Lower Leg and Foot Regional Pain and Gait Deviations: Difference between revisions

No edit summary
(added two updated references)
 
(31 intermediate revisions by 4 users not shown)
Line 4: Line 4:


== Introduction ==
== 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?
<blockquote>"The '''kinesiopathologic model''' was designed specifically to describe the mechanically related processes proposed to contribute to the development and course of [[Low Back Pain|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."<ref>Cholewicki J, Breen A, Popovich Jr JM, Reeves NP, Sahrmann SA, Van Dillen LR, Vleeming A, Hodges PW. [https://www.jospt.org/doi/pdf/10.2519/jospt.2019.8825 Can biomechanics research lead to more effective treatment of low back pain? A point-counterpoint debate]. journal of orthopaedic & sports physical therapy. 2019 Jun;49(6):425-36.</ref> </blockquote>
[[File:Lower leg musculature.jpeg|thumb|400x400px|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 [[Medical Imaging|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.<ref>Lehman GJ. [https://www.jospt.org/doi/pdf/10.2519/jospt.2018.0608 The role and value of symptom-modification approaches in musculoskeletal practice]. journal of orthopaedic & sports physical therapy. 2018 Jun;48(6):430-5.</ref>


== Lower Leg Regional Pain ==
== Lower Leg Regional Pain<ref name=":0">Howell, D, Lower Leg and Foot Regional Pain and Gait Deviations. Gait Analysis. Plus. 2022</ref> ==
So the first pain syndrome that I'm going to talk about is the lower leg tissue diagnosis of medial tibial stress syndrome, also stress fractures also commonly called shin splints. Could be posterior tibial tendinopathy. What are the associated gait deviations that can be occurring with pain in this region? First would be too long a step or stride. Increased knee extension at heel rocker or foot strike, a prolonged heel off or delayed heel off in terminal stance, a loud foot strike, which is associated with increased impact loading and higher ground reaction forces, increased pronation, and a heel whip during the transition from stance phase to swing phase. It can be either a medial heel whip or lateral heel whip.
{| class="wikitable"
|+
!'''Region of Pain'''
!'''Relavent Diagnoses'''
!'''Expected Gait Deviations'''
|-
|'''Calf'''
|
* [[Medial Tibial Stress Syndrome|Medial tibial stress syndrome]]<ref>Bramah C, Preece SJ, Gill N, Herrington L. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8169031/ Kinematic characteristics of male runners with a history of recurrent calf muscle strain injury]. International Journal of Sports Physical Therapy. 2021;16(3):732.</ref>
* [[Stress Fractures|Stress fractures]]
* [[Tendinopathy|Posterior tibial tendinopathy]]<ref>Wang J, Mannen EM, Siddicky SF, Lee JM, Latt LD. Gait alterations in posterior tibial tendonitis: A systematic review and meta-analysis. Gait & Posture. 2020 Feb 1;76:28-38.</ref>
|
* 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|Achilles tendinopathy]]<ref>Van Der Vlist AC, Breda SJ, Oei EH, Verhaar JA, de Vos RJ. [https://bjsm.bmj.com/content/bjsports/53/21/1352.full.pdf Clinical risk factors for Achilles tendinopathy: a systematic review]. British journal of sports medicine. 2019 Nov 1;53(21):1352-61.</ref>
|
* 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 gastrocnemius/soleus being short and stiff)
* Increased hip and associated knee extension in terminal stance  
* Excessive toe-out relative to the line of progression of the foot
* Excessive pronation
|}
== Foot Regional Pain<ref name=":0" /> ==
{| class="wikitable"
|+
!'''Region of Pain'''
!'''Relavent Diagnoses'''
!'''Expected Gait Deviations'''
|-
|'''Plantar heel'''
|
* [[Plantar Heel Pain|Plantar heel pain syndrome]]
(for more information, please see special topics at the end of this article)
|'''First period''' "heel rocker" ( heel contact):


