Documente Academic
Documente Profesional
Documente Cultură
Thoru.as
C. Micha.ud
FOOTORTHOSES
andOtherFormsof Conservative
FootCare
t39(95S9?
1?ta56789tb
transferof calcanealeversionto inrcrnsl tibial rotation r€centlydemonstrated lhal weiShFbearin8 measurements of
increasesas arch height increases. This explainswhy foot ilignment and motion lrg essierto pcrform and providc
individuals with cavusfe€rso oftenpresentwirh kneeand moft.consistent dataIhsnoff-wei8ht-b$tingmeasuremcn$
hip pmblems.Along rhissane tin. of rcserrch,Sommer€r (15). For example,vaious reseatchers hale folrnd hiSh
al. (ll) demonstraredlhar sectioninSrhc lar€ral ankle levelsof interralerreliabilityfor lhe standiogsubtaldjoint
ligamenlsincreascdthc transf€rof calcanealev€rsionto n€utralposition(15),standingfooranelc(16),naviculerdroP
iotcrnll tibial rotationwhile cutting the d€ltoid ligamenr tcst (t5), medialialonaviculaibulge(l?), slaiic calcaneal
decreased th€ transllr of thesemotions. slanccposition(15)andtherearfoot-lowerle! anglePresenl
Altboughthe observationby Nigg e! al. (4) fial rhe durirrgsirgle leg stance(18). (This hst angleis impodant
sublalarjoint supioatesbeyondneutralis consistenrwith as ir measures the maximumdcgleeof rcatloo(evcrsion
another3-D evaluation(5), ir is ai odds with a 3-D sludy availablcduringwalking[2].)
demonstratingcontinued sublalsr pronation $roughoul Il should bc slress€dlhat off-weight-bearing
prop!lsion (12). More receorly,Sicgel er al. (13) m€asuren€nts shouldnot be abandoned as Diamonder d.
incorporated a newmethodof3-Devaluationandfoundthat (19),i€monsirat€dftat erperiffc€d practitionerswcre ablelo
thepositiontherearfootassumes duringstanceis dependenr obiain acccptable tevels of interrater rcliabilily for
uponthe individual'sfoortype: the uncompensated rearfoot dcte.miningthe off-weight-beoringneulralsubtalarjoint
varusfoot typeslrikeswhh the hecl invcnedandprorates positionwhile Snilh'Oricchioand Harris (18) found
slightlyto an uliSnedrearfool-lowerlc8 posilionand then tnoderrtclevelsof interralerrcliabililyfor thai lnglc. Morc
supinates ap oximalely5 de8reesduringpropulsion.This rccently,Sommerand Vallentym (16)dcmonslratedthal
is in conrast 10ihe hypermobileprooatedfoot thal makes qoalitativemeasurcments of the off-wcighl-bearing neutral
ground conlact with the rearfool-lowerlcg aligned and subt.rtar poshionhadan a4ceplable intenatcrreliability(with
pronatesexcessivclydu.ing contact and midstance. subrilar vanim bcing associatedwilh a past hislory of
AlthouBh this [ool lype begins supinatingduring medraltibial slrcsssyndrome)while Astromand Arvidson
propulsion,it is unlblc ro gerto a point within 5 degree$ of (19)demonshtcd$ar anexp€rienced cramincris capableof
raking exremely rcliableoff-weigh!-beaing measurcments
The srudyby Siegeler al. (13)ernphsi?esthe needtor (i.e..ICC averaging.91).
qualily3-D evaluadons in whichindividualsarecalegorizEd Th's is not to say that cll off-weight-beating
by osseorsaligrmenlpariemsin the lowerexlremity(e.9.. mcasuremenr arevalidass€veralstudies havedemonslmted
rcarfoot varus,errcmal ribial rorsion.clc.) andth€ Bngcs of thar both expcrienccd and inerperienced practitionersare
moliooavailableto specificjoints(panicularlytftefirsl ray, unal.le to accurat€ly reprodoce off-weiShl_bearing
talonavicular andsubtalar joinb). measuremeors of subtalarinversion/cvcrsion (18,20.21)
It shouldbe emphasizedthat decisionsconcerninA B.ciuse of !his. thcscmeasuremenls shouldb€ avoid€d.
o horic fabricalion should not be basedupon osseous (Besides, Lananzaetal. [23] conclusively demon$atedftat
alignmentof the foot alone. This infbrmationshouldbe offnveight-bearing mcasurcmenls of sublalarmotiondo nol
coupl€dwirh a complctestructuralcvaluationlhat includes refleclranges availablcduring\teiSht-bcaring.)
assessm€nr of bony .ligt|menl. strcng$. flexibility and In defenscoflhescmeasur€ments. Garbalosa €t ai. (23)
ioint mngesofmorion prcs€nl alongthecntiie kineric chain. found €xlremclyhiSh levels of inlera|er reliabilily when
The overprescriptionof onhotics bas€dupon a limilcd €valuating off-weiSht-bearingranges of subtalar
evaluation of subtalarandtorefoolalignmenthasledMcPoil inversion/eversion.Unfonunately,unlike ihe previously
and Hunl (14)to dcvclop a soff tissuestrcssmodel"as a mentioned studics(18,20. 2t). Carbaloso ct al. (23) did not
b$is for evaluationard lreatmentof foot injuries. ln thi$ erasrithelowerlegandrearfootbisection lincs usedbelween
model. a management scheme is dclclopcd to identify lhe reDfll measurcmenb. Because of this. their conclusions
specifictissucb.in8 srrcssed, evaluatcfaclorscontribuling rcgrrdingintenaterreliabilittmuslb€considered intali.l
to the injury and, if symptoms arc the result of a The final rooic lo be discussedrclatcsto the actual
biomechanicalproblcm. iniiiate a $€atmcnlthal emphasizes Drc\ enceof lhc f;rcfmt vatls deformily. DcPendinglPon
d€creasingtissueslrcss. This may be accomplishedby ihe thc perccntageof lhe PoPuladonpossessing$is
'ource,
activiry modificariot|. using sofi lissue techniquest{l foor type rangesfrom 8 to 8? p€rccnt This disparityis
enhanceflcxibilily, modalidesto accelcrateherling and impimant as inappropriatetreatmcnl of a neutral forcfool
ex€rcisesto improvestrengthand endlrancc. Excessive wiih a forefootvaruspostmay leadto,iatrogenicinjury of
pronalion. whcn present, may be controlled via lhe lirst melalarsophalangeal joinl as it couldlimit first rny
modificationsin shoegear,stock arch supports.paste-in plantarflcxionduring propulsion(seefigurc 2.20 on paSe
rcchniquesand, if necessary. a funclionalonhodc. The 3?).
authorsemphasizethat "foot onhos€sshould be s small paa As meotioncdiD lhis t€xt,lhc pridaty reasonsfor lhe
of lhe treatment plan rather lhan the entire €mphasis of overreponing of forcfoot vtrus deformitiesare lhe Ailur€ to
lrearrhenf(14). idcnrifv frnctional forefoot varus deformities (e.g' a
Perhapsthe mos! inlensively sludied subjecl fun,:tionatly dorsiflexed first ray is often mistakenly
conc€rninglower exremity biomechanicsrelates$ thc identifiedas a forefootvarusdefornrity)andlhe continued
repmducibililyof voriousmeasuring techniques. Il hasbeen rctilnce on the outdatedmelhodof de(erminingsubtalar
ity by measuring off-wcight-bcaring cridcallyevaluaringmanyof thc currentlyacccptedb€lief!
noSes(24). thd improvedmclhodsof cvaluarionand treatmcntwill
akEdy discussed,thc.sc m€asunrncntsarc cxtrcmely come to light.
rnd, cven if they wcrc valid. thc ideal
on ralio of 2:l as dcscribedby Root et al.
occuls.Forexampl€,in a rcccntstodycvaluating
irvcrsion/eversionrarios as comparcdto the REFERENCES
stbldrr ncotrelpositior, Astromand Arvidson (19)
lhe ratiocloser to 2,8 to l. In perhapsthe mosl l) McPoilT, Cornwall,MW. Relationship b€twecnneutral
cdsltdy evaluadngthe reladonship betwcc. subtalar subarkrjoint posilio,land the prttern.of rcadoot motion
of modonand the palparcdneulralpositioo. Bailey ct during walking. Foot Ankle lnr 1994;15(3): l4l-145.
ascd tomogramsto cvahatc lines patallcl to the
pltfold snd the supcrior asp€ctof the calcancuswhilc 2) McPoil T, ComwallMW. Relatiooship bclwcenthree
ar joinl was mainlaincdin neutral and when static anglesof the rearfootand $e pattcrn of rcarfoot
invcncdandevencd. Thescrcscarchers concluded motiondurin8 walkinS. t OrthopSponsPhysThcr 1996;
on everage,subtalarneuralily occured lvhcn 23(6)137G375.
wasinvertcd36.2 Frccnl from thc marimally
position,individuslvariationallowedfor a neutrsl 3) Weed JH, Ratliff FD. RossSA- Bipl.nar grind for
|al posrlton
posirionwrlh
sith invcFron/cvcrsron
invcrsion/cvcrsionntios
ratios fan&ng
ranging rearfool postson functional onhoses, J Am Podiatr Assoc
l9l to l:2.3. Becauscvcry fcw pcople wcrc clos€ ro 1978;69(l): 35.
2:l rado,Bailcyct al. (25) concludedrhatrhe
ofmotionmelhodfor delerniningsubblar ncuFaliry 4) Nigg, BM, Colc CK, NachbouerW. Effrcrs of arch
heigh! of the foor on angular motion of the lower
lll this aside.anotherre{son lo abandootbe 2:l cxlremilicsin running. J Biorncchanics
1993i 26(8):909'
ratio is that, as rcccntly dcmonslElrd by Nigg er 9t6_
invcrsion/eversion ratios vrry b€rwccnmen snd
rnd changeover time. In fact, thc ranScof cversion 5) ArebladM, Nigg BM, Ekstand,t, Olssont, Ekst om H.
waspardcularly sensitivcro chanBeswith ageas ThaEedimensionalma{surcmantsof redfoot motion during
orncn(ages2G39) av.r6A€d17.2dcgr€€sof cvcrsion runDing. J Biomechmics1990;23(9): 933-940.
thcoldcrgmup(sgcs7G?9) avengci ll.4 d€gr!a!.
6) Soutas-LitrlcRW, BeavisCC, VcrstaateMC, Markus,
ro say,suchvariarionwill significanrlycffcct th€ TL. Analysisof foot motionduringnnning usinga joinl
novcmcntmtio and,as such.thistechniqueshould coordinslc syslcm. Mcd Sci Sporu Ex€rcisc I987i l9(3)i
28s-293.
In closing,akhoughthe numbcrof quality scisnrific
i5 relalcdto lowerextrcmitybiomcchanics is lapidly 7) Kitaola HB, LoncnbergA, Ping Luo Z, An KN.
it is clerr thrt there is still mlch to learn. Kinemalics of thr no.mal lrch of lhe foot and rnlle under
srudics.
in addition!o idendrying
themostsccur.te physioloSicloadin8. Fooi Anklc lnt l99si 16(8):492-499.
mcthodsfor cvalultiDg shenkrotationduring s|ance
will hopefullyresolvcthe conrovcrsysumoundinS 8) o'Malley MJ, DelsndJT, L€e KT. Sclcctivehindfoot
castingtcchniqu.s by evaluedngthe diffffcnccs, if arih.od.sis for lhc trcatmcnlof adult acquircdflatfoot
in paticnl sarisfaclio[, ability to conrrol motion dcfomity: an in vitrc srudy. Foot Anklc Ini 1995i 16(?):
talonavicular)andretumntcs for odholics made 4 411.
off-, 6cmi-,and foll-wcight-bcaring imprcssions,
importantp.oject would be to pcrform 3-D 9) M6nnRA. Flatfoorin aduhs.In: Sur8cryofthe Foot
of variousfoot rypesto dcrcrminehow rnicular endAnkl., Ed 2. MannRA. CouShlinM (cds.),Sl. Louis:
may bc modified with differcnt folms of Plerun. 1992:75?-?84.
ive carcle.9..onhotics.srcngtheninScxcrcises.
gait modifications,etc, ll would llso be l0) HicksJH. Thc mcchanicsof rhe foot II. The plantar
to caGgorizc! large numbcr of high school or andthearch. , Anaromy1954188:23-31.
aponcorosis
rthletesaccordingto osseousrligrmenl and ranSeof
andthcnfollow rhcmfor severalyearsro dctcrmine ll) SommcrC. HintermarB, Nigg BM, vaoderBogrnA.
alignmenrpattcrnsare associat€d with specific Influenccof anlle ligamenrson tibial rotarion: an in viuo
(i.c.,Do the"clalsicsignsandsympbms"dcscribed srudy. FootAnUe Int 1996il?(2): 79-84.
texl for cachfoot lypc actually occur?). This sludy
dso bc pcrformcdwhh somc individualsreceiving 12) EnSsbcrSJR, AndrewsJG. Kin€maticadalysisof thc
tic onholic intervenrionin ordcr to evalurtetnc .ioint during running. Mcd Sci
talocalcancal/lalocrural
of orthotics
in prcvcnting
injuries.tt is only by SporfsExcrcise198?i l9l3\: 215-284.
vii
13) Sieg.l KL, Kepple TM. O'Corrcll PG. ccrbcr LH, 26) Nigg_BY,FisherV. A inperTL. Ronsk'JR,
.
Stanhop€SJ. A lcchoiquelo evaluarefool functionduring Fngsb€rgJR: Range ofmorionofdre fmr asa funcrion
of
stancephaseof gait. FootAnkle lit !995;16(12)764-770. age.FootAnklel92j 13: 336-343.
'Addendum
Quadriceps
Popliteus 53
TibialisAnterior,Extcnsor
HallucisLortgls,Exlensor
Digitorum
l,ongus,andPeronelsTertius 54
TibialisPosterior,
FlexorDigltorumLongrls,andFlexorHallucjsLongus 54
Gastrocnemius andSoleus 54
Peroneus I-ongusand Brevis 55
AbductorandAdducto.Hallucis 55
FlexorHauucisBrevisandFlexorDigitonLm Brevis
InterosseiandthcLumbricales 55
CastingTechniques 193
FULL-W!$Ir-BEAR|No
Pol,ysrttENBFoAMS]rEPIN 193
M€thod r93
Rationale 193
Discussion 193
Nnu.rrALPoslrtoNS&Ml-WEr(rlir-BEAfl
NoPoLysryRENE
FoA[rSTip-tN 194
Mothod 194
Rationale 194
Disclrssion 194
NEUTRAL PosmoNOsF-WelGm-BEArrNG
PUSTER
Casrs 195
Method 195
Ratiodale 191
Discussion 199
HANoTEo eu6 PIA$ERCAsr 19D'
Mothod 199
Rationals 199
Discussion 199
IN-SHoE
VAcluM TDq touE mt
Mclhod 201
RNtionale ml
Discussion m1
CADCAM TEcHNlouts 201
Xii COITBNTS
Ch&prer
Six andOnhoticFabrication
Ilbolatory Prepamtion
MoDrnc rloN oF Po6rrvEMoDE- m3
INrsNsrcFoRFoqr PasnNc m3
Sfllrr SElrcroN m5
FonEfoorANDT|PPos'nNoTEdNprrEs
E)(TRrNstc a$
INrarN$cREARloorPosl'tNo 20E
ExrRN$c RlArloor Po$rNc w
OBrHor-lcADDtnoNs 2t2
SroFr-st€qflc V^n|A]Iors 215
T8c10,fl
lN.OrncEFABRtcanoN oues 7,t9
237
ChapterOne
Structuraland FunctionalAnatomv
of the Foot and Ankle
lle hunanlool and arkle contain 28 bones(Fig.1.1) tw€enthe vadous aniculationsand their sutPolting soft tis-
(l) that fiinctiotr in slrcbrony to allow sues.In orde. to fully appreciatethesecomplex aDdotlon
of activitiesftring the difrercnrphas€sof gait: confusingmovementpattems,the following sectionwill r€-
carly statrce phqse the foot dissipates grourid- view fte different planesof motion and elplai! how varia-
forc€sessociatedwilh heel-stike atld becomesa tioD in axis positioDingmay r€sult in ud-, bi-, or triplanar
adapto/' nec$sary to accommodaredisqepancics motioo. This inforbstion will thenbe relatedto the primary
Duritrg lale stance,ihe loot b€comesa "rigid ailicularions of the fooi a ankle with rcgard to thc loca-
nt!" n€cessaryto effectively transfer body woight tions of the individual axes atd their available fiotions.
to forcfoot after heel lift occurs.The foot is Also ircluded in this sectionis a desc.iptionof the various
lcaomolish thesediverse activities via a s€riesof osseo$ and ligameDtousrcstrainitrg mechanisms,Firally,
anddelicnrelybalancedinteracrionsoccurring be. the mechanicaladvantagesallorded individual muscles,as
Flgur€1.1. Osseou!anatomy.
1
2 FOOTORTHOSES
andOtherFormsof Consewativc
!'@! CaJe
determinedby their angle of approachand disence from dorsinexion/planiarflexionocculs io the sagittal plarc, ard
eachof theva ousar€s,wiu be describedin lhischapter. abdlrction/adduciionocc rs in the tratrsverseplane (Fig$.
l.+ 1.6).In addirionto denotirgmotion,il is alsopossiblc
PIANDS oF MorIoN to usethereference planesto describeffxedpositions(Figs.
1.7-1.9).Noticein Figures1.4-1.9rhattcrmsdenoring mo-
ln order to describavarious movemenrsaccufalelyr tion endwilh the sufffx "-ion, ' whereasstaticor lixed posi
the human body has bcen divided into lhree refercnce tior termsendwith "-us" or'red."
planesof molion: fronlal, sagittal, and transvcrse.As illus- Ar importantconsideration is thal motionin eachof
lrated in Figure 1.2, eachol thcscplanesis perpendicslar10 the feferenc€plaDesoccu6 aboul atr .is lying in the two
the othertwo andhasa cardinalplanethal bis€cislhe body's remaidngreference planes.(An axisis described asthclin€
centerof gravity. (Note thrt thereare atr inflnite oumberof abolrlwhich all motion takesplace.)For example,rmns-
concr\pondingplanesparallelingeacbof the cirdinal plan€s.) varscplam molion occurringin Figure 1.6 takesplac
A-!rclatedlo m6r of Lhebody.abducrion/adducrion occursin aboutthe frootal/sagittal axis while the sagittalplanemo,
the {rontal plane; flexion/extensionoccurs in the sagitrll lion ir Figure 1.5 takesplaceaboutthe frontal/rransve^c
plane;androtatioroccu.sio thetransvers€ plaDe(Fig. 1.3).
As relat€d to the foot and ankle, however,motions To dcmonstntethe relationship beweentheposirion
differ as invenior/eversion occurs in the fiontal plane. of ar axisandlhepotenrialmotionavailableaboutthatnxis.
Root cl al. (2) usedan analogyin which a hinge is situared
in a box with eacfiwall represonting on€ of lhe r€f€rence
planes.Figures1.10-1.12itlustratchow an axis lyiry in
l\rn pl €s will allo\r lor pu'r m,{ion in thc remaini0g
plane,i.e.,uniplanarnolion.
giplanarnolion wiu resultwhcnan axisis situ.rted jn
sucha way thal it r€stsio only oncof the reierence planes.
For cxample,the axis in Figure1.13,which wasoriginaily
in the frontal and kansverseplane.hasbecnshifle.dso aslo
Iie +5'to th€ transverse plane.This axis now lies ir tie
fronLalplaneonly,andtheswingarmof its hingedescribes
a parha owing for biplanar motion (in this case,iraffversc
and\agittalplanemotion).Because theaxislies45" ro bolh
plancs,theamounts of lransverse andsagiltalplanemotions
are fqual. If the samelxis had becntilted only l0' ro the
transv€flieplan€ (as in Fig. l-14), {he r€sultingmotion
wou d still be biplanar,bul thenthe sagiitalplanecompo"
nenLof notion would Sreatly exceedthe transverseplane
conlponentof motiotr.Conver$ly, if the axis had been
tilted 80' lo the transversc p|3ne(10" to thesagittalplane),
the l.ansverse planecompooenlof moriotrwould greatly
excfrd the sagittalplanecompon€nl(FiB.1.1-5). A{ a arle.
lhe rnoreparallelan axislies to a plare. lhe lessmolionil
will iliow on thatpldne.
Tripl.nar rnodor will resuh when an axis dcviar€s
ftom all of the referenceplanes(Fig. l.16). Becausethc
ari. in thisillustratiL'nlics45" to eechplrnc, rherwintsarm
will describea patha owing fof e4ualtmounlsof ftontal,
sagillal,ard transverse planemolion.If theaxiswereh lie
closcr(or $orc parallel)to a spccificplane,less morion
wo!ldbe possiblein thatpla e.
riSure 1,2. Cardinal plan6 of th€ body. The sagitlalplane
Note lhat in ali of thcseillusrrationsthe swin&afln
dividesrhe body inro equal ri8hr and letr halves;the frontal
plane (iko rcfercd to as the coronalplan€)divid€sthe body
movcs only in oneplanc(i.e.,lhe plan€perpendicular to irs
inlo nsymm€hicalkontand back halver;the transverse plane axis of notion) and thar pla e may dqscribea path that is
(alsoknown dl the axial plane) dividesthe body into arym- uniplanar,biplanar,or triplanar,dependingon the spacial
metricalupper and lower halves.The cadinal planes inler- relar;onships belwecnthe axisandthc refcrence plan€s.To
sect al the bodyt cenler of Bravityax) which ls localed just put iL anotherway, motionaboula krngaxis.regardless of
anleriof to lhe second sacral tuberosity (sli8htly lower in its positionin spac€.will alwaysoccurin a singleplane,
and rhe terminologyuscdto describcparhwuysrclativero
sagittal
\r
oht^,'l
""."""q.ru
Msdiar
\ f a","r
h/
$ $ {d
11 Dfr
L*\-" '*"""
Figur€1.4. Froblaiplnn€norionf,
3
4 FOOT ORTHOSESand Oth€r FormsofcoNeryative Fool cato
plrnemotion6.
Fi8urer .5. Transverse
Figurer.8. Staticsr8itlalPlan€positions.
ChaplerOne Strulural and FlnctlomlAnatomy of rhe Foot.rd A le 5
Flgur€1.19. Shhftlngof the anLl€ ioint axh of motrbn. axis when the anklc jr plantarfl€xed(8). lAdaptedhom Bar-
Whereasthe laie.altaloealnost alwaysfolmr . irue circle, nett CH, Napier jH. The aris of mrationon the ankle joint in
the variableladiusof the m€dialtalus r,hel) .llows ior a man lB influen€eupon the form of lhe talusand the mobilily
downwardand laleralproiectionot the axiswhen the ankleis of the fibula-AnaromyI 952; 86: | -8.)
(A) and a superiorand laleralproieclionof the
dorsiflexe.l
vi€w
$up€rior
ottghl
lJi
B
ioint anatomy.(A) Three,
1.22. varialionin 3ubtnlar configuration.(Adaptedfrom BrucknerI. Vadationsin the
n. (8) Tdnsilional twojacet confiBuralion human subbl arj oi nr. J Orlhop SpodsPhysTher 1987;8:
twojacel confiSuatioJr.(D) Sp€cial twolaceL 489 494.)
l0 FOCrTORTTIOSFSandolher Forlns of ConscN.rive Foot care
md 40 to 47ofrom the sagit!,l plane(Fig. 1.24).In practi!€, mori,}nwiI produce1' of tibialrclation-lf theaxisis posi-
the approximate positionof the subtalarjoinl axis €aobe tioncd trear70oto the Fansverseplane,lhe amountof tabial
derermined by cornpadng the rang€ of reatfoot romlioDwill greatlyexcr€ed rcarfoot motior (c.9., 2" of rear-
inversion/eversionwith lhe rang€ of tibial rotation as lhe foor cvenior will be accompaded by 80 of intomsl iibill
standingpatiertpmnatesstld supinates thesubtalarjoint.If rotation).The location of the sublalar joinl ixis is clinically
the axis lies 45' to &e transverseplane,every ld of rearfoot signilicant as a high axis could be responsible lor chronic
ChaprerOnc Structurrl rnd Functlonll AtrltoDy ofthe Foot![d Arlle ll
irjury lo sl.ucturesproxinal to thc subtal joinr, while a possiblewithoul ovcrwhelmingthe fcstrainilg ligamenls
'Jo.r axis could be rcsponsible for chronic injury to struc- aod subluxing thc calcaneocuboidjoint (2). As wilh the
llresdistalto thesubtalarjoinr. sublalar joirl lockin8 mcchadsm, lhc midlarsal locking
mechanismis a uniqoely humao trail thal allows for im-
The MidtaNrl Joitrt provedbip€dalambulalion(14).
Shortplanraf
Figur€1.27. LigamentorsanalomyoI lh€ fool and anklc. Figorer .29. Axisof morionfor thc fifth ray.
t2
ChaplerOne StmctuEl !trd F||nctloMl Ar.srom] of rhs Foot fi.lAnktc t3
[.29).The positjonof tltis axis allowsfor rehtiveiy large larflexion)a'ld transv€rse(abdlcrion/adduclion)plrne motion
$Dounlsof doniflexion/pladadexion and invqsion/ever- (r'is.1.30).
gion.Becaus€ lbesxisrilrs20oto rhelransveNe plsne,there Becauseof the localionsof theseaxes,frootalplane
i8a smallbut ctinicallysignilicanlsmounrofabducrior/adduc- motionjs not possibie,andany attemptro ioven or eve( a
{hn prcsenl.As wili rhe fiIs! ray, morionabout rhe fifth ray normal di8it may resull in subluxationof ft€ metatarsopha,
irjs is alsolimiledby tensionin rheresaainirgligamenrs. Iangealjoint (2). Funhermorc, al$ough sagirtatplane mo,
tion at lhe melalarsophslang€aljoinl is extremelyimportant
Metatarsophalalgeal Joints for nornal locomotion,the raflge of fansverse plane mo-
lion is relativelysnlali and of no functionalsigniricance
These jointsrepresent thearticulationsbelween th€dis- duringthe gait cycle.Also, in regardsro lransverse plan€
t l ,irst through6f1h melararsalheadsand their respecrive motion of the metatarsopbalangcal joids, there fias been
proximdpirlangcs.Eachof thesejojrls hashro dislincrand historicrlly much controversyregardingrerminologydiffer-
S9parrte axeslhal allows ior pure sagirtal(dorsiflexiodp]an- entiatingabductionand adduction.For example,the early
B
lEgurc1.30. Ih€ melatarsophalangealioint axes.(A) Lateral aris. {8) Dor5alview demonstEtinqllansvelseplane morian
lliewdemonnralinBsagitlalpline moLion
abourthevanwerse aboutrhe ve(ica I axis. (Adaded trom Rool et at.t2l.)
B
14 FOOT ORTHOSES,nd Other Formsof ConscwativeFoorCarE
Interpholltngeal Jolnts
Each of the interphalangealjoims posscsscsA
ve^c axis thal allows fo. pure sagittrl plane motion (Fi&
t.3.).
INrERAcrloN or FoncBs
Whcreasthc locrlionsof lhe vadousarcs aredetr-
mincdby the shapeof the rrticularsurfaces (4), hovemeni
aboutthesearesis determined by ihe combinedinteractionr
of irll forces acdng on the body (with lhe rnost common
AB forcesbeirg muscular,gravihtional. inertial, frictional, d
Figure ri2. Digihl positio(|s.(A) AMucted .efeF to ihe groUnd-re{ctiveforces). ln ordef to apprcciale jusl hof
transveGe planepositionwhilevrlSus(8) lefelsto the lloni.l $ese forc€sprodNe or rcsist motion, ir is i portant!o un-
derslandrhal all forcespossessmagnitude,diicction, a line
ofapplication,and, poinlof application (Fig. 1.34).
A force will most elfectively produce motion when
occursin a planoperpendic0lar
its linc of applicatioo ro6e
joinr'ssurface(or its axis)md wher ihe pe4,cndicular dix-
ton.c betweenlhis lim of action and the axis is greatcsl
i.e.. when it brs the longcstlcver arm. This is readily
ill
,stlill
ill
lu Fisure1,39, Ihe combinedllne of driveol all muscl€s s|a'
rigure 1.38. fo.cer Fl (line of applicationof bifiring a joint i$ rermed $€ resullant forc€ (opcn artowt.
solv€dinto a norrnalcomponent(rX) and a rheartn8 comPo- VM = vastusmedialis,RF= reclusfemoris,vi = vastusinteF
nern(Fv). m€(lius,Vl = vasluslaieralh.
ChaprcrOnc Structurl ,nd Fuoctloml Alrlolly ol lh€ Foot rnd Arkl. I?
rl\ l
\ | 4aca"r 1"o'marr
lflaenhud€J\ I
n 15'
\
Cosins15"=|/H
Det€rmininSrelatir€ anounts ol forc€ u3in8 equalions,the force's m.Snitude and line of action are rc'
'cohcar[oa."When rolving biomechanical ferr€d to as the veclor,
18 FOOT ORTHOSFSand Other Formsof cons€rvativeFooi Ca@
" --";;;r'brmsofcons€rYativeFooca@
//1///-,",^,," "ii* f l
", X lz ris",r"i""/);;
9.7lbs
1^(W*' I
fi8ure1.42.Determinin8rotaliona|andnonrolatiott"'.,T.
/1
t/ /,/
/3
iN__/ / ]ffi,t
-l
\F
\r. / qh
+----\+
A# *
't%x"
" I '#y
d'"'vsfrc"
fj?r[];fi"*j1fj1;f#ir,l,li:Htf
::i:ilf;."i:'jljil":lji:::1",ff#[,l1tji;,i=-"
B
C6lro.nemiuysoleus.Th.se musclesposr€es lhe actionsof p€roneustediusand exlcnsordiSitorumlontus
leveratmanda peQendicularansleof approach arc consideredidenlical {ahhough Peroneustcrtius ha5 a
axisandarclherefore
nron6ankleplantadlerors. lonBerlev€ra.m fo. pruducinSpmnationaboul the longitudi-
muscles
anSleapp.oximalely48' to the subtala. nalmidia.salandsubtalarioinl axe5).E{ensor halluci! lon8us.
onlymoderare oi thiejointderpne
supinaloB Thismusclehasa lonSleverr.m and a peeendicularangleof
lont levera.m.TheSastrocnemius, unlikerhe approachlo lhe ankle axis and is a rt.on8 dorsifl€xoroi thi,
lhe kneejoint and rhercfor€aids in kne€ joini. h fact,Roo!et al. (2) not€dthat €xiensorhallucjslon8us
digilorlm loryus. Eecauserhis musclehas a is lha stron8estdorsitlexoroi the ankleas swins phasebesins.
andneariypo.pendicular
approach to iheankle Becauseof ils insi8nificantleveralm to the slbtaiar and longi-
asanronEankl€dorsiflexo'.
lt al5oharsmallbut tudinal midtarqaljoint axes, it js unable to produce morion
ams to bolh the lonsitl]dlnalmidlaEal joint about thescaxesand is considereda neutraldo6iflexor ot thc
axis,which al{owsit to developa modefato toot. Note; Exteosordigitorum looSusand extenror hallucis
aboutth€5e ax€s.{Theanterio.retinac!lurn
of lontlr cfeaiest.on8comprersiveforcesat the inr€rphalanSeal
allowstor a nearpe.pendicular anSleot ap- joints lhar acl to rcsisrclarvingor hammerint oi the digirsas
t€rli6. Eecauseot lheir close proximity, theymaintainextensorri8idity(s€eFig. 1.46).
20 FOOT ORTHOSRSand Other Formsot ConscruaiivcFoot Care
B
PeroneNlon8us.In additionto its alreadydis- longusis al|o .apable of producinga stron8pronatoryforc€
of slabilizingthe lessertaruals,rhe pe,oneus aboui the lonEitudinalmidlanaljoinl axis.Eecauseil5 Lendon
i5capabjeofEenerrtinSa powerlulpl.ntrrflec. passesso .lose to rhe ankle atis, it is unable to prcduce
lhe fid ray axie.(_theperonealSrooveof the siEniiicanlamouiis of planla lexion at that joinl. OM./ =
a5 a pulley supplying lhis muscle with an im- oblique midta|3alioinlaxis,StA = subtalarjointaxis.
of appma.hto th€ firsl ray axis.)Peroneus
STJ axis
Ol'rlJA
Adrtuclor
h.lluci5.Theadducrorhallucismus, fiture r.s{. fleror digilorum br€vk. This muscleoriSinates
s€paaleheadsthal p€rfom funcrionally
disrincl from lh€ medialcondvleofthe calcaneusand Dossesses both
obliqueheadhasa signilicani
leverarmro borh a signiijcan(a!8le of apprcarh and leveram to supinatethe
and ve ical molalarsophalrnSealjoint axe! oblique midlarsaljoinl axls (OM,/A).8e<auselt! tendinousin-
an imoo(anl olantarflexorand abduclor of the se ion is below th€ lransveAemelatalsophalangeal ioint axis,
insl€of app.oach
.fiordedadductorhalluci,ir a it i5 an impodant plantarflexorol th€ diAils However, its ei-
of lhe ansleof approachaftod€d abductorhal fectiveness as a disilalpiantarflexoris dependenton thc com.
mus(leshave d con,oint relalionshipwith Iheir pressiveforce g€n€ratedacrcssthe intelphalan8€aljoints by
lhal delorminestheir final aogle of ap, the disital extensoE{rcier back to Fi8. 1.46). railure oi the
equalbut opposireappoach lo lhe venrcil is diSital exrensorsto adequalelycomprcsrthe inteehalangeal
planeslabiliralion
ot thehalluxastheab- joinrswill allow flexordi8itorumbrevisto planta lex only the
forcerarc pe ectly balanced.Action of thc inlermedialophalanx,th€rcby predisposin8ro toe detomjty
is dependentupon prevrousstabilizarionol as the plantarfloxin8intemediate phalanx poducer reiro-
the comp.eesiv€ force Benerated by abdu.tor Brad€doEiflexionof lhe proximalphalanx.
lhe obliqueheadot adductorhallucis.The srabi.
asan anchorthal allows tha transvelsehaad
ins ol lhe meratarsals (which markedly de
on lhc kansveEcmetatarsal|Samenr).Be.ausc
llydislinctirclionr Roorcl il. (2) believ€thar
headshouldbc re8ardedas r rpa.ate murcl€,
reh. ro as rhe transveB€pedismuscl€.
24 FOOT ORTHOSBSand Other Forus of CoBeralive FootCarc
MC, Odon WP. WeedJH. NormalandAbnorftal Funclion in mao.lts infuenceuponft€ formofde tals d lhenobil.
of the Fool. l-os AngelesiClinical Biornechanics,1977.The ny of lhe fbula. Anarony 1952i86: l-8-
inleresied reader is cn@uragedto refer to rhis te for a 6. Wyllo T- Thc dis of thc !trklc joint md irs imponanc€in
moredetaileddiscussiooflheseandothermu$les.) \dblrjaraitbrodais.Ada OrthopScand1963:13: 320-3?8.
7. l-uidbcrgA, Svensson OK, NcmcihG, cr al. The dis ofrut .
References riotrof rhedllejojnt. J BoneJoirl SurgI989;71B:9+99-
8. lrman VT. RalslonJH, Todd F. Illman Walking.Baltjmor:
I. SubotnickS, Joies R. Normalanatomy.In: SlbotnickS (!d). \Villiams& Wilkinr, 1981.
Spons Medicine of rhc tlwd Eilretnily Ncw Yo*: 9. I ambrindi c. Nc'/ opcrationon drop fool. B. J SUB I97;
ChurchillLivingsrone.1989:75. l5: 193-200.
2. RootMC. OrionWP. WecdJH. NonnalandAbtro hal Fuor- It'. IrrucknorJ. Vadarionsh thc humansubularjoint. J Onl$p
tiodof theFml.l,os AnSelcs:ClinicalBioncchanics,1977. sporlsPhysTher1987:E:,lE9-494.
3. llaris GF. Aialysis of anklc and slblalar nrction during 11.I:lflman H. ManterJ. Thc clolutionot fic hnmm fml. eirh
humanlo(])noiio.. In: SrichlJB (ed).lrynar's Joinlsof the ripecial referenceto ih€ ioints. , Anat 1936i70: 5H7.
Artle. Ed 2. Ballimorc:Williams& Wilki6, 1991:7J. 12.hnan m, MannRA. Biomehani6 of lhc tml ard atr](le.lil
4. Hicks JH. Tle me.hanicsof the fmr. I. The joinr.. I Anal Mm RA (ed). Duvrie$ Surscry or ihc Foor.Ed 4. St. l,uis:
1954:8E:345-357. ( V Mosby,1978.
5. BarnerrCH, NapierJH.Thc axisof rotationon lheantlcjoint 13-I nSsberg JR AndrewsJG. Kincn8ticlmlysis of th. t2lsil
.6tt r9t t996t.or
'8961 !.{I013roqq dql :ocsuwrc Bv
-o<t I luloltRlerqns
,l|1JouorrouJostxv .l!
des SSuoded I?rlut{mJ '{atalhg puBorsr.sR{ uss '.eruroj 'c8:691646I.ossY Pey{
-ttsC Jo ,(r!sr.^Fn ',$otBroqv-I3rluBqrarlorg 3ltFe prB looJ t ruotlor! turotlPFtqns d lr.tpr' tv ,hqqrfi
uE'lnq .ql.ro $ilpnls .!4'lnodonllsv I uEulrt .3u rrulsl .8I jlr6l ,ax
'60t-t6c:08
.9/r,9r :6Zl 16161
l€'V lzsDr .sa^suB4 p@ JEtktq.se$ Jo srorli.^ow :
I J}o-qstrdr€e? pos qStql! rcaJ iql Jo rtnB lsurpntteuol '1ffil/]2,:E
^\ot of ploqmuErt8J
3tll Jo ,(ltFl.ls pue |u d r€tpN-u.slog tl $ods tosp€t{ Eoddns
&!uu Buhplurol
gailcycleis thebasicreference in thedescription As the ibot Foceeds tbrough it6 contact period, a
locomotion. Ore full gaircycl€consislsoflhe pe- combinalion of ground-reactiveforcos (which aJeinitially
Bb€tweeDsuccessiveiDsilareralhe€l stdkes: ir applied to the posterclateralheel) and inerlial forces (lhe
lho heeliritially makesgroud contacland pclvis aod lowor extrcmity cofltinre their internal rotation,
monenlthcsameh€elsrrike,,lbe groundwilh Ue which beganduring early swing phase)causestle ankle to
(1), Nole tharalrhoueha small perconrageof the ptantarflex and the sublalarjoinl to pronate.Plantarflexion
makesinitial sroundcontacl at the mid or fore- of the aDlle is resisledby ecc€nldccortradion of the ante-
will referonly to thebiomechrnicalevents rior comparloetrt musculature(5). These duscles play an
wilh lhe more commody seen gait pattem in impodant rol8 in absorbingshock as lhey smoothly lower
ieel is theinitialpointof groundcontac!.Norice the forefoot to tbe ground, thereby minimizing tra ma to
I tie gait cycl€ js divided into slanceandswing the plsntar soff tissues.lntercstingly, Radh and Paul (6)
rhich typicauyoccupy 62o/aand 38/a of the gail state lha! joint motion controlled by nuscl€s lengrbening
@. urder tension is the primary kinemadc proces! respotrsible
a person is walkin&$e gaitcyclela6tsapprox- for shock absorptioD.The adde contiN€s to platrt3liex
(1).As a result,stancepbaseoccun io 0.6 th.oughout lhe first 70% of th€ contact period, reaching a
switrgphascin 0.4 seconds. Because $e disrsl maximally plantarfiexedposilion of 10" (Fig. 2.4). At tbat
kfueticchain is fixed by ground reacriveforcos time, ground-aoactiveforcesbeneaththe forefool causethe
phase,motionsdrfing this portion of the gait ankle to dorsiflex slighdy (i.e., the anHe is stil
refenedto as closedchain moriotrs.ln coor,asl. photari€xsd 5" by the end ol the cotrtactperiod).The con-
motioosarerefefed to as open chain motions lact period efldswith tuU forefoot load (FFL), which occurs
etrdof lhe kinetic chain is Feely mobil€. Also, when the oppositeleg entersiis swing phase,therebytrans-
thc complexityof stancephas€ motions, this tcning full bodywei8hrLothestancephasele8.
