21. Lower back pain as a gait-related repetitive motion injury HJ. Dananberg INTRODUCTION It has been known for some time that patients ‘who injure their lower backs are often an ‘accident waiting to happen’. Some types of repetitious stress act on the lumbosacral spine over a signifi- cant time, which results in an inherent fragility of one or more of its structural components. Once substantial change has occurred, an apparently ‘inconsequential movement can then trigger an incapacitating event. ‘Walking is an activity of daily living. Assuming only 80 min per day of weight-bearing perform- ance, an average adult will repeat 2500 stance/ swing cycles per limb, That equates to almost 1000 000 steps per limb per year. By the age of 30, this number approaches 30 000 000 cycles. IF the subject has a walking or standing job and/or participates in an exercise program, this number can easily double or triple. Should this gait prac- tice be only slightly askew, the day-to-day cumu- Intve effect is disguised by its subde nature yet can be a hidden source that creates and/or per- petuates a pattern of chronic lumbosacral pain. Tn the course of any particular step, many significant actions are interdependent, since the anatomy of the lumbosacral spine, upper torso, and lower extremity are all woven together. Muscle, tendon, ligament, and capsular components directly connect the medial coluran of the foot to the sacrum and lumbar spine (Vleeming et al 1995). While proper use creates a remarkable intrinsic stability, restrictions of motion at the foot level can adversely affect lumbosacral self-bracing and locking. Since this type of restriction is most often asymptomatic at the foot, there is rarely an association made between it and more proximal postural complaints. These mechanically inefficient motions, however, gradually create an environ- ment for neurogenic hypersensitivity, myogenic ‘overuse, and degenerative joint disease as the rotations necessary for secure support reverse themselves. For example, nutation of the sacrum, which is required for sel-bracing of the sacroiliac joint (SI) during gait, demands that the biceps femoris, via its connection with the sacrotuberous ligament, relaxes during the midstance portion of the step as the pelvis rotates anteriorly. This is permitted by the ability of the weight-bearing limb adequately to extend out from under the hip joint during this point in the gait cycle. A pre- viously described pathomechanical foot dysfunc- tion known as functional hallux fimitus has been shown to block this action (Dananberg 1986). Cyclic failure of adequate hip extension, coupled with concurrent flexion of the torso, causes a response of biceps femoris tightness, which restricts nutation and causes in its place counternutation, Self-locking, and therefore stability of the Tumbo- sacral spine, fails to develop. Once intrinsically unstable at_midstance, the ensuing motions required for walking add additional stress to this system. In an average 70 kg adult, each lower extremity weighs approximately 15% of body weight, or 10.5 kg, At toe-off, the large iliopsoas muscles, which originate directly from the lower back, must fire to assist in the development of the swing phase of motion. Considering that this event is repeated at least 2500 times per day, the weight to be lifted equates to 26 250 kg per limb per day. Should the origin of these muscles fail to provide an adequately stable base from which to lift these limbs, cumulative stress mast develop at 253254 EVOLUTION AND Garr this site of origin, ‘This is felt directly as lower back pain, Should the muscle group responsible for this action become hypertonic, mechano- receptors sense this information and relay it to the CNS. The resultant spinal cord reflex gain directly lowers the pain sensor (nociceptor) thres- hhold and can eventually cause secretion of inflam- matory neuropeptides. Less and Jess motion creates greater perception of pain (Zimmermann 1989). Other compensatory motions then occur which assist in the limb lift process. ‘These motions are visible as ‘ateral trunk bends, which are created by the combination of actions of the contralateral quadratus lumborum and gluteus maximus! ‘liotbial band complex. These further add to the lower back pain syndrome (Dananberg 19936). Improper walking, as described above, causes a subele but ever-present repetitive strain injury to the lumbosacral spine. Failure to lift each limb properly for the swing phase can essentially be seen as ‘dragging the lower limbs’ and is there- fore a source of constant stress to the chronic lower back pain patient. Removing this deceptive origin can have a significant effect. In a previously Published retrospective analysis of chronic postural pain patients considered at or near medical end- point for long-term symptoms, 77% reported a 50-100% improvement when asyrapromatic foot function was objectively addressed (Dananberg et al 1990). In a holistic approach to the back pain patient, the applization of this stress would appear to be at least of equal consequence as the con- dition of the site to which it is applied. Objective sait analysis and treatment, as an addition to the physical examination and treatment of the lumbo- sacral spine, become an important adjunct of the therapeutic process. ‘This chapter will first provide a review of the process of taking a normal step. This will include a description of the generation of the power for movement as well as the actual biomechanical response to this power input. Following this, an approach to understanding the pathomechanical process is outlined. Specific pathologic