FOOT ORTHOSES

and Other Forms of ConservativeFoot Care

Thoru.as
C. Micha.ud
FOOTORTHOSES
andOtherFormsof Conservative
FootCare

ThomasC. Michaud D.C.

Newton.Massachusetts

Additional copies ofthie booh may be

purchaaed, from Dr, Thonqs Michavd;
Phone: (677) 9N-2226
loa: (617) 627-5927
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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
noSes(24).
akEdy discussed,thc.sc m€asunrncntsarc cxtrcmely
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
stbldrr ncotrelpositior, Astromand Arvidson (19)
lhe ratiocloser to 2,8 to l. In perhapsthe mosl
cdsltdy evaluadngthe reladonship betwcc. subtalar
of modonand the palparcdneulralpositioo. Bailey ct
ascd tomogramsto cvahatc lines patallcl to the
pltfold snd the supcrior asp€ctof the calcancuswhilc
ar joinl was mainlaincdin neutral and when
invcncdandevencd. Thescrcscarchers concluded
on everage,subtalarneuralily occured lvhcn
wasinvertcd36.2 Frccnl from thc marimally
position,individuslvariationallowedfor a neutrsl
|al posrlton
posirionwrlh
sith invcFron/cvcrsron
invcrsion/cvcrsionntios
ratios fan&ng
ranging
l9l to l:2.3. Becauscvcry fcw pcople wcrc clos€ ro
2:l rado,Bailcyct al. (25) concludedrhatrhe
ofmotionmelhodfor delerniningsubblar ncuFaliry
lll this aside.anotherre{son lo abandootbe 2:l
ratio is that, as rcccntly dcmonslElrd by Nigg er
invcrsion/eversion ratios vrry b€rwccnmen snd
rnd changeover time. In fact, thc ranScof cversion
waspardcularly sensitivcro chanBeswith ageas
orncn(ages2G39) av.r6A€d17.2dcgr€€sof cvcrsion
thcoldcrgmup(sgcs7G?9) avengci ll.4 d€gr!a!.
ro say,suchvariarionwill significanrlycffcct th€
novcmcntmtio and,as such.thistechniqueshould
In closing,akhoughthe numbcrof quality scisnrific
i5 relalcdto lowerextrcmitybiomcchanics is lapidly
it is clerr thrt there is still mlch to learn.
srudics.
in addition!o idendrying
themostsccur.te
mcthodsfor cvalultiDg shenkrotationduring s|ance
will hopefullyresolvcthe conrovcrsysumoundinS
castingtcchniqu.s by evaluedngthe diffffcnccs, if
in paticnl sarisfaclio[, ability to conrrol motion
talonavicular)andretumntcs for odholics made
off-, 6cmi-,and foll-wcight-bcaring imprcssions,
importantp.oject would be to pcrform 3-D
of variousfoot rypesto dcrcrminehow rnicular
may bc modified with differcnt folms of
ive carcle.9..onhotics.srcngtheninScxcrcises.
gait modifications,etc, ll would llso be
to caGgorizc! large numbcr of high school or
rthletesaccordingto osseousrligrmenl and ranSeof
andthcnfollow rhcmfor severalyearsro dctcrmine
alignmenrpattcrnsare associat€d with specific
(i.c.,Do the"clalsicsignsandsympbms"dcscribed
texl for cachfoot lypc actually occur?). This sludy
dso bc pcrformcdwhh somc individualsreceiving
tic onholic intervenrionin ordcr to evalurtetnc
of orthotics
in prcvcnting
injuries.tt is only by
vii
cridcallyevaluaringmanyof thc currentlyacccptedb€lief!
thd improvedmclhodsof cvaluarionand treatmcntwill
come to light.
REFERENCES
l) McPoilT, Cornwall,MW. Relationship b€twecnneutral
subarkrjoint posilio,land the prttern.of rcadoot motion
during walking. Foot Ankle lnr 1994;15(3): l4l-145.
2) McPoil T, ComwallMW. Relatiooship bclwcenthree
static anglesof the rearfootand $e pattcrn of rcarfoot
motiondurin8 walkinS. t OrthopSponsPhysThcr 1996;
23(6)137G375.
3) Weed JH, Ratliff FD. RossSA- Bipl.nar grind for
rearfool postson functional onhoses, J Am Podiatr Assoc
1978;69(l): 35.
4) Nigg, BM, Colc CK, NachbouerW. Effrcrs of arch
heigh! of the foor on angular motion of the lower
cxlremilicsin running. J Biorncchanics
1993i 26(8):909'
9t6_
5) ArebladM, Nigg BM, Ekstand,t, Olssont, Ekst om H.
ThaEedimensionalma{surcmantsof redfoot motion during
runDing. J Biomechmics1990;23(9): 933-940.
6) Soutas-LitrlcRW, BeavisCC, VcrstaateMC, Markus,
TL. Analysisof foot motionduringnnning usinga joinl
coordinslc syslcm. Mcd Sci Sporu Ex€rcisc I987i l9(3)i
28s-293.
7) Kitaola HB, LoncnbergA, Ping Luo Z, An KN.
Kinemalics of thr no.mal lrch of lhe foot and rnlle under
physioloSicloadin8. Fooi Anklc lnt l99si 16(8):492-499.
8) o'Malley MJ, DelsndJT, L€e KT. Sclcctivehindfoot
arih.od.sis for lhc trcatmcnlof adult acquircdflatfoot
dcfomity: an in vitrc srudy. Foot Anklc Ini 1995i 16(?):
4 411.
9) M6nnRA. Flatfoorin aduhs.In: Sur8cryofthe Foot
endAnkl., Ed 2. MannRA. CouShlinM (cds.),Sl. Louis:
Plerun. 1992:75?-?84.
l0) HicksJH. Thc mcchanicsof rhe foot II. The plantar
andthearch. , Anaromy1954188:23-31.
aponcorosis
ll) SommcrC. HintermarB, Nigg BM, vaoderBogrnA.
Influenccof anlle ligamenrson tibial rotarion: an in viuo
srudy. FootAnUe Int 1996il?(2): 79-84.
12) EnSsbcrSJR, AndrewsJG. Kin€maticadalysisof thc
.ioint during running. Mcd Sci
talocalcancal/lalocrural
SporfsExcrcise198?i l9l3\: 215-284.
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.

14) McPoil TG, Huht cC. E;atuationandmanagemcnt of

foot and ankle disordcrs: presentproblemsand future
directions. i Onhop SporrsPhys Tft€r 1996:2l(6): 381-
388.

15) Sell KE, Verity TM. Warrell TW. Peasc BJ,

Wiggleswonh J. Two mcrsucmcntteohniqucs forasscssing
subtalarjoinlposilion: a reliabilitystudy. J OnhopSporis
Phys Thcr 1994i l9(3). 162-161.

16) SommerHM, VallcntyneSW. ElTcclof foot posture

on the incidenccof medialtibirl strEsssyndrome.Mcd Sci
SponsErercise1995i27(6): 80G804.

17) JonsonSR, Cross MT. lntracraminerrcliabiliry,

interexamin€r relisbilirya'ld nonnalvoluesfor nine lower
crtrcmily skeletal measures. J Onhop Spons Phys Ther
1996i23(l)r ?0-71.

18) Smirh-Oricchio K, HarrisBA. lntcrarer cliability of

subtalarncural.calcaneal
inversionandeversion,J Onhoo
SponsPhysThcr 1990:l2(l): 10-15.

19) AstromM, ArvidsonT. AlignmcntEndjointmotionin

rhc nonnaf foot. t Orthop Sports Phys Thet 1995i 22(5\j
216-222.

20) BaumhauerJF, Alosa DM, Rersl.om PA. TrevinoS.

Bcynnon B. A prospecriveslody of anklc injory risk
t0ctors.An J SpodsM.d 1995i23(5): 5f,4-570.

2l) PiccianoAM. RowlondsMS. wonell T. Reliability

of op€n and closed kinctic chain subtahr joint n.utral
positionsand naviculard.op i.sr. J Onhop Spo.rsPhys
Ther1993il8{4): 553-558.

22\ Laltanz L. G.ay G, Kanther R. Closcd vcrsus open

ki[ematic chain measurcme[ts of srbialarjoint evcrsion:
implications for clinicrl practicc.J O.lhop SponsPhys Ther
l9E8:9(9):310.

23) GarbalosaJC, Mccllre, MH. Catlin PA, WoodenM:

Thc Iiontal plam relalionshipof the forcfoot to lh€ r.srfoot
in en asymptomaticpopulation.J Odhop Spons Phys Th€r
1994i zoi 200-206.

24) Root ML. Orien WR. Wced JM- Biomechnical

Examinationof the Fool, Vol. l. Los Angelesi Clinical
Biomechanics,1971.

25) Bailcv DS, Pcrillo JT, ForenannM Subtalarjoint

ne;tral ; srud) usitrglomography. J Am PodialrMed
Assoc 1984i 74: 59-64.
 CONTENTS

'Addendum

Structuraland FunctionalAnatomy of the Fmt andAnkle

Pr.{NEsoF MarroN 2
FuNcroNALANToMY 7
Ankle Joint 7
SnbtalarJoinr 9
MidtarsalJoint '11
First Ray 11
Sccond,Tbird aDdFourltrRays ll
Fifth Ray 1l
Metatarsophalangest Joidts 13
lnterphalangealJoirts 14
I|{r€RAcnoNoFFoRes 14

Ideal Motions during the Gait Cycle 27

STANC€PHASE MoroNs
C,ontactPoriod
MidstancePedod
PropulsivePeriod
SwrNGPttAsEMdnoNs
DETaRMNAN]S
oFTnEGar CYCtr 39
oFT|teGArrCYcrE
GrAnxc SUMMARY 43
SuMMAtvoFMusclE FuNc'floNDUBTNc
rHECArr CycLE 50
Clotew Maximus 52
Ilioco€talisLumborum 52
CluteusMedius 52
GluteusMinimus 5J
TensorFasciaeLatae 53
Illopsoas 53
Sartorius 53
Adductors 53
Hamstrings 53
X CONTENTS

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

ChapterThree AbnormalMotiondudnetheGait CYcle 57

REARFooT VARUS DE!oR^.ITY 58
Pathomechanics 59
ClassicSigrs and SymptomsAssociated$ith the RearfootVatusDeformify 62
Orthotic Managementfor the Rearfoot Varus Deformity 62
ALTGNMENT
oF TriEREARFOoT
ANDFoREFoot U
FoREFoolV.{RUSDEFoRNtrrt 64
Pathomechanics 65
Classic Signs and Symptoms Associatedwith the Forefool Varus D€formity 73
Orthotic Managementfor th€ Forefoot VsrLrsDefotnity 76
FoRtFool VArnusDEFoRMTT 77
Palhomechanics '78
ClassicSignsandSymptomsAssociated rrith the ForefootValgusDeformity 83
Orlhotic Managementfor the Forefoot Valirus Deformity 90
TRANsvERsE Pr NEAUGNMENT oF THEMETAIARSAL
HE,ADS 91
The Plarlar8exed Firsr Ray Deformjty 93
Prlhomecbanics 96
ClassicSignsandSymptomsAssociatedwith the Plantarnexed
First Ray
Deformily 98
OnhoticManagemerl for lhePlantarfexed FirstRayDeformity 101
Treatrnenlof the Plantsrfl€xcdl-esserMeftirtarsal 103
Tteatmentof theDorsiflexcd Metata$al 103
ORTHorrc MANAGEMEN"TFoR VARtous CoMBINATtoNsoF REARFooTAND
FoREFoor DEFoRMITIES 1(x
VaRrAIroN rN ME-TATARsAL
LENG-,|H 110
The Elo[gated Sccond Melalarsal 110
The ShortenedFist Metatarsal 111
The Elongated First Metatarsal 113
LEG LENGTHDTSCREPANCY 114
Pathomecba[ics 115
MTNTMUMRiNcEs oF MorloN NEcEssARy FoR { NoNcoMpENsATEDCAIT t1'7
Differentiating
Caosesof RestrictedMotion t23
ResrrictedMotion Res lting fiom MuscularContraciure 125
 CbMENTS

RastricledMotion Rcsultidgfrom Oss€ousBlocl 125

RcstricledMotion R€sultirgfrom JoldtDystunction
ManipulativeTbchdques 134
NEutoMomRCooRDtNATloN
aNDPRopx.rocErnoN 145
Musclt, R STRSNGTE ANDENDURANCE
PowER, 150
ExcBssrvdABNoRMAL MortoNs 152
The HypernobileSubtalarJoint 156
The Hype'EobileFirst Ray r58
MrlpocitionedSubtalarJointAxis 159
Verticaly Displ.c.d ObliqueMidialsalJointAxis r60
DEVELoPMENTAL TRENDE lNlrvER ExTteMryyAUoNMEM
Transverse PIaneAlignment 163
F ontrl PIaft Aligrment 111
Dcvelopme ofthe MedialLongitudiml Arch t73

Four BiomechaaicalExamination 181

SUnNEEx^MntATroN 181
PxoNEEXAMTNATToN 163
ST^NDINoBXAMINATIoN 18?
DYNAurc EXAMTNA'IoN 18E

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

chapterseven Orthotic DispeDsing,ShoeGear,and Clinical Problem-Solving

OR]lror'tc D|SPENSNG 223
SHo€GEAR
Cl"tr{cAL PtoBEM.SoLvrNc 228

237
 ChapterOne
Structuraland FunctionalAnatomv
of the Foot and Ankle
lle hunanlool and arkle contain 28 bones(Fig.1.1)
(l) that fiinctiotr in slrcbrony to allow
of activitiesftring the difrercnrphas€sof gait:
carly statrce phqse the foot dissipates grourid-
forc€sessociatedwilh heel-stike atld becomesa
adapto/' nec$sary to accommodaredisqepancics
Duritrg lale stance,ihe loot b€comesa "rigid
nt!" n€cessaryto effectively transfer body woight
to forcfoot after heel lift occurs.The foot is
lcaomolish thesediverse activities via a s€riesof
anddelicnrelybalancedinteracrionsoccurring be.
Flgur€1.1. Osseou!anatomy.
1
tw€enthe vadous aniculationsand their sutPolting soft tis-
sues.In orde. to fully appreciatethesecomplex aDdotlon
confusingmovementpattems,the following sectionwill r€-
view fte different planesof motion and elplai! how varia-
tioD in axis positioDingmay r€sult in ud-, bi-, or triplanar
motioo. This inforbstion will thenbe relatedto the primary
ailicularions of the fooi a ankle with rcgard to thc loca-
tions of the individual axes atd their available fiotions.
Also ircluded in this sectionis a desc.iptionof the various
osseo$ and ligameDtousrcstrainitrg mechanisms,Firally,
the mechanicaladvantagesallorded individual muscles,as
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

ri8ure 1.3, Eodymotiom in eich ot the referenccplane6.

\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

Figure1.5. Sagitt l Planamorions.

plrnemotion6.
Fi8urer .5. Transverse

Fig!rer.7. Staticfronr.l planepo6itiom.

Figurer.8. Staticsr8itlalPlan€positions.
 ChaplerOne Strulural and FlnctlomlAnatomy of rhe Foot.rd A le 5

fi8ur€ 1.9. Statictnnsv€rseplam po6itions.

A.xis:frontal ad lranfv€.s€.Morion:sagitral. Figuret.12. Axi!: transverscard sagittal.Molion: fiontal.

Figure1.13. Axi$ frontal (45. io tranwerse).Motion! Gqral

l. Aris: fronlal ind srgrtal. Motion: lramlers€. .rnounts of lranrverseand .a8iitrl.
6 FOOTORTHOSES
andOrherFormsot Corse ariveFoolC{|e

fl8ure r.l{. (10oro tHnlv€Ee),Morion:pri-

.Axi6rrror|tal
marily satital *ith 6ometraneve'3€.

FiSur€1.t5, An!: frlnlal n(r ro etitrrt). ttorion: prim.r.

ily tranrrlrie wlth !o'hc s.gittrl.

fi8ur€ 1.16. Arisr oulide r€Gr€nc. plan!. (4S. to e.ch

pbre). Morkh: cqlal amoonr6of frDntrl, sagitr.l, and tr.nr-

Iigun 1.17. ftonatih. (A) abduc-

tbn, dorsillsion,andeversion.
t4,in+
lkn, (l) Adducrioo,planradlexion,
,nd
 chaprerOrc Siructurrl lnd Fs.cdoml ADtomt otthe troor![d Arlde 7

I plan€smus!not be takento imply lh8ttheindi- clinationsbetweeohorizontaland verticalth.oughoutthe

trcomponenls of motion can everbe segrcgaled, alllle's rango of movemenl, more rccent inve$igation
To describ€ triplanarmotions(whicb are by far rhe domonsaatesthat rll axes!rc closeto thc midpoint of a line
s€er rnotionsin lhe body), lhe rermsplona- conoeding th€ tip6 of the malleoli (7). Becauscof its prox-
supinalionarc used.Pronatior rcfe$ lo the com- imity to thetransvcrsc aodfroolalplanes,thissxistypicatly
dovcmcnlsof abduction,dorsiflexion,and eversion allows foralmost purc dorsiflexiodplanbrncxion (although
$pinationrefersto adduction,plantarfleion,snd thc slight deviation from the tmrsverse plate allows for a
(Fig. 1.17).Thesemolionsoccur in th€ lrans- srnallbut clinicallysignificantrangeof talarabduclionwith
andfiontalpknes,respectively.
sagiltal, ankledorsiflexion{21).lt shouldbe mted ihr| Inmanet al.
(8) slatedthat tlte ankle axis may devhle by as much as23'
FuNc-TroNALANAToMY from the tansvcrse plan€ ard lhat the addedrangeof talar
adduction/aMuctionassociat€dwilh lhis bigh€r axis plays
The ticulatioos of thefmt andanklcwilh respectto an impon nt role in absorbiogthe rotational motionsof the
of axesand molionsavailablewill be re- shanl. Root et al. (2) claim that such larye variation in th€
in lhcfollowiry section.lt is imporlantto stsessthal locatioo of this a)(isis relatively uncommonand is usually
ibingaclualjoint motions!rotationis an impre- foundonly in individualspossessiulimitsd ral|gesofsub-
as i! is us€dto describemovementabouta long Lalarjoiotmotiondudngthecarlyycarsofskeletalgrowlh.
8€crusemostarticulations movewilh a combination The autfiorsstatedthat the unusuallyhigh axis resultsfrom
dide,and/orrock,identifyinga sirglc axisof mo- a functional adaplationof bonc as the ankle atiempls to
b rdurlly impossible, as irs location is oonstantly compcnsatefor the limired subtalarjoint motion by devel-
3s thejoinl moves ftrough rhc availablerangeof opiog a supinalory/pronaloryaxis.
Regadlossof the posilion of ils axis of molion, plan-
urnexionsboulihis axisis limiredby tensioncreatedh rhe
Arkle Joina surrouldingsofl lissu€s(particularlytle anteriortalofibular
ligament)andby an oss€ous blockproducedwhenlhe pos-
'Alro known as the talocruraljoint, the atrklejoint is terior lubercl€ of thc talus cootacislhe postcrior mrrgin of
etionbelweenthe talar trochleaand the distal $€ anicula. sufacc of lhe tibia (9) (seeFig. 1.20). Motion
6bula.Allhough the averagc axis of motion for io lhc direclioo of dorsiflcxion is limited primadly by ten-
Iiesapproximately8" io th€ rransvese plane and sion in the tric€p6 surec musculatur€and the postcrior rc-
to thetrontal plane (3) (Fig. inve-s- srrainingligaments,i.c., the posteriordeftoid ald the
t.l8), numerous
(q-11) hsve denonstratedthat the inegularly post€riorlalofibularIlgrments(Fig.l.2l). Also,bccause lhe
mntourof lhe medial lslus allows for a eonslsnl lalusis wideranleriorly,ankledoEiffexionmayalsobc re-
oningof lhc axisas the ankleis moved(Fig. 1.19). stric!€dby a bony block when the widenedaspectsof the
(6)likensthcshifi of lh€anklcaxislo therotariorof taluscom€inio contacrwilh thedistaltibia andfibula.Ths
clinical significarc€ of a prematureosseousblock will be
Whilethcankle'saxisofmotion maytakevaryingin- discrssedlarcr.

Fi8lre 1.18. Av€r.8e6ri5 of mo-

tion lor lh€ anklejolnt.
8 FOOT ORTIIOSES n|d Olher Foms of ConscrvativeFool Crrc

Flgur€1.19. Shhftlngof the anLl€ ioint axh of motrbn.
Whereasthe laie.altaloealnost alwaysfolmr . irue circle,
the variableladiusof the m€dialtalus r,hel) .llows ior a
downwardand laleralproiectionot the axiswhen the ankleis
(A) and a superiorand laleralproieclionof the
dorsiflexe.l
axis when the anklc jr plantarfl€xed(8). lAdaptedhom Bar-
nett CH, Napier jH. The aris of mrationon the ankle joint in
man lB influen€eupon the form of lhe talusand the mobilily
of the fibula-AnaromyI 952; 86: | -8.)

Figur€ 1.20. An € plenl.rflErion (lal€ral vkw of the l€ft

anHe), figure | .21. AnU! dorsirlerion (medialview of righranlle).
 ChalJlerOne Shuctural lrd Fun.tioral A|titohy ofthe Foot ind Antle 9

Subi{larJoint lided *ittr lhe anterolaterai aniculationof the calcancus-

lh€r€by producjng an osseousblock thal preveDredlu4her
suhalarjoint js locat€dbelweenthc lalus and motion.Whenstressed in Plonation,variationin lhe shape
Thoughrarelymentioned, irdividuslvariationin of th€ threearticulations resultedln ftpid joiri incongruity,
I of lhisjoint mayresBlrin thefomalion of which limited furlher motion. Theseacdoffi allow for a
0r threes€parate arlic{lations(Fig. r.22). Bruc} functionallockingmechanism which,accordingto Elftman
in hissludyof 32 crdavericsubralar .joinrs,notcd and Manter(11), is a udquely humantrajt that allowsfor
s hadlwo dislind anicularions (wnh siighl improvedbipedalanbulation.
t€twcereachone)wher€asthe femaining12 had Motion in the averagesubralarjoinr occ rs abour an
articlllatjons.Upon being plac€dthroughtheir axis ftal lies 42' 1o the traDsverse plaoc and 23" to rhe
of pronationand supination,the articul.r sur- sagitlalplaie (rcf. 18) (Fig. 1.23).The posilionof rhisaxis
thebiafliculared subtalarjoinrsremained congru- allows for triplanar motion with almo$l equal amountsof
wasrcstricledby sofl tissue-reslraining fronial (eversiodinversion) and transvene piane mouotr
j.e.,lhc posteriorandlareraltalocalcaneal lig- (adduction/abducrion). Alrhough Inman and Mann (12)
tbeinl€rossoous ligament. Althoughrot prescnr compared motionat thesubtalarjointto tharwith a mirered
group,Bruckfle.(10) mertionsthe sitrgle hinge,the accuracyof this model is questionedbecauseof a
rutionwouldbe exlremelymobilc,as all rbe small rangeof translationoccnrring betweenrhe coEbined
blendedinto ore, [lereby allowingfbr a maxi- subtalr and ankleaniculations(13). Becaus€ rhe aris lios
arcawithourthe stabilizatbnaffordedby rhe so close to the sagirtalplanq only limiled amounrsoI
Iigament. dorsiflexion/plantarflexion arc possible.
eontrastLolhe more mobilo sinsle- and double- lusl asihereis muchindividualvariationin rheshape
ions,the subtalarjoints with th.eeanicula- oI lhe subtalaraniculations,there is also much variarion in
smalleramountsof conbined articular thelocationof the axis of motion.Numerot,ls invesrigarors
areaaltdsxhibitedfar lessmolion. Whensiressedin (14-l6) hav€not€dpositioralvariatiorin thesubtslarjoirl
lhe arterolaleralarliculationof the talus ool- axis, rangingf-rom20" to 68.5' from lhe trrnsverseplane

vi€w
$up€rior
ottghl

lJi

B
ioint anatomy.(A) Three,
1.22. varialionin 3ubtnlar
n. (8) Tdnsilional twojacet confiBuralion
twojacel confiSuatioJr.(D) Sp€cial twolaceL
configuration.(Adaptedfrom BrucknerI. Vadationsin the
human subbl arj oi nr. J Orlhop SpodsPhysTher 1987;8:
489 494.)
l0 FOCrTORTTIOSFSandolher Forlns of ConscN.rive Foot care

fiture 1.23. Axb of motionfor lfi€

6ubralarioint.

otlh€ s blar ioint axis.(A)4' f.omsagittal.

in positionin8
Figurer.24. Variations (8)47' rfom
(C) (D)
sasifial. 20" fromtmnsv€rre- 6'10lromlra.rverse-

md 40 to 47ofrom the sagit!,l plane(Fig. 1.24).In practi!€,
the approximate positionof the subtalarjoinl axis €aobe
derermined by cornpadng the rang€ of reatfoot
inversion/eversionwith lhe rang€ of tibial rotation as lhe
standingpatiertpmnatesstld supinates thesubtalarjoint.If
the axis lies 45' to &e transverseplane,every ld of rearfoot
mori,}nwiI produce1' of tibialrclation-lf theaxisis posi-
tioncd trear70oto the Fansverseplane,lhe amountof tabial
romlioDwill greatlyexcr€ed rcarfoot motior (c.9., 2" of rear-
foor cvenior will be accompaded by 80 of intomsl iibill
rotation).The location of the sublalar joinl ixis is clinically
signilicant as a high axis could be responsible lor chronic
 ChaprerOnc Structurrl rnd Functlonll AtrltoDy ofthe Foot![d Arlle
irjury lo sl.ucturesproxinal to thc subtal joinr, while a
'Jo.r axis could be rcsponsible for chronic injury to struc-
llresdistalto thesubtalarjoinr.
The MidtaNrl Joitrt
Themidlarsal joiDtconsistsol the coebinedsnicula'
joinls.
i{ons bctweenthe talonavicular rnd calcaneocuboid
jointsfunctionasa unit to allowfor triphnarmotion
occursaboul two dislioct axes: the oblique midtarsrl
ads and rhc Iongitudinal midtarsaljoint axis (4). Al-
individualvariationerists, thc oblique midtarsel
axis li€s 52o lo lhe transverseplcnc and 57o to lhe
ilalplancwhercasthc longitudinalmidtarsaljoint axis
l5o to lhe lrsnsve$eplaneand9' to thg sagittolplme
(Fig.1.25).
The lo.ation of lhe obliqoe midta$al joint axis allows
largeamountsof sagittal and transverseplane molion
ioo and abducliorvrddu.rion,resDcc-
wilh rcletivelysmall amountsof froncalplatremorion
). Thctongiludinalmidbrsaljoi, b€caus.
clost Frximity to the transverseandsagittalplanes,al-
for almostDureinversiortcversion.
Tle midtarsaljoin!is similarto a triarticulated subta-
joirt in that it hasan osseooslockilg m€chrnis{r to pre-
excessive notion (f4. Wheressmovemcntin the
ion of supinalionis r€sistedby sofl tissuc-restraining
rhovem€ntin thc direclion of Dmnadoncomes
a, abrupthah when the superoproximelborder of thc
ing cuboidcomesinto conractrvilh the dorsd border
overharging calcaneus(Fig. 1.26).Furlhermidtarsal
ion is prsvertedby tensionia lhe va ousr$training
(primarily$e long aod short plantarligamcnr$.
olcarconavicularligahent, and lhe bifurcale ligamcnl;
Fi8.1.27).Midlaisalpronalionbeyondthispoinris nol
ll
possiblewithoul ovcrwhelmingthe fcstrainilg ligamenls
aod subluxing thc calcaneocuboidjoint (2). As wilh the
sublalar joirl lockin8 mcchadsm, lhc midlarsal locking
mechanismis a uniqoely humao trail thal allows for im-
provedbip€dalambulalion(14).
Flrst Ray
The 6lst rdy is a fulclional snit consistingof the me-
dial cuneiform at|d the firsl neiatarsal. Firsr ray motion oc-
cl|rs aboul an axis lhat lies approximstely45" to both lhe
hootalad sagilal plancsCig I .28)'nrc locatiol|of this slis al-
lowsfor relativelycqualamountsof dorsiflexiorvplanrarfl €xion
andinversiory'eversion. Becaus€the a)dslies so close to the
transverseplane, lhe rangeof adduclion/abducrionis clini-
cdly insignincanl.Note tlat motion about thc first ray axis
in bolh pronationand supinationis lirdted by soft rissue-re-
slrarDmgmechanisms.
Second, Thhd, atrd Fourth Rrys
The secold and $ird lays consist of rhe secondand
thjrd mehtarsalswilh lhet respective cuneiformswh€reas
the fourlh ray is thr founh metalarsal alone.Althoughthe
exact locationsof th€ir axeshavs not yet beelrdeterBined,
Root er al. (2) postulalethey lie h the transvcrseplare just
proximal to the larsomctauN:rl aniculations, Bec{use of
lhis, motion about these axes occuE io thc sagi[al plane
only, i.e., pure dorsiffcxiodpladarflexion.
Fifth Rry
The 6fth ray is lhc fifth metatarsal alone. This
melalarsalmovesaboot an axis rhat lies rppoximatety 20o
lo lhc lransverseplane and 35" to lhc sagittal plaoe (Fig.
Fitur€ 1.25. IhG midta.lal ioint
axGsof molion: lhe oblioue mid-
lersaljoinl axis (OMIA) and lhe lon-
Blt'din.i nidtarsalioint aris (IMJA).
 ot cubold

Figur€ 1.26. Ihe pronalir8 drboid piwrs about lhe cal-

can€anprcce.r until itr dorsalborder conlactslh€ ov€rhang-
ing calcaneus.lAdaptedfrom Boisen-Moller F.calcaneocuboid
jointandrtnbilityofthe lonsitudinal
archofthefootat hishand
low searpush-of1Anat1979;1291165-176.1

FiBUre1.28, Artu oJ notion for lhe fi6t ray. {A) Ani€rior

vie$ Gectjoned (B)Dorsal!iew.
at thecuneifornrs).
Antoior libiotlbularligameflt

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
[.29).The positjonof tltis axis allowsfor rehtiveiy large
$Dounlsof doniflexion/pladadexion and invqsion/ever-
gion.Becaus€ lbesxisrilrs20oto rhelransveNe plsne,there
i8a smallbut ctinicallysignilicanlsmounrofabducrior/adduc-
{hn prcsenl.As wili rhe fiIs! ray, morionabout rhe fifth ray
irjs is alsolimiledby tensionin rheresaainirgligamenrs.
Metatarsophalalgeal Joints
These jointsrepresent thearticulationsbelween th€dis-
t l ,irst through6f1h melararsalheadsand their respecrive
proximdpirlangcs.Eachof thesejojrls hashro dislincrand
S9parrte axeslhal allows ior pure sagirtal(dorsiflexiodp]an-
lEgurc1.30. Ih€ melatarsophalangealioint axes.(A) Lateral
lliewdemonnralinBsagitlalpline moLion
abourthevanwerse
'taF abdu.tia
\
\ anda midsagithllim (B andc).
B
t3
larflexion)a'ld transv€rse(abdlcrion/adduclion)plrne motion
(r'is.1.30).
Becauseof the localionsof theseaxes,frootalplane
motionjs not possibie,andany attemptro ioven or eve( a
normal di8it may resull in subluxationof ft€ metatarsopha,
Iangealjoint (2). Funhermorc, al$ough sagirtatplane mo,
tion at lhe melalarsophslang€aljoinl is extremelyimportant
for nornal locomotion,the raflge of fansverse plane mo-
lion is relativelysnlali and of no functionalsigniricance
duringthe gait cycle.Also, in regardsro lransverse plan€
motion of the metatarsopbalangcal joids, there fias been
historicrlly much controversyregardingrerminologydiffer-
entiatingabductionand adduction.For example,the early
B
aris. {8) Dor5alview demonstEtinqllansvelseplane morian
aboutrhe ve(ica I axis. (Adaded trom Rool et at.t2l.)
ri8ure 1.31. Digilalmotionsas re-
lated lo ar axial ref€renceline (A)
14 FOOT ORTHOSES,nd Other Formsof ConscwativeFoorCarE

as \lrus and val8usrcfcr lo lrootai planepositions

c.9.. hanux abduclovalgusrepres€otsa deSormityin
the hallux is both abductcd(Fig. 1.32A) and in valSls
1.3:rB).

