Lifts for Short Leg help Hamstring and Low Back Pain

Here are two 1/8 inch lifts under the patient’s left foot. The reason I highlight this is that the patient presented for biomechanical assessment with chronic low back, hamstring, right jumper’s knee and foot pain. In my evaluation, he had mild pronation but significant limb dominance associated with short leg syndrome. Standing evaluation noted 3/8 inch short left. Our follow up today after 2 months reveal complete resolution of hamstring and low back symptoms, and no change in knee symptoms. 

A Podiatrist's Look at Knee, Hip, and Low Back Pain: Lecture at Samuel Merritt University

This will be my lecture to the 3rd year podiatry students this Thursday.

https://drive.google.com/file/d/1hyeborJsdbAHiF8EbHvlpGwTATzDMIJr/view?usp=sharing

Low Back Pain and Orthotic Devices: Email Advice

Hello Dr Blake-

I have severe lower back pain and disc disease. I noticed my lower back at sacrum is twisted to the left and my left hip sways to left and my right ankle pronates with nerve pain between right large toe and second toe. I am walking with a cane in the morning my back is badly twisted in the AM

I found a pair of orthotics that were  custom made at the Saint Francis Sports Med Clinic decades ago. I started using them yesterday and the pain has greatly improved and I can walk up steps now with increased strength and reduced pain.

My question is would you be able to to make a new pair of orthotics for my back pain  since it has been so long? I do not know if a podiatrist provides this service for back pain.I was diagnosed with scoliosis as a child and I have always pronated.

Thanks-

Dr Blake's response: 

     Thank you for the email and I will be happy to re-eval your biomechanics. The low back (in fact the whole body) loves symmetry. Sounds like you pronate more on the right and that becomes a high priority to level the pronation between the two sides. You actually need some pronation in your feet for shock absorption, but it is my job to eliminate the excessive amounts, or the abnormal positions, or at least the asymmetry. I have many patients with low back pain helped with pronation control, or just good biomechanics, since excessive supination (AKA underpronation) is one of the commonest causes of low back pain and of course treated opposite of pronation control. 

     When you are dealing with the low back and biomechanics, you always need to look at structural, functional, or combination short leg syndrome. This causes the base of the spine to be always tilted at L5S1. The body will need to constantly fight this to right itself, and muscle spasms in the low back can be produced. We will check for this also. 

     The pronation control you are experiencing is probably some version of "double crush" syndrome. If your low back disease is causing nerve irritation, even slightly, you can get symptoms down stream when there is a second irritation to the same nerve, thus double crush. The foot pronation, when excessive, can irritate the tarsal tunnel at your ankle where the posterior tibial nerve lies (a branch of the sciatic nerve). Controlling that pronation can relieve these symptoms, as it seems to have done. 

     There are so many other helps for your low back including: sitting posture, sleeping concerns (mattress), tight hamstrings, etc. A back specialist into rehabilitation should always be part of the team. In San Francisco, Dr Robert and Irene Minkowsky do a good job at analyzing and treating these pelvic tilts you describe. They are at 2000 Van Ness Avenue. You describe an anteriorly rotated right pelvis to the right (possibly from pronation or weak external hip rotators like the iliopsoas) with a laterally externally rotated left pelvis. The source of these rotations can come from the foot, hip muscles, sacro-iliac joint, or scoliosis. Sorting them all out is funner for the health care providers than the patient, but it your symptoms improve, you will being to have fun also. It will be good to see you. Rich

Orthotics causing Back Pain: A Common Problem with various Solutions

Dr. Blake,

I had posted about sesamoid problem after bunion surgery, and thank you so much for answering my questions.

I am on second pair of custom orthotics and my back was so irritated that I could not function, missed one week of work, could not even stand long enough to make a meal.  I had times that my right side foot and leg just wanted to give up. Went to see a podiatrist hoping for help, he took the time to look at my x-ray before and after surgery, and told me the surgery was well done, except the first metatarsal bone was longer than it's supposed to be, which caused all my other problems.  He said surgery should be the last option, instead we should try pads.

Dr Blake's comment: Functional Foot Orthotics are just that----functional. They make a functional change in your body, and as podiatrists, we ask the rest of the body to please accept the change. When designing orthotic devices for sesamoid pain, two common problems can occur leading to back pain. The orthotic device places your weight too lateral, making you over supinate, leading to back pain. If this is the case, you should feel that the weight is going to your baby toe as you walk through your foot, or even worse, feel like you can sprain your ankle. Typically, the orthotic devices make you straighten your knee too much, and if you have tight hamstrings, the pull on the low back causes pain. These are easy things to change if recognized. Sometimes a simple adjustment can be made to allow you to be more centered or slightly more pronated. It is up to the prescribing provider to recognize what is going on when they watch you walk. Sometimes a whole new orthotic device is necessary. But, it is important to know what most likely caused the problem in the first place, so that you do not repeat the same mistake. 

This is what I felt ever after the surgery but you cannot do much to change the fact and it is affecting so much of my life now, I am horrified to think about another surgery, but other options seem to be running out.
Dr Blake's comment: If the metatarsal is too long, and it is causing all these problems, a temporary fix with orthotics should be able to be made. A long first metatarsal does potentially 3 bad things: supinates you too much (that can be corrected with orthotics), blocks your ability to roll properly through your foot jerking your low back (that can be corrected with orthotics), and straightens your knee too much by limiting normal arch pronation (that can be corrected with an orthotic device). I would always recommend trying to accomplish an orthotic fix for the problem first to make sure everyone truly understands the source of the problem. Then, if surgery makes sense, go for it. 

Your blog taught me more than all of the orthopedics surgeons told me, I really don't know what to do next, my big toe and the rest of four other toes simply don't land on the same level, and I felt the function of nerves and muscles are all affected.

I will seek other doctor's opinions locally, but I am so concerned about loosing foot and leg functions. Do you think correcting the bone(surgery) would help with sesamoid issue long term, or is it even possible to have surgery with sesamoid issue present?
Dr Blake's comment: You need information based on function not x rays right now. Go to a good sports medicine physical therapy that watches you walk. Do not influence them by previous conceived notions. Let me try and tie together your gait and back pain. I am assuming that the orthotic devices corrected for the sesamoid but lead to the back pain. Right? This is so common, I can not tell u!!! But, it may be an easy orthotic fix. Keep me in the loop. 

Thank you so much for your time, and how I wish I lived in California!

Further response from patient:

Thank you so much Dr. Blake!

I had one Acupuncture Dr. and one Orthopedics Dr. both suggested simply try Dr. Schol's full-length gel pad, which I did, I cut out some felt pads according to your website instruction, simply trying to level other four toes with the big toe, and a cutout to accommodate the sesamoid area. So far, have not had any bad pain yet.

I so appreciate your time.

Severe Low Back Disease: Look to a Physiatrist for Rehab Help

I have severe spinal stenosis, spondylosis, pinched nerves, bulging disc & L4 & L5 out of place, degenerative arthritis, sciatica. What is my best options? I have had epidurals with no luck. Plus I need 2 joint replacements in both knees & it pisses me off more than anything when doctors or people in general tell me to exercise. I can't even stand up for 5 minutes without screaming pain in my back. I can hardly walk because of my knees. What are my options?

Dr Blake's response:

Unfortunately, this is the role of a neurologist or physiatrist to help you. Contact the office of Dr Irene Minkowsky in San Francisco to see if she knows someone in your area or what organization to contact. She is a genius in knowing what the role of surgeons, physical therapists, chiropractors, etc for your condition. She is a physiatrist with an osteopathic bent and definitely attempts rehab over surgery. Hope this points you in the right direction. Rich