The next pain region that I'm going to discuss is achilles pain, achilles tendinopathy, and the associated gait deviations with that pain syndrome. You could have increased forward lean of the trunk or centre of mass. You can have an increased vertical oscillation of centre of mass or the up and down motion or a bouncy gait. You could have the foot crossing the midline of the body during walking and/or running, you can have a prolonged or delayed heel off, or you can have an early heel off if the achilles and gastroc soleus is short and stiff, you can have an early heel off. You can have achilles pain if the achilles tendon and calf muscle is too long with a length-associated muscle weakness status post achilles tendon rupture, status post achilles tendon lengthening, or as a result of overly aggressive calf stretching exercises. You can have a gait deviation of increased hip extension in terminal stance. More likely you're going to have with that increased knee extension in terminal stance. You can commonly have too much toe out relative to the line of progression foot. Then you could have the common gait deviation of excessive pronation.
* 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


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.
'''Second period''' "ankle rocker" (transition from whole foot contact to forefoot contact only):


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.
* Increased pronation or an absent windlass
* Relatively late heel off or early heel off
* Increased toe-out relative to the line of progression


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.
'''Third period''' "forefoot rocker" (during terminal stance):


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.
* 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
|-
| rowspan="2" |'''Great toe'''
|
* [[Hallux Valgus|Hallux valgus]]
* Bunion pain
|
* Increased pronation
* Absent windlass
|-
|
* 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.
* 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)
|-
|'''Forefoot'''
|
* Metatarsalgia
* Interdigital neuralgia
* [[Morton's Toe|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
|}


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.
== Lower Leg and Foot Region Special Topics ==
=== Plantar heel pain syndrome ===
<blockquote>'''Special considerations for plantar heel pain syndrome:'''<ref name=":0" /><ref>Shane McClinton PT, Bryan Heiderscheit PT, McPoil TG, Flynn TW. Physical therapist decision-making in managing plantar heel pain: cases from a pragmatic randomized clinical trial. Physiotherapy Theory and Practice. 2018 Jul 6.</ref><ref>Riel H, Plinsinga ML, Delahunt E, Jensen MB, Landorf KB, van Middelkoop M, Roddy E, Rathleff MS, Vicenzino B, Olesen JL. [https://jfootankleres.biomedcentral.com/articles/10.1186/s13047-022-00573-0 Large variation in participant eligibility criteria used in plantar heel pain research studies-a systematic review]. Journal of foot and ankle research. 2022 Dec;15(1):1-8.</ref>


== Windlass Effect ==
* Professional guidelines and or protocols do not include recommendations for gait analysis and training
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.
** Available professional guidelines and protocols describe evaluation and treatment procedures which are clinically 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
</blockquote>


== Foot Regional Pain ==
It is possible to develop a sub-classification of plantar heel pain syndrome based on the movements that occur during the three periods of stance phase.  This sub-classification is created using gait analysis.<ref name=":0" /> <blockquote>'''According to Dr Jacquelin Perry, the three time periods during stance include:'''<ref>Perry, J. and Burnfield, J. (1992) Gait Analysis: Normal and Pathological Function. SLACK Incorporated, New Jersey.</ref>
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.
# '''Heel rocker:''' the period of stance with only heel contact with the ground. Can also be called foot strike or impact loading.
# '''Ankle rocker:''' the period of stance when the whole foot is in contact with the ground. Can also be called mid-stance.
# '''Forefoot rocker:''' the period of stance with only forefoot contact with the ground. Can also be called terminal stance.
</blockquote>'''The sub-classification can be based on force per area per contact time during stance phase:'''<ref name=":0" />


