More than you ever wanted to know about the foot

MAJ Joel L. Shaw Sports Medicine 24 May 2007

Overview

Describe foot and ankle joints Joint actions during running Related pathology How to prescribe running shoes

Foot function
1. Accept vertical forces during heel strike 2. Absorb and dissipate these forces across
a flexible mid- and forefoot during pronation 3. Provide propulsion as the foot becomes a rigid lever with resupination and toe-off

Articulations

Subtalar Talocalcaneonavicular Calcanealcuboid Midtarsal Tarsometatarsal Metatarsophalangeal Interphalangeal

Subtalar
Triplanar
Supination vs. Pronation

Bones: inferior talus, superior calcaneus Alternating concave-convex facets limit

mobility Ligaments- talocalcaneal, interosseous talocalcaneal, cervical

Subtalar joint
Supination
Inversion by calcaneus Abduction by talus. Dorsiflexion by talus

Talar abduction causes external rotation of

the tibia Position of most stability

Subtalar joint
Pronation
Eversion by calcaneus Adduction by talus Plantarflexion by talus

Talar adduction causes internal rotation of

the tibia
May increase Q angle

Increased flexibility and shock absorption

Subtalar joint
Clinical significance
Mobility Shock absorption Stability

Midtarsal joint
Functional joint- includes talonavicular and
calcaneocuboid joint Triplanar supination/pronation- primarily DF/PF and abd/add Navicular- highest point of medial arch

Midtarsal joint
Assist pronation/supination of the subtalar
joint Maintain normal weight bearing forces on the forefoot Control/communication between rear foot and forefoot

Metatarsophalangeal joint
Biplanar- mostly dorsiflexion/plantarflexion
with 10 degrees of abduction/adduction Dorsiflexion- allows body to pass over foot while toes balance body weight during gait Plantarflexion- allows toes to press into ground for balance during gait

First ray
Functional joint Bones- Navicular, 1st Cuneiform, 1st
Metatarsal Plantarflexion at late stance to assist 1st MTP dorsiflexion Peroneus longus and abductor hallicus brevis muscles

Plantar fascia
Causes tension along the arch Supination facilitated as arch heightened Windlass effect

Windlass effect
Websters: machine for pulling a rope around a
drum. Pulley system to lift anchor in a boat.

Windlass effect
Tension in the
aponeurosis secondary to toe extension elevates the arch by acting as a pulley around which the aponeurosis is tightened.

Ligaments
Spring ligament
Tension wire which helps maintain arch Helps rigidity during propulsion

Long plantar ligament Plantar aponeurosis Short plantar ligament

Function of arches
Stability
Distribution of weight

Mobility
Dampens shock of weight bearing Adaptation to changes in support surfaces Dampening of superimposed rotations

Running gait
Stance phase
40% of gait cycle 2 phases Absorption Propulsion

Swing phase
60% of gait cycle 2 phases Initial swing (ISW)75% Terminal swing (TSW)25%

Running gait

Double float Stride length Step length Cadence

Velocity=stride length
x cadence

Running gait
Kinematics vs. Kinetics
Kinematics- motion of joints independent of forces that cause the motion to occur Kinetics- study of forces that cause movement, both internally and externally Internal- muscle forces External- ground reactive forces

Ankle/foot kinematics
Ankle joint
Dorsiflexion/plantarflexion

Foot joints
Triplanar Pronation and supination

Running gait- ankle kinematics

Absorption and midstance
Rapid dorsiflexion (response to increased hip and knee flexion) Decreased plantarflexion in running decreased supinationcause of increased running injuries??

Running gait- foot kinematics

Subtalar motion determined by muscular
activity and ground reactive forces Midtarsal motion determined by subtalar position

Running gait- midtarsal joint

Calcaneus/talus
supination
Increase midtarsal obliquity Lock joint Rigid lever During propulsion and ISW

Calcaneus/talus
pronation
Parallel midtarsal joints Increased ROM Mobile adapter Mid stance

Axis of transverse tarsal joint

O'Connor FG, Wilder RP: Textbook of Running Medicine, McGraw Hill Companies, 2001. Page 13.

Running gait- foot kinematics

Absorption
Pelvis, femur, tibia internally rotate Eversion and unlocking of subtalar joint Pronation of midtarsal joints Allows mobility and shock absorption. Able to adapt to ground surface. Plantar fascia- relax medial arch

Running gait- foot kinematics

Propulsion
Pelvis, femur, tibia externally rotate Inversion/locking of subtalar joint Supination of forefoot Plantar fascia- increase medial arch stability and invert heel Metatarsal break- promote hindfoot inversion and external rotation of leg

Running gait- foot kinetics

External forces- ground reactive forces
Vertical- 3-4 times body weight Fore-aft- 30% of body weight Medial-lateral- 10% of body weight Newtons third law

Internal forces- muscle forces

External forces
Foot strike pattern
Forefoot Midfoot Rearfoot

Rearfoot striker
80% of runners Initial contact- posterolateral foot Center of Pressure (COP)
Outer border of rear footprogresses along lateral borderthen across forefoot medially toward 1st and 2nd metatarsal head

Midfoot strikers
Most other runners Initial contact- midlateral border of foot COP
Lateral midfootprogresses posteriorly (corresponds to heel contact)rapidly moves to the medial forefoot

Evaluation of running injuries

Training log Shoe examination Arch appraisal Gait analysis Running shoe prescription

Training log

Weekly mileage Transition point Increase in distance or intensity Increase in mileage >10% per week Change in terrain or running surface

Shoe examination
Current running shoes
Age (days and miles) Replacement frequency New brand or model? (change biomechanics)

Shoe examination
Outsole wear
Lateral heel vs. inside heel vs. lateral sole

Midsole wear
Heel counter tilt Midsole wrinkling, tilt, or decomposition

Shoe wear
Based on foot strike pattern, initial contact,
and center of pressure Neutral gait
Wear on lateral aspect of heel Uniform wear under the toes

Shoe wear
Overpronator
Excessive wear on medial portion of heel and forefoot

Underpronator
Excessive wear on lateral heel Wear on entire lateral portion of the outersole

Arch appraisal
Standing arch
contour Wet test Static evaluation=runni ng evaluation?

