DOES A LACK OF FOOT

FUNCTION ALTER
LOWER LIMB
MECHANICS THAT
MIGHT CONTRIBUTE
TO NON-SPECIFIC
LOWER BACK PAIN? A
META-ANYALSIS
ZACK CULLEN

Presented as part of the requirement for an award within the Postgraduate

Modular Scheme at Hartpury University
i
DECLARATION

This dissertation is a product of my own work and is not the work of any
collaboration.
I agree that this dissertation may be available for reference and photocopying
at the discretion of the University

Signed: Zack Cullen

ii
Acknowledgements
This body of work would obviously not have been possible without the hard
work of my supervisor Dr. Stephen Draper, Steve thank you for the support
and most importantly your patience in dealing with me! However, other
names must be mentioned, my ever-supportive parents (Kim and Dave) for
their unwavering support during this challenge, the long days sat at the
computer and my rapid mood swings were not in vein. In addition, I would
like to thank my friends in both the South (Connor, Moffy, Belly, Calvin,
Rachel and Joe), for listening to my constant complaining and providing
some academic guidance, and the West Midlands ( Morgan, Tonks, Mike,
Bear, Luke) for their faith in my ability to get through this, as well as once
again listening to my constant complaining. Lastly a special thanks to Robert
Francis, we got through this together buddy, and I wouldn’t have had it any
other way.

iii
Table of Contents

Section headings Page Chapter

Introduction 1 1.0

Methods 3 1.1

Themes 4 2.0

Anatomy of the 7 2.1

lumbar spine

Foot function and 10 2.2

foot type

Leg length 17 2.3

discrepancy and
pelvic tilt

Shank rotation and 24 2.4

Hamstring muscle
length

Proprioceptive 26 2.5
changes

Conclusion 29 3.0

References 31 4.0

Appendix A 40 5.0

Appendix B 49 6.0

iv
Abstract
The aim of the Meta-analysis is too evaluate evidence for involvement of
Foot function in the development of non-specific lower back pain (NSLBP). A
hypothesis based on a critical review of the relevant biomechanical as well as
clinical literature.
Currently Non-specific back pain effects a huge amount of the global
population, leaving a large percentage of its sufferers unable to return to
work, subsequently costing both the NHS and the government at large in
excess of a billion pounds a year. As of yet it can be argued that that the
relationship between Foot function and NSLBP is not fully understood, with
literature presenting several gaps in knowledge that have yet to be fully
investigated.
The finding presented in this paper suggest that diminished foot function may
have some role in the formation of chronic NSLBP through the creation of a
pelvic tilt and a functional scoliosis. However, this review indicates a need for
more in-depth investigations into the components of foot function contributing
to NSLBP as well as treatment methods for the foot that will directly impact
NSLBP, as well as, possibly, other musculoskeletal conditions.
Keywords: Foot, ankle, musculoskeletal, treatment, footwear, non-spesific
low back pain, risk factors, flatfoot, pronation, gait

v
 CHAPTER 1.0
1.0 Introduction
The average adult human will spend 3.2% of the average day on their feet,
and can walk anywhere from 2,500 steps to 15,000 steps, thus a lack of foot
function can be considered an important facet of physiological programming
for both the strength and conditioning professional and the Rehabilitation
specialist, as, if any one individual suffers from biomechanical lack of foot
function the resulting abnormal movements will cause the body to engage in
compensatory functions (Calnan, 2002) that are known to alter gait
mechanics, force absorption qualities and static stance (Trachtenberg, 2012),
resulting in greater strain on the muscles, bones and joints in regions
proximal to the foot. If this pattern is prolonged it can ultimately lead to weak
muscles and joints causing pain, decreased athletic performance and
increased susceptibility to injury and re-injury.

Indeed, foot disfunction may be the primary cause or a major contributing

factor to a number of musco-skeletal disfunctions, particularly conditions
effecting the back, hips and knees (Rao, Riskowski and Hannan, 2012). This
is a kinetic chain disfunction as the result of postural changes caused by the
lengthening or shortening of respective muscles groups in the posterior
kinetic chain (Czaprowski et al., 2018). This has been described as a direct
pathology in the generation of non-specific lower back pain (NSLBP)
Generally this refers to pain symptoms “anywhere in the lower back, between
the twelfth rib and the top of the legs” (Summary of Recommendations in
Clinical Guideline for Diagnosis and Treatment of Low Back Pain, 2008)
however clinicians have refined this definition further to “pain or discomfort,
localized below the costal margin and above the inferior gluteal folds, with or
without leg pain” (Delitto, 2005). It is worth noting that NSLBP itself is not a
diagnosis, but a description of symptoms with no obvious direct cause such
as disk impairment or degeneration (Rolli Salathé and Elfering, 2013), as a
result of this, current treatment options aimed at NSLBP have been
described as largely ineffective at treating the condition, this has been
confirmed by Keller (2007) who in a meta-analysis of the literature, found
surgical interventions share a similar effect size to non-surgical ‘placebo’

1
interventions such as acupuncture. Fairbank (2005) adds to this in his
examination of 349 patients between the ages of 18 to 55 years, diagnosed
with ‘chronic’ NSLBP, in which after randomisation of participants into
surgical and physiotherapy-based interventions, the follow up testing
revealed a mean disability index change from 46.5 to 34 in the surgical group
and from 44.8 to 36.1 in the rehabilitation group (a mean difference of -4.1 in
favour of the surgical intervention). However, the surgical group suffered a
number of complications during that time including but not exclusive too
Dural tears, excessive bleeding, implant problems, fractures and vascular
injury, leading Fairbank (2005) to the conclusion that spinal surgery is no
more beneficial than intensive rehabilitation in returning NSLBP suffers to
work (Fairbank, Jeremy, et al 2005). In comparison Brox (2010) conducted a
4 year study merging randomised clinical trials, within this body of work he
revealed that surgical intervention, in this case spinal fusion of the lower L
vertebrae, was ‘not superior’ to any given cognitive intervention or exercises
at reliving NSLBP, nor for improving back function or return to work at 4
years post intervention. However, within the data set for non-surgical
interventions, 14 patients (24%) from the non-surgical group underwent
subsequent back surgery in order to correct their issue, which resulted in
non- adherence to the protocol ,while 15 patients (23%) in the surgical
intervention group had to undergo reoperation, subsequently casting some of
these results into doubt. Further to this both of the aforementioned studies
lack a placebo-based control group, and so effects within either group may
be accounted for through the placebo effect (Benedetti, 2005). This prevents
any firm conclusions being reached as to the effectiveness of either physio or
surgical based interventions. It seems unethical however that it is acceptable
to operate on people when there is no clear diagnosis. Despite this however,
it remains permissible to perform fusions on people with the label NSLBP
according to current UK guidelines and legislation
(https://www.nice.org.uk/guidance/ng59.)    

As a result of this, in this literature review the author sets out to summarise
and explain the major pathologies that contribute to NSLBP that can be seen
to be caused by a lack of foot function in the hopes of guiding future research

2
direction for the treatment of this prolific condition. Currently treatments for
the condition focus primarily on surgery (Sivan, 2006), of these spinal fusion
of the lower L vertebrae is by far the most popular form of surgery, having
seen an increase in of 36% over the last 13 years (Deyo et al., 2005) at a
cost of 36 million to the NHS annually (Rushton et al., 2018), this increase in
operations per year has led to dramatic increase in the number of surgeon’s,
in both orthopaedic and neurology fields, per head of population possibly
accounting for the continued prevalence of what has been described as
unethical and unnecessary surgery interventions (department of health
England., 2003).
1.1 Methods

A comparative study of the literature was conducted using the following

academic search engines; MEDLINE, PubMed, SPORTDiscus, Google
Scholar, Worldcat Libraries. Key research terms included; Non-specific lower
back pain (including acronyms such as NSLBP and LBP) as well as;
‘orthotics excessive pronation, podiatric deviations, hallux, kinetic chain, link
theory, ankle instability, ankle dorsiflexion, pelvic tilts, pes planus and
proprioception’ this included combinations of the above words. After removal
of duplicates the electronic search was supplemented by a manual search of
the literature in order to identify sources of potential specific interest as well
as to screen for specific relevance.

Studies only met eligibility criteria if they involved candidates 16 years or

older, as this is where we typically start to see NSLBP to occur (Rolli Salathé
and Elfering, 2013), suffering with subacute or chronic NSLBP, as the
difference between these two groups is not easily identified, and is hard to
distinguish from a physiological perspective, and written in Dutch or English
due to the authors familiarity with these languages, were included. Studies
involving people with issues unrelated to NSLBP where excluded, these
include but are not limited to; sciatica, pelvic problems, pregnancy, whiplash
associated disorders, nonspecific neck pain, fibromyalgia, low back surgery
(den Bandt et al., 2019). Literature was searched up to February, 2020. In
individual papers the studies risk of bias was conducted by using the

3
Newcastle-Ottawa quality assessment scale (NOS) on the advice of Stang
(2010).

CHAPTER 2.0

2.0 Theme’s – overview

Sedentary lifestyles have led to a variety of musculoskeletal disorders, of

which the most common is nonspecific lower backpain (NSLBP) (Thyfault et
al., 2015), this is back pain of the lower lumbar region, not attributed solely to
one cause (Rolli Salathé and Elfering, 2013). Generally, NSLBP is
categorised into 3 types based upon the duration of symptoms; acute
(Experiencing symptoms for sub 6 weeks), sub-acute (Symptoms lasting 7-
12 weeks) and chronic (Symptoms present longer than three months)
(Dionne et al., 2008). It has been estimated that NSLBP effects somewhere
in the region of 18-20% of the population of the UK (including children and
teenagers) (Vogel, 2009, KARARTI et al., 2019), with continued prevalence
of symptoms effecting 23% of NSLBP sufferers, of that 23% a further 11-12%
will be disabled by the condition. In addition to this it would appear that
lifetime prevalence of NSLBP is common, on average 84% of NSLBP patents
will suffer a lifetime prevalence (Walker, B. F., 2000). A worrying trend has
emerged from this data, prevalence of NSLBP is on the rise, Pransky et al
(2011) reporting a fivefold increase in the prevalence of NSLBP over a 15-
year period, the 2010 global disease burden study reinforced this statement
with global age-standard point prevalence being estimated to effect 9.4% of
world population (Non Specific Low Back Pain, 2020).

In terms of continued economic burden, NSLBP can be seen too globally

cause more disability than any other condition, especially in western nations.
The cost attributed to NSLBP annually in the United states is reported to be
over $50 billion (A Description and Comparison of Treatments for Low Back
Pain in the United States, 2016, Pai and Sundaram, 2004). The UK whilst
spending substantially less, still pays £1 billion in costs. This is a substantial
increase in spending from the last published figures in 1998 which suggested
health care costs due to back pain were in the region of £565M in terms of

4
costs to the NHS (Maniadakis, N. and Gray, A., 2000). The indirect costs of
back pain, due to lost production are larger, £3,44M, or £9,90M depending on
the approach of calculation. (Maniadakis, N. and Gray, A., 2000).

In term of identification of a cause for NSLBP, the task is a difficult one.

Savage et al (1997) reported that 68% of subjects tested within the confines
of his study lacked any abnormality of the lumbar spine. In longitudinal
studies, NSLBP has been shown to be able to develop in the absence of any
associated change in radiographic appearance, or deviation of normal spinal
pathology (Wáng, Wu, Ruiz Santiago and Nogueira-Barbosa, 2018).
However, Savages (1997) work does make a certain amount of errors in its
methodological construction, failure to adequately separate ages groups
means the naturally degenerative process of aging is not taken into account
(Öhlén, Spangfort and Tingvall, 1989). Furthermore, even when
abnormalities are present such as degenerative disks, establishing a direct
cause and effect has been shown to not assist in patient pain management
and so can be considered a waste of effort (Anthony Delitto at al. 2012).

