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A systematic review: The effects of podiatrical deviations on nonspecific

chronic low back pain

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Journal of Back and Musculoskeletal Rehabilitation 26 (2013) 117–123 117
DOI 10.3233/BMR-130367
IOS Press

Review Article

A systematic review: The effects of

podiatrical deviations on nonspecific chronic
low back pain
Colin B. O’Learya , Caroline R. Cahilla , Andrew W. Robinsona, Meredith J. Barnesa and Junggi Hongb,∗
a
Department of Exercise Science, Willamette University, Salem, OR, USA
b
Department of Physical Education, Kookmin University, Seoul, Korea

Abstract. Lower back pain (LBP) is a widespread, expensive, and debilitating problem in Western industrialized countries.
Though LBP can be caused by acute injuries, biomechanical discrepancies have also been indicated to cause chronic LBP.
A possible link between podiatrical deviations and LBP has been established in the literature; yet, no comprehensive review
investigating the effects of foot and ankle deviations on low back pain has been published. The aim of this study was to assess
the relevant literature concerning the effects of foot and ankle deviations on LBP. After review, it was determined that there is
limited research regarding ankle and foot deviations and their connection to LBP. Reviewed studies have linked flat feet, ankle
instability, sagittal plane blockage and excessive pronation to LBP. Specifically, excessive pronation has been shown to cause
leg length discrepancies leading to pelvic tilts and LBP. Based on these results, ankle and foot deviations can be considered a
potential cause for LBP due to the disruption of the kinetic chain from the foot to the back. Clinicians should consider the foot
and ankle when addressing LBP, especially if more conventional etiologies fail to describe the condition.

Keywords: Low back pain, kinetic dysfunction, ankle, foot, excessive pronation, leg length discrepancy

1. Introduction Work absenteeism and disablement cost the Nether-

Low back pain (LBP) is a widespread debilitating
condition with multiple established etiologies and oth-
er causes that remain unknown. In industrialized coun-
tries, the rate of low back pain over one’s lifetime is
over 70% [1]. Low back pain typically peaks between
the ages of 35 and 55; however, the initial age of onset
can be found in younger populations [1]. In the United
States, back pain is the most common cause of activity
limitation in people below the age of 45, and the sec-
ond most common reason for visits to a physician [2].
∗ Address
for correspondence: Junggi Hong, Assistant Pro-
fessor, Department of Physical Education, Kookmin University,
Jeongneung-Ro, Seongbuk-Gu, Seoul 136-702, Korea. E-mail:
jhong@willamette.edu.
lands 1.7% of the GNP in 1991 and across the European
Union, low back pain accounts for 11% of all muscu-
loskeletal pain [1]. Low back pain has also been linked
to sleep disturbance [3], along with a loss of physical
function and deterioration in overall health [4].
Studies that examined the back and LBP have re-
ported varied causes. The most convincing mechanism
of back pain is through the spraining of intervertebral
ligaments or from straining the back muscles due to
overuse or an excessive amount of force placed on the
region [2]. Both sprains and strains cause inflammation
and spasming that produces pain and swelling around
the injured area, which decreases overall function. In-
jury can also occur to one of the intervertebral discs
such as a tear or herniation. Due to aging and injury,
discs begin to diminish and shrink in size, resulting in

