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.

"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 back, posterior hip and upper leg musculature.

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.

Back Regional Pain

Potential gait deviations associated with LBP:

1. Decreased gait velocity, less than 1-1.4 metres per second
2. Shortened step length
3. Slow gait cadence
4. Stiff counter-rotation between the thoracic spine and the lumbar spine
5. Changes in expected vertical oscillation of centre of mass (COM)
6. Loud foot strike
7. Can demonstrate either an increased or decreased pelvic tilt
8. Can demonstrate either increased or decreased hip extension during terminal stance
9. Decrease in big toe dorsiflexion, resulting in a functional hallux limitus

Hip Regional Pain

Region of Pain	Relavent Diagnoses	Expected Gait Deviations
Hip Region	Osteoarthritis Can continue status post-total joint arthroplasty	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 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

Knee Regional Pain

Region of Pain	Relavent Diagnoses	Expected Gait Deviations
Knee Region	Osteoarthritis Can continue status post-total joint arthroplasty	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

Back and Upper Leg Region Special Topics

Lumbar Stenosis Gait Deviation

Lumbar stenosis is a common back pain diagnosis in the elderly population. A patient with lumbar stenosis does not stand or ambulate with upright posture, and tends to avoid lumbar extension to decrease and / or avoid pain. They may present with a tendency to walk bent over, and lean on their grocery cart or walker. They will likely demonstrate one of two gait deviations to alleviate symptoms associated with lumbar spinal stenosis:

1. Figure A: Trunk flexion posture with an increased step length and hip extension angle, and an absent lumbar joint moment into extension.
2. Figure B: Trunk upright posture with a decreased step length and hip extension angle, and an absent lumbar joint moment into extension.
3. Figure C: Ideal walking posture of healthy people
   

   Blue arrows indicate the ground reaction force vector, red arrow is the hip flexion moment, and green arc is the psoas major.

Dropped Head Syndrome

Dropped head syndrome (DHS) is a relatively rare cervical kyphotic deformity with symptoms that include: neck pain, restrictions to ambulation, and impaired horizontal gaze. Due to the interconnected nature of the spine, the relationship between cervical alignment and other parts of the spinal column can have an effect on the pelvis and lower limbs during dynamic activities. Patients with DHS demonstrate altered kinematics and kinematics of the lower limbs during walking due to changes in the inclination of the head and trunk. This may cause deviant gait features and altered motor control compared to healthy individuals. Similar findings have been reported in individuals using smartphones while walking. The increased cervical flexion angle affects: cervical loading, walking speed, and muscle activity of the lower limbs.

1. Figure A represents an individual with DHS: backward leaning posture of the thorax, increased ankle-joint dorsiflexion angle, and relatively shorter stride length.
2. Figure B is ideal walking posture: upright erect posture with decreased ankle dorsiflexion angle allowing for more movement coming from the ankle to propel forward and up.

Black arrows indicate the backward tilted thorax and pelvis. Blue arrows are the ground reaction force vector. Red arrow is the ankle plantarflexion moment.

Geriatric gait

At self-selected walking speeds, elderly adults generate decreased joint torques and power in their lower extremities than young adults. These differences are due to the biomechanical and physiological consequences of aging resulting from changes in the underlying neuromuscular components of motor performance and reduction in motor abilities. Pain may also be a factor.

The spatiotemporal changes that occur in geriatric gait:

1. Decreased walking speed, less than 1-1.4 metres per second
2. Shorter step length
3. Slower gait cadence
4. Late or a prolonged heel contact
5. Decreased vertical oscillation of COM
6. Could have decreased hip extension
7. Could have increased forward trunk flexion
8. Could have decreased arm swing
9. Elderly people tend to use hip joint moments more than ankle moments, whereas young people use the ankle to propel forward

Osteoarthritis and Total Joint Replacements

Oftentimes patients with knee or hip osteoarthritis develop gait deviations which continue due to "habit" after undergoing total joint replacements. Patients who undergo post-operative rehabilitation report improved joint pain and stiffness but commonly demonstrate incomplete recovery of gait function.

Resources

Optional Recommended Reading:

• Harris-Hayes M, Czuppon S, Van Dillen LR, Steger-May K, Sahrmann S, Schootman M, Salsich GB, Clohisy JC, Mueller MJ. Movement-pattern training to improve function in people with chronic hip joint pain: a feasibility randomized clinical trial. journal of orthopaedic & sports physical therapy. 2016 Jun;46(6):452-61.
• Harris-Hayes M, Steger-May K, Bove AM, Foster SN, Mueller MJ, Clohisy JC, Fitzgerald GK. Movement pattern training compared with standard strengthening and flexibility among patients with hip-related groin pain: results of a pilot multicentre randomised clinical trial. BMJ open sport & exercise medicine. 2020 Mar 1;6(1):e000707.
• Igawa T, Katsuhira J, Hosaka A, Uchikoshi K, Ishihara S, Matsudaira K. Kinetic and kinematic variables affecting trunk flexion during level walking in patients with lumbar spinal stenosis. PLoS One. 2018 May 10;13(5):e0197228.
• Igawa T, Ishii K, Suzuki A, Ui H, Urata R, Isogai N, Sasao Y, Nishiyama M, Funao H. Dynamic alignment changes during level walking in patients with dropped head syndrome: Analyses using a three-dimensional motion analysis system. Scientific reports. 2021 Sep 14;11(1):1-0.
• Lamoth CJ, Meijer OG, Daffertshofer A, Wuisman PI, Beek PJ. Effects of chronic low back pain on trunk coordination and back muscle activity during walking: changes in motor control. European Spine Journal. 2006 Feb;15(1):23-40.

Clinical Outcome Measures:

• Hip Disability and Osteoarthritis Outcome Score (HOOS) Download PDF here
• Please view the following short video for an overview of the FABER test used in the assessment of pathologies at the hip, lumbar and sacroiliac region.