A popular idea among academics as too the cause of NSLBP is the

increasing rise in lack of foot function, described as a determining factor in
the development of a number of muscosceletal issues, of which NSLBP is
the most prevalent (Ilahi and Kohl, 1998b, van Mechelen, 1992). A lack of
foot function has frequently been associated with a number of medical
conditions effecting how the foot works (Whitman, 2009), the most common
association is with excessive pronation, as well as Pes Planus (Flat feet).
Within the actions of a healthy foot both of these help to absorb and transmit
shock absorbed by the foot during everyday activities such as running and
jumping (Wright, Ivanenko and Gurfinkel, 2012), as well as playing a
significant role in proprioception (e.g. adjusting to uneven surfaces) (Yuji
Ohta, 2014). NSLBP has been attributed to the ‘longitudinal flattening and
loss if rigidity in the arch, in cases where the foot cannot correctly disperse
the force of landing’ (O'Leary et al., 2013), this in turn causes transmission of
ground reaction forces up the posterior kinetic chain to the lower lumbar
region causing pain, dysfunction and subsequent biomechanical
compensation to adapt (Farahpour et al., 2016). A number of casual links

5
have been observed to support this theory, in O’Leary at al (2013) work
evidence of significant pronation was present in 95% of subjects examined
with severe pronation being observed in 70% of the pronated population, in
addition to this multiple studies have reported significant rates of Pes Planus
in people with NSLBP when compared to control groups, for example
Koshavili et al (2008) when examining military recruits suffering from NSLBP
found a significant prevalence (p < 0.0001) of moderate and sever Pes
Planus in his population. Whilst the condition was not identified by the ‘Gold
standard’ of radio-graphic’s both moderate and severe pes planus does
appear to have a correlation with NSLBP (Balasundaram and Choudhury,
2018). However there does appear to be some disagreement as to whether
this is actually the case, for example Brantingham et al. (2007) found flat feet
did not appear to be a risk factor in subjects with low back pain and instead
attributed pes Planus in NSLBP sufferers to the reverse causation effect
(Paungmali et al., 2017), this does however contradict the vast majority of
literature and can be seen to be unlikely (Shantikumar, 2018).

But how exactly do faulty mechanics of the foot cause back pain? The most
common answer is anterior pelvic tilt leading to an abnormal navicular drop
and calcaneal eversion, normally caused by a shortening of the hamstring
muscles and an internal rotation of the shank portion of the leg (Young, Cuff,
Yang and Pommering, 2016) this is especially true if the faulty biomechanics
in the foot can be seen to be unilateral rather than bilateral (Ruhe, Fejer and
Walker, 2010). Subsequently the body will need to compensate for these
effects which can lead to a functional lumbar scoliosis which in turn has been
described as causing the pain symptoms commonly found in NSLBP
sufferers. A key example of this within the literature is the work of Fiberg
(1983) who came to the conclusion that ‘abnormal’ pronation leads to a
function leg length discrepancy (FLLD) causing the aforementioned pelvic tilt
and subsequent lower lumbar pain. The work of Cibulka (1999) seems to
concur with this stating that subtalar joint pronation leads to excessive hip
lateral rotation causing a sacroiliac (SI) joint dysfunction, leading to NSLBP
and a functional scoliosis of the spine. The work of Botte (1981) agrees with
this hypothesis concurring that foot pronation produces SI joint dysfunction

6
causing NSLBP. Further to this Khamis and Yizhar (2007) reported on the
effect of excessive pronation on shank and pelvic joint alignment, they
discuss that upon pronation pelvic alignment shifts by 10 degrees posteriorly,
across their participant pool. This has been shown to have a high correlation
value with increased lumbar curve, a known contributor to NSLBP. In
addition, through radiographic process it was revealed that both the lower leg
and thigh had moved into a significantly pronated position, ‘which could
cause increased hip and back misalignment, along with muscle imbalances
leading to dysfunction in the back’. Yet, the role of excessive pronation on
low back pain has not been confirmed and is still in some doubt among the
scientific community. In the above cases all studies lacked a control group to
compare if excessive pronation was also evident in people without NSLBP
(Pithon, 2013), meaning it is difficult to make a conclusion from these studies
(Saving lives and improving livelihoods, 2009)

2.1 Anatomy of the lumbar spine

In order to understand NSLBP to a greater degree, an understanding of the

Lumbar spine, its function and physiology is required. The lumbar region
forms the bottom portion of the spine, consisting of 5, large movable,
vertebrae (L1-L5) posteriorly adjacent to one another, forming a slight lordotic
curve designed to absorb and transmit various forces of the body. Each
vertebra in the Lumbar spine consists of two parts, vertebral body and the
posterior arch, which form a veritable canal through the centre of the spine in
order to house and protect the spinal cord. This canal when viewed from the,
axial prospective forms what is known as a veritable forearm, this houses the
extension of the spinal column known as the thecal sack, this in turn houses
the nerve which gives life to the lower extremities (Nachemson, 1976, Wilke
H-J, Volkheimer D,2018, Cramer GD, 2014).

Located between the vertebrae are compressible structures referred to as

Intravertebral Disks (IVDs) these compressible structures are designed to
dissipate force and compressive loads through the process of osmotic
pressurization (Waxenbaum JA, Futterman B.2018). In terms of relation to
NSLBP several theories have arisen as to their role, the primary being

7
degeneration, currently the reason why this degenerative process occurs is
not fully understood, but it is hypothesised that natural aging as well as
biological and genetic factors play a significant role (Debnath, 2018, Whatley
and Wen, 2012, Azarnoosh, Stoffel and Markert, 2014). Within the IVD the
annulus fibrosus (AF), is known to be a concentric ring of lamellar collagen
surrounds the inner nucleus pulposus (NP) (McPhee and Graven-Nielsen,
2019). This avascular structure, is responsible for absorbing the majority of
the fluid received by the disc (Hollenberg et al., 2020). In direct comparison
to the discs of the thoracic and cervical spine, lumbar disks have been noted
through radiographical examination to be taller and wider, however at the
same time are known to be more suspectable to injury, this is due to the
greater range of motion available while under axial load, combined with the
fact that the disks in question are avascular and so rely upon diffusion for
sufficient blood supply (Solulabs: Innovative solution for the prevention of low
back pain (LBP) in young athletes, 2016).

We must also consider the back in terms of muscle and ligament structures,
three main ligaments run the length of the back providing support and
structural integrity, these are as follows;

Supraspinous Ligament –

The SSL connects the posterior tips of the spinous processes. The SSL plays
a major role in the resistance of flexion, and minor roles in lateral bending
and axial rotation (Richard L. Drake, A. Wayne Vogl, 2008. Levangie PK,
Norkin CC, 2011).

Interspinous Ligament

The ISL runs parallel with the spinous processes and connects consecutive
vertebrae together between the spinous processes. The ISL is similar to the
SSL in resistance to motion (Vleeming A, Mooney V 2009)

Anterior longitudinal ligament (ALL)

A strong facial band that covers the anterior aspects, of the majority of the
vertebral bodies as well as the intervertebral discs. It is considered to be a
thick yet narrow band that is bound to the periosteum. When examined from

8
the level of the intervertebral disc, the faciale band widens and binds to
fibrocartilage disc as well as the Hyaline Cartilage, vertebral end plates and
the margins of the vertebrae (Mcminn, 2003)

Posterior longitudinal ligament (PLL)

The posterior longitudinal ligament (PLL) is a long and important ligament

located immediately posterior to the vertebral bodies (to which it attaches
loosely) and intervertebral discs (to which it is firmly attached).

It extends from the back of the sacrum inferiorly and gradually broadens as it
ascends. At the level of C2 (the axis) it spreads out and becomes the
tectorial membrane that eventually inserts into the base of skull (McMinn,
1994)

Ligamentum flavum (LF)

Thickest of the spinal ligaments this runs posteriorly to the spinal canal, from
the base of the skull to the lateral aspect of the pelvis. Primarily designed to
resist lateral flexion and bending it also plays a minor role in the resistance of
axil rotation (Nikolai B, 2012)

In addition to this the lumbar spine is regulated by four functional muscle

groups (Stark, Fröber and Schilling, 2012), which for the sake of anatomical
convenience are split into extensors, flexors, lateral flexors, and rotators.
These include but are not limited to Multifidus, Longissimus, Spinalis, and
Quadratus Lumborum muscles as well as muscles groups that help create
intra-abdominal pressure such the transverse abdominal and the pelvic floor.
In-situ with the muscles of the upper shank and glutes these have all been
shown to play an important role in the pathology of NSLBP (Christe and Hall,
2017), for example studies have shown that populations suffering from
NSLBP have a significantly reduced cross sectional area of the multifidus
and paraspinal muscle groups in comparison to healthy control subjects
(Fortin and Macedo, 2013 .Hemming, Sheeran, van Deursen and Sparkes,
2019). In order to fully understand the role these muscle groups play in the
development and continuation of NSLBP it is also necessary to consider

9
what destabilises the back in order to possibly produce this pathology. Meta-
analysis reveals that lateral flexion of the lumbar spine has the greatest
correlation with damaging effects associated with NSLBP (Davis, 2012),
further to this forward bending patterns have been shown to be of equal
concern in the development of NSLBP, its noted that if the lumbar spine flexis
specifically during static posture, vertebrae flex forward causing the veritable
facets to disengage causing a hernia of the intervertible disks or a bulging or
protruding effect in the posterior plane. This combined with a FLLD will shift
the disk uni-laterally causing an axial rotation effect, which in-turn creates
significant muscular load and a compensatory flexion movement to correct
the inappropriate load being transferred through the kinetic chain (Sciascia
and Cromwell, 2012). This in turn causes the hip extensors to fire in an
attempt to correct this pattern which may result in muscular spasm and
tightness, which is considered to be the first symptoms an acute sufferer of
NSLBP will experience (Gordon and Bloxham, 2016).

2.2 Foot Function and foot type and its relation to LBP

The majority of lower limb pathologies can be described as biomechanical in

origin (Barondess, 2001), and subsequently can be associated with foot type
and mechanics due to the compensatory effects needed to counteract the
incorrect dispersal of ground reaction force (GRF) (Allen, Kautz and Neptune,
2011). Consequently, in order to understand the relationship between foot
disfunction and NSLBP we must first understand foot type in its relationship
to foot function. Described by Root, Orien, and Weed in 1977-foot type refers
to the categorisation of an individual’s foot by measuring both the fore-foot
and rear foot alignment, from these measurements emerge 3 distinct foot
types, each of which have their own pathological issues;

Planus (low arched with a valgus hindfoot and/or varus forefoot)

Where the foot over pronates, meaning GRF moves medially through the
stance phase of a person’s gate cycle (Jafarnezhadgero et al., 2019). This
foot type is generally associated with hallux valgus, hallux limitus and rigidus,
and posterior tibial tendon dysfunction (Ledoux WR at al. 2003) as well as an

10
increased risk of injury to parts distal to the foot (Levy JC at al. 2006.
Kaufman KR, 1997).

Rectus (well aligned hindfoot and forefoot)

Well aligned or ‘biomechanically sound’ foot position. Not currently

associated with any particular pathology (Hillstrom et al., 2013)

Cavus (high arched with a Varus hindfoot and/or Valgus forefoot).