movement that may lead to an overall postural decay over time along with lumbosacral stress are detailed. ‘Markers for gait observation are also given, so that individual patients can be examined and proper treatment prescribed. OVERVIEW OF GAIT MECHANICS ‘When the ancestors of our humsin species became bipedal millions of years ago, they needed an ambulation system that would function in a highly efficient fashion over long distances. Upright human walking is that efficient system. In order to appreciate its mechanics, some prior miscon- ceptions must first be addressed. Tthas been theorized that walking is the process in which muscles fire, creating force moments across joints, which in tum drive the weight- bearing limb to push the body forward (Inman 1981). This view cannot be supported by either logic or currently available information on muscle function. Muscles in the weight-bearing limb predominantly function eccentrically (Winter & Scott 1991). Eccentric contraction represents the resistance to motion. While this is highly efficient (1.5-6.0 times that of concentric contraction or muscle shortening) (Abbott 1952), it cannot create & pushing force. When concentric contraction finally occurs in the gastrocnemius, for example, both the knee and hip have already begun to flex forward, This would equate to the concept of pushing rope! Flexible systems cannot be effec- tively driven in this manner. Therefore, another ‘model must be used to understand the mechanics of human walking. Efficiency of the walking process ‘The human body can be viewed as a perpetual motion gait machine. The pendular actions of arms and legs act reciprocally, storing potential energy and rerurning kinetic energy in the process. ‘These actions are visible as counter-rotations between the pelvic and shoulder girdles. Storage ‘occurs in the ligamentous, muscular, and tendinous structures of the lower back (Dorma 1995). The cross-connections between the ipsilateral latissimus dorsi and contralateral gfuteus maximus via the fascia thoracolumbocalis are ideally suited to this storage capacity. Each step prepares for the next fone; the effect is to create a forward-directed rotation on the pelvic hemisphere as it co- ordinates with the limb that is about to begin the swing phase motion (Gracovetsky 1987). During walking, there are periods of both single and double limb support (Fig. 21.1).LOWER BACK PAIN: A REPETITIVE MOTION INJURY 255 b Initial double support Fig. 21.1 Single sod double support phases of gi. Substantial forward motion can onily occur in the approximately 400 ms of single support phase. As the weight-bearing limb supports the body, the contralateral limb acts to pull the center of mass forward (Claeys 1983). In essence, the free- swinging limb acts on the body and ‘yanks’ it over the weight-bearing side. As an analogy, imagine tying @ 3m rope between a rock and your waist, If the rock were picked up and ‘thrown forward, a period would exist when the rope would lose its slack, Once sufficiently tightened, your body would suddenly be drawn forward towards the rock just as the rock would suddenly be halted in its forward progression. In walking, this is the action of the swing limb. It is. ‘thrown out’ ahead of the body. As the swing limb is ‘slowed’ as it reaches its end range of forward motion, the center of mass is simul- taneously pulled towards the forward position thatthe limb has attained, Gravity, continuing to act with momentum, pulls the center of mass towards the ground. Body weight, therefore, becomies the efficient prime mover (Dananberg 1993). In arder for forward motion to occur, ground contact must be present. This is the ultimate purpose of the weight-bearing limb. ‘Through an clegant series of phasic, eccentric muscular con- tractions, the lower extremity is stabilized to accept the force created by the body advancing. above. It can use this to create @ relative ‘push’ or ‘whsust’ against the ground 4s the body is pulled Swing Relative AY Pull thrust | effect effect = |— Single support —| A Terminal double support cover it, The length of the weight-bearing limb provides a mechanical advantage to the pull of the swing limb. I effectively serves as ‘lever-like? structure to thrust the ground beneath the foot. Since the ground does not move, the subject advances. Sagittal plane rotation of the load-bearing. joints It is a basic requirement in human gait for the torso and head to remain erect. For this to occur, there are two specific sites at which motion is obligatory: the hip and the foot. As the body passes over the weight-bearing foot (right limb viewed from the right side), the hip joint rotates in a clockwise direction while the foot simul- taneously provides the same direction of motion. This permits the torso to remain erect as the leg and thigh exsend at the hip. The foot’s rotation permits advancement beyond a fixed point. Shoxld one or the other not be present, the mechanics of ‘walking are significantly altered (Fig. 21.2). Rotation of the hip joint is simple to visualize. It is a ball and secket joint that permits sagittal plane extension during the single support phase. ‘The foot, however, comprises 26 joints, which rotate in a complex yet interdependent manner. It must coordinate the effect of lower extremity internal rotation with the impact at heel strike. It ‘must then reverse the direction of rotation by mid- step, and accommodate lower extremity external256 EVOLUTION AND Garr A Forward pelvic rotation Swing Hip extension during single support phase B Relaxed biceps ea pes position 1 ‘Closing’ the angle between the posterior thigh and