Lower Leg and Foot Regional Pain and Gait Deviations

Introduction

The kinesiopathologic model was primarily developed to describe the mechanistic mechanisms proposed to contribute to the development and course of low back pain (LBP). The main hypothesis is that LBP results from repetitive direction-specific (flexion extension rotation lateral) movements bending or a combination of these) stereotypic movement and alignment patterns in the spine. The model suggests that the patterns originate as a consequence of adaptations of the musculoskeletal and musculoskeletal systems due to repetitive use of specific and synchronized movements in daily activities. The nature and rate of the adaptations can be altered by intrinsic and extrinsic characteristics of the individual for example sex anthropometrics or typical activities of the person. The most common example is that when performing a movement (e.g., forward bending) or assuming a standing position (for example, the lumbar spine moves in a specific direction faster than other joints, such as the knee hip or thoracic spine.[1]

Notice how the legs are connected to the muscles and structures of the legs.

When the patient’s pain is the guide the goal of musculoskeletal physiotherapy is to identify the physiological processes associated with the reported pain. Physical therapists use bone scans to help determine the source of symptoms. But these clinical trials are usually not incompatible with the accuracy with which the patient’s physical symptoms can be detected. Furthermore there is a poor correlation between imaging results and symptom source detection in the absence of trauma or pathology. These two cases suggest that musculoskeletal pain may be common are physically and structurally unrecognizable. The kinesiopathological approach is an alternative to these more traditional diagnostic methods. This approach seeks to guide clinical practice by identifying kinematic or motor control impairments and modifying a musculoskeletal function. By correcting deviant movement patterns to more adaptive movement patterns that are unique to an individual’s consciousness, subjective pain can be improved and function restored.[2]

Lower Leg Regional Pain[3]

Region of PainRelavent DiagnosesExpected Gait DeviationsCalfMedial tibial stress syndrome[4]Stress fracturePosterior tibial tendinopathy[5]Steps too longKnee extension on heel rocker or foot flexion delayed hip extension or delayed flexion in terminal stanceStrong foot flexionNot elevated pronationHeel whip medial or lateralAchillesAchilles painAchilles tendinopathy[6]Increased forward lean of the trunk or center of mass (COM)Increased vertical oscillation of the COM (bouncy gait)Foot crossing the center of the body during walking and or runningDelayed or it lasts (it must go Achilles tendon and or excessively long calf tendon with length and muscle weakness condition after Achilles tendon rupture condition Achilles tendon stretch or due to excessively aggressive calf stretching exercises)Early heel off ( . due to Achilles and gastrocnemius/soleus shortening and stiff)Increased hip and knee attachment width in end stanceExcessive loading relative to leg progression lineExcessive knee extension

Foot Regional Pain[3]

Region of PainRelavent DiagnosesExpected Gait DeviationsPlantar heelPlantar heel pain syndrome(for more information, please see special topics at the end of this article)First period heel rocker ( heel contact):Too long a stepSlow cadenceLoud foot strikeIncreased vertical oscillation of COMIncreased angle of foot relative to the groundFoot may cross the centerIncreased foot loadingSecond period ankle rocker (transition from full foot involvement to forefoot involvement only):Moving objects or lack of airRelatively late heel off or early heel offIncreased toe-out relative to the line from progressionThird period forefoot rocker (during terminal stance):Excessive posterior flexion of the first MTPJ (more than 65 degrees of lateral flexion)Posterior flexion of the greater load or first MTPJ (less than 35 degrees of posterior rocking )Heel extension up when standing endEarly heel off or toe prolonged/delayed/delayedHeelednessHeightened heelHallux valgusBunion painIncreased pronationAbsent windlassForefootMetatarsalgiaInterdigital neuralgiaMorton’s toe syndromeIncreased forward lean of the trunk or COM when walking or runningToo long a stepIncreased pronationAbsent windlassHeel whip medial or lateralToesMTPJ primary osteoarthritisSesamoiditisOsteochondroma of the metatarsalBenign exostosis on the distal metatarsalAmbulate with a limpIncreased toe-outWith sesamoiditis: excessive amount of dorsiflexion in end position.In osteoarthritis: great restriction toe decreased movement dorsiflexion during forefoot rocker (less than 35 degrees)Altered heel off (may have indicated lift or early heel off);

Lower Leg and Foot Region Special Topics

Plantar heel pain syndrome

Special considerations for plantar heel pain syndrome:[3][7]Professional guidelines and or policies do not include recommendations for gait assessment and trainingStandard professional guidelines and policies describe assessment and treatment procedures which is clinically effective for plantar lower back pain. However, gait assessment is not recommended as part of the assessment program or gait training. For physiotherapists, plantar heel pain syndrome is associated with gait so gait analysis and training should be part of a physical exercise program.Plantar heel pain syndrome differential diagnosis should include tendinopathy of intrinsic plantar flexor musclesPain is NOT an indication for stretching exercises restricted movement is an indication for stretching exercises

The plantar heel pain syndrome can be subclassified based on movement during the three stances. This subdivision is done using gait analysis.[3]

According to Dr. Jacquelin Perry, the three poses include:[8]Heel rocker: a pose in which only the heel is in contact with the ground. It can also be referred to as foot strike or impact loading.Ankle rocker: the period of stance when the entire foot is in contact with the ground. It can also be a slow motion called mid-stance.Forefoot rocker: a period of stance in which only the forefoot is in contact with the ground. It can also be called terminal stance.