Where the feet over-supinate, making GRF move laterally though the stance
phase of gate (Kadakia, 2013) this is generally associated with conditions
such as hammer toe and/or claw toe (Sugathan HK et al, 2009). This is
normally defined by dorsiflexion at the metatarsophalangeal joint as well as
plantarflexion at the interphalangeal joint and either a normal positioning of
the distal interphalangeal joint’ (Tollafild and Merriman, 1995) or dorsiflexion
at said distal interphalangeal joint

It is not understood why certain foot types are more inclined toward certain
foot pathologies. Many factors contribute to bone growth and shape, and the
idea that mechanical forces impact on bone development and shape is not
new having been studied since the late 17th century (Buckwalter et al., 1995).
Wolff’s law demonstrates this relationship between structure and function
(Forwood and Turner, 1995, KMo, 2001). Although the relationship is
complex, the conclusion that bone shape can determine function and bone
function which can determine shape, concisely summarises the relationship
(Vogler and Bojsen-Moller, 2000). The relevance to 'foot-type' is illustrated by
the assertion that the concept of foot-type is essentially one of architecture
(Song et al., 1996) and the basic premise of podiatric biomechanics that a
given foot structure will display certain functional characteristics, and that
these characteristics are generally associated with pathomechanical function
of the lower extremity (Menz, 1998). Hiss (1949) added to this, stressing the
importance of arch height and flexible versus rigid foot types. Whilst
approaches to measuring foot-type vary, a majority appear to relate directly
to medial longitudinal arch morphology, and it has been stated that pes

11
planus - the flat foot - and pes cavus - the highly arched foot - represent
distinct clinical entities which differ in their mechanical behaviour and effect
(Cavanagh and Rodgers, 1987). This focus on the medial longitudinal arch is
based on two related observations: the relationship between rearfoot, and
more specifically subtalar joint (STJt), position and the mechanical integrity of
the foot; the consistent and predictable response of the architecture of the
medial longitudinal arch to changes in rearfoot position. The influence of
rearfoot position on the mechanical integrity of the foot, whereby rearfoot
supination induces stability which is lost with pronation, is acknowledged
(Inman et aI., 1994). Despite attributing this change to complex and
inadequately understood mechanisms, a body of literature has since
emerged that provides coherent and rational explanations. This focuses on
the characteristics of the STJt, which forms the central element of the
rearfoot, and includes descriptions of STJt function and subtalar-midtarsal
interdependency (Close et al., 1967,Elftman, 1960, Manter, l94l) and the
contribution of the plantar aponeurosis, through its influence on rearfoot
position, to stability (Hicks, 1954a, Hicks, lg14b, Hicks, 1955). A series of
investigations have been conducted which continue to reveal further insights
into the mechanisms contributing to pedal stability and mobility. Firstly,
substantial evidence has been presented to support the contention that the
tarsal bones are kinematically linked as a 'constraint' system, in which
passive co-operation is imposed by articular geometry and ligaments (Huson,
lggI, Huson, 2000). Secondly, it has been demonstrated that the plantar
aponeurosis, tightened in response to its metatarsophalangeal joint (MTPJT)
dorsiflexion, makes an important contribution to overall stability (Bojsen-
Moller and Lamoreux, 1919), by increasing calcaneo-cuboid joint contact
(Bojsen-Moller, I979b) and the efficiency of shear-force attenuation in the
forefoot (Bojsen-Moller, I979a). Finally, the two have been linked by
exploration of the relationship between rearfoot position and hallux
dorsiflexion, whereby increasing rearfoot eversion reduces and inversion
increases hallux dorsiflexion (Harradine and Bevan, 2000). This evidence
inextricably links normal rearfoot motion with several mechanisms crucial to
the integrity of the foot. It is clear that a number of early observations can
now be considered experimentally verified. The kinematic link between the

12
tarsal bones has been described in detail (Nester, 1997), and details the
relationship between rearfoot orientation and medial longitudinal arch height.
Essentially, STJt pronation involves internal tibial rotation, talar adduction
and plantarflexion, and dorsiflexion and abduction of the navicular and
forefoot, to clearly reduce the height of the medial longitudinal arch.
Conversely, STJI supination involves external tibial rotation, talar abduction
and dorsiflexion, and plantarflexion and adduction of the navicular and
forefoot, to clearly increase the height of the medial longitudinal arch. These
coupled motions were described as exactly defined and predictable (Huson,
1991), providing evidence on the strength of the link. Consideration of this
chain of kinematic events, which directly influences medial longitudinal arch
height, and the influence of STJI position on the mechanical integrity of the
foot, entirely justifies the focus on medial longitudinal arch height as a foot
classification system.

The STJI, by virtue of its oblique axis (Close et al.,1961) creates a perfect
functional axis with the transverse plain. This creates an essential functional
coupling that creates a couplet between transverse plane limb rotations and
pronation/supination within the foot. This is a vital function that allows for
transverse pelvic rotations that occur to minimise the vertical excursion of the
centre of mass and which are transferred to transverse limb rotations, at foot
level. First demonstrated by Rosa (1962) who inserted steal rodding into the
tibia shaft demonstrating that internal tibial rotation “leads to a decrease in
MLA height and external tibial rotation leads to an increase in MLA height.”
This is best compared to a mitred hinge (Bellchamber and van den Bogerl,
2000b, Inman et aI., 1994) in that both offer tri-plainer motion- around a
single oblique joint axis. However, in order to function effectively the joint
requires that the axis lie at 450 between the planes, it is accepted that ‘the
actual orientation of the axis varies between individuals’ (Close et al.,1967,
Kirby, 1989), this can be added to by previous injury. For example, Ochten at
al (2014) found significant structural abnormalities amongst those with lateral
ankle strains and sprains, of the researchers’ 206 participants it was found,
through radiography, effects on all joints of the ankle complex; talocrural joint
(47.2% osteophytes and 45.1% osteoarthritis) and the talonavicular joint

13
(36.5% sclerosis). As well as; high prevalence of bone oedema (33.8%) and
osteophytes (39.5) in the talocrural joint; osteophytes (54.4%), sclerosis
(47.2%), and osteoarthritis (55.4%, Kellgren and Lawrence grade >1) in the
talonavicular joint, as well as ligament damage (16.4%) in the anterior
talofibular ligament, when examined under MRI (Nemec et al., 2010).

As a result, it can be said that abnormalities of the foot might influence lower
limb mechanics which could place greater pressure on the lumbar spine
region, as well as increasing facial tension causing tension transmission to
distant parts of the musculoskeletal system causing overload and functional
restrictions. Further to this some authors such as Wilson and Lichtwark,
(2011) or Matsukiyo, Goh and Asagai (2017), have hypothesised that the
asymmetrical range of motion may lead to changes in specific muscle tendon
length as well as how the muscle its self-functions.

Integration of the lower extremities as a single unit is an understood theory

within the literature (Huang and Ferris, 2009). For example the integration
between the rearfoot, tibia and knee has been investigated, and is
reasonably well understood, with subtalar pronation and supination being
coupled with internal and external rotation of the tibia to influence knee
function (Stergiou et aL,1999, Wickiewicz and Simonian, Iggg,Williams et al.,
200I). Whilst the link between rearfoot function and tibial rotation the extent to
which this mechanical issue are transmitted to the hip is uncertain (Nester,
2000). Despite this however the rearfoot-tibia-knee-lumbo pelvic unit
represents what has been called a convincing mechanic for explaining
rearfoot dysfunction to NSLBP and other lumbar pathologies, however
research into the influence of rearfoot motion and the nature of the
anatomical linkage of the aforementioned integrated unit do need further
research. Despite this the theoretical relationship is described with a
mechanistic High arch Low arch P value Arch ratio 0.367 (0.013) 0.27r
(0.023) 0.000 Eversion excursion (o) I 1.90 (3.73) 13.96 (3.63) 0.04t* EV to
tibial internal rotation ratio 1.29 (0.40\ r.7r (0.92) 0.037* EV to knee internal
rotation ratio 1.00 (0.37) 1.05 (0.48) 0.714 Eversion velocity (o/s) 16s.06
(s8.23) 21930 (6s.34) 0.006 Peak knee flexion 46.48 (4.08\ 49.t9 (5.45)
0.040 Loading rate 62.48 (13.62) 52.05 (10.79) 0.006 86 precision (Kim,

14
2014). Bird and Payne (1999) Botte (1981) Michaud, 7997a, Minkowsky and
Minkowsky (1996) whom go further, stating that subtalar pronation is coupled
with internal tibial rotation, which is subsequently transmitted through the
knee to the femur, to the pelvis which then tilts anteriorly placing stress on
the glutes (Medius & minimums) iliopsoas, piriformis which eventually lead to
a functional lordosis that further impairs lumbar muscle function and can
induce feelings of fatigue and pain.

In terms of treatment, despite the amount of literature available to

professionals concerning the transmission of subtalar rotations proximally to
pelvic and spinal levels, foot orthoses are still the most commonly prescribed
method of treatment. This is evidenced by several reports describing the use
of orthoses in the treatment of NSLBP. This is agreed upon by Murley et al.
(2009) who noted change in foot alignment caused by orthotics, which he
hypothesised may influence the bioelectric activity of muscles proximal to the
condition. It should be noted however that through the usage of forced foot
pronation induced by wedges, such an artificial method of inducing foot
pronation can be considered to not allow for true observation of loading
changes in the foot (Woźniacka et al., 2019). This is due to the unnatural
nature of the pronation as well as the relatively short amount of time the
subjects were in a pronated position, as it has been noted that whilst this
form of inducing pronation might lead to some force alteration characteristics
within the foot, the alterations themselves will be relatively localised and
unable to effect more distal parts of the body, such as the thoracis region of
the spine, due to lack of time(Kulmala, Kosonen, Nurminen and Avela, 2018).

Botte (1981) discussed the relationship between various foot-types,

including pes cavus and limb length discrepancy, and LBP, and although he
described a range of features associated with excessive pronation, the
emphasis of the paper was on pelvic imbalance associated with unilateral, as
opposed to bilateral, pronation. It is perhaps easy to dismiss this paper
because of its observational nature, but several of the measurements used
were radiographic, and therefore less prone to the measurement efforts that
have dogged clinical goniometry. Results were purely descriptive, but
supported the concept that foot position and motion influences pelvic, sacral

15
and spinal mechanics. However, although trends were described, it was
added that the pattern of changes observed were variable and individual.
Rothbart and Estabrook (1988), similarly reported on the association
between excessive pronation and pelvic lists and Chondromalacia, but again
the emphasis was on unilateral excessive pronation. A study of the
prevalence of certain biomechanical anomalies within the foot did show more
promise, in terms of an attempt to measure the biomechanical relationships
in the feet of subjects complaining of LBP (Campbell, 1995). However, even
if the error associated with the traditional biomechanical measurements used
are accepted, this was a preliminary report of 20 patients, who despite being
described as having a '...significant foot abnormality...'were not compared to
a control group. Further 87 results from this project have not been published,
despite it being described as preliminary work. Whilst excessive pronation is
perceived to link mechanically with altered pelvic and sacral function, there
appears to be little experimental evidence that has investigated the
relationship. Several descriptive studies are available, but these are
characterised by their descriptive nature, their use of error-prone techniques,
or both. However, a common theme is the perception that asymmetry in
pronation between left and right limbs is associated with pelvic tilt, altered
sacral mechanics and lumbar malalignment

In conclusion it can be suggested that a lack of foot function exhibited as

excessive foot pronation might cause lower limb medial rotation, in addition
to a functional limb length discrepancy and an increased pelvic obliquity,
which all have been noted to contribute to a functional scoliosis of the lumbar
spine region (Lindbeck, 1985, Raczkowski, Daniszewska and Zolynski,
2010). These balances have been attributed to the formation of NSLBP,
however further research is needed in order to determine the significance of
foot function in relation to NSLBP.

