Back and Upper Leg Regional Pain and Gait Deviations

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

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

Introduction

Gait deviations are likely related to the development of and / or associated with musculoskeletal pain syndromes. It is often the complaint of pain that will lead a patient to physiotherapy. It is the role of the physiotherapist to educate the patient on the aetiology of their pain while treating and correcting the noted gait deviation.

With the patient's pain as a guide, a goal of musculoskeletal physiotherapy is to identify the anatomical structures associated with the reported pain. Physiotherapists utilise orthopeadic tests to assist in symptom source identification. However, these clinical tests are often inconsistent in their ability to accurately identify the anatomical source of the patient's symptoms. Additionally, there is a poor correlation between imaging results and symptom source identification in the absence of trauma or pathology. These two statements suggest that musculoskeletal pain may often be anatomically and structurally indeterminable. The kinesiopathological approach is an alternative to these more traditional methods of diagnosis. This methods calls for clinical practice to be guided by the identification and modification of kinematic or motor control impairments within a musculoskeletal function. By correcting deviant movement patterns to the ideal movement patterns unique to a particular individual, subjective pain can be improved and ideal function can be reestablished.

"The kinesiopathologic model was designed specifically to describe the mechanically related processes proposed to contribute to the development and course of low back pain (LBP). The basic premise is that LBP results from the repeated use of direction-specific (flexion, extension, rotation, lateral bending, or a combination of these) stereotypic movement and alignment patterns in the lumbar spine. The model proposes that the patterns begin as the result of adaptations of the musculoskeletal and neural systems due to repeated use of specific movements and alignments during daily activities. The nature and rate of the adaptations can be modified by intrinsic and extrinsic characteristics of the individual, for example, sex, anthropometrics, or typical activities of the person. The typical pattern is one in which, during performance of a movement (eg, forward bending) or assumption of a posture (eg, sitting), the lumbar spine moves into its available range in a specific direction more readily than other joints, such as the knees, hips, or thoracic spine."

Let's be proactive and think what gait deviations might they show up with? In a sense, this is a kinesiopathologic model. It could be pathokinesiologic, the movement is related to the pain. In this case, they come in with pain, let's figure out what the movement discomfort is going to be.

"Where does it hurt?"

"When does it hurt?"

The next question is what deviations do you expect the patient to show up with? The next question will be what interventions for that gait deviation?

Basically, you're going to state a hypothesis, you're going to state why they have pain or why you're choosing the rationale. What's the rationale for your choice of intervention? So you state a hypothesis, you have an if/then statement, you test the hypothesis. The next step is you refute it or trash the hypothesis or use that hypothesis to continue with treatment. If you happen to trash the hypothesis or refute it, you need to generate another one. So working hypothesis or hypothesis: if it hurts walking and running, then walking and running needs to be observed, measured and analysed. If walking and running is analysed sooner, then I think it's more efficient and effective. ADD IMAGE

Back Regional Pain

What are the potential gait deviations might you see if you have an individual complaining of back pain?