The sub-classification can be based on the power at each point at each contact time in stance phase:[3]

• Strength: Estimated 1.5 times body weight when walking. When you run, that energy is estimated to increase by about three times body weight.
• Time: During ambulation, single-limb support is two-thirds of a standing position; a third of that time can double support. Depending on the walking speed, single-limb support occurs in about 0.6 seconds. If single limb stance phase is 0.6 seconds divide that by three and each stance time will be is very fast about every 0.2 seconds.

Standing time period. The purple area indicates the area where force enters the ground through the foot.

Heel rocker phase: 1.5 times body weight in a relatively small area of the heel in a very short period of time Larger area of the rear foot in a very short period of time time.Period of forefoot rocker: The force per unit area enters a relatively small area of the forefoot for a very short period of time. The first and last postural phases are associated with greater risk because they have the greatest forces acting on smaller body areas.

[3]

[3] Possible gait deviation during stance period Heel rocker too long Stride length Slow paced footsteps Loud up and down movement of center of gravity Increased angle of foot relative to ground Increased foot crossing midline Relative to foot forward angle Toes Camber increases ankle Rocker increases pronation without capstan delay or early heel off increases toe abduction relative to foot forward angle forefoot rocker increases or decreases dorsiflexion of the first MTPJ increases hip extension delay or early heel off in terminal stance Increase toe-out or toe-in advance angle

Windlass Effect

According to a 2004 study published in the Journal of Athletic Training [9]:

• A “winch” is the tightening of a rope or cable.
• The plantar fascia simulates the cables that connect between the calcaneus and metatarsophalangeal (MTP) joints.
• Dorsiflexion during the propulsion phase of gait tightens the plantar fascia around the metatarsal heads. Tightening of the fascia shortens the distance between the calcaneus and metatarsals, thus raising the medial longitudinal arch. This shortening of the plantar fascia is Windlass principle.
• From heel strike to weight bearing: Foot pronation increases the distance between the calcaneus and metatarsals. This lengthening puts tension on the plantar fascia.
• From mid-stance to propulsion phase (i.e., mid-phase from heel lift to toe off [10]): foot supination occurs, causing the foot to become a rigid lever arm, propelling the gait using a hoist mechanism. Same pronation force as supination creates, also applies Tension of the plantar fascia. [9]

Windlass Test: [3] Plantar Fascia Passive Structural Length Test Foot Intrinsic Muscle Active Structural Length Test When performing the test you will see: (1) Arch rise (2) Slight supination of the forefoot (3) Slight external rotation of the tibia Time Test monitor for presence or absence of joint bursts Weightbearing and non-weightbearing tests

You may wish to watch the short video below to learn more about the windlass mechanism and to view windlass tests in both weight bearing and non-weight bearing positions.

[11]

Leg length discrepancy

Two types of leg length differences:[3] Anatomical leg length differences: due to physical bony shortening of one of the lower extremities Functional leg length differences: unilateral lower extremity asymmetry without any shortening of bony components. The deformity comes from Admirable action at the hips, knees and/or ankles.

Anatomical leg length differences can be measured both statically and dynamically. A gait analysis should also be performed to determine how the individual is adapting to this structural change. Noticing and assessing compensatory movements will aid in the planning of physical therapy care and therapeutic intervention.

Compensation movements for possible expected gait deviations and/or leg length differences:

Long legs Short legs Foot pronation Post-supination Ankle dorsiflexion Plantar flexion Knee flexion and extension Hip joint flexion AB External rotation Internal rotation and extension AD

Resources

Optional Recommended Reading:

• Bramah C Preece SJ Gill N Herrington L. Kinematic characteristics of male runners with a history of recurrent calf muscle strain. 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. Can biomechanical research lead to more effective treatment of low back pain? Peer to peer debate. Journal of Orthopedics and Sports Physical Therapy. 2019 Jun;49(6):425-36.
• Lehman GJ. The role and value of symptom modification approaches in musculoskeletal practice. Journal of Orthopedics and Sports Physical Therapy. 2018 Jun;48(6):430-5.