I practiced in a large multi-disciplinary setting. Low Back pain was a very common complaint I would treat. Patients with back pain would be seen by many physicians, some of them podiatric physicians. As with most injuries, sometimes my treatment was very important, even the most important treatment they received, sometimes partially helpful, and sometimes not at all (at that time). I will emphasize "at that time" because my treatment just may not be at the right time, and may be important only after their epidural or low back surgery, etc. Of course, it is safer to treat low back pain with their primary care physician for the back. That physician may be their orthopedist, physiatrist, neurologist, chiropractor, or primary care physician. With 60-80% of adults having some sort of back pain by 60, there are alot of patients out there to help. As a podiatrist, what are the 6 main treatments of low back pain that you may be the expert on in your medical community? These include:
- Tight Hamstrings
- Short Leg Syndrome
- Sagittal Plane Blockade
- Over Supination Syndrome
- Over Pronation Syndrome
- Inadequate Shock Absorption
To make matters a midge more interesting, patients can present with one to all five of these issues at the same time. Which is the most important to treat? Where would be the fun in that if we knew from the get-go! And, if you were asking yourself, how can a patient be an over pronator and over supinator at the same time, these medial lateral instability patients always prove a challenge. There will be more on these patients to come.
The following are a group of questions for self testing with the answers at the end of this post.
1. Subtalar joint ? tends to produce poor shock aborption.
2. Tight hamstrings cause ? knee flexion and low back ?
3. Average adult with a long right leg tends to pronate on the ? side.
4. What are 6 possible gait signs that limb length discrepany exists?
5. What phase in gait is subtalar joint supination problematic?
6. Kinetic ? help with sagittal plane movement from heel to toe.
7. Medial ? Skive is helpful for over pronation syndrome.
8. ? Modification is a lateral arch filler that does not produce a valgus wedge effect but can stop over supination tendencies after orthotic dispense.
9. A Wind Blown Effect is that one foot pronates and one foot ?
10. In the 3 Phases of Rehabilitation, what is the most common phase when orthotic devices are dispensed?
Tight Hamstrings in themselves cause increased knee flexion. The more the knee is overly flexed, the more the knee is unstable. Various forms of knee pain can arise from this. But, proximally up the leg, these tight hamstrings pull down on the pelvis unnaturally straightening the lordotic curve present. This is how low back pain can arise from tight hamstrings. Stretching of the hamstrings should be 3 times a day, and with the foot in 3 positions when the lower hamstrings are stretched. These include a foot straight, a foot pointing medially (to stretch the medial hamstrings more), and a foot pointing laterally (to stretch the lateral hamstrings more). It will not take long for the patient to decide if the medial or lateral hamstring is tighter. The upper hamstrings are probably more important to stretch than the lower hamstrings in cases of low back pain. Here is a short video that shows the difference.
Low Back Pain and short leg syndrome is Biomechanics 101. Every patient with low back pain should be evaluated for Limb Length Discrepancy. Since I devoted 5 posts to this topic, we can move on here.
Sagittal Plane Blockade was popularized by Dr Howard Dananberg as a main cause of low back pain. As we move forward from heel to toe, that forward flow should go unimpeded. If the first ray blocks that forward motion instantaneously, the low back gets jerked repeatedly step by step. The use of a Kinetic Wedge to free up the first metatarsal, similar to our understanding of Dancer's Pads or Reverse Morton Extensions, should eliminate that jerk on the spine. This is called Sagittal Plane Facilitation.
Over Supination is a contact phase issue. As the foot strikes the ground, subtalar joint pronation with its internal talar rotation, allows motion for limb shock absorption, and allows joint mobility of the foot to adapt to whatever surface the foot meets. Subtalar Joint Supination at this time translates into poor shock absorption and its issues, poor foot adaptability, and an abrupt stop of the internal rotation of the leg (with stresses commonly seen for the foot to low back).
Over Pronation causes Low Back Pain due to the instability it is creating in the lower extremity. That instability could be from the position the foot is left in, from the length of time that pronation continues to occur, or from the speed of pronation that must be decelerated. Many patients with an unstable lower extremity will excessively tighten the back and upper extremity as their way of compensation. If we don't gain stability somewhere, we can probably gain that stability temporary in an armchair.
Low Back Pain can be caused by poor shock absorption. This poor shock absorption can be entirely related to subtalar joint supination (orthotic reduced), or by many other factors. Gait evaluation can be the first clue that the patient is a "pounder". Your ears may be the first to pick it up. You will typically see no heel motion (but our eyes can only observe 5 degrees or more). You may see shock waves in the calves if they are exposed. You may start your treatment with more cushioned shoes, adding inserts under the shoe liner that adds "cush". You should have a go-to-orthotic for max shock absorption.
Answers to Questions:
1. Supination
2. Flexion and Straightening
3. Right
4. Head Tilt, Shoulder Drop, Asymmetrical Arm Swing, Dominance to One Side, Uneven Belt Line, Asymmetrical Foot Motion
5. Contact Phase
6. Wedges
7. Kirby or Heel
8. Denton
9. Supinates
10. Return to Activity Phase
