Case Study: Not Every Back Pain Starts in the Spine — Chronic Lower Back Pain Secondary to Charcot Foot

Background

Chronic lower back pain is one of the most common reasons patients seek musculoskeletal care. While many cases originate from the lumbar spine itself, clinicians should remember that abnormalities affecting the lower limbs can significantly alter gait mechanics and contribute to persistent spinal symptoms.

This observational case demonstrates how careful observation and thorough history-taking identified an underlying diabetic foot deformity that had become the primary biomechanical contributor to chronic lower back pain.

Patient Presentation

A 62-year-old woman presented with a two-year history of persistent lower back pain.

She described the pain as aching, pulling, and occasionally sharp, predominantly affecting the left side of her lower back. Interestingly, she explained that although the pain occasionally spread, it tended to travel upwards along the back rather than radiating down the leg.

Despite receiving previous treatment elsewhere, the symptoms had remained persistent with little long-term improvement.

The patient attended the clinic hoping to understand why the pain never completely resolved.

Initial Clinical Observation

Before the physical examination even began, several important observations were made.

The patient entered the consultation room wearing her socks and appeared reluctant to remove them.

More importantly, during walking assessment she demonstrated a pronounced limp with obvious asymmetrical weight-bearing.

Observation of gait is often one of the most valuable parts of a musculoskeletal examination. An abnormal walking pattern frequently indicates that the source of the patient's pain may not be confined to the spine alone.

Rather than focusing exclusively on the lumbar region, attention was directed toward identifying the reason for her altered gait.

Initial Examination

Lumbar examination demonstrated findings consistent with chronic mechanical lower back dysfunction.

Conservative chiropractic care was provided using spinal mobilisation together with a carefully selected Grade V high-velocity, low-amplitude (HVLA) manipulation where clinically appropriate to improve spinal mobility and reduce muscular guarding.

Although treatment addressed the mechanical restriction within the lumbar spine, the patient's abnormal walking pattern suggested that another primary problem was likely maintaining the persistent symptoms.

Further questioning therefore focused on possible causes of the limp.

Further History

The patient was asked whether she had a long-standing history of diabetes.

After further discussion, she disclosed that her diabetes had previously been poorly controlled for several years.

She explained that numbness and tingling had gradually developed in one foot. As time progressed, walking became increasingly difficult. The foot became painful during weight-bearing, wearing shoes became uncomfortable, and she gradually noticed the shape of the foot changing.

Based on the patient's gait pattern, long-standing diabetes, progressive sensory symptoms, and visible foot deformity, the possibility of Charcot foot (diabetic neuropathic osteoarthropathy) was discussed as part of the clinical differential diagnosis.

Only after this discussion did the patient acknowledge that she had previously been diagnosed with Charcot foot but had not disclosed this earlier during the consultation.

Foot Examination

Following this disclosure, the foot was examined in greater detail.

Clinical examination demonstrated significant structural deformity.

The plantar aspect of the foot had developed a rounded "rocker-bottom" appearance consistent with collapse of the normal midfoot architecture.

The arch had progressively collapsed, the foot had become wider, and weight-bearing mechanics were clearly altered.

Because of the deformity, the patient had developed a chronic compensatory gait pattern, placing abnormal mechanical stress throughout the lower kinetic chain.

Clinical Reasoning

Although the patient's primary complaint was lower back pain, the lumbar spine itself did not appear to be the principal source maintaining the chronic symptoms.

Instead, the long-standing alteration in gait caused by the Charcot foot had likely resulted in persistent asymmetrical loading of the ankles, knees, hips, pelvis, and lumbar spine.

Walking is one of the body's most repetitive activities. Even relatively small abnormalities in gait become magnified over thousands of steps each day.

Over time, this abnormal loading may contribute to muscular fatigue, altered joint mechanics, compensatory movement patterns, and persistent mechanical lower back pain.

The patient's limp therefore appeared to represent a major biomechanical contributor to her chronic lumbar symptoms.

Management

The patient was informed that conservative chiropractic care could help improve spinal mobility, reduce muscular tension, and relieve secondary mechanical lower back symptoms.

However, she was also advised that complete resolution of the lumbar pain was unlikely unless the primary biomechanical problem affecting her gait was also addressed.

The relationship between diabetic neuropathy, Charcot foot, altered gait mechanics, and chronic lumbar loading was explained in detail.

The importance of maintaining good diabetic control was reinforced to reduce the risk of further progression.

The patient was also informed that reconstructive foot surgery may be considered in selected patients with Charcot deformity once diabetes is adequately controlled.

Information regarding an orthopaedic foot and ankle surgeon experienced in Charcot reconstruction was provided should she wish to obtain a specialist opinion regarding reconstructive options.

Why Gait Matters

Pain is not always generated where it is felt.

Altered gait changes how forces are transmitted through the entire musculoskeletal system.

When one foot no longer functions normally, the opposite limb, pelvis, and lumbar spine often compensate with every step.

Over months and years, these compensatory patterns may become a significant contributor to persistent spinal pain.

For this reason, clinicians should always assess the entire kinetic chain rather than focusing solely on the location of pain.

Clinical Reflection

This case serves as an important reminder that careful observation often begins before formal examination.

The patient's limp and reluctance to remove her footwear provided valuable clinical clues that directed the remainder of the consultation.

Rather than treating the lumbar spine in isolation, recognising the influence of diabetic Charcot foot on gait mechanics allowed the patient's symptoms to be understood within a broader biomechanical context.

It also allowed realistic expectations to be established.

Conservative care could help manage the secondary lumbar symptoms, but the underlying biomechanical driver remained the foot deformity.

Key Clinical Lessons

• Chronic lower back pain does not always originate from the lumbar spine.

• Observation of gait should form part of every comprehensive musculoskeletal assessment.

• Long-standing diabetic Charcot foot may significantly alter walking mechanics and contribute to chronic spinal loading.

• Thorough history-taking often uncovers important medical conditions that patients may not initially disclose.

• Addressing only the site of pain without identifying the primary biomechanical cause may limit long-term outcomes.

• Successful management combines symptom relief, patient education, realistic expectations, and appropriate specialist referral when indicated.

Important Disclaimer

This anonymised observational case is presented for educational purposes only.

The findings described represent one patient's clinical presentation and should not be interpreted as suggesting that all chronic lower back pain is caused by gait abnormalities or Charcot foot.

Charcot foot is a serious complication of diabetic peripheral neuropathy requiring ongoing medical management. Patients experiencing progressive foot deformity, loss of protective sensation, ulcers, or persistent foot pain should seek assessment from an appropriately qualified healthcare professional.

This article is intended for educational purposes only and should not replace individual medical advice, diagnosis, or treatment.