Interpholltngeal Jolnts
Each of the interphalangealjoims posscsscsA
ve^c axis thal allows fo. pure sagittrl plane motion (Fi&
t.3.).

AB
Figure ri2. Digihl positio(|s.(A) AMucted .efeF to ihe
transveGe planepositionwhilevrlSus(8) lefelsto the lloni.l
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
forcesbeirg muscular,gravihtional. inertial, frictional, d
groUnd-re{ctiveforces). ln ordef to apprcciale jusl hof
$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

Frgure1.33. trler.l view dernoi.r.allng pur€ 3.ainal phne

molion abour the tr.mv€rs€ rres of th. inrerphahn8eal
ioints.

anatomists responsible for namingthc musclesrelur€d to

abducrionar rhc mclaiaNopbalangeal joint 3s movemenlof
a digit away from an axial r€ferenccline projecting distally
through the secondmetataaal wirh {ddoction r€pres€nting
hovementtowardsthis axial refcrcnceline (Fig. l.3lA).
Contary to this, the morecurrenlonhopacdicand podiatic
literatur€rcfersto abductiotr as movemcntof a digir away
from the midsagittal plale ofthe body,with adducrion.ep-
rcsentingmovementtowardsthe midsagittalplaoe (Fjg.
1.318andC). To be consistentwith lhDmorecunentlitcra-
ture, Ihis text will refer to ft€tatarsophalangeal .joint mo-
tions as ltcy rclale to lhe midsagithl plane.
Alo&er point of (ln{lsion .cgarding rermirology
concemslhe useof the tefms varus aod valgus lo desciibe
digital positions.Whereasmafiy authorsrefer to tmnsvenc
planemalposilions as eithervarus(representing adductioo)
or valgus(representing abduction),thisis actudly inconect Fieure1,34. Thc tolr characterislicao{ torce.
 Chaptq Onc Suucror.l rrd FYrcliodrl A[|tom] ot lt€ Fooirnd Alkle
titurc 1,35. Doorhingeanalo6y.
fiEurc1.35. DoorhinS€.nalo8'.
widr a door hinge analogy(Fi8. 1.35). If
worcuscdto operthisdoorby pollingor door-
B, theforce generaledal A would bc much more
thtn the force ceneratedat B. Th€ relative effect
couldbe detcrmined by the fomula M = F x
,t eqlrls the momcnlof force (thc rerm "mo-
t5
rnent" refercto the lendencyor measureof lcndencyto pro-
duc€ notion), F equalsthe componentof force perpendicu-
lar lo the levq arm, ard D €qlals the lengib of the lever
I! this cxampl€,becauselhc force b€ing applicd was
perpetrdicularto the door, the length of lhe lever erm could
be deiemined by m€ssudngthe distancefmm the axis (the
hinge) io thc doorknob.If thes. samcforceswere applicd at
differenl anglesto the door (whilc remainirg perpcndicular
to rhe axis), the lclgti of theii resp€cdvelever arms would
significantly cbange(Fig. 1.36).(RemorDber thalthe length
of a lever arm is the peipendiculardislsnce betweeo the
force's Iine of actio'| andlhe aris of motior.]
If forcesF1 !o F4 wercequalin magdtude,Fl would
have the grcatestmomenl, follow€d by F2 xnd F3. F4, re-
gardlessof ils magnitude, would b€ unable to move lhe
door becauscits line of aclion passesdirectly through thc
oxis,This illusllaliol|alsosorvcsto demonsralehow one
forc€ can producc two disrinct rctions. Notice that if yorl
were to atempr lo open the door by pulling along line F2,
part of rhe force would Bo in|o openingthe door and pan of
thc force would go inlo comprcssingthe hinge.This reprc-
scnts an importart concepl regarding the application of
forccsin thebodyr'When a forceis appliedperyendicularlo
an axis(or prp€ndicularloajoint's surface), the forcemay
be resolv€d inlo fotatiolal and nonrotationalcomponeds,
end the nonrotalioral compomnl will either compaessor
distract the joint surfaces.A simple exampleof this aclion
occursin the knce (Fig. 1.37).
Wlereas the rotalional componenl is obviously im-
portanias it is responsible for producingmolion aboulan
axi5 thc compressiv€component is also important, as it
may be responsiblefor stabilizing a joir|t. Fo. example,as
heel liff occurs, vadous musclesand ligameols must work
togetherto crcate Ihe strong compressivcforcas nccessary
1o stabilize the osseousstructuresas verlical forces reach
their higbGsllevals. Failure to gcderutesufficienr compres-
sive forceswolld allow the bony strucores to shift as verti-
cal forcespeaked.
ln all of thc illustaiiotrs so far, forcesbave bcen ap-
pliedp€rpendicular to lhe axisof motioDatrdhevcbeenre-
solved inlo rotalional and nonrctational components.
However, as one oight $rspect,lhe forces in the body are
not so coopemtiveasto align thcmsclvesperpendicularlylo
a joinl's axis.Wbcn a force'slide of acliondeviatesfrom
perpendicular(as it mosl ftequsntly does),determiring the
rotalional and norrolational componerts requircs first re-
solvingtheline of rction intoforcesactiogperpendiculEr to
the axis and forcesacting parallel to lb€ axis. For €xample,
Figure I -38 illuslrales lhe samedoor picturedpreviously in
Figl|Ic I.35, only||ow Forc€FI is aogled30" supcriorlo
lhe p€rpodicuh. plare of the axis. This force can now bc
resolved into whrl is tened a no@al component (Fx),
which is appliedperpcndicularto lhe axis and poss€sses .o-
tationaland nonrctational components, and a tangentialor
16 FOOT ORTHOSESand olher Forfls of Conseflative Fool Crrc

Figurer.37, Whenthekneeis fl€xed

(A), the seminrembranolus muscle
exerLca srronSrctalionalconrpon€nt
ol torcetR./aoda smatlnonrctational
or compre$ive component 1cJ.
Uponsrraishbning (B, the lengrhof
the mus.le'sleverarmde.reases and
lh€ nonrotationalcompon€nt greatly
exce€dslhe rcrationalcompon€nt,
rherebycomprcrsinEthe adicular

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?

coftporcnl(Fy), which is appliedparallclto lhe ll is possible lo dcterminc the magnirudc of cach

is lypicallyunableto produce morionwitholt sub- force (shearing vs. normal and rolalional vs, nonrotational)
dislocnting thejoinr. by selting up ar cquationin which the componenlsof force
Fonunstely, lhe sheariflgcomponenlof forceprcscnt arc made analogou!to the l.gs of ! righl triangle. For
joints is resist€dby bonc/ligament-restrainingexrmpl€,iflibialis anleriorwer€conuactingwhh a forceof
and/orthcp0ll ofanlagonisticmuscles. Aclas- l0lbs andils insefionangled75oto thejoint'ssurface(15'
o[ how muscl€sinteract to prevenl shearing from peeendicular), the normalcomponentof force (which
Occurs in lhe lnee as vaslusmcdialisand lateralis is equivalenlro thc adjaccntleg of the formed righl tri-
islic forqrs to mainlain the oatella b€tween angle)would equal9.7 lbs, and lhe shearinScomponenl
condyl€s (Fis. 1.39).Bccause rhereis minimal (which is equivalenl to the orDosile ler of the formcd
ion (lhc intercondytar groove is sbrllo*), rhe righttriangle)wooldcqual2.6lbs(seeFie l.4l)
forcescrealedby thcscmusclesmust bc rcla' The rotational and donrotationalcomponcnlscan be
tqual, oticrwise rhe palolla may stray fton ils determined by takingthenonhalcomponent (9.7lbs),doting
ilamaging thearlicularsurface. jts angulations fron thc point of atlachment (in this case,
1.40 demonstrates the varrouscomponent 65'), andthensettingup a similarequation(Fig.1.42).
aslibialisanteriorattemplsto ov€lcomein€r- '[he dorsifleclory force generatedby contraction of
wilh
associaled the early swing phase of gait. dbialis anterior can now bc determimd by lating tho rota-
ineniais ool actuallya force,it is lypically donal compodent(8.8 lbs) and mulliplying it by lhe pe.p€n-
106sotrebecausc of ils lendency|o resi$ motion,) diculaf dislancebclwcco lhe tibialis anterior's tcodon and
tibialisanterioy's line of acrionis almostDerDen- the ankle's axis of motion. Hopefully, lhe rcslltanl force
lheankle'saxis,shearing forcesat themoniseare will bc sufficienlto overcomeinertialforcesandinitiatethe
r,tdwouldnormallybe resistedby theantagonistic dorsifleclory motionsn€cesssry for ihe forefoolto clea.the
groundduringmidswing.

figure r.40. Th€ re.olution oI

forcas associatedwilh contraction
of tibi.lis ade.io.. Nol€ rharfor pur'
poteeof simplificalion, lh€leaction!
are d€scribed only as lhey relat€to
lhe anklejoint, and lhe effectof the
anteriorrelinaculum and the multi
pleallic!lationsthairhetibialisante'
riortendoncrosses is norconsidered,
F/= lineofapplicalionof force.

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=-"

In thisexsmple,inertiswastheonly forceconsider€d. of thc force is dirccteddownward{nnd is considercd lhe I

A mllch more signincentforce is encountered during the
stanccphaseofgair:ground-reacrive farce.Crcund-reactivc
force is also referrcdto as contactforce, and it is consistent
with Nefiotr's Third l,au, which $alesthar:tn obj€ctwill
reactwith a torceofequalmagdtudeatrditr theopposilcdi-
r€ctionlo the firsl forcc.Thus, wheDthe he€l strikesthe
groundwith a forcc of 20Olbs,it cnlta]sobe saidthst tie
$ound strikestheh€elw;tha forceof200lbs.
Ground-r€aclive forcesaresimilarto thoscparalleling
an axis in tha! they {Je dividedinto trormalrnd sfiearing
components. (Ihc nomlal componenris synonymous wi&
venical force.) Figure 1.43demonskat€sthat when the heel
strikesthe ground in fmnt of lhe body's cent€rof trlass,part
I
normalcomponeflt), andpan of the forc€is directedalong I
thc surfrc€(andis referredlo asthe langentiul. or shearing,I
com|onent. I
Thc magnitudcof €achcomponentis determined by I
tlle hi:el'sangleof approach as it slrikesthegroutrdiaslhis I
anglcneaftperpe[dicular, the normil componenlis grcall, I
hc(rsed; as tle angleneaflrhorizontal,lhc shearing com. I
pooentis greatlyircrea$d. Thc sheddngcomponenlot I
force (which may be appliedanteriorly,posteriorly,mcdi- |
aly, laterally.or torsionally)musr bc resiste{lby a high I
coetllcientof frictioE otherwisc.thc toot will remair in I
moti$o (e.&, taling a large stride on ice may resuhin a f.ll I
as !h,: anterior shear forcqs are llnrcslraincd and the heol I
 Chader Ore
rc movefurward).High coefficicnrsof fricrion
for lhedevclopment of lriclionalforceslhsl
t rolesduringslalicard kineticsclivily.(Thc
of frictioml forceasdetcrmin€dby muhiplying
of liiclioll belweenthe lwo surfacesby the
t of force.)
stalic slance,friclional forces markcdly re-
on the supponingligsmentsby resistingftc
dideof tie mctatarsal heads.This acrsro crearca
compressivc force lhal naintainsheightof lhe
lotSiludinal arch,thcrebyminimizingthe ne€dfor
slabilizalion. Nore rhar periods of
slencctypically lasl lessthan I min andaro intcF
C6lro.nemiuysoleus.Th.se musclesposr€es lhe actionsof p€roneustediusand exlcnsordiSitorumlontus
leveratmanda peQendicularansleof approach arc consideredidenlical {ahhough Peroneustcrtius ha5 a
axisandarclherefore
nron6ankleplantadlerors. lonBerlev€ra.m fo. pruducinSpmnationaboul the longitudi-
muscles
anSleapp.oximalely48' to the subtala.
onlymoderare oi thiejointderpne
supinaloB
lont levera.m.TheSastrocnemius, unlikerhe
lhe kneejoint and rhercfor€aids in kne€
digilorlm loryus. Eecauserhis musclehas a
andneariypo.pendicular
approach to iheankle
asanronEankl€dorsiflexo'.
lt al5oharsmallbut
ams to bolh the lonsitl]dlnalmidlaEal joint
axis,which al{owsit to developa modefato
aboutth€5e ax€s.{Theanterio.retinac!lurn
of
allowstor a nearpe.pendicular anSleot ap-
t€rli6. Eecauseot lheir close proximity,
Struclrrll ad FEnclioml Anrtomt ofthc Foot rnd Ankl. l9
rupledwith tcmporaryburstsof muscleacl,vitythal serve
Lo feposition$c meralarsalheads,rhercbyreestablishing
fiiclionalforces.
Duringkineticactivity,frictio l tbrcoshavelhe po-
l0ntial!o gercralelargemoments of forccaboutIhevarious
ax€s,deperdingon theirangleof applicalionandfie body's
momcfltum.ln Figure 1.43,the frictionalforcc gcnerat€d
bclwecnlhe he€latrdthe groundis appliedp€rpcndicular 1()
lhc dnklcaxisandhas? long leveralrn ro $is axis(longer
evenlhrn lhe l|ormalcompon€rl'sleverarm).As s resutt,
tbe friclional forco crearcsa strotrg plantarflectorymotion
lhal is parially resistedby eccentriccontractiotlof rhe anre-
rior compartmcnlmusculature. Contractionof th€semus-
B
nalmidia.salandsubtalarioinl axe5).E{ensor halluci! lon8us.
Thismusclehasa lonSleverr.m and a peeendicularangleof
approachlo lhe ankle axis and is a rt.on8 dorsifl€xoroi thi,
joini. h fact,Roo!et al. (2) not€dthat €xiensorhallucjslon8us
is lha stron8estdorsitlexoroi the ankleas swins phasebesins.
Becauseof ils insi8nificantleveralm to the slbtaiar and longi-
tudinal midtarqaljoint axes, it js unable to produce morion
about thescaxesand is considereda neutraldo6iflexor ot thc
toot. Note; Exteosordigitorum looSusand extenror hallucis
lontlr cfeaiest.on8comprersiveforcesat the inr€rphalanSeal
joints lhar acl to rcsisrclarvingor hammerint oi the digirsas
theymaintainextensorri8idity(s€eFig. 1.46).
20 FOOT ORTHOSRSand Other Formsot ConscruaiivcFoot Care

cles {psrticuladytibialisanlerior)servesto decrease

menluJnof the forefool, thereby minimizing soft
damrgeas the plantal foretbot slrikes the ground
If rhe heei\'€re striking the graund from a I
med;,rtdireclion,triclionalforcesgenerated wouldbe
plicd nearlyporpeodicular to the sublalarsxis and
therfforcpronalethatjoint (Fig. 1.44).Because theforce
applied parallcl to the anklc axis, it is unable ro
moii,]n at thar ioinl (although the normal component sP
plied posledor lo the axis or gravitationalforc€ aPplieda!:
Figure1.46, R€solutionof forceral rhe inlerPhalans€.lioinIs. leriof to the axis would produc€a planlar8ectorymolion
Lrrensrdr8iloru4l lon8u(e\edrd pue ( ompre'svo{o( € at rhe in this caseare besL
prcxinraiand disralintephalanseal joiniswnh no rotational th€ ankle).The ftictional forc€s
bt rihialis posterior, which has nearly a perpEdidilar
component. lxtensorlullucis lon8usexensprinrarilya com' for cohlrolling mF
of al'proach and a signilicant lever arm
pressivelotce with 3 slightdorcifl€ctotyconponent.Eothmue
clesproduce doEiflexion atthemetitarsophalangealioint. l i on Ltl hc FU btal arj oi nl .
Thc illuskalions in this section have hopen !
demorstraledsotrrEsimple but i$portanl conceptsr€gad'
itrg lorceinleractions, sp€cfically!thatthemuscular systeo
worls through a series of bony levers lo either accelemtE

rigure r.47. TibiatisPosrerior.This muscleh.rsa lons lev€f

a.m 3nd an almost pependicular angle of approachlc, bolh
rhe oblioue midtalsalioint axis and subtalafaxis.iThe medi.l
mdllFolusse,ve ai r pulley <upplYFt the nearp^rpendicuh-
aoooach lo the sublalaraxis.)Tibialis potterior also acts to
c€ate a strongpostercmedialcompressive forceIhat is impor_ risure 1.48. Tibiali6 anterior' The tibialis anletior muscle
lant in stabilizingthe lessetla.sals The posteronrcdial pull of p;dd.es a srrcnBdolsiil€ctoryforce about the ankle and the
tibialis posleriorit balanc€dand reinforcedby the posterolal' tilst av des. lt potsessesa mod€rateleverarm for supinitrn8
eral pull ol peroneuslonS'rs Tibialis Posterioralso possestg th€ lofl,ritudinalmidtalsalioinl axis .rnd a rhoder levet arm
a small but significantlev€rarm for prodLrcingplanrarflexion for 'upjnalrnBlhe {rbtalar ioinl r\is. Be.dutc its lerdon {re
at thc ankle joint. OM./A= oblique m;dtarcal,oint axis, aM./A querrly passesdirettly throuSh lhe oblique midtarsalioinl
lonrillldinal midtarsaljoint axis, SI/ axis = subtalarjoinr axis,it is unableto prcducemotion aboutthis axis.sTJaxit=
- subnrlarjoid axi!, rM./A= Ion8itLrdinalmidtarsal joinl axis
 Chaprer
One Structumlard Fufttionsl Anrlonr of rheFoorandAnkle 21
PeroneNlon8us.In additionto its alreadydis-
of slabilizingthe lessertaruals,rhe pe,oneus
i5capabjeofEenerrtinSa powerlulpl.ntrrflec.
lhe fid ray axie.(_theperonealSrooveof the
a5 a pulley supplying lhis muscle with an im-
of appma.hto th€ firsl ray axis.)Peroneus
B
longusis al|o .apable of producinga stron8pronatoryforc€
aboui the lonEitudinalmidlanaljoinl axis.Eecauseil5 Lendon
passesso .lose to rhe ankle atis, it is unable to prcduce
siEniiicanlamouiis of planla lexion at that joinl. OM./ =
oblique midta|3alioinlaxis,StA = subtalarjointaxis.
FiBure1.50. Pe.on€us br€vis.Thismusclelunctionsagonis
ticallywith percneus lonSusto comprcss the ta6als.8€cause
peroneus brcvishasa lon8erleverarm to the subtalafaxi,
'5l./fu,ir i5d nronSerpronro. olrhir jo:nr.Ar5o percne,s
brevistendonpossesses a smallbu si8nificant 'he
leverarm to
the obJiquemjdrarcal joint axis(OMJA)ard i! therctore able
lo produ.e " moderdre p,onatory lo( e dbo"rrhi\ d{n
 andOthcrFormso{ Con$rvativcFootcare
22 FOOTORTHOSES
deceleral€, or stabilizelhc variousaniculationsryaiNt a
mullilude of forcos,Prinurily incnial, gravilational.and
ground-reactivc forces.The abjlily of n muscleto produc€
motionat a particularjoinl dePcndson the lenglhoJ its
leverarm(whichnav b€ iocreased via sesamoid bones)and
thc argle in which it approachesftc axis(which canbe in
provedor mrdemorc peryendicular with lhe helPofvarious
STJ axis
Ol'rlJA
riBure 1.s1. rle,(or diSilorum longus. This mlscle pos-
se;sasa lons lever arm and r n€arly perpendi{ularanslc oi
aDprcach lo both the nnkle and oblique midlarsal )ornt
axes.{Thisapproach k maintainedby the nredial malleolus
a n d su e t en{ ac ulumt ali. )As a re s !l l , fl e i o r d i Si l o ru ml o nS us
is a strotrs ankle planta.flexorand midtalsal lrint (oblique
a l i $ supinat orNot. e t h a Lth e q u a d ra tu sp l a n ta emu s c l cc:-
crts a posterolateral pull on the flexor diEitorun] lonsLrs
(whire arrod lhat acts lo intprcve aligndrentoi its lendons.
lf quadratusplanta€wers !nslable, flexot diSitorum lon8us
wolld bowstfins medially, therebv producins a sheinng
Ior.e ar the metatarsophalangealioinls Fletor hallucis
lonqtls. The lendon oI flexDr halllrcis longls Passesposte
ri o ;l o t he ank lc nx is i n . E ro o v €b e h i n d th e ta l u s . Ihi s
Brooveserver as a pulley livins lhis muscle a lone€r lever
;rm for Drod{rcinBankle ioiill plantarflexio. Becnuseits
kndon paisesclose ro the subtalarixis, it i5 onlv a mc'der
a te su pinalorof ihe s r b l a ' ,]ri o i n l Al s o , l i k e i e x o r c l i 8l l o
ru m l o nS usili is a lv on g s !P i n a to ro f th e o b l i q u em i d l arsal
pulhys, i.c-,the retinacularsh€at. peronealtubc.clc,
lcnlrculumtali,elc.).
Fi gures 1.45 1.56 demonsttal ethe rcl al i onship
wern lhc variousmusclesand dxesof the foot and
whendesigningan
This infotmationis iDvaluable
prog m lo helPstrlbiUze danag€dor hyPermohile
(NorcthatFigures1.47-1.56havebeenadapiedftom
rilure r.s2. flexor hallucis brevis. BeQuse this mL|!{le
o!-ieiratesso closeto the li6t rav axis, il is unabl€to prcduce
siBnilicanlrmouols of iksl ray plinla lexion How€ver,lhe
tend',n, ol fkxor hallu(is brcvis(onlain sa\amoidbonesthat
act :r' pulkrys10makethk musclea stronSplantarflexotol the
fi6t ,rciatalsophalangeal ioinl Note lhal the nredialrnd ld'
€ral ,ltachrnenc of th€salendonsproduc€nlmon purciiBil'
ral plane molion ol the {iEt metal.mophalanBeal joint wilh
mini,daltransveE.planeshearineof lhe hillux Thes€altach-
menl\ ako rerve to stabilize lhe first mctata.sophalar)gen
joint 5y crealinga stiongcoftrprcssiv€ {orce.Abdtr'ior halh'
cis. Ihir nruscle hrs a sisnilicant levet alm nnd adequate
anBl,.ofapproach{ot producinBplanra lexion at the firstmy
and \'.rpinational lh€ oblique nridtirrsaljoint .xes loM./Al.fie-
carn abd'r.br hallucisalso has a sisnificanrlevernm Lolha
veftl,.rLaxis of the nreialarsophalanseal joint, it i, (apableol
prodrcinS a nrong rotational comPonentin the h?neveEe
ol.nf. This abductorvforce is usuallv resolvedinto a prre
.omrftstive forc€ by lhe anhgonislicpull of adduclo.hallu'
 Cl'apler Ore Struclu|al rd FoncrUomlA||riomy ollhc Fooaond AnlL 2l

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
Fi8tre 1.5s. trnbrlcal€s. The iour lumbricalemusclesori8-
inate fmm ilexor digitorum lonsus,passinsmedial and infe-
rio. lo rhe vertical and lransvers€metataroph,rlangealioint
{MIl) axes,respectively.fheir tendonscondnue on to wrap
around lhe medial shafto{ the proximalphala.x, siving ofr a
smallattachmedoo the nr€diodoBalaspectof th€ headof rhc
prcximal phalanx.The final poini of atlachrnentforeach lum-
bri.ale is on the lateraldo6al shaftof the dirlil phalanx.The
medial Dasrag€of lhis tendon around the ve ical met.taF
sophalangealjoinl axi, allows for a mild adductorynronrert,
allhouShjt5 primaryaclion ls to riSidly extend the dirtal rnd
intemediatephalanges(th€ tendon passesdors.rlto the rrans-
ve6c axes)while (realinB , simultaneouscomprcssiveiorce
,l lheseioinls. Becaus€il! tendon oassesinlerior to the kans-
ve6e metar.Fophalanscalioinl axis, il is also able lo plan-
rarflcxthe Drcxiinalohalanr.
MC, Odon WP. WeedJH. NormalandAbnorftal Funclion
of the Fool. l-os AngelesiClinical Biornechanics,1977.The
inleresied reader is cn@uragedto refer to rhis te for a
moredetaileddiscussiooflheseandothermu$les.)
References
I. SubotnickS, Joies R. Normalanatomy.In: SlbotnickS (!d).
Spons Medicine of rhc tlwd Eilretnily Ncw Yo*:
ChurchillLivingsrone.1989:75.
2. RootMC. OrionWP. WecdJH. NonnalandAbtro hal Fuor-
tiodof theFml.l,os AnSelcs:ClinicalBioncchanics,1977.
3. llaris GF. Aialysis of anklc and slblalar nrction during
humanlo(])noiio.. In: SrichlJB (ed).lrynar's Joinlsof the
Artle. Ed 2. Ballimorc:Williams& Wilki6, 1991:7J.
4. Hicks JH. Tle me.hanicsof the fmr. I. The joinr.. I Anal
1954:8E:345-357.
5. BarnerrCH, NapierJH.Thc axisof rotationon lheantlcjoint
FiSure 1.56. Intcr6!.i, The tendonsd
s€veninterosseimuscles(therca€ fcur
pass
sal and lhreeplaniarintercssei)
closelyto lhe transvcEcmetatauopha
i,,inr {ML, .rxc, ,rndaru rherefole
able
exed a mild pl.nladlectoryforce al
axes. However, lhei. tendons
siSnificant
lcverarns to the !€di.al
,ophalan8ealjoim axe, that therebyillow
the de\€lopmenrof eq0atlysltun8
torv/abductorv
mom€nt!.the5emom€nB
rcsoh€d inlo a compresive force
for hansveEeplane stabilizat'on of the
rnetitaFophali,4eal joints.
in mao.lts infuenceuponft€ formofde tals d lhenobil.
ny of lhe fbula. Anarony 1952i86: l-8-
6. Wyllo T- Thc dis of thc !trklc joint md irs imponanc€in
\dblrjaraitbrodais.Ada OrthopScand1963:13: 320-3?8.
7. l-uidbcrgA, Svensson OK, NcmcihG, cr al. The dis ofrut .
riotrof rhedllejojnt. J BoneJoirl SurgI989;71B:9+99-
8. lrman VT. RalslonJH, Todd F. Illman Walking.Baltjmor:
\Villiams& Wilkinr, 1981.
9. I ambrindi c. Nc'/ opcrationon drop fool. B. J SUB I97;
l5: 193-200.
It'. IrrucknorJ. Vadarionsh thc humansubularjoint. J Onl$p
sporlsPhysTher1987:E:,lE9-494.
11.I:lflman H. ManterJ. Thc clolutionot fic hnmm fml. eirh
ripecial referenceto ih€ ioints. , Anat 1936i70: 5H7.
12.hnan m, MannRA. Biomehani6 of lhc tml ard atr](le.lil
Mm RA (ed). Duvrie$ Surscry or ihc Foor.Ed 4. St. l,uis:
( V Mosby,1978.
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

9a rl{uv PrBlooJ rqt Jo{uotsl lBlolrnnf, Pur lBJ[prqs auo FdRqJ

 ChapterTVvo

Ideal Motions during the Gait Cycle

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-

4tA- 62%, ol one lull gail cycle

o% 67o,t,-1@'h _% ol ltam? ohas€
HS I]L TO

+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.

prelental h€elstrike arv,i " obliqucmidtarraiioint

Figure2.3. ldealioint !|o$itions axis;ti4.lA,lon-
BilrdinalmidlaGaljonratis.
 Chapt€rTwo Iderl MoaioB durir8 the GelaCycle 29

figur€ 2.4. Anlle plantarflexion

durinS €arly and midcontact period
is r€sistedby ec.entric conlractioo
of the ant€.ior comparlment mus-
cles (atfow in A). Approximately
40% of the way throughcontacl pe-
riod (B), the tifth metata'sal head
strikes the ground. The forefoot is
then smoothlyloaded from late'ai ro
medial with the entirc lo'efoot mak-
jng arcund contact apprcximately
70% of th€ way throughthe conlacl
period (C).

ginglymusjoh! inlemal rotatiodof the tibia is a neccssary

prercquisitefor lnec flexion (Fig. 2.7).Flexionof tho kree al-
lows lhe quadricepsmusculaturemoretime !o dampenimpacl
forces,lherebylcssoningthepotenrialIor injury.
In additionto its rol€ in shockabsolption,subtalar
joint pronationis alsoessential for sudaceadaplatior,as it
allowsfor an addodrangeof midtarsal joint notion by irn"
proving the alignmeil of the ralonavicularand calca-
neoeuboidaxes (Fig- 2.8). Phillips and Phillips (13)
demonstraledthat this parall€lisrnof axesproducesan addi-
tioral 11.6degreesof midtarsalmotiotr(whichoccurspri
marily abou rhe obliquemidrarsaljoirr a s). This added
rangeof motionallowsfor an improveddeflectionof th€
nedial longitudinalarchthat is €ssentialfor shockabsorp-
iion and surfaceadapratior.Ker Et al. (14) also note thar
defleclionof tbe m€dialarcbprovidesa naturalenergyre-
,J, Subl,alar,oinI pronation causesthe talus to tum mechanism in which approximatcly17 joulesof en-
planlarfler.
orgy are storedin the slretchedmusclesand ligamentsof
lbe afch (primarilylhc planlarfascia,lle long ,nd short
Thesecombinodt{lar motionsallow for sbock plantarligaments,and the sprinSligament),only to be rc-
vislwo distinc(mechanisms. lurfleddur;ngthe lalterhalJof stancephascin lhe form of
talarDlantarflexiotr dir€c0vallowsfor shockah- claslicr€coil.The authorscomparcthis to a bouncingrub-
results in a loweringoftho anklemonise(Fig. b€r ball andclaimthalenoughstrainenergyis sloredin rhe
tionmarkedly r€duces impactforcesby aliow- archto mak€runningmoI. efffcienl.
musculature more time to dampenthe lhroughoulth€ contadpcriod,the midtarsaljoinlre-
. Thisdemonstrai€s an importaDlconcept mainsproMtcd aboul ils obliqueaxis ard supinated(in-
dissipation of Ibrces:lcssforce will be ab- ve(ed) about its longihdinal axis. Theseposirionsare
lissueswhen tbe forcr is absorbedover a mainhinedinilially by lensionin lhe anteriorcl)mportmonl
of lime.An snalogous actionis se€nwheria nusclesas th€ycccentrically conrracrin an atremptlo de-
calchesa lastball-lf rhc playcr pulls his celeratcplantarflexion of the ankleafterhecl-strjke: eccen-
bisbodyarlhe momentof impact,lessforce tric contraclion of tibialisanteriorinvertsthe forefoolaboul
d by the player'shand.If the samefaslball lhe longiludinalmidtarsal joint axiswhileeccentricconlrac-
th thecatcher,s elbowslockedandhis shoul- lion of exlensordigitorum long s and peroneustenius
forceabsorbcd by the handwould markedly pronateslhe forefootaboutthe obliqucmidrarsaljointaxis.
tentially producing injury)asforcoswouldnow Oncethe plantarforefoo! coolactsthe surface,ground-reac,
h a shorter p€riodoI time. tive forcesacl to mairtain the nidtarsaljoint io irs fully
joinlpronalion alsoiodirectlyallowsfor shock pronaledpositiorabourtheobliqueaxis(whichnow hasan
thBrdfucting talus intemally rolatesthe tibia, inereased rangethanksto sLibtalar pronation)and its flrlly
tie kfte to fle,{; i.c., the kneeis nol a pure invenedpositionaboulits longitudinalaxis.
30 FOOT ORTHOSESsnd Other rorms of Conseflalive FborClre

fiSure 2,5. Anterior vi€w of rhe rilhl talusand calcanec.

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.)

Figure2.8. Ant€riorvi€wofthe r;ghtlalurand.:alcanous. Notethep:[allel;sm of thetalonavicular

rrNJanrlcnl.aneoLuboid (CC)jointixes a\ theslbtnlarjointprcnates.

