Lower Leg and Foot Regional Pain and Gait Deviations

Original Editor - Stacy Schiurring based on the course by Damien Howell

Top Contributors - Stacy Schiurring, Kim Jackson, Lucinda hampton and Jess Bell

Introduction

given a patient that's complaining of a pain in a particular region, what gait deviations might you expect that we're going to deal with? What interventions can we apply to those gait deviations or verbal cues? And then finally, what side effects, potential side effects, are there for those chosen interventions for the gait deviations?

Lower Leg Regional Pain

Region of Pain	Relavent Diagnoses	Expected Gait Deviations
Calf	Medial tibial stress syndrome Stress fractures Posterior tibial tendinopathy	Too long a step Increased knee extension at heel rocker or foot strike Prolonged heel off or delayed heel off in terminal stance Loud foot strike Increased pronation Heel whip, medial or lateral
Achilles	achilles pain Achilles tendinopathy	Increased forward lean of the trunk or centre of mass (COM) Increased vertical oscillation of COM ("bouncy gait") Foot crossing the midline of the body during walking and or running Prolonged or delayed heel off (due to Achilles tendon and or calf muscle being too long with a length-associated muscle weakness status post Achilles tendon rupture, status post Achilles tendon lengthening, or due to overly aggressive calf stretching exercises) Early heel off (due to achilles and gastroc soleus is short and stiff) Increased hip and associated knee extension in terminal stance Excessive toe out relative to the line of progression foot Excessive pronation

The next pain syndrome I want to talk about is plantar heel pain syndrome. This is a problem that I have had a particular interest in over the years, and I have some opinions I would like to share with you. Professional guidelines and protocols from the American Physical Therapy Association, Orthopaedic Section, the orthopaedic surgeon society, the podiatry society, all of the guidelines that are, the majority of the guidelines that are available describing what evaluation procedures and treatment procedures are clinically proven to be effective for plantar heel pain syndrome, when you look at them, I've not found any of them that recommend gait analysis as part of the evaluation process or gait training, but plantar heel pain syndrome is associated with gait. So we should include gait analysis and I believe gait training as evaluation and treatment for plantar heel pain syndrome. I also believe that plantar heel pain syndrome we need to include in differential diagnosis, whether there is a tendinopathy of the intrinsic plantarflexor muscles. It's commonly assumed that plantar heel pain is a tissue diagnosis of the plantar fascia directly adjacent and directly deeper to the insertion of the plantar fascia or the intrinsic foot muscles of the abductor hallucis brevis, flexor digitorum brevis, and abductor digiti quinti. And I think a lot of this heel pain that we see is actually probably a tendinopathy and therefore we should treat it differently than we might treat an inflammation of just the passive tissue, the non-contractual tissue of the plantar fascia. Another belief I have for most tendon problems is pain by itself is not an indication for stretching exercises. If you have pain and evidence of limited motion or a certain muscle tendon unit, I think that combination would be an indication for stretching exercises.

I also think that we can develop a sub classification of plantar heel pain syndrome based on the movements that occur during the three periods of stance phase. So the three periods of stance phase, according to Jacquelin Perry, she describes the three time periods during stance as heel rocker, ankle rocker, forefoot rocker. I like to call the first period heel contact only. You could call it foot strike or impact loading. And the second period would be what Jacquelin Perry calls ankle rocker. That's the period of stance when the whole foot is in contact with the ground, others would call that the period of mid-stance. And then the third period Jacqueline Perry calls forefoot rocker. I would suggest we could call it forefoot contact only or terminal stance. So there's those three periods. And I think if we look at gait analysis, we can sub-classify a lot of the foot pain problems, particularly plantar heel pain syndrome. So the sub-classification can be based on force per area per contact time during stance phase. So when walking, single-limb support is two-thirds of stance, one-third of that period could be double support, right? So walking single limb support occurs in roughly 0.6 seconds when you're walking, depending on your velocity. The force is estimated to be 1.5 times body weight. Running, that force increases to estimated to be three times body weight. So each period of stance phase, if single limb stance phase is 0.6 seconds, you could divide that into three and each period of stance would be very quick, 0.2 seconds. So the period of when only the heel is in contact with the ground, when you're walking, there's 1.5 body weight going into that very brief period of time, over a very small area, which is I think a relatively huge force, whereas during mid-stance where the period of ankle rocker, the force per unit area of the foot is relatively lower, because it's spread out over the forefoot and the hindfoot, it's over a larger area. Again, it's for a very quick period of time. And then the third period is what Jacquelin Perry calls a forefoot rocker. Again, the force per unit of area is 1.5 body weight walking and three body weight running. And it's a very short period of time. It's a huge amount of force in a very short period of time. So I think plantar heel pain syndrome and a lot of the foot problems. If we look at the sub classification during stance phase, the first and last period is when there's the greatest risk.