ISSN 1053-8127/13/$27.50  2013 – IOS Press and the authors. All rights reserved
118 C.B. O’Leary et al. / A systematic review: The effects of podiatrical deviations on nonspecific chronic low back pain
vertebrae and facet joints rubbing against one anoth-
er leading to degeneration and pain [5]. Ligament and
joint functionality also diminishes as one ages, lead-
ing to spondylolisthesis, which causes the vertebrae to
move much more than they should. Pain can also be
generated through lumbar spinal stenosis, sciatica and
scoliosis. Others may have a sacroiliac joint dysfunc-
tion that is characterized by pain radiating from their
sacroiliac joint, where the spinal column attaches to the
pelvis [6]. Yet, even with all of these possible etiolo-
gies, no noteworthy or serious cause is identified in the
vast majority of cases [7]. In an effort to understand the
mechanism of injury of low back pain, some studies
have looked into the distal regions of the body.
Some past research has looked into lower limb dis-
tal problems such as deviations of the foot and ankle.
The importance of the feet to the normal biomechan-
ical functioning of the spine often is overlooked. Be-
cause the feet are seldom symptomatic, clinicians fre-
quently overlook examining and, consequently, treat-
ing them. Often times, it is only when a patient does
not respond to the initial care that the physician be-
gins to look for interference from the pedal foundation.
Faulty foot biomechanics can have a negative impact
on all supporting joints above the foot/ankle complex,
including the low back region [8]. An abnormal gait
eventually will interfere with these important spinal
segmental movements. This can lead to serial postural
distortions, muscular imbalances, and spinal joint dys-
function, along with the previously discussed causes of
low back pain [9].
The link between podiatric deviations and nonspecif-
ic low back pain has been established in previous stud-
ies [8,10–18]. However, several studies lacked con-
sistency and availability of recommendations for treat-
ment of low back pain [10,13]. Interventions for as-
sisting low back pain and podiatric deviations include
a wide variety of activities that range from orthotic
prescription to massage and acupuncture [17,18]. De-
spite research linking LBP and lower extremity dys-
function through biomechanical evaluation, the identi-
fication of the mechanism of injury of low back pain
has proven to be difficult for both medical practitioners
and their patients [19]. This is partly due to the con-
voluted classification of the injury, as many patients
complain of pain in the lumbrosacral region, with most
of these complaints end up being characterized as low
back pain [20]. If no conventional deformity or injury
is noted upon initial examination, the foot and ankle
could be a possible region to investigate under further
review.
The primary objective of this study was to review
the relevant literature pertaining to the effects of flat
feet, excessive pronation, leg length discrepancy, sagit-
tal plane blockage, and ankle instability on low back
pain. In addition, this review hopes to provide a pos-
sible explanation for low back pain using a previous-
ly unstudied kinetic dysfunction association between
the foot/ankle region and the low back. By examin-
ing the kinetic chain from the ankle and foot up to the
back, better low back pain classification and treatment
could be utilized by clinicians faced with nonspecific
low back pain.
2. Methods
A comprehensive search of literature was con-
ducted and the following databases were reviewed:
MEDLINE, PubMed, SPORTDiscus, Google Scholar,
Worldcat Libraries. Key words such as ‘lower back
pain, orthotics, excessive pronation, podiatric devia-
tions, hallux, kinetic chain, link theory, ankle instabil-
ity, ankle dorsiflexion, pelvic tilts and pes planus’ as
well as combinations of the above words. The elec-
tronic search was supplemented by a manual search of
reference lists of collected articles and previous review
articles to identify of potential interest. Only those pa-
pers that reported podiatrical deviations and low back
pain were included. Those not published in English or
without full text were excluded.
3. Results
After manual screening, a total of 19 papers were
deemed relevant to the topic and met the inclusion cri-
teria. The major outcomes examined were excessive
pronation, limb discrepancies, pelvic tilts, ankle insta-
bility, pes planus, and hallux valgus. Multiple stud-
ies [15,22] have found significantly higher rates of
pes planus in people with LBP compared to controls
(no LBP). Abnormal or excessive pronation has been
shown to lead to leg length discrepancies and subse-
quently pelvic tilts, causing low back pain [12,24]. Re-
gardless of foot type, those with either anatomical or
functional leg length discrepancy generally have some
type of lumbosacral or pelvic imbalance, leading to
LBP [24]. Similarly to leg length discrepancy, sagittal
plane blockage at the ankle and hallux has been im-
plicated as a possible cause of chronic mechanical low
back pain due to postural imbalance [27]. Interesting-
 C.B. O’Leary et al. / A systematic review: The effects of podiatrical deviations on nonspecific chronic low back pain 119

