Normal Mechanics of the

Lower Limb

Linkage System

BIOMECHANICAL INTERACTION
BETWEEN PROXIMAL AND DISTAL JOINTS

Locomotor Functions
Shock absorption - Stance stability
Propulsion - Energy Conservation
Gait is a Series of Rotations (Inman)
That produce translatory movement of the
body forward in space

Determinants of Gait
Pelvic Rotation
Pelvic Tilt
Lateral Shift
Knee Flexion
Foot and Ankle

Functional Determinants of
Gait

Smooth Pathway of the

center of gravity
Minimal and symmetrical
horizontal and vertical
displacement - 1.75 inches
Alternation of limb length
during stance
Pathway of center of
gravity produced by
intersection of horizontal
& vertical displacement

Dysfunction of Gait
Determinants
Effects of loss of subtle movements
Exaggerated and abrupt horizontal
displacement
Exaggerated and abrupt vertical displacement
Caused by: Loss of Motion Excessive
Motion Loss of Stability

Pelvic Rotation
4 degrees anterior on swing leg
4 degrees posterior on stance leg
Elevates the extremity
Decreases magnitude of vertical
displacement

Pelvic Tilt
Pelvic

crest drops on swing leg 5

degrees below horizontal
Depress the summit
Decreases magnitude of vertical
displacement

Lateral Shift
1 inch toward stance phase leg
Lateral displacement of pelvis

Muscle Function

Gluteus Medius
Stability of the trunk and pelvis Stability of
forward bending and axial rotn.
Gluteus Max. & Paraspinal muscle Contract at
heel strike
Stability of forward bending and axial rotn.
Piriformis eccentrically controls internal
rotation of the lower limb in early stance

Muscle Function During Gait

Hamstrings - decelerate leg prior to heel
strike
Quadriceps - Contract strongly at heel
strike to prevent buckling at the knee
Posterior tibialis - Controls pronation in
early stance
Peroneus Longus - 1st Ray stability and
plantarflexion in push-off-windlass effect

Muscle Function Continued

Gastrocneumius - Propulsion at heel off
controls the anterior movement of the
tibia at midstance
Iliopsoas - Flexes the hip for foot
clearance
Anterior tibialis - Dorsiflexion of the
ankle and toes for clearance - lower
forefoot to the ground after heel strike

Rearfoot-forefoot orientation
and traumatic risk for runners
Busseuil, Freychat, et al Foot & Ankle Jan,
1998
66 Runners with overuse pathology
216 healthy (control) group
Static & dynamic footprint, angle between
heel and forefoot
Injured subjects more pronated -Pronated
foot more risk factor

Structural measures as
predictors of injured
basketball players

Shambaugh, Klein, Herbat Med Sci Sports

Ex May 1991
Quad and Calf girth
Dorsiflexion ankle - RF valgus
Forefoot varus - Leg length discrepancy
Strong relationship between structural
measures and LE injury in basketball
players

Relationship bet. static and

dynamic foot postures
74 professional baseball players
JOSPT, 1999
Donatelli,Wooden,Ekedahl,Cooper et al
65 players excessive pronators (>8 deg)
28 reported (43%) previous LE injury

FF varus and calcaneal valgus in standing

significant assoc. with max pronation during
stance phase of gait

Conclusions
Static RF and FF postures may have value
in predicting dynamic RF movement during
stance
Excessive pronation (>8 deg) was not found
to be a significant factor in development of
overuse injuries
Foot postures not assoc. to player position

Effects of foot Structure &

ROM on Musculoskeletal
overuse Injuries.

Kaufman, Brodine, Shaffer, et al.