ischial tuberosity Fig. 21.2. The coordination ¢Fhip extension, forward pelvic rotation, and biceps relaxation. rotation while simultaneously stabilizmg itself to forces that can reach multiples ‘of body weight pTior to toe-ff. Finally, i must maintain a portion ofits structure in ground contact while permitting the entire body to pivot over it. These actions are repeated at least 2500 times per day, all within the time span of approximately 600-750 ms, ‘The foot as a sagittal plane pivot “The ability of the foot to permit the body t0 advance forward over it is a complicated action. ‘There are three separate sites at which this pivotal response occurs (Dananberg 1995, Perry 1992). “The intial location is the inferior, rounded under- surface of the calcaneus. This motion is com- pleted following heel strike, once the forefoot touches the floor. With the heel and forefoot in contact with the ground, the ankle becomes the next site of rotation. It passively dorsiflexes as the pull of the swing limb advances the center of mass over it Perry 1992). Dorsiflexion of the ankle is a intricate movement. The dome of the talus is shaped as a truncated pyramid, wider anteriorly than posteriorly. Therefore, as dorsiflexion occurs, the ankle joint must expand to accept the widen- jing surface of the talar dome. This expansion is dependent on a translation motion of the fibula. It moves upward and laterally, reorienting the fibers of the syndosmosis that connect it to the tibia. Not only does this permit continued dorsi- flexion, but it also appears to store energy thet will be used for ankle reversal into plantar flexion later in the step. The above two actions occur in « period of less than 200 ms. ‘The final pivotal ‘hurdle’ occurs in the second half of the single support phase. This represents the peak reactive ground thrust periods during the final 200 ms of one-leg support and further coordinates with the greatest forces concurrently being applied. Since the foot must act as both a shock absorber at heel strike and then reverse t0 be a rigid platform for propulsion at this time, a system must be present which regulates these events sequentially and establishes a stable struc- ture from a flexible one. While this occurs, it must continue to permit the body to advance forward directly over it. This action has been shown to be dependent on the proper function of the first metatarsophalangeal (MTP) joint, the final pivotal site. In 1954, J. H. Hicks, a British research physician, proposed such a mechanism in the Journal of Anatomy (Hicks 1954). As recently as 1995, his concepts have been proven ‘most accurate (Thordarson 1995). This action, known as the windlass effect, is a purely mechanical (and therefore non-muscular) response. It uses the plantar aponeurosis asa ten-LOWIR RACK PAIN: A RAPETTTIVE MOTION INJURY 257 sion hand, sitering its tighmess as required by body anal foot position, The plantar aponcurosis riginares fom the base of the calcaneus and ingens into the base of the proximal phalanx of the great toe (as well as providing smaller fibers to the lessor digits). As the MTP joint dorsilexes ‘© permit heel litt, the large, drumlike shape of she frst metatarsal head-sesamoid bone complex serves asa mechanically advancaged cam, Lightening the aponcurasis between the heel and tock. Ar the aponeurosis tightens, ir secondarily dlose-packs the calcaneal cuboid joint on the lateral column of the foot. This action precipi- tates a stabilization of the tarsus, mkdtaesus and metatarsus, beeaase the Forces that would other- wise flatten the foot ate eapidly escalaring as the body advances forward {Bojsen-Maller 1979). The Same movement that petmits the body to pivot over the planted foot sinmuhaneously stabilizes it to the evelically upplied stresses (Fig. 21:3) ‘The swing phase terminates with heel strike, and che endre process reverses, the trailing limb Ueginning its transition to swing movement, The paskage from the stance to swing represents. 9 mechanical challenge. It requires taking the 10.3 kg Fim from an ‘at rest” position to a full- speed, swing motion in 100 ms. The greater the eificieney in this transformation, the less the svscular input required. Initiating swing phase Te appears that the body uses the actual weight of the limb itself to initiate this swing motion. As the former swing limb steikes the ground, the trailing limb immediately begins the *pre-swing” activity. ‘From its extended position’, the kece joint ‘collapses’ into Mexion. With knee flexion, there is a concurtent Hexion of the by june above. Below, the ankle rapidly plantar exes Fig. 21.3 (A) Athoe sti, the sound under ofthe caleanei serves a he nial pivona ste, (8) Once foe Bais tchlewed, saga mation fy now aezonamodate! bythe ale pnt wa derifeson. ¢C) At heel fant motion reverses <0 plarkirNowct athe fhe reuires saga258 EVOLUTION AND Gary while the MTP joint dotsifleses ar the same rate. ‘The thigh therefore, based! on the collapsing of the suppor feints, begins to accelerate rapidly for- ward until toe-olf occu, Just prioe fo toe-of the gastrocnemias provides 4 btief butst of concen- tric contraction, propelling the litnb into the swing phase (Dananberg, 1993a}, (Since the knee sind hip are flexing at this time, it would be ign possible for this gastrocnemius activity 10 push the center of mass directly. Ie would, as described above, be analogous to ‘pushing rope’. Instead, it provides the final thrust from below te initiate the swing phase.) At the moment of rwe-off, che now swing limb's motion is perpetuated hy the hip lexors. the iliacus and psoas groups, which fire at this time, ‘The iliacus