Biomechanical function
Required functions of locomotion
Adaptation Shock absorption Torque conversion Stability Rigidity

Biomechanical assessment
Video gait analysis Always base on running gait, not arch
height Evaluate shoe wear

Gait analysis
Behind- location of heel strike, foot motion
during single stance, foot engaged at pushoff Side- gastroc-soleus flexibility, great toe dorsiflexion Treadmill-based analysis Force plate analysis

Neutral gait
Level Heel
Throughout Gait Cycle 90 Degree Medial Angle Throughout Gait Cycle

Intrinsic abnormalities
Pes cavus- abnormal supination Pes Planus- abnormal pronation

Supination
Normal
Late stance phase Provides rigidity, support, propulsion Facilitates lower leg external rotation

Abnormal
Minimal pronation at subtalar joint Little drop of medial longitudinal arch

Abnormal supination- signs

Lateral Leaning Foot
Surface Placement Inflexible Foot Callus- 1st and 5th metatarsal heads Clawing of 4th and 5th digits

Abnormal supinators
Stable and rigid foot Lacks flexibility and
adaptability

Poor gastroc-soleus
flexibility
Achilles tendonitis Plantar fasciitis

Poor shock absorption

Tibial and femoral stress fractures

Pronation
Normal
Early in stance phase Provides flexibility, adaptability and shock absorption Facilitates lower leg internal rotation

Abnormal
Continues throughout stance phase

Mild Overpronation- signs

Slightly Greater than
90 Degree Angle Throughout Gait Cycle Medial Leaning Foot Surface Placement Some Ankle Instability/ unstable position

Severe overpronation- signs

Significant Medial
Leaning of Surface Foot Great Instability Excessive internal tibial rotation Increased medial stress

Overpronators

Patellofemoral pain Popliteal tendonitis Posterior tibial tendonitis Achilles tendonitis Plantar fasciitis Metatarsal stress fracture

Arch Height Will Produce Different Levels of Flexibility

Normal feet:
are flexible as they grip the ground and become stiff at push off

Flat feet:
are flexible as they grip the ground and remain flexible at push off

High arched feet

are inflexible and do not adjust to terrain well, but provide a good base for push off.

Running Shoe Design

In an attempt to minimize injuries, running
shoes need to provide:
Cushioning

Motion Control
Support

Anatomy of the Running Shoe

Uppers

Midsole Outersole

Midsole

Anatomy of the Running Shoe

Heel notch Lacing system Toebox

Heel counter

Tongue

Anatomy of the Running Shoe

Flex Grooves

Split Heel

Anatomy of the Running Shoe Last (Curvature)

Straight, Semi-curved and Curved

Anatomy of the Running Shoe

Lasts (Shoe Template)
Board Slip Combination

If you cannot remove

insole, remove shoeit is of poor quality

Stabilizing Features
Support is added to the inside or medial portion of the heel to counteract the foot rolling inward (pronation)

Running Shoe Selection

The three basic types of running gait based
on ankle biomechanics are: over-pronation, neutral and underpronation Shoes should be bought to accommodate your running gait, not your arch height!

Shoe prescription
High arch- curve-lasted,
cushion shoe Flat arch- motion control or stability shoes with firm midsoles and straight to semi-curved lasts Neutral arch- cushion or stability shoe

Orthotics
Effectiveness
Gross, et al. 90% with symptom improvement Schere. 81% with complete symptoms relief Blake and Denton. Reduced pain associated with plantar fasciitis by 80%.

Orthotics
Motion control
Control excessive pronation

Shock absorption Pressure relief in specific area

Plantar heel or great toe metatarsophalangeal

Redistribution of forces away from area

Metatarsal pad for metatarsalgia/Mortons neuroma

Orthotics

Adjunct to rehab and training modification Return athlete to full function Prevent further injury Functional orthoses
Alter foot function Guide foot through stance phase Promote biomechanical efficiency

Orthotics
Start with soft temporary orthotic Over-the counter prefabricated devices
Most athletes report improvement

Incomplete improvementcustom orthotic

High arch orthotic

Dropped forefoot Plantarflexed first metatarsal and forefoot
valgus Decreased subtalar range of motion Plantarflexed first ray, unstable cuboid Peroneal cuboid syndrome

Pronated foot orthotic

Flat medial arch Unstable rearfoot and excessive motion of
plantar calcaneal fat pad Weak plantarflexion of first metatarsal head and weak windlass effect

Common mistakes
Only looking at standing gait Failure to evaluate various needs of
different runners Need of different orthoses for running and everyday activity

Summary
Understand normal foot biomechanicspronation vs. supination Evaluate with functional arch and shoe wear Signs of abnormal arch Match shoes and orthotics to running alignment- correct shoes and over-thecounter inserts first

Questions??