FOOT MOTION BACK PAIN

Far left Figure 6a: Trendelenburg gait – inadequate pelvic stability;

Left Figure 6b: normal gait – adequate pelvic stability

Figure 8: Controlling excessive pronation

a)

b)

Figure 7a: Lateral pelvic tilt

Figure 7b: rotational movement (torsional)

increases pathological stresses placed on lumbar structures, such as the discs, spinal root nerves, anterior longitudinal ligament, facet joints and supporting musculature (13). Dananberg identified a common, but rarely recognized, entity known as “functional hallux limitus”; left untreated, this can cause and perpetuate many chronic postural complaints, including lumbar stress and chronic LBP (12–14). In functional hallux limitus the first metatarsophalangeal joint will dorsiflex passively through a normal range of motion while non-weight-bearing, but it cannot dorsiflex during gait when weight-bearing. This is because the first ray fails to plantarflex, thus preventing the first metatarsal from stabilising against the ground, owing to excessive pronation or delayed resupination. The condition is known as “sagittal plane blockage”. In a clinical trial when functional hallux limitus was specifically addressed in a foot orthotic treatment plan, 77% of patients with long- term chronic postural pain exhibited 50–100% improvement despite failing with previous therapy.

Sacroiliac problems

The sacroiliac joint has been implicated as the primary source of pain in 10–25% of patients with LBP (10). Both unilateral and bilateral excess pronation can be the cause of abnormal pelvic movement in various planes, such as anterior pelvic tilt, lateral pelvic tilt (Fig. 7a) and rotational movement (Fig. 7b). As mentioned earlier, excessive pronation compromises core and pelvic stability, which increases pathological stresses on the supporting tissues of the sacroiliac joint, leading to localised inflammation, pain and sacroiliac joint dysfunction.

After the acute phase, Zelle and

colleagues recommend that correction of biomechanical deficits should become the focus of treatment (10). If a sacroiliac joint requires recurrent joint mobilisation, then a significant

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muscle imbalance may still exist, and therefore treatment should focus on biomechanical correction and muscle strengthening, rather than repetitive mobilisation, in order to restore stabilisation (11).

Failure to correct abnormal foot mechanics often leads to frequent recurrence or ongoing problems. Treatment should focus on correcting or alleviating the factors that cause dysfunction, rather than treating the symptoms.

Lumbar spine problems Excessive pronation often disrupts normal lumbosacral function (12). Bilateral excess foot pronation causes the innominate bones to rotate anteriorly, which increases the lumbosacral angle, which in turn increases lumbar lordosis. The effect

TREATMENT

The treatment of LBP has changed dramatically over the past 25 years. Bed-rest and immobilisation were still advocated as the primary treatment as recently as the early 1990s. Optimal lower back treatment requires a multidisciplinary and multifaceted approach, as no single healthcare profession, therapy or intervention provides all the answers (15). In cases where abnormal biomechanics exist, controlling excessive pronation (Fig. 8) should form the first part of the treatment package. This approach is designed to alleviate contributing factors, if not the main cause, of dysfunction. Thereafter, a variety of appropriate manual therapy techniques are required to normalise any muscle

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