originates from the evest of the ilium, whereas the psoas cakes its origin from the lumbar spine, discs, und intervertebral sqpta. ‘They oxen via. a common tendon tw the lessor trochanter of the femur. Their action it complete by 50% of the swing phase cycle, The advance- ‘ment of the swing limb coontmares with the energy retum of the pelvis and shoulder giedie system (Dorman & Vieeming 1995). ‘The pelvis of the swing side is now being propelled forward by the ‘spinal engine’ (see also Chapter 20), integrating the upper and lower body interactions. ‘The now ‘svinwing lib pulls on the center of mass, deawing it over the weight-bearing limb as the cycle repeats itself time and time again (Fig. 21.1), Byala te sity extend aod the fot hase 0 ‘Changing from stance to swing: the pelvis-SYJ interaction In oder for the lower extremity and pelvic gidle to act in a synchronous fashion ay rotations change directions rapiliy, the SIJ acis as an inter~ ‘mediary, or ‘clutch’, permitting the transterence ‘of forces from the stance to the swing limb Dormin S& Vieeming 1995), For the clutch to Close and create ‘self-focking’, the sacrum must undergo a forward rotation known as nutation, Tt is Wis motion which permits both a form and force closare of the SI] and is critical in proper function, ‘Tre sacrum is interconnected to the lower ‘eatremity through a series of anatomic structures “The sacroruberous ligament, originating from the coceygeal vertebrae, the SI} capsule, and the posterior iliac spines, nuns distally 10 the attach ‘ment of the biceps femoris on the ischial uberosiy, Te has been shown thar the bicepssacrotuberous figament is a cominuous scructure (see also Chapter 3). The distal connection of the biceps is © the proximal tibia, fibula, and fibers of the origin of the peroneus longus muscle on the lateral aspect of the leg {Vleeming et al 1995). Through ‘his coupling, motion wf the sacrum is integrally related to the function of the lower extremity. “Vinwrston and) Harris (1983) have “demon- siraned that the Sagittal plane motion of the pelvis coordinates with the motion of the swing limb, (8) Atahe end of single support hase, the ras lin reaches the peak mont &f extension the hip sont The 1 supper surface vie motion a the MTP has.LOWER BACK PAIN: A REPETITIVE MOTION INJURY 259 The pelvis is most posteriorly tilted just prior to toe-off, and is most anteriorly tilted just prior t0 heel strike. Sagittal plane motion of the pelvis during swing phase is therefore from posterior to anterior, or forwardly directed. This motion would directly coordinate with sacral nutation, which is a forward tilting of the sacrum and synonymous with SIJ self-locking (see Fig. 21.2). ‘Synchronizing the lower extremity and the pelvis, ‘The synchronicity of motion of che lower extremity and the lumbosacral spine are essential for normal function. As any step occurs, the weight-bearing thigh will progressively extend at the hip joint until this motion terminates opposite limb heel strike. With this extension ‘motion, the angle between the posterior leg and the ischial tuberosity ‘closes’, thus keeping the biceps femoris in a relaxed position relative to its origin and insertion. This coordination of biceps relaxation and posterior-to-anterior pelvic motion is fundamental in maintaining the appropriate relationship between the pelvis and sacrum. Should the biceps fire prematurely, the forward rotation of the pelvis would be resisted. ‘This would result in an inability to reach the necessary Position required as single support terminates with the impact of the next heel strike. Just prior to opposite limb heel strike, the biceps femoris becomes active (Basmajian 1974), which affects the direction of motion of the pelvis. Once heel strike occurs, the pelvis rapidly reverses its motion and moves from anterior to posterior (Lee 1995). Motion at this time is critical as the impact loads from heel strike must be either attenuated and/or stored as potential energy for use later in the step. The Jong dorsal ligament of the SJ comes into significance at this time. As the pelvic rotation is reversed at this time, the ligament gradually becomes taut as the sacrum counterputates with posterior pelvic rotation. Failure to reach the full forward rotated position would mean that the available range of peivic motion at heel strike would be lost. it would also create a situation in which the long dorsal ligament would be tightened prematurely, thus preventing its gradual loading during the impact period. As double support phase completes and a new swing phase begins, the cycle of pelvic rhythm repeats again, In summary, during norma! function walking is a perpetual motion process. The active pull of the swing side provides a passive thrusting in the stance side against the ground. Pivotal motion of the hip and foot allow for the proper utilization of this power. Coordination of move- ment permits stabilization of the entire lower extremity/lumbosacral structure ideally suited for maximum efficiency. Cycles of stance and swing are repeated at least 2500 times per limb per day. PATHOMECHANICAL PROCESS OF SAGITTAL PLANE BLOCKADE ‘Sagittal plane motion of the foot during the single support phase is critical to normal ambulation. It appears to coordinate both forward advancement with close-packing stabilization. A failure within this process would be repeated more than a million times a year. Wolfe, in the late nineteenth, century proposed the axiom ‘Form follows function’. This was shown to have validity by D'Arcy Thompson early in the twentieth century. It is now considered to be an absolute in under- standing