By Mehrnaz Kouhkan, DPM
2nd Year Resident, The Podiatry Institute
SCIENCE PHOTO LIBRARY
When a patient complains of pain in the foot, hip, knee and/or back, a complete examination that includes the back and lower body becomes essential. It is crucial to evaluate each patient above and beyond the foot.
By observing the whole body, and specifically the lower extremity and gait pattern of each individual, a lot of information is obtained regarding the foot type of each patient and the stem of each problem: the connections above the feet.
A close evaluation of the feet in a patient with excessive pronation (flattening of the arch), curly toes and/or pain in the arch of the foot could correspond with a history of pain in the lower back and spinal symptoms. The spine responds to poor support from one of the lower extremities (eg. a short leg) by developing a lateral curvature. Some studies indicate that gait disturbances, specifically during the stance phase, may be one of the causative factors for idiopathic scoliosis. A brief gait evaluation can reveal abnormalities such as foot flare (excessive outward rotation of the foot) or poor toe-off. The back pain can be the result of the abnormal stress being transmitted from the lower extremities to the spine. Both functional and idiopathic types of spinal curvatures can be associated with pronation, and may benefit from stabilization of the foot (ie, orthotics).
Pain radiating down a thigh or leg, toe weakness or drop foot may indicate pressure on or injury to a nerve as it exits the spine. Such symptoms in the foot call for a closer examination of the spine. An evaluation of the pelvis can provide another necessary clue. When a standing structural evaluation discloses a pelvic tilt; a lower extremity asymmetry; or Tilting of the pelvis during stance, this may like indicate a functional short leg due to unilateral or bilateral single foot hyperpronation/overpronation. Also degenerative changes in the hip joint have been correlated with the stress of a longer leg.
Another important connector to consider when evaluating the feet are the knees. When the foot pronates it puts abnormal stress on the inside compartment of the knee. When the knee does not align properly or track correctly, degenerative wear-and-tear and chronic symptoms will follow. This could cause compensation in the foot due to abnormal pronation forces on the knee joint, which must sustain frequent high forces during walking and running. A simple adjustment intervention such as the use of orthotics could minimize the stress being transmitted and help alleviate back, hip, knee and/or foot pain.
Other clinical characteristics of foot pain from lower back that involves injury to a spinal nerve root includes heel walk, or restricted ability to bring the foot up, accompanied by numbness in the middle lower leg and foot; foot drop or foot heaviness or weakness, which can produce pain that radiates down the outside of the calf and over the top of the foot to the big toe; and difficulty walking on tiptoes.
While there may be many causes of foot pain, it is essential to note that not all foot pain originates in the toes or in the front or back of the foot, nor does it necessarily develop because of some injury or trauma to the foot. It is rare to have isolated foot pain due to a problem in the lower body without any leg or back pain or discomfort.
Many types of foot pain can have nothing to do with the foot, but rather a problem with the connections throughout the lower body. Seek medical attention for a proper and thorough diagnosis.