&e gait cycle hasb€eDsubdividedinto contact, Throu8hout the €ltire contact pedod, rhe subtalar
and ptopulsiveperiods (Fig, 2.2). The tining joint is proMting ftom the slightly supinaredpasition pre-
eventsassocia(ed wilb each ponion of tle gail senl al heel-strike.Normaily, the subtalarjoint will pronate
in thefollowjngparagraph. only during the contact period, with various authors(2, ?,
8) describirg lormal pronatoryrangesthat vary belween4
STANco PHASE MorroNs and 12" fton neutral(the discrepancybetweetrthesefigurcs
ContactPeriod b€ing relatedto varialion io orientationof the subtalarjoint
axis of motiotr).
p€riod begins al heel stnke (HS) and An extremely imponant cliDical considerationis that
Ioad(FFL). As illustratedin Figute 2.2, slbtelar joint pronation is bo r direcdy end indireclly re-
periodlakesplrceduringtie first27%ofslance sponsiblofor shock ahsorptior. The impodanceof this ac-
of on€full gail cycle) and typicaly lastsbe- tion is emphasizedwhen onc considersthe repetitivenessof
0.15sEmnds (3). (Kcepin mindthatthorcis the grit cycle andthc magnitudeof impact forces,i.e., each
in theperca agesandtiming of a phases.) foot strikes the $ound between10 and 15 rhousandtimes
lhe inilial impacrforcesduring the contactp€- daily (9), absorbingthe equivaleot of 639 merdc lons of
or al. (4) nole that du ng a typicsl heel strike pressure(10). Root et al. (2) suessthe signiocanceof this
a person'sground-reacliveforces average information by noting that ary condition preveEtingthe
ald 10%bodyweightin the venical,forward, nomal rangeof subtalarjoint pronationwill result in patho-
resp€ctively. logical anounts of stressbeinESan3rttittedup thr leg, into
thal heel slrike occurs,lhe hip is ide- the pelvis and lumbar spire. lt is of not€ that Fredricb (11)
; thekree is almostfully exiended;the anlde statedthat theseforc€stravel througi the body al a speedof
(hrsiflexed; the subtalar joint is slightly 200mph.
lhe didtarsaljoint is fully pronal€daboutits The subtalarjoint is able to efectively dampenthese
supi0aled(inverted)aboul its longitudinal forces,primarily becausethe talus moves into aJladducted
andplantarflexedposition as th8 subtalarjoint pronates(12)
z7
28 FOOT ORTFOSF,Sand Other Fonns ofcon$wativc F@l Ca.c
1A%
HS ,HL
H6€l
slrika
Swjngpha6€- - -r
riSur€2,1. Cait cycleof the ri8ht l€9.St3nccphasebesins pro\ atelyI15 slepe/min (sli8htlylowerfor menandh
al heel-stke /HSland endswhen the a€at loe leavesrhe for \,omeD0l). lt shouldbe emphirizedlhatther€is
grouod.Swingphase@nlinueruntil theheela8ainstrikesthc indi.idualvariationin stridelendhandcadence, asead
sround.Thelenethof stide, which to lhe distanccbe- son ,eemsto choosea Saitpatternthali5 metaboli.ally
twe€nsuccessiv€ ipsilateral 'efe6
heelstrikes, is app()ximalely 0.8
llnrcsa p€rson's
bodyhei8ht,andlhe avera€e c.denceis .p-
+Cbntaal + F- --+roD{rtsv€-
' -Mtitetanco
P€rlod P€fiod P€riod
Figur€ 2,2. Thc varioui p€Iiod. ofilrnce phrs€. HS, he.l strike; FFl, full forefoot load; IO to€ off.
ffi)
Fi8ure 2.7. Inferior vi€w of the
risht knee. rhe n,edial femoral XI
coMyle is siluared fur{her forward
than the hteral condyle {xJ.l.ternal
ffi
rolation oI the tibia {rs srpplled by
ihe adductins ta[6] allows rhe nre,
di:l ribial plateauto slid€ posteriorlv
(A), th€feby allowinB for flerjon of
lhe kne€ (8). This rotdtioial Acti!ity
occurs 5imulLrn€ously wilh a
rollinly'Sliding motion as forward
momentumof th€ pelvis pushesthe
lemur anteriorlyon the libi.r, which
is m.inlain€d in a rclatively{ixedpc
sition by groundreactive torces-
lPartiallymodilied from Hoppenfeld
S: Physicrltxamination ot the Spine
and [xtremiries. New York: Apple'
ton-century-crcfis, 1976.)
ip prcsent
whenthsnidtarsallockingmecha- hccl (Fig. 2.14A).Secondly,contiDledcontractionof the
soleusand dcep posteriorcompartmentmusclesacts to
eullier.thecalcan€ucuboid joinr will ideally lidil lhc rangeof ankledorsiflexionby deceleratingthe for-
rh€sagiltalbisection of the rearfootis p€rpcndic- ward mornenlumof the proximaltibia.This actionallows
Sround or, as in fiis cas€,whenthe plantarfore- the forwardmomentumof thecenlerof m8ssto be applied
lo fte plankrrearfool.This lockingposilion, directly towa.dslifting the heel(Fig. 2.148). tastly, thc
to stabilizinglhe forefoor agaiDslrhe rcarfoot, gaslrocnemius muscleplaysa panicularlyimporlarlroleby
lo improvethefunctional alignmenrbetwcenthe simultaoeorisly flexing the knee while plantarflcxinSthc
andthe calcaneusand prolects again$ lat- ankle.Thesccombinedactionsservoto lift the kneeupward
of lhe anklemorliseby decreasinS depen- and forrvard (which allows for an improved range of hecl
larcralcompartmenr musculature, lin) whilc alsoassistitrg with hip nexion(Fig. 2.14C).Be-
lhc end of the midslane o€riod. the anllc is causcof this!gastrocnemius indirectlyallowsfor improved
Itr (forwardmomonturnof the body coupled grourdclcarance duringswhg phas!.
knceexlension throughout midslance al' Onccfie heelhaslefl the ground,the fool mustsafely
ve Iorcesalplicd beneaththe fore. channellargeamounts of verticaiforc€s(whichpeskduring
er the ankle).the subtalarjoinl is moving carlyprupllsioo)throlghlockcdandslablearticuhtions. As
tr6l polition,andlie midtarsaljoint is fully statcdby Rootot al. (2), if theproximrlarliculalions arenor
bothaxes,i.e., the midtarsaljoint has stabilized againsrlhe distalarticuladonq theywill bc placcd
y pronatcd abourirs obliqueaxisrhroughour inlo motion(andpotentialiyinjurBd)by forcesactingon lhe
gh its available range of motion has tbol. The foot is ableto proted iBelf by
againtaking advan-
dccrers€d due lo subratar juint sup;narion.
lage oI the cxlemal shankrotation suppli€dby th€ forward
dorsiflexiondisplacesthe naturallywider
upwardly,the syndesmoric momeotumof the opposile swing phasel€9. Becauscthc
distallibiofibular
gapas muchas I.5 mm anleriorly(19) os closedlinetic chaioendsat Ihe metatar$lheadsaftcr heel
erlemlllyrotatesandmovesinferiorly(Fig. lift occurs,thc continuedertemalleg rorationwill supinate
thc subtalarjoinl beyond its neurral position (ground
rcactiv€forcesno longermaintainthe calcaneus in a fired
positionso $at ir is free lo movc wirh lhe rohtiog ralus)
PmpulsivePeriod whilc markcdlysupinatingthe forefootabourtbe obliqu.
pcriodbeginslhe momenthecllifi (rc- midtarsal axis: rhe cntire rearfool pivots mcdially as it
abducrsanddoNiflexesabolt rheOMJA (Fi8 2.!5). Notice
wilh toeofl This periodoccupiestho final in lhis illusrrationhow the extemalleg rotationcreal€sa
phaseandlastsapproximately 0-2 seconds. scrcw-likcmotion3t lhe midloorrhargresdyincrc.scsarch
lpf'€arsto be a simpleprocess, rheactionsre- hcighl,therebyconv€rtingthefoor inb a rigid lcvcr.
producing heellifi aremany.Firstly,rhc for-
of the torsodisplac€s the c€nterof mass Supinationabout the obliqueaxis of thc midtarsal
theforefoot,lher€byminimizingthe vertical joint is aidcdby conrraction of lhe illlriosicmusclesorigi-
c for maintaininggroundcontactat th€ nalingffomthemedialcalcan€us (particularly abducbrhallu-
andOtis FoEnsof G)nsewstiveI oot Care
34 FOOTORTHOSES
cis)andby whatis knownasthewindlasseffeclofllrc plan- rnidrJsaljoinl axis with ils concomitanlinc.easein arch
dorsiflexionof the ioes afterheellift dtawsth€
tnr fa.scla: heighl.
plantarfasciaaroundlhe metatffsalheads, whichac|sto pull Whilc considcr|bleskbilhy is affordedhy the in-
the anteriorandposteriorpillarsof the longitudinnl nrchIo- crcr\cdarchheight,thefoot couldnotbe considered a dgid
gether(Fig. 2.16).This approximaionof thc rearfooland levcrw€r€it not for thc conlinuedfor€foolpronationtltrout
forcfool allowsfor eontinued supinalionabort the oblique rhe bngitudinalmidtarsaljoinl axis.D0ring earlypropul'
CbaptcrTwo ld€il Molioor durirg the Glll Cycle 15
F
15mm
Ihe windlasi effecl of $e olanlar fascia. DlF melalarsrl,with its lal8er head and the pfesenceof sesamoid
perlod, gruund{eaclive forces arc bones (which the plantar farcia invesl) has a dklance ot
lo€s,which acts to draw lhe plantar lascia nearly 15 mm betweenthe lraniverseaxis and the plantarfns
head5(A). This aclion rcsuh5in the ap. cia (O (161.Ae a rcrult, doGiliexjonol the fi6t digil produces
€adoot and Ioretool(B) and allows for thc in- a mu.h ErcarertractioninSeffe€ton the planta. tascialhan
for stabilny(C),Theamounrof
heightnecessary any of rhe less€rdiSits{compareF and C)- ln odcr lo r€sisl
by lhe plantarfasciais directly relatedto thc the gr€atertensileload, the plantar{asciahas its nrongen al-
n lhe lransverseaxk of rhe melatarsopha- laehmenldistallo (he filn metararsal head.The plantarlascia
andthe passaSc ol the pl.nlar lascia:lh€ Srearar also hasstrongatlachmenrsto the rkin beneaththe melatalsa
Sreatarthe pull placed upon lhe planlar fat h€ad! (rta.), which prevent!djdin8 on the skin as posterior
doBillercs.for example,lhe av€ra8eless€r shea.fo.cesare applieddu.ins lhe prcpulsiveperiod{16).
an alecce oi 8 mm betweenils transveBeaxis
oi rhe planrar fas.ia (D) whila the [i6l
Pronated
Figore2.19. Th€€ffectof subt lar posilioningon peroneus axjr /4. Ar the subtalarjoinl movesinio a proeressiv€ly
longusfuncfon.Wh3nthe subtalarjoint is p'onated(A),the supirat€dpoiition (B aod C), Lhepost rclateral
n€arlyhorizontal .n8leofipproich nfiordedperoneus lonsus lbrce is les'en€daJ, as lhe more verticalnpproacholthe
ajlolvslor the produclionof a strcn8post€rolateral
compres- one,rslongustendon allows for Lhedev€lopnrcfio{ a s
sivelorce{/) andn mild doGi{leclory forcerboul the iirslray planrnrilectoryforc€aboutthe insr ray axis lr).
SwrNG PHASEMorloNs
.--..-. -l'/1
telvic rotatio.. Panel A reprc!€nGa lal€ral achievethe sameskid€ len6h {W). This in lu.n dec.eareslhc
cycle wilhout oelvic rutationwhile Pancl I ver(ical drcp du.in8 doubl€limb suppon by app.oximately
mtationfarrowsJ. Nolice lhat he€hl X in A l/8 inch, which efiectivclyflatGnsthe pathwayfor thc center
fa.iShlv in A as rolalion oi the pelvis in 8 de- ot nass lM2 vs. Ml).
nl of hip flexion/extcnrlonnecassaryto
40 FOm ORTI]OSES aDdOlher Foms of Cotsrvstivc Fool Care
rl-chl
pna!€' by kneeflexionduringearlystance
liattene.l
etre.rively 11-
Fisure 2.26. Knee fl€tion/exlemion during stanc€ d
elevationofthe €entefof.ma!s'
phr'e lo@r e\rFmrt\' Folron w'rrt whr.h pre'"entsexcessive
Paa e rep,crents whi'h pre
'ranc" bv knee exte.sion drrirS lite stance f.l_-41,
out lnee fletion *hile Part B repre'enr' lhe urne lcg wilh ccnter of mass stance phase
e;( 5sive lowerin8 of lhe
knee flexiodextens;onNotice that when the lowet exlrenlltv
moiions d€creasevedical oscillalion bv approximalelyl
is straishtenedthroughoutslance phase,the cent€r of mass
Aescr#' a pa*' atone lt'e arc of a circle, wirh the len$h of
the low€r extrcmilv beins the radiusof the circle This Ir' i!
chaptcrTwo ldell Moliotrsdu.iry ihe Gsit Cycle 41
Hip, knee,and anlle inleractions.Ar hoel oI the kiee and hip dlring swins phase 6-Z) allows for
lheanteriof
compa(ment muicleseccentri.ally sufiicienlgrcund clearancedespitelowerin8ol the pelvis lhat
lowef lhe stancele8 lo thc ground A1and i, normally occui.inB on the swin6 leE side. l{ lhe knee and
coupled with simultaneousknce flexion, hip were unableto move thlouEhadequateranSesof molion,
rcou6c for lhe conlarof massduring the the individualwould most likely compensateby circumduet
ankleplantarflexion
fl 2J.Forceir.rl durinsthe int lho 5wingIeB-Thi! action Sreallydislo s movementofihe
markedlyelevrleslh€ le8 fA-Dl and is re centefofmass and i5 metabolicrllyveryexpensivelo perpet&
the mainEnancaof an almo ntaight pathwiy
olftass d!rin8 late slancephascil-41. Flexio|
I t/
(1 ance during the gait cycle, th€
$
weisht'bearingleg adducts,and thc
rying leg abducrr. This allos the
centerof massto be displa.ed later
lu ally over the suppo in8 l€s (PanelA,
NT
ing late midrtance and early
p|opulsion.Fortunately.mosl people
possessa slisht de8reeof Senu val'
Blm lcl lhat minimizesthe de8.eeof
XX
V
Figure2.29. Finaltrrftlation of rhe centct of massdurinSa fr, thec€ntsroi mnssneverrcach€,the
dhpracement
singl€rtrlde, Laleraland verticaldlsplac€menB are rcpre. wolld assumedurin8 sraticsta.ce (which is reprcsa
eentedby A and B, rcspedively. NoticeIhal thesedisplncc- OJ. r'o|wad acceleralionol the centcl of mass,al bolh
menlsare purc sine wav.s, with the fr€quency of ve{ical ancl low speedr is lrearcn at the low points of ve icr
dirplacoment b€ingexacllytwicethatof lhe lateraldisplace- placc,men!(i.e.,duringdouble-limb
srppo ) andleast
ment. C represenls $e pro,ectionol thesedhplacemenc hi8h points(i.e.,durirs midnancep€riod).Anolher
(whichhav€beengreatlyexaggeratecl) ooroa planepe.pen- sayin8lhk is tha! kinetic ene[y i5 grcat€slal lhe low
dicularro the body'slineof progr€ssion.Eecause peak!€rta- wh.rcas poIentialenerSyis greateslal thc hi8h poinh.
cal displaccmertiare feachedslishtlyb€forep€ak lateral bri€r pcriods of acceleration/de.eleralionpres€ntdldnt
dkplacemenrs, thh curvercpreenBa elighllydasbned"lizy g.rirry.le arcdifficult lo obseryebul bacomereadily
eighl."At higherspeeds of walkin8(D), theamplitudeof lar asan iDdividual walksacrossa r(x'mwirh a tull hr)wlot
eral disDtacenEnlir decrcased,and the lat€ral and ve.tical sour':lnorde.to arcid spillinSlhesoup,lhepers{,n
wili
displacem€nts peakat lhe sametime. As a r6uL the perpen- the .rdvancintles dnecllyunderlhe centcrof mast
diculardisplacemenl ot th€ cente.oi massmorecloselyre. avoi,l'n8lhe d€relerationperiodlhal nomally occurs
,embles a "U.' Norc that even at marimal verlir:.l| rwe.nearlycontactandlatemidstance.
Chapter'Iwo ldsl Motlon! durl4 the cait Ctde 43
SUMMARY
GRAPHTC or rHE GArr CYCLE
Singlclimb5uFFon,
righrl.C Sjngl.linb ppon,Ln bg
lWrd of
(r (t (11 /l
tl t ( v /dt u {ru
t\\ \ A\
n
(\ I
)'l ) /\
f-
IS\
---T---- -----T-'---- -T
Hdcl FuIlFor€foot Hed fo€ Heel
Slrike Irad Lifi off Suiko
extendcd t0'
HIP
fler€d
0'
l0'
I.1
,/
20'
I
30'
40' 1I
HS FFL EL TO HS
180'
l?0' '\
/
KNEE 160'
ncxed 150'
140'
130' \
l2o'
110'
FFL HL TO HS
doNinered l0'
ANKLE O'
planrarlcxed l0' >*--l --
m'
Figure2.31. S.g:ttalplanemolions.
Chapte.Tro ldeel Motiobs durlry the GNII Cycle 45
/\ r\ ( t t (t\ (1 { (\ (\
euau0u ditu?*
Heel
Suike
FUI Forcfoot
lnad
H€€l
Ltft
Toe
OF
HeeI
Salke
l0'
0'
5' >*
10'
FFL HL TO HS
0'
2'
6'
I
/
l0'
HS FFL HL TO HS
50'
4U
30'
2U
lr
0'
l0'
tig!rc 2.31-continued
46 FOOT ORTHOSESatrdOth.r Formsof Consenativc Fml Carc
inferior 4'
2'
PELVIS O.
2'
\ ./
HS FFL HL TO HS
6'
adducred 4'
_/
2'
FEMUR O'
z' -...--l
abd$cied 4'
6'
FFL HL TO HS
HS
6'
adducrcd 4'
2'
.IIBIA O. /
2"
\
6'
E'
0'
\
8'
FFL EL TO HS
8'
6'
2'
\
0'
2'
HS FFL HL TO HS
2'
0' / \
2' I
I
6' I
8' /
tigurc2.32 continued
48 FOOT oRTHOSES rnd OrherFoms of Cons€NativcFootcrnre
A A[t[ \ AUA
Heel
Srike
FdI Forcfoot
lrad
Heel
Uft
Too
otr
Hcel
Suile
6'
2'
PELVISI 0'
2'
--
itrternally
HS FFL HL TO
6'
exlemally
2'
FEMUR o'
intcmally ,.
6'
flS FFL HL TO
6'
cxtcruallt
4'
2'
TIBIA O'
.7 \\
2',
6'
Figure2.33. Irdnsverseplan€ motions' 'Ahhoush he pelvis for ,u incre.sedlen8thoi slride. Note thnt ipsilatelal
in this Eraph is jnternally rotated only 2" at heel strike, as oltr p€lvisis countercdby conlralateralrolalionof the
hisher sp€€dsoi locomotion ,re rcachedlhe pelvis may be with the shift in motion occurrnrgal nbout lhe eighlh
maximally intemally rdate.l ai heel_strike. the.eby allowlnS
ChaplerTtvo lded Modoff durbg the Grlt Cyck 49
I'
0' /-t
8'
HS FFL EL TO HS
l0'
5'
0'
5'
l0'
tigwe 2.33-continued
50 FOOT ORTHOSES.nd OIhcr Forns of Conscrvaliveloor Crrc
( t\ (( (A (i l (\ (\
u ttn0u z{t&/)\
He€l
SFik€
FUI FoEfoor
Load
Heel
Lifl
'Ibe
otr
H4el
Slrike
Cluteus
Mlximus
ffihfiil- .T L.
['
-arll
'"frlll
lliocosialis
Lumborum -.|rlllr..
-'rllltt* l$Mfifftlu*
Cluteus
Medius rrf'lTfi4ilffi
tflWwilnvrm
Gluteus
Minimus 44tfltfrfrt
futWVrltun'w*
TFL
4filtn* lrltflHfflffil
lr.-
Iliopsoas nlll
frrtffisffin lMr..-...-
11,"""""
Sartorius {llllur.----.-
\tlfprf"'"-.'
I!amstrings
Miltltnftt* ----{frtlt ,"rrullllll
-rYiltlYYYl
Qua&iceps
ttl$ililitrn'- nu hL
lr' -'wrn
-'rlu
Popliteus {tl'\ltfftt1fit't!il1
fttlliltlttHlt*
Figure2.34. Musclefunction. rFr = Iensorfasciaelata.. l"Blred on inlomatjon lrcm Brsmaiian(i),
I n n u n e t a l . (1 ),R o o le t a l . (2 ),Ma n. (15),I yons(25),aD dothe6 (26 3O).)
Chaprer'rwo ldell MoiioDsdu.ins the Gail Cycle 51
Tibialis
frtilfnffilil* ll rrur-
l||lrfnrr -urrll
"".rtll
Teflius lllrrr-
'wvwnfl
'libialis
Po$erior {nfifrwt
ffifrw'$lf{lslt llr--
Flexor
Longus
.,rlll
'fIvl iltil{wfi{uffiiltl
lllllrh-
ltlltrt'--
Flexor
I-ongus ftlfriltvl|tfrw
HilVhffihF
lllltt^.--
tr,iot,tl$itil{tt
lInt"''
llL
Mtttiti,u^W
llt'
{rrtlftfilfrtt /iltth$ffi-
Figue2.34 .ontinuc.l
52 FIOT ORTHOSm ,nd OtherFoffis of Conserv.live Fool Cale
A A[[[\
Heel
Sdite
Flrll Forctoot
frtd
Ileil
ft
Tbc
off
Abductor
Hallucis rrutrffillfitri
Adductor
Hallucis
4.rlll
"rrrf e\{ffifitttffi
.trlllllA[r
Flcxor
HallucisBEvis lrqllwtftl fl4rtTilili$fftt
Flexor
Di8itorumBrevis fl$fiitlffisffil
lnt€rosssi "ll{
ft!ilftrlftfs
Lumbricales *ililnffifl|i
fVllWlr
I rl l l l l l
lrlion nec€ssaryfor knee flexion, i.e.. rhfoughoutthc mark.d invcrsionof lhe forefoorabolt the
propulsivcperiod,the knecis llcxing while tbe ribia is ei- midr.raljointaxis.
rernallvroradng.Becauserhcscmotionsconfficrwith thc
normalcoupledmorionsassociared with knecflcxion (the Tibialis Posterior, Flexor Digitorum Longns,
libia shouldbe irrlernallyrohling as fie kncc flcxei), rhe FlexorHallucisLongus
fcmur musrrotalefastcrandfunherlhan rheribia for knce
flcxionlo occur.Thc grcaterrangeofexrcmalfcmoralrora-
tion allowslhe normalcoupledmolionsto o{rur, as evcn Tibialis posreriorfuncrionsprimarilyduringul!
thoughlhe libia continueslo cxlernallyrurale,i! conslanrly rn(l midsrznce periodsat whichlimc ir eccenrricj_ yc
rcmainsinrernallyroratedrelativelo themorccttcrnallyro- lo deccl€rate suhelarpronarion. Basmajian and
!atedfemur, starcthat tibialis postcriorprovidcslittle assklarcc
planlarflexing the anklear h€ellifr andils rolear
aplcarsro be a 'lesrairinS one" to preventthe
Tibiolis Anterior, ExteNor llallucis Lotrgus, evcrling ercessivcly. The tong digital flc{ors
ExtensorDigiaoruh Longus.and imnorlantrol.s during rcrminalmidstancc,,s ney
PemneusTertius wilh heellift by decelerating lb€ forwardmomenrun
proximaltibia (sG3Fig. 2.14).
The anteriorcompa{menlmulculaturedenonstrales Thedigiralfiexorsconlinuecoormcring rhrouShoul
peakactivityimmcdiatclyafterheel-strikc. Dlring rhecon- of rhe propulsiveperiod, durilg which rhey
tact period.thesemusclcsdccelerat€ ankle nlankrflexion mrillaifl fte digils againslrhe groundand ssrsr
(which allows for a sm(x)thlowering of thc forcfoot lo th€ halluciswithsupinalingthe fooraboutrheobliquemi
ground).wilh tibialisanteriormaintaining theforefoolin an joinr axis.Unlike flexordigitorumlongls andllexor
invertedpositjonabo t the longitudinalmidlarsaljoinlaxis cis l(hgus,tibialispostcriordemonslrates ils mostcli
doring$e ea-rlyaod midcyntacrp€riods.(Cround-reactivc signilicanractivitydurirg rhemnlacrperiod.whenit
forcesmaintainthisinvcnedposirionduringthelateconracr lior\ s rhestroDgesl decelerarorof subralar joinr
period),Thesemusclesa.e 0ormallyinoctivcduriog ntid, andinlernallegrotation(2).
slrnceandagaificorlractdu.ingr€rhiral stance.(Although
Mann l15l noledlhar with running.rhe anteriorcomparF Glstmcnemiusand Soleus
mcn! musclesremain aclive durin8 midsrnnce,during
which lhcy funclionto accelcralc lhe body by pulling the Bulh solcusandgaslrocnemiui demon(rarcpe{k
proximaltibiaoverthefixedfoot.) tivir\ duringterminalmidstance, at *hich rimelhey
B€causcexlensordigilorumlongusandperoneus ter- lion rc produceheellift Solcusnrev€ntsforward
lius ar€ the lirst antcriorconrpartment mu$clcsto contract the lroximal libia (whichdec€lcrates and€lenlually
duringthe propulsivcp€riod(2), lhey arc ablelo dorsi8cx aolle dorsifiexion) whilegaslrocncmius flexesthckn€e
the anlle while simulianeously maintainingthe lbrefoolin plarrrrflcx€sthe ankl€ (which actuallyinilirtcs neel
n proDared positi('naboulthc obliquemidtarsaljoinr axis. The Iemoralorigin of gastrccnenrius dlsoalbws mls
(Exlensordigitorumlongusalso acb to mainlaina com, cle ro mainlaina constantffexion lensiono0 the
preisiveforceon the lcssermetararsophalangeal and irter thro,rghoutmidstance,rherebyprcverritrg
phalangoal.ioinls.whichprevcnts clawingof tlredigils.) mJt'rv.
The rcrminalstance,earlyswingphasecontraclionof Another imDo anl lcrion of thesc muscies
libialisantcrioralsoassistswith ankledorsinexion.but ils duringq)nlactp€riod,duringwhich soleusdccel€raEs
insenionon thc mcdial cufleiformand firsl metalarsalal temrl rotationof the tibir while gastrocnemius
lows il to producesimultaftousdorsifloxiona'rd inve.sion int€nul rotationof thefemur(2). Thesedualactivilios
of the firstray.The cxtensorhallucisltmgusmusclcactslo minrmizethc buildupof torsionalstrainsal rhckn€ed!
maintaitrtensionon thehalluxduringlateslancenndearly the d,,nhct period. Sol€us conrinues td conlrrcl
swin8,whenit behavcsas thestrongeslankle dorsinexor. mid{tnr)ceand into early propulsion.when,in ddirion
The anleriorcompa mcnl musclesusuallydemon- assistingwitlr heel lifl, it serveslo supinarclhc
slrarea bricf periodof inactivityshorrlyafter midswing, joint, sx1sm31yrotatelhc tibia. and stabilizerne
which is followcd bv simuhaneous conkaclionof all of forelirolagainstrheground(whichDaintninslhelocked
thcscmlsclesduringierminalswing(5). This sirnutlaneous eralcolumn).
laleswingphaseactiviryailowsfor mild dorsiflcxionofthe Gaslrocnemiusalso cofltinucs to cofltracrI
ankleand meratarsophalangeal joints wilh exte$or digito- mid\tl0cc and into propulsion, duringwfiich ir assists
rum loflgusandperoneus le(ius re€stablishinsLheforcfool subrrlarjoinr supinarion andexlcrnalfemoratrotat
in a pronated posilionaboutiheobliqucmidlari{ljoinr axis. An imporlantconsideralionis rhat thc rapid
The la!€ swing phascactivityof tibialisanlerjorproduccs plantarflcxion andkneeflcxionproduc€dby 8llstrocoem
Two ldealModonsdurtrgth€GaltCycle 55
Chaple!
iniliationof he€llifl imoarla forwardand uD- Because of its originon lhe proximalphalanxandinsenion
rn |o rhe kn€e thal grearlyassistslhc hip into the distalmehtarsals! $€ traDsverse headof addtrctor
wilh producing hip Rerionard ther€byallows hallucis(tmnsverse pcdis)hasthe primaryfunctionof pr€-
to assisldir€ctlywith groundclearance by vcntingthe metahrsalsfrom splayingas ir puus medially
on lhe melatarsal headsfrom ils stableanchoron lhe proxi-
mal Dhalanx.Failurs of abductorand adductorhallucis
Pemneus l,ongusandBrevis Obliquehead)to compress/stabilize the first melalarcopha-
langealjoint duringthepropulsiveperiodmakesil impossi-
lhc midslanceperiod,pcrcncuslongusand ble for fte lransverse pedismusclelo preveolsplayingof
, pronarory joinl
forceat th0 subialar (brevis rhcmelalarsals asits utlstablcoriginis s€tinto molion.
longus)lhal panially resiststhe supinatory B€cause abducrorhallucishasa signi6cantleverarm
by lhesuperllcial anddeepposreriorcom- andangleof approach to boththe fust ray andobliquenid-
sculaturc.This anlagonisticacliondecelerates tarsaljoin! axes,ir funcrionsas an importanrplantarllexor
subtalarjoint supinarionandallowsthc subla- ol thefirsl ray (il assistsperoneus longusin fiis action)aod
rcrurnsmoorhlyro il{ Dcutlalporirionb} lare supinaloraboutIhc obliquemidlarsaljoint axjs (it is as-
sistedin lhis actionby noxorhalucislongus,Rcxordidto-
of p€roneus longusalsoacls to nabilize rum longus,flexordigitorumbrevis,andquadratus plantae).
thehidfoolasthismosclcworkssynergisti-
Doslefiorlo creatca comDressiveforce on FlexorHallucisBrcvisetrdFlexor
longusappliesan aMucloryandposE- DigiloruE Brevis
its insenionwhil€ tibialisposlcriorappliesan
posteriortbrceal ils irsenion. lhcseforces By virtue of its lendinous inveshenl of th€
, araight compressiveJorcc thsl prcvcnls sesrmoids, fl€xorhalhcjs brevisis s powerfulstabilizerof
lhe larsalsduring late midslanceand early lhc proximalphalanx.lhis musclefunclionswith llexor
hallu€islongusto crcatea compressive force at the firsl
brcvismusclcis also abl€ lo creatca metatarsophalangeal .ioinrandto mainkin lhc halluxagainst
ive forceas il pullsthe lifth melatarsal thegroundduringpropulsion. Flexordigitorumbrevishasa
andlhc cuboidinto rhe c3lcrneus,liercby similarrolein lhatit tuncrionswitb flexordigitorumlongus
lateralcolumn. Locompressthe mctatarsophalangeal joints of lhc sccond
continueto conlractthnughoul rhe thfolgh lifti raysendallowsrhelssserdigitslo mairtainan
prcpulsive period,duringwhichperoneus cffcctivcgroundconlactduringthe proplllsivcperiod.Un-
cs lhe first ray (which improvesground likc nexofhallucisbrevis,fleror digitorumbrevisassistsin
lor thedorsal-poslcrior shilt of the first producinga srong supinatorytorceaboulthe obliquemid-
joinr'srransv€rse axi!) while perofleus tarsaljoint axisduringpropulsion.
bcvis acr tog€lherto evert the lockedlaleral
transfeniog bodywcighl media y andal- hterossel and tbe Lombricales
highgearpush{f0. Becnuscrh€ peroncals
leverarmsb lhe anklc axis, tbey only The interosseifuncriondudng lale midstanccand
wilh anklcplantadexionduringpropulsion. propuls;onto rnaintainlransverse planestabilityat thc sec'
does,however, havea signilicantlcvcrarm ond lhroughfiftb m€tatarsophalangeal joinls and lo com-
i midhlsal jo;nr axis and is theretoreablc lo press lhe proximal phalanx againstthe metatarsalheads.
ion snoouly aboullhis axis during the Thc lumbrical€s havcrheinreresling abiliryto compress thc
inlcrmediateand distal interphalangeal ioints while also
maintaining theless.rdigitsaBainst lhe groundby crearing
uctoradd Adductor Hallucis a planlarflecrory
forc€abourlhe metalarsophalangeal joinls
(2). Becatrsothe lunbricalerendons pass mediallym the
andadduclorhallucismuscl€sfunclion mctatarsophalangeal joinls, theyar€slsoableto generalea
ve periodto stabilizcthe proximalpha- mild adductorylorcc to resislthe abductoryshearforceas'
againslrhe grcund.(They maintair a sociaredwith grouod conlacr.Since rh€ tendonsof thc
lcnsioDon lhe nr$ mcbtarsophalang€al inlerosseipassbelow the transverseaxis of the metatar
are also responsible for traDsversc sophalangealjoints, they act as plartarflexorsof lhe
o[ lhe hallux, as lhcy acl to createeq'ral proximal phalanxand, in conjuDclionwi$ the lumbri-
I €omponents of forcc on the proxi' calcs,play an imporlanrrole in mainreinilgexlensor
resolveinlo purc comprcssive force). rigidiryof thedigilsduringmidstance andpropulsjon,
56 FOOTORTHOS8Slnd O(herFoms of ConscNrrivcFootC!rc
0.lii
****l
\iilh an 8' tibiofibrlar varum coupledwith a 4" subtalar
varum musl pronatc12'in order for the medial heel to
dlakcgroufldcontact.Unfbrtunately, this fairly largerange
of subtalar pronation does nol represent the final rangeof
contaclperiodsrbtalrrjoini pronation.B€cause theforcfoot
remainsinvenedaboLrtth€ longiludinalmidtarsai joinr axis
duringconlactperiod(this posilior is maintaincd by ecccr
tric con(radionof tibialisartcrior),lfie subtalnrjoint must
continuelo pronatean additiodalf in orderto bring the
to
mcdialforefoot the ground.
The graphin Figurc3.6 :ihowsthatthe rBarfoolvarus
defo.mitvproduces dysfunction of lhesubtahrjointprimaF
ily duringtheconlact p€riod, asthisjoint mosroflenftitums
to a stable positionby mid propulsion. The conlaclpcriod
pronntiorassociated \rith the rearfoot varus dcformilymay
producenrjurvpartlybecause {heoverallrangcis so lcrge
and parllybecause tbesubtalarjointmov€slhDughlhis cx-
aggerated rangein lessthaD0.15 seconds(14).Numcrous dcffrnity i\ capableof generatiog rremendous "-^--' r
studieshavc demonskatedthat ex.essivesubtalarjohl torqrc. rhcsr rorccsmust he d".d.;;;;l; I
plonarionmay sofficienllyah€rthe slr€sses bonc.mus- lrsc'ions of a sea)nd.thousa"ds"ll..,l'"1"
rf rimesperdaf..if,their- -
clc. and ligament Lo caus€a wide v{fi€ly 'a of injuries divirlualis to fenain injrry-free. A seriesof f I
(15 l?). (Excessivesubtalar joint pro,ration is dcfin€das jurics rssociatedwlh the rcairoor J:'#';; I
jilu . ilc d in F is u r c s T . '".""
calcnncal cversionequalro or grcaterlhanl3! Il8l.)
I
Jigu.e 1.7. Potenli!l inluier arso.iatedwilh crcesriveflbla. I
l ar pronal i on.A ' l h" -ubtr.rr i ornlttronJre.
ro, onl r,en' ref . I
d roor vJ.u\ dero' r' ry. rhc r.1,, s o' red tu
', " ddL,,"ld I
# ;l:;.',J'"i:TJ"i:ffJ:il"',^i;:ili i'iilii,:iI
iliililitxijl jffi'ijJili.'Tit,
iill ti,i:'.ijJ,H I
#iirl#$iftf:i*iir:i
""';#,'[I
p | J ''d i n | P . o l | v d p P 'o \ i m J l c | y ] ': m n s i d l
crlcineal eversion{31)).M"","r OOr f't."' ,r'it u, tft.'i"*r',i I
mot r)n ofn right-hrndeclscrewplace.ldircctly abnr lhe suL
j oi al .,\r: A \ rhF (al ca.reu.cvcrE .rl .evfth rS hels. II
' {Lr
rh.i IJVourh,-6 l l re rai ,s.l nreri o' l y. W hi l c rhi ' orh-r' i m4 I
rl o' \ ns qn,franl i n ar nve' rderbnr.i r mdv t,l ava .' l i . r l I
' ol e r rhr,,dr\omc(h" ni c5d\so(;Jl .d$rF.\' c(rtc.uhra. n I
i r,n p,o-.rri .n. a. d ' l ero' Ji ' pl J., ac_r ' ,f l hc rd lu( I
/u. . rhenJ' ( ul .!r'dnd l ,c i nrhrc.| ' v-IoInoverorw ndffd I
'
dod tel .,l vetorel ou r J_d f rl h rJys (8). l he rbrwJd I
mor n ol rhc mal i al cuL.nn:rnl .,l c\thc nredi Jlpl rnra'fa- |
, i a. s i r o,r.es i l ensl e l oadon rhi . l .sue l h,,lm.,vs,eed I
i r. f- r(tonrl Jb l h ro.l ol E ,rc rhepl d-l r' ' a{ rd n rl, I
' ...
ri ve\ ncl nsl i (.l h\ w oul d ,cs-\ r,r ncrecse(l l , \ l i ol nA I
'n
ol rl n' dnJr fd-ci .rr nc,i ol c.rl.rn,(hmc_| ,$hi ch .oul o p o I
tent ,l l y l cd,rro rhedc\el opFenlor r hpel\pur. Ih^ dbJL, I
' ory ro\' m, nl ul rhFmedi :l , ol umnr' -' ,l sooc rn' oon- br c I
for irjury, as it crcat.'sa comprersivetorce ar the junctionol I
rh. rd,Jl r' rd l arcrdl coh,al r.l hi c mJy l e,' dro l ron.( nt e. I
' '
me' " ,,,Gophrl dnB edl h.,ei l .5\,l hJ..nl ._d' Eru i l dl rfi ,,l . I
ChapterThrc! Abnontrd Motior d$rlng thc Goh Cyclc 61
placinS a varuswedgeor postunderlh€ medirl foot. lhe Lransvene rotalionof lhe ribia may corfectclinicalsymP-
basically aclsto bring lhc surfacelo thc palient'sme- tornsatthc k[ee andhio.
foo!,mrherthar forcinglhe patienlto proDatein ord€r The obsewalionthat varusposrsdecr€asc tbe range
bringthemedialfool to lhe surface(Fig.3.1r). andspeedof subtalarpronationhasbeensupponedby other
Useof a rearfootvaruspostto bringthesurfaceto the investicators(39,40).ln fact,Sma ei al. (41) wereso im-
ity repros€nts a bNic tenet of orlholic design:A pressedwith the ability of the varuswedgelo cont.olthe
ade onhotic does nol necesssrilyshift lhe bony rahgeandspcedof subtalarmotiodlhartheyrecommended
froma visuallymalalignod 10an alignedpsition; oscof a 12-to 15-mmwcdgein all casualandathleticshoe
x, it aclslo customconloura sur{acethal,whcnpossi- gcar(alfioughthisanglcscemssomewhat excessive, as lhe
allowsfor no,lcompeosaled movementpallornrj,with avcraBe orLholicis not posted at morethan4o varus,i,e.,7
joilrs flrctioning aboutlheir neuaalposilions(n€utral- mm).Schoenhaus ard Jey(42)staledlhatrherearfootvarus
beingdefincdai maxrmalcrngruencya! the ralonavicu posl should oever exc€cd7 (13 Inm), as an angle greater
arliculation wilh rhecalcaD€ocuboid joint mainlainedifi lhan this would producelaleralinstsbility,lhercbypredis-
posilion). posingthepatientto inversionsp.ainof lhe anklc.
Theabilityof lhe varuspost !o oonlrolsubtalarmo- In additlol| lo the coBlrol alforded by lhe varus post,
ha5beendcmonstra@d by Cavanagh e! al. (20). By subtalar motioos can also be modified by makin8 certain
high-specd cinemalography aod forcc-pliteanalysis, chaogesin the shapeof lhe orthoticshel (whichendsjusl
wereablelo demonstrat€ thal fic addilionof a varus prior ro lhe motatarsal heads).ld orderto accuratelymold
rol only decreased thc overallrangcofsublalarprona- thissh€ll(whichmaybe madefrom a varielyo[ materials),
butalsoproduceda msrkedreductionin the angular a foot imprcssionnusr bc taken with rhe sublalarjoinl
y in whish prorationoccuned.Ir addition,force- maintainedin ir,sneutralposition.The positivemodol of
analysis reveal€da ma*ed decrease in medialshear this impression is thendlteredby addingplasrc.|o lhe mo-
ar lhe rimc of inilisl ground contact.Mann (38) dial longiludinalarch, rhe calcanealinclino angleand, it
thal use of a ftedial suppon would brirg nonweighl-bearing impressionlecbniques havebeenused,
a dec.e$ein cve$ion of lhe calcaneus and inlernal ihe ptantarcircumf€rcnce ofrhe hcel(Fig.3.l2).
ofthe ribia.The authoremphasized thalallednglhe Ths additionof plaslerallows for normaldisplace'
menlof thc planlarsoft tissuosduringgroundcontadand,
moreimponao y, il allowsfor only lhat rangeof subtalar
andmidtarsal(obliqueaxis)pron8lioDnec€ssary to absorb
shock:the mcdialaspeclof the orrholicshcll (particularly
lhc calcanealincline anglc)crealesa physicalblock lhal
disallowscxsggerated pronalion.By varyingtheamourlof
plasterapplicdlo lhe positivemodel,the practitionermay
allow(or disallow)anyrangeofsubtaki motiondesired.
In situations in which thed€grceofdeformitygreatly
cxceedslhc deg.e€of the posting angle, a morc gercrous
amounlof plasle.musl be addedto the po$livc model,as
the subralarjoinl will be mod€rately pronatedprior to con-
Figur€3.13.Th€forefootvarusdtformity.
I
:
l
l
Ch.pLerThree Ablormal Motlon durlng the Glit Cycle 65
rigure3.l4.Thcforefootvalgu!deformily.
t0'
l2'
tiSur€ 3.f6. Stancephasemolionswilh a lorefoot varu. ddormil] (eid lind, HS: heel strike;Ffl =
full iorctootload;Hl = heclli,t: IO = toeofi
Manler(30)clsimedrharrheanta or displacemsnl of
lhe hlus widenslhe gapbetweerthe ravicularandsusteo-
taculumtali and is rEspoosiblefor crcaliog laxily of lhe lig-
amentslhat bridg€this gap (primarily the calcaneonavicular
ligamenl and the deep ponion of the bifurcate ligarnent).
Bgcausethese ligaDents are imponant slabilizers of the
midtarsaljoinl, th€ir laiity will allow for incrcasedranges
of midkrsal motion, particularlyabout thc oblique axis.
This actsto perpetuate and evenamplify the instabilityas
3.r8.ConflictinS talarand tibial motion.durin8late lhe forclbot is allowedto abducland dorsiflexftrcugh
period.5|ar- he poinl ol comprcssion betw€en greatcr nngcs, eventually allowing for lhe collapseof the
I trldr dome and lhe arlic{rlarsurlacebeneath
rncdiallongiLudinal arch.This in tum cnablcsth€ subtala.
joinl to prorale througb progessively lsrgcr rangesof mo-
lion, conslanllysupplyitrgbody weighl with r moreeffec-
,) Exccssive subtalarpronationdunnghte midshnce tive lever alm lo maintain the calcaneusin a fully evened
a biomecharical dilemmair rhatthe tibia is mrin- posidon.
i0aninlemallyrobtedpositionasthekn€eextends. Glancy (52) lheorizedthat prclongedcalcancalcvcr-
Tibrrio(51)mentiooed tharthebodymighrsolvethis sion will creatc pcrmaneDi elonSation of $e subtalar
by me8nsof a processhe refefed 10as comp€n- supioatorqwhicheve$tuallylimits lheabilityof thesemus-
internalfemoral rotation (CIFR). If the fenur u/cre clcs !o store €lastic erergy du ng early $ance phase.As
'io rcvelse its wual direction so as to inlemally rctatc C.vagna et al. repeatedlydemonstrarcd(53, 54), the power
midstance.normal couDledlnee motions would be of conceltric coDtrac{ion(which is neccssaryto roturn the
providedthc femurcould inremallyrotatefanher pronatedsublalarjoinl to treutEl) is scriously compromiscd
lie 6xcdtibia.The grealerrangeof intemalfedoral whcn ihe muscleis flot prestretched.lf the resting lelglhs
wouldrcsulrin $e tibia beingin an ext€rnallyro- of thc subtalarsupinatorshave beensufficieny overex'
positionrelative to rhe felnur, thercby resloring cou-
nolions. Unfoflunately,while CIFR solves one
icalproblen,il createsanotheras the internally
fcmurdrivesils lateralfemoralcondyleinto therc-
parellafacet.Tiberio(51) suggested lhat CIFR,if
colld be an importanteliologicalfactorin the de-
of lateralrerropat€lla aJlhralgia.
cJ(ccssivc lubtalar pronation dlring midsranca
to injurybccause of cotfliclingmovcmentpal-
lhe leg aod talus,conlinuedsublalarprona-
lhc propulsive pedod may be even more
as ir hainlainsa Darallclismof the midtarsal
Th6conlinuedparallelismof lheseaxesessentially
en u[lockingof lhc articulations ar a time whon
slrbililyis needed. This rcsulrsin a pathologicol
of thetafsals. ssground-reacliv€ forcespeakduring
Dropllsion: rhe foot is forcedto behav€as a Rexible
ltm mtherlhadas the rigid beamnecessary 10with- fiSure3.19.Sop€tiorandlateralviewsof the rightlalonavic.
forcos. ular ioint. Loadin8of the neurralsubtalarjoinr incrcases
In additionro the inslabililyproduce.d by tho parol, talonavicular stabilityasthe conv€xheadof the talussettles
of orcs,thc talonavicular joint is mechanically less neatlyinlo the con.avenavicular.(AdaoledfromMannRA.
whcnthe subtalafjoint is pronaled.As Mann (38) Biomechanics of running.In: PackRP(ed).Symposium of the
o0l,the concavoconvex configuration of this joint fool andLeBin RunninsSpods.St.Louis:Morby,1982r28.)
68 FOOTORTHOSES
an(lOlherFom\of Consftvrlive
FootCrr.
digiliquh[
Futt Heel
lorolool llft
joinl lo differentdeformiri€s,
depend-
lhc align'nenlof the metalar$als (Fig. 3.24): lf
rcctusis presenl,rh€ metatanophalangcal joint
lo developing hallur limilus/rigidus;
if mctrtarsus
is presenl,
lhc m€lararsophalanaeal joint is prone
fltutc 3.24.With the toot ln . n rnr.l po.ition, rhe lona.i!
v€lopin8h3lluxabducrovalgus. of lhe s€cond m€tatai!.| rhaft may bc €ilher srr.ithr
TheDrlhomechan icsassocialed wilh eachoflhcsede, (metaIa6ffi reclud ot adductrd {met.l.7tu3 .dduclus) r€la-
will be reviewed, beginnin8 with hallux tiv€ to the lon8.ris of lhe reartool.Notelhatreradlessof
lhe metatrrral'sposition,the toeralwaysparall€lthe lon8itu-
Whcn the subtrhr .ioint remaiospronat.d durirg dinnlbie€ction of therearloot.
