are already present, the use of appropriate podiatric biomechanical treatment can help manage these conditions, alleviate pain and provide an environment to prevent further deterioration in these regions.

   Although this article may be subject to controversy among some of my peers, I write from a perspective of 18 years of experience of using podiatric biomechanical means to eliminate or reduce low back pain in patients to the point where their lives and activities were restored to an acceptable level and often to a non-problematic state.

Why Back Pain Treatment Fails And Where Foot Dysfunction Fits Into The Picture

Recent statistics revealed that low back pain and dysfunction in the United States was in excess of a $60 billion industry.2 More astounding were other statistics that indicated that 71 percent of all low back surgeries failed.2-3 In fact, an ICD-9 code for “failed back surgery” was created. Interestingly, the 29 percent of individuals who had initial success with their back surgery often began having some level of symptoms again within the first 14 months after their surgery.2-3


Very informative and important paper.

I would just like to add that flexion of the spine can also be a result of the pelvis rotating posteriorly, which is called a posterior innominate. Comparing the PSIS to the ground in neutral calcaneal stance position to relaxed calcaneal stance position will help in ascertaining how orthoses will help in unilateral cases.

I am presently doing a study on the relationship of the lateral talus subluxation to the posterior innominate.

Eventually, we should become part of the team to treat the back.

Are there any recommendations for soft vs hard heel lifts in back pain?

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