the reaction of the body to the stress applied to it over time, For a model of postural decay to be sound, it would therefore be logica! to require that the forces applied during function ‘would create the resultant form. Itis he intent of this next section to demonstrate how failure of the sagittal plane pivotal action of the foot results in a cyclic breakdown in maintaining an erect posture and actually causes flexion deformity via a compensatory process. ‘The three sites of pivotal function at the foot were described earlier. The round, underside of the calcaneus, with essentially ‘no moving parts’, rarely fails to provide its initial pivotal action. ‘The ankle and first MTP joints, however, are complex in their movements and, either singly or combined, can act tp block normal progression. Ankle equinus, or failure to achieve 10° of dorsiflexion while loaded, is a common patho- mechanical entity. It has been shown to be an.ee 260 EVOLUTION AND GAIT etiologic source of foot and postural pain in patients diagnosed as having it (Root et al 1977). ‘Techniques of stretching the Achilles tendon and triceps surae complex, ankle manipulations, and ‘even surgical intervention for lengthening have ‘been conceived as methods to negate this patho- mechanical influence. In and of itself, however, it would not impede forward progress provided that the last pivotal site, the first MTP joint, initiated its dorsiflexion motion early enough in the stance phase. Itis the ability ofthe first MTP joint to react, to the pull of the body over it which ultimately dictates the ability to advance the body aver the bearing foot. FUNCTIONAL HALLUX LIMITUS, Functional hails limitus (FD represents @ com- plete locking of the primary sagital plane pivotal site, the first MTP joint, strictly during all or por- tions of the single support phase of the gait cycle. ‘This is true in spite of the fact that full range of ‘motion occurs in the non-weight-bearing exami- ration. As such, it is an entity that represents a paradox between. those findings present during clinical examination and those found during func tion (gait). This contradiction defines Fh. The functional abilities present during non-weight- bearing physical examination concerning range of ‘motion are the opposite of those found during ‘walking. Its capacity to permit forward advance- z ™ Fig. 21.5 (A) Normally, ROM ofthe ist MTP joint when performed in « double sippor stance postion. (B) Dusleg the 2 half o the single support phase of the same fot, note th inability ofthe Ist MTP join o exhibit any ROM. This paraon, dhe: ‘ROM of motion, while available in some postions, fails to occur dscing single support, defines Functional halls Yencs l)- ment while simultaneously creating close-pack alignment never materializes. The manifestad of its presence are most often visible at alterna~ tive sites that act ro compensate for the failure this joint t0 provide the motion necessary for forward progression. Clinically, the patient sill rarely ifever exhibit symptoms of pain oF st associated with this joint. The relationship Fhl and more proximal postural symptoms hes therefore not been readily apparent (Dananbers: 1985, 1993, Wernick & Dananberg 1988) (se ig. 21.5). ‘When driving a car, how hard one steps on the gas pedal is seen by the speed the car achieves. It is the motion of the automobile that serves as the manifestation of the input of power from the engine to the wheels. In walking, the bodily ‘motions visible, for example hip extension, erect body position, knee extension, and ankle plantar flexion, are similar representations of the response to the input of power during the step. Should the site of primery sagital plane motion be blocked at the time of maximum power input, an alte ation of these movement patterns must OCea The total power input for any step (pull of the swing limb, momentum, gravity, elastic energy return) must be equal t0 body weight, of else specd of gait would decrease, The ensemble of energy 10 be dissipated is therefore quite sigmii- cant. When these compensarory motions occur over @ significant duration (more than 20 milion B3 per decade), there is a substantial effect on integrity as dictated by Wolf's Law, fans are quite accustomed to secing 2 of postural ‘styles’ in the course of daily ‘These may include forward head position, si spine, round shoulders, knock knees, Jegs, abducted or adducted feet, or any com- ff these ‘structural’ alignments. Certainly, ‘genetics plays some role in these various Ss, but they also are known to worsen ever . For example, the classic appearance of a xl over’ elderly woman represents an age- 4d degeneration. The flexion deformity that ‘exhibits in her corso was not congenital, nor 4 spontaneously occur on her eighteth birth~ = Instead, there was a gradual change over a life- . Some mechanism (function), subtle enough ‘aid obvious detection, must occur in a cyclic on over decades to produce this postural (form). ‘The slow rate of this change and subtie nature of the process thas complecely ed it as an etiologic entity. This process in individual's gait scyle cam directly relate to Although specific congenital or acute, induced changes may be etiologic for of the classic presenting postures of chronic ack pais patients, Fh! can be partially or responsible and/or act as a perpetuating convribure 10 postura) pain syndromes, par jarly in the lower back. It has been difficult, fer, accurately 10 gonnect the two processes. ive foot pronation was thought to contribute create but 4° or 5° of foot pronation was difficult late with the mogpitude of many postural Semities. Fhl is a