70 FOOT ORTHOSESand Orhcr FormsoI ConseryativeFoor Ctilc
tdffitCh idb
A BC
rhe s{samoidsare typically separatedby an os" seolr cresr(c). (AdapredftomRoorMc, orion wP, weedJH.
lhe Dlaolarfirst m€hlarsal hcad (A). Subra Normaland AbnormalFuncljonof the Foo1.LosAngeles:
durinSpropulrion do.iillexes and inverts tha ClinicalBiomechanics, I 977.J
| (B),which allow, for araduaI ercsionofthe o!-
a mLichlongerleverarrn to rhe vcnical nlst adaptationof the firsi metatarsalheadasboneis addedlo its
joint axis,allowingthat muscleto disial medial aspectand absorbedalong the laleral articula.
anl4gonislic abductorhallucjs. margin of the distal and doEal fust merararsalhead.These
ionsallowfor thesecondsrageofhalhx ab- oss€ouschangesmosl often ocorr in the juvenile fool and
(whichquicklylollows ti6 ffrstslageandmay areconsisleni with HeuteFvolkrnarnard Delpeches princi-
simultaneously jf a lalgemetatarsus adduclusis ples,i.e.,increased or decreased pressure on a physiswill,
shiltillghalluxalsodjsplaces lhe long flexor resp€ctively,decreaseor increasebonegrowth.
teodon$ Ialenllyrelative1()theverticalaxisoI In the third stage of deformity, compressiveforces
halangeal joint. This allows thcseteo- prodlcedby muscu'arconrracliodoD lhe abductedhallux
wilh adductorhallucismuscle)to prcduce producc a ret.ogradeadduclory force on the first ray (Fig.
subluxation of the hallux(Fig. 3.30).lf a 3.31). This producrseven grcaterdeformityof lhe fust
had
rype been present, this patt€rn ofcompensa- meralarsophalangeal joirl .nd resulls in the formation of a
nol haveoccunod,as later3l displacement of the primus metatarsus adductus with its cbaracterislic
long rendons)is minimizedby the well- cuneiformsplit (c.s.in Fig. 3.31),Roolet al. (3) noledlhal
udinalax€sof the firsl metatarsal shaft and the marked displacernentof the hallux in stage3 r€quircs
the formation of a new aniculal surface on tho fus!
ut thesocondslage,abduclionof thehallux metatarsalheadin order to accommodatethe abducledhal-
Eetztarsophalangeal joint to \riden medially lux. Tbey statedthat a "funclionaladaptation of bonec|€-
laBmllv.This evcnt allv resultsin osseous ales a new qiplane axis for the first metatdsophalangeal
72 FOOT ORTHOSESand Olhu Fdms ofcotr*rvativc FutLC.trc
(3) ever returedlhc lhcorylhal halluxabducto' absorprion with cvenrualpronatorysublur(alion of lhc sub-
niral.Theyirongly cmphasized $ar ir is the ralarjoin!. The individualwith a forefootvarusdeforrhily
deformilyrharp()duccslhc destrucri!ccompen- msy compensate for lhe lack of shockabsorption by shon-
arjoirl pronarionthatis congenital(suchaslh€ oning Lheslride length(which lessensthe inirial impacL
nottheaclualmetatarsoph{langeal joinl d€- forces)andby strikinglhe groundwirh the anklcin 0n ex-
etal-(3) conlendrhaLiflhe prop ls;veperiod cessiv€lydorsiflexed position.This positionallowsthe an'
pJonaliorwerenot presenl, halluxabductovalgus teriorcomDanment musclesrnoretime to assislwilh shock
dsvclop.(Ahhough lhis belicf seems a bil er- absorplionas ftey dcc€leratethe anklc ftrough a largcr
hallux abJucrovalgus dcformily is n€arly rangeof planlarflcxion.
in barefoolcdpopulationsof thc world [64] and
tcd with congcniul anomaliesslch as a Clsssic Signs and Symptoms Associaaedwith the
metatarsalhcad165l and/orobliquityof the Forcfoot Vrrus Deformity
neiform.ioint[64].)
considerarionin rhc pathomechanics o[ the I. A lot+,medial longiludinal arch both on and oIf-
s deformilyrelatcslo lhe inabilityof rhc iib- weiqht-bearingtrilh lhe heek e|e e4 during stdlic slance.
muscleto resupinate an excessiv€ly proraled 2. Modemle-to-nmrked ca us jomtlion under the
int duringlale swing phasc.Becausesubklar second,thir.l, and som.timeslourth ,nztot4'slalheadt n'ith
lhe sublalarjoi axis closcr to lhe insertion a "pinch" calkts or tllontt undcr lhe disaolmedid aspecl
ior (Fig.3.33),rhismusclcis freq'renllyun' oI the pntin^l ph^l4nt. This patem of callus formalion
the subtalar.ioinlin limc for the n€xl hccl- followsa Iincalongthutypicalprogression ol torccsassoci-
n result,heel-srrikc oc€urswirh the calcaneu\ ated wirh propulsive period pronation (Fig. 3.23).As the
moreeverred. Subotniek (66)stared thalfail' tissu€s underlhe c€ntral m€talarsal h€ads are lbrced to sup-
iatea phasicallysoundsublalarresup;nalion poll nrcrc weighr, rhey reactwitb a dilfuse hypcrkcrstosjs.
swingphase will lcsuhin a lossol kinoticshock llcoausea large abductoryforce is placcdon the hallur
whenrheindividualterminates propulsionby rollingoll the
mcdialaspedof lhe proximalphalarx,a shcarirgor pinch
callusquicklydevelops.Whcnseenin children,a mild hy-
pcrplasia ofskin al thislocalionmaybe lhe firstsignol im'
pendinghalluxabducrovalgus (3).
3.Hanne ng olthc llth digrr. In a randomsurvey
of palientsrequiringsurgeryfor conractureof Lhelifth loc,
a signilicanrcorrelationwasfoundbetweenthc presence of
a lorefoorvarusand hammering of the fifth digir (67).Thc
lcasonfof rbis is as thc f()rcfoorvarusdeformirymainlains
rhesubtalrrandmidta.sal(obliqueaxis)jointsin thenfully
pronaredpositions,lbe line of drive sffordedflcxor digilo'
rum longusis alteredallowingir 1opull $e plantaraspects
of the lesserdigits medially(Fig. 3.34).This nedial pull
(which invertsthe more lareraldigits)is increasedas thc
calcan€usevertsbcyond perpendicular as the tendonof
liexor digitorumlongusis slretchedby thc sbifljnBslslcn-
taculumtali(blackarrowin Fig.3.34,B).
when thefifth diBitis maintairedin a varusposition,
a seriesof eventsoccur that oredisDose lo a hsmmcred
digir. Fidly, inversionof the proximalphalanxshills fte
rcndonsof the lumbricalesand the dorsaland plantarin'
lerosseiabovetlte transvcrse axisoflhe 6ih metatarsopha-
langealjoint (Fig. 3.35). (Normally fiese lendonspass
onderthisaxisandacrlo planlarflextheproximalphalanx.)
This newpositionof functionallowslhesemusclcs1oactas
Whenlhe subl.lar ioinl ir in iIs neutral posilion
anteriortendonhas a sicnificanllever arm to
dorsiflexorsof lhe proximalph6lan).,thorebyinitialing a
$blalarioinl. How(,vor,whcn the rublalar jolnl harnmeringof thedjgit.Secondly, inversionof lhe proximal
tibialk anteriork unable to control r!blalar phalanrshiftsthetendonofabductordrgitiquinli underlhe
the improvedl€ve.alm affoded extensordiSiro- metararsal h€a4 maliDgit a phntarflexor,not an abduclor
rhitmusrl€to mainrain rh€subralar joinrin of th€digil. As a resuh,rhc thirdplanlarintcrossei is unop-
lh@ughoutrhe entircswinEphase. posedin crealingmcdialdevialionofthe digil. The new rc-
74 FOOTORTIIOSESandOlherFonnsof ConscaalivcFoo(Clrc
digjllqujnii
fi8ure 3.36. (A) Hanmer loe; (B) claw toc; (C) mall€t lof. Focalpoiotsof pressLrre
and irkrion nlay
DtoduceDainfulc:ll!rc5.
propulsion
andLhenremainsrelativelystation halluciswasdemonstrated by Msnnandlnrnan(68),asthey
temaindero{ lhal period),shlaring forc.s on
rccordedelcclricalactivityin variousintrinsicrnusclcsin
buna (which forms ove. the dorsonedial .ornal ard fla!-footedindividuals(Fig. 3.38).Noricerhal
li|sl metlkrsal hcadduring lhe secondslageof Lheabduclorhalluoismuscleilr the flaFfootedindividuali,r
gus)a.e minimal.If the firsl metatarsal electricallyactivethroughsutall pbasesof slance,nol just
to dorsifloxandinvertthroughoulpropul- duringthe laLemidstance and propulsivep€riods.This lry-
would be trappcdbctw€enlhe dalirg Peractivilyis polentiallyinjuriousand most likety repre-
hcadandrheskin(whichi\ hcldin a frxedposi- senlsan alleinptby rhisrnusclcto decrease th€ ligamenlous
gcar),anda paintulbunn,nwouldrcsulr(Fis. strainsassocialod whh excessivesublaiarand midrarsal
FiSure3.37. Eunion,
IEMC adivily in normal (refi cha ) and flat- Inman VT Phaeicactivity of invinsic musclesol lhe foot. J
tight chztt), t\dapted lmm Mann R, B oneJoi nrS urg1964;464l 3):469481.)
76 FOOTORTHOSES
atrdOrhsrForms
of Consclvatila
FootCarc
Becauserhc normal p.ogressionof forces passesbe- (2 of 25) lackeda calcan$nproces\ard lhe coresponding
|lle distal mctatarsalshafts during the propLrlsivepe- adicular surfaceon the calcaneuswas flat. Thc calca-
(1heyare centcredover lhe metatarsalh€ads and the reocuboidjoinl in this siluationcould allow for greater
theorlholic shell and posl b€comenonfunclionalat rangesof forefooLev€rsion(i.e., forefootvalgus),as lhe
whenconlrolis neededmosl. (AlLhough theorlholrc cuboidwould bc allowedlo glid€ alongrhe flEttenedsur-
indirecrl) fun€tional. as it places thesubralar joinl face of the cdcaneus. (Nonnaly, lbe cslcan€anprocess
nore iavoral-le posrlion durinBmid(tanue, thcreby al serves as a pivot that the cdboidwill dorsiflexand even
themusclesto mainraina stablc posilion more ef- abo l unlil ils dorsalbordercortactslle overhangirgcalca-
, i,e., t]rc conlacland mjdstance period levef arm neus.) The calcamocuboidjoitrt lacking the oalcanean
nainlrins the subtalarjoinl in its fully proDalddposi- proc€ssis classiliedas of the planevariety,which allows
is di$allowed,therebyenabling the supportingmuscu- for gealer rangesof gliding nolion, as comparedlo the
to fuflctionmore eifectively during late statcc usualconcavoconvex coniiguralion typicallypres€nt.
whd hasbecomc$e mostwidclyaccepted theoryre-
lf a smallforefootvarusdeformityis present, the g4rdirg thedeveloprnenL of theforeloot valg$s deformity is
periodproDaliornecessary to bring lhe medial described (74)
by Sglarato asdevelopmental overrotatio! of
to lh€groundlypicallydoesnot produceinjury,as the talarneck.Because the forefootlalgus deformityis noi
velfconlrolledbv the rnechanicallv efficientmuscula- s€enin children,i! is believedthata periodof transitioris
lf, however,a large fore{oot va s deformily is presenl reededto transformihe talarneckfrom lhe vamsposition
grsater than4'), thc addedrangeof propllsiv€period presenlal birthto thevalgusposilionthatappcarsby adult-
olionmayproducea sigrificantshiftingof Lh€anicuh- hood.Althoughthesimplicilyofthis theorymakesi! tenpt-
tharmavb€ responsiblc lor injur:e"suchas inreF ing to accepl,the work by McPoil el al. (1) has aU bul
bu[silis, intcidigital neuroma, and buniofl pain disprovcdthis theory.In theh studyof anslomicalabnor-
bul a Iew). maiiriesof lhe talus,they.ould fird Doconelationbelween
The propulsive period pronation associated wili a the foreloot valgrs deformily and the posilion of lhe talar
vrrJsdelor m hyc an b e p re v e n rc dw i l h w h a l i s rc neck.It is possiblelhat post-mortem changesin the fool
to!3 a comp'cssible post to the sulcus. This addition could be responsible lor error in their evaluations, but this
a continualion of tbc forefoot pos! extcnd€d b€ is unlikely since lhis was a paiticularly well-plann€d study.
lhemetatanal h€ads, endingat lhe sulcus (the baseof Thc Rnal consideration regarding lhe etiology of th€
This additionis madefrom a fiexiblemalerial forefbor valgus deformityrelateslo the formation of a p€s
! rubberor cork)so asrol lo limiLdorsiflexion al the ca/us fool, i.e., Dorlanrl's Medical Dictionury denl]trspes
langerljoints.The comprcssible to sllcus post cavls as"an exaggerated heighrof ihe longitudinalarchof
ndedibr all forefooldeformiliesgrealerthan4", the foot, presentfrom birth or appearinglaterbecauscof
rs compensarory propulsiveperiodpronationby conrracrures or disrurbedbalanc€of muscles."Because rhe
in8 tie orlhoticro remainlunctionallor longer peri- forcfoor valgus deformityis oftcn prescnt in the cavus fool,
1ime. possibleetiologiesfor ils formalionshouldircludc lhose
fu wirh castj0gtechniques rnd laboralaryprepara- eliologiesassociated wilh the developmenlof the cavus
l a d d i tion\$ill be dis c u s s c (l
rn d e h i l i n b l a l c r s (c Iool, nimcly, corgenitalmalformalion,neuromuscular dis-
order,variousidiopalhiccondjlions(sLrch asscarlelfeveror
diphtheria,which may producea discrepancyin boneor
FoR[roor VALcus DEFORMTTY musclegrowth),?ndtrauma.Sincethe cavusfool typically
possesses limited rangcsof slbtalarjoint motion(75) and
Theforefoolvalgusdeformityis rhc mostfroqucntly bocause lhc lscl in the cavusfool is ollen mainlainedin a
fionlalplane deform;tyofthe for€foot.Ir lheircvalua- varusallitudo(niferredto as a cavovarusfool), it is quite
0t 116fecr,McPoilel al. (l) noredthar44.87,of lhis possiblcthar lhe forcfool valgusdeformitymereiyrepre-
presenled with a forelbotvalgu! deformily.In rn' sentsa developmenlal malformslionlecessary{o compen-
studyot 552 leer,Burns(72) notedrhat10% ot all satefor theinvertedatrdrigid rearfoot(Fig.3.40).
planedelbrmilies wercir valgu$andlhal thisdctor' In an overviewoI cavus deformities,Dwyer (76)
morelikcly to bc iargcrthantheforefoolvarus.flt sutcd lhat lhe majoriryof thcsedeformitiesare associal€d
benoredlhatthiswasasymptomatic populaiion.) with .curomuscular disca.scard the iBcidcnceof associa-
Theei(acletiologyof thc forefoorvalgusdeformity lion maybeashighas957, ifmethodsof nelrologicaleval-
somewhat obscurc,possiblybeciuscit is ofmulLi- uatior coold be refired. He claimedthat viral or "olher
ni. h maysimpl) a cong!niraI anomal,in Iaclors"may produceilritalingsLimuliin themotortraclsof
id joint 'cp'uscnr
rhatdisallowsthe normd close- anleriorhorncellscapablcofproducirg variousdegrees oI
posilion.For example,in llojsen-Mollcr'sslldy of oveaaclivilyin lhe irvertor muscles,rangingfiom obvious
$boidjoint (73).87, of thecubojdsevaluated sDasmto cli callv undetectable increases in musclelone.
78 FOOTORTHOSESlnd OlherFormsof Corscdarivcfoor Crrc
Ite maintained
lhntthisdeformityis not congenilal.
thar
lbc rl certral nervoussvslemdischartreifliliales in
thc heel,olten in conjunction\:\rithplanrarfascial
rre. andthatthefor€footvalgusdeformiryis co
in rature. Ir should be not€d tfiat l-ariviereet al.
stronglydisagrc€d with Dwyer.Thcy believedrhrt the
foor valgusis thc primarydeformity,noling that
slrlightetringof the inverlcdcalcancus. which would
suc.€ssfulif $e rearfootdcformitywercprinrar!.hasa
mal707.failurcratc.
Glancy(69) hrd a complctelydiffer€ntoptuton
ganlingthectiology.rf lhe cavusfoot.Hc belicvedthdl
causea high percentage of individualspossess cavus
\rI roulunderlyiDg diseaseor diqorder.rhii deformrt)
Figure3.40. The .avus tool. An inverledheel r.luires valsus havc n geneticorigin and should {herclbrebe considercd
componsarionby the forcloot (via ihsl ray plaftl le\ion .rnd nolnal vsrianr.This concllsionwasslrpponed by Bruck!$
eveGion aboLrtthe longitudinal midtarral joiDl nxis) il rhe (78r.wlosc sbdy suggested ftat crvusfoot maybeassocil
plintn' m€dial {oretool is to .raintai. SroLind.onlact (bia.k
aledivilh a lriadiculaledsublalarioinr.
.r/7owin Ar, lhis cin crenl€a self-perpetuatjng cycle in thar
the mo,e lhe forelooleverls,the mofe the.earloot i, aliowed
to invetl (white affow in A), which exponenliallyirrcr-"aser
Patbomechanics
lhe ability ol peroneuslon8usto act as a firsi ray planlarflexor.
Theexrenrofnechanicalmattunction wirh
assacinled
Sincecbsed-chniDpl.niartlcxionoi the firgi 6y createsa rct
rogradesupin.iory iorce ai thc suftalar joinl, the improved ihe Lbrefool valgusdeformitydepends or thesi7-e
of lhed0'
mechani.al advantaScaifodcd percneuslonp.usmiy allow fornrityandth€rigidilyofthe midfoot.Thus,in ordertodF
lor pro8ressiled€lomity as plantarilexionoi thc lirsl r.ry cor- scril€ the compensatory pa$omcchanics associalcdwith
linuallv litx the rcndoorinto i positionof in(:rers€dinleKion. the lbrefoorvalgusmore aocurately, lhis delbrmityis dl
The inveded posilion of the sr.rbtalar joint also acts lo brins vidr'd inlo rigid and Rcxiblesub$oups.The rigid forefool
lhe oblique mi(ltarsaljoi.rt axis (OMlAl inlo a molF vedic.l vallus posscsses lifiitcd rangesof nidursal and Iirslray
position(8),.^s a resull,sround-reacliveiorceslCRt ar€ un' morionand is orly lrbleto bring th{iplantarforefoorrothi:
ablc to produce ihe fronalory forces necessarvto re"is' rhe groundvia supinationof the subralarjoint (Fig. 3.aU)
5upinatoryiorucscr€atodby the intrinsicmusculature{paltic' whilethenexibleforcloorvalgusis ablelo bringtheplantar
ula y the abductorh,rllucis).Be.auscoi thh. thc forcfootk
tbrefootto the groundvia inversio.aboutlhe longiludinal
allowed ro addrct (bla.k arow in 8), and thc detomrity is
midlnrsaljoint axis and,if ncc€ssary. dorsiflexionandin-
ver\ioDoi lhe fir$lray(Fig.-l.4lB andC). In Burn'ssurvcl
ofvirious fool lypcs(72),hc found707,ofall forefootval-
gLrsdcformiLics lo bc flexible-
Fi8ur€ 3.4r . Patterns of conp€nratiotr for the for€too! lalgus thc ot invenion avail.bl€ rbout lhe lon8irudinalmid-
'an8e
defordly, ll lhe torcfoot delormity is rigid (A), the subtalar tarsi,lioint axjs (a5in C), ihe forefool,in ils allenrpllo nralc
ioinl .r!st supinat. in oder to bring the lnteralplifhr ibrc' grouxlconract, wlll inven iB iull rrnge abortthe lon8iludinal
foot ro the Bround.when a fle)iibleforefoorvalAusis prerenl midr,rrlil joint axis (no|e the central metalarsak),then con-
{B}, the plantarrorefootis ible to make gmund contncl widr- tinw io conrpensate vj.r pronationldorsiflexionand invenion)
oui nil€dlnE subtalarnrotiom as long as lhe rangeof knefooi aborr the first rav axis and ,iJpinati.'n(plantarilexionand in-
inversionis l,rl8€enou8lrto conrpensateior lhe forebot val- vereionlabourthe fifrh ray ixi5 frrlorvs in C).
gLrsdciornriry.llo\lever, ii lhe size oi (he dciormity exce.ds
Three Abnormrl MotiondurinSthe G.it Clcle ?9
Chapter
H €€l l l l !
3,42,Thefl€xibleforefoot val8usdetormily poss€ssing loint axiswill be allowcd to pronatethrotigholl all phas€sof
rrnge of invcrsion about the lontiludinal mid|rsal
H6€llill Eadyproplhion
3.4,1.Motionswith a flerible for€fooI vakus d€foF dorsiflexedand inveded lo allow the luil ranSeot slbtalar
Fss{srin8limiled rang€3of longitudinalnidtars.l ioinr prcnation.(Normally.lhe lilst lay do€s not move durina lhe
intelsion,Notehow rheiksl rayat iull forefootloadhas
80 FOOTORTHOSES
andOtherFomsof Conrrvativr Fnx Car(
Hc€llifi
Figure3.45. Footmotionswith flexiblefo.ctoot valgo3d.formily gre.ter rhan6. (posteriorview of
lh€ right foot).
chaptr Tt@ Abnor|trll Motlo. dudra 0t. Gait Cycle 8l
pulling the exlensordigilorum longus tendonproducod acl uropposedin crcatingflcxion delbrmity of the interpba-
rnarkeddorsiflexion of the proximal phalanx(via the sling), lmgeal joints. The fourth and lifth digits arc panicularly
yet had absolutelyoo effecton movemental the iDterPha- pronc lo clawing,a-sthe low gearFush-offlyPicallyseetr
langeal joints- They slated that the extensor digitorum with rhis d€formity forc€sthe lesscrdigils inlo a doriiflexd
longusbccomesar extensorof lhe inlerphalangeal joints posnion tha!, during propulsion,is amplified by conuacliotr
only when the pmximalphalanxis held in a planiarnexed ol rhe displacediolerosseitendons.Since flexor digilorum
posilion.In therigid lbrefoolvalgusdeformily,lh€ inabilily longLNfires briskly during propulsion as it allemplsl0
of the lumbricalesand extensordigitorum longusto extend rnaintaindigitalgroundconl3cl,lhc inreryhalangcal joi s
th€ interphalangealjoints allows flexor digitorum lotrgusto
ChaplclThee Abrornal Modon durlo8 the C.lt Cycle 8?
8. Diflase kueral ankle and k eepoin, Ttrc ia ing teoadhrosit of the hip. Ideally, dufing lhe lale rnidstancC
andabruptapplication of verticalforcesatongthe posLcro- and early propulsive periods, lhe body's c€nler of mass
lateral hecl dudng the cofltactperiod,couPledwith the reaches peaklateraldrsplacemenl andis thenprojected me.
postaxiallransferof forcesduritg {hc proPulsiYe period, diallyso asto allowfor theconlralaterrl heelslrike.Thete-
subjecrs the laleralankleandkneeto a greaterpotentirlfor rum of the certerof masstowardmidlineis dependenl o!
injury.Because the fibularornally supportsonly one-sixth ade(juatehcking of the calcaneocuboid joint, peroneul
o{ the toralaj(bl weighlborncby lhe leg (98).the increase lonEusaDdbreviseversionofthe laldal columnandglutels
in verticalforcesmay produce3 diffusefibularskessrem- medrus(andupperglutellsmaximus)abducdonofthe hip.
tion wilh the p{rtentialfor conicalhypertrophv asih€ fibula Bccrus€Iheindividualwilha rigid forcfootvalgusrlTicay
atlempts!o accommodatc the€xaggerated workload.Ir ad' possasses limitedrangcsof subtnl4rmotion,feronealever'
dition to slressinglh€ bonc,lhe increff€dg(Nnd_rcitclive sionof thc lateraicolumnis often not possible,andtle hip
forccsmay be responsible tbr praducinga relaliveldxily of abductors mitsltue vigorouslyin an,Remptto Prevenl con-
rhe reslmiringligamenrsat the distallibiofibnlararticdr- tinu.d laleraldisplacement of the cetrlerof massduril8
tion lnd/orjoint dysfunctionat theproximallibiofibularaF prof0lsion.The individualmay lean|lo avoidstrai$ing lhe
liculalion. hip,rhductormusculaiure by walkingwith a flrnowedbNe
The p.op€nsitytbr laterrl knee pain in individuals of e it, which dec.€ases Iateraldcvialionof the centcrof
possessing a ca!uslbol wasdcmonslrabd by Lultel (24).In mas\.UDfortunately, while the nanowbaseofgait reducel
his st dy of 213 runnerswith a varictyof hrce injuries.hc gluLcusmediusstrain,it increasesthe risk of inversiot
noted thal individualswilh cavusfeet werc much more ankl. sprain flnd may even pr€disPoseto , Srealef
likely to sufler ftom lateraljoint spacepain i d iliobirial lrochanteric bur$itis.
bandfricrionsyndrome. Lutter's(24)evaluationwaspaaic- The hip joinl in individualspossessisg a rigid lbrc-
ularly intcresling, ashe demon$trated tbnlnea y 80%o[ all fooLvalgus is also prone to injury becausethc erlrenc
kn€e injoriescould b€ relatedto flulty m€chaticsin the mDpeofcompens.tory subtalar*upinalionoecessnO lo' rhe
foot, with pronato.yfeet producingmedialkneepain and planrarforcfootto mal€ groundcontactmainlainsthcenli.e
cavusfect produci[g lateralknee pab. This linding w.ts low(r extremityin an enernallyrotatedpositionduringall
alsoconoborared by McKenzieet al. (25). pharcsof gail. This placestheheadot thefemurintoa pet-
9. Chroaic gluteus medius strain vtith Wsible os- peturlly retrogradc position whilc significartly rcducitlg
chapr€!ThrceAhno.malMotiordurlngtheCaitCtcle 89
contad bctween the head of lhe tbmur and the ac' It is likcly that th€ potentiallbr the individualwiib a
ulum.As a rcsuh,verticalforcesarenow appliedovera cavusfootto developlow backpainis deperidenL uponhow
suface area,which producesa proponionalln- he or she compensates for thc dcformity: iI lhc person
in pressurcand "unmiljgaledshock"ovcr thc sec wal&swith shortslr;des,is rclativelyinacriveand/orlands
o f l h e J or nrlhat havc rc m a i n c di n c o n ra d (9 9 ). l h c toc-heel,lhe potenlialfor injury to the proximalstruclores
ol such an increasein axial loading is an acceler- wouldbe gr€atlyreduced.
late of articulardegenefalionwith joint spacenarrow- Conver$ly,if the individualwere a distancerunner
(99). Thc early sisns of such a lesion iflclude a wilh a long strideand a hard beel-stike,lhe potentialfor
rsngcof hip abduction silh x-rayevidence ot hish-impacr injurywoulddmmaticaLly increasr
dralsclerosis alongthesuperioracetabular rim. In a case bislory relatingdre cavus fooi to lum-
10.Low baekpain. SovcralauhoN havc claimed bosacralfacelsyrdrome,Builderand Man (80) conlerded
lherigidlbrefootvalgusdeformityis causaiin thc de- lhat the cavusfoot is olten respotlsiblefor low back paio,
nroflow backpain(3,32,80, 100).lt hasbeenas' particolarly\rhen a facilitaledspinalsegmentis presert.
lhat thc "shock-wavc" tiom lhe sudden peak in Thcy dcscribeda facilitatcdsegmentas "one in which the
period ground-reaclivejorces is transferredfron motorreflexthresholdis loweredas a resultof somcsub-
foolandlcg,direcllyirto the low back(3). While il has rhreshoidbombardnentof the motor neuronsat $at level
demonslrated thatlhe incr€ased skelelallransienrs as- of the spinalcord." Th€y cited lhe wo* of Denslowand
ialedwilh lhc cavuslbol may predisposc lo lareralknee Kon (102),who demonstrated elecrromyographically lhat
(24)andlx suessfracturesin the fool or f€nur (22),il tb€ paraspiralmusculatore suppliedby lhe facilitatedor
lever be€nproven thal theseshock-wavespredisposeto "lesioned"seSm€nl was lhe firsl to fire andthe lasl to stop
backpain. In fac1,in their evalualion DI 105 variables tiringin response to a givenslimulusanywherein thebody.
ially rcsponsible fbr Iow back psin, Roncaradand For example,mecbanicalstimulationol a spinous
Ilci (10i) lbund rhat individualspossessins cavus processon an unafl'ected spioalsegmenldid no! stimulale
wereactuallylesslikely to sufforirom low backpain. the musculatlreof ftaa segmenL, but it did causethe
sample groupin lhi5stud)was(r"4randomly choscn paraspiralmusculature suppliedby the facililatedsegment
iects.) ll shouldbe notcdthat Roncaratiand McMullen lo Ere.In theircasehislory,BuilderandMarr (80)describe
Feiss'lire measuromenls to idenlify the cavusfeet an individualwho,despitecomprehonsive consowative care
3.60).lftheyhadmeasured thede$eeof forefoolval' (which included manipulation,sacro-occipilaltherapy
d€formily,rhc rangeof midlarsalsnd subtalarmotion along with a vari€ly of lherapeuticmodalities,i.e., uhra-
d'l) sJhtalareve6ion), and/o' evaluatedthe speed soond,massage, andacupunclure), continuedto suffcrfrom
periods btalarpfonation,rheymighl havefound prolongedboutsof chroniclow backpain.Functiooaleval-
l i g nif r c anr
c or elz lio nw i l h l o w b a c kp a i n . uationrevealcda "heavyheol-6trike" thal produceda visi-
blc jarringof tfie lunbar spinc.Treatmenlwith an ortholi€
possessing high-dersilyrubberpaddingunderthe heelre-
sulled in a marginalrcducriorin paroduring tho first 2
weekswiti an almosicompleteresohtionof symptomarol-
ogyby the l2th week.
Theefficacyof reducingskeleraltramientsin persons
presenting wilh low backp8inwasdemonstrated in a s-year
srudyby wosk andVoloshin(103)in which382backpain
parientswerelrearedwith viscoelastic shock-absorbing in-
serts. An astonisbing 80% of those tr€ated reported
signilicanrlyreducedpain levelswith objcctiveimprovc.
merls in mobitity.Bccauseof lhe \omewhatsurprising
'c.
sullsof Lhisstudy,ils aulhorsproposedtbat low backpain
2 patientsare lessablc to atBnuatethe rep€litiveinlerverle-
5 bral impacbassociated wilh walkitrgandarethercforesub-
jecled to repeatedmicrodamageat the troublcsome
3 .6 0 .r eis s ' line.A li.e i s d .a w n b e l w e e nth e i n fe ri or St-I-5-L4area.
of the medial malleolu5and the distal first metalarsal.
By combiningthe resultsoI Wosk and Volosfiin's
/ine ie lhen drcpped dne.tly lhrolsh lhe navicular
study(103)wilh the evaluationoflow backpainconelates
ldo cd l,*) rnd r, dr\idod in'o equdl rhird\. A
{oolis prcsenlif lhe naviculartubeosily is situatedncar by Roncaratiand McMullen (101),ooe is Inost likcly to
upperborde' of rhe fkrl division while a pronaredfoor 6ndthat,althoughthecavusfoorwill noaproducelow back
oftenprcscntwith a nilviculartuberosltyin the eeconddi, pain in a healthypopulaliofl(andironicallymay evenpro-
Leclagainsl low back pain by timiting the degreeof pelvic
90 FOOTORTHOSES
ard Olh.r Fornsof ConsNativ€Foorc{re
Ortbotic Management for the Forcfool When a flexible fo.efoot valgus d€fornily is
Valg$ Deformity lhe shell of the onhodc (sp€cific.ally,fie calcrneal i
rnglc) will lim cxc4ssivesublalarpronalionwhilc
Whethcr lhe forefoot valgrls deformily is flexible or forcloot posl will prevenl lat€ral instability. Schocrl
rigid, thc goal of ortholic thcrapy is to allo\r' neut.al posi- and Jay (79) claim thrl if initiatedearly enougft,uscof
tion funclion of $e sublalar joint. As wilh the foreloot functionalonbotic will prevenlseverehalluxaMuctus
varus dcformity, rhis is besl accornplishedby taking an in- bunionformation.
pressionof the foot that accuratelycapturcsth€ forefoot- When the for€foor valgus deformity is rigid, thefot!
rearfoot rclalionshipwhen the caicaneocuboid joint is foor post is idvaluableduring propulsion,as it assistsin $a
locked snd the talar head is mainbined behiod th€ navicu- devdopmenrof a hieh gcar push-off by shifrinB the ple
la-r.A posilivemodelis thenobtaioedfrom thisimpr€ssion, greiiion of forcesmediallythrcugnthe transvcrsc axisof
and lhe appropriatechangesare madeto allow for soft-lis- thc rnetatarsal h€ads.Us€ofthe high gearpush-otlwillin
suedisplacemenl uponweight-bearing andfor thelowering pro\e the windla$seflecrof the plantarfascia,di$place th.
of lhe medialloDgitudinal drchrecessary for shockabsorp- trRn\ferof propulsivcpcriod forcesawayfrom lhe poslrrdal
lion. Afier rhesechangcshavc beenmadc,which are dis- fibolfi bordcr, and mioimize stretchingof thc more latenl
cussedmore fully in lhe laboratorypreparationsecdon.an interdigitalnerve$as the lessertoes doniflex througlt
orthoricshell is moldedalory the plantarsurface,endirB smallerrangcsof motion.The forefootposlwjll alsobc.f.
just proximal io the melatarsalheads.An angled\rcdgc or fecti\€ durirg the contacl period as il preventssupindory
post is thenaddedto the plantaranterolateralshell, bringing comEnsation by thc sublalar joint, as thc lateral forefool
thc biseclion of tbe readoot to a venical po6ilioo (Fig. will now be supponcd.(Ihis a[ows for a morecqualdhri-
3.61). bulir)n of grourd-reaclive forc€s benealb the meta|alsel
This ot)61should never exceed 15". as shoe 6t b€- headsthatin tum l€sse$lhe polentialfor melatarsalgia.)
comesa problem,and the distal lateral shell night dig ioro Ir must be stress€drhat even thougb the fo.efool val-
tbe shaftoflhe fiflh metatarsal. Whena largcpostangleis gus tr)st preventsexcessiverearfoot inve$ioo during thc
neces\aryt rhe posting should b€ extendcd onder thc cont:rctperiod, it is unableto provide fte continucdmnSc
metatarsalh$ds. (As noled previously, this nddilion is re- of subtalarpronationrc€-€ssaryfor adequateshockabsorF
fened to as a compressibleposl to sulcus).Allhough the ex- tion. This is b€causethe lorefoot post sbouldonly be larSr
tended post may produce difficulties with shoe lit, il will enotgh to briog tbe subtalarjoina Io its neutralposition.
decreaseslrain on the later,rl metataFalshafts.as a grealer While ovcrpostitrgrbelat€ral forefoot to irduce the rangrof
percenlagc ofweighl will be bomeby themetalalsal hcads. subrrlarpronationnec$saryfor shockabsorption wouldbe
Also, thecompressible pst to sulcuswill allowfor contin- idcalduringih€ conlactp€riod(assuming thesuhtalffjoint
ued o holic control lhiough the propulsivc period as the werc able to pronatethis addirionalrange),il wouldbe
progrcssion of lbrc€sremainscenteredover rhc compres$- detrimentalto do so dunng early propulsion,m il would
ible post,Withoutdrisextension, rh€foot with a largeforc- forc(tully maintainthesubtalarjoi[t in a prcnstedposition
footvalgusdeformity (e.g.,greaterlhall40)wil] tip late.slly as vd(ical forcespesk (Fig. 3.62). This sltllalion€ould
into sopinatorycompen$tionthe momenlbody weight is evenuallyrcsultin a permanenl clongalion(plasticdcfo!'
o @@@@
Figur€3.64. (A) ld..l alignmentof the m€tararsalheadsr(B) hann. which would normally be nraintainin8tdlonitvicuhr
a plantarllered third nerarars.l; (c) a dorsiflcx€d first con{uen(y. hasbeenrenrovedjn oder to improveclarity.
metalareal;(D) a plantarfieredfifth metalarsal.Note:Theleft
Lheplantar lbird me|atarsal head and the fleighbor- Bccauseihe congenitaldeformity is so hrge, it basa
intcnncrrtarsophalang.al bursaearc proneto iniury as grerterpotcotialfor producinginjury.lnfact, Roolet al. (3)
aresubjectedto grealercompr€ssiveand sh€arlorces' claim€d thal the congenital plantarflexed first ray is the
clively). mod commo'| clruseof compensatorysublalarjoint supina-
tion,andtheyrelaledthisdeformityto thedeveloPmenl ofa
On the conlrary,if il had beenthe fifth mehia.s&l
cavus foot type. They slaied that when a congedlal pl,n-
tharhadb€€nplanlarflexcdandthe liftb ray wer€ rigid
unablctoatlowthetifth mctatarsal headlo relum10lhe larflcxedfirst ray is pr€sentin a child,the 6rst ray andlon-
uansve6eolaneof lhe olhermelatarsals, the risk giludinalmidta|saljointaxisalmostalwayspossess elougi
wouldgreatlyincreasc, aslhe subtalatjoinl would motion to compensarc for lhis deformity (Fi8. 3 69) How-
lorcedinto compcnsalory pronalioDitr an atlemplto
the medial forefoot lo lhe ground (Fig. 3 66). This
b€haves identically io the forefoot varusdeformity and
subjecled lo the sam€Potcntialinjuries.Fortu-
althoughdefecb in lhe aligomentof a lesser
msyproducepotentiallyinjuriouscomp€nsalory
th€sedefeclsarenot verycommon.
srotions,
H.€lllt
3.66.A rigid pl.nL'flered fifth netalrrsal .equi6 evertcd durinS the contacl period, and subtalar funclion
subt lar ioinr ptonalion in otdet to brin8 lh€ would not hav€ ben comprcmised(althou8hthe fifth fav
tor€footto lhe Eround.Note lhat thc.ublalaf ioint is movementwould mon likelv resuhin a lailor's bunion,as the
in€d in . pronatcdpositionth.oughout 3tancePhas€. dolsolatelal bu6a would be rcpeaiedlv sheared betw€€n the
fifrh wefe flexible,il could havedorsiflcxed and rctatingmetatatsatheadand the skin/shoeSear)
'av
94 FOOT ORT}IOSBSand Olher Fodnsof Cotrsrvative Fool CdIe
tiBu'e 3.69. When the firs! ray and midtaFrl ioinl po$ess fig!.e 3,70. Age.relatedd€creasetin first ray and midtanal
adequaterangesoJmotion,$ey are able to JullycomPensate motion fo.ce rh€ subtalarioint into compensrtorysrPi0a.
for th€ planlarflex€dfirst tay deformity.
ever, as the child reac}esagos 7-15, the range of molion pos\ibleetiologicalfackxs associal€d wilh th8 acquicd.
availableabout lhese axes lessens,and subtalarjoint planradexed firstral,deformilyare3sfollows.
supinaiionis nece$sary to c'ompensalefor thePlantarflcxcd l'lac.itl l{'rallsis or etteme $eaknessof gaslrome.
firstray (Fig.3.70). mi{r. CoDditions suchas polio or surgicallengthening of
This hcginsa cycle in which inversionof the rearf{Dt therchillestendonoftenresultin a marked weakness offie
iflcr€ases $e mechanicsl advanlage alTorded Peroncus gasrrocnemiusmuscle.crhe weakncssassociatedwith sur'
longus,which in tum allows for ar amplificationof thc gicallengthening is only temporary)If for any re8son gas-
plantarflexedfirst ray deformit],. This increasein first ray toclemiu$ is unrble to functiot properly during late
planiarffexio. createsa retograde supiDatorytbrce thal in" nidslance, the long digital flexors aod peroneus longls will
vertsthe rearfooievenfinlherandallo'ts lhc obliquemid' 6rc vigorouslyin an attemplto produccheellift Bccnuse
taNaljoint axis to shift into a moreverticalposition.With thescmusclesare such weak ankleplantar8exors,theyonly
the obliquemidtarsatjoint axis in this new Position,th€ succeed in cla\tingthedigitsandplantarflexing lhelilsl ray.
forefooris allowedto adduct:the mcdiallongitudiflalarcll If tlr;scontinuesover a|l exlendedPeriod of time, an ac'
heigbt greatly increascs;th€ tocs claw; and a pescavusdc_ quirlrd plantarflexedfust ray deformity develops.
fonnityeventually forms(Fig.3.71). Hfpenonicilf of peroneus lortgr6, Any condilion
Although the acquired plartariexed lirst ray defoF lhat causesparn upon dorsiflcxiotr of the lirsl ray or itrver'
mity tendsto be muchsmaller,it is oflen sssociatcd with sion aboutthe longitudinalmidtarsaljoinl aris (suchasan
compensatorysubtalu supinatioDand may thereforebc rc- inflalnmatory rcaction al the first tarsometalat$alaitcula'
sponsiblefor ifljury to lhe proximalstructures.A list of the tion or a cuboidthathasundergone subluxation) will lctult
ChaptcrThr@ A.bDomrl MoltoD drrhS th. G.tl Crde 95
LAF
3,71.Invc.lion ot thc r?..foot (A) brinti lhe obliqu. clawind of the digirs{D). lr is of note that the acquhedplan-
r.l ioint .Iis into a more v.rticrl po.ition (B), which tarilexedfirgt lay, which is much morc common, never re'
thefor€fooito adducl (C).Sincethe lo€salwaysparal- quircsenouShsubtalarjoint supinarionto addld the ioreloot
lhe lon8iludinalais of rhe fool ltAD adduction of tho aboutlhe obliqqemidtarsaliointaxis (OM./A)or reverelyclaw
will res!ll ln a proportionalabducrion(with resultant rhe toes{l).
n 3.72.Ao uncofiDensated
rearfootvaru..Th€slbtalar rigur€3.73.An uncomp€nlat€d for€footvarus,Thesubtalar
is fully pmnated,and the medial londyle ol lh€ cal.a- joinl is tully pronated,
andtheplantarmedialforefoot
ha5not
hasnot made8rcund cotrract. madeEroundcontact,
prol€clivctonic sprsm of peruneuslongus.Becauseof varus fool type lacks the range of eversioo ftccssrry lo
lo thebaseof fte lirsl mctalarsal andmedial bring tbc medial calcancus!o the grolnd, it is refenedlo as
an acquiredplantarflexed nr* ray may quickly tn uncompensated rca ool vaflls (Fig. 3.72). SiDilarly,
Thehypertonic peroneus longusis roadilyidentilied, whcn thc subtalarjoint in an individualpossessing a fore-
rapidlypronaksthelbot du.ingswingphas€. foot v|rus foot type is unableto bring tle medial forefool lo
Flaccd patulrsit or exlrcme ecal essof libiatis an" the ground, it is refen€d 1o as an uncompensatedforcfool
I Weakncss of this musclewouldallow the antaeo" vrrus(Fig.3.73).
petoneuslongusto planlarffex lhe firstray. Allhough thesefoot typesare discussediD a latsr s6c-
Pr.t ncc of an ancomwnsst.t rca4fl or fon[ooa tion, lhcy will be briefly discussednow as lhey are almosl
dalomir. when $e subtalar joi in a rearfoot alwaysresponsible for an acauircdplantarflexedfirsl ray
9(r FOOTORTIIOSES t'borCrre
andOthc!Fomsof Conscrvative
H€61
llft Toeoit
3.77.tool molionswirh a flerible Dlantarflcred
first thefilstmelatalsalheadduringthe.onlaclperiod.Nomally,
. Nole lhe qrdden doEiflexion and inversionol lhe firrt metaialsal
doesnormoveduringearlystance.
H€slSnko H€dln
Fi8ure 3.79. stancc phase morions wlth a rilid plantarflercd firet ray d€fornity.
able rc move to the common transv€rseplanc of lh€ le scr As demonstrated in Figurc3.79.whenit isablet0,
melatarsals, theenlirelowerextremitymay b€ prone!o in- sublalarjoint will pmnaleduringlhc propulsivep€dod
jury, as subtrlarpmnalioocom€,s to m abrupthalt lhc mo- an i!(empr ro minimizerhe latcral instabilily.whilc
mcnt lhe plantarflexed nr$ metatarsal mikes gound lesscns$c Doslaxiallraosfcr of forces and decreas€s
conract(Fig. 3.79).The entirefoor acudly rip6 lalerally. risk of inversionsprain,it may predisposeto olherinj
the.eby transferrin8ground-reactiv€forccs from the firsl to as ir unlocksthe midtarsaljoint at a time whenvert
the fifth metararsalhead.Becauselhe fifth ray pos6€sse-s its forc.s re peaking.This mayeventunllyleadto a
own independenl axisof motior, thelifth metalanial headis cd lnrily oftbe supportingligamcntsandjoisl crpsules,
typicjlly able lo dorsinex atrd evert into a sale posilion the rarsalswill bc allow€dto shift wilh the applicalion
(Fig. 3.79. FFL). While this l€ssensthe potenthl for injury propulsive pcriodgmund-reactive forces.
ro rhe fifth melalarsal h€ad, it iltcrcrse3 intermetatarsal
shcsr (predisposingto intermetataNophalangeal bursitis) ClassicSlgDs
andSymptoms Associaaed wilh ahe
and often r€sults in the formation of an advcntitous bunia PhDtsrfleredFlrst Rry lreformlty
along rhe dorsolalcral fifth metatarsll head (j.e.. tailor's
bunion). The claalic signs and symptomsassociatcdwilh this
Of muchgreaterclinical significance,lhc suddencon- deformily are depcDdenlprimarily on the rarSc of motiot
tact period subtalarsupinatiotrnecessarylo cotugersalefor available to the first ray. If lhe 6$t ray is fl€xibl€. thc foli
thc rigid pladarnexed first ray createsasynchronous movc- lowrrgsignsandsymptoms rhouldhe crpcclcd:
mentpalrms betweenthetalusaodthesbanl(i,e..th€ralus 1. A ncdium-to-high nedid loryiadinol aftli
is forcedto abductwhile the sha[k continuesto interrally hei(ht otl-vcight bearing with d miulo-ntodcrale loveF
rotate) and results in the .apid lransfer of forc€s along thc ing oflhe arch upon t cigh!-bearin9.
postaxialfibulff bordcri lhis foot behavesidentically 10the 2. LIild dllluse cdlhtslomaion under th. N
rigid forcfmt valgls foot iype a is lhcreforesubj€ctcdlo mskllssdl h.dd wilh r iL^tcr d.Ee locaftze.t.all&s
some injuries, i.e., slresstracturesb lh€ fool, laterul ankle the seconl rnclahttul hed. The nild c.llus cenleredbc-
sprains,laleralkneeprin, lateralachiUes pcrilendinitis, ctc. neath the first metatanal head rcsults frcm the prematur!
