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

"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."

Note the interconnected nature of the leg, ankle, and foot musculature and structures.

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 orthopaedic 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 method 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 a more idealised movement pattern unique to a particular individual, subjective pain can be improved and function can be reestablished.

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

Foot Regional Pain

Region of Pain	Relavent Diagnoses	Expected Gait Deviations
Plantar heel	Plantar heel pain syndrome (for more information, please see special topics at end of this article)	First period (heel contact): Too long a step Slow cadence Loud foot strike Increased vertical oscillation of COM Increased angle of foot relative to the ground Foot can be crossing the midline Increased toe-out Second period (transition from whole foot contact to forefoot contact only): Increased pronation or an absent windlass Relatively late heel off or early heel off Increased toe-out relative to the line of progression Third period (during terminal stance): Excessive dorsiflexion of the first MTPJ (more than 65 degrees of dorsiflexion) decreased dorsiflexion of the big toe or the first MTPJ (less than 35 degrees of dorsiflexion) Increased hip extension during terminal stance Early heel off or prolonged/delayed/late heel off Increased toe-out
Great toe	Hallux valgus Bunion pain	Increased pronation Absent windlass
Forefoot	Metatarsalgia Interdigital neuralgia Morton's toe syndrome	Increased forward lean of the trunk or COM when walking or running Too long a step Increased pronation Absent windlass Heel whip, medial or lateral
Toes	First MTPJ osteoarthritis Sesamoiditis Osteochondroma of the metatarsal Benign exostosis on the distal metatarsal	Ambulate with a limp Increased toe out With sesamoiditis: excessive amount of dorsiflexion in terminal stance. If it's With osteoarthritis: limited great toe motion, decreased dorsiflexion in forefoot rocker period (less than 35 degrees) Altered heel off (may show a lift off or an early heel off)

Lower Leg and Foot Region Special Topics

Plantar heel pain syndrome

Use Mcc 2018 reference here

Special considerations for plantar heel pain syndrome:

• Professional guidelines and or protocols do not include recommendations for gait analysis and training
  • Available professional guidelines and protocols from organizations such as the American Physical Therapy Association Orthopaedic Section, the Orthopaedic Surgeon Society, the Podiatry Society, describe evaluation procedures and treatment procedures are clinically proven to be effective for plantar heel pain syndrome. However, they do not recommend gait analysis as part of the evaluation process or gait training. For physiotherapists, plantar heel pain syndrome is associated with gait therefore gait analysis and training should be part of a physiotherapy plan of care.
• Plantar heel pain syndrome differential diagnosis should include tendinopathy of intrinsic plantar flexor muscles
• Pain is NOT an indication for stretching exercises
• Limited range of motion is 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.

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.

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?

Leg length discrepancy

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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