foot motion back pain
How abnormal foot motion can
be a major contributor to
lower back and pelvic problems
The foot is a
masterpiece
of engineering
and a work
of art
(Leonardo da Vinci)
By Nick Dinsdale, BSc
INTRODUCTION
The foot combines mechanical
complexity and structural strength.
The human foot makes up an eighth
(26 bones) of all the bones in the
body, more than 30 joints, and 10
major extrinsic muscle tendons.
These musculoskeletal structures
work together with the neurovascular
elements to provide support, balance
and locomotion during gait. The foot
has three very demanding roles:
1) it must be a loose adaptor to
accommodate uneven terrain
2) it must be able to absorb shock on
impact
3) it has to form a rigid lever during
push-off (1).
If the foot fails to function correctly,
problems can arise anywhere along the
kinetic chain and in the lower back.
Both low-arched and high-arched
feet have been reported to be major
factors in making an individual more
prone to injury (2,3). People involved
in increased levels of physical activity,
such as athletes, tend to be more
susceptible to gait-related injuries (2,4).
NORMAL FOOT MECHANICS
DURING GAIT
Pronation and supination are normal
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The foot contains many bones, joints and tendons that work
together to enable gait. Dysfunction of any of these aspects of the
foot may cause problems anywhere along the kinetic chain and in
the lower back (Fig.1). This article reviews the basic anatomy of the
foot and discusses some of the lower-back problems associated
with abnormal foot motion.
movements of the foot that occur at
spinal scoloiosis the subtalar joint with every step. At
the beginning of the gait cycle, the foot
is in a supinated position. As the heel
abnormal
pelvic tilt strikes the ground, the foot immediately
begins to pronate: the foot rolls inwards
imbalance of in order to gain ground contact, the
pelvic muscles
tibia rotates internally, the heel everts,
the arches tend to flatten, and the mid-
malalignment of hip foot “unlocks” and becomes slightly
unstable (Fig. 2).
Pronation allows the foot to
become a flexible mobile adaptor
to absorb ground impact and
internal rotation of thigh accommodate uneven terrain. As the
body weight moves forward over the
malalignment of knee forefoot, resupination should occur (Fig.
3). Supination converts the foot from a
flexible mobile adaptor into a rigid lever
internal rotation of leg in preparation for the propulsive phase
of gait. The tibia starts to externally
rotate, the medial arch lifts along with
the navicular bone, the heel starts
to invert, the first ray drops, and the
peroneal longus contracts to “lock” the
cuboid bone, making the foot stable
and thus creating a secure platform.
© PRIMAL PICTURES 2009
This is important because the other
subtalar pronation foot is now swinging forward for the
(flat everted foot) next step and the pelvis must remain
level and stable throughout the mid-
stance phase. Once this has occurred,
Figure 1: The kinetic chain - foot dysfunction predisposes the the heel can lift and the big toe joint
kinetic chain to abnormal repetitive stresses
extends (windlass mechanism) to
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 Figure 2: propel the body forward from the balls
Pronation
(metatarsophalangeal joints) of the foot
and toes.
The ability to resupinate and
recover from pronation is paramount to
normal effective functional gait. Failure
to resupinate is often associated with
functional hallux limitus and chronic
postural problems (see below).
ABNORMAL FOOT
MECHANICS DURING GAIT
Figure 3: The feet support the whole body
Supination weight. When things go wrong,
problems can occur anywhere along
the kinetic chain, including in the
foot, ankle, shin, knee, hip, pelvis,
sacroiliac joint and lower back.
Abnormal movement (overpronation
or underpronation) and incorrect
timing of movement may predispose
the individual to injury or magnify the
symptoms that result from abnormal
repetitive stress (2–4).
Figure 4: Severe Generally, patients with low-
heel eversion arched feet overpronate, and patients
with high-arched rigid feet tend to
underpronate and thus oversupinate.
Many people inherit foot types that
are more likely to develop problems.
Other foot problems arise because of
injury or disease. According to Root
and colleagues, abnormal subtalar joint
pronation can be a result of forefoot
varus, rearfoot varus, tibial varum, ankle
Figure 5: Increased
internal tibial joint equinus and plantar flexed first
rotation ray (5).
Excessive pronation represents
the most common biomechanical
problem and is often cited as a key
contributor in many overuse injuries
of the lower limb and lower back (6).
Excess pronation is synonymous with
excessive calcaneal eversion (Fig. 4)
and increased internal tibial rotation
(Fig. 5).
Often asymmetrical gait develops.
If left untreated, this can lead to
abnormal postural changes. It is
estimated that 75% of the population
suffer from excessive pronation, from
children to elderly people, from top
athletes to people with a sedentary
lifestyle (7). Although the majority of
affected people exhibit excessive
pronation, symptoms may present only
following increased weight-bearing
© PRIMAL PICTURES 2009
activity.
LOWER BACK PAIN
Research indicates that at any one
time 35% of the UK population has
12
some form of lower back pain (LBP),
which represents 7% of the workload
of all general practitioners (8). LBP
may arise from various aetiologies and
various regional structures, including
the lumbar spine, sacroiliac joints,
hips, buttocks and pelvis. LBP may
be due to disease, tumour, direct
trauma, overuse, and abnormal or
altered biomechanics. In order to
establish a diagnosis, a thorough and
systematic clinical examination must
be undertaken. The patient should
be screened for potential risks and
contraindications, especially those with
true pathology.
In this article, our focus is on LBP
purportedly attributed to excessive
pronation.
Although LBP is often multifactorial,
and with overlapping conditions, we
discuss the pathological effects of
excessive pronation under three
separate headings: gluteus medius
syndrome, sacroiliac problems and
lumbar spine problems.
CLINICAL IMPLICATIONS OF
EXCESSIVE PRONATION
Gluteus medius syndrome
During mid-stance of gait, the foot
should remain stable, thus effectively
supporting the full body weight while
the opposite leg swings forward. Failure
to provide a stable platform (owing to
excess pronation) compromises the
ability of the muscles responsible for
core and pelvic stability, particularly
the gluteus medius. Consequently, the
gluteus medius and other muscles
cannot function efficiently. Over time
the muscle becomes fatigued, weak,
hypotonic and tender on palpation –
“gluteus medius syndrome”. This often
leads to abnormal pelvic movement,
pelvic muscle imbalance and pelvic
instability. Clinically the patient presents
with a Trendelenburg gait (Fig. 6),
frequently accompanied by hypertonic
piriformis, tensor fascia lata, adductors
and psoas muscles owing to their
compensatory role. The patient may
also present with apparent leg-length
discrepancy. Pelvic instability and pelvic
malalignment arising from excessive
pronation are now recognised as
predisposing factors for hamstring
strains (9). Pelvic stability can be tested
by observing the patient performing
a single-leg squat; it is surprisingly
common to see patients who have
difficulty maintaining a level pelvis.
sportEX dynamics 2009;19(Jan):11-14