ChaplcrTtre€ Abnoi|trd Morlondurl!8 th. Grl. Cydc 99
(which is repeatedlycompr€ssed
againslthe lateralhccl merI of rhe lourlh and Dflh mer rarsalsrelalivcro
ond and lhird mclatarsats (Fig. 3.82). Tlis rc.ulti
2. Moderateno-narhed callus lon ,d,li.m under the chn nic shearingof the inlermcutsrsophalangc8l
f,st, fqfrh, and sometim('sfounh ,netalatsal hcad. As cntcdbetweeothe third aodfourthmetatarsal heads.
demorlstratedby Cavanaghet al. (107), pcak pressure.s be- diti(,n,becausethc rigid plantarflexed first rry
neaththe forefool duriog slalic stanceare oormally grcarest mainlainsthe foot in a low gear push-off
direcdy below the s€condor third metatarsalheads(sesFig. prolulsion,thc iatefdigilalncrve(whichmayakeady
3.81A).However,whcaa rigid plantartlex€d 6r$ ruyis present, ritarcdbv a swollenbursal is oflcn tethered
the foot absorbsground-reacliveforces like a lripod, with rran\\erscligaf,enrby lhe dorsiffcxing ierserroes.
weighl-bearingpoinl't cenlerodbeoeaththe lirst and 6flh 5. M.totartus adduclut tl,iIh digital
metatarsalheadsand benearhthe posterolateralplanlar cal- Whcn a large rigid plantarflexedfirst my dcformity
caneus (Fig.3.8rB). sent-the exaggeratedrangeof compeNatoryr€arlooti
This drasric?llyalrcreddi$tributionof ground-rcac- sionofre forc€sthcobliquerhidrdrsal joint axisinb a
live forces may sevcrelylraumalizclhe first and fiflh venical position.Thc vertical displacem€rtof this
metatarsal heads.Thc libial sesamoidis panicularlyprone Iows thc forcfool !o adduct (which, over lime, lea&
to inj!ry. as th€ ffrstray is usuallyevert€das well as plan- melxlarsus adductus deformily)rnd causeslhetocsto
tarflexed.whichallowsgrouodco[tsct for the mediallbre- (refcrbacklo Fig.3.71).
fool tooccurdirecllybelowlhis scsamoid. Thestin benealh Alsr,,b€cause lhe medialhngi0dinal archhei
lhe firsrandfifth mctatarsal hcadswill llTically respond|o crfl\es aslhc forefoolsuoinnres ahoutthcobliouc
the markedincreascin gruund-rcactive forceswith r reac- joinr a,{i!r,the metalaasalshalls becomeprogressively
riv€ hyperplasia rhatcvenlrallyleadslo Iheformationol thc planrarflexed, which in tum allowsgroond-reaclivc
charactcristicall]' dcnsc,oft€n lucleatedcallus panern.If to d$rsiflexthe proximalpftalanx.This setsthe
the fifth metalarsalis llexiblc,ground-reaclivc forceswill ercn greaterdigital conlraclure,ns lhe interoisei and
also be distributedlo the founh rnetatarsal hcad,wher€a bricrle rcndonsnrc displac€dsuperiorly,andflexor
Icsslocalizcdhyperkerakrtic lesiol mayfo.m. rum longusis allowedto acl unopposedin cla\ritg
3. foilor's br,nion or buaionrlrz. while fifth ray int€ryhalangeal joinN.
dorsiffexion andeve$ioowill decreasc th€ ootcntialfor in- The hallux is particularlyproneto clawing
jury lo lhc fiRh mclatarsalhead.it will incrersethc poten- lhc often severely pla arflexed position of the
iial for roilor'sbunionas lhe dorsolateral bona is sheared metllarsalshaftforcastheproximalphalanxintoa
bctweenthc rorstiogmctatarsal hcad.lndrhesl,in. ofe\lrcne dorsiflexion(Fig.3.83).In fact,it is not
4, lnacdigiul neurot ro andtoe intomelalarsopha- mor for a larg€ dorsal bulsa to overlay lhc firsl i
langeal bu'silis. In addition to inilating lhe first and fifth l anpdal j oi nt.
metata$alheads,the tripod arrangemenl l'n dissipalin8 6. Sigl,'s and srmptonr nslociated ,! h the
ground-rcactive fofccswill allow for a superiordisplacc- forcJbor ealsLsdetorniry. Becausethe\c rwo
behrvc alm'xt idcntically,lhey sharemany of the
sign. and sympbms.c.9.. lalerallnee andanklepain,
venironsprainsrlateralcompaflmentsyndrom€,low
@@@ pain.etc.
3.84.The 2-5 bar posl. A forcfoolbar pon la bar post differcnttermsto det€rib€tha 2'5 barpo6t.Eecause $e plan-
an unanElcdIorctool ponl is situatedbcnealhthe tadered ti6t Ey defonnilyb€haveralmostidenticallyto the
ol rhe secondthrouShftlth metata.sals. The por. forefoolvalgusdefomity (particularlywhen the plantarflex€d
he bar po5tthal would normallv exrendbeneaththe filsl lay is ri8id),manylaboErories prefurthat)ou referlo the
firslmelatarsal
shafrk "cut-ouf in orderto allow lhe 2-5 bar po6ras a for€foolvalgusposl with a iirst ray cut-out.
rgalhcdd lo reet In iN planrarpositionthencelhe The deareeof postin8 necessaryto accommodatethe tilst
of the bar oon js deteF
2-5bar oosl).The thickness melatarlalhead is determined by measurinS the de8rceof
the
by dlstanc€ b€rw€enthe lilsr netatalsalheadand forefootvalgu3betw€onthe firstand fifth met.tar5alheads
lransvelseolane ol the lessermetatarsals:lhe andthe plantarcalcaneus /ar8leX in C).(Thetool ,houldbe
of sufticienl
heishtso tharth€ tirstmetatalsalhead maintain€d in ils neutralposilionduringthis measurern€nr.)
goundcontad,and the raSittalbiseclionof the rea.- Whileit is moreaccurate to referrjothisaddnionasa 2-5 bar
ical.As with all forefootpons, shoe tit is the limit- post (aslon8 as lhe rarond lhrcu8h fifth metataGalsa.e nei-
, anda barpon Brearer
thanl0 mm is oftendiflicull therin valEus orvarus),eitherapproach is fine,andil is really
ll should be ooted thar dificrenl laboratoriesuse justa maherof semadica.
tar first melatarsalheadno longtr stikcs lhe groundprcma- vali ut, \ursicalreferralfor a dorsalbase
closins
turely.The 2-5barpostis inv.ttuable whenucatiogtherigid teok)my may tre nec€ssarylo con€cl the mcchanical
plantarffexedfirst ray defomr'ties as,dudng th€ contacl p€- tun.lion. Rootet al. (3) not€drhatwhenperforned
riod, il atlowsfor lbe continuedrangeofsubhlar pronation adolcsccncc or edrly childhood,this operatioroftcn
nccessaryfor idequale shock absorption.When tr€ating a ducls a sponlaneous reducdonof the cavusdeformity
rigid deformity,Langer(108)recommends addinga(f rear- 3.8r).
foot posl to stabilizcthe heel(Fig. 3.85)and incorporating In coniurclion wift onholic thcrapy,various
shock-absorbing mrterialintoor rndortheonholic. lile shouldb€ usedro bredkdowo any soff
'cchnique\
The 2-5 bar posl alsoservesan importantfuoctionin adhcsionslhat may be limiting joinl motion.
the tieatmcntof semiflexible andflexibleplantarflexed 6rst pad, larly in uncomp€nsaled forefootandrearfoor vdrs
ray deformities,as it preventslhe excessivedoNiflexiol fornitie.! resultingfrom lraumaor prolong€di
rnd inversionof thefirst ray thal is so ofteDresponsible for it is possitJleto resloresublalar/nidtarsalmotbn to a
injury, e.9..abduciorhaUucismyosilis,intermehtarsopha- whi(:h lhe acquiredplailarflered lirst rry defornity
lang€albursitis,bunionpain,etc.If theplantarnexed d€for- If this doesoccur.the 2'5 bar Doslandsub 1 balance
mity is particrlarlylarg€,orthoricconlrolcanbe exlended be r,rnoved. However. reduction of urcomDensaleri
illto lhe propuisivepedod by extendingI comprcssible2-5 typcs rarely occurs.as they are most often associat€d
bar postto lho sulcuswilh r balancefor lesior beftath the tixed osseous deformily(panicularlyin older
6rsr metatarsathard (Fig. 3.86). Bec|oseof this,thegoalof manipulation is mi roforc€
This balnnceis a cusiom-madepocket that supports Dlanrirfliexed firsl metatarsal head back to ihe
the lessermetatarsals andallowsthefirst metaiarcal to drop tran\verse planeof lhe l€ssermetatarsals, but ralh€r,lo
into a cushionedwell. (Ihis is panicularlyeffectivewben pro\c flexibilityby br€akingdowr polentialypainful
treatingsesamoidpain.) When used in the rreatmcnlof tissueadhesions(evenslight improvementsin fiexibiliiy
seminexibleandRexible6rst ray d€formilies, this addition resultin dramaticrcductions in symptomatology). U
preventsthe suddenfirst ray dorsmexionand ijrversionthal
would otherwis€haveoccuned during the early propulsive
period.This in tum protectstle secondmetatarsalhead
ftom tauma and decrcas€sthe sh€aringof lissuesneighbor-
ing the fir$t met:tt|rsal.Whetrusedin the treatmetrtof rigid
plantarflexedfrst ray deformitics,this addition prev€ntsthe
compensatorypropulsive period $ubtalar supination thal
normallyforcesthc foot into a low gcsrpush-off.Thisdras-
tically r€ducesthe risk oI invcrsioranklespraiN, lateral
ankleand kneepain.lateralachillesperilendinilis, and ir-
lerdigiialneuiiris,asthe heelis mdntainedin r moreverti-
cal position and the toesare no longer htperdorsiflcx€d.
Urfortunately.lhe size of the deformitymsy occa-
sionally erceed the accommodativecapabilities of tbe or-
thotic. Sgarlalo (74) nores rhal when A rigid plantarflexed
firsl ray exce€ds10" (as ncisured by degrecsof forefoot Flsur€3.86. Thc sub1 balanc€for lesion.
manipLrlation were lls€d to r€lurn a congenitalplan- dcformity is refered (o as a pladarnexed forefool, and
firsl ray ro the l€vel of the less€rmelata$als!a Roorcl al. (3) claimit is thercsultof conge tal malforma-
larity of lhe planlar tarsomelatarsal and/or lion of the tarsometatarsal joints or midtarsrljoinr (al-
jointrestraining ligamenrs wouldresuh. thoughit se€mslikely tharit may alsoresulifrom acqoircd
Keepin mind tha! the cong€nitalplantarflexed lirst uppcr motor oeurco dysfunction). The plantarflexedfore-
in its mosl sBble Dosition funciionally when il is foor lypically prodrccs a markedclawidg of the digits sec-
(i.c.,it possessesequalrangesof molionboth ondary to lhe incroasedmetalarsaldL,€lio€angle and is
andplantarly),andfie goal of cooscrvalivc treat- ofleo rcsponsiblefor irjury to the anteriortalocnrralarticu-
shouldb€to accommodate, no! alter,thisdeformiry. lation and/or podteriorknee,as the ankle is rnable to pro-
vide the dorsiflcclory rangenecessaryto compensalefor the
of the Plantarflexed lrsser Metrtrlsal plartarflexcd metatalsals(Fig. 3.88).
Cons€rvative treatmenrof tbi! d€formityrequircsa
Thusfar,lhc describedmethodsof oahoticmanage- heellift of sufficienrheightto allow ihe tibia to tilt a mini-
havebcenlimited ro treatnent of the Dlantarncxedfirsl mum of 10' forwsrd from vedicsl. Rarely,the forcfool may
. llowever.lhe samebiomechanicaj principl€sus€'l bc so sevcrelyplsnlarflexedthat surgicalintervenlionis
d|e planlarflexedfirsl ray can also be applied n€cessary lo realiSntbemelararsals.
oneof thelcs\crrals is planlarflexed. For cxample,if
metata6al wereplaotarflexed, a bar postshouldbo Trcatmentof the DorsiflexedMetrllrsal
bencath lhe dishl lirst throuphfourlh metatarsal
(or,phnseddiffcrenlly,a forefootvaruspostwirh a Lasrly, allhoughuncommon!it is also possibleto
cuFoulshouldbc used).lf necessary, a sub5 bal- havea dcformityin whichorc or moreof themetalarsals is
lesioncao be added10 controlpropulsiveperiod dorsiflcxcdrclativeto the commor transverseolane.As
us€of lhis posrwirh a flexibleplanrarflexed fifth with Dlanlartlexed metatarsals. the dorsiflexedmetatarsals
decrcase thepainassociatcd with a lailois blnion, may be congenital or acquiredard canbe differenliared by
fiflh mctalarsalheadno longer doFiflexcs and €ve(s ch€ckingthe availablerangesof dorsi and plantarmolion,
lhcconlaclperiod- i.e.,the collgeoilaldeformity(which is usuallylargeopos-
Whenuscdin the rcatmenlof a rigid planlartlexed sessesequal rangesof upward and downward movement
ny, lhe bar posl preventscompeNalorysubtalar (Fig. 3.89A) while the acquircddeformitypresontswith
(rnd all of lhe potentialinjuriesassociatcd wilh asymmctrical dorsiplanlalmovemenlpaltemsthatvary be-
as il suoDonsihe medial forefoot and accom- tll?een tbetwo feet(Fig.3.898).
lie plantarpositiol of the fifih melatarsal hcad.lf lvhen the 6rst metalarsalis doFiflexed relaiive lo the
becnrhethirdinsreadof lhe fifth mers|arsal tharwa$ lesser metatarsals,it is also refencd to as a melakBus
keatmenlwouldbe assimpleasddiog a bal- prinus elevatus. Wbile the acquiredform of this d€formity
lesion(or a sofraccommodaring marerial)bencath mayoccasionally resuhfrom a tonicspashof tibialisante-
rior, it is mosloflen the resultofa chronicallyevert€dheel
Although nol discussed, it is possiblelo havex defor- that req0ircscompensatory firsl ray profllion. Over time,
whichBll of the meialarstlsarc plantaffiexed. This bony and soft tissrre changes occur thal mainlain the
loa FOOT ORTHOSFSand Othq Foms of Conseryalivclool Care
at
cocoMJ OCCg
figure 3.89. when sL€ssedsuperiorlyaod injeriorly,lhe rangosot do|si ard plantarmovement(A) while theacquird
.oruenital dorsiflexad first metalanal will display €qual d€formitywill Foss€se asymmorricalmolcm€ni patt€rnr(8),
Chapler'thrccAbtromslMotlondlrlrg lheGaiaCycle 105
l{t6
ChapterThree
Abdoml Moliondu.ingth€Glii Cycle 107
createproblemssincelhe rearfool postir this situa- undlteredby eitherthe forefootor rearfootpost.If a flal
can conlrol sublalar molions only durin8 thc contact rearfootpost is addedto stabilizethe heel (th€ posl is flar in
midstancc ocriods.After that.thecontrolafforded thatit doesnot changethe angleof rhe orthoticshell),the
rearfoot postis losl,andthesubtalarjointis forcedto ortholic in Figure 3.94 wilh the larger forefooi varus post
ly pronal€ir compensationfor the rearfoot defor- would allow for the samedegreeof subtalarcontrol during
lhe contact period as the o(holic po5ledwith separate4'
Forcxample, if an individualwith a 4'forefootvarus forefool and realfoot vllius posts. However, becausefte
12' leadool varuswere tleat€dwiLhan onlolic with a plartar surfaceof lhe orthotic witi the large foreloot varus
v!rus posl and a 6o rearfoot varus post (he 60 post and ffat rearfoolpost is perfectlylevel, the orthotic will
postwould allow ths slbtalarjoint to pronate60 not rock mediallydurhg midslaoce, andthe subtalarjoint
to contacting theshell),the orthoticwooldwork well will maintain a more alignod posilior lhroughout ftc re-
rollingsublalarjoint motionsduringthe contactpe- mainderof slancephase,
butthemomentlhc body'scenterof masspassed ante- Becausethis is ao uncommonmelhodfor posting
to the rock lioc, thc subtalarjoint would suddenly (usually sepamte rearfoot and forefool varus posts are
sn addilional6' (theamountequallingthe rearfoot used), lhe orthotic laboratory should be informed rhar the
3stheorlhoticeverlsontolle forefootposr.Whilethis gml wilb lh€ largo forefoot varus post is lo inve( the rear-
mngeofsubLalar pronationmayoot bea problem fool a specific number of degreesand lhar the rcarfoot
'hanyindividurlssince rhe morion occursrelatively sholld bc postedflat to nainrair tbe he€lin this inverted
andmaybc controlledby the supponingmuscles,il posilion. If lhe laboratoryhasnot beeDinfomed that invert-
bepotentially injoriousro oiherssinceir allowsfor an ing lhe rearfoot was done deliberately with an oversized
of lhe midtarsal ioint fwith lhc associatedshifi- forefootpost, it will assumethat therewas an error in either
lhetarsals andmctatarsals) asverticalforcesp€ak. castingor measurcments, and they wi most lik€ly usea
Ratherlhan using $eparate rearfoot and forefoo! forefoor post that bdngsthe rearfoolonly lo vertical.
3 bettetapproachfor reatitrB combinationsof rcar- The nadoor verus/foretoot valEus delontil!, As
ard forefool varus delormilies is to add the desirod notedearlier, this is th€ mosr commonlyfound combinalior
andforefootposl anglestogelher,theDplacea posl of deformities.Orthoticmanag€mertassociated witb this
sizeulldet the medial forefool. Although this gives combination is dependent on therelativesizeof eachdefor-
that the forefoot is being ove{posled(which mity and the specificpattemsof compensatio0 prescnt.If,
produce iarrogenic injury),it shouldbe keptin mind for example,there i! a iaIgc rearfoot varus deformity cou,
degree of forclourdeformiryis capluredin the oF pled with a small forefoot valgus deformily, and gait evalu-
sboll,nol by the location of the posts.For example,if atiotr reveals thal the subtalar joint compensatesfbr the
forefoollarus posl were uled on ar individualwho rearfoot deformity only, i.e., rapid pronation durbg the
nonnally be treated with separat€4" forefoor and conlacl period witb no signs of lareral irslabllily dunng
varusposts,the larger forefoot varus post would midstanceor propulsion, then the goal of orthotic therapy
achievelhe samer€sults as the codbined smaller will be to control the conlacl pe od subtalalmotionswilh ,
asfte rcarfoolwould conlirue to be inv€rl€d 4' from rearfoot post and to leeve the forefoot deformity alone. Io
(Fig. 3.94) while ihe plantar forefoot remains in- fact, a slighl degreeof foiefoot valgus in this situalion is ac-
4'rclativeto theplantarrearfoot. tuallyberelicialandmay represenl a developmenral accom-
This€xampledemonstrates an imporlantpriDciplein modation for the rearfoot deformity since it allows the
onhoticshellmadefrom a n€utralposilionimpres- subtalaljoinl to move closerto its neutml position prior io
basa specificforefool-to-rearfool relationship
that is heellifl. If the forefooldeformityhad beeninadveneny
"x ["
Figu.e 3.94. U5e of an 8' foreloor
varusposton an individu.lwith a 4'
fo.efoot varusha! th€ sane eff€ct as
separat€ 4' forefoot and r.arfoot
108 FOOTORTHOSRS
andOthcrFbrnsofConsewarive
R'otCuru
H€6lllll
Chnpl€!Thrce Abnornsl Motlondurlng lhe Grlt Cycle 109
absorplion(whichwolld eventually
resultin iatro, If suhalarjointpronalionduriDglale midstance/early
injury). propulsionis a concern,an alternateposling techniquc
Be.ause a non-neutral
impressionhasbeenusedin would be to placethe desiredrearfootposl beneath ie fore
on,ir is lheorlhoricposl.nor lhe sh€ll,thalplay\ Iool and have the rea.foot posted flat to stabilize the in-
pnmaryrolein controllingjoinl rnotionsduringstance vertedorlholic shell.Also, a first ray 6!t-out and sub 1
In all siluaLions
ir which lhe for€foolpostis noi in- balancefor lesionshouldbe addedlo accomoodatethe
to bring lhe rcarfoot lo vertical, thc laboratory plantarflexedfirst metataJsal.This orthotic could conlrol
beinfbrmedof yourtfe men!plafls. subtalarand first ray motionsduring lhe entire shnc€ phase.
Therea4ontearusBexible
pbntarflexedfrrstru! de- The reatoot veiatbigid plaatarflaxed fftt rat de-
(ftA. J.96J. Sincosublalarcompensation for the IomilJ OiC.3.92), Becausethe rigid plantariexed6rst
va!!sdefonnilyoftenforcaslhe firsrray abovethe ray deformily mailllairs lhe rea.fool in aEinvened position
lransvcrseDlaneof lhe less€rmetatarsals.
orlhotic andpreventsthe subtalarjoint from pronatingduringmost
t for this combinalion resuifesbolh the use ofa of slancephase,orlhoticmanagemcnt .equiresthe addilior
bar post to accommodale lhe Dlantarfiexed first of a 2-5 bar postwith a sub I balanc€for lesionto accom-
headanda rearlborvdrusooslto orevenL exces. modatethe lirst metatarsalhead and to allow for a condn-
periodsubtalarpronatioD. uedrangoof subtalarpronation.Rearfoolpoststypicallyarc
Thercarfootvarusposris invaluablein lreatingth. not neededsincecontrollingexcessjve subtalarjointpmna-
inedrearfoolveros/llexible plantarfiexedfirst rat de- tion is mrclya concern.
beca{se,in additiol]to prcvenlingexcessive subta- The fotefoot varus or forcIoot valsus with a plan-
prcna$on, il also aclslo increasethe mechanical tuflexed f'st mJ defornio. Treatmentof rhis combina-
of peron€uslongusas a first ray plartarflcxor, lion requircs use ol the appropriate forefoot post (as
€nablesthis muscle lo protect more effectively measuredwith lhe secondthroughfif$ mctataffrl headsas
do.siflexion
andinvemionof thelirsl melat3rsal. fte reference)with a first ray cut-out addedlo accorrno-
FiSur€
3.96.rool r€arfoolvarusflexlbleplantarflex€d
wilh a combination firsl raydelormity.
'notions
rigure3.97.Footmolionswith a €ombination
rearfootvarutriSidplantarflex€d
filJt raydeformily.
I l0 FOOTORT}IOSES
endOlherFormsof CoN€wativeFootC]!re
date the plantarnexedfirst met3rars{l. lf tbe planiarflexcd (pre\umably du€ lo th€ larger forccs on the hallur
first mc|8tarsal is $mincxible or rigid, a sub 1 balance lo lle less€rdigits).
shouldalsobe coNidercd. Fortunately. cventhouBhlhe s€condmeratanrl
An outdaled techdque for tr€arin8 a combinatiorl app!ais slenderand frail. i!$ ovcrallouLlineand
forefoot varus/f,erible plantarflexed Rrsl ray requires tion of densecompactboneallowsil lo cff€ctivclyma
dorsinexing the plantarffexcdfirst ray into a midline posi- profulsiv€ forces.Funh€rmore,the secondlarsomc
tion (i.e..levelwilh thc less€rmetatar$als)u/hilethe neutrat arli(ulalioo seems to be sp€cifically d€signedto
posilion cast is b€ing takcn.Becrusethis maneuvorrisk in- thesc large forc.,s, as lhe basc of the secondme&
advencntsupinatiolof lhe forefootaboullhc longitudinal wcdqed into . relatively rigid socket betwqln lhe
midrarsaljoint axis. lhis techniqueha6 for the mo$t part andlateralcrnciforms(Fig.3.99).This anaromical
becnaba'ldoned (42). nti)n seavcsas a locklng mechanismfor the entire
somelatarsal complex(115).
VARIATIoN n MRIATARSAL LENGTH Civen lhc fact that the disribution of srou
forc.s is dependcnt or lhe rclativc l€ngrhs of
The relative lcngths df the differcDt metalarsalsare mektarsals. il se€msreasonablcto assumethal at
readily evaluatedby planlarflexingthe digit6 flnd Doringlhe sivel!'long or shorlmetatarsal wouldsubjectirs
F,sitionsof the dorsalmetalaNalheads.Ideally,an imagi headto a resDective increase or decrcasc in Dressurc,
narylineconnecting ihedistalmetatarsal headsshouldform
a smoothparaboliccurve(Fig.3.98).In mostfeel,lhc rcla- The Eloogat€d SecondMetrierssl
live lenBhs of the metatarsalscranbe erpresscdby rhc for-
mula bl>3>4>5 or bl = 3>#5 alll). Becrusethc The most commorly s€en varialion io
second melatarsalis lsually th€ loogesl it is exposedto longlh is an elongalcdsecondmctatars{I,i.e., rhc
Sround-rcactiv€ forccs during both high and low gear mel.,rarsalis even longcr thao usual.wkh irs
push-off,with largeamountsof pres$recenrereddirectly heatl projectingdislal to Lhcideal parrboliccone
bencaththe secondmetabrsnl head as thc transition from 3.1{)0).lf this melatarsalis cven slighlly elongat€dt
low gearto high gearp!sh-of[ &aurs. metrtarsnl head is sub.jecl€dlo trcmcndousforcasss
Num€lousinvestigalorshavedemonslnted thal plan-
lar forefool prrssurc valxes measuredduriog walking are
greateslbeneathIhe s€condmetatanal head( I 12, I I 3). In
fact, Crossand Bunch(l 14) took planlarforce cstimate.s
and malhematically dcterminedlhe bendingslrains,shear
forc€s. and axial forces placed upon lhe ir ividual
metatarsalmi&hafts Not surpr;singly, b€nding strain and
shear forces werc grcatcst on lhe second metat3rsrl shaft
OendinSstrainon the 6eco[dmelalarsalis nearlyseven
lim€s greaterthaDbendingstrainon the firsi mctatarsal),
whilc axialforccsweresrcrleston thefir$ mclatarsal shaft
FiSur€3.10r. By distrlbutinS
wei8hlaw.y froh the central
met.ta'3al heads,evena lmall metataF.l prd may de€.€ase
irom low-8earlo hiSh-gear push-oft.The result. pl.nlar metararsal
h€adpressure:by asmuchas50Yo(118).
in prassure
andfriclionDroduc€s a characteris-
inkactableolanlar keratosisbensatbthe second
head(insetA, in Fig. 3.100)andmaybe a causr tribution ol prassure away frcm thc shorrcned first
mctatarsalgia(64) and/or planlar wans, i.c., met8trrsalonto the neighborings€condmctataNal.
stimulalesgrowth of rhis virus ('l l7). Allhough lhe clinical sigrificance of a shonenedfirsi
Also, an elongatediecond motala$al often produces mctstarsalhas been questioned(120), recent invesrigadon
toc dcformity as comprcssiol from a tight toe box (l2l) has corroboral€/ MortoD's th€ory io thar pcak pres-
lhedigil.(Bccruscsboes e fit from hcello ball, sure measu.€mentsraken b€trerth the s€cond metstafisl
sccondmelatarsal is rypicallynor rakeointo head while lh€ patient was walking were significantly
ioll.) greater in individuats posscssidgModon's foot structl|fe
Trealmonlforan elotrgal€dsecondmetatalsalmayin- (i.c., tie firsl mehlarsal was 8 mm or more shorterthan the
th. additionof cushioningmalsrialsplaceddirectly secondmetatarsal) than rhey were io a controlgroup.ll
lhs Dainfol meiahrsrl head (materials such as should bc clarified that a shorl fi$t metatarsalby its€li does
(Spcncol\,ledicalCorp., Waco, TX), poron, and/or nol conslitutcMortoo'sfoot strlcture.A tru€caseof Mor-
maybe invaluablein reducingshearforces),the lon's foot struclurewill paesentwilh a short fifst melstalsal,
mrlatar$alpadsplacodproximalto the metatarsal a lhickenedsecondmetatarsal shaft,anda hypermobile firct
(Fig.3.101)and,if necessary,
anorthoticro accom- melatarsalwith posterio.ly displacedscsarnoids(Fig.
anystrucLlraldeformitythat might be responsible 3.102).
increrscin pressurebencath the second mctatarsel Bccauseof its shon€r len8h, lhe first metatarcalin
a8., a forcfoot varus deformiry. Recommendations this foot typc is only ableto psrticipareio tbe pmpulsivepe-
alsobe madefor well,fittine sho€s rrt do oot com- riod l.ansfcr of forces by exc€ssivclyplrntarnexing abour
thc disraldigit and, if sympromswarrarr, a Thomss $e nd ray axis (Fig. 3.103). h hasbeensuggestedthat this
rockcrboltom m8y be addedlo lhe outer sole of rh€ incleas€dranSeof 619 lay planlarflexion may predispose
iclp rcducc pressurcbeneith the metatlrsal head. the iDdividual with Morlon's foot sEuctur€to degeneral;ve
rdditionsarediscussedin a later soctior.) Of cours€, chmgss al tbe jocdon of rfie firsl a[d second melalarsal
isl rharrhe individualwith an elongatcdsecoltd bascs(122).
avoidhigh-hceled shoesatrdhavethehyperkera- ln somcindividuals, the first metatarsalmay be so se-
trinrncddowniegularly. verely shorteoedlhat the first ray is uoable to plantarflex
throughthe rangenec€ssaryfor the first metatalsalhead to
Tte ShortenedFirst Met{tarsal mainllin gound conhcr dudng midpropllsio[.(n should
be retuembered itrat firct ray planhrnexioDis usuallyless
causefor pain beneaththe secondmetatarsal than10:) This beingthecase,thefirst oetrtarsalis unable
& excessivelyshortonedfirstmetatarsal.
lt hasbcer to participatein the disfibution of g.ound-r€rctivc forces,
lhal rhis dcformity,which was ori8inally de. and thc neighboringsecondmetararsalh€admay be chroni-
by D0dleyMoflonin 1935(119),allowsfora redis- cslly traumatized.Furthermorc,tbe sublalarjoinl will be al-
I | 2 FOoTORTHOSES
andOtherFormsof Conseruative
Fun Csre
Sscondnelatalsal
Fitrre 3,rm, ln orderto demonitrdte the efiectof a sho.t- the iiBi and scond metatarsalheadsto nraintain8rcund
sed fi6r meblaBal, this illustrarion ui€s an analogy in lacl is mininlal. However, when the ll6t met:tarsal
which ice creamnicls of variour l€ngllls ar€ usedto repro- markedlyshortefthan the $econdlas in B), a exteme&
lent the fi.st and s€condmelalarrab. ln seriesA, becausethe of firn ray plnnlar{lexjon
h necessary
for the ikst m€ta
iilst melatnsalis only sliBhtlyshorcr th.rn the second h€arlto mainlain8roundconta€!followinah€ellilt.
nretataual, lhe rangeof firslrry plantarfletion
neces5afy f
fi8sre 3.104. (A and 8) Morton'3e{Gniion. Comparcfirst ray motionswilh and without this addition.
' i1,,i
Figure3.108. W€ight-bearin8evaluationfor le8 l€ngth die of the g.eatertochanteB (which can be iound by havinS
€.cpanci6.The patienlis carclullyposnioned with bolh feet pati.nl tlex and e\tend the hips),and lheir r€spfttile
direcdybeneaththe sreatertrochanterr. The leveloi the me- are ioled (C). The levelr of lhe porteriorsup€rioriiiac
dial malleoli(A) canthenbe comparcd to deteanine whether (PSlss) with lhe patientstandins
areevaluated erccl,lhen
asynrmelrical subtalarp.onation(or supinalion)
is a causeot 90" xi the hip. Finallv,the levelsoI lh€ ilia. .f€stsrhould
functionalleglen8rhdiscrcpancy. Ncxt,thetibialplateaLrsare conrpar€d(D)i and any devlarionof dle lumbar spine
compar€d(B) to d€lerminethe relntivelengthsof lhe lib,a!. ve ical shouldbe noted (O.
Io compare{emorallenSlhs, thefin8edipsare plac€don top
talarjoinlcreatcsa functionalrearfootvarusdeformilylhal sid( of the long leg if tie individlrl attcrnptslo lelel
incrcrsesthc ftnge and sFcd of subtdlrrjoint pronaridn pelvis.
presenldoring the contactperiod- Treilmentin rhissilualioorcquirc\placinga hecl
It ;s alsopossiblelhat conpensaiionfor a leg lcngth ben.ath the shorl Icg and, it Lheraige of subtalarj
discrepancy may produceinjuryoo the$ideoflhc long leg. prcration on lhc long leg side reoains unchanged, an
Bccausethe krng leg moves through a larger arc during tlotic may bc necessary to controllhe exaggented
swing phase(130), the individual offen attemplslo decrease ft i' of particulrrinlerestlhal \orick and Kelle'
the radius of this arc by flexing the kn€e.This motion may noledthatthe additionof a z-mn{hick functional
sigificantly incr€rs€coEprcssiveforcesal the patellolemaral produc€da 4.8-mmelevalionof t}e anklcjoinr'scertr
adiculatioa.Furlhermore.it is nol urcommonfo.lhe individ- masssecondaryb superiorrepositioningof lhe taluson
ual to britrgthe lotrgleg closerto thegroud by narimally calcxneus. Because of thissiluation,lreatmenifor combi
pronatiogthesublalarjointon thalside.While Saoner€t al. tion. of structuraland tunctionaldiscrepancies requi
(131)nol€dan averageverticalchangeof only 3 mm asthe caretulpre-andpostevaluation to ensurethatprop€r
subtalarjoint moves from a n€utral position to a pronated tionhnsbe€nattained.
posilion,it is possiblefo. subtalatjoint prooationlo com- Treatment oJ Struetural $. Fanctional
pensalefully lor structural leg length discrcFncies of 1/2 cies. If a structurallcg lengthdiscrepancywere Fescnl
itrchor mofe.ln somecases,th€ hesdof the taluswill ac- itsell,fteatmenlshouldconsislof placiDg$e
lually makegroundconlact.kodcally, Hiss (132) claims size(lfiee,lifi beneaththeshonleg.Theactualh€ighl
thal this makesrhe foot more stable.as Dhntar conlact hcel lifi is bestdetermined by placingiifts ofvar'ous
with the laiar headservesss a poinl of supportfor the un- bene.lththe shorlleg andreevaluating alignment.The
stabl€medialcolumn.So, even thoughil is a commonly heel lin will levcl the iliac crcrl ard, more im
held belief that the greaterfangeof subtalarjoitrt p.ona- brins the lumbarspineto vertical(l23)- This lechnique i
tion occurson the side of the skucturallyshort lcg, it is surprisingly accuraletbr ev€n subdeleg lenglh discrepaD,
quit€possiblethal an evengr€alerrang€rvill occuron the ci€s. If a he€l lift is recomm€trdedbasedupon informsliot
CiapterThree AbtroldtalModondurlng the Galt Cycle 117
off-weighl-bea'ing measuremenrs (e.9., A.S.l.S. ro tjon thatmay be causingth€ leg lengthdiscrepancy. Io one
jr
nall€olus), is necessary to add approximately siudyby RothbartandEslabrookin whicha combination of
thcmeasurcd di$cfeparcyin orderto attainfull cor functionalonhoticsandmanipulative leclniqueswereused
i.€,.bocausc thetalusis oositioned one-thirdof the to correct functional leg lengih discrepanciessecondaryto
htween rle calcaneusand metatarsaiheads.a heel lifl asymmericalprcnatiorand its associated sacroiliacjoin!
beneath lhe calcancus will raisctl1elalusooly two- dysfunclion,it was doredthat78 of thc 81 patientstreatsd
olthatdistance. For example,a 3/8-inchheellift will exhibil€da completereductionin low backpain wilh 77%
r"lusl/4 inch. of lhes€individualsr€nainingrsymptomatic 6 monthsafler
Mos!authorilies recommend thathe€llifts be osedfor lheir lastmanipulaiive (126).
treatrnent They relaledtle re-
leg length discrepancicsgr€aler lhan 1/4 hch ducedchronicity to lhe fact that thc onhotics (which were
;135).HoweverSrbohick (136)claimsthatbecause madefrom neutralposilion impressions)mainl3ineda more
thrcefoldincreasein erouDd-rcactiveforc€$ associ' functionallyefficienlpostue,therebyallowingevensholl-
ilh ruoning,h€ellifts shouldbe usedon ruoningath- termmanipulation (i.e.,3 weeks)to havea mor€pcrmanent
thatpresenlwilh structuralleg lengthdiscrepancres effect.
ir thanU8 inch. h shouldbe notedthat Travelland Rothbartand Estabrook(126) also lheorizedthat
fl23) arc lcsscorcernedaboulthe effeclsof rela- asynmetrical pronarion(which was defircd as side-lo-side
snallleglengthdiscrepancies. They recommended a variationsin stancephasepronation great€rthan 20) forces
slruclulal leg len8lh disdepancy be treaied ody the eotirelower extremity to iniemauy rotate anddrcp infe-
il is suspecled of beinga perpetuating factorin my- dor, which allows tho innominate on thal side Lo exlend,
painsyndrcmes. Orberwise.ir is \ug8estedrhar i.e,,the posleriorsuperioriliac spine(PSIS)movesartero-
Iifls be usedprevenrivelyonly in tbe treatmentof sup€rior.This setsthc stagefor chroric sacroiliacjoint dys-
les lcnslh discrepancies exceedin81.2 inch or function and may allow for ontrapmenlof lhe sciadc n€rve
betwe€n lhe piriformis muscle and the sac.ospinousliga-
lr isofjnterestthatuseof a h€ellift to compcrsate for ment as the rolaling innominalepartially collapsesthe
leglengthdiscrcpancies in childrerunderthe age greater lcialic rolch. They also claimed that proloqed
isoflendssocialed \airhrhecompleledisappcaranc€ of asymmelrical pronationallowsthe normalamphia(hrodial
leoglh discrepalcy (i.e., leg lengthsbecomeequal) sacroiliac joinl to becomediarthrodial as vertical forces on
7 monlhsofwear(137).As a result,childrenshould lhe repeat€dly collapsitrg limb eventualyproduceligarnen-
at 6-nonlh inlervalsto determine whetherthe lous instability of the sacroiliacjoinl.
;sstill necessary. The lisl of possibleinj!.ies associalodwith asymmel-
Because ofDrobl€ms with shoefil. it is rccommended rical pronation aredetailedin Figure3.109.
lifli greaterthan 3/8 inch be add€dto thc midsole Ir endiry thisdiscussioD of ieg lcngthirequalities,it
andnotplac€dinsidctheshoe.Ileel lifis thatrun lhc shouldb€ clearlhat isolatingthe exacldegreeof struclural
hh8thof the midsolewill prevenlcontraclueof the vs. &&ctiollal leg Ienglhdiscrcparcy is not alwayseasyand
callmusculaturc. Aiso,!o reducethe riskof injury requirosc{refui observatiora'ld examinatior.Beforccasu-
conlralat€ralhio flexors and adductors(which are ally recommcnding a heellift basedupon informationob-
wilh heelliir), largesrructuralle8 lenglhdiscrep- taifled from a single A.S.IS. to medial malleolus
shouldbe maled by graduallyincreasirgthe sizeof measurement, tbe pruclilionershouldhavefully eva-luated
lifl al a rate of approximately 1/4 inch every 4 rcsp€clivctibial and femorallergtbsin a vari€tyof posi-
Duringthis break-iflperiod,the rectusfemoris,il- tions, chsck€dfor sofl tissuecontracturethat might bc
and adductor musculatureshould be gently twisting lhe pelvis and/orlumbat spine,andcarefully evslu-
lo t€drcelftcpotenlialfof iatrogenicinjury. stedfootfunction,bothstaticay anddynamicaly,lo deter-
A pdmffy conlraindication for heel liff tberapyoc- mirc wherher asymmetrical subtrlar joiDt morion is
*hen the lumbarspineis nol iaterallyRexedtoward conlributingto a functionalleg l€ngthdiscreparcy.
shoitleg.Useofa heellift in thissituarion
ft5u11in recurrenl injuryto thelumbosacral spine. Mtr{rMUM RANGES oF MorIoN NEcEssARy FoR
Amther conlraindication is that a heel lift should A NONCOMPTNSATEDGAIT
be usedlo trcal a funclionalleg lengthdiscrepancy
rit do€s nol address the cause of th€ diserepancy afld An important prerequisitefor normal fu.rction is $at
Saencreatea unilaleralweakn€ssof the involved specifc joinls of lhe lower exremitiosand pelvis must
ily (138). move through cenain minimum rangesof motion. This is
Treahenlfor a funclionalleg lengthdiscrepancy re- complicated by the fact thal lhese ranges are subject to
appropriate manualtherapies ro address anysoft changewith differenlactivilies,i.e.,lhe anklemustbe able
conlraclures that may be twistinSthe pelvis snd, if to dorciflex10"for walkjngsnd 25' fo. runring.If for any
r an o{hotic to correclany asymm€trical prona- rcasona joint is unableto movcthroughits requiredmin!
1l8 FOOT ORTHOSESand Olhc. Foms of Consrvaive F{totCnrc
Figure3.1I 2. with the subtalar,oint in its neulr.l Position, pronated,Lheoblique midla6al joini axis shiflsinio a
rhe obliqre midtarsalioint arie allows ior muchfor€foor ab' horizonlal position,ther€byallowinB for s.eiter
dtlc7ion lanov A). However, when th€ subtaiarjoin! is foreiirot dorsifl€xion (anot!,, 8).
il
//
U
oA -
titure 3.r t 3. Whenan ad€quaterante of ankle dorsiflerion (aff.w) and, s is consistentwith Newton's lhid law,
is or€s€nt (A), inertial forces a$ociat€d wlth the toNard forc.i arsociatedlvith elevalinglhe centar o{ masstxl
pro8rersionof the centerof mas!act to prertr€tchthe Poste- now dive th€ lonBer metatarsalheads into the Sround{llat),
rior calf musculaIu.e,lhereby allowing for the evenlual re. the l,eel do€i nol immediatelyllfi from the 8rcundG5
turn of this€nergyduringth€ propulsitep€riod.lf the ankle weal€ned tricepstulae), a recurvatumstres5is applied!o
afld foor arc unable to supply lhe necessry range of posn'riorkne€ (C), which may eventuallylead to a Eenu
dorsiflexion (0),the heells pr€nraturely
liftedtom theEround
HS HL
H€€lllfi T06of
3.116. The uncompensaled rearfoot varus deformity b b.inBlhem€dialfo.efoollo lheSround(a?ow).HS= h€el
.td lltr uocomp€nsat€dtor€foot varus d€formity (B), elrike;ffl = Iull forefoolload;Ht = he€llift; IO = lo€off.
how empensatory tinl ,ay planla.llcxion is nec€irary
DllfertnriodtrgCausesof RcatrictedMotion
Onceit hasbeendelerminedlhal a joint wilh limitcd
motion is a delrimenlally affectilg furction, it is essenlial
ftar the causeoI the decr€as€dmotion be id€ntified since
lhis determines theproperrrealm€nt, i.e.!, joint limitedby
moscular or capsular conlracturewill typicdly rsspondw€ll
to manualtherapies whileajoint limitedby bonyrest.iction
3.117.A limiledranteofsubtalariointmolioncreat€s should be treatedwiih accommodative tecinioues.The na-
3lr€$ al the knee. (Adapted from EnSsber8 JR, 10re of fie restricdonis det.rmioed by evaluatingboththc
TL.A funclionof the trlocalcaneal joint durinBrun, qualily and quaotityof thejoiot's passivesnd paraphysio-
. fool Ankle 1990i 2:91 96.) logiol rangesof molioD(Fig.3.119).
124 FOOI ORTHOSESarldOther Foms of ConseNalivc FootCsrc
Figur€3.120.(A {) Contracl,relax,agonistconlractlon(CRAC)
slr€tches.