EL- 8tt7
Sublalarioint pronationbringslhe inverted phas€
d'e Srounddurint the.ontacl periDd.
Forward rnoiion of the swing pha* leg exler"
slancele& whichin lu.n supinat€s the sub-
nn (15)empharizesIhe rcle Ihe adducloE play
I rolalionof the nance le8 by noting that doGal
nl to lhe rnlerior pelvis and poster,or den approximalionof the calcaneocuboid
lhetemusclesto act e eifecliveleverarms ca-
in8 lhe roRard momentumot the swinBing thc variousrestraining
rotalionofthe nance leg fem0r
Chapter
Two Mo(ids durirg theGlit Cycb 3r
.ld8l
Noticeh Figure2.9the forefootremainsinvertedap-
proximately8" to therearfootthroughout lhe contaclperiod
andlhe medialforefoolis hought lo thegroundvia contio-
tledsublalarjointpronation. Manr el al. (15) claimlharrhe
€nal rangeof subtalarjoinl pronationavailabledur;ngthe
contaclperiodis limited by, ir order of imponancc,the
congonitalplacemeot of the axosof the subtalarand mid,
larsaljoints,thegeom€rryof theirarticulating surfaccs,
and
by theirconrectjng ligamenls. Apparently,thernuscles play
a relatjvelyinsignificant
role in liniting subtalarpronalion.
Midstancc Period
Midstanceperiodbeginsat full forefoorloadandendsat
heellift- lt is the longesrperiod,occupying407. of srance
and lasdnB approximately 0.24 seconds (3).
Throughoutthe majorilyof this period,the subtalarjoinris
maintained in a fully prollstedposirion.However,asgrouod
react;veforcesbeneaththe heelbeginro lessertowardthe
endof midstance, th€sublalarjoinrbeginsro $upinare astbe
foot atempts to cooven hself from rhe mobile adaptor
necessar) during the contacrperiodro rhe rigrd laver
necessary for thepropulsive p€riod.It partiallyaccomplishes
this task by takingadvankgeof the forwardnomenrumof
thecontrrlateral lowerexremiry:tbeforwardmomenlumof
the swing phaseleg externallyrolatesthe pelvis (whirc
anow in Fig.2-10), which then erternallyrotat€sthe
weighl-bearing l€g(blackarrowin Fig.2-10). Sincethe leg
andtalusbeh.veasa clos€dkineticchainduringmidstance.
exlernalrotaiionof the wei8hl-bearing leg causesthe talus
lo abduct,which in turn supjnat€sthe sublalarjoinr. This
motion helps stabilize rhe tarsals by decreasingthe
parallelismof the midlarsaljoinlaxes. All of theseadions
are assistedby variousmuscular;nteractions rhar will be
discussed in moredetailat $eend ofthis sectiox.
Shonly after the end of midsiance,the subtalarjoint
sholld havesupinatedbacklo its neutralposilion,i.e.,the
headof thetalusshouldbedirecllybehindthenavicular.ln
orderfor this to occur,the midkrsaljoint muslpossess an
adequate rangeof eversionaboutits longitrdinalaxis. To
underslandwhy this midtanal motion is necessary. try ro
picture lhe following events: As the subtalarjoinl is
supinating,rhe enrirefoot is inverting. Sincebody weighr
maintainsthe medialfoot on lhe ground,inversionof ihe
rearfootcanonly occurifthe medialasp€crof the forefoor
plantarflexeswhile the lateral aspect of the forefoot
dorsiflex€s(se€Fig. 2-I | ). This motionoccursaboutrhe
Iongitodinalrnidlalsd joint axis and constilutesevercion
aboutlhal axis.
Idoally,de midtarsal joitrtwiil allowonly enoughmo-
Iion for the rearfootto reachvertical. At rlal time. thc fore-
fool will hopofully"lock" againstlhe readootas the superior
borderof the pronalingcuboid comesiflto contactwilh the
bord€r of O€ overhsngingcalcaneus(16). Ilis sud-
joint representsan
oss€ous lockingmechanism thatis maintained by tensionin
ligaments. Continuedmotion,cithcr
subtalarjoint rupinarionor midtarsal joiol pronarion,is nor
 andOtherFohs ofconseryativeFoolCarc
32 F1]mTORTHOSES

figure 2.11. Posl€riorvi€w ol lhe riShtJoot The foreioot

compeosates for subtal ioint supinalionby e\cdingabout
nridtarsal
thelonsiiudinal iointaxis.

late nidstarce Earlypropulsion

Figure 2.t2. ldentifyinSlhe midtatlal ioint

locldng po3ition. One hand maintains the
headol the talusdirectly behindthe navicular
whil€ lhe opposit€ lhunrb doGiflexes lhe
loudh and fihh metatalsalheadsto the point

po.siblewilholl olerwhelmingthe restrainingligamenls less effective propulsion. the unreslrainedrang€ of

andsrbhxatingthecalcancocuboid joint (2). latsil eversionis invaluablc in the graspingof ob.iecls
The osseous lockingof the forefoolagninstihe rear- asrrcebranches. Evolutionof lhe foot requitcd
foot ar thc calcan€ocuboid joint is a nec€ssar!prercquisrte of the calcaneocuboidjoint as functjonal n€edsshifted
for nornal gaiLasil minimizcsmuscularstrainby ailowing wardsa faster,more efncientpropulsivcperiod.Of nolq
for a smooth tnnsfer of accelemtionalforces through a Basmajianand Tutle (18) refer 1()a possibleosseouslock-
lockedIaleralcolumn(17).Basmajian andDeluca(5) slaled iDg nrcchanism presentin the wrist and handsof Af can
that musclesshouldbe considetedonly as a d!'Damicre_ apes.If present,this lockingmecbanism wouldexplainthc
servefor stabilization, as they cannolprovidethe supporl minrtualactivity present in the forearm du ng
nusculalufe
afiordedby a well-d€signed skelelalsyst€m.Fail$e ofthe poriodsof knuckle\talking.
calcaneocuboid joint lo lock into ils close-packedposition Clinically,lhe lockingposilionof thecalcaDeocuboid
wouldresultin a shiftingofthe larsalsasve.ticalforcerare joinr is easilydeleffnined by placingthesublalar.ioitrt
of tte
rrandeffed from re3doot to {orefoot afler heel lifi occur\: prone patientin a rcutral posiiior and applyinga fun
the fool would behaveas a flexible lev€r arm Oat js, of do^rflectory forc€ to the fourlh and fifth heads
metatarsal
course,ineffective i]1the tra sfcr offorces (Fig. 2.12). Thi! dorsiflectory force duplicatesthe aPplica'
It is inlerestinglhal the feel of lowef Primateslack a tion of ground-reactive force durin8early propulsion.nd
midtarsailockingmechanisn(16).Whil€ this makelrfor a give\ lhe examinei an accurite piclure of the forefool/reaf'
 Chrprc,Two lderl Molionsdul6gthe Grlt Cycle 33

. Aslh€ankleplantarrloxesduringthecontact movsmenlls secondary to forc€splacoduponlho tlbulaand

libulashillsanleriorly
andintemallyrotatesan
lamoonl.How6vsr.duringlats midslance/eay
lhe tlbuladropsinleriodyapproximatety
2.4 mm
allyrolalesss mucha6 3.7 degroes(31). Thls
inlerossoous m€mbrane bv acllvo contreclion ol the
p6ron€i,tlbiallspostoriorand tl€xorhellucislongusmu6cles.
Th6 downwardfiovemenl acts to stabillz€th€ anklo by
lncr€aslngthe depthol the mortis€.

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

Figurc 2.14. Hc€l Iift .esull6 from A

the combined aclions of rh€ forward
momentrm of bdy nass (t), muscn-
lar d€celerationof ankle dorsiflexion
(2, and active flerion of lhe knee
produced by Sastrocn€miuscontrrc-
lion /3r. Note that Pane,a js for puF
posesof .lcnDnshiion only as heel
lilt should normally occur qith 8as-
rrccnemiusactivelyilexinCthe knee.

Flgure 2.15. Ertemal leg rolallon (A) acts to

suplnate thc sublala. tolnt (B) while
slnullanrously 6rpinating lhe forcloot .bout the
obllqu€ mldtaleal lolnl o116 (C). These molions
increasearch height(blacka ow), lherebyslabilizingthe
various aniculalionsol lhe mldloot.

cis)andby whatis knownasthewindlasseffeclofllrc plan-
dorsiflexionof the ioes afterheellift dtawsth€
tnr fa.scla:
plantarfasciaaroundlhe metatffsalheads, whichac|sto pull
the anteriorandposteriorpillarsof the longitudinnl nrchIo-
gether(Fig. 2.16).This approximaionof thc rearfooland
forcfool allowsfor eontinued supinalionabort the oblique
rnidrJsaljoinl axis with ils concomitanlinc.easein arch
heighl.
Whilc considcr|bleskbilhy is affordedhy the in-
crcr\cdarchheight,thefoot couldnotbe considered a dgid
levcrw€r€it not for thc conlinuedfor€foolpronationtltrout
rhe bngitudinalmidtarsaljoinl axis.D0ring earlypropul'

Ihe windlasi effecl of $e olanlar fascia. DlF
perlod, gruund{eaclive forces arc
lo€s,which acts to draw lhe plantar lascia
head5(A). This aclion rcsuh5in the ap.
€adoot and Ioretool(B) and allows for thc in-
for stabilny(C),Theamounrof
heightnecessary
by lhe plantarfasciais directly relatedto thc
n lhe lransverseaxk of rhe melatarsopha-
andthe passaSc ol the pl.nlar lascia:lh€ Srearar
Sreatarthe pull placed upon lhe planlar fat
doBillercs.for example,lhe av€ra8eless€r
an alecce oi 8 mm betweenils transveBeaxis
oi rhe planrar fas.ia (D) whila the [i6l
boidlockingmechanism is maiotained
ion of the soleusmusclc,which is si-
theankleandinvcrtingthesub-
ankleDlantarflexionallows for a forward
of bodymass,subralaljoinr inversionallows
forces to dorsiflex the fourth and fifih
lockinglhclateralcolumn.
of thcsoleusmusclein mainraining
lockingmecharsm is only temporary,as
the mngeof anue planhrfledon places
a shortcnedposilion $al is uMble to gen-
forceto invertlle calcareusandcanthere-
lnainlainthe midtarsallockingmechanism
lheconlinucdforc€fu|contraction of per-
CbaptcrTwo ld€il Molioor durirg the Glll Cycle 15
F
15mm
melalarsrl,with its lal8er head and the pfesenceof sesamoid
bones (which the plantar farcia invesl) has a dklance ot
nearly 15 mm betweenthe lraniverseaxis and the plantarfns
cia (O (161.Ae a rcrult, doGiliexjonol the fi6t digil produces
a mu.h ErcarertractioninSeffe€ton the planta. tascialhan
any of rhe less€rdiSits{compareF and C)- ln odcr lo r€sisl
the gr€atertensileload, the plantar{asciahas its nrongen al-
laehmenldistallo (he filn metararsal head.The plantarlascia
also hasstrongatlachmenrsto the rkin beneaththe melatalsa
h€ad! (rta.), which prevent!djdin8 on the skin as posterior
shea.fo.cesare applieddu.ins lhe prcpulsiveperiod{16).
oreuslongus(whichpassesbeneathlhe cuboidiD the per-
onealg.oove)actsto dorsiiexandeventhecuboid,thcreby
maintaining lhe close-packedposilion of thc calca-
neocuboid joint (Fig,2.17).
An important consideradonregardingthe propulsive
periodfunctionof the hte.al column is that b€causcrhe
fourthand nfth metatarsals lre shortorthanlhe remsining
metatarsals!the lateralcolunn is unableto maintsinground
contactduringmid atd lalepropulsionandis lhereforcun-
able to assistwirh lhe forward acccleratior of body mass
duringlhes€porlionsof lhe proPlllsiveperiod.lnckiDg of
the calcaneocuboid joinr ar lhis time continuesro servea
pulpose,as it affordsperoneus longusandbrevisan cffec-
tive I€verarm as they now funcrtion lo directbody w€ighl
36 FOOT ORTHOSESatrdOther Foms of Conscwatile foot Carc
Figor€2.17. Concentriccontractionof peroneuslongug
during€arlyand mid propulGionservesto lift (dorsiflexand
evert)rhecuhoid,the'ebylockingthemidtarsalioaDl.
Pronated
Figore2.19. Th€€ffectof subt lar posilioningon peroneus
longusfuncfon.Wh3nthe subtalarjoint is p'onated(A),the
n€arlyhorizontal .n8leofipproich nfiordedperoneus lonsus
ajlolvslor the produclionof a strcn8post€rolateral
compres-
sivelorce{/) andn mild doGi{leclory forcerboul the iirslray
mediallytowardsthe oppositefoot by eveningthe entirc
lateral.olumn (Fig.2.18).This medialshi{tofbody weighl
is necessarv to maintaina simightgait patternafldlo allow
the final tran$fcrof verticallbrcesto mcur off the medial
forcfoor,whichis bet€r €qxippedto handletheseforces,as
thefirstmetatarsal ii twicc nswideandfour timesasstrong
asanyof theolhermetalarsals (21).
BecauscofiLs passage undertheeuboidandevenlual
inserlioninio the baseof the lirst metat.Jsaland medial
cuneifom, peroneuslongushas rhe inleresti€ ability to
ransf€r body weightmediallywhile sirnultancously stabi-
riSure 2.18. BecaulcoJ dteir short€.slatur€,th€
metrta.sall€av€slhe groundapprorimalely 33%of lhe
through lhe propulsive pe'iod wift rhe fourlh
leavingshortly thereaftcr (20). At that time, .c,ntinued
tfa. ion ofrhe lateralcomparlmentmusculaturese.v€slo
bod! weight medi,rlly towards the opposile ioot
whl, h is just be8innnE its contactperiod.
axjr /4. Ar the subtalarjoinl movesinio a proeressiv€ly
supirat€dpoiition (B aod C), Lhepost rclateral
lbrce is les'en€daJ, as lhe more verticalnpproacholthe
one,rslongustendon allows for Lhedev€lopnrcfio{ a s
planrnrilectoryforc€aboutthe insr ray axis lr).
argle of approach afford€dlhc peronealtcndonasfie
talarjoint is sut'inating(Fig.2.19).
The inprovedabiiily of peroneuslongusto Iurcliod
asa firstray plantarnexor is exlremelyimporta duringlhel
p'otulsiveperiod,asllle incrcased heightof themediallotr',
gituJinalarchcoupledwili lhe normalparaboliccune otr
the $etatarsalhe€ds(i.e.. the frrst metAlarsal is mrmally
shortertbanthe secondglel"larssl[9]) necessitat€s thal$e
firsr r y activelyplanlarnexin order to mainlaitrgru$[d
 chapterTwo lde{l Motlol! du.ln8 tb! Grll Cyclc 37

a(hiriorlo lheobviousimpoftnce of maintdn- push-ofi By ev€rting the laterai column, peroneuslorgus

@nlactso 3sto resislgmund-reactiv€forccs, ac- allows the final lransferof body weight to occur throughthe
ion of th€ Rrst metatarsilallows for lhe transverse axis of tle metatarsal heads(Fi8. 2.21).Useof
shifringof the first melatarsophalsngealthe transvcrse axis suppliesthe ankleplartadexorswilh a
axis that is necessaryfor the hollux to longer and more gffeclive lever arm for acceleratingbody
range0165"dorsiflexion (Fig.2.20). massforward.Failurcof p€roneus longrsto evcrtthelateral
actionsof peroneus longu$asan ever- columnwouldallow for conlinuodsupinaliolof the subta-
columnand a olant&flexor of thc first lav larjoint vrirhthefinal push-offoccuringasa rollingacrion
Bojscn-Mollcr (16) refec to as a high gear rhrough lhe oblique ards of the metatusal heads.Because
tbe oblique axis bas r sholtor lcver arm to the ankle axis
(lheobliqueaxisis 15-20 closer|o lhe ankleaxistbaothe
transvcrseaxis), it allows for a lessefdcicnl propulsionthal
is rcferred to as a low gear push-oft Bojsen-Moller (16)
statcsthat use of the transvers€axis via percneuslongls
contraction reprcsenlsthe final evolutionary changein the
proccsJ,of producinga fasl €fficienlpropulsion.
During the final portion of rhe propulsive period, the
foor will ideallybe supinatedlbour $e obliqtremidtarsal
andsubtalarjoinlaxes.Also, the forefootwill remainfully
pronatedaboutthe loogirudinalmidlar$l joinl aais.This
axisis mainlained in a pronated positionduringlalepropul-
sion as extensordigirorumlongusandperoneus tertiusare
vi8orously contractingin preparationfor lhe swing phaseof
gait. The final lransfer of forces should occur th.ough th€
hallux, which hasbeenslabilizedlhroughoul the propulsive
period by vigorouscontractionof ffero. hallucisloogus.Th€

B€c.ule the firsl metatarsal ie normally

tfte s?cond m€trtaB:|, it musl actively pl.n-
lo maintiin Sroundconrad during the
(A).Ar thetnn metataBal planlarflexee,
lhe
td Bl;desposleraoiyalons lh€ ,esamoidrfal,
fora doBalponerior sh;fioi the t'ansveGe
axit
halan8ealjoinl 1C.,.
Ihis new.xis allows
rin€dran8eofhallu doAi{lexionrD).failurcof
llo plantarflex
duriB propulsion
r0 inhibits
ide of the metatarsnl head on n5 sesamoid1F),
oevenlslhe don?l Dosle,iorshifi of lhe lrdns.
Ilte hallux i! now for.ed to doGiflex aboul rhe
{6,/.Thisrusultsin a "jammin8"of the dorsalca.
ils characlerislicrcsolPlion ot subchondral
lippins ol lhe fnsl metalafsalhead. The in-
of hallux do'riflexion dslocialed with fil'(
ntadlexioncan be dedonstratedon yolrrelf
itin8yourforefoot andnor
{off.weisht-bearinS)
Repeatlhe measurcment
oi halluxdorsiilexion.
fully inveded (which dorsrfleieslhe fnsl Figure 2.21. Thc transvers€.nd oblique ar€s of the
notelhc ma*ed decreasein molion melalarsal
heads.
38 FOm ORTHOSES
andOlhcrFormsof ConseNsliv.
IJoot
Cure

cnlhe lower exLremilyha\ conlinuedto exrcmallyrotare

propulsion
ihroughouL xndintotheswingphaseofgDit(1).

SwrNG PHASEMorloNs

The swingphase.whichbeeinsat roc oli andendsal

heel-strike,occupies 38%of tbcgaircycletlndlastsapp('xi-
mntoly0.4 scconds(1. 2). Th€ primaryfurcrionof lhc foor
andanklcduringthisphaseislo allowenough dorsinexion for
the fbreibol lo clear the groundby midswing.tnd to posilion
fie anicuiationsso the supportingnrusculalurcmay moreci-
f€clivelydampenimprctlorccsa.rthencrl hc€l'stnk€ occurs.
Apparenlly,,s dcmonstrated with infanLr,neuromotorcontol
of swingphrscmotionis instinclive
cxtremityduringslance
Duringcarlyswingphase,
whileconrrolof tlrclower
phaseis n leam€dresponse
groundclearaDc€
(22).
of thefore-
ii
it.
lbol is producedby forccful contractionof the muscleslhat
ffcxtheknceandhip andby concenlric contmction ol rheaD-
€rior compartmcnl musculatunr (which,as mentioned, begin
co ncting duringlate propulsionin preparalion lbr swing
phase).Since lhe ankle rerchesils nnximally plantarndx€d
positionshonly after lo€ off, lhe anteriorcompartnentmus-
cleshavclessthan0.2secords10overcome inenialforc€s
dorsinexlhc forcfoor into a safb positionby midswing.Be- Figure2.22. DurinS€rrly swingphas€,lhe lateral
€auseextensordigitorum longusand perc euslefius re the of e\tensor digitorum lon8usand peron€usterlius
pronnrethefor€Jool(4) whiletibialisanter;or,ir additi
firsi snteriorcompairneotmusclesb conEact(2). the f(ml, in
dorriflering th€ ankle, acliv€ly dorsiflexes and inve.ts
additionto dom;flcxing at theanklc,willimrnediately pronatc firsr ray (4, lher€byallowingfo. improvedEroutrd
abour!h€ obliqucmidtirsaland subtalarjoint axss.(These
musrclcspo$e,sssigoificant lever arms tbr prcnating rhese
xes.)The do$ifleclory c.omponents of lhcsc pronatorymo-
tionsassistlhe dorsiffexing anklein allowingfor inrprovcd Shortly after the forefool has clearedlic
musclesoflhe swingleg havea relnLively quietpcriod
ALmoslimmediatelrrfter extcnsofdigirorumlongus ing whichmolionis maintained by inerlialtbrces
nnd peron€us ienirs contrad,libialisanteriorandcxtensor dun,rgpropuhion.,nd edrl) !$ing (s). Jusrprio,ro
ni lucis longus begin contmcling.therebymarkedlyin- stril.!. lhe anreriorconrpartmcnr musclessimu
creasinglhe dorsiflcclorymovementcreRred at rhc ankie. conrracrin anlicipalionof dampeninB Lheinpttcl lorccs
Root cl rl. (2) claim thar extensorhalhrcislongusis the sociiledwilh theconlrctpe.iod.
sl.ongcslankledorsillexorduritrgearlyswing phase.Tib- Becauscof the; rclationships wilh the various
ialisanterior.bv virtueof ils insertionon {helirsl mctrt rsal ribi,,lisanrcrior
undc\rensor Jigirorum longnsproduce mi
and medialcuneiform,irlsoactsto inprovc groundclear dorsifle on al the anklc,with libiaiisanleriormarkedlyi
anc€bv dorsi6exinglhe lirst ray duringerrly swingph&se vcrLingthe forefootwhilc cxtensordigitorumlongus
(Fip,.2.22).Notic€ in rhis illusmtion how tbc forclbot is pcl ,ncu\ l crl i u\ a(bi sl$i l h ankl edotsi R (ri onrrd
nraintrinedin an evcrtedpositionnbout tle longitudinal of tre forefoolahoul the obliquenidiarsaljoinl a s.0l
rnidlarsaljoinl axis during crrly and midswingphaseby notc,Basmajian and Deluca(5) statedtbattibialisanlelbr
conliruedconlr.ctiono[ 0xlensordigitorumlongusandpel- actsis an ankledorsiffexorduring€aJlyswingphlseandan
oncuslcrtius.Thc dorsiflcctoynolioD of lbe first my, nr invertcrof lhe for€foolduring lrto swing phase.By posi-
additionio improviflggroundclearance, RIsoserveslu cn- tioningthe foor with thc ankledorsiflexed,lhe lorefootin-
hancelhe etficiencyol extensorhalhcislongrrias an anklc vcard, and the subtalarjojrl slightly supinated.lho
dolsillexor.as n resuhsin m anLcrior/infcriof shift of the prc Lcns{:dmusclesof thc foot a lcg rre now pr€par€d to
tirstmerararsophalangeal joinl s rransvers€rxis (Fig.2.23). clf€clivclydampeDground-reactive torcesassociat€d lrith
tsy lhe time midswinghas occuned,the llokle is stan.cphase.Ir is inreresdng thal wilh sprintrunningand
dorsiflexcd to a ne3rneutralposition;the subldarand rnid- anti(ipatedfalls,olhcrshock-abso$ing muscles(gastrocne-
tarsal joints are pron?ted($e midbrsal joint is pn)natcd miu\. vastuslatcralis,gluteusmaximus,elc.) hecom€fiy-
aboulbothaxes)tandlh€tirslray is dorsiflexed lnd inverled. ncracrivcpriorto hecl-strike
astheyprc-tense in a effortto
TheseL:olnbined actbnri.wh€ncorplcd wilb kn€cand hip dftmlrenmoreeffeclivclythc perceivedincrcase in ground.
nexion.allowfor rnarimumamounls of groundcle&ancc. rcacliveforces(23).
 ChapterTwo fderl MotioN du.io8 th. Grit Cycl. 39

Jit!.e 2.23. Dor.iflerion of the

first r.y by ribialis anlerior (A) sfiift3
lhe firsl m€larariophalanS€al ioi.rl's
transv€B€axL bacl lo its o.i8rnal
positioo fbhcl dol) thercby limitin8
tfte r.n8€ of hallui do'sifletion pos-
sible,i.e., only 35' of doEiflexioa
are aviilable aboul the new axis.
The plantadlectory morion of rhe
halluximproves thc etiicicncyof ex-
i€nsofhallucislon8u, as an ankl€
do6iflexorby srabilizinS its insertion
on rhedisblphalanxl5rar.

ANTSOF 'I'HE GA|T CYCLE lion, as themusclcswouldbe forc€dio accommodate thesc

allgulardisplacements. Furtherstrainwouldbc placedon lhc
ion1()thepreviouslydcsofibcd aclionspresent supponingmusclosas they atlempr!o absorb,lhenacceler'
cycle(e.9.,shockabsorption. surfaceadapta- ale,theseforc6 astheexaggeral€d cuwcsrcvcrsedirection,
acceleration of thc ccnrerof mass,elc.),it is ln orderto minimizethemetabolic co$ of locomotion,
fiat de bodymuvethrougheachcyclewith cachpersoniocorporalesspcific acliotrslhal effectively de-
coordinatcd structuralinleractions
that creasezngolardisplacemenr of the My's cirnterof mass.
musculars(rain.lr is for this reasonthrt Theseaclions,or delerminarts, rJe listedas followsrpelvic
al. (24Jreterlo lGomorionas "$e translation rotation;pelvic till; knee ll€xiorvextension during slance
ot na\s throughspacealonga palh requiring phase;hip-knee-aokle inl€raciionsiand labral pclvic dis-
turoofenergy." placem€nl. The followingilluslralions,which wcrc adaptcd
iixomDle. il an individualwcre lo walk with the from Saurderser al. (24), demonstrai€ how cachdetcrmi
andlhepelvisstifl thebody'sc€flterof mass nanteffeclstranslationof the centerof masslhroughspace.
ltouBh a sericsof abr0pllyinters€cling arcs
8rca y incrase rfu mctabolic cosrof locomo-

.--..-. -l'/1

telvic rotatio.. Panel A reprc!€nGa lal€ral
cycle wilhout oelvic rutationwhile Pancl I
mtationfarrowsJ. Nolice lhat he€hl X in A
fa.iShlv in A as rolalion oi the pelvis in 8 de-
nl of hip flexion/extcnrlonnecassaryto
achievethe sameskid€ len6h {W). This in lu.n dec.eareslhc
ver(ical drcp du.in8 doubl€limb suppon by app.oximately
l/8 inch, which efiectivclyflatGnsthe pathwayfor thc center
ot nass lM2 vs. Ml).
40 FOm ORTI]OSES aDdOlher Foms of Cotsrvstivc Fool Care

Fiqure 2.25. Pelvic tilt. Ecc€ntic

co;traction of tlre hip abducto6 dur-
ins midstancelowe6 thc P€lvis on
the side of the ,wing leE larrow5In
B). This decreasesvedical dhplace'
ment ol the center ol mres by ap'
proximately1/8 inch.

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|

Figur€ 2.2a. Ialeral p€lvic dis-

placemenr.ln ode. to mainlain bal

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,

It X). lf the lower extrcmirywere per

fecrlysrraishi(as in PanelA), the de'
grce of lateraldeviationnecessaryto
mai nl ai nbal ancek si gni fi canll.his
markedlyincreare,woftload placed
on thc hip abduclorsand percneals
as thesemusclesaltemptto a.celer
ate ih€ cenier of massmedially dur-

NT
ing late midrtance and early
p|opulsion.Fortunately.mosl people
possessa slisht de8reeof Senu val'
Blm lcl lhat minimizesthe de8.eeof

nl lare'al displacementby allowinB for

a morc approximatedbase oi Sail
/Y). A rnild genu val8um also allow5
the tibia to move throu8h rhe Sail
cycle in a near ve(ical posilion
(Panel8).
42 FOOT ORTHOSESand Olher Forns of Con$wativc Footcdrc
Figure2.29. Finaltrrftlation of rhe centct of massdurinSa
singl€rtrlde, Laleraland verticaldlsplac€menB are rcpre.
eentedby A and B, rcspedively. NoticeIhal thesedisplncc-
menlsare purc sine wav.s, with the fr€quency of ve{ical
dirplacoment b€ingexacllytwicethatof lhe lateraldisplace-
ment. C represenls $e pro,ectionol thesedhplacemenc
(whichhav€beengreatlyexaggeratecl) ooroa planepe.pen-
dicularro the body'slineof progr€ssion.Eecause peak!€rta-
cal displaccmertiare feachedslishtlyb€forep€ak lateral
dkplacemenrs, thh curvercpreenBa elighllydasbned"lizy
eighl."At higherspeeds of walkin8(D), theamplitudeof lar
eral disDtacenEnlir decrcased,and the lat€ral and ve.tical
displacem€nts peakat lhe sametime. As a r6uL the perpen-
diculardisplacemenl ot th€ cente.oi massmorecloselyre.
,embles a "U.' Norc that even at marimal verlir:.l|
XX
V
fr, thec€ntsroi mnssneverrcach€,the
dhpracement
wolld assumedurin8 sraticsta.ce (which is reprcsa
OJ. r'o|wad acceleralionol the centcl of mass,al bolh
ancl low speedr is lrearcn at the low points of ve icr
placc,men!(i.e.,duringdouble-limb
srppo ) andleast
hi8h points(i.e.,durirs midnancep€riod).Anolher
sayin8lhk is tha! kinetic ene[y i5 grcat€slal lhe low
wh.rcas poIentialenerSyis greateslal thc hi8h poinh.
bri€r pcriods of acceleration/de.eleralionpres€ntdldnt
g.rirry.le arcdifficult lo obseryebul bacomereadily
asan iDdividual walksacrossa r(x'mwirh a tull hr)wlot
sour':lnorde.to arcid spillinSlhesoup,lhepers{,n
wili
the .rdvancintles dnecllyunderlhe centcrof mast
avoi,l'n8lhe d€relerationperiodlhal nomally occurs
rwe.nearlycontactandlatemidstance.
 Chapter'Iwo ldsl Motlon! durl4 the cait Ctde 43

SUMMARY
GRAPHTC or rHE GArr CYCLE

Urc R,IIL R,TO I.F5L

+-
12 50 62 68

Singlclimb5uFFon,
righrl.C Sjngl.linb ppon,Ln bg

lWrd of

DooblFlimblupporl rhe feetsimultaneously the lime spEntin double-limbsupportdecrcasesd.asticallya!

twicedutinsone full Sail cycle:trom rhe iodividual'sspe€dincRasesso rhat when runni.& rher€is
5H2% ti.e.,rhefirsr.ndlan l2% of sranc€ no doublelimb suppot and each sin8le-limbruppod stance
lhe filst t2%, lhe opporireleg i5 completingits phaseit followed by a bief ai6o.ne period in which neither
and doringthe final l2%, the oppsite le8 foot contacls the Prollnd.
conlad pe.iod. lt should be emphalizedthat
44 FOOTORTIiOSE,S
ia ndi

(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

(\ (\( nll. ([(\ (\

AU ELdOU AT& AU
Hecl FoI Forcfoor Hocl Toe Hccl
Srikc laad Lift off Slnte

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'

Fi8ure2.32. tront l Plnnemolions.

 ChaplerTwo ld€€l Motldts durhg lh€ Gtit Clcle 4?