unifying concept in under- ing the relationship between foot mechanics postural form, Since the sagittal motion sd for pivotal function between the foot Supporting ground surface is 30-40° during Single support phase, the magnitude of this, at the foot requires compensatory action ‘= series of proximal sites. Excessive pronation ‘medial longitudinal arch of the foot is one by which these compensatory motions . Knee, hip, lumbar, and cervical spines it additional locations at which this slow, LOWER BACK PAIN: A REPETITIVE MOTION INJURY 261 repetitive deforming process takes place. Fhi, however, because of its asymptomatic nature and remote location, has hidden itself as an etiologic source of postural degeneration. Identifying and treating this can have a profound influence on the chronic lower back pain patient, ‘THE PROCESS OF SAGITTAL PLANE COMPENSATION “The elegance of the power of motion is to move the body forward efficiently through the sagittal plane. This is the process of forward walking, As the power is input for this purpose, the center of the body must advance over the planted foot. The general joint motions of the lumber spine, hip, knee, and ankle are all in che extension dirsetion. ‘The MTP joints of the foot provide a dorsifesion motion so as c germic forwant advancement, while the joints above extend and maincain an ecect torso. Failure of the MTP to provide this motion, at the time when the power is provided to create i, causes an immediate need for these proximal joints to ‘give way’ in the sagivcal direction 28 an accommodation to this power (Fig. 21.6). This is the process of sagittal plane blockade, Tables 21.) and 21.2 below will hhelp in understanding the nature of this process. ‘Tete 21.1 deseribes the normal motion directions at the specific time they should occur. These are classified in terms of the single and double support phases of gait. This classification is clinically significant because it relates to. the energy prodhiction versus energy storage procest of gait. The double support phase equates with braking moments applied to the body by hee! strike. This is also the period of energy storage. ‘The single support phase applies to acceleration moments as the body advances forvard during this period. This is essentially the period of ‘energy return. ‘When Fhi is present, the entire period of single support phase movement is adversely affected. ‘The ability of the joints proximal to the first MTP joint to undergo extension are directly related to the physical capacity of the first MTP joint 0 provide its normal range of motion. Should this pivotal action of the first MTP joint fail, the more proximal joints would now provide262 EVOLUTION AND GAIT Cervical flexion emp Straight lumbar spines Decreased. hip extension Flexed — knee Delayed heel lift —> Limited shoulder motion Fig. 21.6 Fleion compensation for Fil during single sunpes phase ‘Table 21.1 Nosmat joint cr segment motion Joints orseuments Initial double suppor: phase Ankle Planta Sexi initially, hen sorsifexion Kove Immediate flexion, then ‘rads exention ip Init exon, shen gradual Peis Rapid posterior rotacon ater heal srke Single Suppor phase “Tevminel Gouble suppoe phase Dossifexion cvaiaues Plantar Nexion t to-off through heel, den everses co plantar feson ‘Continued movement to Rapid flexion 10 :oe-0ff earful exten ‘Continued movement to Rapid flexion to toe-off Fl extension Rapid posterior rotation after ccomualetes! hee nike egins 2c masionim boserior postin and rotates Sraerory ol ond of single support ‘Table 21.2 Joint moron reversl os rlated vo funcional hal mus {ali double suppor phase rant exioninitaly, den sdoritexion Knee Immediate Nexon, thea sradual exendion Hip nicl esion, then gradual Petrie ‘Rapid posterin rotation afer ee ste ‘Single support phave "Terminal doable Suppor pas ‘Continues excessively wit Linmine planar tenon layin tiiatng plantar Bein Delays 0 coxly fails 10 achieve extension Deas soul fais co achieve extension Slowed Hexion due t failure » achiewe full extension Slowed flexion due o failure achieve fll exension Lees ofposterioe ange af mot thee sike Stops enterior rotation or ‘commences posterior rotation at midstanceBis motion. Therefore, movernent will occur 480° opposed to the motion that should be taking. ‘place, For example, the thigh must extend on the ‘Bip, but failure co pivot sagittally at the foot ‘negates the responsive hip joint motion. Flexion ‘must replace extension as the accommodation to the power input for forward motion is now peaking. Table 21.2 above describes the motion ceversals that occur. It is important to note that | these motions may occur together or as indivi- dual compensatory movements. "THE EFFECT OF LIMITED HIP EXTENSION When Fhi is present, the most evident marker is its effect on hip extension, During normal gait, the hip joint will extend approximately 15° by the ‘tad of single support phase. This action (1) per- fits the corso to remain erect, (2) allows for ‘shrust against the support surface, (3) positions he limb appropriately in a position from which it fn be lifted for the next swing phase, and (4) “closes the angle’ between the posterior aspect of she weight-bearing leg and the posterior aspect of ‘the ischial cuberosity. Each of these is significant fn understanding the process of lower back pain, Facilitating an erect torso As the thigh extends from under the torso, the rotary motion at the hip peratics the lumbar spine 0 remain upright. Should hip motion abruptly s19P, lumbar flexion occurs that creates disc com- ‘pression as well as muscular overuse. Undergoing extension for thrust “The extension of