126 FOOTORTHOSIS
andOrherForms Rrn (arc
ofCon\epativo
suggeslthal lhe use of mruimum r$istancr during lhese Satcgaer al. (I7I) cleim rhalthc besrwry to
slrclchesshouldt'e avoidcdsirrccforccfulconlractions pro- lcnirthenconneclivclissuc stnloluresis with
duc€a lingeringafier-dischargc rhal can dc$jmentallyrf- lo$-inrcnsitystrcrchespcrformedarelevated tissue
fecLnusclelension(164.165). nturcs(greaterthrn l(XoF),with the mulclescooled
While manyauthonibclicvcthala ma)iirnum motrac- relcrsingthe lensbn.Thcy imply rhat hearinglhe
lion is necessaryto slimulatclhe Colgi lendonorgan's wh lc slrclchiDe it allows for a destabilizalionof
rcflexiv€relaxalionof rhengo ist ( 166. 167),rbishasncvcr molccularbondingwhich,whencooledbeforcrc
becnconclusivelydemonslrated. In {acl, H,)h (168) feels loq J the collagenous microstruclure to .€stabilizc
lhat thc agonistrelaxadonfollowing isomet.icconlraclion neu slretchcdlength.
stemsnot from an ;ncreascin infornutiontiom thc Ooig' A lisl oflh€ morecommonlyuscdin-officeand
rcndonorgaD,but rather.fron a decrease in informaliur strcrchingprocedures follows;drevariousperperuadng
liom the musclespindle.Apprrently.the isom€aiccontrac- torsandthc biofiechanical effectsof proionged
lion $omchowlessens theflow ofimpulsesf|om thespindlc lre ,rlsonoted(Figs.3.121-3.125).
complcx.Thc cxad m€chaniimfor thc lcssened discharge
rcmalnsto oe proven, Rcstricled Molion Resulling fmm Osseous
h shouldalso bc mentionedlhat studf,by Mlr)rc
and Hutton (159) demonnratedlhat lhe CRAC slrcrches Thejoin6 nust likcly ro be affectedby bony
wereassociated with rhehighesllevclof EMG activityand lionr are th€ anklcjoint. thc subtnlarioint. andrhc
th.l they were more likcly lo prcducepain during lhe melrlarsophalangeal joinl. Thc cxactnaturcof rhese
stretch.This pronlptedSlanishandHubley-Kozey (169)to rcslricrionsand ih€ appropriatcmerhodsof lrearmert
recommend lhat lhe strctchedmuscle'santaBonist nevcrhc discussed in th€lbllowingsections.
conlracted duringlhe slrcrchingprocess for lenr ol produc- The Ankle Joint. ln rddilion o the relarivel]
ing an fter-discharge thal would cvcntualb tighrenthc conlft)n bony reslricrioflassocialed wilh impinSemcnt
osto\es(ref€rback lo Fig. .1.114),ankledorsiflexion
Because oflhe poteolial lbr delayedmrscularrighten- alsobc restrictcd bv variouscongenilal/developmcnlal
ing followinglhc maximumrcsistanc€ hold-relaxstrerches formations-The mosl commondelbrmitvaffecling
rnd thc cRAc slreiches.rh€resisrancc strelches d.scribed do^iflcxion is the natrcnedtalar trochlea(Fig. L
by t wit are prcfcr€d over lhe nrorc ligorous INF Whrn Dresent. thc flattcncdtnlartrochleaallowsfor a
stretches. Travelland Sinons(123)claim€dlhat the lJwil marur€h)ny conracrbctwecnthe anleriordistaltibia
lcchniqueis rcmarkably€ff€crivcllt reducingpainftltrigger dorsalt us thallinits anklcdorsifleiion-
pointsas longas the libersbeingstretched arcpleciselythe Anothcrbony anomalythat nray rcslricl
tibersthat havebeenrcoscdor shortened by lrigg€rpoinl dorsilicxion relateslo a congenitrlly wide d tcrior
activily.This is rcadily accoNplishcd by alternallrgjoinl donrc.Normally,thewide portionof the rnteriortrlus
angleswhilc pcrfoming repcal$lrctchcs unlil lensionis feh fit snuglyitrlo rhe mortiseforncd by the disialribia
in lhe arcaof rhe triggerpoint (e.9.,a triggcrpoint in $e fihula. lf the lahs oossesses an unusuallvwide
medialbelly on lhe gaslrocnemius musclccanbc acccsscd donrc or if rhc intermalleolar distarce is rlanowcd
by everlingth€ suhalarjoinl while performingrhc gcnrle ond.tryto ftactureofthe dislallibia orfibula,n bony
hold-relax str€tch€s). lion ofien developslhrt limils the aEilabl. ran8e
In additionlo the useof AMRTS,the useof Dassive dorsiflerion(Fig.3.127).
muscularrclaxationtechniqu€s (PMRTs)shouldd\rays bc If r bonyblock sufficientlylimits anklcdo
considercdshce a fecrnt comparisonof PNF vs. st,rlic rhc ditidunl mayrltemntiir comnensatc for the
slrctcheson hamslringflexibilily demorslrared thrl static rrn!.cof molionbv pronalinglhc sublalarjointand.if
slretcbesproduccdsignilicanlreductionsin oxygencon- tssr.ry.dremidtarsaljoint. Sin(j!ir is impossible ro
sumptionwilh corresponding improvcmenls in gail ccon- dccroased rangeot moli(D Lrrsociated with a bony
omy (170).The decreis€doxygenconsumption wasrelated tior lrcatmcnlmusl bc gearedtowardaccommodalin8
ro an improvcdantagonislresponsc.codges ct al. (170) dcforrnity.
staredthatthc "staticstrerching procedrreprepared rhcsub- For limited ankledorsiflerion,this is
.icd for more economical gait by applying lhe end range simfly by rddinga lift benealhrhchcel(Fig.3.l2R).A
stretchin the $nrc planclhar the musclesare going to hc inch hcel lifl will allow for all additional3" of
!scd. ' Thc .esulrsof rhatsrudysugSesr rharsraricstrctchin8 dorsiBexion. Because of lhc rclalivelyinsignificanl nrDo0it
of thc lowercxlremitymuscuhturcmayb€ an effecliv€way of rnklc doniftexion restorcdwith an in-shoeh8elllff
to irnprove€nduanceduringbcomotion. (which is lypicaUyno inorc than l/4-inch high),il is sug.
Other.rdvocates of PMRIS claim rhesetechfliqnc$ g!sl(d lbaLInrgeljfts he incorporaled inlo lhe soleof lho
morc effectivelyproduccplasticdcformily of connectiv€ shocor llar rbe individurl wcar shoeswirh sumcienr h!.1
tisliuesdndallor{ for morepermanent nuscularelongalion. height(runningshoestypicallyrai:i€lhe heelsl/2 inch).
ChaptcrThrce Abno.Dal Motior .tu.ir8 thc Gail Cycl€ 127
3.121.Poste.ior
compartment.lretchcs.Thegasttoc- idcnlicallvro the reariootvarusdeformitv.Unlike the osseous
husclemay be slrcrchedby dolliflexin8rh€ ankle rea oot vaftrsdetonnity,the functionalrcariootvaruswill rc,
kTa f r I y c r r endc d.l h € m .o ' rl . c c n t r' , o , I rl e rJ l du.e by nrctchina lhe conracted musculdure and strenBth,
of lhis muscle may be acce5red by applying the ening the antagofislicperoneals.Foot function will alro be
forcebenealhthe laleral/central,or mcdialfore- compromisedbY contraclur€in the kiceps 5u€e musculatLrr€
resp€{:tively (i.e.,applying prersu€ benealhlhe medial as the ,ubtalarand mjdlalsalioints attemptto comp€n5atefor
whiledorriflexinB the anklewill inv€ the rcrfoot, a limited ranseof ankle dolsitlexionby prcnatinSdurinEihe
fora betterstretchol the lateralSartrocnemius mLir" latrer hall oi sranc€ phase. When perfominE stetches on
Tht sanrepfocessis rcpeal€d10 sretchthe soleus thesemus.les,lhesubtalarjoint mustbe maintainedin a neu
only lhe knee is nr.iniained ifl a {lexedposition.fib' tfa or supinat€dposition to ensurelocking oi rhe midraBal
iof ir also stretchedby dorsiflcxlr€ lhe ankle wilh joinl. Alro, wfiile convacrurein fl€xof hallu.is and flexordisi-
flexed;only rhe lateEl toreioor i5 ldaded so as lo torunr lon8uei5 fairly un.ommon, it may rcsultin flexion de-
elcrt the heal. tlexor hallucis longrE and flexor formiry of rhe involved distal phaianges(122). Perpetualing
lonEusarc nrerchedwilh lhe kneeflexod,ihe ankle facrors:Ex.essive,ublalar joinl pronationduring the propul
and the respedve digiG maximallydorsiflexed(8 sive period i, a major factor responsiblefor overloadinsthe
tffeclsof (ontraclure:Contraclurc in tibialkposlerior posleriorcompartmentmrsculalu.e.In addition,tibiali5 pos,
soleus is a .ommoacausoof functionalrea{ootvarus terior may be chronicallytlghtenedin individualspos5essins
. -h s oir c nor c u' , n a l h l e rc r i n i -mp .-F a rearfoolvarusdefomny. Activiliesthar may perpeiuatetrig-
(padiculaiy ' n !o l !e d
bark€{ball andvolleyball), wh€rcexercise- Ber poinl fomation in ihGsemuscl€5includethe frcquenlu5€
hypedonicilyof rhe ponerior.omp)rtment mus.u,a, of hish'heeledshoes,sle€pingin a prche position wilh lhe
allows Ihes muscles to ovelpower rhe antaSonistic ankles plantarllexed,and spons feqliring vigorous anklc
c( r r 6ull. lhe . hr on i ,a l l ) i Bl .rc " e d,b i a l qp o ' tF planta lexion. {Even lwimming may aggralate these mu5
,o l eusm " r ( k { m d n u i n rh e re d rfo o L in an in
pos,l,ondu' i8 swirS pLrdse.rnd lhp foot behrve5
fiture 3,122. lat€ral compadm€nt stretch€s. Pemneu! beirg fie c.se,therubLalrrjoint is maintained
in a
lonsLrsh stretchcdby invertinSthe heel, dorsiflexing lhe pos,tronthrcuBhoutewl16 pha\e. rnd hecl.sr kc usurlly
ankle,and applyinga dorsiflectory force b€neaththe fitg cul\ c,nlhem€dlalcalcaneus.Perpeluating
factors:
The
merararsal head(A).Percne5 brevisis sretchedby inveding var',s {ool ryp€ i\ lhe mosl .omnon pcrpFrudlrnA
Ihe heelwhileplantarfl€xing andrdductinadie for€fool.Thk pen'neuslon8urcontra€ture.
Thc inrpmvedmechaical
js accomplished by applyinaprc$ureov€rthe dorsalbas€of vanragealtorded peoneus lonSos by the inveded
the fitth m€tarafsil la). ffi€cls of contr.clure: A tighioncd ioinr Drcduceschrcnic strain on this mus.le- Trcatmenl
peroneus lonSusalnrostalwiys rcsultsin n funclionalplan' rhis condilion should include manipulativelechniques
lo
tarflex€dtirsrray.This is freq'rently seenin maddl€dislance pro\€ foor fundion .nd, when n€cessary,a forcfoot
runoe6andclassical balletd.ncers,in whomrheprolonsed t osr Io ls$n lhe deSreeof raarf@t inversion. Cont
appli€ation of forcesbeneaththe fiKt m€talarsal headpro- rhe ir$al comoartinenlmusc!latur€mav aho be
duc€sa lingering after-disch.Ee in peron€us lonSus thatmay by,)verdevelopedposteriofcompanmentmurculat!rc,
eventuallyresultin conlracture. AlthouShmuch l6s com- ous ianal coalitions,and pasthisto,yoflrauma wilh
mon,peroneus brevismayalsopr€senr with coDlracture.This joirrtdysfuoctionin subtalarand/orcalcaneocuboid joinb,
B c
3.124.Intrinsicmuscleslietches.Abducrorhallucisit diSitalflexolg.arclyprodrredi8itald€fomity,althou8hihey
b \ . r . , ) r nc inin Srh e a n k l e i r n e J trd l 5 l B h t l ) maylimil theo!€rallranEeol diEitaldoAlflexion. Perpetuai-
fle.xinglhe haliux,and applyinsan abducioryforcea! lhe ing facloE:As wilh thelareElcompartmenr mur.ulalurc,ab
intephalanBeal joiot {A). Flexorhallucisbrevisand flexor ductorhallucisandthc rhod digitalflexoG arc almoslalways
b.€vir are 5tlelched by applyng a doElflectory conlracted in the piesence of a cavovarus footrype.Ako, ihe
at theproximalphalanxof thc hallux (8) and lhe middie abdlclorhalluci,mus(lemaybechronjcally contactedin in
s of lhe lesserdiSits (C). respRtively. The ankle dividualswho sleepwith theirankl€splantadlexed. Thismay
be maintainedin its neutralposiliondurinEallofthesc _F\Jlria re.dlcrrr.nr hee pa,1.p.nicula4v rr tl.emo n,' B..s
to ensurelhal the qr€tch is generaredin the sho.l lhe conkactedthsuesorc nre(cheduponwe'EhrbearinS. lo
Iletols.Effeclsof cont.aclur€: Ken&ll and Mccreary !rcalthir diifi(ult-lo-manaSe perpelualingtactor,Wapnerand
claimedlhal .ontracturein thc abductorhalluci, mus' Sharkey (tl3)su8sested lltlinglhe patientwnh a niBhtbrace
will "pull the fool inio forcioot varus," with ihe hallux thalmaintains theanklein a posilion ol5'dorsiflexion. This
mainrained in in adducledposilion-Severe€ontra€lur€ formof treahentis rcmarkably efectivefor trealingnot only
abduclorhallucls mos.le may be responsiblefor en- abduclorhallucismyositisbu! also for tr€ating.e.!rrent
ne!rupahy of the mediDland lateralplantarnerves achillestendinilis andplantarfasciitis,
whichoften.e!ulttrcm
backto Fig. l.2Q). Unlike their anta8onkc, rhe shorl laultysleepinB posture.
fi8urc 3.125. Ho.n. stn{de.. All of the ponerior compnn- ertk milies,andsli8htlyllex theknees:a Bentlestrelch
mentmusclesmay be siret.hedwilh a {andardcalf nrcl.h be f'.lralonglheoutcrleg.Theanle.iorcompadmenl and
(A).8y placin8an an8ledpieceot corkor a foldedwashcloth intri'1sicmuicl€! can be strelclEdby havinSthe patienrrit
beneathlhe medirl forcloot(B),the lat€rallibersof the sas- a ch.rirwiththeanklecrossed ove.theoooosile kne€,The
trocnemius musclemav be ltretched.h h oossiblelo rlrctch fcrc,t muscles nraythenlte str€tched asdescribed in
rhe medialfibersof lhe sarnemusclesinrplyby placinglhe 3.12, and -1.124. Anothermothodoi str€tchins lhe a
weds€underthe latcralforef.t)t.the medialfiber.of loleus comr)adment murclesjs lllusrraled
In [. 8y partially
ard tibialirp(rsteriorshouldalsobc strctched wilh rh€wedse bodt weiShtontothc plantarflex€d .nkles,the an|erior
underthelateralforefoot; onlyfte kn€eshouldbe majntained partrnent muscle!aregraduallylenslhened. Thelaleral
in a sliShtlyfle,(€dposilion lthe lateralfibec atP strctchedin of e' rensordigiiorum lonAu5and p€roneustertiusmaybe
positioo 8 r,/ilh lhe koee th.)€d. The diEilal flexotscan be cesr(d by adducting the Iorefeel fd'rowi in E) whila placi
strctched by placin8alowelbeneath thedi8itswhilepertorm- towrl L'nderthe toas will increaseIhe amounl of
in8 bent kne. calf stretches (C). Peroneurl.'n8usjs best plac,.don all of the diSilalextensors.
Of course/lheee
stfetched by placinSa tcnnhball benealhthe firstmelatarcal only a few ofthe potentialhomeetrelches,
.s a knowleige
headsandthenhavinsthepatienlfle,(thekn€es{D).An nlteF each muscle'soriSin and jnsedionwill allow the practil
natemelhodof str€tchin8 pe.oneus lonSusis lo havethe pa' to pn"s.ribe any of a va.iely of slretchcs.
tient aMoct the hios 45". ade.nallv robte lhe lower
Chapte.Threc Abnormal Motion d.rhg the GaiI Ctcle 131
Figurc3.127.Althoughanld€plan-
ta.flexion is Bot affecled (A), the
foot with a wid€ anteriortalusmay
dorsiflexonlyuntilthe anreriortalar
dom€ €n8agesth€ anterior surfa€€
of the distal Ialofibutar articulalion
(slarsin B). A : wldth of anteriof
lalar domc; P = width of posterior
132 FOOT ORTHOSaSand Other Formsof Conswadve FootCnrc
F.
usrd to br€akdowr lhe collagenffbral cross-linl- dcnccthal mobilialion do€s,inde€d,b.eal down lhe colla-
wifi pmlongeddisusdimmobili"ation and gencross-fibercformed during imDobiliz tion.
thc normal accessorymotiols necessaryfor a ln addition to being csse irl for [offesl.icted rarge
dovc lhrouShits full rangeof motion. In a detailed of motion, the restoftriod of a smoothend-plsy allows the
beatinB histolog.icalchangesassociatedwith im- artiorlations of the feet to dampcnground-rcac ve tbrces
Wooel al. (178)providedquartitative
evi- mor€ eflectively through lhe naturalspringinessor elastic-
134 FOOTORTHOSES
rnd Olh.r ForBsof Conscrv.tivcFoolC!ru
ity associated wilh srr€ssir8healthyconnccliverissue.lliss pull gas€sout of the synovialfluid. However,ir h not
(132).who hashadrhe€xp€ricnce ofadiusringseverathun- cav,fationlhat produccstbe favorabi€rcsponse, bur
drcdtholsandfccr,stat€dtharallholgh ir canrakesmonths th€ breakingof collagcncross-fibrilslssociared wilh
to restoremotionto an old fibrotic foot ("il lakesa lot of seprrl|ionol joint s|]rfaces.
poundinglo drive a nail into hardwood").somerimes even 'l'h€ frct rhai mobilizario etfecrivclybrcaks
thc slightesincrcasemovcmcntcr! oftenspcll the diffcF cro\s-linkswas demonstrated in the srudyby Wooct
ence belweenpnin and completerelief. Figures3.134 (l7il) in whichthe fibroticjoinh weremobilizedartic
through3.157illusrale the variousmanualtcchniqnes for of I cycle of flexion/ertcnsion evEry 5 scconds(hrcc
jointsof thefool andrnkl€. cles were performed,with the majorityof charges
Nole that theseprocednres nre not intcndedto repre. ring duringthefirstcyclc).
sentr cookbookformulafbr manipulation. Rather,by cou- Although clinical expericnccsoggustslhat marl
plilg a thoroughunderstardingof anicular archit€c1ore lion morc quickly restoresmotion, this hls ncvcrb{cn
with lhc cxpericnce gainedby palpatingmotionbanien in clusively dcmonstrded.In fact in many siluatiols,
thousands of fcet.the pracrilioneris encouraged {o modify joinrs of thc fcet arc so tighlly articularcdrhatclen
the line of drives,corltsctpoints,and forccsin wtys tbal higlr- velocity lhrust of manipulationcsnnotcrearg
beslsuir€achparicnts individ$alneeds.Mairland(179)de- sufllcienlscDaration ofthe articularsurfaccsto crvitatc
scribesfive gradedoscillations that may be usadwhile per- joinr. This is padicularlytruefor theintercrneiform and
forming theseprocedurcs(Fig. 3.133). navicular-cuneifom arliculaiions- ln thelicshuations"
Th€ d€cisionofwhethcr ro mobiliz€or manipulatcis bestto takethe ad\.iceof Paris(l8l), who suggesrs
dependentupon the practiti{)ner's experiencewith thcse lizirlgthevery stiffjointsnndmadpularinB thcslightly
tcchniques.Becaus€an improperlyappliedmanipularion joinls. Usingthis approach. ir is not uncommon for m
may potentiallydamagethe joinl, ttseof a higb-velocily lr€n]clyfibrolicjoint ro bccomcso flexibletftar,ovcr
lhruslshouldonly be aticmptcdby thoseexpericdced wilh thc ioinK cnn be cftecriv.ly manipuhr€dwith I mini
suchlechniques, AllhoughCood (180)chims that cavira-
tion or crackinglhe dysllnctionaljoinl is ncccssaryfor It shouldbe norcdrlul themostcommoncaose fof
trealmentto bc completelysuccessful, lhis claim is un- jur,! aisociarcdwith ma0ualtechniquesis failureof
founded. praditionerto evaluatemotionbanicrs properly.I
Theonly diffcreoqrbetwcedmobilizrion andmanip- idenrifving{ hypernobile.ioinrprior to manipularion.
ulrtion is thal manipulation oacursso rapidlythatit gcneF is {spccirlly impo ant witl rhe ralocruraljoint, w
atcsa negrtivepressurc capableof pullinggasesout of $e mant practitioners roulinclyincorporatelongasis
liynovialnuid.(Cavitalionrefersto th€proccss of crearinga lationas prrl of a poslinvcrsion sprainlrcatrnent regi
cavity,in lhiscrsc,a vac[um.)Because mobilizationoccurs CIh^ ;s mo6llilely besusc thc poppingnois€
morc slowly,thc vacuumneverb€comes strongenoughto witl this manipulation givcs borh the prflctitionrrand
pati(nt a sensethat som0thing lhlll wrs 'out of pla@"
now "iri place.")
Bcc0uscrep$ted manipulaliondamagcs rhe
w'eakened rcstrainingligaments.il may be responsible
chronicpain panernand/orrecurrentinj{ry. Treattncnt
this s;luationshouldincludcstrcngthcning exercises,
prio,cptiv! (xerciscs.and mrnipularionof the Deigi
hyprmobilejoints, not manipulalionof thc h
talo.ruraljoint. h additionlo drc dangcrsassociabd
mrnipuladnghyperfiobilcjoinls, manipularion is als{)
lraindicated duringthe rcute stagesof inllammtioq in
presrnceof $live inflammslorydiseasc, ilndwhcn
is re'trictcdby a bonyblock.
Keepingthescconlrairdications in mind,rhe
ing ,cclionwill reviewthc variousmrnipul
lion.llcchfliques foreachjointof rhcfoor.rnd anhle.
riSure 3.133. (A{) The fiv€ Eradedoscjllaliors useddur;n8
manral lhcr.py. / = small ,mplilude movernentnear the
staning positjon; /l = larSe amplitude movement irear the Mrnipdallve Thchniques
na{in8 position; tl/ = lar8c amplitude movenent endin8 nl
tho alasticbar.ier;/V = small amplitudemov€nrenrborderinB The M.talarsophalangeal and
the elastic ba(ier; V = manipulation:: smrrll-anrplilude, Joirl.!. All of thescjoints shouldposscss an appreciabL
high-velocilylhrusl accessin8the paraphysioloBical
spaccbur elasticsplinli whenstressed io long axi$extension.To per-
nol exreedingthe dnaronri(allimit o{movem€nt. fo.nr $i! oraneuvcr on a meratarsopha langcaljoint, theex-
ChaplerThrqeAbmmd Modondurbgrhe G.il Cycle 135
3.134. Lom dis extension al the second metatar- figure 3.135.tat€raltih of lhe secondmetalarsophal.ngeal
ioi6t. ioint,
FootCue
andOtherFo.msof Conservative
136 FOOTORTHOSES
--.".rt
forcewhile simukaneousty applyinga sm$ll-ampliludc ab- Allhoughlhe exactmcchanism for fie surprising
duction-adductionand/or rotalional motion. (Theseniove- cessrateof this treahent is unclcar.it is Dossiblethal
nlenls ar€ applied in an oscillatory manner*ith a rangeof ular.onof mcchanoreceptors in lhe subjacent bone
motion no! to exceed lf.) Becrus€ this procadureis per- pain cycleassociated with rcflexsympathetic i
formedwilh thedigit in a midlincpositio[ neithert]lejoint Manhnd (152) staredthar the joints mosrofian
capsulcnor the slabilizingligameDts are stretchedin fny trearment with compression are the fiIst
way, therebygivitrg the practitioler ioformathl that could langcaljoinls, th€ hip joint, the glenohumeral joint,
trothavetrcenaltainedwilh noncomprcssive lests, patellofcmoraljoin1, aad thc carpometacarPal joinl of
fie class;ccxamploof when this prog€dureshouldbe thunlb.
usedis on lhe individual presentingwith a stubb€dtoe. Nor- The Dislal IntcflwtatarsarJarits. No.mdlly,a
mally,sucha prtientwill repottno Painon P:Lssive teslinS, perior-inferior gliding moliol is prosentbelwecna]l of
but fte addition of |] compressiveforce will often praduce nretrtarselheads.Becaus€the c€nlml hetatarsalheads
excruciating pah. fiis beiogthecase,lreatment wouldcon- slabilized by the sronge-rt ligaments, inlermetrlarsal
sist of small-amplitudeoscillatory motionsperformedwhile tion is least belween thc second and third
genrlycomplessing thejoint.As patietrlloleranceimProves, slighlly greaterbelweenthc neiShborirgmctatarsak,
the compie\sivefo.ce is graduallyinqeas€dunlil the syEp- srcaLestbetweenthe fourlh and fifth metatarsals. Th€
toms are gone. Repeatedtreatrnenb,which arc rcadily per- of moveme may be evaluatedby graspingthe headsof
form€d by the palient at home, arc remerkablyeffecliv€ at jacent metatar€alsbet\peenthe lhumbs and index
reducingpainrssociated wirh thisryp€Dt injury. andrltematelyshearingupanddown(Fie.3.137)
Chagter
Three AbnormalMolion durhg the G.it Cycle 137
.l
,l
',.,,i,i
.
".?",^
',1
With regardsto thc fir$ larsometatarsnlrrticulation. a mel" a$al (Fig. 1.142).By graduallyincrcasing lhc
very efieclivemethodof rcsloringiotbriorglidc is wilh lhe ing lorcebel\recnthelirstandsecondmetataKals. rlc
manipulaljonilluslralcdin Figure3.141.In this mrnipula- litionercanbuild up to a dynamicthrusrwilh whichth€
tion, the patientis supineas th€ practjlioncr'srigh! ftand metrtarsalis planlarflexed ad evcnedwhile the
conkcts the first melala$al betw€enthe middle phalaru of merrtarsalis slabilizedagaiostrhe prlm of the left
lhe indexfingerandlhe them.€mincnc€. Theleft handthen Thi\ processmay be repeatedlo ra\lore inferior glide
"hooks" the medial cuneiformwith thc third finger and trac- of lh€ t?rsomebtarsalaniculaliorrs simply hy movil8
tions upwardly (black anow) as lhe righl hdrd beednsto conractpoints latelally,i.e., conlactil|8the plantar
planrarflex A$ thcjoinr reach€s
the first metararsal. its erd- metrrtarsalwhileshearing thedoNals€condmetatars|l
range,the palm of lhc left hard wmpssccurelyover d1c riorly, etc. Noto thal this manipllationis invaluable
dorsal midfoot. anemPingto reducea fun.tion l forcfootvarus
ThDmanipulalionis giver with thc lefr wrisl exrend- Supcdorglide at lhe tarsonretatrrsalarticulario0s
ing (lherebyprovidingtractiooingoo lhe mcdialonciforo becvaluated andteatedhy posirioning the handsasio
lpwardly via cootactwith the third finger) nd thc righr ur€ l.l43A. By plecing lh€ pisiform of thc riehl
wrist rsdiallydeviaring(whichallowsthe thcnareminencc agein$theplarltar6.stmerararsalshaff with thepalrnar
to plantarflexthc nrst metalarsal). 'l'he praclitioner'schest face ofthe lcft handcontactingthe dor$lsecond
is directlyoverthepatient'sfoot so thata long axisFaction shati.a sheariogforceis developed by cootfitctiog lhe
may be appliedduringthe manipuiali('n. lnt€restillgly,Hiss lomlismusculaturc (thcpractitionrir chesljs tosition€d
(132)not€dth8tjoint dysfunctionin thc firsrtrrsomeratarral rcct! overthc paticnt\ tooDlhlr drivesrhefirst
articulalioo. which is almoslalwaysprescntin a cbronically sup.riorly and the second metatarsal infcdorly
pronatcdfool is a commoncausrofdcsc.scd proprioaep- 3.14.1B).
tion. This nanipulationmay bc rcpeated al anyof rhe
An alernatc mcthod of restorinBinferior glide at thc sornctatarsal
afliculationsandis particularly usefulwhon
iirct tarsometatarsal aniculalionis lo contactlh€ dorsallirsr temnling to rcduce a lunctional planlarflexedfir8t
melata:':ialwilh the centerfingcrwhjlethe palmarasp€c1of atd/sr funclionallbftfool valgusdcformity.11should
thc oppositehaodcontaclsthe plintar surfaceof thc secood bc r'ot€drhdt ir is possibl€ro resronja rcstricred nng.
ti8ure 3.r4I. Manipolation to reslore inferior Blide lo fi'.l Fi8ure 3.142. Altenate nanipllalior for rctorint iofcrior
larsom€latarsalarliqrlation. Slidc at la$otn€Lt ]3.l aniculatiorb,
chaptcrTtrec Abrormi Moltooduriq iftc G.il Cyctc 139
K9
tion ro fie 6eld of manipulativerehabilitation was his de- againsllhc palionfsdistalthighwhile firmly Srabbing
scriplionof subtalarjoint turction.While otheranatomists fooL.tusr belo$theankle(Fig.1.152). Thecxamrnet
in the 1950sand 1960sdiscussed subtalarjointmotiononly leans back againstthe patient'sdislal felnur (A)
as il relaledto p:rssiverangesof inversionllnd eversion, mairlaining alongrhelong,\is ol rhe
.r counrc'force
Menn€llwasdcscribingsubtlerockrngmotionsbe$*eenlhe (B). This longaris forcEis transferred equallylhnugh
talusand calcaneus that absorbshearforcesrl heelstrike web\ of bolh bands.whereit ooensthe talocruraland
and to€ off and act to prevenl injury about th€ arkle com- lar juints in longaxisextension. is prs
Ifjoint dysfunction
plex wh€n the foot/ankleis sprainedor srublred(150).lfl senl.fl dynamicthrustis anpliedal the end-range of
lact, Mcnnell(15{l)staresthalif lr werenot for thescinvol-
untaryrockingand glidiog motions,"fiacluredjslocations This positionalso allows ibr evaluntionof
alouodtheanklewouldbecoftmonplace." glidf oI thc calcaneus beneaththe talus(whichwas
Thesejoint play movements, which consistof lDng ousl! illusiratedin Fig. 3.115).By srabilizingth€:
axisextensioqforwardandbac*wardgtidc,atd m€dinland taltr' rith lhe righl hand,the eraminer'sleft hand
lsteralside rill. may be elicilcd in the folloring manner. glid(s rhe calcancusforwardbeneaththc talus(C) whilo
Tle supinepntienlis positjonedwith the hip aMuctedand mairtaininga long axis taction on the joinl. Backwad
extemallyrotaied.wilh the kneefl€xed90", and wirh the glid. canb€ evalualed by reversinghandaclionsso thcleff
anklein its neutmlposition. Whilesittingonlhdedgeofthc handserves s the stabilizerwhile lhe righthandglidestha
-examining table, the practitioner plac.s his or her back salcrneuspostcriorly(D). It is pos-sibleto cvaluntelalenl
ChaglcrThre€ Abnonnrl Motlotrdu.bg tbe Gllr Cycle 143
Dainlaining the longaxislracrionwhilc €verring$e rhis adjushenl, tbc plantarhe€l is stabilizedby friction
(E). Medialrih. which is frequentlylosr tollor{- fton the cxamjning table wbile lhe crossedthumbsapply a
irversion sprainof $e anlle, is cvaluatedby inverting postefiorshearforce throughrhe talus.Inilially, a force is
s wilh theripsof thc lesscrdigits.U joint dys- appliedgeDlly,causi0gthe talusto glidepo$eriorlyon lhe
is notcdin anyot tlc\e tcslingpositions,a gentle fixa1edcalcaneus.Whenpedormedpmperly, a smoolbelid-
ipulationmay b€ performedby conlinuinglhe lesl ing morionshould be fek, and the forefbot shouldLtt
whilesimultaneously lr0clionlng on thcsublalar sliShtlyoff $c examiningtable.At thejoinfs end-rang€, a
carc mustbc laken whcn performingtheseprocc- springyend-playshouldbc roted as the cross€d thumbs
aslhe practitioner car gencralca surprisinganount pushinto theelasticbanier.lfjoint dysfunctioois presenl,
sxis truclionby l€aningback inlo the patienl's s€veralshortdyDamiclhrustsmay be appliedal this end-
rango.
An elt.rnrtemolhodfor adjuslingthcsuhalar.ioinrid The Taloc ral Joitta, This joint shoold possess
or laleralside tilt is illustrarcdin Figure3.153. both long axis exlensionand anterior-posleriorglidc. l-ong
mainbioingthe subrala.joint in loog axis lraction, axisexrensiormay be cvsluat€dwith the samelestiogpro-
lih maybc resioredby havingthe palm of the rjght cedureusedin Figurc3.152or, morecommonly,by hook-
evo lhecalcaneus while the lcft handdriveslfuoush ing the talar neck wilh crossedfingeB and lrrclioning
(theteb)shearinglhe calcrneuslaterallybencalh inferiorly(Fi8.3.155).lfjoint dysfunctionis notod,a dy-
To manipulate$e subtalarjointio mediallilt, thc nlmic thrust is applicd by lracrioning tbe joint ir loDg axis
lo$ilions andmovemensare reversed. cxtensionwhile slighdy radirlly deviaiio8 tbe wrists (black
Alother manipulationfor rcsloring lorward glide of ar.ow). Anrerio.-postc.iorglide of lhe talocrunl joiot may
benealhtheralusis illustratedio Fieure3.154.In be evalualedas illustrarcd in Ficure 3.156. A loss of either
144 FOOT ORTHOSESand OtherFofts of Consepalive Foor Care
Figure3.156.Evaluarion
of ant€rior"post€rior
Blideal
talocruralioint
TypellRber(AU)
tmmftowe,sp€y endhg
Gammamoro.neuronsto nrEf!$lmus.le lbe6
Alph,rmoto.neuronto €xlralusalmuscletiber
ExtraflsalmusclelDer
fiSure 3.158. The inlrafusalfib€r and itr inn€rvation. Anar')myand Physiolosy.West Cdldwell, Nl: the ClEA
(Modifiedfrcm NenerF. The NeNousSystenr.Pad Onc, l edi ,)not^tedi call l l urtrari ons,
1981:1985.)
A perte€1
exampleof how proprioceptors
interaclrc rodrccth€ proprioceptive irfonnationsuppliedby skrnre-
a d€siredmovementoccrrs during the positive cDptors,lherebylesseningthe planlarllectory force devel-
i n g re dc t ion.I n r his r c fl e x .rh e $ e i g h l o l th e b o d y oped by the digils. Becauscof their researchfindings,
uponrhefooi spreads lhe melalarsophalangeal and Robbinset al. (189)clain thatiflappropriate slimulationof
angeal joirts andstrelchesthe inlerosseimuscles. the skin receptorsbcneaththe arch and/or excessivec0sh-
informationtiom lhe srimulabdmuscleandjoint ioning benealhthe metata$alheads may resull in a
produces immediate reflexcontraction oflhe "pseudo'neurolrophic arthropathy"oI the metatarsopha-
musculallre,Lhereby convcrtingrhe entirelower langealjoints.They supportthis hypothesis by notingLhal
ily inloa fi|m bul compliantpillar. shodpopulations havea greaterincidenceof osteoarlhrosis
Theimportance of thc foot proprioccplors is clearlo at thc metatarsophalangeal joints,while unshodpopulations
whohaseverhadhisor herfootfall asle€D aftcrsiF havea greaterincidenc€ofost€oanhrosis al thedjstalinLeF
closs-legged; upon slanding,il is nol uncommonfor phalanseal joinls(r90).
kne€lo buckleas thc temporaryanesthesja associsted Giventhe delicatebalancebetweenaffercntandeffer-
ckculatory impairmenlinhibiLsLheposilivesupporling enl discharges, il shoLrldbe clearthal sven slighr inpair-
O'ConnellanJ C dnu, (188) verificd rhc mcntof the Foprioceplivesystemwill detrimentally affcct
oi lhef(x)lproprioceptors by performingan cx- lhe appropriale motorresponse. This situationmay resultin
in which a blind-foldodindividuaiwas suddenly injury, a$ the muscularr€astionto a given stimuli may
from dn el(vdledchzir onlo a gymna\iumnoor occurtoo laleto protecrthejoht. In facl,l,entellet al. (191)
(By randomlyraisingand lowe.ingthc chairvanous demoNtratedthat individualswith r€cune anldesprains
priorlo lhc rcleasc,thc subjectlost accurale scnse usuallypresentwith proprioc€ptive deficits,rot strength
lo themat.)In ths first two rrials,whcnthe foo! deficits,as is mosl commonly.€port€d.Inpaired proprio-
ioceplors were lefi inract,the individualreudilyre' ception ma] slso be responsiblefor nore sublle lymploms,
balance uponcontacLitrg thc Roor.However,in thc ls recentinvestigadon (192)suggesled that muscleaclivity
lrial,thefootproprioceplors wercanesthetized by sub- duringlhe gail cyclc is mainlained by a c€ntrallygererated
ingfteln in icc waterfor 20 minutes.Uponconlacting neiifal locomotorpaltcrn(which existsprimarilyat local
duringUis trial, the individualim.nediately crum- spinai levels)that is dependenlupon lhe proprioceptive
tothematasfcflexiveexlensionoflhe lowerextr€mily inpulassocjated wilh rhyrhmiclimb movem€nls.
notoccur.Il is of clinicalsignificance thal shoegear In describingthisrelationship, Rowinski(193)stated
ahductioflof lhc digits (such ,s poinred dress thal abc atio.rsof joint pioprioceptors may "disrupt the
may also inhibit the posilive supportingreaedoa phasicrclalionships betweenfeedbackand $e cenlralpat-
lern" and producesymptomssuchas the inabiiity to de-
In addiLionto the stabiiity affordedby the muscle and velop high velociliesand accelerations during lhe gail
proprioceptors,rhc importanceof skin proprioceptors cycle.an increased senseof effol in theconlrolofgait, and
licllady Meissner'scorpuscles) was recentlydemon' an increased amountof lolai conscious involvernenlin the
in a particrlarlyintersstingstudyby Robbinset al. function of drnbulation. while rhjsmaynorbc D\seriou\or
obviousa problemas recurrontaDklesprainssecondary to
'l hesercs€archers demonsrrated tiar rellcx response inpaired proprioception, the significance of this informr-
iousslimulationof Lheplantarcut0eous receptors lioo cannotbe overstated,
in relalionto thc locationof thcslimuli,i.e.,st;mula- Defectsin the propdocepdve sysl€mare readilyde-
of theskin underthe metatarsophalangeal joinl pro- lerminedby wha! Freeman(194) refers1o as a modified
rellexcorlracLion of $e digiul piantarflexors(which Romb€rg's test.Thepatientis irst ctedto slandon oneleg
for a redislribnlion of groundiercriveforcesaway with eyesopenandclosed.If afterseveralattemptsthe pa-
the mctalars heads toward the distal digits) while liert is uDablcto bolancelbr 10 seconds, thenit canbe as-
ion oi lhc skrn undcr(hc mediallong;ludinalarctr sumcdthat the proprioc€ptive syslemis mafunclioning.
tle opposite effeetin thnt it causesthc digitsro refex ('fhe averag€lengrhof time an asymptomatic individual
do$iflex(which concenlrales Drcssurebereaththe catrbalanceon otreleg beforolosingbalanccis 22 seconds
headsas ground-reacljve forcesarc no longer tr95l.)
equallybetw€enthe melalrrsalheadsand ftc While damageLothe proprioceptive systemmay be
diCrt9. the resultofperiphe.alreuropalhyor posteriorcolurnndis-
Robbinset al. (189)conrendrharinappropriareuseof casc,a mucbmorecommoncauseis previoustrauma(such
supporls
mayresulr;n slimularionof the skin bencath as invcrsionsprains)or repeated microlrauma (asoccurqin
mcdial longiludinal arch, thereby exposing rhe a mechanically maltunctioningfoot).Theseinjuriesfieorcl-
herdslo trauma,as the digilsare no longer,ble icnlly dcslroyproprioc€ptive
atlerenlsaodmay produc€in-
x with full tbrce.They alsocollcnd thatexces- jury due to impanedmuscula!strbilizatjoo.Cyriax (196)
cushiuningplacedbcncrlhlhc mcrararsal hcadsmay ciaim€dthariftbe proprioceptive systenis malfunclioning
la{t FOOTOR'IHOSFSandOlhd FormsofConie alivcFoorCarc
neus!progressalong lhe laleralcolumn duiing the rnid- harcfoolrunningproduc€d an increased tonein the
stanceperiodand,nnallytraverseth€ metatarsal hcadsand foor mlscLrlature (panicularlyflexordigilorumbrcvis)
roll off the halhx to terminatethe propul$iveperjod. lf su- rcsuitedin $o incrcased heightof the medialarchar
perimposcdbody weight makesearly rctum to acrivity sured or laleral rveighl-t'€aringx-rays. Ahbouehlte
difficull lhe palient should be encour.g€d ro walk waist tive importrnc€ of muscular vs. oss€ous suppoat
de€pin a swirEsing pool. mai,rtainingthc medisllongitudinal archr€mains
Anolh€r altcmative would bc !o have thc p.'ltienr is reasonableto statc that th€ dcmandsplaced upon
march or g€ndy bounceon a homc minftr.a'poline: poisi- mussularsysted vrry inveN€ly wifi lhe bony
ble variationsars limilcd only by the practitioner's imagi- i.c.,an individualwith n singl€aniculatodsubLalar j
nation. ln chronic cascs,it may be o€cessary!o have thc gojng to rcquiregreatermussrlar supportthansi
patieni p€rmln€ ly alter his or her gait pitt€m. For exam- witlr a lrianicularcdsubtslarioinL wheremotionis
plc. ar individual with a rigid lorefoot vllgt$ deformity and prinrarily by ioiot incongruily. [t most bc cmphaized
hamme. to€s may have to develop s high gcar push-olTin lhere is a limit to the suppon affordedby the muscdar
order lo avoid irritaling a chronic itrterdiSitalneurids.Also, tcm. As staledby Perry@05),"Even with maximrl
individuals wilh recalcilrantq canealstressfracturesmay lar lu[icipalioo, tbe capabilityto rneetthe valgus
have lo developa forefool sfike patlem in order to less€n impos€don the foot is lidrited,providings strong
ground-reaclive forces beneath the h€cl: Civanagh and for lhe careful selcctior of footwear and th€ addilion
kfonune (201) rcted thal shock scord arc often halved add.dsuppon."
when experimeotalsubjccls swilch from a he€l strike ro a In mostsilualions. wh€nan individualwirha
mid or forefoot strike paltem. ically dalfiuctioning foot pres€nts with muscle
Il should be not€d that a forefool strikc pattem may strcngthening cxercisessbouldinilially be avoided,
markedlyaggravaiean achillesrcndonand/or planiarfascia the musclesarc almost always overworkcdand w€ak
injury. With lheseinjories,it is bcsl to hrve the padent fatiirue.The prcmatureincorporationof a
maintain a rearfool strikc patlera and, if nec€ssary,to proPnm will ovcrloadlhe alrcadyfatigucdmus.les
shonenhis or her lc[gth of stide is order to reduceforces mdl p€rp€t ate a fauhy movemcnlpsltern iII the indivi
during the propulsivepcriod-Whilo recommendations to ci- who hssleamedto compensale for rbcchrcricallyslrai
ther increaseor dccad.see patieot's nalural stride lengtb is nusculatur€.This bcingthc case,the first srageof rh€
u$ally associatedwith a I or 2% ilcrease in the mctabolic habilitalionFocessis to slrelch$e overworked
cosl of loconotiofl (202), the polential benefitsassociated genrlY.
with a .educed.ateof injury usuallygroatlyouweigh any As notcdby Janda(206),Lhr posruralmusclsc,
metabolicpenalties. aslibjalisposterior, soleus,andgastrocnemius, arc
larl\ proneLotighlcningwir}| fatigue.This is troub
Muscur-{n STRENGTE, PowER, At\D ENDURA cE h lhat tbe faligrcd and tighlenedpostu.sl musclewill
producereflexinhibilionof theanragonistic phas'c
Perhapcno ropic in $e field of r€habilitativcfix)t care (pafliqrlarly peroncuslongus and tibialis anterior)w
ha5 been the center of morc controversytha lhe role of necLlle\s to !ay, crealesa confuscdstateof motor
strengthedng excrcisesio lhe mainlenanc€irnd develop- Becrus€ of this, stretchesfor the farigued and
mcnlof lhe mediallongitudinalarch.Over4l) yearsa8o.iD posturulmuscle3shouldhe incorpuratedsimu
an articledescribingthc etiologyand lreatmcnlof tftc hy- wilh strcngthenilgexercises for the weake$ed andI
perhobile flatfoot, Harris and B€ath(203) arguedthar mus- enedphasicmusCles.
culsr stren$h wlrs not ihe most imponant facloa in The cla$ic examplcof how posturalandphasic
maintaioingthe shapeof the nedial arch (lhis was rhe mosl cles work logerhcr to produc€ fo{rt dcformity occurs
widely accepted view at thattime)aodthala poorlydeve! fte lypermobilesubklarjoinl: lhe overly mobile
opcdarchwasfte rcsultof bonyabnormaliti€s ill the tarsal joirt often requiresmore musfllar stlbilizalionthan
bones(primarily i|l thc subtalarjoint) thrt matss them pos(uralmusclcscrn providc.As a result,lhc$e muscles
strocturallyrnable 10supportbody weight. They statedthat liglc and dghtco, which in turn producesreciprocalinhibi.
rhe muscularmechanismsrcsponsiblcfor Inaintainillg thc tion of lh€ antagonistic Peroneals. Sinc€ even sligh
alch are for occ.sional us€otrly, sincr. unlikc hony and lig- weikness of pcrcncus Iongus will allow for an incrcas.d
amentousrestrainli they are unable to function rnr€mit- rang. of sublalar pronation s€condarylo dec.e&sed shbi-
tirgly. Tbey supportedthis b€lief with the observalionrhal lizarionoflhe fir$ ray.thesrbtalarjoinlis allow€dto movc
feet that are complelely paralyzrd with poliomy€litis oflen throughan even grcaterrange of pronation,which stresse$
havelittle deformity. the libialisposlerior,soleus,andgastrocncmjus mus.lcsto
This is nol to say that muscularsupportof the mcdial the poi at which they cln no longer st8bilizc lhe fe8 ool.
longitudinalarch is noi irnponad. On thc contrary,a r€cent Thii placeslhc forefool into a constantlyinvenedposition
study by Hannab end Robbitrs (Z)4) dcmonstratedthat relalive to the rearfool,which may evenllally bccomefx€d
ChrptcrThrceAboorn.l Motiotrdurlnglh3Grll Cycle 151
3.162. Abductor h.llucii. Ieslr The examinerforce- bilizationol rhe medialforcloorduringthe lauerhalfof the
alemptsto abduct the hallux aSainslpatienl resistance prcpulrivep€riod(e.8.,,econdmetaia.$lnressr.acturc. cap-
(Thisdirectaonis rcvcE€d to test adductor hallucis). sulitis,et..)andfor hyp€re,(tension
ofthe fi|srinleehalanEeal
i prclon8cdwcJkne$ ol the aMuctor hallu(is mus. ioint. SranEely enoush,complet€paralysis of flexorhallucis
may rcsull in hrllux aMuctovalsu, defolmity, lon8utis occasionally foLrndin longdistancerunnels.Flexor
f'd ray delormily,and/or an excessrve lowerinB diSilorumb'evi! and longus.Tesls:Stren8lhin llexo,digito,
lh€ mediallongiludinalarch-Weaknessot addu(tor hallu, rum brevisir evaluat€dby applyin8a doBifleclorylorce b€,
is €lely seen.Flercr hallucisbr€visand longus,TestsrTo neathlhe middlephalanaes of the patientt ,econdthrough
fle)(orhallucisbrcvis,rhe examinerauemptsto dolsiflex fifrhdigits(.rgho.Thelonsdisitalflexorisevaluared by apply-
proximalphalanx a8ainsl patient .eristan€efcenter,A). in8 thesameforcebeneaththe distalphalan8es whil€ main-
halluchlongur is teftd by applyinSrhe sametorc€ be- tainin8 lhe interphalangeal joinls in a flexed position.
l h rh e dis r il pF J lanxr ll r. \o re rh a r th c i n l e rp l -rl d n g cal Weaknessr As sus8estedby Robbin,et al. {189),weakncs,in
ie mainlainedin a fiexed position when kning llexor thedi8ilalflexol,mayallowfor a loweringoithe medlallon-
llucislonSur.Waaknesr:A weakileior hallu.isbreviswill gitudinalarch and for chroniciniury to the metatarsopha,
Ior clawinSof th€ rrear toe and lessenedstabilityof ihe lanSealjoinrs,as rhe d;sraldigilsarc unableto effectiv€ly
l l o n ti ludinalar c h ( 17 2 )w h i l e a w e a k l l a x o r h a l l u c i s dislributesround-reactjve forcesaway from th€ metatarsai
may allow fo! injuriesassocialedwith inadequatena,
I s2 FOOTORTHOSES
andOIherForms
of Cons€nativc
FootCsrc
(Fig. 3.166).Olherconmon homeexerciscs are illustralcd a singlc tull effon musdecontraction(as is usedin
in Figurc 3.16?. ln all situatiors,an ex€rcbe program nelrrologicalassessments) and musi be evalurtedby
shouldatlemptto duplicalelhc sp€edof conlraction, joint ing the involvedmusclero the poinl of faligue,then
angles,and lypesof conllaction(i,e.,ecccntdcvs. concc - parirg rhe 6nal Dumberof repctilionsto thc -
tdc) thar the musclesare O be functionally stressed.The sidc.The neurologically induccdfatiguemay bea sourcc
essiestway to do this is with barefootwalkidg.As the pa- chrooic fool injury and treatmenlmusl be dircctcd
tiont improvcs,theexercisos canbe mad€moredifficuhby resl)ringoptimslspinalbiomechanics: in ordgrfor an
having lhe patienrpedorm rcpeat sidc-to'siderunning cisc progra to be €ffec{ive,one must first idenli{y rny
drills, progressively tiShtcr"figure8" drills, voriousplyo' all tnctorslhatnay be perp€tuating
thewcakness,
metdc cxcrcises,aloog wilh Cadoca mateuvers(Fig.