Table 1
Description of podiatrical deviations
Podiatrical deviations Clinical definition
Flat feet (pes planus) A condition in which the foot does not have a normal arch when standing. Flat feet can lead to excessive pronation
but the two conditions can also be mutually exclusive, as some people that exhibit flat feet never develop excessive
pronation and actually have a neutral or underpronating gait.
Excessive pronation A condition characterized by chronically developed pain during gait due to an excessive rolling inward of the
foot and wearing unsupportive footwear.
Leg length discrepancy A condition in which the legs are noticeably unequal after examination.
Sagittal plane blockage A condition where the first metatarso-phalangeal joint motion is impaired.
Ankle instability A condition characterized by a recurring “giving way” of the outer (lateral) side of the ankle that often develops
after repeated ankle sprains.

ly enough, individuals with functional ankle instabil-
ity had a more delayed time to stabilization and are
more likely to develop LBP than individuals without
functional ankle instability [11,12]. All of these podi-
atrical deviations are important physical characteristics
thought to be relevant to low back pain.
4. Discussion
The foot is the foundation of the human body, as it
is the first part of the body that contacts the ground
during gait. When no evident podiatrical deviations are
present, the foot provides limb stability at midstance
because the entire plantar surface of the foot contacts
the ground in a normal fashion, flowing from heel to
forefoot [12].
4.1. Flat feet
Pes planus, or flat feet, is characterized by a col-
lapsed arch of the foot, with the entire sole of the foot
coming into or near contact with the ground at all times.
Pes planus is found both bilaterally and unilaterally and
is common in young children but not as widespread
in adult populations [21]. Multiple studies have found
significantly higher rates of pes planus in people with
LBP compared to controls [15,22]. Koshavili et al. [15]
examined the prevalence of pes planus in military re-
cruits and evaluated its association to low back pain.
The researchers screened 97,279 recruits and catego-
rized them as having none (control), mild, moderate, or
severe pes planus based on the position and flexibility
of the arch. The researchers found a significant preva-
lence of low back pain (p < 0.0001) in the moderate
and severe pes planus group (10% occurrence) when
compared to the control and mild group (5%). This
increased prevalence of back pain could be due to the
longitudinal flattening and the rigidity of the arch, as
the foot cannot correctly disperse the force of landing,
which transmits the force up to the back, causing pain
and dysfunction. While this was a retrospective study
and pes planus was not identified by radiographic tech-
niques, moderate to severe pes planus does seem to
have an effect on the occurrence of low back pain.
However, there is conflicting evidence concerning
the role of pes planus and low back pain. Brantingham
et al. [23] found flatfeet did not appear to be a risk fac-
tor in subjects with low back pain. The authors initially
postulated that low back pain could be caused by abnor-
mal navicular drop and calcaneal eversion, especially
if the condition was unilateral. While there were no
significant differences for any measured characteristic
between people with and without LBP, the degree of
pelvic tilt was not measured, which could be caused
by these abnormalities and lead to LBP overtime. Fur-
ther studies, using randomized controlled trial (RCT)
study designs, are needed to confirm the effect of pes
planus on low back pain, as conflicting results have
been reported using mostly retroactive study designs.
4.2. Excessive pronation
Pronation occurs during the walking cycle when a
person’s foot collapses upon weight bearing. Prona-
tion has two important effects on gait as it: 1) acts
as both a directional torque transmitter, absorbing the
axial rotation of the leg and 2) prepares the body to
react against the contact [12]. Both properties reduce
the shock absorbed by the foot and allow the foot to
adjust to uneven surfaces. However, over or excessive
pronation can lead to stress and inflammation in the
foot and ankle region, along with a myriad of other
musculoskeletal and neurological problems. Excessive
pronation can be due to structural weakness within the
foot or ankle and leads the body to have an unstable
foundation [12].
In a study examining 97 people with low back pain,
there was evidence of excessive pronation in 95 subjects