the ieg and thigh permic the Body sfficiently to use the process of energy etum to create forward motion, Failure of this ‘motion then requires additional muscular input, — sesulting in fatigue. Positioning the limb to initiate swing phase The process for efficiently initiating the swing ‘phase was described earlier, Should the thigh fail to extend adequately, this entire mechanism fails. LOWER BACK PAIN: A REPETITIVE MOTION INJURY 263 As the limb to be lifted weighs 15% of body weight, and it therefore represenes a significant load on the iliopsogs structure. When the iliopsoas fires but the femur is fixed, Kapandji has shown that the lumbar spine will side-bend and rotate (Kapandji 1974). These pathomechanical actions ‘will shear intervertebral discs and create an en- vironment that has been shown to induce inter~ vertebral disc herniation. Hiapsoas overuse will also produce both back and groin pain associated ‘with this pathomechanical process. ‘Closing the angle’ between the weight- bearing leg and ischial tuberosity ‘The ability of the pelvis to rotate forward during single support was shown earlier to be related to the relaxed biceps femoris. Should hip extension fail ro develop, the angle between the posterior thigh and the ischial tuberosity will instead ‘open’. Torso flexion replaces hip extension, further exacerbating che situation. This will create tension i che biceps and, when sulficient, will cause Golgi tendon response and biceps firing. I will then force a premature halt of pelvic forward rotation, and if rorso flexion is sufficient, pelvic rotation will reverse to an amerior-to- Posterior movement. This action will create tightening of the long dorsal ligament as the revertal of motion cteates a sacral counter- nnutation, Motion which is necessary atthe ensuing heel strike is prematurely exhausted. Patients with lower back pain as a rule exhibit tight hamstrings. This underlying mechanism should be noted, as the standard treatment of stretching the ham- strings will not alter the mechanics that bring about the tightness (Pig. 21.7). THE ACCOMMODATION OF LATERAL ‘TRUNK BENDING ‘When full extension of the weight-bearing limb ceases, the ability {0 create the following swing phase efficiently is lost. Obvious overuse to the itiopsoas results, but additional mechanisms are available to assist in developing the next swing phase motion. A universal accommodation to this sppears as the lateral trunk bend. Patients will routinely264 EVOLUTION AND GAIT stressing the OBJECTIVELY EVALUATING hamstrings PATHOLOGIC GAIT a4 Completely covering gait analysis is far beyond the scope of this chapter. Specific markers will be described which can be helpful to the clinician Fig. 21.7 Limited hip exension ane hamstring contraction, treating the chronic lower back pain patient. ‘The principle of multiple viewpoints is import- ant, When viewing X-rays of the patient, itis well bend from the ipsilateral restricted side 10 the known that a single view of the body is not accept contralateral side at ipsilateral toe-off. This motion able. Generally, three views provide a far more is generally created by two muscle groups: the accurate picture of a three-dimensional being, contralateral quadratus lumborum and contra- Viewing a patient walk is no different. Simply lateral gluteus maximusiiliotibial band complex. watching a subject walk back and forth in a hall When activated, these steucnares create a lateral limb into the swing phase. Several pain patterns can be created by this mechanism: pain in the Angle between {quadratus lumborum between the ewelfdh sib and posterior leg iliac crest; greater trochanteric bursts; lateral knee and posterior pain; and, owing t0 the quadratus lumboram’s ischial partial insertion into the ikolumbar ligament, disc ‘compression pain related to rotation of the 5th tuberosity lumbar vertebra (Dananberg 1993b) ‘opens’, Table 21.3 Joint motionfegment markers during moitiview gait analysis Lee Reahont Sade “Treatment indication/option Heed ‘Look for left-right head lt Look for forward head posture Consider heel if to short side for snd timing of any tilting ting; reat Fi for forward head motion posture Shouldedazm ‘Areshoulders|evelordoes Da arms swing symmetrically; Lack of shoulder motion, fs lower during homoleteral ate chey moving fom the parcclatyunateral wil usvaly single seppor? bows or showlders? {neat long fm foncional accommodation Plvistumborseral Look forlevel of pelvic bate; Look tor straight or lardotic Elevation of ASIS/PSIS with spine look forsymmetry ofrotation spine; aes the rasa ex on concurrent lowering of homolaterl tele and right the pelvis during SSP? fhoulder indicates long limb function; wast flexion during SSP ‘ngistes FR Hipsttigh Nor visible on sea view Compare hip extension duting SSP hp extension is aerial ‘SSP; asymmetry suggests leg marker. Treat for Fhl and length aifereneo reexamine Vorus orvaligus alignment; Look for fll extension during Varusalgus ligament indicates watch forming of intemal’ SPs this failure symmetical? need for custom orthosis lack of external rostons| fill extension may respond ts FB Look forsymmetry ofhes lit} Is Fhivisibles does the foot Failure ro ive hee during SSP Ge the heels it prioe to pronate? indicates Fl unilsteral presence contelateral hea strike? ‘ndicate leg ength uneaal SSP = single suppor: phase; ASIS = anterior supvior lac spine; PSIS = posterior superior ae spineLOWER BACK PAIN: A REPETITIVE MOTION INJURY 265 way loses the entire sagittal plane view. Although most offices are not equipped for gait analysis, the use of a treadmill can be helpful in providing the multiple