3.168),In udditionto increasing srenglh,thcscmovemcnts ExcEssrvr/ABNoRMAL
MorroNs
producelhe cooKlinated,svochronousmtl\culir interaclions
thal are essentialfor full recovery.In silualionswhere large Becauseof the extrem€sin ground-reactiveforces&F
dctbrmity ,nd/or proprioceptivedefcils are pres€nl,il may sociilted with locomolion, the most rcliable protcctiol
be nccess{ryfor lhe patienl !o wear o.thotics $d/or prolec- against ahnornlal or excessivemolion is a well-desigoed
tive wrappingto preventreinjury. skelctal system. ldeally, the articulations of fte foot ur
In ccalainciases,a given musclcruy not respondto a fornred in such a wa:. lhat they funclionally int€rlockard
strcngtheningprogram. Possibl€causd for this include the rcmrin stable even wilh lhe superimposedstress€sof
continued prcsenceof aciive trigger poinrs (which impair wei$ht-bearing (215).
lhc musclc'sability to recruitfibers),joint dysfunclionin Thereare,bow€ver,numerouscongenitalanonalies
the ncighboring articulalioDs(two separdtesludies (209, that signific"lntlyimpair rhe ability of bony restraininS
210)demonstrAted tbatmobilizationofa hypomobileartic- mechanisms lo resis!exc€ssivemolion,
ulationmry produceimmediatestrenglhgainsio the sup- The most significanl of lhesr congenilal anonralie$
poningmusculalure), andor nerverootcntrapnrcnl. occrrs in the subtalarjoirt. As describcdby Hafiis ald
As nolodby l.ee@r1),oneof the firstsignsofnervc Beirh (215), an architecturally slablc subtalarjoint will
ruol irrilolionis an acceloralcd fatigabiliryof the involved fornr in sucha way that the headof thc lalusis positioned
muscle.l hisdccreased endlrancemaynol hc apparent with direLllyoverthc atrterioretrdof thecslcaneus. ln thispos!
ChapterTlrce Abnormal Molior during the Glit Cyclc 153
3.164.Tibialisanterior. Te5t:The examinergra5pslhe peroneuslonguswilh the test pos tion illtjltrat€d in B. In lhk
s medialfore{ool(jusl dislal to thc insedionof tibialis tesl, the palient h positionedwith the forcfootslightly plan
a .d d er , pls lo v r F o ro L s lpv rn ra rfk x rh c i n re e d tadlexed and evertedwhlle the examinergraspsthe medial
againtlpalienlresittance{/eftl-Weakncss:The mon obvi' iorefoor.Agalnn maximal rcsistanceprcvided by the palienl,
floblem nssociated wirh weak4essof tiblalisanlerioris a the examiner alteinptsto doBiflex and inved the forciool.
. Aho, the lorefooroflen "slap!" lhe Broundloudly Weaknels:A weak peroneuslonrus allows for the develop'
n8 th€ conlactperiod. Rooret al. (3) noled lhar exlreme menl of an acquireddorsiil€xedfirst ray, as the medial fore-
oi libla is anteriormay allow rhe anlagooislicp€F Ioot is no Jon8erdabilized during lhe prcpulsiveperiod. fhis
longlslo cfealea planta lexed fi6r ray defomity. Tib- may eventuallylead lo defomity at the first metatarsopha
tterior.Ten: The mon common tesl positionh to have langeaijoint. Weaknessio peron€usbrevk is also trcuble
ienradducrand planrafflexthe forefoolwhjle the ex, some,as il allows for the developmenrof a flnctional rearfool
, with a medial midfoot .omacL anemptsto dolsillex varusdeiomiry as the mll5clesresponsiblefor inve(in8 the
ev€dlhe fool lcenrerl.Could {208),who claimed{ha ib' tubtalafjoinr ovelwh€lm lhe weak€nedperoneahduring late
posterior is probablythe most overlookedmusclein tha swin8 phase,allowing he€lsrfike to occur with the reartoot
in l€rmsoi muscularrtrenSth,suggeslstestingthh mu! exce,sivelyinvened.tlhe foot will behaveidenricallyto one
iirnrlygratpinEthe heel and having the palient rcsjsl wlth an olseousrcadool varu defomity until slrenglhis re-
n e j s e! er qonnii. r . t f rh ch e e li 5" b ,o l ,e n "w R h l e $ storcdto the lateralcompa.henl muscles.)Also,weaknessin
20lb, otpressure,tibialisposterior5houldbe conridefed the peroneahmay resukin chronic invesion anklesprains,as
Weakness: Pfogressive lowerinSof the medial lon8itu, peronels brevis i, unableto everl lhe laieralcolumn, iorcing
archwith lhe possibledev€lopmentof a functjonalfore, Lhefool lo roll lhrcu8h ils popukive period with the rea oot
wrus defomiiy and/or dorsiflexedfir$ ray. Peroneus excessiv€lyinverled as a low gear purh'off i, majnlained-
andbrevis.TesterAsn group, lhe pelonealsaret6ted Thi! movemen! paltern may eventually lead to interdi8ltal
inEthe pati€ntwirh lhe lorc{ootsliShtlys!pinated neuritis,recufientankle sprain,and/or laleral hip pain as the
plantarflexed,and inve cd) (flgh). Againrt reris- Bluteusmedius muscle fire5 vigorouslyin an attemptto dis-
prcvidedby ihe examiner {contact point on dorsal, place thc center of massmedially towad, the stancephase
lfifih metdtar5al),lhe patient attempc to abducL l.E
d n d .! e |h. r ox ' oo r (A). l r i r p o rs .b l el o i i o l a r^
154 FOOT ORTHOSESand Orher Foms of ConscrvativeF@r Carc
l:loxor
hallucis
longus 'llbiarisantoior
3.157.Homeex€rcher.fhe peroneals
may be exe. tar forefoot
allowsforan impovedslrcngth€.iing oflhe digital
i so l o ri (. llydr
. ' llus lr at e In flexo6.By placinsthe towelbeneath
d A. l i b i a i rsp o s l e ri oma
r yb c thefil51melatalsal
head
s€dwirhwhatAker(202)d€scrib€s as a sand-scraping andinslructifigthe patientto planbrllexthe an*leand eved
i the patientactivelyadducrsand inveds rhe torefoot theforefoot(E),percneus longusl, effectavely (Ihi,
exercis€d.
rcsistanceprcvided by frictio. benealh lhe lateral is a padicLrlarly
usefulexercis€ whentryjn8to teachthe pa-
(B).lhe useoftowel-curlshas be€omea standad fo. ricolhob ro inrli/lea hi8hEcarpurh-ofl)Theinteros5e ady
ning the digital flexo'. and exlensors.The patient be exe.cisedby havinBthe patientalternately adductand
tlsthetowel into a b.ll(lrapping lhe towel betlveenlhe abdud lhe diSitswhh tull etfort(F)while aMuclor hailucis
lnd lhe lip! of the toer) and theo adempE to srEighten maybe exercised by havingthe patientaddlct the Brcattoe
el byexlendin8 $e toes(C).Thisexerckemaybe p€r asainstlricttonfrom the floor (G). lt shouldbe pointd out
byLrsin8 friclioniromthefloor(orth€insideofa shoe) thatwhilemanypractitioneA claimthatstenafteninBthe foot
of lhe lowel. lhe Dollcrio.compr mert rrurclesma) musculatlrek an efteclivetorm of treatmentfor variou!
exerchedwith single les,heel l"ise, (w€i8his may b€ ov€ruseinjuries,lhere €laimsse€mlo be exag8€rat€d (46,
dto the shouldcGor hands)or by perlormiosrcpeatsin- 213).In fact,Awb.eyet al. (213)foundthat parients treared
jumps(Bradually incrcasins the hei8htot lhe jump). with 3 monthsof foot exercises for plantarfas€ialinjlry
0 illustar€s how placipgr Lowelbenealhrhedi8itsand showedno impfov€rnenl ascomparcd to a conaolSroup-
lhe patientro _asp fir\l thc hel and then the plan-
156 FOOT ORTHOSESrnd Otl'er Fodnsof Consln ative Fm! Care
Figur€3.158.Ca.iocaererci!€s.Thepatienlpcrtormrrepedt
ridc-to'side
drillswhilc ahernately
crcssinsonc le8in fruntoi Fi8ur€3.169. ldeal d€v€lopmenlof lhe sustentCl|lum
rheorher.(Addpred fromSetoJt, BrcwsrerCE,Loftbrrdo5T,
et al. Rehabililation
of the kneeafrerant€riorcrucintelisa-
menlreconstruclion. JOnhopSponsPhysTher1989;1l (l):
a-18.)
The HypermobilcSubtslarJoint
Unfonunarcly, a sructufflly srable sublalai joinl is
not always pres€nt,as onlogenic defects in subtalardevel-
opmeot may sllow for deformity in whicb lhc headof the
taluslies ante or and medialro the end of rhe calcanett',
with the sustentaculumlali erdstingas a tonguelike p.oc€ss
lhal projectsproximally(Fig. 3.170).This beingthe cas€, ri8ltr€ 3.170. lhc poorly dcvelop€dsun€nhcrrlumtali is ul
lhe olcaneusis unableto suppoltth€ headof the t us and .ble to .d€quatcly support lh€ lal.r he.d, i^dapled fom
superimposcd body weightallows lhe ulos io adducland kacingroi x-ra)Bas illustrated by Haris Rl, ge.th T. Hyper-
plantarflexns the calcan€us simuhaneously everts.The cx- mobrleilatfoorwilh shon tendoachillcs.I 8o'reJointSurB
cessivetalarplanrarflexion only servesro unplify theinsla- l94lrj.lOAil): 116-138.)
bilily as thc headof rhc talusactsas a wedgcthatfu(her
separalesthe incompctentsuslentaculumlali from the
navicular.This wedge-likeaclioooflhe talusis a collstant of drctalurimay e-scape
transversely fronrthc ruvicular&.
sourceofiritslion, as ir placesrh€springandlong planhr etabulum.Vogler(216)noledthal whenthc lalsrhcadci-
ligament$ on rcnsionandmay eventuallylcadlo plaslicde- capc\approximately 50%of rhenavicllarac4tabulum, it is
fomity of thcserissues. funcrioring oul of conrol," ard a r€trogr0de compre$ive
Talarsdduclionalso lcadslo instabilitv.as the bead forcc develoDsat lhe Droximalnlvicular that driv€sOe
chaplerThoe Abmrmsl Motior during the Gait Cycle 157
The hypermobileflalfoot deformity can be idenrified wilh a hypemobilcflalfootis how to accommodare rh!
by theextremeloweringof themcdiallongitudinalarchon crer\ed rangeof anklc dorsifl€xion.Becau,(c the
weighFbearing, thechronicallycv€rtedheel,rhedrasrically ftnllc ofankledorsiffexion is almostalwaysassocialcd
increasedrangcof lorefootinversion(with $e concohi- a p.|lhoiogicalrangcof compensarory midtarsaljoint
lantlydecreased Iangeof anklcdorsiflexion)and,mostim- tion. it is imponantthatthc practitionerinco.poral€
portan y, by lhe medial displaccmcntof thc talus relativc lo pmllriat€ly sizedhcel lifl and/or useonly dle soflcr
thc calcaneusduriog static slance.A supcrior/infbriorx-r.y shellr as useof a rigid shellwithouta he€llift a
servesasa llseful index for dcterminingth€ degreeof defo.- wals leadsto iatrogenicinjury as the pronaringmi
mity, as it demonstmtes a shadowwbererhe headof the collidesinto rhc onhodc shell.Also, arcmDr.\should
talusis not supponedby the ant€riorcalcarcus(e.9.,com- ways b€ mad€io leDgth€tlthe achilles rendon(the
palc the shadedareain Fig. 3.I 70 ro the shadedaftn io Fig. joinl mustalwaysbe in a [eutralor supinated position
3.169). pcrli)rming calf stetches) and $rengther th€ s
To be comprehensivc, trcatmeotof this subtalsr mus.ulatrreGfflicolarly dbialis posterjorand sbd
anomalyshouldincludovariousmanualtcchniques lo !d- hallucis).
drcssany soft tissuecontractlrrcsassociat€dv./iththis defor-
mily. and an orthoric,which actsas a physjcalbarri€rro The liypcrmobile First nay
prevcnl excessivedisplac:emeolof the lalar bead.Allhorgh
lhc onhoticwill not conectthe dcformilywhenusddaller In additionto fauhyfoot functiooassociated wilt
osseousmaturity, it cao greatly reducestrain placed upon anorrnloussublalarjoint. anolherosseous
lhe supportingmusclesandligamcnts, asit basicallyaclsas thalnllowsfor abnormalnotion is obliouitvoflhe firsl
an extrinsicsustentaculum lali. somNtatanal (Fig. 3.172).This panicubr d€forniryid
Whcnapplicablc, fl rearfoolvaruspostshouldbe used throsbackto th€ primitivr arborralfout. *hcre
LoreDosilion thccenterof massof thecalcaneus benenrh the skills, nol mechanical $ldbility,was thc pdmary
canterof massof tfte talus.This posl rhay be invaluable,as Evolutionaryremodelingof lhe foot necessilated a
il lc\senslhe lengthoflhe leverann affordedbodyweighl migr.rtionof th€ fiN ray in order to allow a morc e
for pronalingthe subtalarjoint, which in tum altowsrbe propulsivep€riod(218).
muscularsystemto becomcmore effectiveat conlrolling lf deformity of the firsr tarsom€tata$aljoinl
subtalarmotioos.fie uscof a forefool varuspo6tshouidb€ lhc lirsl r.y to b€ meintaincd in ao adduct€dposition,
pr€scribed with caulion, as prolonged sublala. pronalion 6rst mcratarsal headwouldbe unableto b€arweicht
oftcn rcsultsitr lhe develoDment of a funclionalforefoot tivelv sinc€.unlikethe sccondmctalarsal- it is nol
varus whcrc the forefoot deformity is mainhined by sofl slabilizedby rn osseouslocking mecha[isnr.Nolc
lissuccontncture.Useof a forefoolva s postin thissilua- whcDthc firsl metatarsal is in a midlire posirion,il crrl
lion wolld only maintah the forefoot deformity and rnay efferlively stabilizedhy rhe supponingmusc|llaturc
cventually lead lo progr€ssivcdeformity of th€ first first ftelatars?l hasstronccr musclesallachedlo il lhan
mehhrsophelangealjoinl. ot the othermetararsals [219])and by ligamcntous
Thc most imporlantclinical conccmwhen d€aling monrsto the securedsecondmetalarsalbese(the bascof
metatarsal is looselyheld lo the baseof the s€cond becausethey allow for exc€Bsive motion,articularanom-
rrsalby theLislranc'slisament). aliesmay alsoproduceinjurybecause theyallowfor abnoF
Withthc first ra) situat€din thisbiomcchanically sta- malmotion,i.e.,because it isthe articularsudacegeometry
midlircposilion,evaluationof th€ nngesof motionbe- thst determineswhore a joint will go upor, rEechadcd or
thc basesof tle first through fiflh metatarsdlswill musculardemand(221),variationin articularshapemay
an averagemovemenlratio of 2, l, 2, 4, 5, respec- allow for a funclionalmalpositrotr of a joint's axis of mo-
(132).In other words, the first metalarsalshould tion-As Feviouslydescribed in the anatomys€ction,varia-
lwic€asmuchasthe secondmelatarsal,jusl asmlch don in subtalarjoinr anatornynay atlow the joint's axis of
6e third melatzrs"l,half as much as the fourth morion to be positionedatrywherefrom 20 to 68.f rclative
and two-fffths ai much as rhe lillh metatarsal, to lhelransverse plane(Fig.1.24CandD).
obliquih ol lhe firsr tarsomcrararsal aniculationis The approximat position of (he subtalaraxis cad be
it is not uncommonfor tfie adductedfirst rav to be clinicallydetermin€dby standingbehindthe patieoland
poorlystabilized lhat rh€inlermelararual
movemenr ratio noling lhe relative amountsof calcnnealinveBior/oversion,
5,t,2 ,4,S. as comparedto exlernavinlernal tibial rotation.lf the axis
The extremehypermobilily of the first ray makes it lies near70", the amountof tibial rotationwill greatly€x-
lo resistsround-roacliveforc€sandallows for an Ex-
tangeof subrrlarpronation.Ttis is particularl,
whenit occurswirb a realfootor foreloolvarus
i1y,asthe€xaggeratcd arue ofsublalarpronatioris
incleased,Lherebyforcirg the frst melatarsalinlo a
andinverledposition,This allowsfor mpid de-
of a Grude3 halluxabductovalgls as theforces
Fopulsio0 subluxatc the proximal phalanx (Fig.3.173).
Thedorsifiexed andinvertedlirct ray may also pro-
dcgenerativecharges at the base of tbe first
where a dorsal baseexostosisofien forms sec-
lo the compressive forcesthat.developalonBlhe
tarsomelalarsal aaticulalion.This exostosis is parlicu-
lroublesome in thatit oftenproduces entrapmenl of thc
pcroncalnerveand/orlenosytrovitis of $e extensor
longus/brevis tendons,as these tissuesbecome
betweeo theconstantlyshiftingexoslosis andshoe
(Fig.3.1?4).
Tr€atment of a hypermobile fi$t .ay r€quiresa prop-
postedorthotic thal preventsexcessivesublalarprona-
and improves tie mechanical efliciency of lhe
musculalure(particularlyp€roneuslongus).
it is ofter n€cessary to includebalanceboardexeF
andmaniDulalion of the interlarsalandta$ometatarsal
sincerhe hdividual wiri a hypennobiletusl
oftenprescnlswilh impaired proprioceptiotrand a de-
rangeof 6lsl rayplantar8exion.
Carofulseledionof shoegearis a mustsincethead- figure 3.173.Obllquilyof the firll larsometalarsal atlicula'
6rslray slmostalwaysrequiresa roomytoe box to tion (insetl resulain an adductedtirst that h tln
compression oflhe melatarsal heads.llis ofienn€c- 'retatarfal
resultsin abductionof the tatlur laroD. As the foot with
to h8vea cobblerstretchtheuoDcroverthedorsome" lhis detormitymovesinto ils propulsive pedod,grcund{eac-
firs! mclatarsalhead10 preveDrlhe formationof a tiveforc€,centercdbenealhthe halluxnrc will havsa medi'
bunion.(Note: Tbis treatmefli prograrricao also b€ ally direcledcomponent/FM),which equalsfK x lange.iof
whentreatirg a splay fool deformity itr which arlcular analeA A5a rcruh,a halluxrhali, abducled 60'will pushIhe
has allow€dfor an abnormallransv€rseplane headof tha fi6t metatarral fiediallywith a forcethat i5 ] 7
timesgrcaterthanthatof pushoff.As slatedby Bojsen-Moller
ofthe melatarsals, seeFig. 3.175)
{106),thisspois thesrabilnyand the m€chanics ol the {ore-
foot and caus€spaintulpresrurcE betweenthe metatarsal
Malpositioned S||btalar Joint Axls headandthesho€.Theseinlernallorces mayeventually rcsult
in the"totalcollapseof the fnstray."(Padiallyadaptedfrcm
An irlportant considerationin this discussionof artic- Eojsen-Moller F.Anatomyofthe forefoot,normalandpatho
anomalies is rhar,in additionro prcdisposing to injur] loBic.ClinOrthopRelated R€e1979j142:r0.)
I 60 FOOT ORTHOSES.nd Olher Foms of Conserva$vcR)ot Carc
Thisdisnaltreatmenr prognosis
is nol sharedby Hice Eigute 3.177, A vetticall\t dhplac€d oblique lnidtaFal joirl
whoclaimsil is possibleto eff€ctivelymanageihis dis (OMIA) allows for ercessive abdlclion ot the for€foot
thesubtalaljoinl
ily aslongastheorthoticmaintairls uFon weight-bearin& as evidenced by lhe characteristic
F near ncllLlal
posiliondoringmidstance. To accomplish changesin lhe lateralcontoor of th€ calcaneocuboidioint,
162 FOOT ORTHOSESand Othcr FormsofconscFalivc Foot Carc
Adult
FiBUre planealignment
3.r79.lde.l Iransrerse in inFrnts.ndadulis.
164 FOO] ORTHOSES
andOtlterFonrsof Con$Narilc loot Cflre
shearlbrc€sare appli€dmoreperpendicular to the pingomentof the talusupon the lalelal aspecrof the ca!
axis andcan ftercforc generatea strong pronatory canorlsulcus(whichoftcn leadsto a flaneningand broad'
It is for thisreasonthatindividualswith lffge.angcs enillg of the lateral talar process),and a nafowing of the
rolation!r lhe hip arepredisposed to medisllib- poslerio. ialocnlcrreal facet Also, the first melatarsalhcad
rtoss reaclions(229). may also be damagcdas the individMl "rolls off' the m6-
A loe out gail pancm m-ayalso pr€disposeto inj!ry dial forefool; this forceslte firsr ray into a dorsifiexedand
it allows for a prematuremedial displacementof invened position aod may predisposeto libial sesamoiditis,
Dornalprogr€ssion of venicalforces(Fig. 3.181).This dorsalbas€exostosis,enddorsonedial bunion pain. It is for
bodywci8h!with an effectiveleverarm for main- lhcse reaso[s thal Macconaill and Basmajian(228) claim
lhesublalarjoint in a pronaledposilionthroughout lhal toe out gait psttomsdetrimentallyaffect meanlevels of
andpropulsivep€riods.Accordingto Davenpon musclcactivity muchmorelhan toe in patterns.
excessive subtalarpronationassociat€d with a toeout In lhe adult,a toe iD gartpaltemis relativelyharm-
tallcmmayevcDtually resultin lossoflhe mediallon- less,cveflthoughit forcestheindividualio naintaina lolx-
arch,adapriveshorEningu[ the p€roneals,im- gcar push-off, which makesfor a less efficient propulsion.
166 FOOT ORTHOSESand OtherFoms of CorsFalivc Footcare
90' By intemdlyandcxlernallyrotatingLhefcmurand
ing the positionof lhe tibia whcn the gcalcr troc
par.,llel io Lheexaminalionrabl€.thc approximate
{cmo.al flnte or r€troversioris casily dttermincd
3.1s2).This tesringpositionis alsousefulfor noringthe
grcf ofintemalandextemalf€moralrotalion(Fig.3.1
Lln6ol progr6$lon
Fi8ure3,181.(A) Normalpmgression of forces,(8) proSre.-
sion of forc€ with a toe our tait pinern.
3.188.In lhe nornal foot, a line bis€crin8rh€ h€cl (C and D), the heelbis€ctorwill passbetweenthe thkd and
pa!6bctweenlhe s€condend lhi.d di8its (A). lf a mild foudhand tifthdigitr,respectively.(Modifiedflom BleckEt.
or for€fooladduclls is Drcsenl,lhe line will pass D€veloomeotal onhooaedics. lll. Toddlers.Dev Mcd Child
rhc lhid di8,t. In modcra'c ad mrrked del'ormrlies Neurcl1982:24r513-555.)
bhection of the rca oot intersecrswilh tle oppositefcet and e gentle slretching procedurewbere lho
headsGig. 3.188).Also, the lexibility of lhe parcnt abducls thc forefoot rgai$l the stabilized heel.
shouldbe evaluatedby passivelyabdllcliogthe fore- Thesestrelchessholld b€ Dainrainedfor 40 secondsandbe
agairstlhe slabilizedrearfoot.If rhe dcformity is flexi- rep€ateda minimum of l0 lioes daily-
thc forcfool may be abductcd bcyond midline; if Becauseit is difiicult lo correcta metatarsusadductus
ir csn bc movedto midlineonly, and a rigid or forofoot adductosaft€. idancy, it is suSSesled that mod-
nitycannotbe movedto midline, erateandmarkeddeformitiesb€ treatedwith serialplasler
Unfonunatcly, thereis no clear-culcritedafor detcr- casts(proferablybefore8 monthsandideallyrt theageof4
ry which doformitics continuelhroughosseo0s matu- mooths).This tr€atment involveswearing a plastercastlhat
: often,a markedsemiflcribledeformityresolves during mainlainstheheelin varuswhiletheforefoolis moldedinto
whilea mild flcxibledcformitymaybecomeper- abductioD.Two or thre€of thesec3sls,chatrgedevery I or 2
As a genomlrule, it is suggesledthat mild deformi wcels, areusually suffci€nl lo achievecorection.
receiveno lreahcnt other lhan recommendalionsfor While ma6y investigalorsfeel lhat conscrvativetreal-
in sirtingandsleepirgpostorcs, weariogshocson ment in the form of casts, bnc€s, shoc gcar, and/or
170 FOOTORTHOSES
andOtherFormsof Conreryativ€
Footcsrc
sho€smay
figure 3.190.Stiff-soled
forc€thecr.wlingchildto inlernally
or ext€rnally rotatc lhe l€gs.
(Modified f'om pholosraphsin
schurl€rRo. The effectsoi modem
footgear.I Am PodiatryAssoc1978:
68 (4)r215.)
Physlologicgenuvalgum L6gsslraight
wlth Protecliveloe in
\oso'
"\
3.193. Normally, rh€ ankle ioinl will fo'n in suo a
thatils artlcularsuriaceis pe.p€ndicular to th€ tibial
(A).lr is, however,
possibletor rheanklejoint to be in,
or evertedrelarivero thc tibial shalt {244)-An evcded Primale
joinl resullsin the formalionof a 5ubtalarvalgusdeloF
(8). Nolp rrdr rhir .s d Flrtively rare prenomeron j FiSure3.194. As vi€wed in lhe frontal plane,the lud€rfacu-
lum lali shouldbe angledin sucha v/aythal it supporhlhe
talus,displacingit late.allywith superimposed bodyweirht
{A).lnman(247)staledthatthesustentaculum taii ln a neutral
loo ml.lchweight. This lllay resrllt in ialrogenic in-
foot will showa positiveansl€beween5 and 15". Nolic€
how thesunenlacul!m tali in theprimatei, an8ledinferioy,
to themedialcalcaneal condyleand/orIissuesbenea$ therebyallowinsfor a plantarmedialmisrationoi lhe talus
calcaneal inclineargle.'Iheseinjurie! may be avoided (B).Coulder al. (241)nor€drhala hyperpronat€d loor will
lakjngweighL-bcaring foot impfessions with the patient prcsenlwith a 0'or ne8ative an8leot the rlstentaculum taii.
g in a no.malbas€olgait wbilemainlaining{donav, Ihey also noledthat the sunenlacullmtali shoLrldbe fully
congruen0y, Orlholicsmadcftorn theseimpresstons
174 FOOTORTUOSES
andOlherFormsof ConseNative
F@lCtre
mity are descrit€din the following scclion.Note th thc spriin disruptsthc adhesions. sometimes producing
lirst two typesof ffatfootdefoimilya{e mentioned only for paci|alingpain.
puFosesof cxclusionsincolhsy are relativelymre 8ndare Consewalivetrealmenlfor lhc oeroncalsDastic
ireat0dwiLh aggressive castingiechniquesand/orsurgery fool should include manipulalion,itrlmobilization(short
duringthetirst few monthsof life. lontr leg cast may be used),aad/orfool orthotics
Convexpes i'alga.s. Also known as a ve(ical Ialus (251) reronrnended thnl fool oftholics be m:lde by
or rockerbottom foot, lhis uncommonconditioncan bc fte ibot in its most comt'brtableposition d thenusing
identificdin the ncwbomby the dorsiflexedand abducl€d appropriatelysized forefoot and/or readoot poststo
forefoo! that is rigid anddoesnot rcduce.Ir representsa pri- tair this positionduring ambulalion.Althoughdr&e
mnry dislocationof the talonaviculNr joinl in which the muchconllictinginformationin Ihc literatorcregarding
taiusis lockedin a platrtarflexed posilioqwith thenavicular effil-acy of conservativecare, such tr€atmefltsshould
articulatiflgwith thedonal aspectof thetalus.(A crerseac- wa}\ becnnsidered sinc€theyaresafeandveryohen
tually forms along the dorsal talonavicularspace.)This tjvc (Frticularly in casesof acut€lraumaafld i
causesthe sole of the fool to appearconvex as the talar arthrilisl250l) ln manycnses,however,consen,stive
headbulgesplantarly.Although the etiology f,)r this condi- mcnt affords only temporery reliefl as it docs nol
lion rcmainsunc€rtair,it is bclievedto be the resultofneu- $h:r i s mo\t often rhe uoderl yi l g causeof rhe
romusculardiseaseor defectsin tarsalevolurioothat are spasticflatfoot:tarsalcoalitions.If symptomspersist
aggravated by iDlmulerinemolding(248).It is onfortunate spilr comprehensiveconsewotivecaJe,surgicxlexcision
thatconservative Eeatmentfor tlis deformitywith casting the coalitionmay be necessary- S0rgicalinterventiol
andmanipulation is seldomeffective,andopcrativecorr€c- morc Iikely to producea favorableresultif thecoaliLiot
lion is almostal)vaysrccessary. naflow 3ndthepatienlir young,i.e..lessthrn 20 yea$old.
TaWs cal&neovalgus. This condition is often rc- Hfpenabik fla{oot. As prcviou\lymenrionc(
fened to as congenitalflatfoot and is simiiar to the venical hyp,rrmobile f,atfbotnxy be secondary ro anatomicl,l
vaiil!
ialus in that the lorefootis dorsillex€daod evened,(Ihe tion ii the shapeoflhe sustentrculumlali or to gener0
foot actuallyappears to bc tbldedlnlerallyuponilselt) Be- lignnrntouslaxity. Il can be readilyidcntifiedby the
causethisdeformityis alwaysnenible,il respoDds well to a treme low€ring of rhc m€dial longitudinalarch
corseflatilc treatmentprogr.m of taping,manigulalion, weight-boaring,the increasedrange of forefoot invcrsion,,
and casling as long as trealmenlis initiatedbefore 18 m€dialdisplacemenl of rhe talusrelativeto th€ calcane8,,
monthsofage (249).As with theverlicaltalus,theoliology and the dramalically rcduc€d range of anlde dorsiflexio!.
renainsunc€nainbut is mostlytikelythere,sult oiinlrauler- Thc severilyof the deformily can be determinedby m$sur-
ine posirionjng or neuromuscular disease. ing th€ lalometatarsal angJeon laletalweighr"bearing x.
Percr,eal srystic lalfooL Also known as rigid flaF raysrlf the talometatarsal angleis betweenI and 15",a
fool, rhc peroncalspasticflatfootis associat€d wilh spasm mil(l dcformityis pres€rtia 16 30 " anglerep.isents mod-'
of th€ lateral comparlm€nt musculalure, which naintains erar'jdeformily;andan anglegealer than30" is considered
the heelin a lixcd position of valgus. (The heel is resistant a severcdefonnity(Fig.3.195).
1o both aclive and passivc ioversion.) In approximately Onhotictreatment shouldonly beconsidered a{te!thc
7[H0% of th€secases.the etiologycanbe relaledto vari- agc of 3 sinceagesl-3 represcnr .1holdingperiodduring
ousrarsalcoalidonstharmaybe osseous (synostosjs),cani- whichno specifictr€atment is need€d, otherthanfim, srp-
laginous (synchondrosis). fibrous (syndesmosis), or a ponivcshoegearwith a smallarchsuppon(252).Childrc!
combinationthereot The mosl commonconlitionsoccur with moderateor severedeformitics are cindidatesfor fool
betweenthe talusa d rhecalcaneus with calcaneonrvicular orthoscs,particularly if there is n fanily hislory of fiatfool
coalitiom being the secondmost common.Becauscof Successfulonholic trcaiment necessita!€s rhar an off-
difficultiesin idertifyingrhevariouscoalitionswilh r-r.ys, weight-bcaring plaster castbe tdken in which all segmenls
CI or MRI may be essential. The iemaining20-3{)7oof are nrainrainedin iheif oeutral posirion (252).A polypropy'
caseswith peroneal spasticflalloormaybe relaledto anyof lencshellis thenmoldedover the positivemodol (nole$at
sEverrlfoclors,includingmuma (fractureor sprain/strain). rh€nredialIongiludinalarch is not hwercd),and lhechiid is
tuberculosis of the ta$als,rheumaloidarthrilis.tronspecific insfiLrcled
io wear the orthoticsconslantly, prcferably in
tarsalsynoviris,tenosynovitis of lhe percoealsor ribials higb-top shoes with long stiff beel counters.Illenl
poslerior,osteoarthrosis, n€oplasnr, or subtalrrarthrodcsis wei;rbt-bcrring x-mysshouldbe takenwilh the odholicin
(250).For r,/hateverreason,the diminishedsublalarjoint ihc shoe lo ensure thrl proper corrcctiofi has been
motion sornehowcrealesa cfcle of pain, pcronealspasm, aohi.v€d,lf the talometatarsal anBlehasnot beenrcduced,
and calcancovalgus. which becomesprogressivelymore the orthotic must be refabricatcd.Bordelon (252j has
rigid wiah time. Although the peronealspasticffattbolis demonstraled thatwh€nworn conslantly,th€orthoticspro-
often presen!from birth, il rarely produc€ssymptomsbe- duct a rateof conecaionin the talomelatalsal anglcof 3F
fore adolescence, wben exc€ssiveactivity or a $udden proximately5"/year.
ChapterThreeAbmnnrl Moaioddurhg the Gall Cycle 175
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ChapterFour
BiomechanicalExamination
I !*,
il'l
il
't!,t'
u:t.
Tltc6ral po(ion ofthe supin€examshouldincludca shouldalwaysbe the referercepoiris. II the medial and lat-
ovalualionof r!usclestrensth. eral surfacesof the calcanBusmusl be used,bony deformi-
ties($ch as Haglund'sdeformityor atr aboormallyshaped
PRONE EXAMTNATToN calcaneus) shouldbe ignored.
lt cannotbe overstressedthal adequatemarking of rhe
T}e patieolis plac€din a proneposilionandihelower calcanealbisectionis cssedialfor properevaluationand
ity is rotakdto bringthc posteriorsurfaceofthe cal- lrealmetl,as an incorlectbiscclionwould produceelfor in
inlo the frontalplane.(This may requireplacinga bolh the reerloot and forefoot measur€men1s, e.9., the r€aF
towelbcn€athth€ contralaleral oelvis.)The calca- foot biseclion in Figure 4.6 thal usesthe nedial and lareral
is Lhcnbisededby pincbingthc planlaraspecls of the contoursof the calcareusfor references(dashedline) givcs
andlaleralcondylesanddJawinga line that is peF the impression of a combincdsubtalarvaiunvforefootyal-
to the line counectingtbesepoints(Fig, 45). gus delormilywhile lhe lrue bisection(solid line) clearly
plantarskinconlollrshouldnot be usedasa reference demonstratese neutial forefool and rearfoot,
bisecting the heel,as a chronicallypron ed ioot will Once the cslcaneushas beon marked,the distal one-
thd pldnlarheelso lhar lhe skin appcrrs inverledrel third of the leg may be bisecled.The alignmontbelweenthe
lo the plantercondyles-(The oppositcis lrue with a post€riorcalcaneusand Lbedielal leg may now be mcasurcd
icrllysupinated reaJfoot.) (Fig. 4.7). Although Rool et . . (7) originally mainlaincd
Also,althougbil hasbecomestandadpracticeto bi- that the neutralposition of the subtalarjoint should be de-
lhecalcaneus u$ingthe medialard lateralsurface,slbr terminedby noting the overall rangeof motion available to
thisDracticeshouldonlv bc consideredwhenthc thesublelarjointandthenplacingthecalcsneal bisectionin
oI !h€fat pador thjckness
oflhe skin negatesbisecting a position lhal is one-third of the way from its fully
calcaftusvia palpationofthe planrarcondyles.Because pronatedposilion,this techniquehas b€en all but aban-
ouline of the Dost€riorcalcancusmost ofteD forms a donedb€causevadalion ir sribtalarrangeof motion nakes
id, marking lhe calcaneusby bisccLioglhe medial for muci inconsistency.
latemlsurfaceswouldproducea line thatdevist€sfron Also, wbile most authoriliee recomftend measuring
perperdicllarbi:eotionof thc plantd condyles(Fig. the raDgeof subtalareversionwith lhe patientin a pronepo-
Sinceit asthelocaiiorof ihc condvlesthatdctemrutcs sitior, more recent investigation demorslrates that off-
phasemotion ol lhc subhlar joint, lhe condyles weight-bearing neasuremenls of subtalareversionare nol
184 I'oOT ORTflOSES and Othcr Poms of ConservatlveFoot Cere
tigurc 4-9. Eccaulerh€ ranEeof midtarial ioinr motion i! (A) while evaluatinErfie forefoovrearfool relatioffhip
dependenlon the posilion ot lhe subi.lar ioinl, measuring the sublalarioint pronalcdwill r€3t,,hin a falsefor€fool
lh€ forefoovrearfuot ielalionshlp trith rhe subtalar joint gusmea.urem€nl (c).
stloidaled$/ill reruh in a fals€ forefoot varus m€asurem€nl
D
iiKt ray(E),
vaftrs(D), flexibleplantarflexed
Figure4.10. Plantarcallusp.tlern!. Thesepattensshow rcafi$y'forefoot
compensatedfea ool varus(A' compensatediorefoofvaflJs and( ompenraied
eq||inusdefomrity(f).
(B), i8id plantartlexedtils| ray tC), uncomp€nsated
chaptorFow EloloecharicalEx{minarior 187
is anvdoublas to lhe oosilioDof lhe nrsrmelatarsal andeversionmay now be measured by placiogthe subtslar
hoad,the pmclitionershould use only rhe ccritrulthr€c joinr in irs neulratposirionand notinSthe locationof the
hcadsfor reference.
Also,a suspectedfunctiona] calcanealbileclioh relativeto the ground. The Prtient is
varusshouldbe vigorouslymobilizedprbr to msa rhenask€dto eyen the heelmaximallyand lhe changein
angulationis noted. The procedureis reversedro measure
rheforeiool/rcarfoorrclationship. rhe r.nge of inversionand is repeatedbilaterally. This
Wilh the forefoot maintainedin its ncrlral position, positionalsoallowsfor neasuremenl oflhe weight-bearing
enl of the metatarsalsshould then be rccorded,{nd neutralrearfootposjtion,lhe neulralsubtalarpositionand
Iallgcof 6rst ray dorsiflexiofl and plantadexion should the subtalarjoint angle presenldurin8 relaxedcalcaneal
noted. Hip rang€ ot motion is readily €valuared by slanceandsin8lel€g stance(s€eFig.4.ll).
ing theknees90' and observirgLibialpositionsas the The slanditrgevaluationcodinueswitb observalion
is maxjmallyintcmallyandexlemallyrotaled.The legs oI lhe lateralcontourof the foot dudng relax€dstanc€:a
tien st.aigbtened,
and thc rangoof hip cxtcGion and vcnicallypositioned joilll axiswill result
obliquomidtarsal
nexionis checked.Notethanwhenevaluating hip ex- in an aculeangulalionat the calcancocuboid joinl (refsr
ion,onchandshouldb€ placedovcr thc sacrurnto cn- backio Fig. 3.177)while a foot wjth an inadequate suslen-
6a[ motion is coming only f.om th€ hip and nol laculumlali or singleaniculat€dsubralar joint will prcsonl
compcrsalory sacrojliac
or spinalexlension.
A sus- with a sraight lateralcolumn,despjtethe m€dialdisplace-
leg len$h discrepancy shouldbe evaluakdand,if mentofthe |alusrelativeto th€calcareus.
specificmusclesshouldbe checkedtbr conlrac- The possibleeffectsof a leg lenglh discrepancy
shouldbe notedby checkingfor lateraldeviationof the
The final ponion of the plone examshouldinclude spine,as well as the levels of the iliac cr€sls,grealer
I cxaminalionof planhr cal'uspatterns,
asthesepaF troclanlers,tibial plateaus,and medial malleoli.A fuoc-
provideinvaluableintbrmationregardinglhe degree lional leg length discrepancysecodary to asymmeHcal
shearandcompressive lbrccsprescrtdurirg slancephase pronationwiil resultin an excessivelowerinsofone medial
4.r0) mallcolusrelativeto the other.The standing€valualioncan
bc complctcdby performingan equinuscompensation !€sl
STANDTNG
Ex MINATTON (F'g.4.12),a modifiedRomberg'stest,and by nolingdis-
placemenl oflhe fal paduponweight-beadng (Fig.4.13).
Thepatienlis askedto stand,andthc iDiegrit)of thc
longitudinal archis nokd on andolfweighrbearing.
informaiion is usefulin jdcntifyingvariousfoot types.
eromple, an individualwith a fo!€footvarusdeformily
classicallypresentwilh a lossof the mediallongiludi-
atchbolh or and olf weighcbearingwhile lhe rigid
frtsrray de{ormitywill r}pically rcsultin a
ial lorsitudinal arch thal is elevaled bolb on and off
.h.jaring.Allhoughinterrarerreliabrlitylor evaluat-
archh€ightis low (13),rhisinfornatior shoirldslill be Fl!!B a,ll, 6y pl.cltrgltr. pd.nt In lh. pFp.r .n!b .nd b... ol q.ll
asit he'pscorroborale olherexaminarion lindings whll. tl| lalowlcul,|rlolm |l mlnt h.d In h. cloF!.clqd !o!hron, rn.
.4|[l po.|nd ol lh. r4rloor {a) crn b. h{!u.d by no no ln..ngr.
leslstheinlegrityof thesubtalarandmidtarsalreslrain- lod.d b.iren lh. c.lc. rl bh.c on .nd lh. !rclnd. Thl. rr rn
htdLnt DtL .. h rFcnnt rtE Mbln .l .r.y.. ol th. losr r.s .nd
qamen$. nllrEr .ubr.I.r ns.unmnt.i .r., . l.ur dasd |omr |.! vem du.
