When Lower Extremity Dysfunction Contributes To Back Pain

George C. Trachtenberg, DPM

   What perpetuates some of the failures seen in the treatment of low back conditions? One, back surgeons may not be aware of the possibility of lower extremity biomechanical causes of back pain. Secondly, I think traditional medical thinking has developed into a paradigm in which we see more treatment of symptoms and test results rather than treating people and their conditions. Lastly, I think we often treat our podiatric patients that have biomechanical disorders by directing foot motion in the incorrect plane needed in particular cases or by using corrective posts that may be stabilizing the wrong plane, thereby often creating a wonderful supportive environment but a less than optimal movement environment for their given condition.

   In my experience, I have found that back pain responds favorably with appropriate podiatric biomechanical care in a large number of patients. In fact, I think that most low back dysfunctions that are not caused by a congenital back abnormality or a substantial local injury — falling out of a moving truck or some other significant event causing a truly localized traumatic episode — are the result of walking dysfunction. Another scenario is the patient who has had a previous, legitimate, traumatic injury to his or her back that never seems to heal or dissipate. This may be the result of a walking dysfunction that interferes with the recovery of the injured area.

   Dananberg published a study involving patients who were considered to have “end-stage” low back dysfunction.3 He found that the use of appropriate orthoses either improved their back pain by 84 percent or lead to them being pain-free, and they were able to maintain those results. There is a known 71 percent recurrence rate at 12 months (for those who had back surgery). The results were equally astounding considering those patients had symptoms for years and had previously been treated with various modalities, including surgery.

   When you consider these statistics and study findings, it seems that a significant number of low back dysfunctions may have been caused by foot dysfunction.2,3 Dananberg’s study also suggests that many back conditions may be caused or influenced by “repetitive motion” of abnormally functioning feet, resulting in secondary gait-related postural compensations responsible for the low back pain.3 Dananberg’s study also suggests that patients who had injuries to their backs 20 to 40 years ago, as some of those who were included in the study, were likely not getting better because their repetitive dysfunctional gait disturbances had not yet been addressed.3

Emphasizing Assessment Of The Sagittal Plane

Getting back to the point about treating test results rather than patients, we often see findings on X-rays and MRI studies that seem abnormal but are in fact incidental findings that are revealed during the course of evaluating the patient for a different condition. Additionally, is it reasonable to question some of the findings observed on these imaging studies, particularly when it comes to backs, if they are done with the patient recumbent — as patients usually are with MRIs — when in fact their symptoms often only occur during standing, walking and/or sitting?

   So, ultimately, what is the real value of these imaging findings? Additionally, how many patients do you see who have normal tests but significant symptoms? This is not necessarily uncommon in many people with low back pain. Many people with low back pain often see many different practitioners and have various tests performed, often resulting in no significant findings. I have seen many of these types of patients and what they generally have in common are podiatric biomechanical dysfunctions, particularly those dysfunctions that involve limitations of motion in the sagittal plane.


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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