a)
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
www.sportEX.net
Far left Figure 6a:
Trendelenburg
gait – inadequate
pelvic stability;
Left Figure 6b:
normal gait –
adequate pelvic
stability
b)
Figure 7a: Lateral
pelvic tilt
Figure 7b:
rotational
movement
(torsional)
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
foot motion back pain
Figure 8:
Controlling
excessive
pronation
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.
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
13
imbalance, improve and encourage fluid
exchange, reduce fibrous tissue, and
mobilise and adjust joint positions. In
conjunction, a suitable rehabilitation plan
is necessary to restore full range of
movement, muscular strength, balance
and proprioception. The patient should
perform weight-bearing closed-chain
exercises while wearing foot orthoses
in order to ensure that correct limb
and pelvic alignment is maintained
throughout. Emphasis should be placed
on simple but specific exercises for
restoring core and pelvic stability,
eg. hard-surface single-leg balancing,
progressing to a soft surface. If
necessary, electrotherapy modalities
can be used to assist in pain control
and tissue repair.
5. Root M, Orien WP, Weed JH. Clinical
biomechanics. In: Normal and abnormal
function of the foot. Clinical Biomechanics
Corp. 1977. ISBN
6. Bolgla L, Keskula D. A biomechanical
approach to evaluating and treating lower
leg dysfunction. Journal of Athletic
Therapy Today 2003;8:6–12
7. Vasyli lower limb biomechanics workshop:
rear foot mechanics. Manchester,
September 2005
8. Norris C. Sports injuries: diagnosis
and management, 3rd edn. Butterworth
Heinemann 2004. ISBN 0750652233
9. Fleet T, Edge D, Catterall K. Prevention of
hamstring injuries in a professional football
club: using a multidiscipline sports medicine
team approach. sportEX Dynamics
2008;15:10–14
10. Zelle BA, Gruen GS, Brown S, George
S. Sacroiliac joint dysfunction: evaluation
and management. Clinical Journal of Pain
2005;21:446–455
11. Prather H. Sacroiliac joint pain: practical
management. Clinical Journal of Sports
Medicine 2003;13:252–255
12. Dananberg JH. Gait style as an etiology
to chronic postural pain: part 1. Journal
of the American Podiatric Medical
Association 1993;83:433–441
13. Dananberg JH. Gait style as an etiology
to chronic postural pain: part 2. Journal
of the American Podiatric Medical
Association 1993;83:615–624
14. Dananberg JH, Guiliano M. Chronic
low-back pain and its response to custom-
made foot orthotics. Journal of the
American Podiatric Medical Association
1999;89:109–117
15. Patel K, Patel S. Who owns low back
pain? sportEX Dynamics 2007;13:19–22.

References The Author

1. Padiar N. Foot orthotics: their role in
injury management. sportEX Medicine
2001;8:6–8
2. Razeghi M, Batt M. Foot type classification:
a critical review of current methods. Journal
of Gait and Posture 2002;15:282–291
3. Quinn G. Foot posture, biomechanics and
orthotic selection workshop. Cheshire July
2007
4. Cornwall MW. Common pathomechanics
of the foot. Journal of Athletic Therapy
Today 2000;5:10–16
Nick Dinsdale originally trained as a sports masseur and later qualified as an
osteopath before completing a BSc (Hons) in sports therapy, gaining a first class
degree. Over the years Nick has worked as team masseur to the GB and England
cycling teams, covering both domestic and overseas events. Nick has been a keen athlete,
competing in running and cycling events at all levels, culminating in winning the national
cyclo-cross series. Nick is a part-time tutor at the Northern Institute of Massage (NIM).
Specialist workshops include: i) Electrotherapy, ii) Lower limb biomechanics and orthotic
prescription. Nick is a visiting lecturer at Teesside University and has carried out consultancy
work for the University of Central Lancashire.

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