So, what are the gait deviations associated with plantar heel pain syndrome? If we look at the three periods of stance, the first period is heel contact only. What are the gait deviations that might occur that are associated with pain in the heel? Could be too long a step or stride. Can have a slow cadence, you could have a loud foot strike. You could have evidence of increased vertical oscillation of centre of mass, bouncy gait, you can have increased angle of foot relative to the ground, accentuated angle. The foot can be crossing the midline and your foot can be, foot progression angle can be with increased toe out.

The second period of stance when plantar heel pain syndrome can occur, the gait deviations I think that occur during that period of stance are increased pronation or an absent windlass, which is what I'm going to talk about shortly. You can have a relatively late heel off or early heel off, that's that transition from whole foot contact only to forefoot contact only. That's when that transition is occurring and during that period, you can continue to have an increased toe out relative to the line of progression.

The third period of stance when plantar heel pain syndrome can show gait deviations is the forefoot only contact period or terminal stance. Here some gait deviations that can occur are excessive dorsiflexion of the first MTPJ. If you're doing the gait analysis, you need to be barefoot to make this gait observation. And again, if it's more than 65 degrees of dorsiflexion, I'm going to consider it deviant. You may have the opposite, which would be a decreased dorsiflexion of the big toe or the first MTPJ. Again, if they don't have at least 35 degrees of dorsiflexion, I would suggest that that's deviant. During this period, you may see increased hip extension during terminal stance. Again, during this forefoot contact period, which is the transition from whole foot or mid-stance, they may show early heel off or prolonged or delayed or late heel off. I think again, they can show increased toe out. I've seen patients with this who have increased toe in and plantar heel pain syndrome are the gait deviations I think that we can look for sub-classifications of plantar heel pain syndrome.

Windlass Effect

For a moment I want to talk about windlass. An absent windlass. We've all been taught where the windlass is when you raise the big toe, the arch should raise. Classically. It was a test for the plantar aponeurosis and many people assumed that it was a test for the passive structure of the plantar fascia, which is ligament, has no active component. But classically tests the aponeurosis which includes the intrinsic foot muscles. Again, the abductor hallucis brevis, flexor digitorum brevis and adductor quinti. So essentially when you're raising the big toe and looking to see if the arch rises, you're doing a length test for the plantar fascia, but also for the intrinsic foot muscles. The test says that when you dorsiflex the first big toe, the MTPJ, you should see the arch rising. You should see a slight supination of the forefoot, a slight bit of external tibial rotation. You could, in the clinic, monitor whether there was presence or absence of pain or joint crepitation, excuse me, just crepitation coming from the tendons, tendon sheaths. I believe we should test this motion both weight bearing and non-weight bearing. Gives you valuable information, much more functional.

Foot Regional Pain

So, the next pain syndrome I want to talk about would be hallux valgus, commonly called bunion pain. What are the gait deviations associated with this big toe problem? Could be increased pronation, could be an absence of the windlass during terminal stance. Dynamically, when you switched from midfoot to forefoot only, the big toe is dorsiflexing, there should be a shortening of the intrinsic foot muscles, and a raising of the arch. So if during that period of forefoot rocker, if you don't see the arch rise, the proximal metatarsal head raise dorsally, I would call that an absent windlass, and I think that's deviant.