(95%), with 70 of these subjects exhibiting excessive
120 C.B. O’Leary et al. / A systematic review: The effects of podiatrical deviations on nonspecific chronic low back pain
pronation on the same side as the low back pain [12].
The authors proposed that excessive pronation caused
either a leg length discrepancy or a static pelvic tilt
based on the faulty biomechanics the body had to over-
come. The spine must account for these faulty foot
biomechanics and leg discrepancies through lateral de-
viation of the spinal column and rotation of the verte-
bral bodies, causing a functional lumbar scoliosis and
LBP. Botte [24] 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 [14] hypothesized that toeing
out results in subtalar joint pronation and excessive hip
lateral rotation, leading to LBP due to sacroiliac (SI)
joint dysfunction. Botte [24] suggested that unilateral
foot pronation produce 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 causing lower body kinetic dysfunction.
Khamis and Yizhar [25] investigated the role of ex-
cessive pronation on the alignment of the leg and hip
by having participants stand on wedges that simulat-
ed 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 [26]. Both
the lower leg and thigh were also found to be internal-
ly 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 [26] participants did not
suffer from LBP, a change in the leg and thigh or pelvic
alignment could have serious consequences on the low
back overtime, as excessive pronators consistent put
their backs in a compromised position.
Yet, the role of excessive pronation on low back pain
has not been confirmed. Rothbart and Estabrook [12]
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 [14]
only based the conclusions on a specific case study
looking at the effects of excessive pronation and LBP.
Further modern research utilizing a randomized control
study design and a significant number of participants
with and without LBP is needed to find if there is a
relationship between excessive pronation and low back
pain. The cause and effect relationship also needs to
be examined, as low back pain could be the cause of
excessive pronation.
4.3. Leg length discrepancy
Leg length discrepancy (LLD) and pelvic tilt are
both characteristics of pronation syndrome, as exces-
sive pronation has been found to lead to leg limb dis-
crepancies [12]. When LLD is present, the spine at-
tempts to reestablish balance in the body as well as
maintain efficient posture, creating functional scolio-
sis. This correcting of the spine to maintain the center
of gravity causes extra strain on muscles and ligaments
in the back or sacroiliac joint that are not meant for
posture or support, leading to chronic LBP [24].
Leg length discrepancies can be classified in two
ways; a true anatomical leg length discrepancy (ALLD)
or a functional leg length discrepancy (FLLD). ALLD
includes cases where one leg is truly anatomically
longer than the other, while FLLD includes cases in
which the pelvis has tilted, creating a functional differ-
ence in leg length in both posture and gait. Function-
al leg length discrepancy has a close relationship with
excessive pronation, as excessive pronation can cause
FLLD. When a foot is excessively pronated, the in-
ner longitudinal arch of the foot drops to provide more
support and creates a shorter leg. If the pronation is
asymmetric, FLLD and a pelvic tilt can occur. FLLD
can be further sub-categorized into static and dynamic
pelvic tilts; static being that the tilt is consistent on one
side, and dynamic being that the tilt changes from side
to side. Research suggests that a dynamic pelvic tilt
does not contribute to LBP, but that a static pelvic tilt
may be a primary cause of LBP. Static pelvic tilts and
asymmetrical excessive pronators have a correlation of
0.97 [12]. Regardless of foot type, those with either
anatomical or functional LLD generally have some time
of lumbosacral or pelvic imbalance [24]. The pelvic gir-
dle is the anatomical connection between lower limbs
and upper quadrants of the body. By understanding the
connections between the feet, lower limbs, and pelvis,
one can begin to treat and cure lower back pain.
4.4. Sagittal plane blockage
The sagittal plane facilitation of the foot focuses on
the ability of the sagittal plane rockers, particularly
the first metatarsophalangeal joint (MTPJ), to function
efficiently during gait. If sagittal plane motion about
these rockers is impeded during gait, this is defined
 C.B. O’Leary et al. / A systematic review: The effects of podiatrical deviations on nonspecific chronic low back pain