viewpoints necessary for accurate determination of cause and effect. ‘Table 21.3 above indicates the various levels of, the body and the visible markers that would indicate a pathologic condition. Following this, a description of examination to identify Fhl will be given. IDENTIFYING FHL Aside from the visualization of Fhl during gait, there are two examination techniques for static recognition of this pathomechanical entity The first involves the patient in the scated position. For the right foot, the examiner places his or her right thumb directly under the first metatarsal head. A plantar-to-dorsal force is exerted, Then, with the left thumb placed on the underside of the great toe interphalangeal joint, a dorsiflexion force is placed on the toe. Failure to achieve 20-25° of dorsiflexion prior to resistance indicates Fh, ‘The other method involves the patient standing. With the weight shifted predominately to the side to be examined, the examiner attempts to dorsiflex the great toe on the first metatarsal. A failure to raise the toe indicates Fhl (Fig. 21.8A-C) ‘TREATMENT OPTIONS FOR FHL. Since Fhl is @ functional disorder, treatment ‘must promote normal motion at the first MTP joint during the period in the gait cycle when this motion is required. Simply taining and/or stretching muscle groups will not adequately Fig. 21.8 (A) Inthe non-weight bearing analysis, ROM of the Ist MTP joints avalale-(B) When examined clinically, pressure ofthe clinician's thumb under the Ist metatatsal bere while simultanenusly attempting te dories the halle, feels an absence of avilable ROM. This testi iagrostic OF FHL (©) As an alternatively se of examination 0 (B), ROM ofthe Ist MTP jsnt can be examined with dhe patient standing on one fot, Failure to dorsifles the [st MTP joint 20-25" alse diagnostic of Fh266 EVOLUTION AND GarT address this problem, Just as eyeglasses can correct @ functional visual disturbance, so can functional, custom-made foot orthotic devices be ‘effective in dealing with chronic postural com- plaints based on subtle gait disturbance. ‘The subject of custom orthotic fabrication is far beyond the scope of this chapter. Courses are available on which orthotic design and prescrip- tion writing techniques are taught. The Langer Biomechanics Group, Inc. (Deer Park, NY, USA) produces # patented, temporary orthotic device (licensed under US patents 4,597,195 and. 4,608,988 and produced a Kinetic Wedge Orthotic; EPO, UK patents also apply), which is specifically designed co treat Phi. This can be suitable as a test appliance to determine whether gait changes may be helpful to a particular Patient. Accommodations for limb length differ- ence as well as other functional aberrations can be made ta this device. Actual custom orthotic fabrication is more complex than it would out- wardly appear, and setting up relationships with podiatrists or others familiar with Fhl and ics postural affect leads to a complete team approach to dealing with the postural pain patient SUMMARY 1, Viewing either recurrent acute or chronic lower back pain as a functional disorder is an advance in the current treatment process. The subtle alter ations in an individual’s gait when repeated over millions of cycles create overuse-type symptoms in the structures of the Jumbosacral spine. The functional disorder may create abnormalities that, over sufficient time, become visible on either computerized tomography or magnetic resonance imaging. Just as often, however, the structures of the lambosacral spine can be quite normal in appearance yet be painful in response to the cyclic stress placed upon them. The abnormal gait process causes repeated strain on the lower back by destabilizing the natural support mech- nics at specific times in the gait cycle, Th results is a series of mechanical inefficiencies that culminate in the failure t0 initiate compecently the swing phase of motion. Since each limb weighs 15% of body weight, the stress load of lifting this limb improperly can be enormous (over 20 tons per day). The cumulative burden of “dragging a limb’ into the swing phase can create the non-specific-type symproms that are so common in the lower back pain population, ‘These include: + myogenic overuse symptoms of the iliopsoas, group, quadratus lumborum, and gluteus ‘maximus-iliotibial band complex + structural symptoms at the origin of the iliopsoas lumbar spine), insertion of the quadrats lumborum (L5 — via iliolumbar ligament), and SIfs via anatomic connection of the biceps fernoris/sacrotuberous ligament. 2, The dysfunction of the foot plays a major role in preventing the body from passing over it efficiently during gait. The compensatory mations (listed below) ate visible in the structures proxi- ‘mal to the foot, and can be thought of as ‘gait ‘markers’ in observing the recursent acute/chronic lower back pain patient: + forward head position ~ cervical flexion + straight lumbar spine ~ torso flexion + decreased hip extension during single support phase + flexed knee in midstance + failure of heel lift during single support phase ~ visible foot pronation, 3. Since these can all be manifestations of asymptomatic functional aberrations at this pivotal size, examination of the biomechanics of the foot is essential in this patient population. ‘When foot mechanics, Fhl, leg length discrepancy, and the overall style of walking were addressed as a primary stress-creating mechanism with properly fabricated custom foot orthovies a retrospective outcome study of chronic, tectrrent complaints demonstrated 77% near or complete resolution of symptoms. 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