The next pain syndrome I'd like to talk about is metatarsalgia and/or interdigital neuralgia, Morton's toe syndrome. What are the associated gait deviations with this forefoot pain? One that I would be suspicious of would be an increased forward lean of the trunk or centre of mass when walking or running. Too long a step or stride. If it's too long during terminal stance, there's going to be increased stress on the forefoot only period in the back end of that long stride. You can have increased pronation. Again, an absence of windlass or a failure of the arch to rise during terminal stance. Again you have to monitor that shoeless. And you may have the heel whip, it could be medial or lateral, causing a shear force on the forefoot and the metatarsal heads.

The next pain syndrome I want to discuss is big toe pain of first MTPJ osteoarthritis and/or sesamoiditis, or I've had a few patients with osteochondroma of the metatarsal, a benign exostosis on the distal metatarsal. What are the associated gait deviations? If it's one side, they're going to have a limp, they're more than likely going to have an increased toe out. They're going to have, if it's a sesamoiditis, I would be suspicious of an excessive amount of dorsiflexion, increased dorsiflexion in terminal stance. If it's osteoarthritis, limited big toe motion, they're gonna have decreased dorsiflexion, less than 35 degrees, in forefoot rocker period. They may have an altered heel off. They may show a lift off or an early heel off.

Special Topics

So I've gone through some of the pain syndromes, the more common pains syndromes, these are not all of the pain syndromes you'll see with associated gait deviations, but I've presented a clinical reasoning process to pain syndromes that you see and what do you see when you see those gait deviations? So given a pain location, what gait deviations might you expect to see? Once you've identified the deviation, what are the interventions you might come up with? And once you come up with the intervention, what are the potential side effects?

So, let's say you've got a patient with posterior knee pain, such as a painful baker's cyst. What gait deviations would you expect to see, what interventions? What if the patient has a peroneal tendinopathy? What gait deviations would you expect to see and what interventions might you expect? What if the patient has a cuboid syndrome status post lateral ankle sprain? What gait deviations might you expect and what interventions might we come up with? So given pain in whatever region, given the potential gait deviations, what interventions are appropriate to optimise movement, and then what are the side effects that we need to be proactive for?

Touch on another area, not necessarily a pain syndrome, but could be. That's leg length discrepancy. We all know that there's either an anatomical leg length discrepancy or a functional leg length discrepancy. Anatomical leg length discrepancy is there's a physical osseous shortening of one of the lower limbs, whereas a functional leg length discrepancy is unilateral asymmetry of lower extremity without any shortening of the osseous components. The deformity is derived from admirable movements at the hip, knee, and ankle. So what are those we're going to talk about.

So, we can do our static exam to make inferences about anatomical leg length difference statically. But I believe we cannot solely rely on the static exam. We need to do a dynamic assessment. We need to do a gait analysis to determine how that subject accommodates for that structural variation. They may compensate in a very appropriate way and we may be able to come up with a better intervention or compensation. So what are the gait deviations might we expect if we have a subject with a long leg on one side? I think the foot would pronate on the long side. You may see ankle dorsiflexing more during stance phase and swing phase. You see increase in knee flexion, you may see an increase in hip flexion attempting to shorten that long leg. They may abduct it, abduct at the hip and the hip may internally rotate. They may demonstrate changes at the pelvis, posteriorly rotate or lateral pelvic drop.

What are they going to show on the short leg? To make that leg longer they're going to supinate at the foot. They're going to plantarflex at the ankle, probably do a vaulting type of gait. They're going to try to increase that length, and they're going to fully extend the knee. At the hip, they're going to extend the hip, they're going to adduct to compensate for that short leg, externally rotate and the pelvis, they may have an anterior rotation and they may show a contralateral pelvic elevation.

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