as a sagittal plane blockage, and compensations within
other segments of the body are predicted to occur [17].
One of the few studies looking into sagittal plane block-
age (SPB) relating to lower back pain proposes that hip
extension allows a normal stride, and therefore, an effi-
cient and erect gait, which can be restricted by podiatri-
cal deviations [27]. Functional hallux limitus and ankle
equinus are two examples of pathology that can restrict
foot movement and results in what he terms a sagittal
plane blockade, kinetically inhibiting hip extension and
a normal stride. Ankle equinus is stated to be the in-
ability to dorsiflex to 100, and functional hallux limitus
is defined as a first MTPJ that structurally has a normal
range of motion but is unable to dorsiflex adequately at
the appropriate time in gait [28]. Dananberg [27] has
mostly related sagittal plane facilitation theory to more
proximal posture-related problems, such as lower-back
pain.
Sagittal plane blockage at the ankle and hallux has
been implicated as a possible cause of chronic mechan-
ical low back pain. An extensive search of the litera-
ture, however, failed to show any studies that showed
the incidence or prevalence of SPB in a normal healthy
group of subjects compared to patients with low back
pain, so this needs to be addressed. Although no direct
association could be made between chronic mechanical
low back pain and sagittal plane blockage, the slightly
higher occurrence of SPB in both the ankle and hallux
in individuals with chronic mechanical low back pain
deserves further investigation [23].
4.5. Ankle instability
Ankle instability is characterized by three causes:
mechanical instability, functional instability, or both.
Mechanical ankle instability (MAI) occurs because of
anatomical changes that arise post injury, such as patho-
logical laxity, synovial changes, and development of
degenerative joint disease. Functional ankle instabil-
ity (FAI) is related to the neuromuscular control of
the ankle and is characterized by impaired joint kines-
thesia and altered muscle recruitment patterns. Ankle
instability may predispose individuals to developing
LBP [10–12].
Marshall et al. [11] investigated the link between
FAI and trunk instability through assessing the time to
stabilization (TTS) response to sudden balance distur-
bance. TTS is an assessment measure of lower limb
function and FAI. Trunk instability has also been asso-
ciated with LBP [11]. Investigators screened 24 indi-
viduals, 12 with FAI and 12 without FAI. Researchers
121
found support for the use of TTS as a predictive mea-
sure for individuals with and without FAI. Individuals
with FAI had a more delayed TTS and are more likely
to develop LBP than individuals without FAI. Rothbart
and Estabrook [12] also identified the correlation be-
tween moderate-to-severe lateral ankle instability with
LBP in 63 of 75 participants.
In a prospective study, Nadler et al. [10] examined
the incidence of LBP in college athletes with leg length
discrepancy, hip flexor tightness, and lower extremity
acquired laxity or overuse. The researchers followed
257 college athletes representing seven male and seven
female varsity sports. Throughout the following year,
participants were observed for non-contact LBP requir-
ing treatment by athletic training staff. 57 athletes were
found to have acquired lower extremity ligamentous
laxity or overuse; 14 developed low back pain (p <
0.001). Nadler et al. [10] suggests that these findings
support the kinetic chain or link theory – abnormal
forces distally are transmitted more proximally and dis-
tally – as a credible cause of injury occurrence.
However, Fairbank et al. [13] found from a study
of 446 adolescents, 115 experienced LBP. 14 students
(12%) required to take time off from school and 28
(24%) stopped playing sports because of the severity
of back pain. Seventy-two had significantly less (p <
0.002) right and left tibial rotation than those with-
out LBP. Because of these conflicting results, more re-
search is needed to solidify the causative measures of
ligament laxity on LBP.
4.6. Treatment
The most common treatment for foot discrepancies
leading to LBP is corrective footwear such as orthotics.
The functional goal of this corrective footwear is to
firstly provide a cushion that absorbs shock transmis-
sion to the lower limbs, and secondly, to compensate
for biomechanical deficiencies. Most commonly cited
deficiencies include excessive pronation and leg-length
discrepancy [29]. Bird et al. showed that foot wedging
during the gait cycle can produce measurable changes