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.
* '''Force:''' Estimated to be 1.5 times body weight when walking. When running, that force is estimated to increase to be three times body weight.
* '''Time''': During ambulation, single-limb support is two-thirds of stance; one-third of that period could be double support. Depending on ambulation velocity, single limb support occurs in roughly 0.6 seconds. If single limb stance phase is 0.6 seconds, divide that into three and each period of stance would be very quick, approximately 0.2 seconds each.
[[File:Stance sub-phases, force over area of foot.jpeg|center|thumb|500x500px|Stance time periods.  Area of purple notes area of force going into the ground through the foot.]]
<blockquote>
* '''Period of heel rocker:''' 1.5 body weight going into a relatively small area of the heel for a very brief period of time.
* '''Period of ankle rocker:''' the force per unit area of the foot is relatively lower because it is spread out over the forefoot and the hindfoot, a larger area, for a very short period of time.
* '''Period of forefoot rocker:''' the force per unit of area is going into a relatively small area of the forefoot for a very brief period of time.
* The first and last periods of stance are associated with greater risks as they have the greatest amount of force over a smaller body area.
</blockquote><ref name=":0" />
{| class="wikitable"
|+
<ref name=":0" />
!'''Stance time period'''
!'''Possible gait deviations'''
|-
|'''Heel rocker'''
|
* Too long stride length
* Slow cadence
* Loud foot strike
* Increase in the up and down motion of centre of mass
* Increase in the angle of foot relative to the ground
* Foot crossing midline
* Increased toe-out relative to foot progression angle
|-
|'''Ankle rocker'''
|
* Increased pronation
* Absent windlass
* Late or early heel off
* Increased toe-out relative to foot progression angle
|-
|'''Forefoot rocker'''
|
* Increased or decreased dorsiflexion of the 1st MTPJ
* Increased hip extension in terminal stance
* Late or early heel off
* Increased toe-out or toe-in relation to foot progression angle
|}


== Special Topics ==
=== Windlass Effect ===
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?
According to a 2004 study<ref name=":1">Bolgla LA, Malone TR. [https://www.ncbi.nlm.nih.gov/pmc/articles/pmc385265/ Plantar fasciitis and the windlass mechanism: a biomechanical link to clinical practice]. Journal of athletic training. 2004 Jan;39(1):77.</ref> published in the Journal of Athletic Training: 


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?
* A “windlass” is the tightening of a rope or cable.
* The plantar fascia "simulates a cable" attached between the calcaneus and the metatarsophalangeal (MTP) joints.
* Dorsiflexion during the propulsion phase of gait tightens the plantar fascia around the head of the metatarsal. This tightening of the fascia shortens the distance between the calcaneus and metatarsals to elevate the medial longitudinal arch. This shortening of the plantar fascia is the hallmark of the windlass mechanism principle.
* From heel strike to weight acceptance: foot pronation increases the distance between the calcaneus and metatarsals. This lengthening applies tension stress to the plantar fascia.
* From midstance through the propulsive phase (i.e. the period from the end of midstance when the heel lifts to toe off<span class="reference" id="cite_ref-9"></span><ref>Kawalec JS. 12 - Mechanical testing of foot and ankle implants. In Friss E, editor. Mechanical testing of orthopaedic implants. Woodhead Publishing, 2017. p231-53.</ref>): foot supination occurs causing the foot to become a rigid lever arm, using the windlass mechanism to propel gait. As with pronation, forces generated during supination also apply tension to the plantar fa<span class="reference" id="cite_ref-:5_8-1"></span>scia.<ref name=":1" /><ref>Williams LR, Ridge ST, Johnson AW, Arch ES, Bruening DA. [https://jfootankleres.biomedcentral.com/articles/10.1186/s13047-022-00520-z The influence of the windlass mechanism on kinematic and kinetic foot joint coupling.] Journal of Foot and Ankle Research. 2022 Dec;15(1):1-1.</ref>
<blockquote>


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.
'''The [[Windlass Test|windlass test]]:'''<ref name=":0" /> 


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.
* A length test for the plantar fascia, a passive structure
* A length test for the the intrinsic foot muscles, active structures
* When performing the test will see: (1) the arch rising, (2) slight supination of the forefoot, (3) slight external rotation of the tibia
* When performing the test, monitor for the presence or absence of  joint crepitation
* Test in both weight bearing and non-weight bearing
</blockquote>


== Resources  ==
You might like to view the following short video for more information on the windlass mechanism, and to see the windlass test performed in both weight bearing and non-weight bearing positions.
*bulleted list
 