2.3 Leg length discrepancy and pelvic tilt

Limb length discrepancy (LLD) is described as a condition in which one of

two limbs is of a ‘functionally’ different length when compared to the other

16
(Mahmoud, 2017). When the condition is present only in the lower extremities
(the legs) the condition is referred to as leg length discrepancy (LLD)
(Gurney, 2002). Estimated to effect 70% of the population an LLD of 20mm is
believed to effect 1 in every 1000 members of the world population (Desai,
Dramis and Board, 2013). Within the population suffering from LLD two
categories have emerged from the literature; structural limb length
discrepancy, which is a shortening of the lower limb through a decrease of
the ‘bony structures of the limb’, frequently this is described as ‘true’ limb
length discrepancy or anatomical leg length discrepancy (ALLD) and is
generally present since birth or due to the effects of surgical intervention due
to catastrophic injury requiring the removal of a portion of the bone.
Functional limb length discrepancy (FLLD) in comparison, is created through
a tilt of the pelvis, creating a discrepancy in the size of the limb but not
actually physically shortening the limb its self, FLLD can be further
categorised into static tilt; in which the pelvic tilt is only present on one side of
the body and does not ‘switch’, and dynamic pelvic tilt in which the tilt
changes from side to side. Whilst literature has demonstrated LLD does not
directly contribute to NSLBP (Tatsumi et al., 2019) static pelvic tilt has been
associated with NSLBP with a correlation coefficient of 0.97 (Minicozzi et al.,
2016) however as this study is only observational in nature it is worth noting
that the correlation does not equal causation and so this statement must be
applied with caution (Saarimäki, 2019). Further to this Gilies and Turner
(1981) in their meta -analysis of FLLD and NSLBP research reported that of
the 7% of subjects which suffered no prevalence of NSLBP, the average
FLLD was 10mm, while four of five studies demonstrated that 13-22% of
subjects who in fact sought medical advice for the NSLBP sought general
practitioner advice. In a follow up to this work Giles and Taylor (1982)
conducted testing on 217 persons, of these participants 18 (8%) also
suffered from an average FLLD of 10mm. This led to the hypothesis that it’s
not FLLD per say that leads to NSLBP but rather the size of the FLLD. This is
supported by the work of Friberg (1992) who using radiography found the
average FLLD was at least 5mm, this was correlated with a 1.7-time greater
prevalence in the NSLBP group compared to the control. The prevalence
grew to 5.3 times greater with 15 mm FLLD. As a result, it can be said that

17
the treatments aimed at equalizing the FLLD should help with the symptoms
of NSLBP. This idea correlates with the later work of Giles and Taylor who
after treating FLLD with shoe inserts to equalise the leg length reported a
marked decrease in pain symptoms as well as an increase in range of
motion. Work by both Gofton (1985) and Helliwell (1985) in a clinical setting
agrees with this, finding major (45%) or complete pain (44%) reduction in the
lumbar region as well as less days off work due to NSLBP. In comparison
surgical interventions are also relatively successful, for example in a study by
Rossvoll et al (1992) LBP patients with an average FLLD of 32mm were
treated surgically with shortening osteotomy. Post-surgery, an average LLD
was significantly reduced to 4.3 mm, in theory as a result of this, pain related
to NSLBP was significantly reduced. In addition, Tjernstrom and Rehnberg
(1994) performed 100 surgical leg-lengthening procedures. Before
lengthening, 18 of these patients experienced NSLBP, after a six-year period,
participants were followed up and it was revealed that over half of the
participants (7) no longer experienced NSLBP symptoms. However this is not
to say that surgical intervention is a superior method for treatment of FLLD
and NSLBP, for example the relative small sample size present in the
majority of leg lengthening research and the lack of standardised assessment
and reporting put expressiveness for the majority of papers supporting
surgical intervention at a low evidence level. As well as this the surgical
procedure itself is not without risk, for example in a meta-analysis of surgery
effect Hasler and Kreig revealed that 2.5% of patients suffered from Nerve
palsies of the deep peroneal nerve as a result of excessive femoral
lengthening as well as the increase of internal scar tissue. In addition, its
reported that 10% of subjects will experience a breakage of the lengthening
implement used, for example broken wire or bolt loosening, this is in
comparison with other implants which on average only experience a 5%
breakage rate on average (The 24th Annual Meeting of Children’s
Orthopaedics, 2010). In contradiction to this several investigations have
found limited or no correlation between FLLD and NSLBP. For example,
Hellsing (1976) in his work examining military recruits over a 4-year period
found limited correlation between FLLD and NSLBP. In a similar manner
Nadler, when reviewing collegiate level athlete’s, found no correlation

18
between the two. However, both of these studies were conducted outside of
a clinical environment and suffered from small sample sizes. Soukka et al.
(1991) however does confirm with the latter statement, and when using
radiographic equipment found no association between mild FLLD and LBP in
247 men and women.

FLLD is known to have close links with excessive pronation, when the foot is
excessively pronated, the inner longitudinal arch drops to provide greater
levels of support, subsequently shortening the leg, creating pelvic tilt. This
leads to the knee and hip of the long limb to flexion and shorten the long leg,
the short limb extends at these joints to lengthen the short limb, increasing
postural sway and disrupting balance. Changes within Gait will subsequently
include further compensatory mechanisms such as circumduction, increased
hip or knee flexion that can shorten the longer leg or lengthen the shorter leg.
This leads to decreased stance duration, step length, decreased walking
velocity and increased waking cadence on the short side (Blake and
Ferguson, 1993, Dahl,1996, D'Amico et aI.,19S5b). These changes can be
described as a compensatory mechanism, whereby the longer limb pronates
causing the lower limb to internally rotate and drop inferiorly, increasing
tensile strain on the iliopsoas and piriformis and narrowing the greater sciatic
notch to induce sciatica (Michaud, L997a). The limb rotations also lowers the
ipsilateral innominate leading to a rotation of the L5 vertebral body to the
short side, inducing the lumbar spine to straighten by lateral flexion towards
the long leg, which compresses the lateral aspect of the discs on that side,
which may result in joint degeneration. Correlations between LLD and pelvic
tilt of 0.843, sacral tilt of 0.639 and scoliosis of 0.338 (Hoikka et al., 1989)
indicates that some inequalities may be absorbed as they progress up the
skeletal chain, reducing the effects of smaller discrepancies. There does
however remain potential for LLD to cause asymmetries that might manifest
in the lumbar and lower lumbar regions through asymmetric limb rotation
transmits to the proximal skeleton disrupting normal loading patterns
(Michaud, 1997a).

FLLD results in asymmetrical limb rotations, differing amounts of inferior and

anterior pelvic tilt, and torsion within the spine, due to left and right limbs

19
rotating different amounts, caused by kinematic changes in the skeletal
chain. The long limb pronates to a greater degree than the shorter (Blake and
Ferguson, 1993), causing it to internally rotate and drop inferiorly, increasing
tensile strain on iliopsoas and piriformis and narrowing the greater sciatic
notch to induce sciatica. The ipsilateral inominate also drops inferiorly,
leading to a rotation of the L5 vertebral body to the short side, inducing the
lumbar spine to straighten itself by lateral flexion towards the long leg,
compressing the lateral aspects of the discs on that side which may result in
joint degeneration (Michaud, I997a, Minkowsky and Minkowsky, 1996). In a
comparison of lumbosacral joint angles in a group of LLD subjects and a
group of controls, it was found that the angle between these joints and the
horizontal were smaller on the shorter side (Giles, 1981). These findings led
to the conclusion that asymmetry could predispose to osteoarthritis in the
lumbosacral region (Friberg, 1982, Giles and Taylor, 1982, Young et
al.,2000).

The relationship between asymmetrical foot pronation and spinal alignment is

probably not as straightforward as suggested. A study of the relationship
between FLLD and pelvic tilt, sacral tilt and lumbar scoliosis revealed
correlations of 0.843, 0.639 and 0.338 respectively (Hoikka et al.,1989),
suggesting that some rotations are absorbed as they travel proximally,
reducing the effects of the FLLD. Such insight into the transmission of motion
through the integrated lumbo-pelvic unit helps explain apparently
contradictory results between studies that tend to use varying amounts of
artificial or true FLLD. It appears possible that the musculoskeletal system is
capable of absorbing small amounts of FLLD, and coupled with the inherent
variation present in a biological system and functional differences, goes
some way to explaining the range of results obtained. The suggestion that a
significant FLLD should be defined in terms of functional outcomes
(Abraham, 1992) seems appropriate, and is supported by the consistently
positive response of patients with symptoms apparently related to even small
amounts of FLLD to treatment (Gumey, 2002). The ultimate conclusion must
be that limb length discrepancy, whether of anatomical or functional origin,
carries a potential for disrupting lower limb mechanics and altering alignment

20
up to the spine, where they may result in pain. Young et al (2000), simulated
the effects of FLLD necessary to recreate a pelvic tilt of 1.2 degrees and
above on pelvic trunk flexion and torsion, the results showed the innominate
contralateral to the lift rotated anteriorly compared to the ipsilateral side and
that lateral flexion of the trunk increased toward the side of the lift. In addition
to this Giles and Taylor (1984) came to the conclusion that patients with
FLLD showed abnormal radiological findings in comparison to the control
group, this included wedging of the L5 vertebrae as well as concavities of the
endplates as well as traction spurs and osteophytes of the vertebral bodies.
The work of Raczkowski (2010) agrees with this to a point, having reported
that “asymmetrical loading forces acting on the spine secondary to scoliosis
caused by LLD result in early degeneration affecting both the intervertebral
disc spaces in the form of osteophyte formation as well as arthrosis of the
facet joints on the concavity of the scoliosis”. Conversely however Hoikka
and team (1989) found that the relationship between FLLD and functional
scoliosis was not as clear as previously reported in other research. He found
that whilst pelvic tilt correlated reasonably well with functional scoliosis on the
frontal pain (r=0.843), only mild correlation was found sacral tilt (r=0.639) and
poorly with Lumbar scoliosis (r=0.338). As a result of the team proposed that
the body compensates for the asymmetry associated with FLLD, meaning
there may be an association between FLLD and NSLBP, however FLLD is
probably not the root pathology of NSLBP.

In comparison Giles at al.(1981) examined patients suffering from FLLD with

a radiography machine, the team found that within the examined group that ‘
lumbosacral facet joint angles on the short side were smaller with the
horizontal compared to the controls’, from this they postulated that this
asymmetry of joint angles could predispose certain patients to an increased
risk of osteoarthritic changes at the lumbosacral joints. This theory is
supported by the work of Greenman (1992) who stated that FLLD resulting in
a pelvic tilt and thus an unstable sacral base were twice as likely to
experience symptoms of NSLBP than control groups without a FLLD and
thus a stable sacral base. Within the research he concluded that that an un-
levelling of as little as 4mm should be considered clinically significant and

21
thus be in need of treatment. Several pieces of research agree with this for
example Schuit et al. (1989) found that of the 14 subjects suffering from a
FLLD, nine participants also suffered from a SI misalignment however the
research failed to mention which side of the sacrum this effected (DePhillipo,
Corenman, Strauch and Zalepa King, 2019). Pitkin and Pheasant (1936)
further described an “innominate bone rotation of between 3 and 19° in
patients with FLLD”. Cummings et al. (1993) described a similar relationship
describing the condition as a “posterior innominate bone rotation on the side
of the lengthened limb and an anterior rotation on the side of the shorter
limb”. Further to this the author also hypothesized that that innominate
rotation could possibly limit range of motion (ROM) as well as movement
strategies and patterns during activities that involve movement of the pelvis,
such as the hinge pattern, that might result in uneven biomechanical loading
of the SI joint, which has been described as a factor in degenerative changes
within the joint as well as a possible causation of certain muscle imbalance
injuries (Vleeming et al., 2012).

Botte (1981) also came to this same conclusion of abnormal pronation

leading to leg length discrepancies and the subsequent pelvic tilts causing
low back pain. In a case study, Cibulka (2016) hypothesized that toeing out
results in subtalar joint pronation and excessive hip lateral rotation, leading to
LBP due to SI joint dysfunction. Botte (1981) suggested that unilateral foot
pronation produces SI joint dysfunction as well. Asymmetrical pronation, not
just excessive pronation, could actually be the cause of low back pain due to
the over-rotation at the pelvis needed to correct for the asymmetry in the
distal limb. This over-rotation produces muscle imbalances, as one side of
the body compensates for the dysfunction in the contralateral side which
causes lower body kinetic dysfunction. Khamis and Yizhar (2015)
investigated the role of excessive pronation on the alignment of the leg and
hip by having participants stand on wedges that simulated excessive
pronation. Upon pronation, the pelvic alignment shifted anteriorly
approximately 10 degrees across the participant pool. Anterior pelvic tilt has
been found to be highly correlated with increased lumbar curvature, which
can lead to low back pain. Both the lower leg and thigh were also found to be

22
internally rotated when in the pronated position, which could cause increased
hip and back misalignment, along with muscle imbalances leading to
dysfunction in the back. While Levine and Whittle’s (1999) participants did
not suffer from NSLBP, a change in the leg and thigh or pelvic alignment
could have serious consequences on the low back over time, as excessive
pronators consistently put their backs in a compromised position. Yet, the
role of excessive pronation on low back pain has not been confirmed.
Rothbart and Estabrook (1988) only examined patients with low back pain
and did not have a control group to compare if excessive pronation was also
evident in people without LBP. Cibulka (1999) only based the conclusions on
a specific case study looking at the effects of excessive pronation and
NSLBP. Further modern research utilizing a randomized control study design
and a significant number of participants with and without NSLBP is needed to
find if there is a relationship between excessive pronation and low back pain.