1. The first one is going to be, they're going to be slow, slow cadence, slow velocity, less than one metre or less than 1.4 metres per second. They're going to have short steps. They're going to have a low cadence, low number of steps per minute. They're going to appear to be stiff in terms of counter rotation of the thoracic spine between the thoracic spine and the lumbar spine. They're going to have either an increased up and down motion, a vertical oscillation of centre of mass, generating pain, generating impact loading, or they may be in pain and then compensate with a decreased vertical oscillation of centre of mass or decreased up and down motion walking without any spring in their step. If they have a loud foot strike, if they're a clomper or stomper, generating impact loading, increased braking forces may be contributing to back pain. They may have an increased or decreased pelvic tilt. Posterior anterior pelvic tilt. They may demonstrate an increase in hip extension or a decrease in hip extension during terminal stance. And then later on, we're going to talk about, they may have a decrease in big toe dorsiflexion, a functional hallux limitus.
   1. There's an interesting work by Claudine Lamonth done in 2006, where she looked at a group of individuals with back pain and did gait analysis. The title of the work was The Effects of Chronic Low Back Pain on Trunk Coordination and Back Muscle Activity During Walking and Changes in Motor Control. So all of the individuals in this study with back pain walked slow. They had a slow velocity they had short steps. They had slower cadence. She took a subset of those patients that had non-specific back pain, that's a very common diagnosis we in physical therapy address, and she asked them all to walk faster and they were able to do so without increasing their back pain. I think this is an interesting thought in terms of see something, do something. If you see a patient with back pain walking slow, a gait training would be to walk faster with the hypothesis that if you walk faster without any increase in pain, you're increasing caloric expenditure, decreasing body weight. If you're walking faster, you're improving the counter rotation between the thoracic spine and the lumbar spine. You're getting arm swing. You're getting normal, optimal movement when walking, I do believe there's a subset of patients that may have non-specific back pain that can be subclassified as having instability. The patient with spondylolisthesis. Those are the patients that I don't think we would want to increase velocity and increase hip extension, increase lumbar extension. Very interesting study by Lamonth.
   2. The illustration is directly from an article by Igawa, I G A W A. And the title of the article, I think, was lumbar stenosis gait compensation. I think that's the same thing as lumbar stenosis gait deviations. So individuals with lumbar stenosis, a common back pain diagnosis in elderly population, are going to have one of two gait deviations or gait compensations. In figure a, this individual is not with an upright posture. He has a relatively long step length. The blue arrow is ground reaction force, the summation of all the forces being transmitted from the ground into the body and in figure a, it goes into the lumbar spine. So there's no lumbar joint moment into extension. We all know that patients with lumbar stenosis don't like to extend their spine. That's the reason they tend to walk, bend over, they tend to lean on their grocery cart, lean forward on their walkers to decrease and avoid pain. He identified a second compensation in figure b. Again, the blue arrow, the ground reaction force, is into the spine so there's no joint moment into lumbar extension, but the difference between a and b is there's a very short step, and again, probably slow velocity. Whereas in c there's a big step and that ground reaction force is posterior to the lumbar spine, that patient in c, if he has lumbar stenosis is probably in pain. When you look, when you think about what's going on with what we cannot see, which is the joint forces, I think a potential another intervention would be to take this subject in b, he's walking erect, he's got good posture with a short step, ask him to take more steps, he or she to take more steps per minute. Increase his cadence, increase his energy expenditure, decrease his body weight, his body mass index as an alternative gait training that could work for patient with back pain.
   3. Igawa has done a more recent study published in 2021, where he describes the gait deviation of a dropped head posture. In figure A, this is the individual that's walking down the road with his head pointing, the top of his head pointing down the road, as opposed to pointing to the ceiling. We'll see this in older people with very bad posture. You'll also see it nowadays with people that are looking at their text on their smartphone all the time, developing into this posture. So in figure A, the top of the head's pointing down the road and it's a relatively shorter stride and there's a backward leaning of the torso. And if you look down at the bottom of the illustration, the red arrows are indicating ankle joint moments. So there's greater dorsiflexion in figure A and less ankle plantarflexion external joint moment. We're going to come back to plantarflexion in the elderly and in people with pain in the back and hip. So figure B is a normal posture, it's erect and you have more movement coming from the ankle to propel forward and up. Interesting, dropped head posture gait deviation.

1. I want to talk for a moment about what would be classified as geriatric gait. They may be in pain or just, just maybe a geriatric gait. The spatiotemporal changes that occur in old folks is they walk slow, less than 1.4 metre per second or one metre per second. They take shorter steps or strides. They have a slower cadence. We've all seen this. In the kinematics, they have a late or a prolonged heel contact. They're going to have a decreased up and down motion, a decreased vertical oscillation of centre of mass, could have decreased hip extension, may have increased forward lean that we saw with lumbar stenosis gait compensation, and they may have decreased arm swing. Often the older people will just walk with their hands held behind their back and not even swing their arms.
   1. This is some interesting work by DaVita and colleagues, originally published in 2002. It's talking about the age lower extremity kinematic forces, comparing it between old folks and young folks. So the amount of propulsive force when walking and running varies across the joints in the lower extremity. How much is being propelled forward or up. Old folks, geriatrics, elderly people use hip joint moments more than ankle, whereas young people use the ankle to propel forward, ankle plantarflexion. They use that more than the hip. So if you look at the table, the propulsive force in the elderly is maybe 75%, whereas in the young it's one-third, roughly speaking, whereas down at the ankle, old folks only use the ankle to propel forward by 12%, a very small amount. So I think this is an interesting thing that we can take advantage of when we get into gait training and intervention with our old folks that are increased risk for falling or having pain, we can get them to use their ankle more.
   2. So this graph is the AP force, the fore-aft force that occurs during stance phase. So the horizontal axis is just stance phase, the vertical axis is the force that's the brake or the propel forward, the fore and aft that occurs. And there's in the first half of the first period of stance, there's a negative braking force stopping you from going forward and in the second half from midfoot to forefoot rocker or terminal stance, that's when you propel forward, also propelling up. So DeVita and colleagues did some, they were able to amplify and augment this and provide feedback to a group of normal subjects, trying to get them to increase that propulsive force with an instrumented treadmill and the camera right in front of the treadmill. And they said, we want you to increase that, increase it. And both the old people and the young people were able to increase the total lower extremity propulsive force given that feedback. That was real-time feedback. But what they discovered was both the old people and the young people, to generate that increased force to get it above the threshold, both the young and the old used their hip. They didn't use the ankle. So they did a follow-up study where they gave the feedback and just look at ankle joint plantarflexion external moment and they were able to, with augmented feedback, increase the propulsive force coming from the ankle joint. We don't have in our clinic, these augmented feedbacks, instrumented treadmills, and sophisticated equipment, but what I take from this is when we give a verbal cue, not that I want you to push more, I want you to propel up, leave an imprint from your foot, move from your ankle. Again, we're going to talk about internal cueing and external cueing. Basically the soundbite that I use is I want you to walk with spring in your step. That's going to get you to use the ankle if the gait deviation is decreased vertical oscillation of centre of mass or prolonged heel contact.