*x
{{#ev:youtube| vzTdSXgTCsY |500}}<ref>YouTube. What is The Windlass Mechanism of The Foot? | James Dunne. Available from: https://www.youtube.com/watch?v=vzTdSXgTCsY [last accessed 29/06/2022]</ref>
or
 
=== Leg length discrepancy ===
<blockquote>'''Two types of leg length discrepancy:'''<ref name=":0" />
 
# '''Anatomical leg length discrepancy:''' due to a physical osseous shortening of one of the lower limbs
# '''Functional leg length discrepancy:''' a unilateral asymmetry of one lower extremity without any shortening of the osseous components. The deformity is derived from admirable movements at the hip, knee, and or ankle. 
</blockquote>
 
 
 
Anatomical leg length differences can be [[Leg Length Test|measured]] both statically and dynamically. Gait analysis should also be performed to determine how the individual accommodates for that structural variation. Noting and assessing compensatory movements will help develop a physiotherapy plan of care and treatment interventions. 


#numbered list
'''Possible expected gait deviations and or compensatory movements of leg length discrepancy:'''
#x
{| class="wikitable"
|+
!
!Longer leg
!Shorter leg
|-
|Foot
|Pronation
|Supination
|-
|Ankle
|Dorsiflexation
|Plantarflexion
|-
|Knee
|Flexion
|Extension
|-
|Hip
|
* Flexion
* ABDuction
* Internal Rotation
|
* Extension
* ADDuction
* External Rotation
|-
|Pelvis/Ilium
|
* Posterior rotation
* Lateral pelvic drop
|
* Anterior rotation
* Contralateral pelvic elevation
|}


== Resources  ==
'''Optional Recommended Reading:'''
*Bramah C, Preece SJ, Gill N, Herrington L. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8169031/ Kinematic characteristics of male runners with a history of recurrent calf muscle strain injury]. International Journal of Sports Physical Therapy. 2021;16(3):732.
*Cholewicki J, Breen A, Popovich Jr JM, Reeves NP, Sahrmann SA, Van Dillen LR, Vleeming A, Hodges PW. [https://www.jospt.org/doi/pdf/10.2519/jospt.2019.8825 Can biomechanics research lead to more effective treatment of low back pain? A point-counterpoint debate]. journal of orthopaedic & sports physical therapy. 2019 Jun;49(6):425-36.
*Lehman GJ. [https://www.jospt.org/doi/pdf/10.2519/jospt.2018.0608 The role and value of symptom-modification approaches in musculoskeletal practice]. journal of orthopaedic & sports physical therapy. 2018 Jun;48(6):430-5.
== References  ==
== References  ==


<references />
<references />
[[Category:Course Pages]]
[[Category:Plus Content]]
[[Category:Pain]]

Latest revision as of 18:56, 28 January 2023

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

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

Introduction[edit | edit source]

"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."[1]

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.[2]

Lower Leg Regional Pain[3][edit | edit source]

Region of Pain Relavent Diagnoses Expected Gait Deviations
Calf
  • 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
  • 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 gastrocnemius/soleus being short and stiff)
  • Increased hip and associated knee extension in terminal stance
  • Excessive toe-out relative to the line of progression of the foot
  • Excessive pronation

Foot Regional Pain[3][edit | edit source]

Region of Pain Relavent Diagnoses Expected Gait Deviations
Plantar heel

(for more information, please see special topics at the end of this article)

First period "heel rocker" ( 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 "ankle rocker" (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 "forefoot rocker" (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
  • Increased pronation
  • Absent windlass
  • 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.
  • 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)
Forefoot
  • 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

Lower Leg and Foot Region Special Topics[edit | edit source]

Plantar heel pain syndrome[edit | edit source]

Special considerations for plantar heel pain syndrome:[3][7][8]

  • Professional guidelines and or protocols do not include recommendations for gait analysis and training
    • Available professional guidelines and protocols describe evaluation and treatment procedures which are clinically 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

It is possible to develop a sub-classification of plantar heel pain syndrome based on the movements that occur during the three periods of stance phase. This sub-classification is created using gait analysis.[3]

According to Dr Jacquelin Perry, the three time periods during stance include:[9]

  1. Heel rocker: the period of stance with only heel contact with the ground. Can also be called foot strike or impact loading.
  2. Ankle rocker: the period of stance when the whole foot is in contact with the ground. Can also be called mid-stance.
  3. Forefoot rocker: the period of stance with only forefoot contact with the ground. Can also be called terminal stance.