In conclusion it is suggestable that people with NSLBP may have a distinct

compensatory mechanism stemming from an increased pelvic tilt, which puts
the lumbar spine under higher stress. This is arguably caused by the
anatomical linkage of the pelvis to the foot and lumbar spine, it is argued that
changes in ‘pelvic inclination’ effects the size of lumbar lordosis and thus
could possibly contribute to NSLBP (Al-Eisa, Egan, Deluzio and Wassersug,
2006). Whilst this theory has been challenged, by a number of studies that
show little to no correlation between the angle of the pelvis and lumbar
lordosis (Youdas, Garrett, Egan and Therneau, 2000, Youdas et al., 1996) for
example Hoikka et al (1989) who showed that leg length discrepancy had a
‘moderate correlation with sacral tilt, and a poor correlation with lumbar
scoliosis’, it can still be considered to be a valid hypothesis as to the
causation of NSLBP, mostly due to the amount of literature contradicting the
dissenting view (Albright, 1998, Grundy and Roberts, 1984, Saito and Sasaki,
2019).

2.3 Shank rotation & Shorter Hamstring muscle length

23
The idea that foot function effects rotation of the shank leading to lower back
pain through alteration of pelvic mechanics is an established idea within
literature, previous research has shown that pronation of the foot as well as
calcaneal eversion is often accompanied by internal rotation of the upper
portion of the shank (Tibia and Femur) the greater the pronation or calcaneal
eversion the greater the magnitude of the shank rotation (Khamis et al 2006;
Coplan, 1989), which in turn is said to create greater lumbar lordosis in the
thoracic region, this however is only applicable when ‘internally rotating the
legs at extreme ranges of motion’ (Pfluegler, Borkovec, Kasper and McLean,
2020). Conversely Khamis et al. (2006) states that whilst calcaneal eversion
has some effect on the degree of pelvic tilt these changes are usually within
one degree of the participants norm and thus doubts the effect of calcilial
eversion on NSLBP, however later work by Khamis and Yizhar (2007),
confirms some linkage between foot pronation or hyper-pronation and pelvic
tilt. This is primarily due to the coupled relationship between the shank thigh
internal rotation and anterior pelvic tilt, however within the confines of this
study it was found that there were limited changes based on the degree of
pronation thus only a weak direct relationship could be established. This
confirms the work of Churchill et al (1998), Iwaki et al (2000) and Wilson et al
(2000) who through their usage of three-dimensional motion analyses
hypothesised a weak direct relationship.

Hamstring tightness is frequently found in patients with NSLBP (Jeon et al.,

2017), this is primarily due to its role as impact absorber within the gait cycle,
when a subjects foot is not strong enough to effectively absorb the ground
reaction force (GRF) being directed through it as a compensatory measure
the foot flattens, or pronates, towards the floor causing the internal rotation of
the shank towards the midline of the body, to adjust to this the body must
compensate by recruiting oppositional muscles in order to oppose the
created tension. Muscles recruited include the lateral hamstrings (biceps
femoris), lateral quad (vastus lateralis), and lateral calf muscles (peroneals).
This induces the muscles into becoming tight and over active which leads to
compensatory patterns in the hip and thoracic region in both the gait cycle
and static posture. This in turn causes a shortening of the hamstring muscles

24
causing a posterior tilt on the ischial tuberosity thereby exaggerating lumbar
lordosis. However a number of literary reviews seem uncertain as to the
validity of this claim, for example in Hellsings (1988) work it was concluded,
after a study of 600 participant’s, that limited association correlated between
hamstring tightness and NSLBP, Van Wingerden et al (2004) goes one step
further suggesting that hamstring tightness in NSLBP sufferer is due to the
reverse causation effect and thus a compensatory mechanism of pelvic
instability.

During the stance phase of gait, it is suggested that rearfoot pronation–

supination is coupled with lower-limb and hip internal– external rotation
(McPoil and Knecht, 1985; Tiberio, 1988). This coupling would imply that
pronation in the rear foot would be coincident with both hip internal rotation
and rearfoot supination, meaning the rear foot and hip motion are
independent of one another. (Tiberio, 1988). Recent experimental findings
suggest mechanical interdependence between the rearfoot and hip during
gait (Snyder et al., 2009; Souza et al., 2009) increases in late rearfoot
pronation cause increases in hip internal rotation during walking (Souza et
al., 2009). The hypothetic injury mechanism is an excessive lateral patellar
displacement due to a concomitant prolonged and excessive hip internal
rotation (Tiberio, 1988). This is in direct contrast to works by Nester (2000)
and Reischl et al (1999) who hypothesised a direct relationship between rear
foot motion and hip tilt within the transverse plain, however the studies in
question used procedures that can be considered inappropriate to examine
this relationship, for example they considered the foot as a single rigid
segment unable to produce mechanical power thus ignoring the role played
by the foot generating mechanical power during the gait cycle (Zelik,
Takahashi and Sawicki, 2015) as well as disregarding evidence that the foot
is in-fact a series of several interconnected flexible structures (McKeon,
Hertel, Bramble and Davis, 2014). As well as this, both experiments use
marker sets that can be considered to be inappropriate due to the lack of
error minimisation (Chiari et al., 2005; Manal et al., 2000; Schache et al.,
2008). Further to this Nester’s work (2000) did not consider possible time
lags between curve pairs, causing a possible limitation due to the fact

25
‘possible temporal relationships between joints' displacements may show
time delays (Derrick et al., 1994; Li and Caldwell, 1999). Conversely
Snyder’s later research (2009) found some links between the strengthening
of the hip external rotator muscles in decreasing rearfoot ankle supination
involved in the deacceleration of the foot in running subjects, therefore it can
be inferred that there is “some level of interdependence and synchrony
between rearfoot pronation and hip internal rotation, and between rearfoot
supination and hip external rotation may exist.”

Hamstring tightness is considered as one of the most common findings in

patients with NSLBP. Mechanically it is thought that this causes shank
internal rotation leading to a posterior tilt of the pelvis at the hamstrings
origin, the ischial tuberosity which in turn increases Lumbar lordosis which
can result in NSLB. Due to the accepted anatomical relation between the
pelvis and the Lumbar region of the spine, its accepted that changes in pelvic
alignment will affect the degree of lumbar Lordosis (Levine and Whittle, 1996;
Day et al, 1984).

2.4 Proprioceptive changes

Current research has reported that patients suffering from NSLBP have
shown impaired postural control during both simple and complex tasks, for
example statically balancing unilaterally on an unstable surface with their
eyes close (Berenshteyn et al., 2018; Mazaheri et al., 2013). During these
tasks it is considered that proprioceptive re-weighting, during which the brain
is believed to weigh and integrate precepts from the multisensory estimates
of the foot in order to accurately guide movement (Sexton, Liu and Block,
2019), becomes exponentially crucial (Carver et al., 2006; Peterka, 2002).

In the above example, standing on an uneven surface reduces the ‘reliability’

of the ankle propricpetion function (Ivanenko et al., 1999; Kiers et al., 2012),
causing the central nervous system (CNS) to reduce the weight given to the
proprioceptive function of the ankle joint, in order to dissipate CNS function to
other proception organs within the body, including the Lumbar spine
(Brumagne et al., 2004; Kiers et al., 2012). Currently a number of studies
demonstrate a not insignificant correlation between lack of postural control

26
and NSLBP. A key example of this is Jacob at al’s. (2011) work which
revealed longer movement times as well as reduced hip extension during the
sit to stand test (STS) in individuals with NSLBP, this correlated with a
change in brain potential and motor components known as contingent
negative correlation. However, this is not applicable to the population at large
due to the large deviation in cognitive ability found between subjects. In
addition, other studies have shown a relationship between changes within the
neurology of the brain and postural control deficit shown again by slower
times in the STS test. This has been attributed to “a cortical thinning of the
anterior cingulate cortex and a decreased global efficiency of information
transfer across white matter pathways” (Caeyenberghs et al.,
2017; Pijnenburg et al., 2016). In addition, it has been noted that a poor
proprioceptive reweighting ability has been linked with reduced muscular
integrity, this is due to the association between muscle strength and
proprioception (Scheper, 2014). Moreover, a poorer ability for proprioceptive
reweighting during standing was associated with a reduced microstructural
integrity of the superior cerebellar peduncle in subjects with NSLBP
(Pijnenburg et al., 2014). However, it remains uncertain at the current
moment whether subjects with NSLBP show structurally different brain
alterations as a direct result of processing ‘incorrect’ proprioceptive
alterations. Neural processing of proprioception in NSLBP sufferers has been
further investigated by applying muscle vibration, to the feet of participant
groups, this is considered a strong proprioceptive stimulus (Roll and Vedel,
1982; Roll et al., 1989) This paradigm has been used successfully to infer a
relationship between NSLBP and poor proprioceptive ability in both healthy
young adults (Cignetti et al., 2014; Fontan et al., 2017; Naito et al., 2007) and
healthy elderly subjects (Goble et al., 2011; Goble et al., 2012), however to
the authors knowledge, very few studies have examined group brain activity
during mechanical sensory stimulation at the lower back. Hotz-
Boendermaker et al (2016) work is one of the few that takes this into account,
in this study mechanical receptors within the spine's musculoskeletal
structures, such as; ligaments, muscles, joints, were stimulated by inducing
intervertebral movements with manual pressure. This revealed activation in
primary and secondary somatosensory cortices (S1, S2), cingulate cortex

27
and anterior cerebellum in healthy individuals (Boendermaker et al.,
2014; Meier et al., 2014), and a reduced activation and reorganization of S2
in patients with NSLBP. However little to no correlation for the simultaneous
activation of tactile receptors has been shown. In addition to this the
consequences of the observed difference proprioceptive based activities
remain uncertain in terms of association as the subject has not been properly
explored (Hotz-Boendermaker et al., 2016).

Conversely it has been shown that NSLBP sufferers are comparably poor in
terms of proprioceptive re-wrighting when compared to control groups not
suffering from the condition. NSLBP suffers predominantly rely upon ankle
proprioception regardless of the conditions they find themselves in (Claeys et
al., 2010) and are subsequently less likely to be able to ‘up-weigh’ back
proprioception which has been described as a significant reoccurrence risk
for mild NSLBP in young adults (Claeys et al., 2015). In addition to a lack of
static postural control and proprioceptive ability NSLBP sufferers are
frequently associated with a lack of postural control within the gait cycle,
which is evident in the increased time candidates took to perform five stand
to sit (STS) movements present in Claeys work (2012). At the current
moment however, literature is admittedly uncertain as to the direct cause of
this, a lot of focus has been given to peripheral factors, such as the sensitivity
of muscle spindles, and central aspects, more specifically the neural
processing of afferent signals from these muscle spindles (Brumagne et al.,
2004; Eklund, 1972).

In conclusion motor control adaptions within NSLBP may contribute to a

number of issues within the spinal tissue. These include but are not limited to
degeneration of intervertebral discs and other tissues as well as incorrect
loading upon the spinal tissue. However, the underlying biological and nuro-
biological issues that cause this effect are currently poorly understood and
seem to vary highly depending upon the given individual being tested, which
is often reflected in the effect sizes demonstrated (van Dieën, 2018). In order
to personalise treatment for this kind of issue more basic research into motor
adaptions due to NSLBP is required, especially when one considers the ever-
emerging evidence concerning cortical circuits in driving motor control

28
adaptions during the course of NSLBP. In addition, further research is
necessary to clarify the functional relevance of cortical reorganization in
chronic LBP. Is this simply a by-product of moto control adaption caused by
NSLBP or is it casually related to the reoccurrence of said condition?

CHAPTER 3.0

3.0 Conclusion

In conclusion it would appear there is some strong but limited evidence that
foot function effects NSLBP. However, limited effect size found in the majority
of studies indicates that this relationship is tenuous at best, and as a result
might be considered to be only a minor component in the risk of developing
NSLBP. Results of the review would indicate that gait and leg length change
due to lack of foot function can potentially lead to NSLBP due to changes in
pelvic alignment, however research in this area can be considered to be far
from complete. It could be inferred that deviations in the foot and ankle
complex have the potential to trigger chronic NSLBP however the validity of
the claim is currently somewhat uncertain. The majority of studies reviewed
did not consider reverse causation due to compensation for NSLBP, leading
to changes in gait characteristics causing loss of foot function by changing
their gait and podiatrical characteristics to try and reduce their pain. Further
to this a lack of random control trials (RCT’S) permeates the literature,
specifically in looking at foot function characteristics and their effect on
NSLBP. Currently it can be argued that validity of RCT’s is in some amount
of doubt, at their best, they provide an unbiased estimate but arguably this is
of ‘limited practical value’. This is due to the fact that estimates only apply to
the sample population selected, invariably this is selected using a
convenience sampling method and so applicability to the population at large
is doubtful, as a result justification is required in order to apply it to the
population as a whole. Further to this, demanding external validity can be
considered ‘unhelpful’ as it expects too much of RCT’s whilst simultaneously
undervaluing its potential contribution (Imbens, 2018, Nichol, Bailey and
Cooper, 2010).