in the timing of muscle activity within the lower back
and pelvis in subjects with excessive pronation, but
suggested that further investigation is required to deter-
mine whether the changes in muscle activity contributes
to LBP [17]. Rothbart and Estabrook suggest that ex-
cessive pronation shortens the limb and leads to pelvis
miss-alignment [12]. Treatment for this is based on
controlling the pronation using orthotics can improve
SI alignment and LBP. The authors also noted that a
122 C.B. O’Leary et al. / A systematic review: The effects of podiatrical deviations on nonspecific chronic low back pain
correlation factor of 0.77 was noted between a decrease
in lower back pain and the use of orthotics. It has also
been suggested that subjects with LBP using orthoses
experienced more than twice the reduction in pain for
at least twice as long when compared to subjects with
LBP using traditional back-pain treatment [18].
Joint mobilization and manual therapy is a common
treatment for acute LBP, however, is less commonly
used in chronic LBP. However, when compared to ex-
ercise and strength training for LBP, manual therapy
produced significantly larger reductions in pain, as well
as significantly better results in function, general health
and range of motion [30]. The authors suggest that this
difference could be due to the specificity of manual
therapy. In exercise, it is more difficult to target one
specific muscle or joint that is causing problems, and
instead one tends to exercise the lower back as a whole.
In manual therapy, it is possible to target one specific
area, muscle or joint that may be causing imbalance or
pain in the patient.
Massage, acupuncture and self-care have also been
prescribed for LBP treatment, however, these modal-
ities don’t treat the cause of the pain, only the symp-
toms. Massage has been found to be more effective
than both self-care and acupuncture, and is both more
affordable and uses fewer medications than the other
two groups [31].
From these treatment modalities, it can be inferred
that treatments for LBP need to focus on the etiology
of the condition, stemming from excessive pronation
to leg length discrepancy to pelvic tilts, as opposed to
symptomatic treatments that focus on the indications of
the condition. If one can functionally treat the underly-
ing pathology, the need for symptomatic treatments will
be eradicated. For further information about treatment
options for LBP see review [32].
5. Conclusions
There is little evidence regarding podiatrical devia-
tions and their connection to low back pain. The results
of this review indicate that a change in gait and leg
length due to podiatrical deviations could potentially
lead to low back pain due to a change in pelvic align-
ment. The research in this field is far from complete; it
can be inferred from this review that deviations in the
ankle and foot have an impact on the lower back and are
a potential cause for chronic LBP. However, the cause
and effect relationship between the deviations and LBP
comes into play, as most of the studies reviewed did
not examine if the subjects were compensating for their
low back pain by changing their gait and podiatrical
characteristics to try and reduce their pain. Also, there
have been no RCTs looking specifically at any of these
podiatrical characteristics and LBP. Further RCTs need
to be done examining the cause and effect relationship
and to find the specific deviations that cause low back
pain.
If these future studies find a statistically relationship
between podiatrical deviations and low back pain, fu-
ture research should examine the treatment options in
the foot region that significantly decrease the symp-
toms of low back pain. Future studies focusing on inex-
pensive treatment options would be relevant to a large
range of people, considering the prevalence of low back
pain in the general population. Other regions distal to
the low back besides the ankle and foot, such as the
shoulder, neck, or arm, should also be examined to see
if similar deviations in these regions cause low back
pain. In general, whole body kinetic chain dysfunctions
are a relatively unstudied field, but future research has
potential to find causes for unexplained injuries that
have previously confounded the scientific and clinical
communities.
Ethical statement
The authors declare that they have observed and ad-
hered to the ethical principles normally practiced in the
field of medical science in the acquisition, interpreta-
tion, 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.
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