The sub-classification can be based on force per area per contact time during stance phase:[3]

  • Force: Estimated to be 1.5 times body weight when walking. When running, that force is estimated to increase to be three times body weight.
  • Time: During ambulation, single-limb support is two-thirds of stance; one-third of that period could be double support. Depending on ambulation velocity, single limb support occurs in roughly 0.6 seconds. If single limb stance phase is 0.6 seconds, divide that into three and each period of stance would be very quick, approximately 0.2 seconds each.
Stance time periods. Area of purple notes area of force going into the ground through the foot.
  • Period of heel rocker: 1.5 body weight going into a relatively small area of the heel for a very brief period of time.
  • Period of ankle rocker: the force per unit area of the foot is relatively lower because it is spread out over the forefoot and the hindfoot, a larger area, for a very short period of time.
  • Period of forefoot rocker: the force per unit of area is going into a relatively small area of the forefoot for a very brief period of time.
  • The first and last periods of stance are associated with greater risks as they have the greatest amount of force over a smaller body area.

[3]

[3]
Stance time period Possible gait deviations
Heel rocker
  • Too long stride length
  • Slow cadence
  • Loud foot strike
  • Increase in the up and down motion of centre of mass
  • Increase in the angle of foot relative to the ground
  • Foot crossing midline
  • Increased toe-out relative to foot progression angle
Ankle rocker
  • Increased pronation
  • Absent windlass
  • Late or early heel off
  • Increased toe-out relative to foot progression angle
Forefoot rocker
  • Increased or decreased dorsiflexion of the 1st MTPJ
  • Increased hip extension in terminal stance
  • Late or early heel off
  • Increased toe-out or toe-in relation to foot progression angle

Windlass Effect[edit | edit source]

According to a 2004 study[10] published in the Journal of Athletic Training:

  • A “windlass” is the tightening of a rope or cable.
  • The plantar fascia "simulates a cable" attached between the calcaneus and the metatarsophalangeal (MTP) joints.
  • Dorsiflexion during the propulsion phase of gait tightens the plantar fascia around the head of the metatarsal. This tightening of the fascia shortens the distance between the calcaneus and metatarsals to elevate the medial longitudinal arch. This shortening of the plantar fascia is the hallmark of the windlass mechanism principle.
  • From heel strike to weight acceptance: foot pronation increases the distance between the calcaneus and metatarsals. This lengthening applies tension stress to the plantar fascia.
  • From midstance through the propulsive phase (i.e. the period from the end of midstance when the heel lifts to toe off[11]): foot supination occurs causing the foot to become a rigid lever arm, using the windlass mechanism to propel gait. As with pronation, forces generated during supination also apply tension to the plantar fascia.[10][12]


The windlass test:[3]

  • A length test for the plantar fascia, a passive structure
  • A length test for the the intrinsic foot muscles, active structures
  • When performing the test will see: (1) the arch rising, (2) slight supination of the forefoot, (3) slight external rotation of the tibia
  • When performing the test, monitor for the presence or absence of joint crepitation
  • Test in both weight bearing and non-weight bearing

You might like to view the following short video for more information on the windlass mechanism, and to see the windlass test performed in both weight bearing and non-weight bearing positions.

[13]

Leg length discrepancy[edit | edit source]

Two types of leg length discrepancy:[3]

  1. Anatomical leg length discrepancy: due to a physical osseous shortening of one of the lower limbs
  2. Functional leg length discrepancy: a unilateral asymmetry of one lower extremity without any shortening of the osseous components. The deformity is derived from admirable movements at the hip, knee, and or ankle.