Onemelhodlo quanrifychargesin archheigbtmore . tm d.gm.lbL|.r lolnl v.tun ahould 9r.dsc.. .lr d.gd. @rroor
wu d.lofr[y. thh .nd. h.lrr d.t frh. lho .lD ol th. n ddl p@l
ro measurcthe navicularditfe,entialas the ln ..4 2lLlr h 6fis i!'t{nr. ti. drhlm ol ft. c.lc!mu. .l h4l
noves's
arrui {alhoish rh. &ru.i Do.hlon ol rit .drtoor .| hld .lrlh. v.d.!
ftom iis neutralDositionto a Dositionof felaxed d.!.ndhg uro. tetd rsn d .D*1, be ol !!B !t$!ft, .nd $. u.!
stance. (ThenaviculardiffcrenlialrefersLothechange ot onftoric.: ..d.. onhollcr lncr.tx th. dsd ot L..l@l lnv.r.lon
gtunr .t hsrlirlt whrb .mnoftdlnc .-|Nl.d l30l .nd . dldd
heightoI lhe naviculartlbcro3ityrelativt to lhc floor.) b... ol s.ll Ptl m.y .Lc|lu Edoor hwtul.n el h..l .t'|r.). Afi.r
nollft d!. ..ulral r.rnoo! rorltlon, tha slghr.ba.rlna NLrl .u!l.l!r
mothod allowsfor quantifiablechang€sin archheight l.hr angl. c.h b. nd|{r*l by nodq tlf, .nd. tom.d b.lwFn lh.
crl..dl .nd lo* l4 bh.c{da lht mOl., *nlch .hould mrct' lh.
otl-Flcht.borlnq 6uuomnl, l. th.n om..urd.. th. p6ll.nl lkrl
Thepraclitionershouldthenslandbehindthe palienl moer ro . r.lu.d ddbh lknb dlc.dl .i.nc. F.nlon 4d tlnrrlv ro .
shor. te !nc. oGrrlon, Ai noi.rt bv llcPoll .nd comlrall (32), rh.
notelheamounlofshanl rotatiooasthepatientactivcly us-h r.iin.d by lh. F.rloot .nd lour l.s dunng .ln!|. h! .lim. (E)
sda .. !n Indlc.lor ol ft. d.gr* ol n.rlnuD Mdron po*lbl.
andevefisthe r€arfoot.As mentionedpreviousl!,a durlngfrx.g ldlh4ch ryDlony$. .ubtd.r lol rlll pM.l.lo.n.nd
subhlarjointaxiswill allow muchlibial rotationwith r.hgtrM.wlE. t rffin rh. i4tlng c.lc.ndl.LE. od rlngl. t.g
.LM D!r.), D.r.drno lrd tn Du@. hyD.rpmson q|.r wmn
ly insignificanl
amounlsof obligatorycalcaneal in- rh. dlll.Enc. b.tsd ilE n.ul' r .!brrl.r .ngl. .nd rh. .lngt. l.g
.Lrc. .n.l..rc€dr la dem., lrEo ltr nrn.t lh.r ton..urnort
cr\iun,shrle a low subralar
Joinr ayic will have eu..tbn r'h. !l!n|r,c.n6 oI lrdbi el.i'. ru.i@t n...uFh.nl. &
lEN.r.. pbn. .h.rk rot.rld.pp..r. ro b. r hor. &cu-t. Indlcllor
opposite effect.The rangeof sublalarjoint inversion ol Nbt l.r prcn.flon l3al.)
186 FOOTORTTiOSES
ddOLher PollrsofConsedalivcF€I C.rc
B
rigur€ 4.9. Eecau!€thc ran8eof midtanai ioint motion is
d€pendenton the posiliofi of the subtalarioinl, m€:e!rin8
th€ forefoovrearioot relation$hip with lfie subtalar ioint
surinaled will rcsuk in a fake tor€foot varus measrremcd
? n I
D
Figur€4.10. Planla.calluspatt€ms.Thesepalternsshow rcarLotlforcloot vafus (D), flexible plantarfloxed flln ray (E),
compen5at€d rcarFoot forefoolvarus and (onlpensaredeqr.rinus
varur(A), compensated deformity(F).
(B), riSld plantadlexedftst ray (Ct lncompensated
Chaprer
Four Alone.hnic.l Et.mln.tion 187
is anydoubtas to thc posilionof the firsr metatarsal andeversionmay now bc rncasured by placingthc subtalar
llrcad,thc practilioner shoold llsc only the cenlral thrcc joinl in its neulral position and noling the locationof the
calcaneal bisection rclstive 1o fic g.ound. Th€ prtienl is
I heds for refercncc. Also.a srsoectedlunctional
varusshouldbe vigorouslymobiliz-ed prior to mca- thenaskedto evert thc h€cl maximallyand the changein
an8ulationis noted, The proccdurcis reversedto melsurc
rhefor€loolhcartootrclationship. thc rangeof itrvcrsionand is repcatedbilaterally This
Wilh thc fofefoot maintaincd in its neutral posilion, positionalsoallowsfor m.asuremenl ofthe weiShl'bcaring
of the meratarsals shouldther be rccorded.and ncutralrearfoolposition,lhc ncutralsubtrlatposhionsnd
rrn8eof Iirsl ray dorsiffexion andplanbdexionsholld thc subtalarjoinr anglc prcscntduring r€lax€dc.lcaneal
noted.Hip rangeof morion is rcadily ovaluatedby sFnccandsinBlclegstsnce(sr. Fig.4.ll).
ng th€ knccs90oand observingdbial positionsa.5thc The slandingevalusliol continueswith observation
is maximallyinlernallyandexlernallyrotated.The legs of the laleralcontorr of fte foot dlrirg relaj(edstanco:a
thcnstraighl€ned, ard Lhsrangeof hip extensionand vcrlicallypositioned obliquemidtarsal joifil axiswill rosull
flcxionis checkcd.Notc lhanwhene!aluatinghip cx- in an acuteangulalionat th€ calcancocuboid joint (refer
ion.onchard shouldbe Dlaccdoverthe sacrumlo on- brck to Fi8. 3.177)whilc a foot with ar itladequate 6usren-
thal molion is comin8 only from lhe hip and not taculumrali or sioglearticulstcdsubtalarjoint will presenl
compensatory sacroiliacor spinalexrension. A sus- with a straightlaleral@lumn,despitethe medialdisplace-
lcg len8rhdisc'cpancyshouldb€ evalusredand. il meorof the lalus relative to the calcaneus.
!lcd, specific musclcsshould be checkedtor cootrrc- Th€ possible effecls of a leg length discrepancy
shouldbe notsd by checkingfor l.teml devialionof the
']he final porlionof rhc prcneexamshorld include spino,ls w€ll as lhe levels of ihe iliac crests,grearcr
cxamination of planlarcalluspatlerns,as thcsepal- lrochanlers, ljbial plateaus,and medial malleoli.A func-
provideinvaluablsinformalionregadinglhc degree lional leg leoglh discrepancysecondaryto asymmetrjcal
shcarand compressi!e torcc\prcscntduringslanccphase pronationwill.esull in sn excessive loweringof onemedial
4.r0). mallcolusrelativero theother.]'hc standingevaluationcan
bc completedby performingar equinuscompensation tcsr
STANDTNG Ex MrNAfloN (Fie. 4.12), a modified Rombcrg's resl, and by nolidg dis-
plac€ment of thefal paduponwcighlbearing(Fig.4.13).
'it
Thcpaticrris askedro srand,andrhe inregrilyof lhe
longiludinal
information
cx?mple,
classically
archis nolcdon andoffweighcbearing.
is usefulin idcntityinSvariousfool types.
an nrdilidlal with a forefoolvarusdeformily
pr€sentwith a lossof thc mediallongirudi-
archbolh on and off weiShl-bearing while the rigid
u
__v_
frsl ray dcformily will typicallyrssult in a
longitLdinalarch lhat is elevaledbo$ on and off
'bearing.AlLhoughinteffal€rreliabilityfor evaluat-
archheightis low (ll.), thisinformationshouldslill be ahur a,[. artr.dnlrn ,.n h rh. FGFr.tlar. .id b.n ol $h
rded,,s it helpscorroborate olhcrcxamination fiddings {irat r.rdrvlarlr|o|m b n|.Lt ird In lL do*r.dcil9o.nbr, |n.
nrrt. l Doti.n ol d! nd@r (a) c|n b n $ur.d !y.othe fi..nd.
tcstslhc inlegrityof lhe subtalarandmidtarsalrestrain- lo(fid b.rl.n rh. cak.Nl bl.acrbn rd rn 96sd, rhl. l. m
rdrodln .nd. n rf..- r tr c.6urrd rat! otfr. ror r.!.ra
ogamenr$, n{lnr aubLre -|me||lmLr a.!.. . l4r .asr- r.sr rq Y.Nm du
Onemeftodlo quantitychangcsin archheightmore . rF .ttr.. .ubrdlr lolnr v.Mn .iour{l . .k dqo r..tool
nrlr| dtotrn[v. Tli. rmh h.l!t dn mh.tn. '|!{E dt or ln....nool0o.l
is to moasurethe naviculardiffercntialas the (... r.r. 2rll rr I orbn rn .o.Uon ot tt ..|€rft. .t h..l
.lrlt {.lhough rh. ..rurl porllon oi lh. urloor .r hol .fir. v.rl..
molcsfromils neulralDositionto a no$itionof rclaxed .l.t ndh9 ur.n lEro.r .*h .r .F..d, b.x ot
-or..anb g.lr, .t!r,th, .nd rh. u..
icstancc. or onl.tcai ..s., ortholl.. lEd... th. d.er.a or ...r@r rnv.rrrd
(The&vicular diffcrentialrefersto thechange Dnr.{r .l n .t itrrt rnrb .r.ftdn.nh9 .|mls f3!l ..d . *ld.r
heightof the naviculartubcrosilyrclativeto the 8oor.) b... ol c.h l31I D.y.Lcr.r|. r..rl@t lffild n t .l .rdr.). Ali.t
ri.
nollno Nlrd mrt@l lorlllo.,lh. fitcht 6.!rlnc n srnl.ubLli
m€thodallowslor q'ianri6able changesin archh€ight iotnl dgl. ..n b. M.rr.d b, nod6l dr. .nd. lom.it D.l{s u.
..k i.d lffr h! bl...d.ir, Thf.rrtlq $i.h .ndld mtctr ft.
bcrccorded. oal.r.hlrt.ncrh! d.-uaflnt, b nrm ridu[d o dr. td..l d
-d
Thepraolitioncr shouldlhen shnd bchindthe pali€nt M dnrL
ro . r.Lnd d.!br. lhnh c.lc.dl
hs .116 !r
drE
kP.{
Ello
rrl
Dd ll..llY tn .
cdrl|tr (az), th.
ro.ldoo. A. mt d
norelheamounrof shankrohdonasthepatientactiv€ly .naL torind hy ni dtoor ..d ron l.l drrht .hd. L0 .l.m. G)
ql lh. .hro
li[. .tr lallqlr or tr|.iDuE .Yrdon 9oa.lDt.
andeverisihc rearfoot.As mentionedpreviously,a rtu ha $lkhg
- (.nhd4h tyDlc.llt rh. {!t'lu lolnl dn td.t |. m md
subtalarjoirtaxjswill allowmuchtibialrctationwilh nn!|-|a.{rno hisi $. i..dns olc.rii.l .l.n4 .fl| dnd. |.t
d.n{ .n9r.} Ir.Fnrtnt lpon ir. .oum, hrFrFqr.tm .rn wh.n
y irsignilicanlamounGof obligab.y calcanealin- rh. dlti.r..c. b.r{{n $. nsrnl .ubr.l.. rnd. s.t lh. .lntl. 1.0
.Ln...n.1. .rc..d.la d.onr, lK-! ln olnd $.r .onr.uhor.
ion,while a low subtalar.ioinlrxis will have qu..tloh iID.l!nlllc$c. oI irdri pl.i. r..rtoot m...unnnl. .!
tnnDd. !l.N .n.nr rcbtld .rrara ro b. . n@ e.udl. Indlcrtot
opposite elTect.The rangeo[ subtalarjoint iove|sion ot .!brd.r nrq.rroi [BI.)
l8E FOOT ORTfiOSES ard OUs Form$of Corrc.varive FootCarc
timcof heelstrike,full torefootload,heellift, afld toe load shouldalso be noted,and mNcular controlof con-
on Typical oommenlsrecordedduring this evaluation lact periodground-reaclive forcesshouldbe obseNed:Is
iBighlruadi"Hccl-strikeoccurswith the rearfootexces- therea parlicularlysmoolhaDdsteadyrateof anklc pl!n-
y inverted, with rapidsubtalarpronationoccurringdu!- tarflexion/subtalar pronation,or doesheel slrike occuras
eafly conract.The calcaneusr€mains mod€rarely a hardandjarritrgactionsecoodaryto inadequate muscu-
throughoul mid andearlypropulsioD (lherearfootis lar stabilizarion?
approximarcly 50al heellift) wilfi a low gearpush' The slructuralinleraclionsoccurrirgduringthe mid-
relurning lhe calcaneus to a slightiyirv€rtedpositionby stanccperiodarelhe mostdilficull to evaluate, As lhc cotl-
lsron.The nnalpush-oUoc.urs throughthe rrans- tacl pcriod 6nds,in addhionto noling fte frontal plale
axis,with theswingphas€motionsnonr€markable." Dositionof theslcan€usat full forcfooiload.ihe examincr
Observation of frontalplanemovements ofthe calca- shouldboobscrvingthecortralaleral swingphaselegexler
hasbecomclhe most commonlyus€d methodfor nallyrotatingtheslancephaseleg:theexternalroratorymo-
subtalarmotionduringgail, as the calcaneus is menlcreatedby rheswing leg shouldbegin!o supinatethe
leaslnobile scgmenl,the easiesrto record,and it! subtalarjoint by lale midstance. Remembe.that during
t accuralely refleclssublalarmorions(16.22).Ai- midstance,the subtalfi joint is mainraincdin a pronat€d
ir is .liffi(ult ro quanlifywithoutvideoequipment, positionas musclesand ligadenrsof rhe foot and leg are
raogeof frontal plan€ rearlbot molion should alwaysbe storing€nergyrhatwill be rctumedduringpropulsion.
!s accurarel)a\ possible.Bccause i( is impossible Tfie frontal plane position of the calcan€usduring
us4oxacldegroes while p€rfomingthevisualexam,d€- heellifr shouldbe noted,and the amountof hip and kne€
ibjng molionsas mild (0-5), moderar€(5-10), and enenslon,15 w€ll as lhe degee of atrkledorsiffexiorpre-
(gr(dtcrrhan10') wrll suffice. senLduring rerminalmidstance,shouldbe recorded.Re-
In all situations, the jdorrnationobtainedduringthe memberthat ideally,the hip will be exteded 10",the knec
€valualio!shouldbe consistenr with your€xaminatioo shouldbe straightandrhe ankledorsiflexed10"at hecllitl.
, ln the rare cascthrL your nreasuremcnts do not Any deviation from this palte , such as a premalurehe€l
theobserved gait pa{tem,il is suggesled thatonere- lift and/ormidtarsalcompensation for an ankle equinus,
anyquestionable pon;onsoftie examthatmightbc re- sholld be noted.It shouldbe emphasired that manyindi-
ible for the discrcpancy. (Problcmsassociatcd with viduals diffcr ftom the ideal in thal ftev move inlo ft€
stength,docreascd proprioception, and/orsofl tis- propulsivep€riodwith thesubialarjointmark€dlypronat€d.
conlraclurcare notorious for producing unanticipated As lonBds he/sheis ableto supinatethe subtalarjoi$rduF
lattems.) itrg early propulsion(i.e., heel lift releasesthe cslcanous
ln additioflto notingfroolalplanemotionsof therear- from ground-reaciiveforces,th€reby allowing the subtalar
theexaminer shouldalsorecordthe variousslructural joi lo apidly supinalewith thc initiation of a low gear
ionsasth€yoccrr duringeachsuccessiv€ ponionof push-off),this patternof gait shouldnot b€ considered
gailclclc. During lhe conlscrper;od.rhe apprcxrmate parhological,as it may represenla variation of nofm (17).
ionof ihe kneeal heolstrikeshouldbe noled(anyab" The finsl observationsmadedudng tho midstanccpe-
ities,suchas an hyperextcnded kneeor Nn exces- riod shouldincludeevaluationof pelvic noiions. Ideally,
y liexcdhip, shouldbe recorded),ard lhe rangeof lhe contralateral ionominateshoulddrop rH" as the torso
Ilorionduringcontactperiodshouldbe estimated and movesoverthestancephaselog (18).Pelvicmotionsarean
bilaterully. (Ar individualofiencompensates for excellentindicatorofstructuralle8 lengthdiscrepancies. as
stirclurallcg length discrepancyby hype exing the 1ie cenlerof masson lhe longleg sideappears to pole-vault
-lcgknecduringthe contactperiod.)Any toe in or toe over the midstancep€riodlower exlremily.Furthermore,
Bairpauemshouldbe recordedandcompared to ths an- ost€oarthrosisof lhe stanc€phas€hip often producesa Blu-
,ngle of gait as cslimaledby the off'-weight-bear- leusnediusgail patternin which theendretorsotilts laler-
measor€mcnts (i.e.,combined|alar,ribial,and fenoral ally over the midslarceperiod fenur (Fig.4.14). Also,
tions).An in or oul loegaitpatrernthaloccurswhedos- althoughuncommon,it is possiblelhal exlremeweakness
deformities afe not prese[lsuggeslsthe presence of of the hip exl€nsors will allow the cntiretorsoto hyp€rcx-
tissue imbalance. rcndoverthepelvisduringearlystancephase(Fig.4.15).
Becanse of difiicuitieswirh observation, il is sug- As th€ fool movesinto its propulsiveperiod,th€re
thatlfansverse planemotionsofrhe thighandshark shouldbe a visibletransitiorinto a low-gearpush-off(it is
as thepatienlwalkslowardsthe examinerex- oftenpossibleto seelfic plantarfasciale$e) with thecalca-
subtalar prorationshooldproducea cofiesponding ncuscontinuingIo inven asthe anklesimultaneously plan-
in internallibirl rotation.while femoralantever, tarflexes.Al this time, lhe contralaieralpelvis should
oftenresullsin an cxlrcmemedjaldisplacemenl of the continueto rctaleforward,andlhe nedial longitudinalarch
duringcontacland midstanceperiods.The fontal shouldincreasein heighr.The presenceof an abductory
posilionof lhe forefoot al heel stike and full forelbot twisl ar heellifi shouldbe notedandrelatedto possibletor-
190 FOOT ORTHOSESand other FormsoI Cons€rvaliveFool Cde
g3i!
normal tcmalesbelweeqthe agerof l8 and 30 ycars.J O hop 23. Klavg K, Hen€en ST, lvlasqueloi AC. Cli
Spons PhysTher 1988;9: 4{)6-409. quanUlellv€ aBsessmonl ol lhst larsometalar6al
12-Blms MJ. NoFweiAhtbs.inacastinpressiotsfo. the @n- in lhe saglltelplans and lts relalionlo hallux
strudio. of onhotic dcvices. J Am Podi0r Asoc 1977: defo|lrlity. FootAnU6 Inl. 1994:l: 913.
6 1 1 l ): 7 90. 24.Elveru FA, RothstoinJM, Lamb FJ.
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tbopRehtedRes1983;lZ:9. and naviqiar drop |€6t. J Onhop Spods phw Ther
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17. Clmphcll KR, GEbircr MD, Havlhorne DL Alcxarule. U. 6s(lo)r 797.8@.
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lheIncld€nce
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subi€€16
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and roarlool dudng runnlng. J Orthop Spons Physlh€t
1995:6:317.327.
ChapterFive
CastingTechniques
Method
As tbenameimplies,thisteehnique involvestakinga
plastercastwith th€ patient'sfoot mainlainedin a nert l
position. This procossrequircs four strips of extra-fast"sc!
ting pla.stcrsplinls (each slrip is folded in half), a tray of
warmwarcr,anda towclto cleanup the mess.Fhst,the pa-
lient's lowerexlremityis rolatedso thatthe foot restsin a
venicalpositlon.(Thismay requireplacinga towelbeneath
lhe pntieni'ship.) Althoughthis proc€duremay be done
wilh rhe patientpmne or supine,for simplicity,only lhe
supine techniquesare illuslrated. (Both prorc and supr'ne
casliostechniques produoecomparable resultsllI l.)
With the foo! in a verticalposition,the subralar joinl
is placedin its neuEalpositio., and a Rrm dorsiflectory
force is placedotr thc fourlh andfiftb metatarsalheads(Fig.
5,2).The p|ticlljs instructedto keepthe foot as closeto
this positionas poslibtewhile lhe plasteris beingapplied:
this prevenlsbucklingoI lhe plasterwhenthe foor is laler
reposit;oned andloaded.A plastersplintis preparedfor ap-
plicatiorby foldinga dry splinl into the palm of the hsnd
while pirchirg the free end bclween t$e thumb and irdex
finger (Fig. 5.3). The plsstcr strh is lhcn submergedidto a forcc be uscd while loading rhe metatarsalhcadsrnd tid
tray of werm water (for appmximatcly3 saron&), gendy tirlonavicular corgruency be nainlaircd in i posiliol i[
squeczcd,andrcmovedfroft rhewater.Tbc plaser ofParis is whjcb thc hcad of the lalos is slighrly mor6 palpablcon it6
th€n mixcd thoroughly thtuugh the clolh by rcpeatedly medialside.The foot is heldin rhispositionwhilelhepla6-
squeczing thewer pla.sterrtrip in the palmof thehand.It is ler hfidens(for approximately 2 minutes).
imponant that rhe fre-eend be drmly hold throughou this An ahematemethod of loading thc forcfool is witu
proccss.asdoing so allows unfoldin8of thewerplasrers8ip. the suspe$ion rcchniqrc (12, l3). This popular
Once the plastcr hasmixed with the cloth, the plaster requireslhar lhe pmctitiooer fir ly glrsp the proxinal pht
slrip is opcn€d,andthc upperborderof tle strip is foldcd aF langcsof the fourth and fffrh digits b€twe€trthe lhunb and
Foxamfltely l/4 inch, therebycroarioga lip along the endre index0nger (Fig. 5.11A).The foiefool is rheolo.dedby
upperedgefFig.5.4).The plasteris thenappliedlo thefoot g€nlly plantarnexing tle fourth {nd 6fth digirsuntil they
by wrappingit aroundthe heelaod'tscking" it downto lle parallel the long axis of rhe foot (this allows the respcctivc
lop of the tirsr and lifth metatarsalheads(Fig. 5.5). The metrlarsal lrca& lo dorsili€x slighlly, blacl armw in Fig,
brnging plastcr is then smootftedag|in$ lh€ m€djal arch 5.llB) whilc simrltaneouslyapplyinS at| upwardrnd
(Fig. 5.6), then overlappcdby the lalersl strip. The smattv, slighlly larcral forcc in ord€r to lock rie calcrne&uboid
shaped nat that forms ar the base of the heel is lhen joinr. Tfuoughoul this process,lhe to€s are rrsctionedin
smoothedsgairlsr the c{sr (Fig. 5.7). The secoDdpiece of long axisexlcnsion(therclaxedfoot is actuallysuspcnded
plasreris applicd by drapingir over rhe torcfoot (the plosrer fmnr tle rable),which allows for proper elongalionof rhe
on thc dorsal foot is tacked againsttbe prcvioussrrip) and Dlar(arsofi tissues,
folding it as illusrared in Figures5.8 and5.9. The patiert is The flished cast is renoved by pirching the skin or
the. askedlo relax,and lhc tor€fool is loadedby pr€ssingup the dorsumof the fool (white anows in Fig, 5.12)and
on the founh and 6fih mehrffsal he6dswhilc mainlainillg pulling down on the h€€l-The pradidoflerthencarefully
talonavicular congnencywith theoppositehand(Fig.5.10). pus}es the casl forward, geotly shaking it until the c!s1
Bccauseof thc dangersassociatedwith capturing a glidesofl thc forefool(Fig.5.l3).
supinaredimpression,ir is suggestcdthal , slighl aMuctory The accuracyof the negrtive inrpressionmay nowb.
Ch+ler Five Clsdrg Techniqu6 19?
ed by placing the imprc,csioD on a level surfaceend (whicl will resul in a falseforefoot varusor valgus,respec-
$!e frontal DlaneDostrionof the h€el: if a forefoot tively), and/orfauhy useofthe suspension techdque(in-
is present,the bisectioDof lhe reaifoot should be appropriate do$iflexion oI the toes vi/ill rosull in a
if a neutralforofool is pres€nt,the rearloot sholld plantadexed laleral colurDnwhilg excessivepressure{rom
verticil; if a forcfoot valgus or plantarflexedfirst ray the thenaremiftnce may producea false forefoot adductus
presont, thebiseclionsiould be inverted(Fig.5.14). sealndaryto InadveateDt supinationof the forefoot aboutthe
The most importantcriterion to considerwhen evrlu- oblique midtarsaljoint ar(is). If for ary reasonthe neutral
lhe rcgative model is thar lhe plaster impressiot foot and negativeimFession do not match, the carl should
metchin ev€ry derailthe shapeof rheneutralposition
(Fig. 5.11. DevialioD ftom the anti€iparedfoot shape
commonly.esulLsfrom insufficient loading of lhe lal- Rrtionale
column (which gives the false iftpression of a
lateralcolumtror foretoorvarus),tsking the This techniquecapturcs a pict{re of the foot in its
wii\ the subtalar jctint supinai€d or pronated most stableposition: the subtalarjoinl is in neutral and the
198 FOOT ORTHOSESsnd Olher Forns of CollsewariveFoot cN
A
+q^)
l+ t
t-CQrhu
p;*'""*
t\
t\
'q$
Figure5-r4- Evalualingforefoovr€arfoot
r€latioDlhips.
.ln addilion ro MR, white liShl and las€r scanning, north. Of notc, in the nor too disuni folurc,
anorhcrlropularCAD{AM lechniqueis conhcrdigitjzin!. millinS mnchincswill be available(tbiswill
This methodinvolvcs having lhe padenrstep on a trsy dily tumov€r).
containing576 four miltim;&r;ide pistonslhat are
maintailcd in !n elevatcdposition by a stre{In of conFollcd
arr prcssorc. As lhe padenfs foor displacEs rhc pilrors. a RefercDces
computc.rnalyzesrl|c infonr'adonandproducesa 3D image L Arotr'nD. Snith C. Vacuumcasrinsli'r lid
that can bc modificd. Thc final inagc is rh€n senrro a PodiatrAseF 1976:66(li):581.
milling machin€andconvenedinlo an onholic. prcs€rrtv- l. Robhnrr
SE.Hrnn. AM. Ru|ln;n!-relurd
injury
onhoticsm0nufacrurcd wi$ rheconracrdigirizingr€chniq;e throush brrefrxn adaplarnhs. Mcd Sci Stioni
arelimitcdto a comDr€ss€d EVA maerial l 9(l ):148-156-
r. RobbinsSE. Cdu$ CJ. Hann! AM. Ronni
Rstionrle prcvcnrionrhrou&hir.atc arnl)uct-modcrurirg
Sci Sporls&erc I989i ll(l): l-1lrll9.
CAD-CAM technologywas developedto providc l. Olrncl J. Onhoticcontrcl ol grolnd rcactio0|
proclirionefli
wirh r fLstandaccumre
melhodofduplicaringa pmpulsionr u prcliminrryrcpon.OnhotProflhcrI
patient'sfool andpreciselymodifyingjt to conlrol rnolion 5. Crm cll JW. InmanVT. Treahrelrof pknut
!n or rcdistributcprassore, calc ed splj| wirh llc UC-BL shor ins{n.Clin
IntedR cs1974i103:57.
Dlscussiotr ,,. W3llcrlF. tlindftut rnd nidirnn prcblcnsul rh'r
Mick RP (cd).SyrnposirNot the Foorlnd Lcg in
when pcrforminga scan,the paticnls fool fiay bc Spo s. St-L.uk: Cv Mosht. I98l:?1.
mainlaircd in a neut al off-weight-besdngposilion (as wilh t. Root MC. O'ion w?. W€ed lH. Nomrn and
thc ltscr optical scan)or n scmi-wcight-bcaring or fuil- Flnction ol tfte Fool. Los AnAclcs:(tinical
wcight-bcarinS position (as with contact digitizing 1977.
r€chniquc!). B€caus€som€critics point out $rt lhe off- il. l)'Amica JC. Pre$ribD! lb.'r onhoies:thc
wciSht-bcrring inprcssiofls requir€ substallial modification pr.cess. Foor and leB func|ion. Decr Park,
of thc positive model (this is true \r,helhe. a lascr scan or mcchanic\ Croup19|n: l{l):3.
plastcr casr is takcn), Bergmaoo Orthoiic Lrborutory \). Virrk M. Kcrkc P. TEalm€nrof rcjtion l anomars
providesa glass plaacro compressthe patienfs foot dudng fool sifi i tundionnl s4ponive inla!. O hopadc
thc scrn (thereby duplicating a semi-weiSht-b.aring l9E9: l:7(l): l5-: l.
imprcssion). Irr.schusrcr Ro. NeurBlplaflarimprersion
cnsr-ncrhod
ln rrgards to onhodc producdoo,a mqior criticism tior!l(. J Am Podia,r
Ai-$c 1976:66{6}411.
of someCADCAM labs.elalesto the limitcd sclcclioool I L McPoilTO.SchuirD. KrcchrHG. Comm.isonafrht!.
shcllmarcrialsii.e..MR lechniques aretypicallylimhedto ods usedlo obhin a nertml Dld\|cr toor ihur€ssion.
the rigid plasticswhile labs utilizing contactdigitizcrs
providconly compressed EVA. (Alfiough labsproviding l:. tsurrs MJ. No!-weiehlbrarii8clsl irnprcssi('rs
for
contact digitizers correcdy point our that it is not the sllucri.n of .flhoric dclrce\ J Am Podutl Aso
matcrialrhit mrkes an orthotic funclional.it is thc post 0 7 (l l ) : 7 9 0 .
angles.)B€cause laserscanning incorporuiesan intcrmcdiat. Lr. Valma\svRL. AdvrnuAcsanJ disadvanrrgcs di
model.the practitioner may choosefrom thesomemateriols J An P(nliiu A!\oc . IeTq:6q(l:t. 7tl?.
ing rechniquc..
availablewith nanual productiontechniques. e.9.,laather, I L RossAS. JonesL. Non-weighlbcarg negarilccasl
gmphire.ctc, ti()n.J Am PodiatrAssocl98li ?2(12):634.
Another cilicism of CADCAM devicesrelatcs to thc l\. Broln D. SmirhC. Vacuumc&sringi(tr fuaronhors,
acctrracy of the milling machims. Someof th. catly CAM Podia! Asroc 1978:66(8): 5ll:.
systemsrequircdconstanlrecalibralionot the comPleted 16.Black E. Automatedlab technoloqy.
onhodc *ould be differeol than the ooe displaycd on thc l*si 4n-7A.
compurcrscrc€n(his couldresultin iatroScnic injury a! on
incorEctly slopedan:h would conuse thc con$ponding sofi
tisstics), This, howcver, is no lodgcr a problcm as advances
in microcomputer-millinginlcractionsallow for exacl
duplicationof thc d€sirEdimag€s.(This is why rEmtlc mtcs
for CAD.CAM rnd manlrallyproduccdonhodcs arc the
samc.) Thc primary advanlagcsof the CADCAM systems
ralalc to spcedof usc(a foot can be scanncdin sccoods)and
accuracy (rhe laser optical system caPtu.es thc
forefooy'rcarfoot rclationship within l/l0oth of a dcgrcc).
The p.imarydisadvanrage relatesto cost: the lsscroPtical
syrtcms sell for approximrt€ly 8,000 dollars, while a
contacldigitizer c!0 b3 leas€dfor about 160dollaJspcr
ChapterSix
fi8|lre6.3. Possiblevariarionein ihell shape.(A) The standad shell,cul to the speciticalion5 outlined in FiSure6.1. (8) The
lirn raycur-oulis u5edto treala planta lcxed fi6t lay delormily.When keatinglarS€ plantarflexed fiEtray deiomities. il i5 sug-
gesld thal a 2-5 bar post b€ u5ed(which may be sdended to the sulcus)in coniunctionwilh a sub I balancefor lesion.(C) A
1i6tandlilth ray curoul is usedto llear pl.nta exedfi6t and iillh rays.(D) The hiShmedialflangeis inco.poratedto butlrestlhe
lontitudinala.ch and may be usedto trealcxcessivepronationasrociatedwith a SenuvalSum.an oul-toeSait patlem,and/or a
highobliquemidla6!l ioint axir. (E) Hi8h medial and lateralflangesmore €ffectivelyslabilizethe ,ubtalarand midta6al joiDrs
andmry be urcd when more cifecrivecoorrol oI morios is desircd.The dofted fDe illlnrates the shapeof a lalc€l clip that k
typlcallyuied irr children with toe-in deformitiesto prevenlthem from ,lidins ofi of the ortholic. (n The deep heel 5eat.This
ifiodiflcationh uscdro preve dkplacemenlofrhe inkacalcanealfar pad.This pad, which consiscof collm nar . n) ngementsol
s€ald far,leryesto di5tribuleground-reacrive forceeover lhe entlreplanlarheel,therebyprolectjnSthe morc prominenlporlions
oi the calcaneus frcm aauma. As notedby JoGensenand Bojs€n-Molle.(a),confinementof the pad incrc.sedit, ,hock'absorb-
irg capabiliriost'y as much a! 49v0.(C) The bunion flanSemay be us€dlo pmtecl a sensilivehallux abducloval8usdetormily.
(H)Thc5limorlhoricrhelli5 usedro allow fo. a henerfil in dressshoes.h may b€ requ€stcdthat the areaof the ,h€ll cortespond-
inSlo the lateral.olumn be removedldotled /iDe.,or thal lhir area plu, lhe centerol lhe h€cl seal b€ removed.(Note ihat al-
thourhcmoval of rhc c€nter heel ,edr allows for a berle, fit, il occasionally.suhs in an infracalcanealbulsrtit.)(l) The gait
plare,which ha5an exrensionof rhe lar€ralshell,encoura8essubtalarjoinr pronationd!ring the propukive psriod and i5 otten
tiledto trearmild toe-indefomiriesio children(alrhouShils effkacy hasneverbeendemonstratedj.(J"LIUC-BL, modifiedWhit"
rnanand modifl(jdRobe s, resreclively.(UC-81 is an acronymfor Unive.silyof CaliforfliaBiomechanicaLaboratory.) TheseoF
ihoticshellsare modernvecions of th(-Whihan and Robeft foms that were ori8inallydevelopedlhe 1920, and 1910swhen
t|e perceivedBoalof odhoiic trerhenr was lo changethe shapeof lhe foot, not necessarily to controlmotion. (Theseshellsarc
typicallynot posred.)Eecauserhe bulk of ihe5eodholics make for dimcukieswilh shoe fit .nd becausetheir rcetriclivenalurc
inayimp.n prop.iceplion, theseshellsarc rarelyused.etcepr in (hildrcn wilh hypermobiletlal fee!and individualrwilh flaccid
irralyrir. (M) Heel stabilizer.This shell shapeis ued ro conuol rcarlootmotion in childr€n by ma;ntainingthe calcaneusper-
pendjcular to lhe suppodinSsurface.Hcol 5labilize6may be fabricat{ wjth a varietyof options,includingdeep heel cops,iat-
erdlciips,medialflan8es,etc.
208 FOOI ORTIIOSBS snd Olher Foms of ConservativeF.,ot Catc
Postinqelevator
riSure 6.9. M€thod fo. fabricarin8 an extrinsic r€arfoot mm posting elevatoE, lesp€ctively.However, rs
varuspost.Theplant&proximalodhoticshellis scu{fed, and stratd by RossandCumick(s),lt is notsomuchthoheiSht
an extrinsicposris gluedso tharits distaled8€reetsapproxi- the heellhat deteminesrhe sizeof the postingelevrtorai it is
mately1/2 inch distalta rhecenre.of the heelseat(A).The the ,rngulationof th€ heel tlope in the shoe.An exampledi
ed8esof the postarerh€nfil€ddown,andthe heeii5 placed this s illusrr.@din H. Despirethe height of its heel,an ol.j
on a horizonlal,ander(8).Thedistalodhori.i! pasitioned on thoti. for this shoeshould be sround ilat becausoof the aclr&
a supportingplalfom (C).andtheed8eol theonhoticsh€llis an8!larionof the heel seat.Eecauseof thk, the heightol tfid
angleda sp€cificnumberofdegre€s with analullrinumwedse posling elevalorshould be selectedlly placins a flat bar(t
(D), Th€ heelof lhe odhoticis then firmlv oressed into the tonsLredepressorworks well) illrsh againu rhe hecl seatand
sander, which allowstheolantarrearfootoostto stabiliz€tbe notirl8rhe dktance be&een dr€ bar and the point \ahe€fi6
€nlireodholicshellin lh€ desiredof varus(E}.lf theonhotic odh,,ri ,w i l l end (l ). Thi sdhl rnce repre:Ff| \rhei dea hei ghi
is lo beworn in drerssho€s,it is frequenllynacessary to usea of thr postingelevator.In addilionto usinBa postinBelevaloi
postingelevator to ensurethatthepostwillresrflatagainst the it i5 rlso polsiblelo allow for inrprovedshoefil bv raquenini
heel sealof the shm. for exanrple,it lh€ exb'insicrcadoot thc redloot pod be Sround inlo lhe sheli (r). lhis
postwaegroundor)a levelsurfaceandtian placedin a h;gh modrficationsi8nificantlyreducesthe bulk 01 llle extrinrie
heelshoe,the Dlanrar surfaceot theoostwouldb€ unable1o pon by decr€asin8lhe hei8ht thal the odhotic will raisetho
adequalely conlactlheheel,thercbyn€ealinsthe post'sabjl- heel. The stabllityilnd resiliencyoi the rearlootpou nay k
ity to control rcarfootmotions(Fl This probl€mcan be imprrved by addinsa medjnl or lateralflafeto the Dost(() fto
avoidedby placin8the orthoticon a postingelevatorwhen ,onl rnl ex,e{ i ve p' o.a' i on o, supi nati on.
rcspF(l i vcl y)
dd
B ndi!]Elhe rcarfoolpost{C), By duplicating rherelarionship by ninlotcing the posl mat€ri.l wirh nylon s(rews (L). Bet
betweenlhe planlarheelsea!and foreloolof the shDe,rhe causr the mosl common postio8marerialk a comprcssible
postinselevatorallowsthe entirereadootpostto sit flolh crepc,the plantarrud,ce ofthe pon is usuallycoveredwltha
asainstlhe heelseatOhe tinkhedposrin C lvould{it par thin, high'densityplaltic in order lo pre\,€6texcessivew$rl
hctly intoshoeF).As a Ben€mlrule,shoe!wilh l/2-, 1 , and {Thisis referre.d lo as a "post-protector':)
I l/2-inchheelsareaccornmodaled by using4-, 8-, and 12-
blocks the necessarfrangeof stlbtalarand midlaruaipro,ra- quakly absorbshock),and it atlowsthis molionlo occui
tion necessaryfor shockablorpdon during the early contact too l:rLein the gait cycle.(By midstance all pronalorymo-
period. The najor probbm $sociared with incorporatioga lionsshouidhavcended.)
biplanargrind is that althoughit doesallow for subtalar The problens associatedwith biplanarSrindsarefur
pronation,rh€rangeit allowsis too little (a 4'gdnd allows rhercomplicatedby the fact thal dreability oJ theorthoricto
only 4" of rearfootmolion,which is not cnoughto ade- rock medially is dep€ndenlupon the firmnessof lhe sole.ftr
ChapLerSi3 hborstory PEp!rulion and Ortholic Fal}'icalioD 211
4
Foufdegreesol pronalion
Flgure6.10. The blpl8nar grind. ThB distal medial lhe axis of the gind (C), the readoolpost mainlainslhe
podionoi lhe extinsic rearfool posl correspondingto subtalarjoint in an inverledposilion(D) whileallowinglhe
lhe shaded a'ea (A) is ground lo a deplh of sublalarjoinl 10 pronatethe four degreesnecsssarylot
approximately4 mm {lhis is a gradualgrindlhat p€aksal shock absorptiononce lhe progressionof lorces are
lhe distal medial corner ol the post g). Accordioglo centereddistallothe axisol the biplanargflnd(E). (Adapted
Weedet al. (6), rhe biplanargrind allows lhe rearlool lrom We€d JH, Hallif, FD, Ross SA. Biplanargrind lor
posllomainlainperfectosseusalignment duringtne conlacl rearloolpostson lunclionalorlhoses.J Am PodialrAssoc
periodii.e., when weighl is cenler€d posteriorio 1978;69 (1):35.)
ligur€6.13. Ihe variousbalanc€sfor lesions.{A) Thc slb l wan (s!ch as a bar pon, melatarsalpad, to€ cren or sub
bal,ncelor lci on (aka "dancer'spird") is lsed to ac.ommo- metaratsalbzldnce)is c inicrlly indicared.(E) An accessory
d alea p d n ti rilc x edlir ( r ay w h l e l h e s u b 1 ,5 b a l a n c e(8 ) navi cul ar,
w hl ch may be atachedto l he parcntnavi c!l arvi a
l a k a"d o !b e dan. c ls pad" ) i s u s e d ro a c c o m m o d a l cl h e a synchondfosis, ofle. rcquiresproleclionfiom t-"nsil€,shear,
pla0larflexed iirsr .nd liflh r:ys o{ten .tsociated wilh cavus and comp.e$ivc forces.This may be accomplishedby addinB
loorlyp$. (C and D) Thc ho6eshoepad ac(ommodationmay a U-shapodbalanceto a laGe medial flanSe.Thi5 balance ,
b0 lscd to ac.ommodaiea cai.aneal sp!r, a pl.ntadlexed ueualy ueed in conjunction wiih the approprirte rearlool
lesscrmelalarsa,ir promincnl plantar condyle ltnset)or a dal tt to etuu' vJru\ po,ri _ oroer l o m.r' ni /F c\rers,\c
planlarwirr, e., l)eLausL'prossure stlmulalesgrowrh oi llre subtalafp.onalion that would otherwiseinitale lh s Dtseous
virus(19),an)' iddlrion that dccreasesprcssurebeneaththe
214 FOOT ORTHOSES8nd Oth.r Formsof Crft€r/ativc Foot carc
dial forefoot may actuallyencouragesubtalarpronallon,the Mctatorsl pads. Thesc pads, which ar€ ry?ical]i
kin.lic wedgehaslhe pot.ntirl to createlhe exactcondition madc from eithor spongerubb€r, felt, or PI'I, allow for {
il was designedto prevent funcdonel hallux limilus. redistribution of pressureaway from the metatarsalh€d(b
This is nol lo say the kilclic wcdge should never be by sopponidglhe dislal metalarsalshafu (21). As a re$ L
!sed. 16 siluarjons in whicb &formity of the finl melatlr_ metntalsalpadsmay tre an effective form of trcatt|entfor
sopbalangealjoint is secondaryto a lotg firsl melal3rsal, €longaledsc$trd rnctatalsals,plantat keratose.s,
interdigilrl
lhe linelic wedgemay allow for lhe ihproved raDgeoI RrsI oeurorhas,inletrnetatarsophalangcalbursitis, Planlaiwatq
ray pladarflexion nec€ss5ryto prev€nt conlinued dcfor_ rod/or plamadexed l€ssermetatatsals.To be effective,th!
mity. (As long as il is us€din conjunctionwiih a long rcar_ metrtarsal pad, which q)m(}s in a variely of shapesad
foot vaaos post id order to prevenl €xces.\ive subtalal size( (Fig. 6.1t, shouldbe positionedjust proximal lo thi
Dronation.) me{irtarsal heads,
chapkr si\ l.sbomtory Preparadonrnd Odhotic Fsbrlcrtion 215
plug.
Figure6.17. Theint€rdighal
,.)opo;;
ing and running) arc typicaly trealedwiih semirigid shells datid. is lace walking. Becauseof their extendedlengt[
with maximum amountsof r€arfoot and if necessary,fore' sr (lc, tbeseathlelesmaintainthcii heelson thegound
foot pos{ing. lf lhe running athlete strikes th€ ground in a suchlongperiodstharit is not unuimmonfor desc
to€-heel s€quence.the rearfool post shouid be placed be- uals to requircas mt|ch as35' of ankledorsiflexionto
neaththe forefoot anda compressiblepost to sulc(lsadded. for noncompensated function. Sinco this rangegreatly
Also, in order to meet the training requirementsof a long- ceedsthenorm,theoseofbilateralheellifts hasb€€ome
distancerunner,it is suggcsted thatth€ mediallongitudinal rulc ratherthsn lhe exceplion.d\ wilh olher unidirectional
arch ifl lhese individuals be reinforc€d with either PPT or sports,theseindividualsrespoodbestlo fully posledoF
cork and thal a compressiblcposLto sulcusbe usedlo pro- lhotics made from non-weighl-bearing mutral posiliotr
tectagainstpropulsive periodinjury.