AJSM 1999.
Risk Factors: Dynamic pes planus, pes
cavus, restricted ankle dorsiflexion,
increased rearfoot inversion
449 selected to enroll in study (559 Naval
Trainees) 149 suffered overuse
Ave. age 22.5 years

Results
Arch type and risk of injury was statistically
significant for pes planus when assessed
dynamically in shoes
No relationship between foot structure and
iliotibial band and PFS
Most common overuse injuries: stress Fx,
iliotibial band syn., PFS, Achilles tendonitis

Discussion
Static lower extremity measures have
limited value in predicting dynamic lower
extremity function
Classification of the foot characteristics of
an athlete based on dynamic factors during
performance is important
Increased RF inversion and dec. ankle
dorsiflexion (knee ext) Achilles tendonitis

Additional Studies

Lutter, Foot and Ankle, 1980

study of 213
runners, demonstrated that 164 (77%) knee
injuries had a relationship to biomechanical
dysfunction of the foot
Segesser, 1980 found ankle instability and
hyperpronation predispose people to achilles
tendon disorders
Giladi increase stress Fx among soldiers high arch
Simkin high ach femoral/tibia
low arch
metatarsal stress Fx

Stress Fx Leg length

discrepancy

Effect of Foot Postures on

the incidence of Med Tib
Stress

Summer, Vallentyne
Med Sci Sports Ex 95
Varus alignment of
FF and RF were
predictive of
previous history of
Medial Tibial Stress
Syndrome

Injuries in Runners: a
prospective study of alignment

Wen, Puffer, Schmalzried Clin J Sport Med

1998
350 started study- 255 finished the study
Volunteers from Marathon Training Prog
Arch ht, heel valgus, knee varus, leg length
90 subjects with overuse injuries
Minor variations in LE alignment were not a
major risk for overuse

Alignment & Joint Motion in

the Normal Foot

Astrom & Arvidson

JOSPT 1995
120 healthy subjects 2050 years old
STJ neutral 2 degrees
valgus
FF varus 6 degrees
Calcaneus in stance 7
degrees valgus
Tibial to vertical angle 6
degrees varus

Garbalosa,McClure,
Catin, Wooden
JOSPT, 1994
120 healthy subjects
FF varus 86.7% mean
8 degrees
FF valgus 8.75%
mean 5 degrees
neutral 4.58%

Overuse Syndromes

Clement 1019
runner
Knee 41.7%
Lower Leg 27.9%
Foot 10%
Hip 5%
L/S 3.7%
Upper leg 3.6%

Stanley James
60% of running
injuries results from
extrinsic factors:
excessive hill, uneven
terrain, overstriding,
excessive shoe wear

Foot Types/Overuse

Pes planus and Pes

Cavus
Low Arch and High arch
Forefoot varus and
valgus
Calcaneal valgus and
varus
Excessive pronation and
supination

Pes Planus

Characteristics of pes planus

that contribute to overuse
injuries:
1.Excessive inversion of the
forefoot on the rearfoot.
(calcaneus is stabilized)
2.Forefoot Varus (STJ
neutral/non-wt)
3.Calcaneus Valgus (eversion) in
stance
4.Limited dorsiflexion of the
ankle
5.Increased/prolonged
pronation in stance

Pes Cavus

Characteristics of pes cavus

that contribute to overuse
injuries:
1. Forefoot valgus(STJ
neutral non-wt)
2. Ridge plantarflexed first
metatarsal
3. Increased inversion of the
STJ
4. Excessive supination of the
STJ Calcaneus Rock during
stance (varus movement of
the calcaneus)

Excessive Inversion of FF

Stabilize the calcaneus

with one hand and twist
the forefoot on the
rearfoot into inversion.
Excessive forefoot
inversion - plantar surface
of the foot parallel to
rearfoot
Limited eversion of the
forefoot
Collapse of the midfoot in
stance

Forefoot Varus

In the prone position with the

foot over the edge of the table
STJ held in neutral
Forefoot position is measured
to the rearfoot position
One arm of the goniometer on
metatarsal heads and the
other is perpendicular to the
rearfoot.
Compensation calcaneal
valgus in stance (increased
pronation)

Calcaneus Valgus

Standing calcaneus
everted position
Eversion movement of
the calcaneus in stance
greater than 8 degrees
(pronation)
Increased eversion of the
calcaneus in the nonweight bearing position
(greater than 10 degrees)

Soleus Syndrome

Michael and Holder Am

J Sports 1985

Medial achilles tendon made

up from soleus muscle- lateral
tendon gastroc
Soleus inserts to posterior
medial lower 1/3 of the tibia
Excessive eversion (calcaneal
valgus) during the stance phase
of gait causes a strain to the
soleus attachment on the tibia
Posterior Medial stress
syndrome