Hip Regional Pain

Maybe change to special topic: OA and TJR? Next region of pain I want to talk about is hip pain, osteoarthritic pain and the gait deviations that can continue status post total hip joint replacement. Oftentimes patient with hip osteoarthritis develops gait deviations and has a habit and even when they have a normal joint, they may continue to walk with that habit, that deviated habit.

Region of Pain	Relavent Diagnoses	Expected Gait Deviations
Hip Region	Osteoarthritis Can continue status post total joint replacement	Decreased cadence Shorter step or stride length Increased base of support (BOS) Decreased counter-rotation between the thoracic spine and the lumbar spine Decreased range of motion in the sagittal and frontal plane at the hip Decreased extension particularly in terminal stance Increased toe out Increased lateral trunk lean Increased contralateral pelvic drop Increased lateral shift of centre of mass (COM) Late or prolonged heel off Decreased propulsive ankle force
Lateral Hip	Gluteal tendinopathy Piriformis syndrome Complaint of "buttock pain"	Too long a step Contralateral pelvic drop Lateral shift of COM Loud foot strike Decreased daylight or insufficient separation between the knees Foot crossing the midline of the body Oblique popliteal skin crease (excessive medial femoral rotation) Varus or valgus thrust Lateral deviation of the knee during stance phase Increased pronation of the foot
Anterior Hip	Femoroacetabular impingement (FAI) syndrome Acetabular labral tear Status post repair of the acetabular labrum	Unfortunately, the literature on femoroacetabular impingement is somewhat ambiguous Some literature suggests that individuals with an FAI will demonstrate biomechanical differences when ambulating on stairs

Lateral Hip Region Pain

So what do you do when you see gait deviations? See something, do something. Before we leave the hip, I want to talk about some interesting work done by Dr. Marcie Harris-Hayes with two references, one in 2016 and another in 2020, they're both open source and they have excellent illustrations. And in the appendix, both of the articles deal with individuals with chronic hip joint pain, piriformis syndrome, gluteal tendinopathy, hip osteoarthritis, labral injuries, and so forth. And so she suggests some verbal cues and interventions. One is contract your buttock muscles as the heel hits the ground. Another cue for walking is land softly. Another cue is avoid completely straightening your leg from the point your heel hits the ground to the point your toes leave the ground, always bend in your knee. So in future sections, I want to challenge you to take Dr. Marcie Harris-Hayes's statement, which is a complicated, not very good verbal cue for the, obviously it's too wordy. It's not short. It's internal focused. There's a lot of things we can do to improve the work of Dr. Marcie Harris-Hayes. So, we're going to come back and expand on see something, do something if you see these gait deviations.

Anterior Hip Region Pain

However, there is an interesting paper published by Ranawat, and it's published in 2017 where he is proposing looking at the gait of individuals with suspected FAI or impingement or instability by looking at the degree of toe out at their preferred and then asking them to walk by toeing in 15 degrees. Then also from their baseline, asking them to walk toeing out, consciously toeing out, 15 degrees from their baseline. So if this individual clinically you think has FAI because you did an exam on the table with flexion, adduction, internal rotation, eliciting discomfort, and you get suspicious. Well, if you walk and you toe in 15 degrees and that also produces pain, then you get two signs that suggest they may have FAI. So it's kind of a test, it's not so helpful in terms of intervention but it does show the relationship between gait and pain.

Knee Region Pain

The next pain syndrome I want to touch on is knee pain associated with osteoarthritis and/or again status post total knee joint replacement, that gait deviations may continue.

Region of Pain	Relavent Diagnoses	Expected Gait Deviations
Knee Region	Osteoarthritis Can continue status post total joint replacement	Increased lateral trunk lean Lateral shift of COM Decreased knee extension during stance phase Increased degree of toe out (more than 10 to 15 degrees from the foot progression line) Demonstrate a varus thrust, lateral deviation of the knee or a valgus thrust (varus thrust is most common)
Anterior Knee	Patellofemoral arthralgia	Too long a step Contralateral pelvic drop Increased degree of toe-out or toe-in Decreased daylight or insufficient separation between the knees Foot crossing the midline Oblique popliteal skin crease (excessive medial femoral rotation) Increased pronation Heel whip Increased hip or knee extension at terminal stance
Lateral Knee	Iliotibial (IT) band syndrome	Too long a step Contralateral pelvic drop Lateral shift of COM Increased knee extension at foot strike or heel rocker Loud foot strike Insufficient daylight or insufficient separation between the knees Foot crossing the midline Oblique popliteal skin crease (excessive medial femoral rotation) Varus or valgus thrust Increased pronation Heel whip

Resources

• bulleted list
• x

or

1. numbered list
2. x