Heel Full Fotefoot Toe H€el

Sldkc Load ofr Strikc

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

Itcel Full FoEfoo! Hcel Tb€ Heel

Suike laad Lifr off Srdkc

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

SIMMARYoF Muscl-tr FuNc"roN DURTNG

rHE
CArrCvrLE

( 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"'"-.'

lt " '' - ---' "-"litltil,frllr.---

l|l.'' -.rlt/t
-v ll

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

Heel Full Fonfool IIccl 'fo€ Heel

Srrike Load Lift off Suikc

Tibialis
frtilfnffilil* ll rrur-
l||lrfnrr -urrll
"".rtll

Extensor llllh,,,. lllltr..r- .-r.rrl

lrngus Tirrwl
llllftw'' '|lf llltw".-'

Exlcnsor lllx.. l l rrrr-

tongus lllwr'
"rfmylf l f tw - ' mtrtw

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

Figtte 2.34-.ont inued

GluteusMaxiEus limh suppori to single-limb supporl. Pe8k aotivily is

duri|1gtbeearlyandnjdpropulsivepenods(5),
This muscle contmcLsduing late swing and early al this dme preventsao exaS8erated lowering of the
slancephaseto decelerateflexion and iniliat€ extcnsiotrat eral pelvis as the co[ualateral gluteus mcdius (whiclt
lh€ hip (althoughit may alsomildly alsisl with qMuctiot of venls low€ring of the swing phase leg) does
rhe hip). BasBajian and Deluca (5) demonstralodthat dur- denronstratepeak activity until lhc end of the
ing terminal stance(toc of4, the middle fibcrs of ghleus proprlsivc period. Waters and Morris (2?) norcda
maxirnusdisplay a brief bursl of activily. contmction at this bust of activity dutiry the latter hllf of swing pha.se,
as
tine possibly lllows theseffhers to assistgluteus medius mu*clepossiblyrontracis to assid the wetkening
with abductinglhe slring pbas€leg. Lyons et al. (2t noted eml qluteusmediusin rajsingthc ipsilateral Pelvisin
that the atrglesof approachalTordedthe various seclionsof ratio[ for hecl-strike.
this muscle allow its low€t portions to act as hip extensoN
while the upperportions act as hip tbduciors. lnteresti[gly, GluteusMedius
Ducheme (26) downplaysihe significarc€ of gluteusmDr-
imus during relaxedwalking by noting that conPlel€ paral- Gluleusmediusis the pdmaryfronlalp,anc
ysis of this musclehasminimrl effect on gait. of ihe pelvis. It begins contracting during lale swing
conrlnuesthroughoutmidslanc€and into propulsion
niocostllis L|Imborom actility occursduring early midstanceas lhis nusclev
ouslv costracisto preventexcessive loworingof lhe
Becnuseiliocostalis is the mo$ lateral of the ercclor tralalefal pelvis (which is €ntering its swing
spime musculalure,il is able to assistin maintainirg Irontal BasmBjian aod Deluca(5) not€da briel bulsrot
ptanestabilityof the pelvisdrring transilionsfrom double' thc rnterior libers of gluleos m€diusduring loe oif;
 C'haplerTwoldeslMotlori durlnSth!Gllt cycle 53

fiberspossiblyassistswith abductingandin- constantly lhmughoutthcgaitcycle.Also, it is possiblerhat

rhefcmurdurinSearlyswingphas€. thc mor€horizontals€clionsofrhe adductors assislthecon-
tralateralswing phasepelvis v,/ilhexlomallyroladoglhe
GluteosMinimus femur dudng lhe ipsilateralmidslanceperiod(15) (refer
backlo Fig.2-10).
muscle firnclioN aSonistically witl ghteus
earlyslancephase. Thu briefbursrolactivity Ilarnstringr
ing mostlikcly allowsfor continueditrlernal
lhe ham riflgsdemonstrstc pcakactivityduringthe
tcrminslportionof swingphase,durirg whichtheydecel€r-
Tensor
Fssciae
Latae ateforwad molionoflhe rapidlyexlcndingleg.Thesemus-
clescolllinueto conlnct throughthc majorilyoflhe contact
of ils insenioninto lhc anleroproximal ili. pcriod, at which time they assislth€ Sluteusmarimus with
contraction o[ tcnsorlasciaelataedurins the deceleraring llexionandinitialingextension of thehipjoint.
actslo balanccdre forceplacedon the ili- Irterestingly,Hollinsheadand Jenkins(28) noledlhat be-
by simultan€ous contactionof gluleusmax- causeth€ distalseminembranosus releases fibrcusattach-
has lhe greatestpercenkgeof irs fiters menlslo lhe posteriorhorn of lh€ mcdiel meniscus.it is
$c posteroproximal iliotibialband).Contrac- ablelo prev€ntimpingement by drawir8the medialmenis-
fasciaelara€duringcontactp€riodtherelorc cusposteriorlyasthekneenexes.
ior displacerncrtof thc band and supplies Wilb regardto propulsivepcriodactivity,Basmajian
!s wiLha stableinscnion.Tensorfasciac and Deluca(5) clain that in someindividualssemitendi-
duringlatc propulsionard earlyswing, nosusdemonstrates a mild burst of activiiy during late
il dcmons[ales its grcalestactivilyas i1 as- prcpulsion,when it may act lo assislgastrocnemius with
with flexingthehip. flexingthe klrce.Ellior and Blanksby(29) rcled thatwirh
running,all of the hamstringmusclesmaidajn higb levels
lliopsoss olacrivity duringth€propulsiveperiod,whenthcyfunction
aspowerfulknee flexorsatrdmoderate hip cxr€osors.
musclcdemonslrales peat activilydur-
andearlyswingphasc,duringwhich it eusdrlceFi
lensorfasciaelatae,r€clusfemoris
wilhflexinglhc hip. Thc quadriclpspre-tensc duringlateswingphaseand
lhatthc momcrlumgainedby rapidlhigh demonslmle peal(activityduringlhe early contaclperiod,
carlyswinSphas€may play an imporlanl dlring which time they forcefully contractlo decelerate
acoeleralionof lhc cenlerof massduring knft flcxion.Thesernusclesconlinueto contractuntil the
(1s). ccntorof masspassesin frcnl of thc knee(1). A brief ard
les$forcefulburslof activityis seenduringlatestarceand
S{rtorius earlyswingphaseas rectusfemorisacts1oassistwilh hip
llexion(parricularly
at fasrerspeeds)andthequadriceps acl
is acliveonlyduringswingphasewilh peak asa Sroupto decelerale rheranSeofkncc flexionassociated
afterlocoff. Becauso of its originon rhean- with carlyswing.
iliacspine(ASIS)andinsenionon lhe proxi-
libia, rhis musclcis able to assistwith Poplit€us
lnee andhip whilesimultaneously internally
during lhe6tsrhalfotiw;ngphase. Thc popliteusmuscleis a stancephasemuscle$at
dchonstralcs a slightpeakofactivity at hcel-sfikewilfi an-
Adductors othcr more ruslained peaklhrolgh midstanc€and propul-
sion. During ihe contaclperiod,popliteusconcentrically
3s a groLrpdemonslrarc pcakaclivity contncls to assisithe posteriorcruciatcligamenlin pre-
whichtimetheyflcx lhc hip al|dpossibly vcnlingan excessive forwardglidc oflhe femuron the tibia
ly rolalin8theswingphzscfemur-Tlese andpossiblyassistth€subtalarjointwirh producinaintemal
durin8laleswingas they pre terse rolalionof lhe libia.Duringthemidstance period,rhismus-
ofgmund-reaclive forces.Althoughdlcreis cle eccentricallyconlracis to assislgtstrocnemiuswith de-
vatiationin lhc behaviorof the adduclors celcraringcxtensionar the knce. During thc propuls:ve
Deluca(5) notedthalwith rbcexception period,poplileusagainconoentrically contracts,pcrhapsro
t'eriod at midswing,adductur magnus fires assislwilh producing therapid rangeofexternalfemoralro-
 5a FOOTORTHOSES
andOIhcrFomsof Conserv.rivc
FoorCrc

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
R€f€r€Dces
l. ln'na. VT, RalsbnHJ. Todd F. Humanwatlriq. Bdrimorc:
Willirms& Wilkins,l9ltl.
2. Rol MC, OrionWP. WeedJH. Nomal md Ab.onnal Func-
tion of theFml. tl)s Angelcs:Clinidl Biomech ics.lr)77.
3. Scnnbn PE, ct nl. Suppodnhreekincmdicsof the ft,ot. It
&rcman JE Tro$ Aw (cds).Th€ FootandAnklc.Ncw York:
Thicrne-Stmtton,1980.
4. KatohY, ChaoEYS.taughmnnRK. Biomechaoicrl anrly$is
of fool functionduiiggait andcliniclrlapplicarioff.Clin Or-
lhop I983i 177:2]-33.
5. Basnajiar JV, Dclu.a CJ. MrsclesAlive: Th€ir t'trncrions
Revealed by Elcctrunyogr8phy. Ed 5. Ballimore:Willilml &
Wilkitrs 1985:377.
6. RadinEl- PaullI-. D'rs c!.til.ge omplidc€ rcdua stclclal
impacl lor&? Thc rclalive forc. arcrualing prcperd€sol !F
ticuld qnilage. synovialfluid. p€rianicrlarsoft ris.tues
und
bonc.ArthrilisRheum1970i13: 139-144.
7. suboinickSI. aiotndchinicsof thc sot'talarand nidultal
joinrs.JAm Podi$rAssocl,)75i651756.
8 WrighrDC, Dc\si SM, HendermnWH.Actionofthc subttrlar
snd antl. jotnl complexduringthc stancephrseofwalking.J
BoncJoinrSu.g1964i46.\1361.
L Bojs€tr-Moller F. Anutomyofthc forcfoot,nomaland narho'
logic.Clin OflhopRclacdRes1979;142:10.
10.MaBa D. OrthoPcdic PlysicalAssim.rt. Philadclphia: WB
SaundeB,l9U7:ll7.
I L Fredrich Ec (cd). spofl Shoesand Playins surfacls. Cham-
paign,IL: HumanKinelicPublishc6,1984.
12.HoppetrIeld s. PhysicalExaninationof th. Spin€and Er-
tuemitias.N'jw York:Applcton-Century'Crofis. 1976.
13.PhillipsRD, PhillipsRL. Ou nlilativeanalysisof the l€kin8
positioDof the midlanrljoinl. J Am PodialrAssoc1983;7:l
518-522.
14. Ker RF. Bcn..rr MB, Bibby SR, KesrerRC. AlcxnndcrR.
'Ihe sprinain rhc lrch of lhe humanfoor.Nrture lgti7l 325r
t47 149.
15.MM RA- Biomcchanisof running.Ir P3ct RP (ed).Sym-
posiuFon rhcF(x)rsnd lrg in RunninaSpons. St. Louh: CV
Mcby. 1982:26.
16. Bojscn-Mollcrn Cr.tcancocuboid joint .nd srab
longitudinal arch of thc fool ar high and low 8ear
Aral 1979;I29: 165-l?6.
17. llicks Jtt Tnr fechanic. of thc l(x)r. L The
195{ 88:345 357.
18. rurtle R. Bas.jian JV. El.crrdmyognphy of
in8: rcsulrsofforr cxpcdmcnlsonthc foearf, of
r\n J PhysAnlhrcpol197?i37r255-266.
19.ClorerR. SomeltoolicariorK of rhc lunctional
rntlcjoint.JBon€JoinlSurg1956i
38,,\:761-781
?0.S.lrvartzRF,HeathAL. A qurntilalivc
.nalysis;f
variablcs in lftewalkingpaliernof nomal adulis.I
Surg19641 46A: 32+334.
21. HutlonWC, DhancdBnM. ahe mcchs.is of lomd
llx val8usfcar:a quanritarive srudy,Clir Onhop
7 13.
2?. ElfimanH, ManterJ. Thr cvohrtionot lle bumd
.spccial rcforenceto thejoint. .l Atrat 1936;70: 56-6?.
:3. Ven' A. Komi P. Elcdromyographic aclivityin
rpeedsrungingfiomsub-nrnximsl
rosrpru-naxinal.
sporlsExcrc1987i19:266-2?4.
24. snundersJB, lnmanVT. Ebcrh!fl tJT. The najar
ranlsin nomal andprlholoSicul gnir.J BoneJojnt
J8A: r53.
15. l-yonsK, Perl' J, GronleyJK. l'lmin8 and reialivc
of lhe hlD exlen$r and rbdlcror mffilc adid
xndsrairanbulation.PhysTherlg&ii 63: 1597-160t
26. DuchenruCBA. Physiologicdcs MovcmenL\.
,nd t ondor; WB S.unde.s.l9a9 hriginally
lli6?).
27. warc6 Rl- Modis lM. Elcdricalrctivity of mus.l6
r rnk duringwalking.J Anat 1972;lll: l9l-199.
28. HollinshcadWtl, J€nkinsDB. Futrctiotral Annrotny
I-imbsed Back. Ed, 5. Phlladelphia: WB Saundcrn
:70.
29. illiotr BC. BIanL\by8A. lhe srn(hroni/oli,'nnf
hvilv and bod) rcgmentnrovcmcnrs Jurint a running
Medsci SponsFIerc 19?9:ll:2-27.
3t, (ilancv J. Onhoticconrrclof lround rcrcrrveforc€s
funning(a prelirnimryrcporl).OnhorProsrhel
12-40.
Sl.JohnsorlJE. Shap€ ol the lrochlea aDd mobllily
tateralmalleolrjs.In: SllehlJB (ed). Inman's
the Anklr.Ed 2. Baltimore:Wlliams and Wlktns,
17.
 ChapterThree
normal Motion during the Gait Cycle
for tho previouslydescribedideal oovement
; sevenl parameiersfor norm mustexisll
ildividral $ands io his or h€r nomal baseof
leg shouldbe pe.pendicularto th€ gmurd
subtalarjoitrt is maintainedin its neutralposi-
crlcaneocuboidjoint is locked in its close-
(Fig.3.r), the verlicalbisectionof rhc
shouldpaJalcl the veltical bisection of rhe
ard fbula (a2'), lhc planrarforefoor should
to lb€ venical biscction of lhe calca-
plantarmetatarsalheadsshouldall rcst oo
plarc.
cdensionsof the metara$al heads should
pataboliccuw€.
mustbe of eqral len$h.
aniculatiotrsof the lower extremity and
movcthroughspecificminimum rangesof
6. Neuromotorcoordinationmust be inlact, and the periar-
licular tissuesmust provide amplepropriocepliveinfor-
7. Tho supportingmusclesmust lross€ssadcquatestrength,
power,andenduranc€.
8. The atticular architcctureshould protect agsinst cxccs-
sive andlor abnormelmotioDs,
9, Onl,ogenyrnusl allow for the formation of a relatively
straight lower cxtremity (in both the frorlsl ard rrans-
verse planes) and for tbe developdent of a fuocriolal
mcdial longitudinsl arch.
As one musl exp€ct, whenever therc are spgclic
guidelines identifying the norm, the.€ are bound to be
situadonsfu v/hich individuals deviele fiom thos€ouilised
parametels.In fact, individual variation h tbe shap€of the
arliculal surfaces6nd/or defecls in th€ triplanar d€velop-
ment of the osseousstructurcsale so common that devia-
tion from one or moreof theseoutlioedparamctclsis the
rule ralher thatrthe exception.As will be demonst.ated,de-
Figure 3.1. Par?meter.for norm. fte pati€or resrs in a
pronepositionasthe€xaminer maintains theheadof thetalus
dhecllybehindthe navlcular. Thisis re{effed
to ar lhe neutral
posationof the subtalarjolnt. The examinerthen fhmly
dorsiflexes thefoudhandtifthmetatarsals, therebylo€kinSthe
lat€ralcolumn.Thisillurtrationdemonshates idealalisnmenl
of the le8, rcadool,forefoot,and metaiarsalheads
5E FOOTORfiOSI-s andOthc.Foms ot con*flalive Fot C.E

paiurc from even onc of lhcscparnmelerswill resdt in ro ageinto irfantile(l 3 ycars)andrdol€scent(8-15yells)

some typ6 of biomcchanicalmalfunction.The folkrwing ffinrs with the infantileform uDlo frve tim€snrorccom-
sectionswill revicwtheDathonrechanics
associatedwith de- mon (5). Althoug! describedas an osleochondrosi\
viationfromeachofthc dercribedparameters. Bloflnt'sdisease appears lo resultfrom abnormalcompres.
sive forccsalong lh€ nedial tibifll growth phte andnot
REART,'octt VARUS DEFoRMI l". fronravascular nccrcsis(6,7). Numerousinvcstigatorsfcrl
thal lhcjrvcnile form of Blount'sdis€ascmay aclusllyIc-
lly far. the mosrconmon deviationfrom hc outlincd slll fmm early walkingwhen physiologicvarunlis at ib
panmctersdefinillgnorm is the rcsIfool varusdefbrmily.
This deformity rcpresentsrn os.scousmaltbrmationio
whicb rhc tibia hasfomed in a bowedposilion(Fig. 3.2),
and/orthe subtrlarjointhrs formeditr sucha way thal thc
calcaneusis exc€ssivelyirlvertedwhen the fool is main-
taincdin iK neutralposhion(Fig. 3.3).As a resullof rhis
deformiry,lhe lowerleg is typicallyunablelo assum€ a peF
pendicular positionduringheclsrrikc.
Becarselhe rcarfbotvarusdeformityrepr€sents ths
combineddegrees oflibiotihula(varumsndsubtalarva.um,
deformilygrcalerthrn theidealof4'(a f variaflcelbr sub-
talarvarumplusr 2'vsriancefor libiofibulurvaront is cx'
lremely common.ln on€ epidemiological study of thc
varioustbol ryp€s,McPoiler al. (l) tbud a rearfoorvarus
defornritycxcccding4" in 98.3%of the individualsmca-
surcd.Bccauscof this. it is morc approprialclo rcfcr to a
straightlowcrleg astheidealftlher thanthenornr.
The ctiologt of lh€ rcarfool vrr s deformity is relalcd
ro a failure of $e libia and/or calc:ne|ls !o slraighlen fr()m
rheirinf.rntilepositions(2) (Fig.3.4).tn rcgardslo subhlar
varum,thecalcrncusnormallyderotates 3 lo 4' duringearly
childhood.l f for aoyrcnsonthecalcaneus d(xs nol dcrutale,
or if derorarionis incomplete, ! subtalarvarumwill resuh
(2. 3). In addirionro subtalarderotation,lhe tibia mustalso
stra;ghtcnfrum its infanrileposidon.The graphin figure
3.5 demonstrates typicalfrontalplanedevebpmentdLrring
th€growti ycars,
Whilc pathological genuvanrmmay resultfronrv{ri- Figud3.3.subt.larvalum.
ous mctabolic/hcrcditary disorders., sruchmor€c.o'Dmon
cause is Blount $ disease. This diseas€is dividcdaccordins

fi8ure 3.4. As a ]eslll ot in ure'o poritioninSdurin8lhe lfti.d

trimNt€.. rhe ribiasar€ bowed(anow), and thc calcanei..e
ri8ure 3.2. Tibiofihdar var!|n. inverled.

10 1t 12 13
0.lii
figurc 3.6, Stanccpha.e molionswith a rearfool varusdelo.mity (tolid lind,
h,s beensugSestedlhat th€ applicationoI
in lhe prcsenceof a lar8e Senuverum may
them€diallibiofemoralcomDanment
tl,em€dialtibialphysisis irhibited(which
lheHeulsr-Volkmann principle).The re-
(hformily only s€Nes ro amplify $e com-
llBreby increasingthe mslformalioo. Cook
a bio|n€chanicalmodelto demonslrate
vtrum in a 2-ycar-oldchild would crcale
to relardphysiological
growth.Thistheory
theclinical observalionthat children from
rnd Africa, vrhcreearly walking during in-
, lypicallypres€ntwith a markcdphysio-
Cha crThtoe AbnorlnrlMotlondurlrg lheG.lt Cyde 59
rigure 3.5. DcveloFnenlof rh€ tibioremoial .ntle. Note the
physioloSic tnnsilionfrom6enuvarumto valgumduinE the
eadyyearsofgrowth.Thisgraphis basedon clinicalandradi-
ognphic measurements of marc than 1400 childfen.
(Adapted fromSalenilsP, VankkaE.Thedevelooment of the
libiofemoral anSlein childr€o.I BoneJointsuG 1975;57A:
259-261.1
logic3lvarum(I2). Kling (13) $atedthalwhile $c rrueed-
ology of Blolln!'s diseaseremainsuncenaiD,therc is con-
s€nsus lhat slres! add growlh combine to produce
progressivevarusdeformjly.
Pathomechr cs
Becauseof the excessivelyiDvertedposilion of the
rcarfoot,inilial grouodcontactoccursalongthe postcroiaF
eral edge of the crlcaDeus,To compelsate for this defoF
mily, lh€ sublalar joilt musl prornte excessivelyjust ro
briog the medirl codyle of the calcaneusto thc ground
(Fig. 3,6).Notelhat the degrecof subtalarpronaiioDis di-
60 FOOI OR'IIIOSES
andOtlerFomsof Co$cNalivcFootCa.c

rectlyrelatedlo the degrocof thDdeformity,c,9.,a persoo

****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

In addioonro producingvaJiousitrjuricsin dc foor.

ivesubtalar joint pronationmaybe responsible for a
rsngcofinjuries alonglheentirekineticchain.For ex-
il has bee[ documenledthat excessivesubtalar
ion is causallyrelatedto shin splints(15, 19) (3hin
bein8definedas pain alongtie medialdislallwo-
oftie ribis).Also, Malhesoner al. (22) demonsrraEd
.rcessivesubtalarpronadotrpredisposeslo lowcr tibial
Iractures,possibly becausethe distal tibia, wilh irs
low polarmomenrof inenia(23),is unablelo ror.
the increas€dlorsional strains associaledwith €xcs-
hlaradduclioo.
Thecrcessiveintcrnaltibial mtationmav alsobe re-
iblc for mcdial knee injury, as the medial tibial
is forccdinlo rapid poslerior glide beneathlhc mc-
femonl condylo.This movem€ntstrainsthe mcdial
andlhc medialjoiol capsuleand mry producr
pesanscrine bursitis.(lt shouldbe rotedthatLuttcr
wasablelo rclaLe77% of 213 kneeinjuricsto fault'
of thefoot.)
Whileftosl authoriliesfe€lexcessive subtalarDrona-
mostliequentlyproducesmedial knee injury (25),
(26),in a sludyof lm individualsdiagnosed with ili-
bandtiiction syndrome,concludedthar e,(ccssive
joinl pmnationwas a significanl stiological faclor
dev.lopmenlof thal iojury. Apparcrtly, the excessive
tibialrotalion"drass"lhe distaliliotibialbandover
lemoralepicondylc, therebypredisposing to this

Anolhcr point of interest relar€slo reiropat€llapain

rxcessivcsublalarjoiflt pronaiion.Although il has
froquontly notcdthstexcessivc proradonincrease$the
, lhcreby predisposiDg patientsto reropatclla
(27),lhis is only rrueduringstaticsrance,when
crucialcligamcnFmainlainthe cx@ndedknec In a
po$ilion.Whenlhe knec is flexed(as it i5 during
pcriod),lhe tibia inlernallyrotatesfunherlhan the
, therebydecreasingthe Q angle(28). This rnay be r€-
ble for mcdial rctropatellsinjury, as Hubsiti lnd
(29) demonstrated rhat a r€ductionin the Q anglc
ipproximarety 50%ollhe rime,resuhin a redudionof
benea$rhel0tcralDatellafac€lwiih a redistribu-
lhispressure clscwhere (therebyinse$irg the po-
for chondromalacia at rhescpoints).Perhapsrhis is
Kegeneis er al. (28)staledtharexc€ssivc subtatarjoinl
ition is ascausallyrglatedlo lhe plical bandsyndrome
incrcascd O angleis rclatcdto exrensormechanism
Thc finalposturalconsiderarions associatedwith ex-
sublalarjoinl
pronation canbe directlyrelatedro lhe
rangcof interMlfemoralrolatior(Fig.3.8).
In Figurc3.8.excessive inlcmalroutionol lhe femur
produoc injury as it increascstersilesfain or the
ofglulels daximus(B) and may ther€forebe re-
forchronicstrainof thattendon.Also, thegrealer
Flgur. 3.8 (A-F) PoElural .fiacta aalochiad $,lth
axc.talva aublrl.r pron lon. (se0 text.)
trolhanleric bursa is more pmne to injury as thc pmrimal
femur roraresthrough a groaterarc of motion. This acls lo
increascshear forces oo this bursa, which is located bc'
twecn lhe greater lrochanter and proximal iliolibirl band.
OCmuchgreaterclinical significanceis the effect that irlter-
nal fcrnonl rolalionhason the pelvis.Inrcrnalrotationof
thefemurdisplaces lhe femoralheadposleriorly(C), which
in rum causesthe entirepelvis io tilt anrcrio y (D), This
may produce a wide range of injuries as thc sacral basc
angleis jncreased, the intervertebaldiscsbecorhewedgcd
posteriorly,andthc spinousprocesses are rpproximated as
rhc lumbarlordosisincr€ases (E). Also, lhe antcriorlilting
of the pclvis tracdonsthe hamstringorigin (F) wbich,be-
causelelldi'loussliDsfrom biceDsfcmorisarc continuous
 62 FOOTORTHOSES
ard Othff Formsof Conscry.rive
FNt Cire
with the sacrolubcrous
ligamcnl may predispose
to sacro-
coccygeal dysfuncrion.
Cltssic Sigls and Sympioms Associrted with lhe
Rerrfoot VarusDeformity
Becausa rh€variousstruclural/kinetic dcvialionsfrom
thc oudinednonn producevcry spccificpatlemsof conl-
pen$lion,kn8er andWernick(32)havcdcscdbed a list of
classicsignsInd symptomsassociated with exchofthe var
ious deformitics.Rcmcmberthflt this list refleclsonly the
most frequcrrly seensigns and symproms;|nd do€s nor
applylo all cases(esFci.lly rvhenonecoosiders $ar vari-
ouscombinittions ofdeformiticsmay€xistlogclh€r):
L A meltium height to lhe neilinl Io aitu.linal arch
olf.$'eight-beaing *,ith onl| a slight lot erinC of the arch
upon weiSht-bearing(Fig. 3.9).
2, Miw.lotrcdemte collusfonnarion un.ler thc scc-
ond and lhint netatarsal heads. Bccausethe subtalar
joint is pronated at thebeginningofpropulsion,thearticul$-
lionsofthe foorrcmaiounlorked,andlhe fiIst metalarsnl is
unablclo b€arweighlcffeclively.As a resull.a dispnpoF
tionaleamountof weighris shiftedro rhc secondandrhhd
metatarsal hcads,which pr.disposes 1opain nd a diffuse
hypcrkeiatotic lcsion.
3. ExaEgeraledshoe N'earalong lhe lot?rdl hecl,
4. Retucalaaneal bursitis or pump bamp (Fig,
J.ro). This bursa may b€ chronicallyirritntedas il in
shearedbelwccnthe skin (which is maintainedin a somc-
what fixed posilionby lhe lateralheel counter)and th€
overlymobilecalcaneus.
Fitur€ 3.9. App€aranc€ of the m€dial lontittidinal arch with
a rearfool varus deformity. Bcc.usecategorizinSrhe nrdinl
arch as hish, modium, or klw i! so subjectiv.. Dahle er rl.
(33) recommendedmeasuringthe an8le fomred betwa€nfie
dislal nre.llal malleolus, thc nivicular tubcforhv, and lhe
melataEalhedd. li the res{rltanransle approachee180!, the
.1rh is considercdhi8h; in ansle between 130 and l5o" is
considercdmedilm; and an an8le nea.inr 90o rs considered
low. h should be noted rhar this methodis far from iderl and
lhat, with practice,subjecliveirtcrpretationmay be nlore fcli-
5. Morniry hecl pain. n hasbecndocumenred
35) lhal a rcarfoot varusdeformity can producemi
agero lhe variouslissucsinscrlingon lhe planlar
(pardcularlyrhe plrntar fasciaand abductorhallucis
I)uring period\ of prolongedresr,an
ede a mny accunularcwithin the limiredconfn€sof
con ectivc tissre sepla.This inflammaloryr&crion
pro(tucccnoughswellingto comprcssncighboring
libel\ lherebyFoducingpain (36).Thh painwill be
cncJafier brief periodsof w king as nlolcmcnti
ven,us and lymphaticdrainage,thercbydecreasing i
conrparlmenlalPressures-
6. Hannc nc of th.jlth disA lr lbe subtalsrj
is mrintainedin a pronatedpositionduringpropulsion
is with a largerearfootvarusdeformity).lhe pull of
digitorurn longusis displac.d m€dially, th€rEbyprcd
|o h nmcring of the fifth digit.
7. Chronic of e mascalolurcb
',,yositisllendinilis
spo,tslhlef,or dccekfaling sub/lalarprcnation, TibialtE
ante or andposterior, Ilexordigitorunrlongus,fl.xor hillo.
cis rnd lhe lriccpssul?emusculalure all rnay
'ongus,strained,as theyareforcedlo decelerate
chronically subtr.
lartxrnationthroughlargerrangesri fastersp€eds (19.37),
8. Stmptons associatedwith etdggetuted lo'llion
ahelowerettnmit!, i.e., r/'esstactutc of the disul tiw
m.dial re.mpdtellaadhmhia. pes anscdw hu'sitt,
gftotcf ltuxha .rie bvrsilh,etc.(secFigs.3.6a 3.7).
Orthotlc Manrgementfor the Rerrfoot
VarusDeformity
Keepingin mind rhat rhe rcarf{x,l varus is an osseoB
defonnity that cannot be changedshort of surgically
slraightenilBthe bowcd starcture.the goal of re{lrnenr
nusr be lo decreirsethc nc:edfor comp€nsatory $ublal$
prorrrtionby d€signinSan orlholicthatwill accurarcly ac-
conm(xlatcthe deformity.This is panially accomplishd
Jl8ure3.r0.IhG i(hilles "pump'bump"(A).

placinS a varuswedgeor postunderlh€ medirl foot. lhe
basically aclsto bring lhc surfacelo thc palient'sme-
foo!,mrherthar forcinglhe patienlto proDatein ord€r
bringthemedialfool to lhe surface(Fig.3.1r).
Useof a rearfootvaruspostto bringthesurfaceto the
ity repros€nts a bNic tenet of orlholic design:A
ade onhotic does nol necesssrilyshift lhe bony
froma visuallymalalignod 10an alignedpsition;
x, it aclslo customconloura sur{acethal,whcnpossi-
allowsfor no,lcompeosaled movementpallornrj,with
joilrs flrctioning aboutlheir neuaalposilions(n€utral-
beingdefincdai maxrmalcrngruencya! the ralonavicu
arliculation wilh rhecalcaD€ocuboid joint mainlainedifi
posilion).
Theabilityof lhe varuspost !o oonlrolsubtalarmo-
ha5beendcmonstra@d by Cavanagh e! al. (20). By
high-specd cinemalography aod forcc-pliteanalysis,
wereablelo demonstrat€ thal fic addilionof a varus
rol only decreased thc overallrangcofsublalarprona-
butalsoproduceda msrkedreductionin the angular
y in whish prorationoccuned.Ir addition,force-
analysis reveal€da ma*ed decrease in medialshear
ar lhe rimc of inilisl ground contact.Mann (38)
thal use of a ftedial suppon would brirg
a dec.e$ein cve$ion of lhe calcaneus and inlernal
ofthe ribia.The authoremphasized thalallednglhe
fiSur€3.11. Th€ r€irfoot varuspost.
ChapterThrceAbrormrl Molior duriry th. Grlt Cycle 63
Lransvene rotalionof lhe ribia may corfectclinicalsymP-
tornsatthc k[ee andhio.
The obsewalionthat varusposrsdecr€asc tbe range
andspeedof subtalarpronationhasbeensupponedby other
investicators(39,40).ln fact,Sma ei al. (41) wereso im-
pressedwith the ability of the varuswedgelo cont.olthe
rahgeandspcedof subtalarmotiodlhartheyrecommended
oscof a 12-to 15-mmwcdgein all casualandathleticshoe
gcar(alfioughthisanglcscemssomewhat excessive, as lhe
avcraBe orLholicis not posted at morethan4o varus,i,e.,7
mm).Schoenhaus ard Jey(42)staledlhatrherearfootvarus
posl should oever exc€cd7 (13 Inm), as an angle greater
lhan this would producelaleralinstsbility,lhercbypredis-
posingthepatientto inversionsp.ainof lhe anklc.
In additlol| lo the coBlrol alforded by lhe varus post,
subtalar motioos can also be modified by makin8 certain
chaogesin the shapeof lhe orthoticshel (whichendsjusl
prior ro lhe motatarsal heads).ld orderto accuratelymold
thissh€ll(whichmaybe madefrom a varielyo[ materials),
a foot imprcssionnusr bc taken with rhe sublalarjoinl
maintainedin ir,sneutralposition.The positivemodol of
this impression is thendlteredby addingplasrc.|o lhe mo-
dial longiludinalarch, rhe calcanealinclino angleand, it
nonweighl-bearing impressionlecbniques havebeenused,
ihe ptantarcircumf€rcnce ofrhe hcel(Fig.3.l2).
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$livc model,as
the subralarjoinl will be mod€rately pronatedprior to con-
Figurc3.r2. A planta.medialview of a posilivemodel.rhe
rhrdeda.err.ep'csenllocarionof lheadditionalplaster.
64 FOOTORTHOSES
rnd OtherFormsof Conscrvalivc
Fmt C:tc
lactinglhe sheU.For exanplc, if a 15" rearlbotvarusis
treatedwith an orlhoticshellposredin 4'varus.lhe subralrr
joinl will haveprcnatedI I'prior to slrikingrheshell.As a
resuit,theconlourofthe medialarcbwill havesignificanlly
lower€dfrom lhe neulralpositionprior to contacringlhe
shcll. lf this were not takeninto considerariorby adding
greateramounl(of plastcrto thc positivemodel,thesofttis-
suesbcncntbthemedialarch(particularly nearlhee3lcuneal
incLincangle)would be chronicallycontusedas lhey col'
lidcd with theinadequately loweredo(ho1icshell.
Additioml informadonregardingfabricationof the
onhodcshellandthevariorsposdngtechniques will be dis-
cussedin rhelaborarory preparatiofl
section-
Theclinicaleflic3cyofortholicsliat alkJ\\,tor ncuttul
subrdlarpos'tioninghar been well docLrmented (17, 39,
4H5). In facr,in a studyof 53 prtjenr$reccivingnellral
positionorthorics,Donrt€lliel al. (46) statedlhat 96ti, of
thescindividualsreportcdrelieffrom pain with 70% bcing
$le to returnto theirpreviousl€velof activity.By combin-
ing an accurai€lycontouredshell with a post angl€ that
lessens the needforcompensalory subtalarpronation, an or-
rhotichasrheabilitylc)improvefunctionalalignmcnlofrhe
sublalar.ioinl.therebylesseningpolcnlialslrainalongall is-
pec.sof lhe kineticchain.
AL|GNMENT or rHE RtrARFoor AND lloRErool'
As mentioned.the calcaneocuboidjoinl shouldlock
posilionwilh th€verticalb;sectionofthe
in itsclose-packed
Figur€3.13.Th€forefootvarusdtformity.
pcrpendicular
rcarrool to lhc planrar
surface
ol rhc
Unlliltunately,this is not always the caseas individualvai
arjon in lriplanaronrogenyof the tarsalsmay allow$ej
planrarlbrcfoorLobe maintainedit| cither an invenedot.
evcncdposilionwhcn lhc calcancocuboid lockingneche.
nisnris engag€d. If lhc planlarforcfootkrcksanan invcned
positionrelaLivelo theplantarrcarfool!it is rcferedto 0sr
fdretbot vanls deformity(Fig. 3.li). Conversely,if the
plantnrforefootlocksin an everrcdposition,ir is refened l0
asforelbolvalgusdefomity (Fig-3.14).
As expect€d,lhe forefootlarus andvalgusdcformi-
ties producevery differedtpatternsof compensalion. T},e
tbrclbotvarucdcformilyriill be discusscd first,as il is uru-
ally rhemoredesrruclive.
FoREFoor VARUS DDroRn[ry
Alrhoughthe forefootvarusdeforrnityis prese in
lcss,han q% ol rhepopulation ( l), rheindividual
possesing
lhis Lbotlype is frequenilyseenin a clinicalsettingeslhc
lbrclbolvarur is respoDsibie for manyknee,hip andpelvic
disoders.Strauss(4?) originallyd€scribedthis deformily
in 1t)27.attriburirrg
it to a failur€of the ralarneckto delo-
lare lronl its infanlile invertedposition(Fig. 3.15).A1-
rhough mosl authoririesconrinueto blame talar necli
defonnily,McPoilel al. (48) recentlydisprovedthislhcory,
sLrggcsting dla1the forefoolvarusdeformityresullsfrom
ossc,)usabnormalilyin fte talonavicularand/.rrcrlca-
nco.uboidjojnts, nor from varialionin the talar heador
I
:
l
l