29
In terms of the future direction of research concerning NSLBP, a strong
correlation between lack of foot function and NSLBP needs to be shown. As
well as research considering whether NSLBP is caused by areas such as the
shoulder, neck, or arm, to see if similar deviations in these regions cause low
back pain. After this, study’s focusing on alternate inexpensive treatments
needs to be conducted in order to alleviate the economic burden of treatment
on the health system in the UK, and the patient in the USA. This would be
relevant to a number of people considering the current prevalence of NSLBP
in the world’s population. Further to this foot functions links to other
pathologies distal to the back must be investigated, in an attempt to see if the
kinetic chain dysfunction radiates though the entirety of the posterior kinetic
chain. In general research concerning kinetic chain disfunction is a relatively
unstudied field, but has significant potential to find pathologies for largely
unexplained injury’s that occur within both the sporting environment and
everyday life.

Ethical statement

The author declare that he has observed and adhered to the ethical
principles normally practiced in the field in the acquisition, interpretation, and
finalization of the information for writing this literature review.

Conflict of interest

No funding was provided for the writing of the paper and the authors have no
conflicts of interest that are relevant to the content of this review.

4.0 References
Albright, J., 1998. Point of View: Low Back Pain in College Athletes. Spine,
23(7), p.833.
Al-Eisa, E., Egan, D., Deluzio, K. and Wassersug, R., 2006. Effects of Pelvic
Asymmetry and Low Back Pain on Trunk Kinematics During Sitting: A
Comparison With Standing. Spine, 31(5), pp.E135-E143.

30
Allen, J., Kautz, S. and Neptune, R., 2011. Step length asymmetry is
representative of compensatory mechanisms used in post-stroke hemiparetic
walking. Gait & Posture, 33(4), pp.538-543.
Azarnoosh, M., Stoffel, M. and Markert, B., 2014. Anisotropic
viscohyperelastic behavior of intervertebral discs: Modeling and experimental
validation. PAMM, 14(1), pp.91-92.
Balasundaram, A. and Choudhury, D., 2018. Association between hyper-
pronated foot and the degree of severity of disability in patients with non-
specific low back pain. Journal of Bodywork and Movement Therapies, 22(3),
pp.757-760.
Barondess, J., 2001. Musculoskeletal disorders and the workplace: Low back
and upper extremities - Executive Summary. Theoretical Issues in
Ergonomics Science, 2(2), pp.142-152.
Benedetti, F., 2005. Neurobiological Mechanisms of the Placebo Effect.
Journal of Neuroscience, 25(45), pp.10390-10402.
Botte RR. An interpretation of the pronation syndrome and foot types of
patients with low back pain. J Am Podiatr Med Assoc. 1981;71:243-252.
Calnan, M., 2002. Musculoskeletal Disorders and the Workplace: Low Back
and Upper Extremities. Panel on Musculoskeletal Disorders and the
Workplace, Commission on Behavioral and Social Sciences and Education,
National Research Council and Institute of Medicine. Washington DC:
National Academy Press, 2001, pp. 429, £39.95. ISBN: 309-07284-0 (HB).
International Journal of Epidemiology, 31(3), pp.702-702.
Christe, G. and Hall, T., 2017. The screening process of a patient with low
back pain and suspected thoracic myelopathy: a case report. Journal of
Manual & Manipulative Therapy, 26(1), pp.11-17.
Cibulka MT, Winters K, Kampwerth T, et al. Predicting Foot Progression
Angle During Gait Using Two Clinical Measures In Healthy Adults, A
Preliminary Study. Int J Sports Phys Ther. 2016;11(3):400-408.
Cibulka, M., 1999. Low Back Pain and Its Relation to the Hip and Foot.
Journal of Orthopaedic & Sports Physical Therapy, 29(10), pp.595-601.
Claeys, K., Brumagne, S., Dankaerts, W., Kiers, H. and Janssens, L., 2010.
Decreased variability in postural control strategies in young people with non-
specific low back pain is associated with altered proprioceptive reweighting.
European Journal of Applied Physiology, 111(1), pp.115-123.
correlation between pes planus and anterior knee or intermittent low back
pain. Foot Ankle Int. 2008; 29(9): 910-913
Cramer GD. The Lumbar Region. In: Clinical Anatomy of the Spine, Spinal
Cord, and Ans. Elsevier; 2014:246-311. doi:10.1016/b978-0-323-07954-
9.00007-4

31
Cummings G., Scholz J.P., Barnes K. The effect of imposed leg length
difference on pelvic bone symmetry. Spine. 1993;18(3):368–373
Davis, A., 2012. [online] Southernhealth.nhs.uk. Available at:
<https://www.southernhealth.nhs.uk/_resources/assets/inline/full/0/78677.pdf
> [Accessed 26 July 2020].
Debnath, U., 2018. Etiology and Risk Factors of Lumbar Intervertebral Disc
(IVD) Degeneration. Research in Medical & Engineering Sciences, 4(5).
Delitto, A., 2005. Research in Low Back Pain: Time to Stop Seeking the
Elusive “Magic Bullet”. Physical Therapy, 85(3), pp.206-208.
DePhillipo, N., Corenman, D., Strauch, E. and Zalepa King, L., 2019.
Sacroiliac Pain. Clinical Spine Surgery, 32(6), pp.E282-E288.
Desai, A., Dramis, A. and Board, T., 2013. Leg length discrepancy after total
hip arthroplasty: a review of literature. Current Reviews in Musculoskeletal
Medicine, 6(4), pp.336-341.
Deyo, R., Gray, D., Kreuter, W., Mirza, S. and Martin, B., 2005. United States
Trends in Lumbar Fusion Surgery for Degenerative Conditions. Spine,
30(12), pp.1441-1445.
Dionne, C., Dunn, K., Croft, P., Nachemson, A., Buchbinder, R., Walker, B.,
Wyatt, M., Cassidy, J., Rossignol, M., Leboeuf-Yde, C., Hartvigsen, J., Leino-
Arjas, P., Latza, U., Reis, S., Gil del Real, M., Kovacs, F., Öberg, B.,
Cedraschi, C., Bouter, L., Koes, B., Picavet, H., van Tulder, M., Burton, K.,
Foster, N., Macfarlane, G., Thomas, E., Underwood, M., Waddell, G.,
Shekelle, P., Volinn, E. and Von Korff, M., 2008. A Consensus Approach
Toward the Standardization of Back Pain Definitions for Use in Prevalence
Studies. Spine, 33(1), pp.95-103.
Farahpour, N., Jafarnezhad, A., Damavandi, M., Bakhtiari, A. and Allard, P.,
2016. Gait ground reaction force characteristics of low back pain patients
with pronated foot and able-bodied individuals with and without foot
pronation. Journal of Biomechanics, 49(9), pp.1705-1710.
Fortin, M. and Macedo, L., 2013. Multifidus and Paraspinal Muscle Group
Cross-Sectional Areas of Patients With Low Back Pain and Control Patients:
A Systematic Review With a Focus on Blinding. Physical Therapy, 93(7),
pp.873-888.
Friberg O. Letter-to-the-editor. Spine. 1992;17:458–460
Friberg, O., 1983. Clinical Symptoms and Biomechanics of Lumbar Spine
and Hip Joint in Leg Length Inequality. Spine, 8(6), pp.643-651.
Gait & Posture, 2016. Solulabs: Innovative solution for the prevention of low
back pain (LBP) in young athletes. 49, p.211.
Giles LGF, Taylor JR. Low-back pain associated with leg-length inequality.
Spine. 1981;6:510–521
32
Gofton JP 1985. Persistent low back pain and leg length disparity. J
Rheumatol, 12(4):747–750.
Gordon, R. and Bloxham, S., 2016. A Systematic Review of the Effects of
Exercise and Physical Activity on Non-Specific Chronic Low Back Pain.
Healthcare, 4(2), p.22.
Greenman P. Clinical aspects of sacroiliac joint function in walking Paper
presented at: First Interdisciplinary World Congress on low back pain and its
relation to the sacroiliac joint1992; San Diego, CA.
Grundy, P. and Roberts, C., 1984. does unequal leg length cause back pain?
The Lancet, 324(8397), pp.256-258.
Helliwell M 1985. Leg length inequality and low back pain. Practitioner,
229(1403):483–485.
Hellsing AL, Bryngelsson IL. Predictors of musculoskeletal pain in men: A
twenty year follow-up from examination at enlistment. Spine (Phila Pa 1976)
2000; 25: 3080–6.
Hellsing AL. Tightness of hamstring and psoas major muscles. A prospective
study of back pain in young men during their military service. Ups J Med Sci.
1988;93:267–276.
Hemming, R., Sheeran, L., van Deursen, R. and Sparkes, V., 2019.
Investigating differences in trunk muscle activity in non-specific chronic low
back pain subgroups and no-low back pain controls during functional tasks: a
case-control study. BMC Musculoskeletal Disorders, 20(1).
Hillstrom, H., Song, J., Kraszewski, A., Hafer, J., Mootanah, R., Dufour, A.,
Chow, B. and Deland, J., 2013. Foot type biomechanics part 1: Structure and
function of the asymptomatic foot. Gait & Posture, 37(3), pp.445-451.
Hollenberg, A., Bernstein, D., Baldwin, A., Beltejar, M., Rubery, P. and
Mesfin, A., 2020. Trends and Characteristics of Spine Research From 2006
to 2015. SPINE, 45(2), pp.141-147.
Hoikka V, Ylikoski M, Tallroth K. Leg-length inequality has poor correlation
with lumbar scoliosis. A radiological study of 100 patients with chronic low-
back pain. Arch Orthop Trauma Surg. 1989;108(3):173-5.
Huang, H. and Ferris, D., 2009. Upper and Lower Limb Muscle Activation Is
Bidirectionally and Ipsilaterally Coupled. Medicine & Science in Sports &
Exercise, 41(9), pp.1778-1789.
Imbens, G., 2018. Understanding and misunderstanding randomized
controlled trials: A commentary on Deaton and Cartwright. Social Science &
Medicine, 210, pp.50-52.
Jafarnezhadgero, A., Fatollahi, A., Amirzadeh, N., Siahkouhian, M. and
Granacher, U., 2019. Ground reaction forces and muscle activity while