Anatomical leg length differences can be measured both statically and dynamically. Gait analysis should also be performed to determine how the individual accommodates for that structural variation. Noting and assessing compensatory movements will help develop a physiotherapy plan of care and treatment interventions.

Possible expected gait deviations and or compensatory movements of leg length discrepancy:

Longer leg Shorter leg
Foot Pronation Supination
Ankle Dorsiflexation Plantarflexion
Knee Flexion Extension
Hip
  • Flexion
  • ABDuction
  • Internal Rotation
  • Extension
  • ADDuction
  • External Rotation
Pelvis/Ilium
  • Posterior rotation
  • Lateral pelvic drop
  • Anterior rotation
  • Contralateral pelvic elevation

Resources[edit | edit source]

Optional Recommended Reading:

References[edit | edit source]

  1. ↑ Cholewicki J, Breen A, Popovich Jr JM, Reeves NP, Sahrmann SA, Van Dillen LR, Vleeming A, Hodges PW. Can biomechanics research lead to more effective treatment of low back pain? A point-counterpoint debate. journal of orthopaedic & sports physical therapy. 2019 Jun;49(6):425-36.
  2. ↑ Lehman GJ. The role and value of symptom-modification approaches in musculoskeletal practice. journal of orthopaedic & sports physical therapy. 2018 Jun;48(6):430-5.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Howell, D, Lower Leg and Foot Regional Pain and Gait Deviations. Gait Analysis. Plus. 2022
  4. ↑ Bramah C, Preece SJ, Gill N, Herrington L. Kinematic characteristics of male runners with a history of recurrent calf muscle strain injury. International Journal of Sports Physical Therapy. 2021;16(3):732.
  5. ↑ Wang J, Mannen EM, Siddicky SF, Lee JM, Latt LD. Gait alterations in posterior tibial tendonitis: A systematic review and meta-analysis. Gait & Posture. 2020 Feb 1;76:28-38.
  6. ↑ Van Der Vlist AC, Breda SJ, Oei EH, Verhaar JA, de Vos RJ. Clinical risk factors for Achilles tendinopathy: a systematic review. British journal of sports medicine. 2019 Nov 1;53(21):1352-61.
  7. ↑ Shane McClinton PT, Bryan Heiderscheit PT, McPoil TG, Flynn TW. Physical therapist decision-making in managing plantar heel pain: cases from a pragmatic randomized clinical trial. Physiotherapy Theory and Practice. 2018 Jul 6.
  8. ↑ Riel H, Plinsinga ML, Delahunt E, Jensen MB, Landorf KB, van Middelkoop M, Roddy E, Rathleff MS, Vicenzino B, Olesen JL. Large variation in participant eligibility criteria used in plantar heel pain research studies-a systematic review. Journal of foot and ankle research. 2022 Dec;15(1):1-8.
  9. ↑ Perry, J. and Burnfield, J. (1992) Gait Analysis: Normal and Pathological Function. SLACK Incorporated, New Jersey.
  10. ↑ 10.0 10.1 Bolgla LA, Malone TR. Plantar fasciitis and the windlass mechanism: a biomechanical link to clinical practice. Journal of athletic training. 2004 Jan;39(1):77.
  11. ↑ Kawalec JS. 12 - Mechanical testing of foot and ankle implants. In Friss E, editor. Mechanical testing of orthopaedic implants. Woodhead Publishing, 2017. p231-53.
  12. ↑ Williams LR, Ridge ST, Johnson AW, Arch ES, Bruening DA. The influence of the windlass mechanism on kinematic and kinetic foot joint coupling. Journal of Foot and Ankle Research. 2022 Dec;15(1):1-1.
  13. ↑ YouTube. What is The Windlass Mechanism of The Foot? | James Dunne. Available from: https://www.youtube.com/watch?v=vzTdSXgTCsY [last accessed 29/06/2022]
Retrieved from "https://www.physio-pedia.com/index.php?title=Lower_Leg_and_Foot_Regional_Pain_and_Gait_Deviations&oldid=326232"