3.15.Th€{oref€€lare mainlainedin an inventedoorr
lhelhird trime.ter.
RBgardless
of irs origin,the invert€dforefoorshould
ideallyderotaiedbrck to a neulralposnionby ,gc 5
Pathomechadcs
Tocompensat€
forthecoostantly
invc!!€d
posirion
of
thesubklarjoint is forcedro prcnat€through
lang€sof motionjusl to bring the medialforefoor
groutd(Fig.3.16).This exaggerated rargeof subta,
ion caus€sthe Laluilo shift rnediallvrelarivek,
which in turn suppliesbody weightwith a
Ch.pLerThree Ablormal Motlon durlng the Glit Cycle 65
rigure3.l4.Thcforefootvalgu!deformily.
muchmoreeffectiveleverarm for maimainingthe s bhlar
joint in a pronat€dposition.Tbis createsa vi.ious cyclein
$at th€ rarge of sublalar Plonation necessary10 compen,
satefor the lorefoot deformity during contaq period allows
body weighl !o rqaintain the ptonatedposition thfoughout
midstance anderrly propulsion.
The increascdmnSeof subtalarpronstionpresentduF
iog the contaci period predisposesto lhe sametypes of in-
judes seen wilh a rearfootvarus dcformilv. However.
exaggerakd subtalar pronation throughoul midstanceand
propulsionmakeslhis deformity particularly destruclive,as
it disallowslockirg ofthe calcan€ocuboid joitrl andcreales
a seriesol coniicting motionsbetweentie kneeandlalus.
B€causcthe lalus is held ir ao adductedpositiontJy the
prondedsubtalar.,oint(tlis positionis mainrainedby th€
superimposed bodyweigh0,theexternalrolalionalmoment
createdby fte swingphaseleg is unable!o generate a force
srrongenoughto abducrlhe talus.As a resull,rheronional
forcesassocjated wiih thisextemalrotationalmome musl
be temporarily stored in the siance plase lower extremiry
(Fig. 3.1?). The releas€of tbesestored lorsiooal forces is
IiequentLy €videnccdby a sudden"abductoryt\rist" of the
r€arfoottie moment fie heel lift occurs; i.e., because
ground-reactive forcesno longermaintainthe plantarheel,
lhc ortire rearfootis free to snaprhedially,as lholgh re-
leasedfrom a loadedspring. Clearly, rhe developmenrof
suchtoisioral forceshasthe potendalto do much damage.
Becausea chah is mosr Iikcly to give at ils weakesl
link, lho prolonged rpplication of these forces will mosr
often produce a pathotogical laxily of lhe involv€d joint
crpsules,parlicularlythe lcnee.Coplan(50) conobomled
66 FOOTORTHOSES
andOthcrFonrsof CoDscdative
FoolCarc

t0'
l2'

tiSur€ 3.f6. Stancephasemolionswilh a lorefoot varu. ddormil] (eid lind, HS: heel strike;Ffl =
full iorctootload;Hl = heclli,t: IO = toeofi

this rhcoryby noringfiat individualspoisc$sing excessivc

rigure 3.r 7. when a forefoot va.usd€tormily is pr€s€nl,thc
e{cmal lotalory moment.reat€d by th€ swinSph.s€ le8 (A)
is unabl€lo generalca for.€ suf{ici.nl lo 6hlft lh€ subtalat
joint frcm ils fully pronar€dposilion(8),
rR ecs of sublalarpronationwcrc more likely lo display
signiiic:mtly grealerral|gesof tibiofenmralrotarion. psdicu-
larl) .rsthc hrce approaches full cxlension(irsnormalposi-
don of funclion as rorsionalstrains peak doring lrte
mid\rance).In her study,which wasdoneolTweight-bear-
ing. rhe mcrn ran8cof tibial roktion \rhen the kneeqas
flcxeil5'was 11.4"for the normalgrorp and 18.5"for rh€
pronrrring group.She speculated that lhc opposingrotary
lorquespres€ntduringlhe latc midstanceperiodproduced
laxir! ofrhe lissu€stharnorm^llylimit kneerotalion.
Anotherpolentialinjury that may re$ullfrcm th€se
conflicling motions(,ccurswhen lhc antemmedialtalar
dom. $llides iolo the articularssdacebcdeaththe medial
mallfolus(Fig. 3.18).Repeated Lromprcssion of theselwo
surfrr'esmay cvcntuallyleid to chronicsynovilisard/or
chonlromalacia ofdle tal{r dome(sla0.
Possiblythe most detrimentalasPeclof excessive
subtolar pronaiion throughout latc midsbnce is that it
disallowsthe normalcouplcdmotionsneccssary for knec
extension.i.e., becauscthe knee is not n purc gingllmus
joint. the tibia musr externallyrolate for thc knec to
smonthly€xtend.(The knee c8n €xterd withoul extemal
tibialrotation.bul thisistr subluxatory rrthcrthana snoot!
 Ch3ptcrThree AblorDl Molior durln8lh. Gril Cyclc 67

allows for increased stabiliryonly when forcesarc chan-

ncl€dthrougbil with the sublalarjoint nearneutral(Fig.
3.19). Becausethe ch.onic{lly adductedposhionof the
lalusassociatedwith the forefoolvarusdeformitydisallows
lhis saddlejoint relalionship,the tslus is allowedto shifl
planl8rly,mediaUy, andanleriorlyasSroood-reaclive forces

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.
lendedby prolonged calcancal theywill bc uDablc
eversion,
to rcrumthe pronaled subtahrjointro irs neutralpositionds
fteir ability to slore and r.tum plasticener!ryis ld\t. A! a
rcsulr,a cl,clc of exces\iveslbtalar pionation,soli lissuc
elongadon,musculardystunctil)n,and conlin ed sublalar
prormtionis perpetultcd,Thir cycle mav cvcnruallyend
withsubluxatiorof rhcunslablcalticulations.
Thc chronicallyevertcdheelassociat€d wirh forcfoo!
varusdeformilymay prodrccolher injudesas il (racfi(,lts
the Libialnervcand cs,rcomprcssvariousbrancb€sof lhc
calcanealnervesal severalsites.Thc medial and laleral
plantarnervesmay bc compressed againstthe sharpfarcial
edgcof rheabductorhallucismuscle(55)(Fig.3.20),while
branches of lbe lateralplanlarnene andlhe nerv€to abduc'
tor digiti quinti may be compr€ss€d b€tweenthe plantar
apon€urosis, inirinsicf(x)rhuscles,and the calcaneus (56)
(Fis.l.2l).
A valgushcel m y alsoproduceinjury to lhe plaalar
fascia,as thc adductedtalusinhibiNthe normalpropulsivc
periodsupinationthar occursaboutthe obLiquemidlarsal
joint sxis. This ocgaleslhc approximarion of the antcriu
and posteriorDillarsrssocillcdwith lhe windlassmrcha-
nism(referbackto Fig.2.16),andrhetensilesrain dcvol-
oped in thc plantarfasciais tran6fefeddhccdy into rhar
tissucs pedosbalatlachmenl on themedialcalcancaltuher-
cle. Ovcr rime,lhe prolongedtractionmay producci!|lirm-
maloryerosivecbargeswith prolifcration ofnew bone,4,e..
spur
calcaneal formatioo (57).
Smilh(58)strtedtharlhe rrem€ndous shcir loadscre'
atedby thepull of theplanllr fasciaagainslthe medialcal-
cancalcondyle crcalcsa cyclicloddingarthejunctionof the
mcdialcondylcandtheq)rpuscllcaneurnthalis opable ol'
producjngmic'osorlicalfructurear this sitc. The allhor
clnimsthatthisslress-induccd micK)fracturehaslhe Dolcn-
rial for unstablecrack propagalionlhal might ullinrarely
Figure3.20. Calcan.aleveBionnr.ayprodoc€compressionof
the medialandlaleralpl.ntarn€lve6.
leadto comminuedfraclure.Thi$ is consistent
lvith
nral,ofl provided by Williams cr al. (59), ar lbey
slmredthat 60% of 52 pAinful h€elsshowcdi
uprrkeoftechnetium-99 isoropear thcc||lcaneum.
Possiblyihe moslimponantfncrorlimiringpropu
periodstabilityin the forelmt v:rrusdeformilyis rhe
ity of pcroneuslongusto stnbilizethe first ray when
subrllarjoint is Fonat€d.As previouslymcnlione4
hr t rcnllion alter\rheangleofapproachrfforded
lontrLlsto $e 6rst ray dxis,nuking il ineffectivcasa
ray plantarffcxor,Becauseground-renctive forcesar€
mallv lransfenedro lhc medialforcfootdurins
(Fit. 3.22).lhe first ray muil be €ff€cdvelystabilized by
m€chanically effici€ntpcron€uslongusif il is lo resisl
plicxtiorof theseforces.
Failureof Fron€us longust,r stabilizcrhe fitsrny
qill resulrin a dorsalshifting of rhc firsr m€raiarsal
gro.,nd-reactive forcesaru applicd.Cfhc lirst ray will
ally doniflex and invert,)Thiscventuallyleadsto the
hation of a hvDermobilefirsl rl! thflt is unable lo
with thotranstirrof forcesduing propulsion(Fig.3.23).
s rc\uk. greateram,unlsof prc\surcarc borneby the
ond and third mektarsal heads,which pr€disposes
melxtersalstressfncture$ and hvDerkeratotrc l€sionsbe
nearhthc ceotralmeiatarsalheads.In fac1.Huehes
demdnstralcdthat individualswilh forcfoor vrrus deformity
arc $.3 timcs morc likelv to devcho a slre!$ frachre,,reac-
tion lhantho6€with normalme||s$r€meoa.
Rootet al. (3) ncntion thatpropulsiv€period
tiun of thesubtalarjoinl(wirh ihc assocint€d
dorsalshifling
of the hype.mobilefirsl ray) will predisposethe fr51
digiliquh[
llg6m6nl r'_._:_ M6di6landlaleral
---- - planiarnerves
tigorr 1.21. 8r.nctrcs of lhe l.lcral planlar newe and lh.
ncrre to aMrctor ditili quinli may b€ conprtis€d b€lwcer
thc nbductorhallucisad qu.dr.tus plantaemuscles(nol il.
l$lr.rted). Compresrionmay also oc(:uras ftee D€rvespas,
nea,rhemedialtubercleofthe cal(aneus, whcteIhcymaybe
subl'.t ro pr.su.e ftoni a calc.nealspuro. Iocaliflflamma.
rbn rsso(iated with planlarf.sciitis.
 Thrc. AbnormolMollordurln8lheGtlt Cycl. 69
ChEptcr

propulsion, ground-rcactivcforces mainlain the firsl

Itl oll
3.22. Nonnal progr€idon of forc€6 durir8 slanc€
8€rause lh€cenl€rofm;s5is shiftinS laterillyoverthe
duin8the lirrt hall of stan.e,the lorcecuryek main-
alonsthe laleralcolumn. Medial displacemenlof the
of m.$ by Blureusmedju! ,rnd lhe percnealsduring
enerhaltof ilanceshiflslhe forcccurvethrcu8hthefnrt
whi€hir fimly st.bilizedby peroneuslon8u!-
padaally
flom RootMC, Orion WP, Weed Jll, ct al-
and Abnonnal Function o, the Foot. Los Aneeler:
Biome(hanic',1977.)
mcbtarsalin an cl€vatedposition(Fi8.3.25).This is delri
menralro the ffrstmelararsophalangeal joint, as it disatlows
rhe normalplnnhrffecroryrsn8€at the firut ny neessary for
lhe dorsal-posteriorsbifiioS of lhe first m€tala$ophelangcal
joint's rransvcrse rxis (Fig.3.26).As 3 resull,lhehalhx is
oniy ablelo reachthe mdgcof dorsiflexionavailrblcaboui
the origioal axis. Becausethis ralge is typically lcss lhan
35o.lhe dorsalcsrtilageof thc phalanxquickly collides wilh
thc dorsal canilrge of tbe fi.sl metatsrsrl hcrd (Fi8. 3.24.
Root €t al. (3) mention€dtha! the repeatedcompressionof
cartilag€in youngerindivldualsresuhsin characteristic prc
liferativechangcs alongthedo$al fils| metalarsal head'saF
ticular sudacc.In older individuals (i.e., older than 3{}), the
rcp€ated trauma may produce drgen€ralive changes
throughoutthe motatarsophalalgeal joint. Over timc, the
rangeof mo(ionav{ilableto the first metatsrsophslarl8oal
joinl will araduallylessen(rcferredto ashallu( limius) and
Iney ev€rlually tr€comeankylosed(hallur rigidus).
The biom€chmicsl factors producinB hallux
limituvrigidus\r?illonly occur if the metala.sals are in a
recluspatternor if the angleof the met{tarsusadductusis
te.ssrhan lf (3). lf rhc meralarsus adductusis ll'or

Futt Heel
lorolool llft

1,23.Progrelsionof fotc€swith lhe forefoot v.rus de-

Ira88€raledrubralar pronarion inmedi.lely di!
lh€ force curve towad lhe nrcdial he€l and arch.
Froneu\ lontur is unable lo nabilize lhe fi6t f.y,
cu.vc shills toward the rantral meuraEal head!.
propLrl$on,lhe curve relurnsto lhe hallux,a, the inoL
r,vith
lhisfootryp€trequenrly
i€mrinatespropulsion
by
oli themedial*pect ol the hallur.(Adapted
partially
RoolMC, Oion WP, Weed lH, et al. Nomal and Ab,
funclion of fie Foot. tos Angeles:Clinical 8iome,
1977.1

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

Figur€ 3.2s. The eve?ted pGition of rhe rearfoor in pad A

haintains the for€fool in ;tr tully invened posirion about the
longitudinalhidtarsal ioint axis. B€caurelhe fanse oi rcaF
toot eversionassociat€dwith rhe rorcfoolvarls lieouenrivex_
ceeds th€ range ot lonSirudinalmidtalsal jD'nt inveBion
(which is approximatcly8'J, the phniar forefoor cao onry
miinldin Sroundconk I il rhc f,r\l merara,.al.toreifle\eean;
invedswhile the fifih metararsalplanrarflexes and evert, (B).
Note that becausethe s€condtfiro'r8bfourrh metaraBatstack
their own axis for lronlal plaN motion, rhey r-"mainiully in
leded about the lonSitudinalmidt lsatjoint aik {m/.

ri8urc 3.27.As the halluxreachesits tull of

availabl€aboulthe originalaxis,ll'e do.sat'ans€
pha-tanx
wilh thc metatarsal
headtA). lf rhepropukivepefiod
conllfue, rhe finl inteehalangealjoinl may be ro.c€a
comPensatory hypefexrension(8).

SreaLer. rhe rrao$verse planepositionof rhe

low\ for lhe development of halluxabducrovalgus.
al. (3) d€scribcdfour slagqsin the d€velopmenl of
abdlrcbvalgus thrt rre ouLlined asfollows.
As mentioncd,an uostabilizedfiist melatarsal
dorsiflexlrndinvertas ground-r€acrive forcespeal
earlypropulsion. Bccause rhe haLluxplantnrflexors arc
orouslycontractiflg duringearlypropulsionitr ordcr!o
biliTclhegreattoeogainslrheground,thehalluxis held
fixe(lpositionandis thereforeunabl€ro movewilh lhe
metrttar$al. Sincerhe fir$ metatarsophalugeal joint
ar rxis lo allow frontalplanemodontefer backto
l.l(li. in!cr\ionol rhc firslmrrrrarsal agJirsrtheI
lize( h,rlluxcreatcsa torsionalslraiDcap$le of
theIneuhrsophahng€al joinr. h thefirsrstageof halux
ducr,,valgus, the meratarsophalangeal joint instflbility
atedby Ihedorsillexhgaodinverringfirslmeraranal
the rfansvcnie pedismuscleto sh'It th€ proximal
later:rIy(Fis.3.28).
Thisshifiingof lhc halluxi-\dsstruclive, asjl
dirphru\ lhc sesamoids lmm rhcirplanlarfi$.
FiSure3.26. Planta.flexion of th€ first ray (A) alows for a groovesand evefltuallyleadsio mechanical erosionof
dorsal-pocl€riorshifting of th€ firrt merararsophatanScal articr ar cre-st(Fig. 3.29). Becauscrhis crests€wcs
joint'srransv€rse
axis(8).rhis shifris ne€essaryior rheha ux guid:ng{Iongefor the sesanoids(whichatlowthe
to achieverhelull mnseof dorsiflexion necesenryior a noF and ldductorhallucism[sculalurelo dcv€lopequrl
malprop!lsio. (i.e.,65'). Inonlents),its destructionprovidesrhe adductor
 CnapterThrce Aboonnal Moalon duirg th€ Cala CJcl€ 71

n8ure 3.2E. firsl slage hallux abductovalsus.Nomally, the

p@ximal phrlani acls as a dable origin for the tansveBe
pedi, nruscle,whlch conlacts dudrg propllsion to prevenl
tplayin€ of the lessermetatarsals.Becaus€lhe {irst melalaF
eophalangealjoint ls unstable when lhe subtalar joinl is
pronaledduin8 propllsion, the hallux js unable lo aci as a
fixed anchor, and il shift, lalefaliy as rransvaBepedh con-
tfads. ndapled frcm Rool MC, Odon WP, Weed lH. Nornal
and AbnormalF!nclion oftbe Fool.LosAn8€lesI Clinical Bio-

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

fi$rr€ 3.30.Secondsta8€hallux.Huclovalsus The laloral rhe

;tnd
shiftin,jof thchallLrtin Stase1 luppliesadductorhallDcis
lhe lon8 fl('xorind exlensoitendonswith r siAnificant levef
..m b abdud lho hallux-li thisoccuc duringRovth ycals.
{undionaladaptation of bonequicklyiolloM. (Adapted ircm
RootMC, OrionWP,w.<l JH.NormalandAbnormalronc'
rionol lhe Fool.to5 Angeles: CliniGl Eionechnnics,1977)
ti8ure 3.31,ltird stageof hallur abduclov.lSG.
dlly ,lispla.erlnlusclA an(ltcndonsin Sta8e2 will
.rbd,'cllha halluxonly until the distalphalinx presses
nc )lnning digit. At that linte, a rclrc8rad€rolary
reflrrted bark into the ficl metat')rsal,iotcin8 il inlo a
rion of adductionkefeftd lo as mebtarsurprimus
(Ad.'ptd hom Rool MC, odon wP. Weed JH-
Ahn,trmalFun.tion of the Fool. Lo! AngelesrClinical

joint which is uled lhroughoul the range of hallur

dorsificxion.The orilinal transverse planeaxis is slill prc-
scnr. bul only for hallux molion in the Plantarflcxion
range,
Thc pro8rcssion of deformit] typically endsduring
rhe lhjd stageof hallu)iabduclovalSus as dlc individ l.
hecauseof pain or instability,leam\ to avoid bcrrirg
wcighron lhe hallur by devclopingan aproptllsive SBilpal_
lcrn (i.e.. lifiing the heeland tbrefmt simukaneously)lf
the hallux coalinuesto bearweight,lhe fourth and frnal
stageof dcformitr will folbw. This stageis charrctcriT.cd
by complclcdi$localionof lhe halluxtron lhe melalatsrl
head(Fig. 3.32).This dislocalioncanonly occurif thestc-
ond mctatarsal losesils bunressing effecl,suchas whena
dorsallysubluxedsecondmelalarsophalangeil joinl nllows
lh€ halluxto l|nderride thc digit. 8€cause ofthe extrcmeaF
ticularinstabililyneccsNary lo allow dislocation, thc fourlh
strgc of deformity rarely occurs wilhoul underlying
fieumaticinflammatory diseaseor neuromuscular disorder
(3).
Ir shouldbc cmphsiz€dthatthisoutlincdbiomechan-
ical modcl for the development of hdlux ahductovlgls
represenN only onc possihleetiology,as thereis no single Figure3.32.Fourthstageof halluxauu.tovalSue.
theorythll cancxplainthe myriadof formsthis delbrmity uie |l lhe hallux duinS prcpukion evenlualJyrcsulttin
may prcsent wilh. Ilowevcr, nunercus invesligaloflr cariof ot rhe fil9t meratarsophalan8erl joint. (Adapled
(61-63)beliovcthalabnormalsubtalar joint plonationis the RoorMC, Orion WP, W€ed lH. Nom.l and Abnomil
primary causcof nosl hallux abductovalgs defornit! tion ,'{ lhe foot. LosAnselesrClinhrl Eiomechdni€r,1977

(3) cvenrcfuredthe lheorylfiat halluxabducto'
corgcnihl.Thcyslronglyemphasized $at ir is the
dcformitylhat producesthc dcsl.uctivecompen-
rjoinl pronalionrhatis conScn ital (suchaslhe
notlhe actualmelatarsopha langealjoinl de-
ct al. (3) conrendriar if rhepmpulsivep€riod
ationwerenot pre$enr, hallux abductovalgus
dcvclop,(Allhoughthis bclief s€emsa bil ex-
hallux abducrovalgus d€lbrmity is nearly
in barcfooted popularions of theworld [64] and
atedwith congenitalanomaliessuch as a
net8latsalhead [65] and/or obliquity of lhe
neilbm.ioirrl6,al.)
lconsiderarion in Lhepalhomccharlics af rhe
detormilyrelaleslo the inebililyof the rib'
muscleto resupinate an excessively pronarcd
duringlarc swing phasc.Becausesublalat
iflsthcsubtalarjoiot axiscloserlo rh€inserlion
ior (Fis.3.33),this muscleis trequentlyun'
lhesubtalarjoidlantime for the nexl hecl'
a rcsull,hecl-strikeoccurswirh the calcaneus
mor€cvencd.subotnict(66) sraredrharfdil-
a phasicallysoundslrbtalarrcsupination
swingphase wiilresultin a hss of kinelicshock
lhesublaLtr
ioinl i! in ils n€ulralposition
lendonhasa sitnific.nl lever a.m to
lil.r joinl. However,whcn the eubtalarjoinl
libialir anleior ir undble lo control lubtalar
inprovedleveram affordedexlensordi8ito'
lhism us c let o m a i n ta i nth e5 !b ta l a fj o i niln
lhroughoutlhe cnlir€ swingphase.
Chaprer
Thrce AbrormalMollor du.irg lheGaltCylle 73
absorplionwith evertualprunatorysubluxatiorof lh€ sub'
Lalarjoin!. The individualwith a foreiootvarusdefbrmiry
maycompcDsale for rhelack of shockabsorptionby shon
ening lhe sride length (which lesscnsUe ioirial impacl
tor$s) andby suikinglhe groundwith the arkle in an ex-
cessivelydoNiflexedposilion.This positioltallowsthe ar-
leriorcompartment musclesmorc drneto assistwith shock
absorptionas Ihey dccolcratcthe atrklethrougha lsrger
rengeof plantarflexion.
Chssic Signs snd Symptoms Associated rlith the
ForcfootVarusDeformity
L A lo"' dedial longitudinel arch both on and olJ.
wcieht-bearinewuh the heelseverteddurine staticstaBce.
2. Modarale-to"nnrked ca us fomatiofi under the
secon{ thi..l, and somalimeslourrh metataNal head\ with
a "pinch" csllus or lfloma lnder the dist,'l medial aspec,
olthe prcxhnalphalant. This patternofcallusformation
lbllowsa hnealongthcrypicalprogression of forccsassoci-
atedwith propulsivepcriodprooalion(Fig. 3.23).As the
lissuesundertheccntralnetatarsalheadsar€forcedro sup-
pon moreweigbt,thcy reactwith a diffuschypcrkerarosis.
Ilccalse 3 large abdLrctory force is placcdon the hallux
whentheiodividualterminales propulsionby rollinBoff tie
rncdaalaspeclof the proximalphalanx,a shearingor pinch
callusquicklydevelops.Whenseenin children,a mild hy-
perplasia ofskin at rhislocntionmay be the 6rstsignof im-
pendinghalluxabductovalgus (3).
3. Hannering ofrhcffth dift. In a randomsurvey
of palierlsrequiringsurgeryfor conlracture of thc fifth toe,
a signincanlcorrelalionwasfotrndbelwee'ltheprcsencc of
a foreloolvarusand hammcringof rhefith digh (67).The
rcasonfor lhis is as lhe forefoolvarusdeformilynainlains
thc subtalarandmidlarsal(obliquearis)joinls in theirfully
pronarcdpositions,the line of drive affordedflexordigilo-
rum longusis altcrcdallowirg it to pull the plantaraspects
of the lesse!digits medially(Fig. 3.34).This mcdialpull
(which invertsthe more lateraldigits)is increased as the
calcaneusev€ns bcyondperpendicular ss the rendonof
llexordigilorumlonSusis str€rched by the shiflingsusler-
laculumtali (blackarrowin Fie.3.34,B).
Whenlhe fiflh digil is mainlained in a varls positioo,
a s€ri€sof evenlsoccur that predispos€lo a hammered
di8it. Fnsdy,inversionof the proximalphalanxshifts the
tcndonsof lhe lumbricalesaDdthe dorsaland plantarin-
terossea abovethe tmnsverse axisof thefiflh meratarsopha-
langealjoinl (Fi8. 3.35). (Normally thesc tendonspass
underthisaxisandacrto plantarffex thepoximal phalanx.)
This newpositionoffurcrior sllowsthesemusclcsLoactas
dors'flexorsof lhe proximaiphalanx,the.ebyinitiatinga
hammeringofthe digit.Secondly, inversionofthe pmximal
phalanrshifislhe rcndonofabducrordigiti quinr'underthe
metatarsal head,makingit a pla.tarn€xor,not an abductor
ofthe digil. As a result,thc lhifd plantarioterossoi is unop-
posedin crearingmodialdeviationoftbe digit.]'he newrc-
72 FOOTORTHOSES
andolhcr Formsof Conservaiivc
FootC: c

fiSure3.30.Secondstagehalhr atduclovalgus, The |rt{'ril FiBUre

3.31.Ihird ,lageof h.llur abductovalgus.
The
,hiftin8of lho hallu'(ir StasoI supplies
addudorhalluci!lnd nllv .lisplacedmusclesand tendonsin Stage2 will
the lonSikxor and extensor rcndonswith n ,isnificanllever .1bd,,ctthe hallux only lnlil lhe dirtal phalani prcsse6
am ro rMuct thc hallux.It lhis occursdurinsRowth ye?rc, neiFrboriry di8it. Al that tinp, a rct,og.adeoiary
tun.tionalrdaptationof boneq!ickly {ollor/s.lAdaptedfrom reik.led back into lhe faal Inetalrrs.rl,forcint it intoa
RootMC. orion WP,Wced Normal,lndAbnormalfunc- lion of adducl,onireferrcdto as mcutarsusprmus
Iionoflhe Foot.LosAoselesr ClinicalEiomechnnics,
'H. 1977.) (Ad.,pted
trom RoorMC, Orion WP. WeedlH.
AbD,rmal Funclionof the fool. LosAnselerrClinical
charl.!, 1977.)
ioint which is used thrcughoutthe range of hallux
dorsiflexion.The origirtrl lransverse plao€ax;sis still pre-
sen(, b$l only for ha'lux molion in the plafltarlicxion
range,"
The prcgressiolof d€formirytypicallyendsduring
the lHrd stageof hallux abductovelgus as the individual.
becauseof pain or inst$ility, leams to ,void bearirg
weighlon lhe hallur by dcvelopinganapropulsive gail pal-
lem (i.e.. lifiing tbe hecl and forefootsimuhaneously). lf
the hallux conliou€sto bearweight,the fourrh and finnl
strgc of dcformitywill follow. This sla8eis charactcrized
by completcdislocationof rhe halluxiiom lhe mcktarual
heid (Fig.3.32).This dislocationcanonly occurif lhc scc-
ond mctatarsal losesits b0 r€ssingeftbcl,suchas whcn a
dorsnllysubluxcdsecondmehlarsophalaogeal joiflt alkrws
thc halluxto underridclhc digir.Because ofthc exremc ar-
licularinstabililyfleccssary to allow dislocaliofl,lhe follrth
stagc of d€fomlity rarely occ1fiswilhorl undcrlting
rheumalicinfammarorydisease or neuromuscular disordcr
(3).
Ir shouldbc cnphasized|J|arthisoutlinedbiomcchafl-
ical model for lhc dcvclopme of hallux abducovalgus
reprcsenls only onc posdbleetiology,as ihercis no single fiture 1.32.Fou.lhst t€ oth.llux aMudoral8us. Conlin
theory$at canexplainthc myriadof forms this deformit) uie,,f lhe halloxdurinSpropulsionev€ntirally
rcsulrs
an
may prc,sentwith. llowevcr, numercus inve$ig&tor$ joint. (Adapted
caliof of the firs1firclatarsophalangcal
(61-.63)b€lievethdtabnormalsobtalarjointprunationis rhc RoorMC, orion WP,WeedlH. Nomal andAbnomal
primary crusc of mo$t hallux abducloval8us detbrmity. tidn of lhe Foot.LosAnAeles:Clinical Biomech.rnics,
1977.1
 Chapr$fi@ AbnonnilMotlotrdurlry aheGiir Cycle 7l