33
walking on sand versus stable ground in individuals with pronated feet
compared with healthy controls. PLOS ONE, 14(9), p.e0223219.
Jeon, E., Jung, J., Moon, J., Jung, K., Won, Y., Kim, S., Hahm, S. and Cho,
H., 2017. The effects of spinal support device on pain and extensibility of the
hamstrings in patients with non-specific low back pain. Journal of Physical
Therapy Science, 29(8), pp.1301-1304.
Journal of Children's Orthopaedics, 2010. The 24th Annual Meeting of
Children’s Orthopaedics. 4(4), pp.359-387.
Kadakia, A., 2013. The Cavus Foot. Foot and Ankle Clinics, 18(4), p.xiii-xiv.
Kararti, C., bilgin, S., Dadali, Y., Büyükturan, B., Büyükturan, Ö. and Bek, N.,
2019. Are biomechanical features of the foot and ankle related to lumbopelvic
motor control? Journal of the American Podiatric Medical Association,
Khamis S, Yizhar Z. Effect of feet hyperpronation on pelvic alignment in a
standing position. Gait Posture. 2007; 25(1): 127-134.
Khamis, S., Dar, G., Peretz, C. and Yizhar, Z., 2015. The Relationship
Between Foot and Pelvic Alignment While Standing. Journal of Human
Kinetics, 46(1), pp.85-97.
Kim, S., 2014. Hypothesis Testing For Arch Models: A Multiple Quantile
Regressions Approach. Journal of Time Series Analysis, 36(1), pp.26-38.
Kosashvili Y, Fridman T, Backstein D, Safir O, Ziv YB. The
Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive
Analysis. 5th Edition. Philadelphia. F.A. Davis Company. 2011
Lindbeck, L., 1985. Analysis of Functional Scoliosis by Means of an
Anisotropic Beam Model of the Human Spine. Journal of Biomechanical
Engineering, 107(3), pp.281-285.
Mahmoud, A., 2017. Functional leg length discrepancy between theories and
reliable instrumental assessment: a study about newly invented NPoS
system. Muscles, Ligaments and Tendons Journal, 7(2), p.293.
Matsukiyo, A., Goh, A. and Asagai, Y., 2017. Relationship between muscle-
tendon length, range of motion, and resistance to passive movement in
children with normal and increased tone. Journal of Physical Therapy
Science, 29(2), pp.349-355.
McKeon, P., Hertel, J., Bramble, D. and Davis, I., 2014. The foot core
system: a new paradigm for understanding intrinsic foot muscle function.
British Journal of Sports Medicine, 49(5), pp.290-290.
McMinn, 1994. Last's Anatomy Regional and Applied. Edinburgh: Churchill
Livingstone (ISBN: B0084AQDG8)
McPhee, M. and Graven-Nielsen, T., 2019. Recurrent low back pain patients
demonstrate facilitated pronociceptive mechanisms when in pain, and
34
impaired antinociceptive mechanisms with and without pain. PAIN, 160(12),
pp.2866-2876.
Minicozzi, S., Russell, B., Ray, K., Struebing, A. and Owens, E., 2016. Low
Back Pain Response to Pelvic Tilt Position: An Observational Study of
Chiropractic Patients. Journal of Chiropractic Medicine, 15(1), pp.27-34.
Murley, G., Landorf, K., Menz, H. and Bird, A., 2009. Effect of foot posture,
foot orthoses and footwear on lower limb muscle activity during walking and
running: A systematic review. Gait & Posture, 29(2), pp.172-187.
Nemec, M., Koller, M., Nickel, C., Maile, S., Winterhalder, C., Karrer, C.,
Laifer, G. and Bingisser, R., 2010. Patients Presenting to the Emergency
Department with Non-specific Complaints: The Basel Non-specific
Complaints (BANC) Study. Academic Emergency Medicine, 17(3), pp.284-
292.
Nichol, A., Bailey, M. and Cooper, D., 2010. Challenging issues in
randomised controlled trials. Injury, 41, pp.S20-S23.
Nikolai Bogduk. Clinical and Radiological Anatomy of the Lumbar Spine 5th
Edition.Churchill Livingstone: Elsevier. Feb 2012.
Öhlén, G., Spangfort, E. and TINGVALL, C., 1989. Measurement of Spinal
Sagittal Configuration and Mobility with Debrunnerʼs Kyphometer. Spine,
14(6), pp.580-583.
O'Leary, C., Cahill, C., Robinson, A., Barnes, M. and Hong, J., 2013. A
systematic review: The effects of podiatrical deviations on nonspecific
chronic low back pain. Journal of Back and Musculoskeletal Rehabilitation,
26(2), pp.117-123.
Paungmali, A., Joseph, L., Sitilertpisan, P., Pirunsan, U. and Uthaikhup, S.,
2017. Lumbopelvic Core Stabilization Exercise and Pain Modulation Among
Individuals with Chronic Nonspecific Low Back Pain. Pain Practice, 17(8),
pp.1008-1014.
Pfluegler, G., Borkovec, M., Kasper, J. and McLean, S., 2020. The immediate
effects of passive hip joint mobilization on hip abductor/external rotator
muscle strength in patients with anterior knee pain and impaired hip function.
A randomized, placebo-controlled crossover trial. Journal of Manual &
Manipulative Therapy, pp.1-9.
Physiopedia. 2020. Non Specific Low Back Pain. [online] Available at:
<https://www.physio-pedia.com/Non_Specific_Low_Back_Pain> [Accessed 1
August 2020].
Pithon, M., 2013. Importance of the control group in scientific research.
Dental Press Journal of Orthodontics, 18(6), pp.13-14.
Pitkin H., Pheasant H. Sacrarthrogenetic telalgia. II A study of sacral mobility.
J Bone Jt Surg. 1936;18(2):365–375.

35
Pransky G, Borkan JM, Young AE, Cherkin DC. Are we making progress?:
the tenth international forum for primary care research on low back pain.
Spine (Phila Pa 1976). 2011 Sep 1;36(19):1608-14.
Raczkowski, J., Daniszewska, B. and Zolynski, K., 2010. Clinical research
Functional scoliosis caused by leg length discrepancy. Archives of Medical
Science, 3, pp.393-398.
Rao, S., Riskowski, J. and Hannan, M., 2012. Musculoskeletal conditions of
the foot and ankle: Assessments and treatment options. Best Practice &
Research Clinical Rheumatology, 26(3), pp.345-368.
Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell.Gray's Anatomy
for Students.2nd edition . Churchill Livingstone: Elsevier. 2009
Rolli Salathé, C. and Elfering, A., 2013. A Health- and Resource-Oriented
Perspective on NSLBP. ISRN Pain, 2013, pp.1-19.
Rossvoll I, Junk S, Terjesen T. The effect on low back pain of shortening
osteotomy for leg length inequality. Int Orthop. 1992;16(4):388-91.
Rothbart B, Estabrook L. Excessive pronation: A major biomechanical
determinant in the development of chondromalacia and pelvic lists. J Man
Phys Ther. 1988; 11(5): 373-379
Ruhe, A., Fejer, R. and Walker, B., 2010. Center of pressure excursion as a
measure of balance performance in patients with non-specific low back pain
compared to healthy controls: a systematic review of the literature. European
Spine Journal, 20(3), pp.358-368.
Rushton, A., Staal, J., Verra, M., Emms, A., Reddington, M., Soundy, A.,
Cole, A., Willems, P., Benneker, L., Masson, A. and Heneghan, N., 2018.
Patient journey following lumbar spinal fusion surgery (LSFS): protocol for a
multicentre qualitative analysis of the patient rehabilitation experience
(FuJourn). BMJ Open, 8(1), p.e020710.
Saarimäki, N., 2019. Methodological Issues in Observational Studies. ACM
SIGSOFT Software Engineering Notes, 44(3), pp.24-24.
Saito, N. and Sasaki, M., 2019. Effect of Familiarity on Subjective Leg Length
Discrepancy and Gait Pattern Change due to Objective Leg Length
Discrepancy When Walking. Rigakuryoho Kagaku, 34(6), pp.739-742.
Savage RA, Whitehouse GH, Roberts N. The relationship between the
magnetic resonance imaging appearance of the lumbar spine and low back
pain, age and occupation in males. Eur Spine J. 1997;6:106
Scheper, M., 2014. The association between muscle weakness and activity
limitations in patients with Ehlers Danlos (Hypermobility Type): the impact of
proprioception. Osteoarthritis and Cartilage, 22, p.S201.

36
Schuit D, McPoil TG, Mulesa P. Incidence of sacroiliac joint malalignment in
leg length discrepancies. J Am Podiatr Med Assoc 1989;79:380–3.

Sekiya, T., Aota, Y., Yamada, K. et al. Evaluation of functional and structural
leg length discrepancy in patients with adolescent idiopathic scoliosis using
the EOS imaging system: a prospective comparative study. Scoliosis 13, 7
(2018). https://doi.org/10.1186/s13013-018-0152-4
Sexton, B., Liu, Y. and Block, H., 2019. Increase in weighting of vision vs.
proprioception associated with force field adaptation. Scientific Reports, 9(1).
Sivan, M., 2006. Letter to the Editor: Nonspecific Lower-back Pain. Clinical
Orthopaedics and Related Research, 452, p.287.
Soukka, H. Alaranta, K. Tallroth, M. Heliövaara. Leg-length inequality in
people of working age. The association between mild inequality and low-back
pain is questionable. Spine (Phila Pa 1976), 16 (1991), pp. 429-431
Stang, A., 2010. Critical evaluation of the Newcastle-Ottawa scale for the
assessment of the quality of nonrandomized studies in meta-analyses.
European Journal of Epidemiology, 25(9), pp.603-605.
Stark, H., Fröber, R. and Schilling, N., 2012. Intramuscular architecture of the
autochthonous back muscles in humans. Journal of Anatomy, 222(2),
pp.214-222.
Tatsumi, M., Mkoba, E., Suzuki, Y., Kajiwara, Y., Zeidan, H., Harada, K.,
Bitoh, T., Nishida, Y., Nakai, K., Shimoura, K. and Aoyama, T., 2019. Risk
factors of low back pain and the relationship with sagittal vertebral alignment
in Tanzania. BMC Musculoskeletal Disorders, 20(1).
Tjernström, B. and Rehnberg, L., 1994. Back pain and arthralgia before and
after leg lengthening: 75 patients questioned after 6 (1-11) years. Acta
Orthopaedica Scandinavica, 65(3), pp.328-332.
Topics in Pain Management, 2008. Summary of Recommendations in
Clinical Guideline for Diagnosis and Treatment of Low Back Pain. 23(6), p.7.
Trachtenberg, G., 2012. When Lower Extremity Dysfunction Contributes To
Back Pain. [online] Podiatry Today. Available at:
<https://www.podiatrytoday.com/when-lower-extremity-dysfunction-
contributes-back-pain> [Accessed 24 July 2020].
Van Wingerden JP, Vleeming A, Buyruk HM, Raissadat K. Stabilization of the
sacroiliac joint in vivo: verification of muscular contribution to force closure of
the pelvis. Eur Spine J 2004;13:199–205
Veterinary Record, 2009. Saving lives and improving livelihoods. 165(14),
pp.4-4.
Vleeming A ,Mooney V . Movement, Stability & Lumbopelvic Pain 2nd
Edition . Philadelphia.Churchill Livingstone .1st March 2007
37
Vleeming, A., Schuenke, M., Masi, A., Carreiro, J., Danneels, L. and Willard,
F., 2012. The sacroiliac joint: an overview of its anatomy, function and
potential clinical implications. Journal of Anatomy, 221(6), pp.537-567.
Vogel, S., 2009. NICE clinical guidelines. Low back pain: The early
management of persistent non-specific back pain. International Journal of
Osteopathic Medicine, 12(4), pp.113-114.
Wáng, Y., Wu, A., Ruiz Santiago, F. and Nogueira-Barbosa, M., 2018.
Informed appropriate imaging for low back pain management: A narrative
review. Journal of Orthopaedic Translation, 15, pp.21-34.
Waxenbaum JA, Futterman B. Anatomy, Back, Intervertebral Discs.
InStatPearls [Internet] 2018 Dec 13. StatPearls Publishing. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK470583/
Whatley, B. and Wen, X., 2012. Intervertebral disc (IVD): Structure,
degeneration, repair and regeneration. Materials Science and Engineering:
C, 32(2), pp.61-77.
Whitman, R., 2009. The Classic: A Study of the Weak Foot, with Reference
to its Causes, its Diagnosis, and its Cure; with an Analysis of a Thousand
Cases of So-Called Flat-Foot. Clinical Orthopaedics and Related Research®,
468(4), pp.925-939.
Whittle MW, Levine D. Three-dimensional relationships between the
movements of the pelvis and lumbar spine during normal gait. Hum Mov Sci.
1999;18:681–692
Wilke H-J, Volkheimer D. Basic Biomechanics of the Lumbar Spine. In:
Biomechanics of the Spine. Elsevier; 2018:51-67. doi:10.1016/b978-0-12-
812851-0.00004-5
Wilson, A. and Lichtwark, G., 2011. The anatomical arrangement of muscle
and tendon enhances limb versatility and locomotor performance.
Philosophical Transactions of the Royal Society B: Biological Sciences,
366(1570), pp.1540-1553.
Woźniacka, R., Oleksy, Ł., Jankowicz-Szymańska, A., Mika, A., Kielnar, R.
and Stolarczyk, A., 2019. The association between high-arched feet, plantar
pressure distribution and body posture in young women. Scientific Reports,
9(1).
Wright, W., Ivanenko, Y. and Gurfinkel, V., 2012. Foot anatomy specialization
for postural sensation and control. Journal of Neurophysiology, 107(5),
pp.1513-1521.
Youdas, J., Garrett, T., Egan, K. and Therneau, T., 2000. Lumbar Lordosis
and Pelvic Inclination in Adults With Chronic Low Back Pain. Physical
Therapy, 80(3), pp.261-275.