Limited Dorsiflexion of the

Ankle

Closed chain dorsiflexion

anterior movement of the
tibia over the talus
Open chain dorsiflexion
10 degrees - with STJ in
neutral
Compensation increased
pronation of the
midtarsal- Midtarsal
collapse during the stance
phase. To allow the tibia to
move anterior to the talus

Forefoot Valgus

Eversion of the
forefoot on the
rearfoot with the STJ
in neutral
Rigid Plantarflexed
first Ray
Compensation in
stance - increased
supination (varus
calcaneus)

Measurement of Tibiofibular
varum and overuse

Tomaro , JOSPT 1995

Measurement of
tibiofibular varum in
subjects with unilateral
overuse symptoms
Significant difference
between the amount of
Tibiofibular varum
when comparing the
injured and non-injured
leg

Compensated FF varus & valgus

Medial arch Height

Used to classify foot structure and foot
dysfunction?
Huang found plantar fascia and plantar
ligaments support the medial arch
Kayano-during stance there is a dynamic
change in medial arch thru. a complex
relationship of: body wt. -- bone structure
ligament -- muscle force

Nachbauer and Nigg

Shock absorption, reduction of vertical
impact, is not effected by arch height
High arch feet are not necessarily rigid
Low arch feet are not necessarily mobile

Measurement of Medial Arch

Height
Navicular drop as a composite measure
excessive pronation
Mueller et al , J Am Pod Med Assoc 1993
Distance between navicular height in
neutral and full weight bearing
Abnormal = greater than 10mm
Composite of FF and RF deformities

Tarsal bones are poorly

aligned the load is carried
more by muscles leading to
arch collapse

Foot structure and Injury

Summary
Forefoot varus non-weight bearing
Rearfoot valgus in standing
Limited ankle dorsiflexion in stance
Overpronation - excessive/prolonged
Excessive Supination of STJ - inversion of
calcaneus in stance (Calcaneal rock)
Excessive inversion of the forefoot nonweight bearing

Foot Orthotics

Eng et al , Phy. Therapy 1993

Evaluation of Soft foot Orthotics in the Rx of
PFPS
Excessive pronation alter normal rotation of
the tibia may disrupt Patellafemoral joint
Foot orthotics altered Q angle-more even
distribution of PF joint reaction forces
Foot orthotics (spenco insole) FF and RF vast
posting / 6 degrees and 4 degrees

Results
Control group used flat spenco insole
Both groups isometric quad contractions,
stretch to hamstrings and SLR 2sets 10 reps
Treatment group greater reduction in
pain with walking, running,
stairclimbing, squats
Both groups improved secondary to
exercises.

Foot Orthotics
Johanson, Donatelli, Wooden, et al
Effects of 3 different posting to control
pronation Am Phy Therapy, 1994
Most effected posting FF and RF varus
posting to control pronation
FF post was 60% of the FF varus measured
RF post was 50% of the FF varus measured

Foot Orthotics

Comparison of custom and prefabricated

orthoses in the initial treatment of proximal
plantar fasciitis
Pfeffer et al, Foot and Ankle Internat., 1999
15 centers, 236 patients, plantar fasciitis
5groups % improvement: silicone insert 95%,
rubber insert 88% felt insert 81%, stretching
only 72% custom orthosis 68%
Prefab insert + stretching most effective

Strength Training

Feltner et al Med Sci Sports and Ex 1994

Isokinetic training increased strength of the
invertors and evertors (Concentric/Eccentric 3
sets 8 reps, at 3 different speeds)
Improved function by reducing pronation &
supination during the stance phase of gait.
Non-Isokinetic group- balance board, surgical
tubing, step-ups, toe-raises, jumping, running,
hopping (wt-vest)

Rehabilitation
Considerations in the LE

Foot Orthotics controlling pronation and

supination of the STJ and Midtarsal
Isokientic strengthening increase strength of the
invertors and evertors to control pronation and
supination
Quad strengthening and Hamstring flexibility to
improve PFPS
Improve flexibility of gastroc-soleus
Correct Muscle Imbalances of the Pelvis
Correct training errors