(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

Figore 3.34. The middance and propulsiveperiod

pronation associated wilh th€ for€foot varus defor-
mily prodrccs abduction of the forefoot wift simul-
taneous eversion of th€ calcaneus, These movcnr€nls
negatelhe nofmal laleral pull of quadratusplantae
necessaryto straiShrenllcxor diSilofunr longus's
ansle oi approach towad ihc digits (A). Instcad,
quadfdtusplanlaeexens its fdce strai8htposteriorlv
land mry even pull poslen)m€dially),allowinB the
long dlgital iiexor lo bowstrinsmedially,drawinslhe
nm,e h re r r l d E . l\ I nr u J \n ru ( p o 3 rrro n' .rri o E I i r'
upper left corner of A),

Figur€3.35. Displacem€ntof lendons(6racka o$5) associ-

at€dwith inlersionof the di$it(tdtitpa o99).

digjllqujnii

fi8ure 3.36. (A) Hanmer loe; (B) claw toc; (C) mall€t lof. Focalpoiotsof pressLrre
and irkrion nlay
DtoduceDainfulc:ll!rc5.

latioflsliDlhesetendonshavewilh thc transversc melatar- 1. Ha ux abd ctovaleLcot ha ur limktr,

joiflt
sophalangeal axis albws rhc involvcdnlusculalurc lo ing on the angte oI Iorefoot a&)uctus, Itoni.lly,
maintainthe proximal phalanx in a dorsiflexcda'ld invcrted forelbotvsrusdeformilytypicallydoesnol prodlce
positiofl with the proximal interphal$geal joint pah (-l). Bccars€ the forcfoot varus fool rype
planrarflcxed. Over time. contrachrcdevclopsin tnc re- throrgh the propulsiveperiodwith rciativelylittle
speclive joint orpsulesthat perp€tuatcsthc dcformiry-Thc menrbetweenthe dorsalmelalarsal headandllrcskin
vadoustypesofdeformityareillusrrated in Figure3-36. the iir$ ray movcs into a andinverted
dorsillcxcd
 Chapler
Tblee AbrorlnalMotionduriogtneGaiiCycle 75

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

pain with possibleentrupnent neurupathies. 6. Medial achiuesperitendizit8. Using high-speed

evededcalcaneu! predisposes lo enrrapment
of the mediaiand laleralplanlarnervesand
abducrordigiri quinti. (Thesenewos are
asclssors-likeaclionbelweentheevertingcal,
lh6neighbodng sofi rissres.)The eve(cd hecl
lo planlarthsciilis,microconicalfrac,
calcaneus, and/orrnyosiiisof the abduc,
uscle-
Theincreased strainplacedofl obduclor
cinenatography, Smarlet al. (41) demonstatedLharpro-
longedpronadonwill producea "whippingactiooof bow-
stringeffecl" on th€ a€hilleslendon.Thcy e&phasized that
the forefool varusdefonnityis a frequentcauseof pro,
hnged pronationand lhsl the resultantsnappingof the
achillestendoncanpolentialenicrotears,particularlyalong
the m€dial side of lhc rcndon.Becaus€of lhe extreme
forceslhat ihe achillestendonis subj€cted!o during the

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
propulsivcpcriod(rltngingfiom 5.3 to l0 Linesthc body
wcighr [69]). thcsc micmtcafsmay iniliale peritendinitis
and/ortendinosis andmly evenlerd ro lotalruptrre(:ll).
The rnedialaspeclof the achillesh individualspos-
sessingthe forefootvarusdeformilyis evdnpronelo injury
duringsraticsraoce,as lhe evertedcalcaneus placesa con-
stnnltensileslrainon the mcdialaspeclof lhe tendor.This
prolonged tructionproduces a vascularimpairrlll;nt
thatnray
predispose lhe tendonlo subsequenl degcnerative changes.
The sectionof leodonapproximately 2-6 cm proximalro
$e inscrton is particdady prone to injury becaus€ of ils
relativeavascularity.
7. Chronic hfpembbilitt oI the ankle andlor knee
joint The conflictingmovemert patternsbetweenlhc
talus and pelvis during propulsioncreat€torsionalstrains
capableofcrealingpla.\ticdeformhyofth€ variousrcslrrin-
ing ligamcntsaroundthc ankleandknee.fte initialsymp-
tomsassociatcd wilh rhishypcrmobilitymaybc asmild asa
vagueachewith occasional cavitationof theinvolvcdioinL-
Other injuriestbat mny lesrlt from thcseconllictingnG
tions includetibial stess fracture,retropatollaa.lhralgia.
pesanserincbursitis,and/orchondronulacio of thc rnlcri.tr
mcdial&tlardom€(seetcxl).
8. S.ta{icd. In a l97l snicle plblishcdin thc .4tr-
nols eJ t!rc Sviss Chiroptactors Association,Curchod(70)
claimodlhal 4 54l,ol lll scirlicacasesresultfrom frrhy
posrurcof lhe k)oL,panic!larlywhenthehe€lis maintained
in an evcrLedposition(as wirh lhc forefootlarus d€fbr-
mily). Onepossiblcnechanismlbr this js thll in approri-
mately 10,/,of tlrc population.the sciaticncrv€cmerge!
frornrhcpelvicbowl bclw€cnlwo ponioN r)1-the tendinous
origjr of lhe pidlbrmismuscte(71). Becausclhe pronaled
subldarjointlnainlainsLhclowercxtremityin an inlernally
rolalcdporilion,the pirif()rmismuscleis coDslanily being
tructioncd.thcrebvpredisposing to enknpnrenr neuroparhy
as tfic sciaticnervc iJjcompr.ssedbetwccnrhe tendinors
originsof therightened piritbrmismuscle.Whilolhis reprc-
sentt one possiblceliologylor sciaiicneuralgia,curchod
rigure 3.39. (A{) Ihe torefool
(70)fclt tharthcpainpatlcrnassocialcd
with lhe
was not a lrue sciAlicabul actu ly rcpresentcd
n
sl r.l rome ui l h pai n i n the {oor.mal l col i ,l dreral
rh€ rhigh, ghleals, ard the lumbar rcgiofl. with
anteior riltingof rhe ilium anilconrr;icrJrc
af
muscle.Hc referr€dto lhis syndromeas a "falsc
ica" andclaimedthatthepainpatternmayexiond
Orthotic Management for the For€foot
Varus Deformity
ln order10rert th€forefootvarusdcformily
a nLgarivrimpressionmusrbc lakcn thdl
ture{ rhc forfoorrenrfool relationr,hipwhen lhc
posilion.A positivemodel
maiftaircdin its neutra-l
trcm lhis inrprcssionand,aller tbe approprille
fira( ro xlk,w for soft li.suc di\placcmcnr. !
mol,lcdalongrheplantarconrour.An angledwedge
is lhenDlacedundd thc disrrl mcdialasDecrof the
sh€lloust prior u rhe rncialanalherd$).This post
Ici l hr suffi .i cnrro hri ng ' hc sagi Irl bi sccri onol
foor ro verlic.rl(Fi8.3.39).
By supfoflingr|leinvenedforefo(,t,thepost
pro|lrrlorycompensation by thesubtalarjoinl and
IoorLoenLer lhe propuhite peri'rd
$ilh all of us
tionr lockedand stable.As with lfic rearfootvaru8
mh]. theorrhoticdoesnorchrng€lhe osse('u:r
it mcrelyaccommodarcs the deibrmityhy b nging
k)m'|noldcdsurfaccto rheneutralposirionfoor.
ln rcgardto controllingmotjonduringtcmirul
phale,a majorsho(comingof the ortholicshellis
ctiusr ir endsalong thIJdisbl metaraaalshNfrs, iLis
thlL k' conirol morion during Lontlr(l !tuj midslancc
(i .e..$hcn hod) qerphl i \ ccnr(hJ ovcr rl c onhol ' c
For rhisreasonClarcy (69) slared(hal"lhc fool and
comilex is rnoslvulnerableto injury andrnosl
conl1t bctwcenheellift rnd toeofT."
 ChipterThreeAbmnil MotiondurlnelheGaitCycle 77

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
Figure3.40. The .avus tool. An inverledheel r.luires valsus
componsarionby the forcloot (via ihsl ray plaftl le\ion .rnd
eveGion aboLrtthe longitudinal midtarral joiDl nxis) il rhe
plintn' m€dial {oretool is to .raintai. SroLind.onlact (bia.k
.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
lhe ability ol peroneuslon8usto act as a firsi ray planlarflexor.
Sincecbsed-chniDpl.niartlcxionoi the firgi 6y createsa rct
rogradesupin.iory iorce ai thc suftalar joinl, the improved
mechani.al advantaScaifodcd percneuslonp.usmiy allow
lor pro8ressiled€lomity as plantarilexionoi thc lirsl r.ry cor-
linuallv litx the rcndoorinto i positionof in(:rers€dinleKion.
The inveded posilion of the sr.rbtalar joint also acts lo brins
lhe oblique mi(ltarsaljoi.rt axis (OMlAl inlo a molF vedic.l
position(8),.^s a resull,sround-reacliveiorceslCRt ar€ un'
ablc to produce ihe fronalory forces necessarvto re"is' rhe
5upinatoryiorucscr€atodby the intrinsicmusculature{paltic'
ula y the abductorh,rllucis).Be.auscoi thh. thc forcfootk
allowed ro addrct (bla.k arow in 8), and thc detomrity is
Fi8ur€ 3.4r . Patterns of conp€nratiotr for the for€too! lalgus
defordly, ll lhe torcfoot delormity is rigid (A), the subtalar
ioinl .r!st supinat. in oder to bring the lnteralplifhr ibrc'
foot ro the Bround.when a fle)iibleforefoorvalAusis prerenl
{B}, the plantarrorefootis ible to make gmund contncl widr-
oui nil€dlnE subtalarnrotiom as long as lhe rangeof knefooi
inversionis l,rl8€enou8lrto conrpensateior lhe forebot val-
gLrsdciornriry.llo\lever, ii lhe size oi (he dciormity exce.ds
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 $e rearfootdcformitywercprinrar!.hasa
mal707.failurcratc.
Glancy(69) hrd a complctelydiffer€ntoptuton
ganlingthectiology.rf lhe cavusfoot.Hc belicvedthdl
causea high percentage of individualspossess cavus
\rI roulunderlyiDg diseaseor diqorder.rhii deformrt)
havc n geneticorigin and should {herclbrebe considercd
nolnal vsrianr.This concllsionwasslrpponed by Bruck!$
(78r.wlosc sbdy suggested ftat crvusfoot maybeassocil
aledivilh a lriadiculaledsublalarioinr.
Patbomechanics
Theexrenrofnechanicalmattunction wirh
assacinled
ihe Lbrefool valgusdeformitydepends or thesi7-e
of lhed0'
fornrityandth€rigidilyofthe midfoot.Thus,in ordertodF
scril€ the compensatory pa$omcchanics associalcdwith
the lbrefoorvalgusmore aocurately, lhis delbrmityis dl
vidr'd inlo rigid and Rcxiblesub$oups.The rigid forefool
vallus posscsses lifiitcd rangesof nidursal and Iirslray
morionand is orly lrbleto bring th{iplantarforefoorrothi:
groundvia supinationof the subralarjoint (Fig. 3.aU)
whilethenexibleforcloorvalgusis ablelo bringtheplantar
tbrefootto the groundvia inversio.aboutlhe longiludinal
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-
thc ot invenion avail.bl€ rbout lhe lon8irudinalmid-
'an8e
tarsi,lioint axjs (a5in C), ihe forefool,in ils allenrpllo nralc
grouxlconract, wlll inven iB iull rrnge abortthe lon8iludinal
midr,rrlil joint axis (no|e the central metalarsak),then con-
tinw io conrpensate vj.r pronationldorsiflexionand invenion)
aborr the first rav axis and ,iJpinati.'n(plantarilexionand in-
vereionlabourthe fifrh ray ixi5 frrlorvs in C).
 Three Abnormrl MotiondurinSthe G.it Clcle ?9
Chapter

As Figurc3.418 and C dcmonslrsre. rhe patLernof sessingrormal or dccreased rangesof longitudinalmid-

ion in a flexibl€forefoolvalgusdeformityis de- rarsaljoint axis invcrsion with increasedr|nges of longilu-
on fic mrse of motionavailableaboutthe mid- dinslmidiarsaljoint axisevenion(Fig.3.43).
joint. Io some cas€E $e flexiblc forefoot valg|ls During the contacl period, the individual wilh this
ity may possess such large rangcsof longirudinal rangcof midtarsalmotioncould prcnalelhe sublalarjoint
ioinrinversionlharthesubtalarioinr is allo\redro only until lhe forefoot rcacies ils fully invened position
€xcessively throughoulall psriodsof stancephase (wi$ motionoccurringal both the longitudiMlmidlarsal
3.42). joinl axis andfirst ray axis;s€eFFL in Fig, 3.44).At that
WhileFiSufe3.42represents onepossibleEovement time, the sofr tissuc-restrdning mecbaDlsms rhat stabilize
lccn with thc flexibleforefoolvalgusdeformity,a tbeseaxeswolld preveotconliouedsubtalar joinl molion,
commonmovement pa(em is seenin individualspo6. Duting ca.ly propulsion,this foor can usually ac-

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

Fi8u.€3.43. Noflrully, lhe ,or€fool cen cv€rt trom its tully

inv€.t€dposiliononly until the pladt r for€fool re.ch€! hori'
zontal(A,Nl. However, whena llexibleforefootvaleusdefor-
rnity is present,
lhe planlarforefootis ablelo cve heyond
horizonlalwhile lhe ran8eof lnveGionremaintlimited(8).
(Notehow theove,allranSe o{ morionremaans thesame.)

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(
complisha phasicallysoundrcsupinarion of thc subtahr
joint. Howcv€r,be.auscof th€ increased rangcof cversion
availnblcabourrhelongirudinat midtarsaljoint axis,rhccal-
cancocuboidjoint does nor lock wlen lhe rearfoor rcaches
its vcnical poshionafterhed tift. If thc rangeof avaitable
forefooreversionis small(i.e.,lqssthan6"), rheindividual
may allemptto lock th€ laremlcolunn duringthe propul-
saveperiodby inveningtherearfoot(seeearlvpmpulsionin
Fig.3.44).
Whil€ this increasedrangc of subtalarsupination
hclps stabiliz€ the articdariors by bringing thc calca-
neocuboidjoint inlo irs close,pack€d posiri(in,it can be
damaging.as il creaiesa l.tteralinsrabilityc,rpftble of pro'
ducingchronicinversiorsprainof $e anklc mortisc.lb
protectrgainst this lateralinstability.thc individu.l wiU
ofien invert &c for€foot abourthe longitldinal midtarsal
joint {nd, if necessary, the first ray aris, lhercbybringing
lhe.ctrfoot back ro s more stablc position (sce mid-
propulsionin Fi8.3.44).Althoughthe-s€ motionsreeskblish
frontrl planestabilityoflhe anlle, rheymry bc deslrucrivc,
as thcy ser lhe aniculalionsof the mid- and forefoorinto
molion as verricalforc€spedk.This may lead to chronjc
bunionpainovertbedorsom€dial tinit anddorsolabral6fth
metaursal headsas the adlenrilious bursaeare sbcaredbc-
twcenthe skin (which is maintainedin a fixcd posirionby
shoegcat and the rotsling meratarsalbcads.
Also, inversionof rhcforefoorduringprupulsionprcvcnrs
the nomal planrzrllect{nymoriotrof t}|e6rsr ,a} neceslaryfor
thedorsal-porterior shift of the li6t merslarsophiaogcal joint's
lrafirvencaxis(Jndmay thcrelorebc rcsponsiblc for rhedevel-
oprne of hallry limitus or hallux ab&clovalgus)and will
lessentheabililyoftbc firsrmelata$alheadlo rcsisrground-
rcacliveforces(as is evid€ncedby a diffusc crttus forlnarion
benealhthcsecondandthirdmerata$alhcuds.)
If the flexiblcfoicfod valgusir greatclthan6", lhc
cxcessivcsubtalarsupinalionncccssaryto lock thc calcl-
neocrboidjoint may be evidentas carly as llte hldsrunce
(Fig.3.45).This pre'n.rture subtalarsupinlltionincrcflses the
Figure3.45. Footmotionswith flexiblefo.ctoot valgo3d.formily gre.ter rhan6. (posteriorview of
lh€ right foot).
ranfc of calcanealinversionand extcmaltibi{l rou
rvhidhstraiN theperoneals as thes€musclesalemplrc
cel.rateth€€xaggemted movements. As lhis foot enle6
pronulsiveperiod,the individualinirialty prorect"s agai
the lareral illsrabiiity by invening rhe for€foor abour
mid!arsaland first raya.xes.
However, when a large forefool vatgus dcformity
prcscnt, rheamounlof forcf.mrinversionn€eded to brin!
rearlootlo perp€ndicularoff€n exce€dslhe mngcsof
available aboultheseaxes.This bcingthccase,theconri
rdnlc of calcineal evelsion nece\saryto bring rhc
b{cl, Lovenical can orly occrrrvia suddcnpronalionof
rubtirlarjoinl(scemidpropulsion in lrig.3.45).Thisof
pre(lisposesto injriry,as il rnlocksall of lhe aniculrtions
lhe lootat o timewhenmaximum siabilityis€sscnrial.
Whilc th€liexiblcfbrefoolvalguldcfornily
Iaterrlinsti$iliry(with its associll€ddysfunction) primad
duri rg fic tcrminalsranccphasc.rhe riBid forefoorv
defomiry,rcgardless of its size.will produccposturald
fun(tionduringall portionsof slanceph{re(Fig.3.46).
Duringtheconhcrp€riod,rhc individualpossessingr
rigid forelootvalgusdeformirywill bc ableto pronatc
subtrl$ joinr only until tbe planrarforefootmalesgmund
conlrct.Ar ihal time, the subtalarjoinl is forcedinrorapid
supi alory comFensation(referredi{) as *rupioarory
as lhc rcarfoortipri larerally to bring the plantal forcf@tto
the uround(s€emidconlactitr IriB. 3.46).If lhis f(xx had
beenflexible,the first ruy and midrarsaljoinr wouldhavc
compcnsatedfor rhe forefoot valgus defornrily by allowing
thc colire forefootto inverr.Howevcr.b€causethis tool
posscsses suchlimitedrangesol midtarsatand firsrraymo-
lion. thelatcralaspeclof rhepladrarforefootcanonly makc
grcundcontacrifthe subralarjoint supinates.
Whilc the patternof compensation itlustrdtedin Fig-
urc -1.46is oftcn describedascla$.sicfor I rigid for€footvaf
gusdefornily (79),clinically,il is rarelvseen,Morcofren,
thc individual\rirh this forcfootdcfbrmityis ablc to avoid
lhe supin0loryrock by strikingrhegroundwith thercadool
Hc€llifi
 chaptr Tt@ Abnor|trll Motlo. dudra 0t. Gait Cycle 8l

Mldcanlacl Fulllo6loolload Eanypopulsion Midpopulsion

tigure3.46.rool molionswitha d8idforefoolvalgus(poslerior

viewoflh€ rightfool).

associar€d wirh a lateralhoelstrike,manyindividualswith

3.47. B) exr€sively inv€rlin8 lhc r?arfoot prior to
(A), lhe individualwith a rigid forefool vilBur de- hjnd the laleralmalleolus)and may be responsible
is .llowed lo pronate lhe sublala. ioini Ihrough a
nngeo, molio. (B),avoidin8th€supinatory iock thal wherethisrcrve pierceslhe fasciabetweenthe anteriorand
hateolheiwis€oc.u.r€d.Unfodunatelv. inveGionof
.eatfooldu ng late swinSphascdisplaleslhe inatialpo;nl
(onrdrI lalerallyI'1J.,whrch. bc(aLrseol rhe limrlcd
availablelo absorblhe5eforces,predasposes the lateral
€xlemity to high-impact njuries. This srrike paltern
explainwhy individlals wilh cavu5feel are more likely
ircnrfefioral slres5fract!.o (22),B.ealerlrochanteic
(25),and ilioribialband iri!lion syndrome(24).lr also
why so many investiBato6believethat the rigid foie'
valSusdelormitypredispose! low ba.k pain (80) and
lhisfool typei5 ofien fefered to'o as a hi8h-impacrfoot.
inver(ed(Fig. 3.47).This may be a learnedre-
in whichthe subtalarjoinr is dcliberarely inverred
nculralin anlicipalionol lhc supinatoryrock, or,
commonh,- is the rcsult ol a combinalionrearfoo( ial nerve.As statedby Radin(82), inversiol|of thc hccl
toor!algusdclorhiry in whichrhedegreeofrear-
varusis equallo or exceeds thedegreeof for€foolval-
In older to n;nimize th€ deslrucliveforce imDulscs the posteriortibial nervein lhe subrednacular
a rigid forefootvalgusdeformitywill sirikelhegroundwilh
thc anklc in an excessively dorsinexedposilion(16). Be-
sidcsdelayingrhe inirial contactof tlrc planrartorefoot
(whichallowsthe subtalarjoinr to pronarefor a longcrpc-
riod oftimc) theinfieasedamouDtof ankledorsifcxionaf'
fordstheanleriorcompartmenl Dusclesmorelimc Loassist
with shockabsorption ss lhey decelsrale the ar*le lhrou8h
grcatcrnnges of planlarncxion.Unfortundlely,although
!hispalrernofcompensation may improvethe foot's abilily
rc absotbshock,ir may ,lso predispose to chronicmyosi-
liVperiosriris of lh€anleriorcompartmenl lissues.
while fte rigid forefool valgus deformily produces
high-imprctsymptomsduringthe contaclperiod,the mid-
stanc€pcriodmolionsarerelativelynormalwith theexccp-
tion thal the rearfoot is maintainedin an exccssively
invertedposition.Unforllnately,thismay resultin chronic
lenosynoviris of peroneuslongus(which is lraclionedbc-
for an
cnlrapmenlneuropalhyof the superfcialp€ronealncrve
lareralcomparrments(81)(Fig. 3.48).
(81) clain that the excessave
Cangialosi and Schall
subtalarjoirrl supinationassociatedwith rhe rigid forefool
valgusd€formitycrealesa "lauhessoflhe fl€rveagainstils
fascialwindow" which providesthe initial stimulusfor a
neLlrophy. They noted thst the clinicll signs of lhis
monoocuropathy may ranget'iom hypereslhesia to hypoes-
thesia,or evcn anesthesia, alongthe dislal lalerelleg ar
dorsalfool. TheyalsoclaimtharpalpatioD in theareawhcre
$e nerveexits lhe fascialwiodow may reveala nodular
fibrosisalongrhecourseof the neryeandlhatcompression
al thispoin{mayeracerbate thepainaloflgt& n€rve'sscn-
sorydistribulion.
It is alsopossiblefor the .igid forefoolvalgusdcfor-
mity to prodoceentrapment ne!ropatbyoflhe posleriortib-
significanllynanowstheinterspace belweenlho modialcal-
cancusard the flexor relinacuhim(i.e-,the tarssltunn€l),
which resullsin an increased coftprcssiveforceplacedon
space.Irita-
82 FOm ORTHOSESundOlher ForN of C'otr\cNrlive Fdn Carr
Fiture 3.{4. The incr€aled rangeof
lubtalarsupinationdurin8rhe mid-
stance Deriod strains th€ hi€al
comoarlrncnl mu.culature G) and
predispGesto enlrapm€ntn€uropa-
thy wh€re the snp€ ichl pero,|eal
ncrv€pierccsthc f:scia (8). Ihe ren,
vtry dirldbulionoflhis n€ruei5 illu+
trntedin partC. 5L/ axis = subtalar
riSure 3.49. Normally,rhe subblarloinl pronalesdurln8 latc
proFrlsion (A), which allotl/s tlie final push-off to oc€ur
aboul lhe lransverse met tarsal ark (which runs b€t*elln
lhe firrl and r€cond m€hrarsal hea&). Nore rhat th€ plnntar
fasciais visibly lensedduring this pr.rshofl. Conve6€ly,whcn
. risid forefoolval8{s defomity is p.esent(8). the agrd and
invededdispositionof the rcarfooidisallowsuse of the tl,ns-
ve6e axis, and lhe foot as torced to roll oii ils oblk+re
metaLlrsaldxk. (Thes€illustratiotrsw€re adaptedfrom pho.
loSraphsfrcm EojsenMoller f. Cdlcaneo.uboidioid.nd nil-
bility of the longiudinal ar(h ot the foot at hi8h and low Sea.
push.oit.I Anat 1979j 129: 165-176.1
tion oflhc ncrveat thissiteis furtheraggravaEd by rhetact
tbat cversionof the forefoottractionslhc lateralDlantur
ne e, therebycrealingan environmenlthal favorsthc dc-
vclopmcnlof larsaltunnelsyndrome.
As the foot with a rigid forefootvalgusdeformilyen-
:
.-j
tcrs alr pn)pulsiveperiod,lhc subtalarjoiot is ollcn u
kr nrcventlareralinstabilirybccaustof thc typicallylimikd
ranlc of sublalarcversion(cvcrsion in a cavusfoot is o !|l
limiLedto 5" or less[?5D..Asa result,lhe subtalarjoi re
mains supinaredand the applicationof gruund-reactiv.
foaccsprogrcssesftom the latcral heel (o thc latcral fore.
foor. wherc the final rransferof force occursabout$e
obl;,lucmetrtanalaxis,not lhe rransversc mcrsrarsal axis
(Fis.3.a9).
As mentioned earljer,Bojsen-Mollcr (73)relbrstothc
uscofthe obliquemetatarsal lxisas a low gearpunh-oflb!'
ca0scof lhe significanllyshortcrlever arm !ftbrdcdthis
a'(i\ He wasabl€to studythesrrucluralinreraclios as$c!
atedwith a low geafpush-ofT by usinga lnrgcglassplxtc0s
.i wrlking platformandthenrecordingrhcvrriousporrions
of rhcgait cyclewilh a high-speed camera.The photosrc'
vealcdtharwilh lo$ gearpush-otl.propulsionproceedcd as
e rolling actionover the lateralpart of the ball of rhefool
wilfi the leg exlemilly rolate4 the refflool inve|tcd, andth6
forclool addrcted.As the fool movesinlo its linal shgesof
pmpulsion,continuedground contactat lhc lateral forcfool
forccs$e lesserdigitsinlo an excessively doFiflexcdposi-
tion. which predispos€s lo Monon's neuoma (84, 85),rg
dori'llexionofthe less€rtoestrsctionslhe i|Iterdigital neoc
agairsrthe transverse ligamenr(Fig. 3.50).Aho, because
the sccondtkough fifth metatarsal headspossess smallcr
radii lo th€ plantar fascia (rcfer back to Fig. 2.16),
dorsiflexion of lhe lesser digits rcsults in only m
insjgflificarltighteniflgof the plantarfascia.andthe$tabi-
lizaljonaftbrdedby thewindlassmechanisnis los!.

This was demoosrrated in Bojser-Moller's (73)
in thsrduring low gcar push-oIf,althoughthe
archbecame high,ncitherthc plantarfascianor peF
lolguscouldbe se€!Lolenseundertheskin.Also,he
thlt throughoullow gear push-off, rhe rearfool
invercd, thcrebyerposingthe postaxialfibular
to lafger verrical lorces. He compared rhis lateral
of propuisiveforc€s to rhoseocflrring ir lhe
of amDhibiansard reoliles and lo those in the
i!8 footofarborcalprirnales(73)(Fig.3.51).Il scems
lhat this laleral displacemeD!of propulsive forces
prcdisposcro fibular and oih€r lAteralktreeiniuries.
chaptorThrse Abmntr l Motiondffirg lhe Crit cycl€ 83
fiturc 3.50. Us€ ot the obliqus mclatarsalaris durinS the
p'oprlsive p€riod maintainsthe lcss€rditils in a dorsiflex€d
positionfor an €xt€ndedlengthof time (rrow in ,ns€t),This
actionfesuhsin a lelh€tn8oftheinterdiEital nerveaSainnthe
distaledgeol lhelranlve6emetataEal ligament (rta.in rric0.
Because lhe poximalportionofthis nerveis fixedby atiach-
menBro flexordisitorumbrevislwhichfiresvisorou,lydurin8
prcpukion),the nerueh tractioned dt bothcndsas il bends
againslthefibfoused8eottheliSameni.
Figure 3.sr. The postaxial fibular
border lbiacl h A) is €tpos€d
lo propublv€"[ow
torces in a variely of
amphibians,r€ptil6, and tr€e'{limb-
ing mammals. (Parlially
adapbdf'om
Caffoll Rl. Vedebrate PaleontoloSy
and EvolutionNew YorkrFrceman:
469.)
ClassicSign6andSymptoms Associated
rryiththe
For€footVslgusDeformity
Tho signs and symptomsassocialedwitb the forefoot
valgusdeformityafe depondeDl uponthe ffexibilily of lhe
midursalandsubtalarjoinls andoDthepanicularpattemin
whichtheindividualconpensates for thedeforlniry.For ex-
ample,if tbe forefoot valgusis associatedwith a large range
of motion about the longriudrnalmidtarsaljoint that allovr's
for continued subtalar pronation tlroughout propulsio!
Geferback !o Fig. 3.42),lhe individualwill displaysigns
and lvmDtoms similar to lhose of a fo.efoot varus defor-
84 FOOr ORTHOSES
andOlhcrFo.rnsof ConserviveFdn Care

mityr hauuxrbduclovalgus, medialcchillcspcritendinitis, roliLlirsmehlarsalheadsand tl€ skin (which is hcld