38
Youdas, J., Garrett, T., Harmsen, S., Suman, V. and Carey, J., 1996. Lumbar
Lordosis and Pelvic Inclination of Asymptomatic Adults. Physical Therapy,
76(10), pp.1066-1081.
Young, J., Cuff, S., Yang, J. and Pommering, T., 2016. Comparison of spinal
and pelvic posture and muscle flexibility in those with spondolytic and non-
spondolytic low back pain. Journal of Musculoskeletal Research, 19(03),
p.1650011.
Yuji Ohta, E., 2014. Effects of Foot Arch Structure on Postural Stability.
Clinical Research on Foot & Ankle, 02(02).
Zelik, K., Takahashi, K. and Sawicki, G., 2015. Six degree-of-freedom
analysis of hip, knee, ankle and foot provides updated understanding of
biomechanical work during human walking. Journal of Experimental Biology,
218(6), pp.876-886.

5.0 Appendix A- ethical approval

POSTGRADUATE DISSERTATION PROJECT PROPOSAL AND ETHICS

FORM

Personal and project information:

39
Name: Zack
Cullen
Programme of
study: Msc
Strength and
conditioning
Supervisor:
Stephen Draper

Does a lack of foot function alter lower limb mechanics that

Project title: might contribute to Non-specific lower back pain? A meta-
analysis

Which type of Project are you proposing (please tick)

Research Article

Vocationally Relevant Inquiry

Critical Review of Literature x

Background and rationale: Give a brief background and rationale for the project.
This should include a review of previous research on the topic and a justification of
why this project is unique and of scientific importance. This must be supported by
appropriate references.
Non-specific lower back pain (NSLBP) is a highly prevalent problem worldwide, this
has been hypothesised as being due to an increasingly sedentary lifestyle world wide
(WHO, Physical inactivity a leading cause of disease and disability, warns WHO,
2020). However recent research seems to disagree with this statement, for example
Chen (2009) in a meta-analysis of the literature surrounding the subject was only able
to find one study of significant quality (Sjolie 2004) which expressed a high enough
confidence value, that demonstrated a meaningful positive relationship between
NSLBP and physical inactivity. It is worth noting that although the degree of

40
association reported in the study was strong (OR 6.2), the 95% CI was wide (2.2–
17.3), implying a high degree of uncertainty towards the robustness of the
association.
Other theories have emerged as to the cause of NSLBP, for example low
educational status, obesity and occupation have also been referenced as contributors
to NSLBP (Citko, Górski, Marcinowicz and Górska, 2017) however it appears unlikely
that these on their own are causative of NSLBP (Vadhanan, 2017). Rather the author
believes it is the cause of a biomechanical issue originating in the feet, Vogel (2009)
agrees with this statement suggesting that ‘altered foot function’, for example Pes
Planus or pronation, causes shank rotation, leg length discrepancy and a shortening
of the hamstring muscles, which in turn cause a pelvic tilt that can lead to a functional
scoliosis placing altered stress on soft tissue structures surrounding the spine leading
to NSLBP. This can be further aggravated by every day movements such as driving.
Literature seems to agree with the possibility of a biomechanical link between the foot
and back in NSLBP sufferers, for example the work of Brantingham, Lee Gilbert,
Shaik and Globe (2006) notes that individual’s with low back pain have been shown
to more likely suffer from flat or pronated feet, Menz et al., (2013) in his seminal work,
found a strong association between a lack of foot function and NSLBP. Further to this
it has been noted a statistically significant increase in internal shank rotation (p <
0.0001), internal hip rotation (p < 0.0001) and anterior pelvic tilt (p < 0.0001) was
identified when blocks of varying degrees were used to induce pronation in healthy
participants (Khamis’s 2017).
As a consequence of the High prevalence of NSLBP, it can be seen that health care
systems around the world are inundated by this issue, in 2000 the health care costs
due to back pain in the United Kingdom were £1,632M and this has steadily risen
(Savigny P, 2020. Maniadakis, N. and Gray, A., 2000) and reported costs are now in
excess of £500 million (Industrial injuries advisory council 2007), or £481million with a
further £197 million incurred from non-NHS costs (Johnson 2012), showing a clear
need for further investigation into the issue in order to overcome the incredible
financial burden attached to the condition.

41
42
Aims and objectives: List the overall aim of your project and provide
several achievable objectives that you hope to complete through your
study.

To provide a comprehensive review of the literature surrounding the

physiological conditions that may contribute to NSLBP, with the idea of
providing a comprehensive guide that will inform future research in the
area.

43
Experimental design and methods: Summarise the methods you will use
to achieve the aims and objectives of the project. Depending on the nature
of your project, this might include information such as study site, study
species, sample size, equipment and resources needed, sampling and
recording methods and media and statistical analysis. The methods must
be supported by appropriate references. Please note that whilst Hartpury
equipment and existing resources are available for utilisation by
students, funds are not available to cover project costs (e.g.
equipment purchase, travel, accommodation). If your project requires
consumable items, then a list and costs must be provided.

A comparative study of the literature was conducted using the following

academic search engines; MEDLINE, PubMed, SPORTDiscus, Google
Scholar, Worldcat Libraries. Key research terms included; Non-specific
lower back pain (including acronyms such as NSLBP and LBP) as well as;
‘orthotics excessive pronation, podiatric deviations, hallux, kinetic chain,
link theory, ankle instability, ankle dorsiflexion, pelvic tilts, pes planus and
proprioception’ this included combinations of the above words. After
removal of duplicates the electronic search was supplemented by a manual
search of the literature in order to identify sources of potential specific
interest as well as to screen for specific relevance.
Studies only met eligibility criteria if they involved candidates 16 years or
older suffering with subacute or chronic NSLBP, as the difference between
these 2 groups cannot clearly be delineated from a pain physiological
perspective, but rather stems from epidemiological convention, and written
in Dutch or English due to the authors familiarity with these languages,
where included. Studies involving people with; sciatica, pelvic problems,
pregnancy, whiplash associated disorders, nonspecific neck pain,
fibromyalgia, low back surgery, or any other medical condition besides
NSLBP were excluded. Literature was searched up to February, 2020.
In Individual Studies Risk of bias was assessed using the Newcastle-
Ottawa quality assessment scale (NOS).

44
45
Ethical considerations: Please list the ethical concerns that you believe are
inherent in this project and explain how you plan to address them. This may not be
relevant when handling secondary data but is likely to be important for most
projects. This could be through such methods as storing data appropriately and
adhering to the data protection act, considering the 3Rs and limiting suffering. This
must be supported by appropriate references.

Please note that whilst if ethical concerns are fully addressed the supervisor
is able to sign off paperwork, where ethical concerns remain the paperwork
will need to be submitted for ethical review. This may take up to 3 weeks.

Three guiding principles in terms of ethics for a quality research synthesis have
been identified from the work of Suri (2018) and Suri and Clarke (2009) these are as
follows:
• Informed subjectivity and reflexivity
• Purposefully informed selective inclusivity
• Audience-appropriate transparency

46
Documents enclosed with this proposal and ethics form (put a X in
the appropriate boxes). These documents MUST be completed before
you can be signed off by your supervisor to begin data collection.

Completed questionnaire (if you are completing a

questionnaire-based project this MUST be
enclosed)

Risk assessment (this MUST be enclosed for all

experimental research)

Site permission form (this MUST be enclosed

where the research is conducted off-site)

Placement approval certificate (if applicable)

Participant permission form (this MUST be
enclosed unless your project does not have any
human / animal participants)

Research collaboration form (if applicable)

Laboratory consumable costs (if applicable)
Other (please specify)

47
Signature of
Zack Cullen Date 23/07/2020
student

Signature of
Steve Draper Date 31/07/2020
supervisor

48
6.0 Appendix B – Mandatory reflection questions
Outline the strengths and weaknesses of your project. Explain how you might
address these given the opportunity.
The piece of work in question has a number of strengths associated to it, for
example a review of this kind concerning the topic of foot function in its
relation to NSLBP, has been conducted before however to the authors
knowledge no meta-analysis has previously gone into as much detail on the
subject nor compared so many possible contributing factors as in the body of
this work, normally the literature instead focuses on one particular aspect
contributing to NSLBP, thus failing to provide a total over view of the subject
as a whole. This is an opportune time to conduct such research due to the
current rise in NSLBP, and as a result of this in its current form could
contribute to a better understanding of the condition and fill some current
research gap’s present in the literature. Further to this it can be argued that
there is no over reliance on any types of source material, for example books
or internet resources.
However, it can be argued the piece suffers from a number of weaknesses,
for example, usage of seminal texts is minimal. Whilst this is possibly due to
a lack of literature around the topic area, the author has however identified
some pieces of literature as such. Given the opportunity to correct this, initial
literature searches would be used to identify these pieces of work. To identify
seminal works, number of citations is usually a good indicator as to the
importance of a piece of work in its given field, the greater number of
citations the grater likelihood of it being a seminal work. Subsequently these
pieces will be examined and reviewed in order to provide a greater
understanding of the literature contributing to the piece. It is worth noting that
as seminal pieces of work are generally older, using a date restriction will
severally limit the opportunity to identify these works. Further to this is the
tendency to discuss literature in a descriptive/unconnected manner, leading
to the he says, she says’ approach of literature discussion, which in turn has
led to a possible lack of synthesis within the body of this work. In order to
address this fully, the author must be more conscious of the style of writing
required in an academic piece of work, and thus refrain from falling into a
more narrative system, further to this the author feels that reporting the
information within the piece using different words and phrases would have
aided this. Further to this it can be argued that the research presented is not
fully up-to date, whilst some amount of literature is present for the period
2016-2020 it is arguably in the minority of the research referenced, whilst this
again can be contributed to the lack of more modern literature around the
subject, over relying on such research that could now be considered out of
date, does present an issue with the reliability of the work presented. In order
to correct this, given the opportunity, the author would during his initial search
of literature, conduct a specific search for the dates mentioned in order to
ensure the research is up-to date. Lastly in its current form it can be argued
that the piece is not well balanced, in places the work is superficial and does

49
not fully analyse the work presented, however in other instances the piece is
too lengthy and not succinct enough to covey the ideas presented efficiently.
A revised structure making it easier for readers and the author to navigate
would aid this, as would a more extensive editing period, provided by correct
time management strategies, as this would enable the author to truly focus
on the language and structure of the piece. Which he believes are the main
contributors to the lack of balance.

Describe the personal and professional skills you have used during the
process, and how these have developed over the course of the module.
Independence – In order to effectively complete a dissertation-based piece of
work the author must be able to work on his or her own in order to complete
the work in a timely manner. Previously the author has struggled to work
independently on such styled pieces of work, needing continually advice and
relying upon supervising staff more than is appropriate. However, with this
piece of the work the author feels he was better able to work independently,
this is due to a number of factors for example the author feels he was better
prepared for the challenge of working individually by academic staff, having
been given the tools he needed to succeed through attending earlier
modules and lectures.
Self-motivation and work ethic – with COVID causing major disruption to the
academic calendar the author admits at the beginning of the dissertation
process to feeling a lack of motivation and work ethic, something which
arguably has plagued him through the majority of his academic career, often
leading to pieces of work being submitted at the last minute, or in some
cases not at all. Throughout this process the author came to realise that in
order to accomplish what was set out, motivation would have to become
internal rather than external. This shift in mind set had a direct effect on work-
ethic, once motivation was internalised the author feels that his work ethic
subsequently improved, leading to a greater quality of work produced over a
shorter time period. This subsequently enabled the author to take regular
breaks from the work, something he has never been able to do before.
Communication – Whilst the author has always considered communication to
be among his stronger attributes, he feels his ability to communicate over the
process of conducting this research has drastically improved. Previously the
author can be considered to have written and communicated in a prolonged
format, often failing to get succinctly to the point. Over the course of the
dissertation process the author has learnt how to effectively communicate
spoken and verbalised ideas to supervisors, through using correct
communication strategies. Further to this the author has arguably become
much more direct in written communication, being able to disseminate the
ideas he presents and writing them succinctly.

50