B€caus€weighl of the orthotic is a legidmateconcam When dealing with athl€tes involved in multidilto
1o lhe runningathlete(be€ruseof the lenglhof lhe lcvcr lionrl sporls, however,the exacropposit€situationoccu$,
arm ro the hip, each10Og addedto thc foot incre$€sthe In ord€r to allow for the various c'uts. Divots and lalenl
aerobicdemandsof runniflgby 17o[22]),.nany distance molemenlsnocessaryfor theseathietesto 'feel" theplayiig
rumers orefer to tlaitr h the heavierthemoDlasticorthoses \urf.rcc.il i5 customary to uses€mi-weight-bearing impr.$
atrd race in the lighter Plasrazoteor graphile laminates. sion Icchnique,s with minimrl rearfoorposting(0" is themosl
Sprinling athlelcs also have specilic treedsin lhat they re- conrmonrequest)ir conjunclion wilh thc soft Plastrzoleor
quire controlof lhe excessive rearfootmotionsassociated lea{hershels (allhough graphite is an excellentaltemrtivo
with speedwork (contr|ry ro previo$ reports.sreed work becNuseof its ability to flcx in rhe frontal plnne).lf nece$
is associatedwith an increasein rearfoot molion [2] that is sar]. lhe forcfoot deformity may be tully or partislly pothd
wors€nedby the fact thal racingflats are lessablelo control (i.e.. while a foreloot valguspost nuy be es.senlial for slebil.
sublalarpronationI23l),while alsorequiringthe id€alrear- iiy with lateralmotions,a larg€ forefoot varuspostmayini.
foovleg alignmeDtneccssaryfor thc achillestendonlo mrx- tat€ rhe diskl firsr melata$al shaft and posdbly producean
irnallyparticipate in an explosiv€propulsivcpcriod. invc$ioo aokle spmin during ihe propulsiv€F€riod).Mih
Becauseof these concem$,it is suggesledthat or- mulridirectionalsport! that includemuchjumpiry (e.9.bas.
lhoses fbr ihese athletes incorpont€ larBe rearfool posls kctblll, vollcyball,aerobics), full lengthtopcovem&e usad
with compressiblc postsextend€dbeneaththe melatarsal and additional shock absorbing materiols are typicrlly
headsin order to more effbctively control notion during placcdbeneafrthe metatanalheadsard heel.
eirly andlarestrncephnse.In fact,to controlthepropulsive Co|l is a multidircctional soort that Drovidesao inter-
periodmotions{ar the longestpossiblelimc, Sisfley(24) esringbiomecbanic8l dilemmabecause of its asymmetrical
suggesled extendingthe compre$sible poslsall th€ wly 1o rcquirements:the riAhl foot of the righl-handedplayern$l
thetoes.Because of thelimitedspaceandextremelastsfre- be able to pronale Ihrough a large range during the end
qu€ntlyseenin racinBflats,it is rccommended thal {latsbe stageof the swing. while the left foot requirc-sfirn digital
sent10the laborfllory for customfilting of the ortholic. stabilizarion pith prolectionagainstlatemlinskbility(Fig,
Aootber unidirectional sDortthat reouircs accommo- 6.18).
ChaFcr Sir l-rbonlort PrtFntion .nd Odhotic Frbdcrilon 21?
Figure6.18. root motionsduringthe end-stag€ of a golf in8 in an allemptto Saina "to€ hold."(Modifiedftom pho-
slroke.Notice how lh€ ritht fool is Inaxim.lly pronated rosraphs in Segesser W (eds).Th€Shoein Sport.
B, PfoffinSer
*hil! Ihe left fool is inv€.t€dwilh its diSilr cliwing or g.asp- Chicaso:YealbookMcdical 1989:125.)
Publirheri,
W E€vel€d
OrthoticDispensing,ShoeGear,and Clinical
Problem-Solving
ORTHorlc DTsPENStr{c hoursthe s€condday,3 hoursthe third day, eic., until it can
be worn for 8 cons€curivehours without discomfon. After
On receiving the onhorics from the laboratory, the that, the o hotic may b€ wom consta'|dy.
ioncrshouldevaluare the finishedposlsto makesure Dep€ndingon rhe type of onhotic and thc de8reeof
thcy marcb the requestedangles. Allhorgh this is postiog used,il is possible|o anticipatethe loelion of po-
t with an ertrinsic forefoot pos1,and impossiblewith tential problen spotsatrdto cautionthe paticnl accordingly.
forefoot post, lhe accumcyof ib€ rearfool post For example,a rigid orthotic witb a lalge rearfoot varus
bc del€inined by pressioga fiDger mto tho c€nter of post is mo.e likely to produce latenl knec and ankle dis-
hr'l cup and noting how far ths distal !@dial edge of comfort, while an ortholic with a 13196forefoot valgus post
onlotic raisesfiom the tabls a 4" rearfoot Dostwill is more likely !o produc€ soleus srain. If these or olhcr
lhe edgcapproximately7 mm. If the o:thotics are lo symptomsdo developdespitethe graduajbreak-in, the pa-
in dressshocswith clrved shanks,theaccuJacy of tient shouldbe told to decrease r,earinglime to a poinl at
's postingclevalor c{n be d€terminedby plac- which thereis m discomforrand thenlo increasewearing
tll6h€elof the onhotic on a variable heigbl platfoft (a time againgadlally by approximatelyl/2 hr/day.
of cardsworls well) and nodngthe amountof heel lift As mighl b€ exPected, rigid orthotics witb large
for the extrinsic post to rest flat wtile the distal posts a.e more dimcult to break-in than the softer, m-
shelljust barelycontactsthe supportingsu.facc.Of posl€d accommodativeorthotics. In fact, it is often possi-
lhe orthotic should also be €wluat€d r! the sho€ to blc to completely bypass the brcak-id process wben
properanterior-posteriorslability. prescribing accommodativeo(holics. lt is of clinical in-
Thcnextsrepis ro placerheonhoticagarnsrlhe pa- lerest that indivi(fuals who procced through the break-in
foot and evaluareall contours.lf the orthotic shell period wilhoul iocident are more likely to havea favorable
morcrhln I cm Droximalto the firsr metatarsal prognosis(2).
it will mostlikely be a sourceof fulurc initationand In order for the patientto fully tolcrale lhe orthotic, it
accordinglybe shaved down. The patieot is th€n may bc necessaryro begitr a trealmentpmglam that incor-
to staBdon the or$otic and gentlymove througha ponles vadous manipulative and physiological therapeu-
nngeof inversionandeversion.Paidul contadpoints tics. Aithough thrs approachmay be ess€ntialfor tresting
thc heclcup or medialedgemay havelo be filcd functional foot deformitiesard equinusconditions,lhe rou-
(Evcrypractitioner shouldown a smalldremel.) tine useof ultrasourd,electric musclestimulation, al|d foot
Withth€palientstill standingon theonhodc,talonav- exercisesare of quesiionablevaluc, as Donatelli el al. (2)
congrueocyshouldbe evahated,and the headof rhe demonsrrdedrhat individuals trealcd wilh these therapies
shouldprojectjust mediallyto the navicularacetabu- Dlus onhotics had the sane successral€ as individ0als
Notethat it is oot uncommonfor the patiert io state trcstedwith onhotics alone.
beor shestill "feels pronaled."In thesecrses,it is nec- A similar obs€rvatioowas lloted by Awbr€y et al. (3),
lo explainhow rhe onhotic must ailow enough as rhey discoveredthat ice, stretchcs,and shin cuil exer-
ion for shockabsomtionand how an orthotic is actu- cis€sw€re inefrectivein th€ treatmcntof planlar fasciitis (?
nore eficcrivear conrrollingmotionduring dynamic of ? patienb treatedshowedoo changcin symptomsaller 3
lhln duringstaticstance(l)- months) while individuals reated with off-the-shelf srock
Regardless of whethertheprescribed onhodcis func- oihoses pr€senledwith a 507, reduction in pain after 1
eccommodative, dhcct mold, or paste-in,thc finished month,a 90-957. reductionafter 3 months,and no pain at 6
will ahcrfunctionalinteracliotrs alonqrh€entireki- months.This study was particula.lyiDteresting in that il
chainand/or producea redistribulion of planler foot demomlratedthat lidocai[e/corti6oneinjcclioos were not as
Because of lhis, rheparienrshouldbe rold ro e,r. effective as stock orthotics (2 of 7 treatmentfailures witb
r nor achesand pains during the ffrst few weeks of injections alone) and tbal lhe combiDedusc of injections
.0d tlat the odhotic shouldbe broken-ingredually, and orlhotics showedno sigdfcant imp.ovementover the
ltreonhodcshould bc wom for I hour the firsl dav. 2 useof orthosesalone,
223
224 FOOT ORTHOSESmd Other Formsof ConsewativeFoot C.re
'@
fiSure 7.1. Compon€nb of a well-nEd€ shoe. The he€l foreti)ot lifts more than this.) Th€ toe box should provide
counler should in securely{it may b€ necessaryto balanc€ ample spaceso ar nol to compressa doEomedialor lal€ral
Haslund's deformity wrth fell), and its lrise.tion should be bunion. Becauselt allows for Breaterreparationof the oppef/
veftical to lhe supponinSsortace.(Poorquallty conlrol often Blucherlacins may be n€cessary to acconrmodalethe b!lkier
allows for an asymmekjcalhe€l counterthat is ekher iovefted odk'ses (q. If th€ patienl complain! thal his or her lool is
or €'€.ted rclalive to the table top; see A). Also, the shank didi[8 tblward on the oilhoti. (which often occuB whenheel
should lt able to rcsisrforcelul comprcssionwjthout deform lifts ire used),a slrip of adhesivefelt may be placeddlonsthe
inC (B), and ir should be angled in such a way that when the und..surfaceo{ the tonEuethat Eentlyprcsses the Jootponer
heel eat is compress€d(C), the plantariorefootlifts no mor€ orly onto the odhoti., thereby prcl,entin8slippa8eand im-
thar a few millimeters(D). (A-P instabilitv is presenrif th€
ChapterSclen O hotlc Dispeffir8 Sho. Ge|r, atrd Cliricsl Pmblem-Solvirg 225
A
tigure 7.2. 5h@ modification. (A) By suppodins thc addiiion of a rcckeFbotlom(l) allows the palicnt ro prcceed
neialaf,al neckr, a Thomasba! may de(€ase pressurebc- through rhe prcpuhive period withoul bendinSth€ metalar
neathlhe mchtars.l heads.(8) A s(hosterhel w€d8e it use- sophalangeal joinls. {Thismodificationis oftenessentialwhefl
lul wher hcel lifts grcaler lhan 7 mm are requi.ed. (C-t) trealinghallux i8idur deformiti€s.)The final modificationrc'
Decomprcs5ion pad, mdy be usedlo disi.ibutepressu€away quiresmakinSclrs in the sole of the sho€ in order to encour
tom a vrricty of bony prominence,(in€ludinsdoBomedial age a hi8h or lolv 8ear push'off (r): A hiShgeaf push'ou
and ateralbunionsand HaSiund'sdeformiiy).(D A wins-heel ,hould be encouraSedin an individlal with a risid forefoot
may be ncldedto rein{orcethe media heel while a varti$ val8u, and recalcilranl nlefdigilal neuritis while a low Sear
wedBemay also bc incoporated inlo tho heel itself(G).(Note push-offrhoujd be encourasedin an i.dividual wilh a hallut
Ihat €xremal modilicarionsof shoes aro nol as effeciive at abduclovaJgus defomily as$ciated with ex.essivepropul!ive
controllinsmorionas iniho€ onholes16l.)(H)An overly flex-
ible rhank may be rcinforcedwith a filler m.terial while lhe
226 FOOTORTHOSBS
andOthe.Formsof ConscrativeFootCarc
A B
rigure 7.3. The last refers to the fool-shapedhigh-densiry ior., oot and should be recornmendedoDly for individoah
polyelhylene moldthata ,hoeis conslruct€d around.Ar prc with metata6usaddu.tus(E). (Theinadvertcnluseof a curve
sefl, shoesnreeitherslrrilrhlor cutue-lasted.
A ltrai8ht-laned lasl(alshoe by nn individual with a melatarsusrccrusr!o!r
shoaiswell-alirnedin lheiorcfootandrearlool nndshouldbe oftcr resultsin a painful adventitiousbu6a lomins ovcr rhe
rccommended fof individual,with rcclusfool types(A),On dorsolateEliifth n)etalarsal
head.)
lhe cantfary,curve-lasled shoesare anSlednrediallyal the
B
Figurc 7.4. A board-lasl€d shoe {A) har a hard fibrous ble, rnd roornierin the toe box (makinSth€m an excellenl
board on its iflncr slrfice that Drovidesstabililv and is more cho,e for nrdividlralswilh cavus fool lypet. Ihe combina-
appropriarefor individuals who overpronat€ (7). Unfonu- liof l,rslshoe(C) providesthe besl oi bolh worlds by provkl-
nately,the boar.l'll5te{lshoe is ,tiffe. and may pr€cipnalean inH rcirdoot rtability with a bodrd-lailed he€l while
achilleslendon ini'ry. In a slip-laltedshoe (8), ihe upper is mainriininBilexibilltywith a ,lip-lisled forefool.lhis is a nic€
stitchedinto a one-piecemoccasin;rnd thenglued lo lhe sole. .onll'ination when lreatingindividualswith rear{ootvaru,de'
Theseshoesprovide les. stabilily but are lishter, morc ilexi'
ch.pier Seven Orthotic DisprtrsiDg,Sho. Gerr' .nd Clhidl Pmbl€n-Solalo8 227
Duromeler
tshoreAl -Had
Flgure 7.6 Although th. over.ll rengo of
prcnatlon wlll rcmiln unchangod, a laig6 lateral
tl.re (A) provldca grcund.reactive torcla wlth a
longer l6v.r rrrn (X, tor pionaling lh€ rubtll6.
Flnr ai hocl 3t.ikc. This l€alur€ produce6 signilicanl
increasesin lhe iniligl rangeand vglocily ol pronatlon. Note
lhal a miclsolewith a negalivsllaro (B) providesgfound.
roaclivelorces wllh a shoder l€ver arm (X') tor pronalinglhe
subtslarjoint.
CUNICALPRoaLEM.SoLVr c
Table7.1'
SPECITIC
PTOBLE PROBATLE
CAUSISAND CORXFCIIVIACTIONS
'tS:
to€lion of Dtuconforr PocsibleCeurer.nd Ralional. CorraclivcActlon
Bunionpainincreas€s
with use a. Largerearfooy'forefool
varus a. R€evaluate needfor poning.
postliftingth€mcdial lfthe poil anglerarecorrect,
{orefoot (andbunion)ink) hav€laboratory Sfindthe
post5to theshell.Thislow-
er! theoverallheiShl of ihe
orthodcwirhournftectinS
function. nothermethod
of treatmenli9 to havea
cobbler$re1chlhe leather
overthe bunionor swiich
to shoewilh wider toe box,
Chaplcr&vei Onbodc Dhp.nsinS, Sho. Cetr, rld clhh.l Problen-SolYlo8 229
pain devalopswith
Sesamoid a. odholic roo long . a. Relumlo laboralory for adjust-
menlor simplytapetlhe dittal
edgein olflce.
b. LarE€fo€ioot val8usposl b. Reevaluat€ needfor post.lf
causinSforefool to slide lhe posl is conect, us€sp€n-
co top to prevenlslippaae.
Table7,1 ---eontinued
Locarion of Discoirfo.t PossibleCarees and Rarionale
c. Castwastakenwith torefoot
b. Inadeqxate(r€ngth, b. Increasefrequcrcy of
flexibjlity,and/or treatm€nGand/or home
rehabprocedures.
c. Incorrecichoiceof maleriaI c. Consid€rchanginB
(panicul.iriyii riBklrhell is materirisor add s.rfllDp
usedfor dsid toot Lypel. cover to presentorthotic.
d. FuJlarchheightusedwith d. Add tempoary bilateral
equinus{ootrype:15the heel lifis. halt: laboralory
midla6rlr anemptto com lower the medial lon8il{d
pensalefor limikrd ankle inalal.h, ard/or usesofter
do$iflexion, the planur
medial arch i$ conrpress€d
M€dial Lrorderot orlhotic a. tabofaiory e(or: failu.eto a. Have laborabry iower arch,
diSSinginto ,oft lissues. lower arch lor equinusfoot add bilateralheel lifts,and/or
useroftero.lhotic!-
b. Inadequill6slro.'g.ar: b. changeshoegearand/or
patientrullin8 over remakeodhori. wirh
d. OveryeiShtpatienlwith a d. Remakeorthoticwith
raGegeDUvaEunr. nredialflanse,reinforce
thoe 8ear,strengthen
intrinsir mrls.ulalLrre.
ChapterSevci Orthollc Dlspersitr& Sboc ce!r,.nd Clidc€l Pmblcm.Solvlng ?31
Planlar
fascia
l/media
I ar.h a. Too linle controlor rissues a. Consider ueinSmore
dis.omfonconrinuesdespire too inflamedto toleratea funclionalo.lhoticand/or
funclionalortholac. usclow-dyetapinS
procedures \,vithonholic.
b. Inadequalenren8lv frcquency
b. Increase of
tfearment and/orhome
prcceduf
rehabiliialion es,
c. Inco(ecl diagnosisof Considornighl brace.
mechanicalfool p;in. The c. R€questappop,ia(elaborn,
sercn€Ealive spondylo"
arthropalhiesoften poduce
symptomsal the medial
lube(xity of the calcaneus.
accommodalenew les! or
sendto laboratoryand adda
compressible pon to sulcue.
CThi,disrrib!re,weightoff
themetararsal neaksonlo
lhe m€tatal5alhead$.)
b. Labofatolyerror lhe medial b. Relurnto labo.rloryfor
dislal edte of devicetoo long. adiustment (orjuslErind
ed8edown in office).
discomfortat theedgeof
the otthotic.
Achilleslendinjtis
deve,opsor a. Onhotic undeFor oveF a, R€€valuate
postar|8les.
contanu€s,derpiteuseof the poned wnh resukant
misalignmedof rcarfool
andleg.
b. Fallureto lowerm€dialarch b. Lowefmedialarchof
ior equinusfoor type;dris odhotic,addbilareralheel
increaseswo.k loadon the lifts, andlort|sesoiler
achillestendonas
midtarsalcompensationis
disallowrd.
c. conl€cluro ol triceps surae c. Increasa€trstchlng,
congidernlght
Soleusstraandevelop.wirh a. Incorect us€of fo.efoot a. Renbveposl and srr€rch
valSus post:thefaulryposr
is prematurely lc.cking
fte
midtaFaljointprio.lo h€el
laft,therebypreventingrhe
rearfoottrom jnvertinSlo
Ch8plerScven Ortbolic Dhpeositrg' Sh@ cear, oEd Cllnlcal Pmble|n-Soleiag 233
Peroneus
lonsusand/orbrevi5 a. Normal pan of break-in a. Slowdownbrcak-ina^d
discomforr
dd{lops wilh as p€fonealsdllemptlo pe6n€al
ncorPorate
accommodalefearlool
f able7.1 -continued
Locatior ot Dircomtort Po!6ible Caus€sand Rarional€
supinaled), andlorircoriecl
choiceof flaterialt e.9.,a
riaidodhoticwasusedro
treata rigid toortype.
ilanserS.Oftho!. adiunmenrs
BuideLanserBionechankrNrwtldrl€rDeerP.rL NYiLan8efsiom€hanic5oroup,I 987;
Eady{eie,en.e
l4(2 )r4 .
lens to probabl€ causesand correciive actioN. While the 3. Awbrey BJ, &mardone JJ, A)nnolly TJ. Th. prospecriv{
list may seem intimidatitrg in sizc, rcmemberlhal break-in tvnluation of invosive a'rd doo'inv$ive lrealmenl prolocoh
problemsrequiring morc $an chargesin shoegoarare rela- ntr phdar rasciitjs.RehabilResDev Prog R€p 1989150,
tivelyuncommonand,re readilyavoidedasth€praciilion€r 4. Il.Poil TG. Adrian M. Pidox P. Efe.ts of fool orrfioGcs
on ccn-
becomes proficientwith the principlesof biomechanics ler of pr€ss!ft yattemsin wo[len. Ph'6 Ther 1989i69P): 149.
and
J. Brum I, Sp€ncerA. Limb donin.nc€rils rclalionship to fool
orthotic fabrication.
lcngtt!. J Am ?odiatr Assoc 1980:70(10):505-507.
6. RnseCK. CoF€.tion of $c prcn?rcdfoot. J Boo€ Joinr Slrl
RefeIttrces
(b) 1962i44: 642.
L Novick.AhKelleyDL Posirjon andmovcmenl chslg$ of the 7. NlcKcn?ieDq Cbnenl DB. Tr mlonJE. Rordng rhoes.oF
fmt with odlrclic intcrrcnlior durirg lhc loadirigrssponsof rhoricsard injur;e.s.Spons Med 1985;2: 334-347.
gan.J OfthopSponsPhysTher1990;I r(1: 301-312. 8. Fddc.ickEC.Thc runningshoe: dilcnnas anddichoromies in
2. Don{tcltiR,HulbcnC,ClnawayD, St.Picrc R.Biomo.brni- dcsigr. Ihr SegesserB, Pforlineer W (eds). fte Shoein Spod.
cal foor odhossra retrGpccrivcstudy.J OnlropSpds Phys Chica8o:Yedbook Medic.l Prblisier$, 1989131.
Ther1984t10(6)1 211. 9. Nigg BM, <lsen lLA. The jnntlenceof tunnilg vclocny and
.r :(atrtr86l 'dnargs;it'rq5 ''lsr(dou !886r suodspS p.t! €urssir l ilDr?I3tt
-n[lolg $3qql :AN ?pA &c{ i FtElirN salurtpalwig 'eaa
-r|I9 roioru FqFr?, puRsosuodsar ftol?4dserolprso uo adlt
rqSrq'rplnA coaej3Jer-.{.prlr ru!q46n$s 4lortuo S rrtdq .tl .ortsJonteJja I tr@srp!5u a spog'sd uosp"orc,r tr.uJEH .t
I
'gL-U .16Z:([)6rtl86l.roxg
:(r)gl :8tnl p.n $ods I uV 3uluuryioLto.rr rl sado, suodspS0rJt s?r.r{tl?edq! p,|tpqolr?ltorduo s{qa StrtLttnr
.F r. .xE SatN tI
lcclJ,rtr!o r.tosu!aoqscF!€too5sla ts Jo brlg tie{ Iw.rsl Jo .!llen0u €rlf, h rt?oFon ,w{ €:ltN .0r
'I8I*4L€I '.066Iptw luds '..Rtf uV r'lmod Frg '6J?J0Z :? :886t qsQrul-I8 sirortsr tq.Eq!r
Irl]g 3 ,o t tD. 3g :liugruq alrd*poq fi dpog.f rdsurfroi Z I -llru ool.leq q saorq l'trdut I'u{xr uo sssuprsl.lo4pt@
237
2J8 INDEX
Colhgenc$s$nbcF, 133.ll4
neulralposilionoff-weighlbeaingplasler@s!s,195-199../t:t-
200
dis.uiqionot 199 fversionby peroncus longu$,17
cvllualingfbrefoo/rcar{ooL rcladonshi}s.
197./99 lncdon'lurbs pmpulsilepcdrd,3J-36
evalualingneAalivecasts.I 97, ?Ot locked,32
mcthodfor, 195-197 rlabilizarion of. 55
€tionalefor, 197'199
suspctrsiontcchniqDefor, 196,198 postlo s'lcus,?0it.204
Conrt,rcssible
INDEX 239
Forc!(s) foEfoolvalusdeformity,
64-76.6+77
inte.ac on of---.corrirflr"d rorcroorvs,Bofvarsuswirhprdnhrncr.dn
I
for inl€rossei,24
arinrcrphalangeal
for lumbdcal€s,24
joinrs,20 n*i.""HTilkl$#,,,-,,,.,,,.
I
for pcrcncusbrcvis, 21
for pcroncuslongus,2./
$::l#ixtr.'f;l,flfillHy:e3-'!03e I
rcarflotv.nt6exiblcpl-inl,rnexcd
nBrrsydcfomny.109.
fo. ribilltu snbrior. 2, I
fo. libialis poncrior, 20 rerrfoorlan5/foret@tvrlCu dcfomity. t07-t09.roE I
rclrfootvrrus/for.efoot
varosdcfornity, lO5-107,
/0er07 I
trotpcrycdicularto !iis, l5-17, t6 Earflor varuvrisirlpla rffcxed li6r ny dcfonnit).lm,
nonnll and shcr.inS coq,onenrs of, l5-17, /6 I
trrBwrs€pl@.lierne of dctltaF.lhcrds.
el-93,92.
I
alignncntvith rcarfoor.64 vndiario$irTmetaraNllen8rh.I ll)- | ll
gmund clcarancedurin8 errly iwing phase,18
invonjonin u&ro,65
o'';t'l"xT*'"L"'"".".^.,, I
d( I
peroneuslc.rius,54 Heelpain,231r-232t
poplircus,5354 dle to folefoot varusdeformity, 68, ?5
mornmS,duelo rea.foorvarusdeforniry,62
Heel strile, 27. 28
Heu'er-Volkmann principte,59.j1, t?r, t75
sldmary ol, _r0.J2 High-impaclsymprods,2341
rcnsorIasde larae,53 HiP
libialisanlerior,54 extcnsion of,?4, 53, 118
{ibiali$postcrior.54 Roxiorof, 44, 53,55. ll8
Paranereis fo! rom in,5z 57-58 intc.actions with kneeafldarlle durinSeait,4/
sagittalplanenotionsdudng,14-45 os'eoanhrcsis oi ducto torctoorvaltu\ defohnr,
shnccard JtwinS phases of,28 a8
stancephasemorions,27,38,2A-J7 at hcel-strikc,
Positaon 27
sw'nApnas€ motions,3E.J8-J9 langesof motionof
riarsveBeplanemorionsdurinS,4a-49 measurcmenr of, I E7
vid€orecordinsol 190 l9t re.esary for noncompcnsared gair,I t8t //9
Gzit piats, 170,170
Camnrtoop sysrcm,145 ra8inalplanemolionsdurjngBaircycle,44
Camma'motor .eurons,145,146 Hom eiercises,1.10,152,/Jt
Gcnulecurvatum, 120,t8l Hypermobilejoirls,148
de€reascd outpurlroD ploprioceprors
.round,t48
due!o forefootvarusdcformity,T6
Cllteusmdinus gairpa e!4 r89,190 hNr ray, 158-159../Ja-160
Glur€lsm€diusgailparle,n,189,/9, joinr.150,156JJ7, 156158
subralar
Colt,2t 6-217,2t 7
ColgilendonorgaDs, 145-146 Itioribialband,53
Iliotibialbardfrictio! syndrcrne
Haglund'sdefomiry.87, 183 excessileeblalar.ioi pronationat!d,6t
IIaUux iorcfoorvalgusdefomily aod,88
limncd,l3?, /Jj fornatun of collagcnorossfibersduc ro,133
rneasuringwirh goniomerer,l8l, /82 muscleweatnessdle ro, 151
necesary{or noncomp€caled EairjI23 Impirgenentexosroscs, 121,l2l, I26
srabiljariondunngproputsive perioJ,j7 Incriia,lT
Halluxabducrovaleus, 80, /Jt Iniiacalcanca.lfar pad, 187,/d8
duelo ncxiblelbrefootvatglsdefomity,84 Inrrafusalfibois,145,14d
duero forefoolvarusdeformit!,69,15,7172 Interdigiralneuritis,230r
dueto obliquity of lirs1taBornetalsBalrnicllarion,159,
t5 9 duelo forefootvdlgusdefomity
oiiologyol72 73 fl€xible.84-85
fl6r snge of, 70 7t . 7] rigid,87
loutrhslrgeof, 72,72 duero dgidplatriarflexcd filst my deformity,t00
se@ndstageo171, z InlerdigitalptuAs,215,2/6
third staEeof,71-72, 72 lnterphalugealjoinls
evalualingfor supedor-infer'or gtid!, 135
HalluxIimiruvrigidls,8,{) tunclionalanatonyof, 14./4
3sontraiadicarionro ma.iptrlarion, lJ2 mmipularionof, 134-136,./3i, /J6
dueto doEiflexcdflstray, t05 r€slnrion of lorces ar,20
duero etongated lirsr motaLarsal,113 I nterveaebrald kc, 118
duo!o nexibleforefoorealgusderbmiry,84
dlc 1,oforefoor va.usdetormity, 69-/0, 70. t4-75 of forefool in utcro, 65
or midtaBaljojrt, 11,47
dueto rigid rorofoorvatgusdefomiry,85
hammerinS ol fiIth disit fi fth,13
ducto forefoorvarusdefornity,73-74,74 fust,11,17
due lo rea.footvarusdeformiry, 62 dldng swjngphase,38
Hangrechn'q ue.l 9t 2ul . SpeaLo casrinqrR hnioue! ot slbtalarjoinr,9, 35
H ee l (o u n tc ^, 227 dlc to leg lengthdiscrcpancy,
Heol l i fL ,3 1, - 14 115,116
measurcnertof, 18?
He€llifis,33,J-i, 212-?13
caulions nbouiuseot,212
conlraindicalions ro, I t7 diffcrcntialing
causes of, 123,125
dre to muscular c.nfa€lure,125-126
tor leg lerglhdisqGpancy, 116-l I 7 duelo peridlicularadhesiom.
ru rl i mi tc d 123,124
dnk ledoF if ler ro n d u e rc o s q ,u s b tot2.L6,, t2 ,), due!o subluxarion, 124,t 25
132 esrricredmoriorduc ro,132-134
mal€rials for, 212 c joinrs
Joirts.Se?specifi
242 INDEX
Ki.elic wedgc.:13-214
Marip!lalior,134-145
eflc.r of rcsrricrcd subtaldmorionon, 122,12J ol itrklcjoitrt, l4l-144,.114
e xrcn s' on
of , 53, 118- 11 9/.1
, 9 ouions aboutuseof. 134
forcfootvarusdcf{trmiryand.6G67 c|nrr2indicalio.!ro, 134
flcxion/cxtcusior of ol distalinremekraaaljoinrs,/J4, 136-137
ncasurcmcnt of, 181 ol disralribiolibula.joinr,I44-145,/r'J
duringnaD@phtrsc, 29.-?0,40, # li" futrcrionalfoiefootvdrusdolormiry.l5 |
flexionof, 5-1,54.l18-l 19 hnri)logjcalchanges ussociar€dwith. 133
for.csaffccrinSntolioril|t,15,/6 hl .loryoI, 132
hypcrextension duc to lcg lcn8lhdisgepancy,I l5 inrdriescansd by. 134
hypemobili(y duc to forcfool !!rus dcformity, 76 or melarafioplalarSeal andi.rerphahrScal.idints.l3+136,
intcBctionswilh hip andanklejoint du.ingeair.?,i I J5-1.!,6
rnedialinjurics du. m cxceisivesllblaldjoinl pmmtio!,6l o{ midtaMljoints,139.141,/,|{r./.t2
pair due lo forot@t v.lgrs defonnily, 8a v:. mobilization, 134
posiriotrat hccl-strikc,27 fq pldtarnexed firsl ny d.f(rmity, I t)2-103
rangesof motiotrn46sary for non@Dpcneted e{ir, I l8,l19. fo. proprioq:ptive impaim.nr"s, l.llj
I19 o' btalarjoi , 14l-143,/4-1.i44
sagittalplane notionsdurinAgdl cyclc,44 ol rirsonchrarsal joinrr, 137-139,I 37-l -t9
M.s\rge,crosrhictional,148
Mctlid longiludimlarcL ?7
Knock-kn€e brace,l7l d(velopm€nr ol 173-175
Knucl(lewalkin8,-1? el ed of excessivc sublalarprollllionarsocialed
eiLhloeoll
gait patternon,105
trnger Pediatc Cbunt$Rotsriotr System.167,I6a cl lcr of planb!fleredlint fsy defnmiryoD.94
l-eg fenglhdiscrepanct,I l4-l11.ll4-ll7 crcessively highsupponfor, 193-194
@Bpuslions of, I l.l h lbrcfoot valgls defomity
duclo asymmcricrl fcmorrlmck ingles, | 1r'.//' llexible,34
manualncltdlsfotdcrcmirarionof, ll+l15..l/J. l8l gid.85
s,rh faref@lvarusdeformity.73
palttomechanics ol I l-5-l 17 nrsuld vs.Neous suPporr of, I50
prcdEins injuryon sidcof longle& I | 6 on hos6 lor Eaint.trecc of, | 6lt
standingcxaminalion for cffoctsof, 187 in pla arffexedfiBl ray dcformity
slructu.alvs-funclional,I l4 tl€xiblc.98
trcarmcnt of, I t6-ll7 dgid,99
wcight-beangcvaluationlor, l15, //6
xjay ev^luationtn. I 14 in rcarfool ves d€fornity. 62, 62
k vcra m, 14. 22 sl. ntlingcxlminalb! of. 187
dcfinirionol lcnSthol l5 sli,nulation of skinuder, 147
L.wn tcchniquc,125.126 srLcnsrhcninS cxcr.iss for Inainrcnancc
anddev€loFncnt
of,
150
anleriortihiolib!lar,,i2 Mci\\ier's corpuscles.147
bifurc.rc,I l, 12.67
cr lus fom.tion und€r
cal@n€onavicul&r (sprins),Il. /2 in torc{ool valgrs dcfomily
effecr of forcfoot vrrus dcformity on, 67 flcxiblc,8'4
cftecl of rcrrfoot !0rus dcfomity on.60 risi4 85
itr forsfoor v6ru.leforniry. 68. 73
pliitunexed liN ray dcfomily
'n flerible, 98-99
l o n g .ll, / . : . 69 riAi4 l0O
sh o n .ll, . i2 scmiflcxibte.99
pGleriordclloid,7, ,! in rearf@lvarusdctomily,62
cfl ucI of excssive cusfiioninSundcr. | 47
clcd ofmalposiliorirgon foot funcrion.92-93
wilh hanr$red or ctawcdproximrlphdlangcs,9?,92
id.rl rlignmentof, 9?, 110,/.111
lraNveneandobliqueates ol;17. JZ
rnrsvefic plsncalignmenr of, 9l-93. 92.9.r
Mcri ral sal pads,I1l ,,i //, 2l J. 214-215
rranslerse
m.lararsal, 2{, 6r'
lc$edngof intcfdigiralmpc against.
82.a-r beidingslrair,dial forccs.andshcarnr6or, I l0
Y ligancmof tsi8clo*, l8l do,sin xed,103-105,lO,
Listrdc sjoint, I10, /10 lourth ,nd nfth hetataFals lcavin8 grcund du rg propulsiv.
pcdod, 35. .i6
trmbosacRl facctsyndrcme,E9 Dli ntarflcxcdfirsl ny dclormil!. 93- lllS
INDEX 243
pl.ntarflcxed lessermclalarssts,
103,104 idcrrilyinglockingposirionof, Ja 32
rar8esol moriontor, 159 in\c$tor of, 11,47, t22-123.124
rigid pldra,flcrcd fi ilb ,nclat&$at, 93, 9J naripll^tio\ ot,139-147, l40 142
sa s,a l p l ancm or iuns
dunnB g a Li ry c tc ,4 J m,dstance period.3t-33
'n
osseous lockhg mechanism for. 1I , .12
dle ro dc(dasedanklodoBiftcxion,t20 tZl planrdnexionof, t1
duelo limitedsuh!al!.molion.122 posrno.st ft€elsrike, 27,28
vaii a l i o n s ler gr hoi l l0- 1 1 3 pronatioroI, 38,?5, 49, 119
etongated liBr mobtaBal.lt3 orltoscslhaldisallownornatangeo1168
elongaled secondnelararssl,t10-l)t, I propulsive period,33-35..?6
shorrened firsrmerararsal, 1t 1-)t3, I 12- j 'n
Mclala6ophalargeal joills
effcctolsubtalarjointprorationon, 29
abdlclionol 13-14.1J-14
necessaryfo.noncompersaredgain,122-t23, IZ4
adducLiolr oi 13-t4, /J-l4
ax€sol rnorionfor, 13,/J rrars!eBptane
e moti ons durheeancycte,49
cornpessivB proccdures for, 135t36 Mrn' trampol icxe(i
ne ses,
dorsifl€xion 150
ot, 13,4J Mobihzarion. 134.Se"a/ja ManiDutatiotr
cvaluarinS foi superiorirferiorglide,135 ModiriedRodbers\ tesl,r47, l8]
Morlon s cxtension,
112-113,1./3,213
dclomdies$suciatcds t, rolctoorvarus.oo-22,6a.71 Moiton'stootsrruct!rc,I ti,llz
I 'mrre molion
.l ut , 112,/ J J Monon'sneu.oma.62
runctionat enalom)of, 13J4, 13,.14
manipularion ol 134-136,/Jj iJ6
pldlarflexionof, 13,45
abductor hallucis,22
5a8i rra l p l ane
nor ionsdur int s Eacny c t€r', J dcri\irt in norDalandflar-loored pc6ons,75,b
funcri on ddri ngB aicycte,
r tr,55
rfansversc
Plancmolionof, l3_14 hype.aqivilyof, U0
Mel8tarsus.dductus,
/69 Fyosirisducro plarrtufl$ed!tr..l,ay deformir],99,go
planErfleleJfihr ra) detbmir, duclo sealnsot.96
dueto rigitj pt$rarncxeJijlsr l!y deiomirv. lLro
rersuonshrP roaxesoi i @ r,2z
wirh lorcfoorvarusdctu.miry,69,69
tcslirlg strcngft of, .l5J
s bocsfo r,l 7 l, 226, 226
roein gaitduerc, 168
lreamcnrof, t69 170
functionduringgsircyctc,Jl, 55
Melalaisus primusadducrus. Tl, 72 obliqueh€adof, 23,55
l4etalarsusprinus elclaus, ]03
lelationship
ro axesof fool,2.1
I'arsverse
hcadof (iansvelsepcdis),23,55
wnh loretoolva!!s dcfornity. 69,69
shaeskt. 226.226 adductoF,functionduriDggancycte,J0, 53
anGrrorrcmpadnenl.5- ErbnsorJ,SilorunlorSrsi lxlcn\ul
Mitlsoles,226,227
F!rtucrstorBusiPeroneus leniu.;Tibiatisanrcrior
dbde.sit\ , 226-227
biccpsferoods,tighrne,ss of,l8l
Midslance period,27,2a.3t ,33,3t -J.l evaluatirgslrcnglhol 151,?Jl-./J4
exrensordiSirofl rn brevjs
Jointpositiorsat endof,l3 lesringsrergrb of, /J2
l@lintsarcdl!dneo!uboi,l jornrdurns, 3t-J3
m idrrEaj lo i nrr D,3t - t l exrensordigitorunlonAls,19,20, 82
joirt in, 31, 33
sublalar
f$nc[onduringgaitcycte,j.t.54
Midra'saljoinr
in dgid for€lbolvalgusdefom'ry,85-8?,86
dujng swi.g pfiase,38,J8
rBling srrerglhol /52
axesol motionfor, ll, /1
longiludjnal(LMIA), ./1,19 2./,28 erlctrsorlallucisb.evis,/60
rffofoorpronarion alx,ut,34-35,37 resringslrengthot, 152
in forefoDtvslgusdeformny,79,79_80
measudng forefoorinveKionabout,181.i82 extensor
nalluci!longus,19,16,
obtiqua(oMt L), t 1, 20-2t, 28
func on dudnggail cycle,J.r,54
plarldrnexcdnrslrar doformityand,94,95
planurlexedfirslray dsfomiry dueto conrradurcoI,96
suprnatron abour,13-34,J4, 37,4J duringswin8ptusq 38
. vc.ri.allydisplaced. t6O-t62,t6t t62,187 resnnSsrrenSrhof, 1J2
Fronets lotrgus,19,82
RcxordiSitorumbrcvis -.orrirued cffe.l oI forefoorvarusdcformity oq 68
tcatingslrengthof, 1-51 tutrctior durinSgan cyclc, Jl, 55
plantarflcxedffrst ray deformiry du€ ro hypenonicilyof,
tlcxordigitorumlonsus,rq 22 95
furctiondurilg Bailcycle,J/.54 in propulsivcperiod,35-37,J6
rcldionship lo ds of fml and anlle, 22 €latioBhip ro alcs of foot andanHc, 21
slnh duc lo r€{rfoot varusdeformity, 62 \trah due ro flexiblc forcfoor valg6 dcfomiry,85
tcsting {renglt of, /5, renosyr4iris of, 87t 88
reslidSsr.engrhof, llj
Scxortl.llucis brcvis' 22 wsrn€ss of, l$. l5j
rctivity in norhal a.d fat'foot.d persom,75 pcrcrela renilts, 1?, ,9
function drring gail cycle, 5r, 55 rlnctotr duringgail cyclc,Jl,54
relalionshipto des of foot, 22 durirs swing phase,38, J8
lelling sheryth of, .r51 poptilels, functio. during gait cycle,5r, 53.54
posleriorcompartm.nt.SedFleror digironrn longus;Flexor
Roiorhallucislongls.,9, 22 hallucisloryuri Tibiats onte ot
cortmclion durins prcpulsivc pcriod, 37 prcprioccptoEir, 145
tuncfionduringgaitcycL, 5r, 54 guxdrsrusluDborum, conrracrion\airh dcrea!.d Inc. Rcxioo,
paralysisot, l5l 119
rclatiorship to axesof foor ard anktc,22
slnin due b Edf@t varur dcfonniry. 62 qurdrice!6, functioa dr/rirg 8ait cyctc, JC 53
lcsting $rcngth of. I5t
lunctior during gai! cyclc, 53
sat,o.ius,
tunciiondulin8gaircycle,50,53
conracdonwilh d€crea\ed kne€ferioD, 119
tunctiondldrA gall cycle,33,51, 54-55 (ffed oo koeeBorion, 16
immobilization-hdu.ed wcatnars of, 151 Iucriotr duriq gait cycle,53
plhtarflexcd flst €y d.formity due b naccidp.ralysi6 or scnrit€ndinosu,fumtion durinSgaii cycle. 53
exrremewealoe$ of, 94
rclationsbipto 4{€s of foot atd arkle, ,9 fundr'd du.iry gair cyclc. 33. Jl, 5+55
ica ng ltrengtb of, 154 Idnobilizatior-inducld wcaknessof, l5 I
tiShtcningwilh faligue, 13) ot midurlal loctirg mec}anismby, 35
'Mirlenar.e
relstion5hipto ixss of fod ard dkie, ,9
nrain &e lo d€creas.dkne. exrensioq I t 9
fonclion durirg gait cyclc, Jr, 52 rtrain due lo overposlingof l0l€ral fo.efoor,91. 9,
paHlysisof, 52 \|rai! due to useof oniotic, 2321-2331
rcstingsrrengrhof! 154
corlruclion with dEcrcasctlknesflexion. ll9 righlcninswilh fatiguc,150
lunctionduringgail cyclc,54,, J2-53
$rain due to forefoot valgus dctormiry, tB t€n,ponl i s,l l 2
eluteusdirimu! function du ng gait cyclc, J4 53 tcn$r fasche latse, tuncdonduring gair cydc, 54 53
tibiilis anerior, /q 82, 150
conrmctur€of. 170 .tr .t of forcfoor vrrtls dcformily on, 73. 7J
fondion duritrg gait cycle, 50, 53 i undior during gair cyclc, Jl, 54
Sh tn es s of , l8l tildbrflexcd 6rst ny d.formity due ro ffsccid paElysisor
iliocostalislombo.um,functiondrrinSBoitcyclc J4 52 exrrede wcaknessof, 95
rclatiorship to axesof foor ,nd anue, 2d
conrraclurc
of, t70 r€soluiionof forccsasgociatcd wilh conrrsctionof. 17,
tunctiondurirg gail cycle,50, 53 l7
straindu€ ro re8rlootvrrus dcformity. 62
acliviry in nornal arld Rst-loo&dlcrsons, 7J ,luritrgswilg plas., 38. JE
functio,du.inggaitcycle,Jl. 55 rssri4 slrengthofi ,JJ
rclrtionship to aresof foot, 2,
ribi'li! post€rior,.r9
tunction durirlg gait cyclc, Jl, 55 lirciion &ring gait cyclc, .t,1,54
r.latiorship to axesof fmr. ?{ rrle{olEhip to axcsof foor and ankle,2,
in ridd fo'efool vargusd€forniry. 85"86 86 {tmil dle to dccr€a!.d kneecxr.nsion, I 19
testingstrenS$ oi ,52 st6in due to rerdool vass d€formity, 62
rcsting$.cn$h of. 153
! rghleningwitl fatiguc.I 50
Fron.us brevis,19,82 welhe$s of, ,J3
tunctondudnggdt cyclc.t, 55
r€lationshipto des of foor andanklc, 2I srrair dne to rofffool varosdefomity, 62
srmi, due ro ffexible forefool vrlgus defonnily, 65 vasrusiDr.medius, 16
lcsling strcngrhof, 153
vasllsmedialis,.16,l7
INDEX 245
Tr$arn.ts.ur6nll€iltt
.v,t!*iing supcrior=iDfdtor
Fldc o! t37-138
i&al,l58
obli4tjtiYrof!
lrJE i58
mrnFdario of, It-139, 137\!J9
prbdut 2Jlt
!q-cord,110, Jr6
?crtdo!.
e40!€
cfiecrof fb|Efoorvatgu deJAmtly04 67
off€ctofhrcrsor rltus d€tbrmitioL tt76
heallTu fo! lrr:uls rddd'i oi fu2 T-qg.Ct4ge! ps4.t!rrx04-166rfd6
IentdEniryof, 1?5 iID8ro bs Llgih dtrqlnsnoy.1I5
slilnglh:aJngo{, 158 dhcto sft rio6orc@rlctutes-lm
irt!roa3€],Jj TbposrEls,2U
Ilibhdiis;5s T!!l'ene mc&,rsal ffeA,9l
PqohcusbI-ovisr2,r Tri$tss6 $lii|p],2
'ItonE$bir,111,225
d€,llopment oflowcrexrlE$iry
rltgnner{tn,,6J, I63-r?1
!lbi4J nooors gsit Gydq 48-{9
'n 167
TwidErc'bral,
Ls bN lfls\ I0t-iU2,10h102,213
Vscuumtcdhls!€, 20r, 301.S.da{roCasil8 t€.tujqs€s
v4i wadSg3?5
Vldeo rc.or=&!&190"r9r
tlkiglu.be$iD8-ra€ocirtcd fool srrucrorB
chrnres.l9j
whdlrrG 34.tt 82,15?
'!rcl'a'i!,!,
Wins-t!':i,22J