plantartasciitis,erc.Howcver,if the individualpossesses n tiofery br-shoegear).As a result.painfuliflfiamedbuni
flc\ible forefoolvalgusdcformilytbatproducesa lateralin- ;rre!xrrcmelycommonwilh rhisfool llpc.
stability durin8 the propulsive p€riod (ret'€r back ro 5. Intermelawsophalangeal bu^iais toith passibh
Figs. 3.44 3nd 3.45), lhe tbllowing signsand symptotus intetdigital neurotut. In addition to prcdi$posjngh
bunionsandbunioneltcs, thcsuddcnpropulsivc plriodrorq.
l, A tnedium"to.high me.lizl longitudinal arch tior of lhe metararsal hcadsassocialed with comDeJNalio0
height off-weight-hea ng eith a ltlight lob'edng ol the lor r dcxiblc forelborvalgus Jefomil) ma) prodce
arch upon weight-bearinB. chronicsh€aringof lhe intermetatarsal t ursae(Fig.3.
2. Mid-b.motlerde cs usfotualion t{ler lhe frsl, will) cvenlualbursitis.Wlile oumerousauthorshav€sus;
second, and somelimesthi4l metatanal heads, DEti',E gesrddtharmolionof the mBtatanalheadscausesa
rhc contactpcriod,the jndividral with a flEriibleforefoot pinchingof the ;nlcrdigjtalncrves(ihis thcorywas
valgusdeformityposscssing limitedrangesof longitudinal nall-postulatcd b) T. G. Mo on in I87h[87]1.theloc.rri
midtarsaljoint axis inyersionwill mostoflen be fbrcedIo of rLrenerveunderthe transversc ligamenlm*es suchdii
dorsifiexlhe firsrray in ordcrto pronrtcthc sublalarjoinl rect enLrapnrcnt urlikely. Rath€r,it hasbcensuggcsted bI
Geferbnckto lig. 3.44).'lhis resultsin an cxcessivcload- Bossleyand Cairney(ll8) lhat xn interdigihl neurorna €-
ing otlhe planrarfirs! mcmra$ilheadwith evcntualdiffuse sull\ when tbe inffamed,swollenbursais suffrcicnily djs-
c.rllusfbrmation. plared from its inlerspacelo causecompression of th8
The flexibleforefootvalgusdeformirynlay alsoplr). neurovascular bundle.They noledlhat duringsurgicalex-
duce,r diffusecalluslormationunder$c secondandthird plofttion of a painlirlinrcrspacc. lareralcompression ol th8
metatarsal he3dsls drring lhe propulsiv€pcriod,thesubta- i ui ,l oor di d i ndee(icaLrserhc i nfl dnrcdbursal o
ldr nnd/ormidlarsalmolioosnecessary to bringthe r€arfool lronrbctweenlhe metalarsal heads,whereil presscd agaid
back ro a vertical position may inhibit thc normal lhe L rcrdigitalnerve-
planlarflcolory motioosof thefirstray.This lesscns lhc abil- Apparenrly. no partofthe ncrveis prorcctcd fron the,
itt of the firrt metarars.rlheadto bcarweight(duclo thc al- conrprcssive force. as hislologicalfindingsincludcepi-,
tercdargle of approachaftbrdedpcroncuslingus), which peri'. ard endoneural fibrosis(89),The third inlrrspiceiJ
in l rn forc€sthe s€condandthirdmetala$alheadr|o sup- panicularlyproDeto injury, t$ h fcceivesbranchcs fton
pori a grealcrpercentaSe of Sround-reactive lbrces(predis- bol| lhe medialand lateralplanl:rrncweslnd is lhercfon
posingki diiTusehypcrkemlosis). thickestol lhisjunction(Fig.3.53).
J. Hn G limitus, ha$ux aM.uctovalgus- lt ptopul Clinicall). it is ofLenpossiblcto idcrtify a neurcna
siveperiodcompensariotr tbr the hteral instabilityincludes by .queezingthc metata$alheadslogelher(which con-
pronarionaf the first rny (Fig.3.45),a hall r limiru$dcfor- pres\esrhe bursae),then rpplying pr€ssure
mily nay result,rsthe dorsal-posterior shiftingof th€ firsl alor-qlhe plantar
'nterdigital
surfaceof the affecEdweb spacc.Il0
metatarsophalangeal joirrl's tnnsversc lrxis is suddenly nsuromais prescnt,this pkntar pressLrre will Produce 3i
blockedjust as lhc hallux is rcachjngirs p€ak rangeof immcdiatejncrea.sc in prin as lhe neuromais compressed
dorsiflexion.lf a significantmctatarsus adduclusis prcsent
(i.c., greaterlhan lr'), thc suddcnpropulsilepetiod lirsl
ray pronationmay producesubluxationof the metrlar'
sophalangeal joint wiih the evcnLual formationof hallux
abductovalgus defonniry.Because thefirsl ray is allowedto
planlarfl€xduring carly prrpulsion, lhe nretalrsopha-
lang€aljointdcformityassoci ed with rheflexibleforcfool
valgusdefornily is usuallymild, i.e..the halhx abdudo-
valgusrarelyprogresscs bcyondthe secondstage.and thc
halluxw ill maintaidat lcasl45"of dorsillexion.
4. Dononedial and dorsolatelal butlion pai . (Noae
tha! ,he dorsolateral bunion is often nle ed to as a lai- nerye(neurovas.ular
Ior's bunian or a bunioneue).The sldden propul$ivepe- bundle)
riod shjftingof the articularions a-\.rociared with srbtalar.
Figure3.s2. Ihe intermelahrsophalangeal bursa (lB), which
midtanal,andlirsl rayconpcnsation foi thelateralinslabil-
tnny be up to 3 cm lon& e{ends b€tween lh€ melaliteal
iry increascsthe fronral planc motion of the metataNal heallr and erd! dislally near lfte center of the proximalpha'
heads(rh€ iirsr mcraLars:suddenlyioverNwhile the fifth lanx.The exceptio. to lhis occuE at the fourth ard fiflh i.lets
melatarsal everts;sceFig. 3.45).This increaredmovemenl sp"r.c,wherc lhe blrsa doesnot extendbovondlhe transv€Ae
producesa markedshearingof thc dorsomedial anddorso- metrtaca ligamenl,which mosl likely explainslhe rarityof
hteral adv€ntitior$hursae,which are trappedbelweenlhe svmtjtomsal lhrs Interspd(e.
 Cbnpler'l
h.ee Ahornrl Motlondrrhg tle CaitCycle 85

to pronntclhe sublalarjoinl.A chroricmuscularachcir the

lateralcompartm€nl m8y be thc only symplomassocjated
with thisexaggerated muscularstabilization.
Whilc theabove-mentioned signsandsymptomshave
beenassociated\rjth the flexible forefoot valgusdeformily,
a differenigroup of injuriesshouldbe cxp€credwith lhc
rigid forefoot vatgus defomity. The classicsigns and
symplomssssociared wirh rhe riSidforefoorvalgls defor-
mity areasfollows.
l. High medial longitudinal orch, bolh oB and ofJ-
weight-bea ng, \,ilh the heeb inveftad .hring stlttic
stance(Fiq.354). The potenlialfor injury is dircctlyre-
latedto the heightof the mediallongitudinalarch,as high,
archcdpcoplearemorelikely to bc injured(90).
2. Modercle.ro-nafted callas fonnztron under lhe
f.rcr and f.fh netnlaaal rr€cdr. Becaus€of tbe fixed po-
silionof forefootevcrsionassociated witb therigid fbr€fool
valgus,lhe inilial point of groud contacllor the plantBr
forefoololten occursdirectlybeneaththe lirst metatarsal
head(Fig. 3.46).As thereis a markedlylimired rangeoi
molionavailableaboutthefilst ray axis,the frsLDelatnrsal
is mainlained in its plantarposition,whichsubjedstheskin
3.53.The third inlerspace((;are, receivs bran(hes underthe lirst metatarsal head(particularlyunde.the tibiai
bolhlhe medial(A) and lder.l (8) plantar nerves.
sesamoid) 1orelalivelylargeimpactforc€s;a localiz-ed hy-
perkeraloliclesionquickly follows. As the subtaiarjoint
compensates for the folsfool d€formityby invertingthe
rearfoo!, ground-reacliveforces shifi from the lirst
metatalsalheadlo the fifth metata$alhead.As this foot
movesinto its propulsiveperiod,ils characterislic low-gear
pusb-olIcausesground-rcactive forcesto p€ak underthe
lifth met8larsalhead,which may result in markedcalhs
formationat thatsite.
3. Cloaing or hanmedng oI the dieits (parti.ubrlr
the Ioufth andlifrh). The larger metalarsaldecliDeangle
a.ssocialed with lhe cavusfoot forcesthe proximal phalanx
into a dorsiflexedposirion(Fig. 3.55).Unforruoalely, this
createsa biomechanical environment that favorstbeforma-
tionofdigital codraclures, asevensligil donifleton ofthc
proximalphalanxresultsin a sup€riordisplacemcnt of the
lumbricaleandioterossei tendons(Fig.3.56).This superior
3.54.R€lal(€dcalcanealsr.nce wilh a riqid foref@l
displacernenl, if nild, will preventlhes€musclesflom ac!-
ing asmelalarsophalaDgeal joint plantarflexors, as tlteywill
be ablelo createonly a comprersive force ar thisjoint. lf
lie distal,inlirior aspectol the swollcn bursa.Obvi- lhis superiordisplacemenr is sufficienr,rhe interosseilen-
, lighl-nllingshoeswould grcadyamplify the symp- don will act abovethe lransverse axisof lhe metatarsopha-
associalcd withinlermetatdrsuphalangeal bursiris. larg€al joint, making lhis muscle a dorsiflexorof rhe
6. Mlositis oI the lateml conryrtmenl ma$uLlture, proximalphaianx.
th€ flexible forefool valgus is grealer than 60, com- Theextcnsordigirorumlongusmusclc,evcnthoughiL
sublalaJ supination and extemalleg rotarion basno direclauachmenl !o rheproximalphalanx,will am'
durinsrhe laremidsrance period(Fig. 3.45).These plify th€ metataNophalangeal joint deloritrityby virLLre of
ls muslbe rcsisrcdby vigorousccccnrricconlrdc. ils tendinous sling thatwrapsaroundrheproximalphalanx
of pcrcneus longusandbrevis,which may predispose (Fig.3.56,bhck anow in B).
lrinic slrair of thesemuscles.Peroncus bievis is also DurioSa cadavericevalualionof the digilal exrensor
duringthepropulsiveperiodas il altemptsto stabi- mechanisn,Saoajianet al. (91) noledthatwhentheproxi-
agairsllaleralinstabilityby co.ncentrically conrracng mal phalanxis ir a slightlydo^iflexedposilion,manualiy
 andOtberloms of carsenativeFel clre
86 FOoTORTBOSES
Figure3.ss. Th€ ptoximal phalanr in a cavusfoot is main-
tainedin a do]lmex€d posirion.
Fi8ure3.56.(A) lde.lly, th€ lumbrical(t) and intero$ei(l)
t€ndonswill oa36b€low the lransv€rs€axis of the melatar-
sophalangealioint (TA).whichallowslhcse mrsc|6 ro acl as
plantarflexoFof the proximalphalanx.The lumbricaland
extensordisilorumlos8ls GDa, t€ndoN conlinuenlorg a
pathwaydoBalto the inteehalanseal joints,whelelheyc.c-
pulling the exlensordigilorum longus tendonproducod
rnarkeddorsiflexion of the proximal phalanx(via the sling),
yet had absolutelyoo effecton movemental the iDterPha-
langeal joints- They slated that the extensor digitorum
longusbccomesar extensorof lhe inlerphalangeal joints
only when the pmximalphalanxis held in a planiarnexed
posilion.In therigid lbrefoolvalgusdeformily,lh€ inabilily
of the lumbricalesand extensordigitorum longusto extend
th€ interphalangealjoints allows flexor digitorum lotrgusto
aie rhe(ompreslivuforcenec€ssary to mainlainthedigilsin
(B) Dotsiflexion
full ixtension. of lhe pfoximalphalanxdis
pla(dsthe lumbricaleand int€rossei tendon5(C),wh6rcin
coniunction diSilonrmkrngus,
with extensor lheyallowflexot
di8ir,'rumlongusto createa clawlnBoI lhe interchalangeal
acl uropposedin crcatingflcxion delbrmity of the interpba-
lmgeal joints. The fourth and lifth digits arc panicularly
pronc lo clawing,a-sthe low gearFush-offlyPicallyseetr
with rhis d€formity forc€sthe lesscrdigils inlo a doriiflexd
posnion tha!, during propulsion,is amplified by conuacliotr
ol rhe displacediolerosseitendons.Since flexor digilorum
longLNfires briskly during propulsion as it allemplsl0
rnaintaindigitalgroundconl3cl,lhc inreryhalangcal joi s
 ChaplclThee Abrornal Modon durlo8 the C.lt Cycle 8?

Bordclon(92) notedtlat the proximalphalanxmay

forccdinro cx[eme dorsiffedonduring crrly 6wing
rs exlcnsordigitorumlongus fircs to assistwith
ndclearance of lhe forefootby midswing.Over time,
occursalonS the dorsal metatarsophalsngcsl
andplantarinterphalangcal joints,whichwil maintain
dcformity. is
lt of clinic"l significance thatdigitalcon-
displace thc fat padsnormallypresenibeneafithe
hcads anreriorly, thereby predisposinglo
secondaryto decreasedcufioring (93).
Unfonunalely,Callier (94) rn€ntioosrhal digilal coD-
aremostofle,rresistanllo manualslrctchinslcch-
whilc Schocnhaus and Jay (79) claim thal evcn a
funcliooalorthotic is unableto rcduc€the decree
conmcture.Consequcntly, lhe paiienrshould be in-
ofa possible poorprognosis with cons€rvative care, Figurc3.57. Haglond'!defonnity (H) refeE to I bony prolru-
recommendations shouldbe madefor modificrrionsin lion alonglhe po5terlor luperiorportionof lh€ calcan.us.
gcar(pa icularly strelchinBsectionsof rhe loc box
lhedelbrm€ddiSit).
4. Intedigital neuromss- while the flerible foro- chronicinflammatio!,with or wilhout calcificationof lhc
valSusprcdisposes to inl€rdigitalneuromasecondary rctrocalcanealbursa,which is shEaredbetwcenthe bony de-
ionb) a swollenbursa,therigjd forefoorvalgus fornity and the achiUestendon.
Fodu(einjury via dhcct m€chanical irriralionof the 6- Latersl acfill2s perltcrldriit8. The achilles teo-
against lhc lransverse ligameDti b€cause the inrerdigi- don may b€ chronically injurcd even if Ha8luod's defor-
nerv€s$ntain rc elaslir (84), lhey are incapableof mity is not presetrt,as ihe excessivenoge of calcaneal
Bsting or strclchiog. Becauseof this, the excessive inversion neccssaiyto compensatefor thc rigid foaefoot
ionofthe lessertocsduing low gearpush-offwill valgus deformity may gready incr€as€lhe lensile straiN
thc nervcovcr thc disralcdge of the uDyielding plac€don the laleral sspeclsof the acfiilles tendon.The in-
ligamenr(Fig. 3.50).The rep€ared retheringof credsedtension may serio sly compromisethe already ir|-
nerveagain$lhc ligamenlmay €ventuallylcad to a adequa@blood supply presenth rhe tendon, particularly
rcactionwith reactivescarriopof thenefle, the sectioo2-d cm proximal lo lhe cnlcanealinsefiion.
Be[s (95),who origiMly suggesred thai srrelching, The effecrof tensileslrainon tcndinourblood flow
ssion,was thc causeof inrerdigitalnervepain, was noted by Ralhbun and MacNab (96) as they demon-
s that$c ne /e in fie lhird iflterspace is parricllarly stratedftat incrcased tensionon the supraspiflatusandsub-
lo strclchirjury bocausc thc proximalportionsofme- scapularis musculalureresultsin a reducedfilling of th€
3ndlatclo|planlarncrvcs(whichlaterjoin ro form lhis vascularb€dsof the tendoos.By applyingthis infomalion
ilal nerve)originstefrom oppositesidesoI the to thc calf, it se€msquite possible$at an excessivelyin-
digjlorumbrevismuscleand mry becomcfixod as verted calcaneuscould sufficieotly "slrangle" the latcral
muscle contracBduringpropulsiun.This markedlyin- achilles te[don (padiclllarly during cady p.opulsion, wben
6e shcaring forcesuoderthetransvels€ li8ament,as tensilestrarnsoDtbe &ndor may excred1200lbs.I9l) to
prorinalportionof lhe n€rveis held stalionarywhile tho point of producing a morbid degencration(tendinosis)
nervcis pulledby $e dorsifiexing loes. of the neadyavasculartissues,
5. Haglund'sdclormilt teith nt ocalcaoea! butsitb. 7. Chmni. /r.n,6trrotilis of pqvn us longasaadlor
lhe heclof the individualpossessing a rigid fore- invc'sion tpmir,"t of th. an*le ,rotir?. Thc invened po-
velgusis maiolaioed in a varuspositionduringsktic sirion of tbe rearfoot,coulled with the exagSeratedheight
lhe superolalcralponion of ihe calcaDeusis frc- of rhe nedial longitudinal arch, aqs to creatca strcng trac-
comprcsscd into lhe shoes heel counter.This is tion forc€ oll tfro pe.ooonsloogus lendon (Fig. 3.58A and
y lrouble\ome whenassocirted wilh enlargement B). This may p.oducea cfuoniclenosynovilis of percnous
superior ponionof the os calcis(oftenrefenedlo as longusand may evenproduc€an entnpm€nl neuroprthy of
's deformilyor achilles"pump bump"; see Flg. the supedcial peroneal nerve. lo additioD, beouse the
asrcpeatedcontactbotweer the deformedcrlcaneus ank,ein a cavusfoot possesses a higher ceriterof mass,the
laloralheeloountermay producea localizedperios- compensatory inve$io! of lho rearfoo!associalcdwith
lateralachill€stendinilis. lhe forefootvalgusdeformityis muchmorelikely to pro-
Aho, as mcntionedby Bordelon(92). the enlarge- duce chrooicankle sprair, as it createsa markedinveF
of lltesupcrolateral calcaneus may lre responsible for sion instability(Fig. 3.59).
88 FOOT ORTHOSESard Olher Forns of ConseNativeFodt Care
rigure 3.s8. rhe clevat€dmedial longit'dinal
arci associat€d wilh lh€ cavus foot displaces
lhe inse{ion o, peron€us lon8us superiorly
(A), thereby ircreasing tensil€ itrains pla.ed
on the remainderoflhc muscl€(B), The co'r-
rirued fan8eofsh.rnk extenul roLationasoci'
ited wlh a low-8e.rr push'oft (c) funher
n8grav:testhe problem by strainingthe pe.
oncus longuslendon ai its passngebehind thc
fib!la and beneath the peroneal luberclc
Figure 3.59. Nole how block A can
be tilled 45' and still nol fall on it$
side. In block 8, th€ elevaledcenter
oi mass (l,la.k do, is quickly dis-
placecllateral to its baseof suppon,
ca u si n gi l t o f all. I his ac t i o ai s a ra l o -
ltour to how a top-heavy jeeP is
m o re l i kc ly t ( r f lip whe. m a k i rrS;r
8. Diflase kueral ankle and k eepoin, Ttrc ia ing
andabruptapplication of verticalforcesatongthe posLcro-
lateral hecl dudng the cofltactperiod,couPledwith the
postaxiallransferof forcesduritg {hc proPulsiYe period,
subjecrs the laleralankleandkneeto a greaterpotentirlfor
injury.Because the fibularornally supportsonly one-sixth
o{ the toralaj(bl weighlborncby lhe leg (98).the increase
in verticalforcesmay produce3 diffusefibularskessrem-
tion wilh the p{rtentialfor conicalhypertrophv asih€ fibula
atlempts!o accommodatc the€xaggerated workload.Ir ad'
dition to slressinglh€ bonc,lhe increff€dg(Nnd_rcitclive
forccsmay be responsible tbr praducinga relaliveldxily of
rhe reslmiringligamenrsat the distallibiofibnlararticdr-
tion lnd/orjoint dysfunctionat theproximallibiofibularaF
liculalion.
The p.op€nsitytbr laterrl knee pain in individuals
possessing a ca!uslbol wasdcmonslrabd by Lultel (24).In
his st dy of 213 runnerswith a varictyof hrce injuries.hc
noted thal individualswilh cavusfeet werc much more
likely to sufler ftom lateraljoint spacepain i d iliobirial
bandfricrionsyndrome. Lutter's(24)evaluationwaspaaic-
ularly intcresling, ashe demon$trated tbnlnea y 80%o[ all
kn€e injoriescould b€ relatedto flulty m€chaticsin the
foot, with pronato.yfeet producingmedialkneepain and
cavusfect produci[g lateralknee pab. This linding w.ts
alsoconoborared by McKenzieet al. (25).
9. Chroaic gluteus medius strain vtith Wsible os-
a-l
teoadhrosit of the hip. Ideally, dufing lhe lale rnidstancC
and early propulsive periods, lhe body's c€nler of mass
reaches peaklateraldrsplacemenl andis thenprojected me.
diallyso asto allowfor theconlralaterrl heelslrike.Thete-
rum of the certerof masstowardmidlineis dependenl o!
ade(juatehcking of the calcaneocuboid joint, peroneul
lonEusaDdbreviseversionofthe laldal columnandglutels
medrus(andupperglutellsmaximus)abducdonofthe hip.
Bccrus€Iheindividualwilha rigid forcfootvalgusrlTicay
possasses limitedrangcsof subtnl4rmotion,feronealever'
sionof thc lateraicolumnis often not possible,andtle hip
abductors mitsltue vigorouslyin an,Remptto Prevenl con-
tinu.d laleraldisplacement of the cetrlerof massduril8
prof0lsion.The individualmay lean|lo avoidstrai$ing lhe
hip,rhductormusculaiure by walkingwith a flrnowedbNe
of e it, which dec.€ases Iateraldcvialionof the centcrof
mas\.UDfortunately, while the nanowbaseofgait reducel
gluLcusmediusstrain,it increasesthe risk of inversiot
ankl. sprain flnd may even pr€disPoseto , Srealef
lrochanteric bur$itis.
The hip joinl in individualspossessisg a rigid lbrc-
fooLvalgus is also prone to injury becausethc erlrenc
mDpeofcompens.tory subtalar*upinalionoecessnO lo' rhe
planrarforcfootto mal€ groundcontactmainlainsthcenli.e
low(r extremityin an enernallyrotatedpositionduringall
pharcsof gail. This placestheheadot thefemurintoa pet-
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

extensionassocialedwitb exc€ssivelower extremity inler- cenlereddislal lo lhe orthoticshcll. i.e.,early

nal rotation),it may play a signilic.arlmle ill p€rperuatirg wii!:h couldrelull in continuedsymptomatology as
in evenminorlow b.rckiojury. siveperiodforcesaretransfencdalongtheposratial

Orthotic M.nrgement for aheForefoot When a fl€xible forefoot valgus dcformity is

Vslgusllelormltt lhe shell of the onhodc (specifiq ly, rhe calcaneal
angl.) will limit excessivesubldirr pronationwhilc
Whether the forefoo! val$rs deformity is flexible or tbrefool posl will prevenl lateral instability. Schoen
rigid. thc goal of onhotictherapyis lo allow neunalposi andJay (79) chim thal ii initialedearly enough,usc
tion function of thc subialar joint. As with the forefool functionalorlhoticwill preventseverehalluxabductr$
varusd€formity,this is bestacoomplished by rakingan im" bunionfofination.
pressionof the fool that accurat€lycaptu.€sthe forefoot- Wbenthc forefoo!valgusdeformityis rigid,the
rearfoot relaliodship whcn the calcancocrboid joint is fool post ir iovaluableduring propulsion,as it assistsin
lockedandthe talarhcadis mairraincdbehi[d the navicr- dcv(lopmenlof a high gear push-offby shifiinglhc
lar.A positivemodclis thenobtaincdfrom thisirnpression, Sresiion of forccs modially through the rransverseark
alld the approprialcchsngesa.e madeto allow for soft-tis- ihe mebtarsalheads.Useofthe high gcarpush-offlvilli
suediBplacementupoll weight-bcaringand for Ihe lowering pro\€ the windlasseflectof the plantarlhscia,displace
of lhe medial longitudinal arch necessaryfor shockabsorp- tran\fer of propulsiveperiodforccs awayfrom the
tion. After th€s. changeshavc been madc,which are dis- fibulrr border,and minimizesretchingof rhemorela
cus-sedmore fully in lh€ laboralory preparationsection.an inrerdigitalnervcs as thc less€rtoes dolsiB€x6
ortholic sh€ll is molded along the planlar sudace, ending smallcrrangcsof morion.The forefoorposrwill alsobc
just proximalto the metaursalh€ads.An angledwcdgcor feclive dlrrirg lhe conlact period as ir preventssupi
postis thenaddedto thc plantaran|erolateral shell.britrging compcnsalion by thc lublalarjoinr, as thc lateral
the bisectioflof lhe reartbotto $ vertical position(Fig. will now be supporled. (Thisallowlifor a morccqualdi
3.61). bution of ground-rsrctiveforccs beneaththe
This post shouldneve.excecd15", as shoc fit be- headsthatin tum lcssens rhepoientialfor metslarsalgia.)
comesa problem.and th€ distal laleral shell mighr dig ino h must bc stressedthat evcn thouph the forefootv
the shaft of the fifih metatarsal.When a largc post angle is gus post prevenlsexc€s'siverearfoot iovelsion during
nccess y, lhe posling should b€ extendcdunder the conraciperiod,il is uoableto providelhe continu€dn
melalarsal heads.(As noledpreviously,this addilionis re- of subtalaiprcnalionnecessary for adcquate shock
fenedto asa comprcssible poslto sulcus).Allhoughtheex- tion. This is becausc the iorefootpastshouldonly bc I
tend€dpost may produc€difficultieswith shoefir, il will eflongh to bring the subtalarjoin! to ils oeural posiliofi
decrcascstrain on thc lateral metalarsalsbaf!\, as a greatcr While overposlinglhe lateralforefoot to iodocethc range
p€rcenlageof weighl will be bome by lhc metatalsalheads. subri ar pronationnec€ssaryfor shock akorption wolld
Also, thecompressible posrto sulclrswill allowfor corrin- idealduringthc contacrperiod(a\$umingthe subralar
ued orthotic control tfuough the propulsive p€riod as the were ablc to pronatethis addirionalrange),il wouldb€
progression of forcedrcmainscenteredovcr lhe compress- detrimentallo do so duringearly propuliion,as il wo
ible post,Wlthoutrhiscxrcnsion, tho footwith a largefore- forccfullymaintainthc subtalarjointin a pronat€d position
fool valgusdeformity(c.g.,greaterlhao40)will tip laterally as venical forccspeak (Fig. 3.62). Thi\ siluationcould
into supinatorycompensalion th€ momenlbody w€ighr is €ventuallyrcsultin a permaneot clongation(plasticdcfor-

Figu.e3.51. (A{) Thc forefool val-

8usPo{.

3,62. Ovcrpostint lhe forefool c|n producc an in-
of $rtt.lar prcnation, wbich would be
'rnt€
during th€ contacl period, as il would allow for
ihock ahEorption,Lnfoduaately,rhi\ posr wi
n lhe calcaneusin an evertcd posilion durinS mid-
andearlypropulsion,
potentiallyproducinS
a varietyof
(primarily
chronicsoleusrlrain{riar)).
of thcspringligament.chronicm€dialachilesperi-
and/orchrooicsuainoflhe soleusmuscle.Soleus
is perhaps
lhe mostcommonialrog€nicitrjuryaisocr-
widr overpostingthe lateral forefoot, as this muscle
viSorously
in an attenprto rcestablishsubtalarneutral-
by inve dg the ontire foot up rnd over the oversized
Thconlyway an individualwith a rigid forefootval-
car poperly absorbshockis if the subtalar
possesses adequarcrangesof sublalar pronation, Be-
thismotionis so frequentlylimircdin s{ch patienls,
of$eir high-impact symptomswill co inue despite
ia& uscof the forefoot pos!. It is for lhis reasonthal
aulhorsclaim tha( rigid foot types respondless fa-
to onhoticlberapies (79, 104).Howevor,the rigid-
lhis fool typ€doesnot neccssitate a poor prognosrs.
lSgressively manipulatinginflexiblearticulations, the
al is oficnablelo rc\umca symptom-free life-slyl€.
il cannotbe overstatcdthat when the lang€of
pronationis limited bilaterallyand/orthe joinfs
is hsrdandabrupt,il shouldbe suspected thatlhe
nnge of molion is associalcdwilh a lrianiculated
joint in wbicb casc manipuhtionis cotrraindi-
) as a lransversemetatsrsalarch by me3suringplanlar pres-
Evenif increashgthe rangcof subrslarpronationis
thosymptomrlology may slill be lessened by
inse ing shock-absorbing mate al urder the he6l
it inlo atronhodc),instructing th€ individ-
walkwilh shonerstridesand, lastly,l€[ing lhe pa-
to wcarrunningshoosas oflen as possible.McKcnzie
ChaprorThrceAbnor|nrl Motlor durira the Gslt Cycle 9l
ct al. (25) advocate that irdividualswith cavusfeetshould
wear sliPlasred, cuwclastcd shoes with softer elhylene
vilyl acetate(EVA) midsoles.Also, in orderto mioimize
patienlfrustration wilh a treahentprogram,lh€scindividu-
als shouldbe informed that cavusfeel ars lypically slow to
heal.ln onesrudyrelatingcertainfoottypesto kneeinjurics
in runners(105), it was notedlhrt the cavus-relaredinjlrics
required86 days before full rElurnlo ruDdng w.s possible
whilc Oe pronatior-relatedkneo injuries required only 46
days.
In closingit shouldbe emphasized lhat thc mechani-
c8l dysllnctionassocieted wilh the rigld forefootvalgusi!
ofien progr€ssive, which mak€smostfolms of mechaoical
oontroltemporaryandever-changing. As a result,this foot
typeshouldb€ evaluarcdregularlyto ensurcthat the mosl
eff€ctive treatmetrrprogramis being rendered.If significant
chanSesin forefoovrearfool alignment do o.tcur, lhe fool
shouldbe recasted,rod the post anglesshouldbe alrcr€dac-
cordiogly.
If cons€rvativclreatmentis unableto halt $e progres'
sionof this deformiry,surgicalinrewentionmay be neces-
sary.Fonumrely,thisis rarslythecase,asrheva$ majority
ofpatienlsrespondfavor&blyto conservative carc.Schoen-
hausandJay(79)arepsaicularlyoplimislic,astheyclaima
wcll-made onhotic will eliminale retro-achilles i.rilation,
alleviale symptofis associatedwith the plantar calhs for-
rnstion (by dislributing r{,eigbtacrossall of the metatar$l
heads),aod reduc€synptomatology associatedwith inler-
digital neuromas,lsrcral calf and knee pain, and scialica.
Th€y did ackmwledgc that the digital contractureswill nol
chaogesignificnntly and may ev€n progress,panicularly at
lhe fiftb loe.
TsANsvERsf, PL{NE AucNMf,Nr oF THf,
METATARSAL HEADS
As wilh lhe for€fool varus and valg|ls deformilies,
alig[mert of the metata|salheadsis checkedwilh the fool
ir ils rcutral position. Although lh€ lilerature is full of dis-
agre€menlregardinglhc presenceor ahgnce of a lrensversc
arch at th€ level of thc melatarsalheads,Bojsen-Mollrr
(106) explains thi! phsmmenon by Doting fiat $e
mctatarsal shaltsarecurv€dlongitudinally, with lhe cenlral
helalarsalsextendingfunhestdist&lly.He notedtbatthese
factors Sive a false impressionof a tra$veas€ metatsrsal
arch while, in rcalily, all of the metata$albeadsrrc resling
od the samelraBversc plrnc (Fig. 3.63). Cavanaghet al.
(107) conclusivelydemonstdtcd thrt thet€ is no such lhing
surc pstternsb€Deathth€ metatar6dheadsin symptom-free
individuals.Because peokpressure pointsweregreatestbe-
neaththe centralmetalaffalheads,they cotrcludedthal a
transverse archat thel€velof th€metararsal headscouldnor
tre pres€tlt and that slch a concept should be conplelely
discrrded.
90 FOOTORTHOSFS
an{lOtherFomsofcon*rvative FoolC0rc

extcnsionassociated wilh excessive lower extremityintcr- cenrcreddistallo the onhodcshell,i.e.,early pro

nal rokliofl). it may phy a significantrole in perpcltraling whi,jh could result itr cofltinuedsymplomatologyas
an evenminorlow backinjury. sive periodforcesare transfenedalong the postarial

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!'

ritur€ 3.61,(A{) Thefor€fooIval-

8u5po3t.

3.52, Ov€rposrin8rhe for€foot can produc€ an nt-
nns. of subtalar pronrlion. which would bG
durin8 th€ cortacl p€riod, as il would allow fot
shockabsorption.Unfo unately,lhis posl wi
i. the calcaneur in an eve ed porltion duftr8 mid-
andaarlyprcpulsion,potentiallyprodu.inEa varietyoI
chronicsol€usstrainlsrar))
{primarily
) of rhcspringI'gamenr,chronicmedialachillesperi-
itis,and/orchronicstain ofthc soleusmuscle-Soleus
i! pcrhapsthc mostcommon ia!rcgeoicinjury associ-
wilh overposting the Iateralforefool,as this muscle
vigoruuslyin an attemptto reeslablish
subtalarneltral-
by inve(inglhc entife foot up and over the oversized
Tle only way an individualwith a rigid forefootval"
defomitycanproperlyabsorbshockis if the subralar
possesses adequale rangesof sublalarpronalioo.Be-
thismotionis so frequenllylimitcd in suchpalients,
of lhcir high-impaclsymptomswill @rlioue despile
ialeuscofthe forefootDosl.ll is for thisreasonthsl
I author\claimthat rigid fool typesrespondles\ f3-
rblyto orlholictherapies (79, 104).Howev6r,the rigid-
of lhis lool typc doesnot neccssitare a poorprognosis.
aggressivcly madpuladnginflcxiblearticuiations, thc
is oftcn ablelo resumea symptom-freelife-style
il cannolbe overstatedthat when the rangeof
proflationis limited bilaterallyaod/orthe joint's
y is hrd andabrupt,it shooldbe susp€cled thal the
rangeof flolion is associaled wilh a triarticulated
ar joint in whicb cas€ manipulationis contraindi-
) as a traDsveme metalarsal arcbby measuringplantarpres-
Evenif incrcasing the rang€of subralarpronationis
possible, lhe symplomaiology may still bo lessoned by
insertiogshock-absorbing nlterial uflderlhe heel
il inroan orlhotic),inltructingtheindivid-
to walk$irh shonersrridesand,lssrly,lelling fte pa-
to wearrunnin8sho€sas oftenas possible.McKenzic
AbnormelMotlondurlngih€G.lt Cycle 91
Chapre!Thrce
et al. (25) advocatethatindividualswith cevusfeetshould
woar sliplasted, curvolasr€d sho€s wirh sofier ethylcne
vinyl acetate(EVA) midsoles.Also, in orderro minimize
patientfrusrratiod with a lreatnentprogram,theseindividu-
als shouldbe informedlhatcavusfeetarc lypicallyslow to
heal.In onestudyrelaringcedain fool lypesto kneeinjuries
in runners(105),it wasnotedthatthecavus-related injuries
required86 daysbeforefuUretumto runningwas possible
while th€ pronation-relaled lm€einjuriesrcquiredonly 46
days.
ln closing, il shouldbe emphasizedtbar th€ mechani-
cal dysfundion associatedwith the rigid for€foot valgus is
ofter pmgressive,which makesmosl folms of mechanical
controltemporaryandcveFchanging. As a result,this foot
type shouldbe evaluated regularlylo ensurcthat the most
cffectivelreatmenlprogramis beingreddered. Ifsignincanl
changesin forefoot/readoot alignmeDtdo occur, the fool
shouldberccasled, andtheposlan8lesshouldbe alteredac-
c.rdingly.
If coosewalivetrcatmeotis lnable to halt the progres-
sioo of this dcformity, surgical interverlion may bc n€ces-
sary.Fortunately, lhis is rareiythecase,asth€vsstmajority
of prtierltsr€spondfavorablyto conservalive care.Schoen'
hausandJay(79)arcparticularly optimistic,astheyclaima
wcll-madeonholic rvill eliminateretro-achilles irrilation-
allcviatc symptohs associatedwith the pla[tar callus for-
mation (by distributing weighr acrossall of $e metatarsal
heads),and reducesymptomalologyassociaredwith int€F
digital latemlcalf and ktreepain, and sciatica.
They did 'leuromas,
ackmwledgcthatthe digitalcortraclures will nol
chsng€significantlyandmay cvenprogrcss, particularlyat
lhc lifth toe.
TRANSVERSEPrANE AUGNMUNT or rHa
ME'IArARSAL EEADS
As with the forefoot varus snd velgus deformilies,
alignmentof the mctatarsal headsis checkedwilh the foot
in its neutralposition.Althoughthe lite.atureis full of dis-
eSresmenlrcgaidillg the pres,enco or abscnceof a kansv€rse
srch at the level of thc metatarsalheads,Bojset-Moller
(106) €xplaiff Ois phenomercn by floting that the
mctatarsalshaftr are curved lonSitudinally,wilb the central
metatarsalsextendinSfurthest distally. He noted $at these
factors give a false impressionof a transvcrsemeiatarsal
archwbile,in realily,all ofthe metata$alhoadsarerosling
on the sametransvefteplane(Fig. 3.63).Cavanaghel al.
(107)cotrclusively demonstrated thatthereis no suchthing
srre pattemsbencalhthe motalarsalbeadsin symptorn-Fee
iDdividuals.B€caoseperk pressurepoints were greatestbe-
n€ath lhe central mctalsrsal heads,lhey concluded that a
transversearch at the level of the metataftalhe8dscould not
be presentand that sucha conceplshouldbc completely
discarded-
s2 FOOTOR]}IOSESandOtb$ Formsof ConscNalive
FoolC.trc

Figure3.53. Not€ how the metata.salshaftsforfi a trans-

v€rsearch (A) while th€ metaiarsalheadsr€st evenlyon th€

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

tigure3.65.Theprorimalphalarxofa hanmeredor claw€d

diSit crealesa r€troSrad€planlarflectoryforce (A) that maln.
tairE its re.p€clivemetalarlal headin a low€r€dposilion (B).
Thisis possiblaprimariiyberausethe ligamenhthatrcstrajn
lanom€lntarsal motionsar. lessabielo resirlplantadectory
lhandorsjflock,ry molions(106).

While |lll of the metatarca'headsshoujdideallybe eve|lulcerntion dueto an uncqualdistributionofpressures,

restingon the liamelransvcrscplaa€,th€reare numenrs
situationsin which eilhercongenitalor acquir€danomdies
allowoneor nloreof the metatarsal headsto d€vaatc ahovc
or belowlhe commonlransvcncplanc(Fig.3,64).Bojscn-
Moller(106)describes {n intcrcslingphcnomerbn in which
a hammered secondor thnd digil will force its r€specrivc
metala$alh€adinto a pla rarflericdposilion(Fig. 3.65),
which mdyeventuallyr€suhin paidul planbr collosiiiesor
The ability of a nulpositionedmetatarsal hcadto €I-
fccl ioot functionderrimcnlallyis dependent on whichof
rhcmc|:ltars:s is involvedand,moroimponantly,he rangc
of nrorionavailableto that metataral.Fof eiample,iI tlle
lhird melatarsalis situaiedin a plantirflexedposilionandils
mchtarfalheadeasilyshiflsbackto thecommontran$versc
Dlanroflhe othermetatarsals. fool functionwill nolbexeri-
ouslvcompronised.and thc risk of injury is minimal(a!
 chsplcrThrcc Abnormd Motlor drringthc C.il Cydc 9a

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,

FIRST RAY DEFORMITY

PLANTARTLEXED

The plaotarflered firsl ray d€formily (Fig. 3.67) is

mor€commonand ol grealerclinica! siSnificance
lessermehlsrsal. This deformity is Pre-
s pla-otarflexcd
in approxirnakly15% of lhc poPulation(l ) ard may be
congeniral or scquired.ll is possiblclo asccnaitr
a givendeformilyis congenilalor acquired,3s lhe
deformityis typicallyvcry largeandrhefirstray
deformityusuallyporscsses €qualamountsof dorsi
plontarmolion(Fig.3.68).
Colversely,lie acquiredPlrnLalllexedfirsl ny defor'
possess€s osscousor sofl tissuc rcstrictioN thal linit
ny movcmcnl andprodlceasymmetrical dorsi-planlar
lhal oflen vary markedly belween lh4 two Lct.
advancing age,it is oficn difficult to distingukhbe-
congcnital and acquheddeformities,as .8e-related
in lillt ray molion msy allow for asyminetrical
patl€rns in thc congcnital deformity. tigure 3.57.Ihc plaotarfler€dfirlt r.y detormiry

H.€lllt

3.66.A rigid pl.nL'flered fifth netalrrsal .equi6
subt lar ioinr ptonalion in otdet to brin8 lh€
tor€footto lhe Eround.Note lhat thc.ublalaf ioint is
in€d in . pronatcdpositionth.oughout 3tancePhas€.
fifrh wefe flexible,il could havedorsiflcxed and
'av
evertcd durinS the contacl period, and subtalar funclion
would not hav€ ben comprcmised(althou8hthe fifth fav
movementwould mon likelv resuhin a lailor's bunion,as the
dolsolatelal bu6a would be rcpeaiedlv sheared betw€€n the
rctatingmetatatsatheadand the skin/shoeSear)
94 FOOT ORT}IOSBSand Olher Fodnsof Cotrsrvative Fool CdIe

Figurc3.68. rh€ cong€nilalplantarfleredfirs! ra' will usuallydorsifler andplanlarflei throughequal

ran8e5(^P:AD).

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

LAF
3,71.Invc.lion ot thc r?..foot (A) brinti lhe obliqu.
r.l ioint .Iis into a more v.rticrl po.ition (B), which
thefor€fooito adducl (C).Sincethe lo€salwaysparal-
lhe lon8iludinalais of rhe fool ltAD adduction of tho
will res!ll ln a proportionalabducrion(with resultant
n 3.72.Ao uncofiDensated
rearfootvaru..Th€slbtalar
is fully pmnated,and the medial londyle ol lh€ cal.a-
hasnot made8rcund cotrract.
prol€clivctonic sprsm of peruneuslongus.Becauseof
lo thebaseof fte lirsl mctalarsal andmedial
an acquiredplantarflexed nr* ray may quickly
Thehypertonic peroneus longusis roadilyidentilied,
rapidlypronaksthelbot du.ingswingphas€.
Flaccd patulrsit or exlrcme ecal essof libiatis an"
I Weakncss of this musclewouldallow the antaeo"
petoneuslongusto planlarffex lhe firstray.
Pr.t ncc of an ancomwnsst.t rca4fl or fon[ooa
dalomir. when $e subtalar joi in a rearfoot
ChaptcrThr@ A.bDomrl MoltoD drrhS th. G.tl Crde 95
clawind of the digirs{D). lr is of note that the acquhedplan-
tarilexedfirgt lay, which is much morc common, never re'
quircsenouShsubtalarjoint supinarionto addld the ioreloot
aboutlhe obliqqemidtarsaliointaxis (OM./A)or reverelyclaw
rhe toes{l).
rigur€3.73.An uncomp€nlat€d for€footvarus,Thesubtalar
joinl is tully pronated,
andtheplantarmedialforefoot
ha5not
madeEroundcontact,
varus fool type lacks the range of eversioo ftccssrry lo
bring tbc medial calcancus!o the grolnd, it is refenedlo as
tn uncompensated rca ool vaflls (Fig. 3.72). SiDilarly,
whcn thc subtalarjoint in an individualpossessing a fore-
foot v|rus foot type is unableto bring tle medial forefool lo
the ground, it is refen€d 1o as an uncompensatedforcfool
vrrus(Fig.3.73).
Allhough thesefoot typesare discussediD a latsr s6c-
tion, lhcy will be briefly discussednow as lhey are almosl
alwaysresponsible for an acauircdplantarflexedfirsl ray
9(r FOOTORTIIOSES t'borCrre
andOthc!Fomsof Conscrvative
deformily.Ir borh of thesesituations,the planlarmedial
rearfoolis only ablero makcgrcundconhct via cxcessive
plantarflexion oflhe first ray(Figs.3.74and3.75).Thus.an
acquiredplantarflexcd first ray q'rickly develops.The un-
compensatedrcrrfoot larus deformily is notoriousfor pro-
ducingan acquiredphnurllexed6rst ray d€tbrmity,as lhc
invert€d rea ool greatly increas€s th€ mechanical
cfficiency of peroneuslongls ns a first ray plantarfleJ(or.
WeakaessoJ lhe iwinsic musclesresponsiblelor
stabilizitrg the plaatar proxinnl hollux (patricula f db-
tiuctor ha vci andlor contracture or cxlcnsor holhrcis
,orrg!r. Both of the,seconditions rllow lhe hallux to
dorsiflexexcessively, whicfi placesa rclrogrudcplanlarllec-
tory forceon lhe firs(metalanalhead.The extensorhallucis
longusmusclcwill ofien producea visible llantrtliexioo
wilh the firstray durilg earlyswingphasc.
Figur€3.74. An acquire{ plantarfler€dfirst ray setondaryto
an uncomtensaledrearfool varus.
Fi8ure3.7s. An .cquir€d pla.larflered fitst ray secondaryto
an lncomp€ftated for€fool varus.
The saw poorly undersuxtd neurcnuscukr
de^ assoei ed wilh a pes c.trus na! ilso be
Ior an atquircd pha,adexed f^t nJ deto tity.
mentjoned,thc pes cavusoftcn presentswith a
rar:s. forcfootvalgu\.and pLnrarnexcdfiJsrIa\. A.
Ihe lorefool valgus deformily,the cxlent of
with a pl$tarflex€dfirsl ray is
malfuncrionassocialed
p€ndcnlon thesizeof the deformityandihe rigidityof
midfoot (specifically, thc availability of 6lst
do.',iflexion). Because of this,theplanlarflcxcd
firstrIly
formity is categoriz€das eilher flexible, semiflexiblc,
rigi,.l.depcnding on fie dorsifiectoryraogeavailablcto
fitsl ray (IJis. 3.7i).
Paahomechanic6
Rcgardlessof thc rangc ol rnorion alailablc ro
lirsr rc). the downwardprojccrionof Ihe iinr
sha I causer lhe 6r.t mctalasal hcad lo strike lhe
prenulurely.Whenth€ planlarflcxcd 6rst ray defonnity
Rcriblc. ground-r€activeforces quickly shifl ih€
melitarsalinto a dorsiflex€dsnd inveaedposition
3.7_i).
Durirg rhc conlaclp€riod.the flcxiblcpl
firsl |!y will dorsiflexandinvertrhrougha rangrof
mer. that is direcrlypropodiondllo thc rdngcot
prondion,i.e., the more the rearfootevcrls.lhe morc
firsl rnywilldorsifloxandinvcrt.Unfonunately, thcffexi
plar,rarflcxed firstray deformityis almostalwaysassocr
witl r compeDsared rearfootvaarsdcfotmiiywbici, ssd9r
scrircdeajlier,requiressometimcs largcftngcsof
satorJsublalarpronation.Whenthc planmrflcx€d tilsl ot
andrearfootvarusdelbrmitiqsdo occufLogether (asin Figi
3.7-l).lhesecordmetatarsalhedis particularly pron€toin'
jur). as lhe lirst fny is often forcedb dorsillexabovelhc
lcv(l of lhc lesser metalaBah.(\prNing lhe \ecofil
metrtarsalh€adto a greaterpercenlag€ ol groundreaclivc
lhis alterationin lhe dislributionot ground-reactivf
forcrsrlpicallyprcduces a mjld diffusecalluspattemundcr
the iirst metatarsalhcad (associated wilh lhe prenalu!
loadrngof the tirst m€latars.hcadduringthc contactpc.
riod) with a morclocslizodanddensecnllustbnnadon di-
recllyundcrthesccondmctatan$lhead(associated withlie
exccssive loMin8 ofthis metatarsal herdduringthEproPul.
siveperiod).
lhe flexible plsntarllcxedfirsi my may also bc rc"
{ponsrbieIur dor\omedialbunionpainandhr inlcrmehtar-
sophaiangealbursitis, as the rapidly dorsiflexingand
inve(ing iirsl ray createsa shearingforcc bctweenfic fi$t
atld secondmetatarsal hcads(predisposing to bursitis)and
bet\\eenthe dorsomedial firsl metatnrsal
headandlhc $kin
(whichis beldstatjonary by shoegeao,therebyshcaring thc
advrrtitiousbursa.
 ChaptorThree AbnorDd Moaior duriog the Gltt Clcle 97

3.76, Cat€€orizalionof th€ phntaroexed first rays.

+
)o
@r@
B c
level as lha lelser met ia6ak (8), il is .€lelred to as a
tirslray is maximailvdoBiflexedas the lelser metatarsals semiilexibledefomity, and if il is unable to reach the com,
stalionary.lf the iiEt ray cao dofsiflex above the mon rEnsveAe plane of the lessermetataEals(C), it i, re-
t.ansverceplaneofthe lcssermetataEah(A), it is re, ierfed to a, a figid defomiry.
to as a flexibledcformiiy. l{ it doKiflexcato the sanre

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.

II is alsoquilecommonfor th€ medialbranchof the verscplano of the lessermetatarsals,so the sheariDgforces

I cutaneous nerve(whichpasses overthe dor- associatedwiih excessivefirst ray motion afe mirimized
aspectof the first melatarsal head) to becom€ (whicb decrsasesthe potential for btrrsitivneuritis), and the
betweenlhe rotating mctalarsalhead and lhe secondmelatar$l headjs prokated from trauma.However,
gcar.The repeated compression of Lhissensory the sesrmoids (paircularly the tibial sesamoid)are row
oftehleadslo a mononeuritis capableof producing subjeclcdto potentialinjuy, as they aro literaly "driven"
rod pareslhesiaalong the dotsonedial aspecl of the into the groundby forcesevartinglhe rearfool(i.e.,starin
O[ oocasion, this pain will be refenedproximally Fig. 3.78).Overtime,a reactivehyperplasia of skrnoccurs
theantcrioraspec{of the ankle(3) andshouldnor along the plantar medial margin of the fir$ mehtarsopha-
with radicular pain. Tho pain associat€dwith langerljoinl,which o y actsto amplifypr€ssure alotrgthe
neuritiswill typicallysubsidequickly oncethe iibial sesamoid,as this hard callus is less yielding ro
iri1antha! beenremoved,i.e.,therangeof sub- ground-reectivefoJces.
is conaolled and/or tie Srst ray is no longer In Figure 3.78 the midslanceand propulsive period
tg dorsiflexandinverl throushsuchao extremearc. sublalarmotions are not eff€cted by the serbiflexibleplan-
Whenlhc firsl metaracalis semiffexible,the firsr Ernexed6rsl ray deformity.This would not b€ the case
headis unableto movcabovelhecommontrans- wcre the lirst ray rigid. When the first metararsalheadis un-
98 FOOToRTHOSESando$er Fonn.ofco'servarivcFoorCare
H€slSnko
tigure 3.78. foor nodons with . 3€nm€xiblepla.tarf,excdfirst ray defoinity.
Fulllbrolool load
Fi8ure 3.79. stancc phase morions wlth a rilid plantarflercd firet ray d€fornity.
able rc move to the common transv€rseplanc of lh€ le scr
melatarsals, theenlirelowerextremitymay b€ prone!o in-
jury, as subtrlarpmnalioocom€,s to m abrupthalt lhc mo-
mcnt lhe plantarflexed nr$ metatarsal mikes gound
conract(Fig. 3.79).The entirefoor acudly rip6 lalerally.
the.eby transferrin8ground-reactiv€forccs from the firsl to
the fifth metararsalhead.Becauselhe fifth ray pos6€sse-s its
own independenl axisof motior, thelifth metalanial headis
typicjlly able lo dorsinex atrd evert into a sale posilion
(Fig. 3.79. FFL). While this l€ssensthe potenthl for injury
ro rhe fifth melalarsal h€ad, it iltcrcrse3 intermetatarsal
shcsr (predisposingto intermetataNophalangeal bursitis)
and often r€sults in the formation of an advcntitous bunia
along rhe dorsolalcral fifth metatarsll head (j.e.. tailor's
bunion).
Of muchgreaterclinical significance,lhc suddencon-
tact period subtalarsupinatiotrnecessarylo cotugersalefor
thc rigid pladarnexed first ray createsasynchronous movc-
mentpalrms betweenthetalusaodthesbanl(i,e..th€ralus
is forcedto abductwhile the sha[k continuesto interrally
rotate) and results in the .apid lransfer of forc€s along thc
postaxialfibulff bordcri lhis foot behavesidentically 10the
rigid forcfmt valgls foot iype a is lhcreforesubj€ctcdlo
some injuries, i.e., slresstracturesb lh€ fool, laterul ankle
sprains,laleralkneeprin, lateralachiUes pcrilendinitis, ctc.
H€dln
He€lllft
As demonstrated in Figurc3.79.whenit isablet0,
sublalarjoint will pmnaleduringlhc propulsivep€dod
an i!(empr ro minimizerhe latcral instabilily.whilc
lesscns$c Doslaxiallraosfcr of forces and decreas€s
risk of inversionsprain,it may predisposeto olherinj
as ir unlocksthe midtarsaljoint at a time whenvert
forc.s re peaking.This mayeventunllyleadto a
cd lnrily oftbe supportingligamcntsandjoisl crpsules,
the rarsalswill bc allow€dto shift wilh the applicalion
propulsive pcriodgmund-reactive forces.
ClassicSlgDs
andSymptoms Associaaed wilh ahe
PhDtsrfleredFlrst Rry lreformlty
The claalic signs and symptomsassociatcdwilh this
deformily are depcDdenlprimarily on the rarSc of motiot
available to the first ray. If lhe 6$t ray is fl€xibl€. thc foli
lowrrgsignsandsymptoms rhouldhe crpcclcd:
1. A ncdium-to-high nedid loryiadinol aftli
hei(ht otl-vcight bearing with d miulo-ntodcrale loveF
ing oflhe arch upon t cigh!-bearin9.
2. LIild dllluse cdlhtslomaion under th. N
mskllssdl h.dd wilh r iL^tcr d.Ee locaftze.t.all&s
the seconl rnclahttul hed. The nild c.llus cenleredbc-
neath the first metatanal head rcsults frcm the prematur!
 ChaplcrTtre€ Abnoi|trd Morlondurl!8 th. Grl. Cydc 99

of lhar meralarsalheadduring the conraclp€riod. 2. Mderate-lbrnarkett collus lofituliorr undzr the

cdlusis alsodescribedas a "fulln€ss,"sincethe orly
of thismild hyperplasia may be a lhickcningof the
linesundcrlhc lirst melalarsal
head.Beca|lselhc 6rsl
heado(tcndorsiflexes abovethe commontans
Dlaneof the lcssermctatarsals.it is urable lo berr
ctfectivelyduring thc lallcr half olslance phasc,Nnd
perccnlaSe of ground-rcaotive forc€sareshjfledlo
selondnetatarsal head.LJnlcssrhisindividuallearff ro
lhepropulsive pcriodby short€nitrg lenglhofstride,a
looliz€dcalluswill quicklydevelopunderfte sec-
|Detata$al head.
J. Do$onedia! bunion pia xt,th inrnn butsoph4.
&..silir. 8€caus€the posilion of the firsl ray axis
for almoslcqualamounlsof fiodal andsagittalmove-
signmcanlshearingforceswill developwhenlbe 6rst
hesdis forced upwad durirg rhe conhcl period.
shearirgforccsmay raumatizeanyof lhe neighboridg
panicllsrlylhe do$omcdialadvenlitious b rsa end
inlermctahrsophalangeal bursa(which is sh€aredbe-
the roialirg firsl and stationsry second metat{rsal
Thedorsinexing and inveningmetatarsal headmay
Foduce enlrapment neuropalhy(with associatedpares-
of lhe colaneousncrvcs locatedalonc the dorsoma-
,spectof thenetalarsophalangeal joinr.
4. Dorsalbate el/;ottosis. ln additios to shearinsthe
;ng tissues,the erccssiveconlac-t periodlirst ray
mly even lcad to 3n osleoanhrcsis of lhe fiasl
cunciformarticulation- llis is oficn as-
wi6 dccr€ased joinl spacc,sclerosis of th€ anicu-
nrrgins and, if severc, ero$rosesalong the donal
irNof lhejojnt (panicularlyalongthe baseof rhe 6rst
A commonsequclaof suchbony oulgrowthis
of lhe neurovasculer bundleof ihe tibialisEntc-
!.t Iy ad thedeepperonealnerve:because thisblndle
direcLlyabovclhe baseofthe firs1m€tatarsal, it is
entrapped betwoeDthe rotatingexoslosisand ihe
gear,Th€ cxacl locationof the tleurovascular
is illusrratcdin Figure3.174.
5. M.did planur Iascid stain sndlor aMu.lor M-
nJoJ|iiir. As rhe fitsl .ay dorsiflexesand inverts dur-
contactDeriod.lhe firsl melahrsal headlraversesa
and upward arc that greatly increasestraction on
planlarfasciaandlbductorhallucismuscle(Fig.
Thisincrcasein tensilesirainmsy producechmnic
plan u nedtol frtst mculsttul h.ad wilh an occdsiordl
pit ch callus uder thc ditut mqti.l asped of c proi-
nal phalant. B€cause the first metatarsal can only
dorsiiex back lo lhe commontransverseplaoeof the lesser
melala$als, any condition lhat allows th€ rearfool lo everl
exccssiv€lywil greally load the planlar medial asp€ctsof
thc first m€tatarsal he{d and hallux.The den$ecallusthal
forms underthe metata$ophal&gealjoint incleasesthe po-
lcntial of tibial sesamoiditis,,s th€ hardered skh is less
ablelo dampcogroufid-reacliveforc€s.
RomEmborthal as long as the la'|8e of rcarfoot ever-
sion do€s not exceed the range of midlarsal inversion
(which is usually lhe c6s€),th€ ability of the 6tsl mctatarsal
headto dorsifex abovethe lessermetatarsalsis of only lim-
ited concem sidce lhe lotrgirudinsl midlarsal joidt aris is
able lo fully compersarefor the ftnge of subtalarpronaiion.
Ideslly, the first metatarsalherd will never b€ forced ro
dorsiflcx above the level of thc lcssu mclala$als. Ttere-
fore, whcn associatedwith e pmperly functioning subtalar
and hidtarsaljoint, the semiflexibleplantarflexed firsi ray
deformity will rarely produce injury other lhan directly
below the planlarflsxedmetatarcalhead.
If th€ plantarfexedfirst ray deformity hasbottr rigid,
thc followilg signsandsymptomsshouldbe expectod.
| . A high t rcdittt tangittrdinat a'ch, balh on ard ot-
weight bearinE, vith thc h.cls itty.ta.d dadng sElic
Jroaca The rnv€nedheclserc offen aesponsiblefor lateral
achilles perilendinitis (s€condaryto the increas€dtensile
slrain placedon th€ lateral achilles lcndon), retrocalcaneal
bursilis (lhis is padq rrly lrue whcl| HsSlund'sdeformity
is prcs€nt) and/or periostitis of lhe dorsolaienl calcarcus

6. Signsand sttnplomsdssocialedh,ilh the rcarhot

toot qpe. Bcc use the nexible plantarflexed first
alwayssssociatdwilh a r€arfootvarusdefor-
manyoflhcir signsandsymplomsintermix.
lflhe plantarflcxcd
firstray deformityis scmiflexible,
signsard symptoms shouldbe expected: Fl8!.€ 3.m. A3 th€ for€foot becomertully x/ei8ht-be.rin&
1-A neditm-.o.high maliol la^gitudinal arch otI. the flrst m€t.tars.l headshifb fonvrd .rd uprs.rd from its
N,ilhont, a slieh! loteeriaqoJ the arch on pl.nt rflcxed po6ition(A). The fo.ward motion (8) lractions
thoplanlarfasciaandabdlcrorhallucismuscle(C).
lfi) FOOTORTHOSLS
artdOtherFormsofcorseNilive Fftr Cfc

(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.

rigure 3.81. Planrar pf€.sur€ dbttibution du.ing srafic

dance. (A) We'ght-b€aringpoinls in a normal foot. (8) Figure3.82. cround-reactivefo?c€5(wr,il€ aro*f) crerl!
Weight'bcaringpoinls when a riSid plantarflexedfi6t ray i5 $perior displa.emeni of the fourth and fifih
Ilres€nt.Note that pr€ssurcrb€nealhthe heel ire 2-5 times headswhile the umupport€d secondand lhird
Srearerrhao forcfoor pressurcs. herd{ are affow€dlo drop (bleckaffo*d,

2-5 Bar post
3.84.The 2-5 bar posl. A forcfoolbar pon la bar post
an unanElcdIorctool ponl is situatedbcnealhthe
ol rhe secondthrouShftlth metata.sals. The por.
he bar po5tthal would normallv exrendbeneaththe
firslmelatarsal
shafrk "cut-ouf in orderto allow lhe
rgalhcdd lo reet In iN planrarpositionthencelhe
of the bar oon js deteF
2-5bar oosl).The thickness
the
by dlstanc€ b€rw€enthe lilsr netatalsalheadand
lransvelseolane ol the lessermetatarsals:lhe
of sufticienl
heishtso tharth€ tirstmetatalsalhead
goundcontad,and the raSittalbiseclionof the rea.-
ical.As with all forefootpons, shoe tit is the limit-
, anda barpon Brearer
thanl0 mm is oftendiflicull
ll should be ooted thar dificrenl laboratoriesuse
Mrnrgemelt for the PlantarflexedFiftt
RsyDeformlty
of whether the plantarffexedfi$t ray de-
ir congenilalor acquircd,ffexible or gid, ihe ini-
of onhotic therapyis !o accommodaterhe plantar
of th€ llrst m€latarsalhead. Thc first step h this
is lo takcaDimpae$sion that accuratclycapturcsthe
firslny planlarflcxion whilc rhefoot is in ils neLr-
chapterThroc Abrormrl Motlondurlrg the Grit Ctete 101
Figure3.83.Th€ri8ld pl.rtartler€d tirst tay d.formily tor€€s
th€ piotintal ph:l.nx into a dordflexd po3itlon(A), ,hich
ofter r€srlls in an €Itre|ne chr|iin8 of the firrt dl8ll.
differcnttermsto det€rib€tha 2'5 barpo6t.Eecause $e plan-
tadered ti6t Ey defonnilyb€haveralmostidenticallyto the
forefoolvalgusdefomity (particularlywhen the plantarflex€d
filsl lay is ri8id),manylaboErories prefurthat)ou referlo the
2-5 bar po6ras a for€foolvalgusposl with a iirst ray cut-out.
The deareeof postin8 necessaryto accommodatethe tilst
melatarlalhead is determined by measurinS the de8rceof
forefootvalgu3betw€onthe firstand fifth met.tar5alheads
andthe plantarcalcaneus /ar8leX in C).(Thetool ,houldbe
maintain€d in ils neutralposilionduringthis measurern€nr.)
Whileit is moreaccurate to referrjothisaddnionasa 2-5 bar
post (aslon8 as lhe rarond lhrcu8h fifth metataGalsa.e nei-
therin valEus orvarus),eitherapproach is fine,andil is really
justa maherof semadica.
lr3l po$tion.(In flexibledetormities,this requiresneuual
position casting whilc .igid deforeities may toleratc somj-
weight'b€aring stepin techdques). A shcll is thenmolded
to rhc positive model, which has b€cr slighlly ahered to
allow for soft tisstle displacement,attd a 2-5 bar po6t is
placed beneaththe distal shafts of the lesscr meiatarsals
(Fig.3.844 aodB).
The 2-5 bar post allows lhe fo.efoot to load smoothly
frcm the lareralto the medlalmetatarsal heads,as theplan-
102 FOOTORTHOSES
nndOtherFoms of ConrcnativcFoorC"!e

tar first melatarsalheadno longtr stikcs lhe groundprcma-
turely.The 2-5barpostis inv.ttuable whenucatiogtherigid
plantarffexedfirst ray defomr'ties as,dudng th€ contacl p€-
riod, il atlowsfor lbe continuedrangeofsubhlar pronation
nccessaryfor idequale shock absorption.When tr€ating a
rigid deformity,Langer(108)recommends addinga(f rear-
foot posl to stabilizcthe heel(Fig. 3.85)and incorporating
shock-absorbing mrterialintoor rndortheonholic.
The 2-5 bar posl alsoservesan importantfuoctionin
the tieatmcntof semiflexible andflexibleplantarflexed 6rst
ray deformities,as it preventslhe excessivedoNiflexiol
rnd inversionof thefirst ray thal is so ofteDresponsible for
injury, e.9..abduciorhaUucismyosilis,intermehtarsopha-
lang€albursitis,bunionpain,etc.If theplantarnexed d€for-
mity is particrlarlylarg€,orthoricconlrolcanbe exlended
illto lhe propuisivepedod by extendingI comprcssible2-5
bar postto lho sulcuswilh r balancefor lesior beftath the
6rsr metatarsathard (Fig. 3.86).
This balnnceis a cusiom-madepocket that supports
the lessermetatarsals andallowsthefirst metaiarcal to drop
into a cushionedwell. (Ihis is panicularlyeffectivewben
treatingsesamoidpain.) When used in the rreatmcnlof
seminexibleandRexible6rst ray d€formilies, this addition
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
vali ut, \ursicalreferralfor a dorsalbase
closins
teok)my may tre nec€ssarylo con€cl the mcchanical
tun.lion. Rootet al. (3) not€drhatwhenperforned
adolcsccncc or edrly childhood,this operatioroftcn
ducls a sponlaneous reducdonof the cavusdeformity
3.8r).
In coniurclion wift onholic thcrapy,various
lile shouldb€ usedro bredkdowo any soff
'cchnique\
adhcsionslhat may be limiting joinl motion.
pad, larly in uncomp€nsaled forefootandrearfoor vdrs
fornitie.! resultingfrom lraumaor prolong€di
it is possitJleto resloresublalar/nidtarsalmotbn to a
whi(:h lhe acquiredplailarflered lirst rry defornity
If this doesoccur.the 2'5 bar Doslandsub 1 balance
be r,rnoved. However. reduction of urcomDensaleri
typcs rarely occurs.as they are most often associat€d
tixed osseous deformily(panicularlyin older
Bec|oseof this,thegoalof manipulation is mi roforc€
Dlanrirfliexed firsl metatarsal head back to ihe
tran\verse planeof lhe l€ssermetatarsals, but ralh€r,lo
pro\c flexibilityby br€akingdowr polentialypainful
tissueadhesions(evenslight improvementsin fiexibiliiy
resultin dramaticrcductions in symptomatology). U
Flsur€3.86. Thc sub1 balanc€for lesion.

Figure 3,85, (A) Plantar view of a A B

shellwilh a 2-5 bar post;(B)planta. 2-5_Barpost
view of a shellwilh a 2-s bar posl
and a 0o r€artool po6l, i.€., th€ posl
llabiliz€slhe he€lin a verticalposi-
lion (c).
 Ahomtd Motiondurlry lh€Grlt Cycl€ 103
Chapr€r'fhrce

3.87.Dorsalbaseclosin8$/edg€oneotomya$ocialed (ruse of lhe d€formhy/in thiscasea ri8id planhrllexedfirsl

. riEidpl.ntadered fi6t ray. 8y chansinSthe decline my, hadnot beencorrccted- Thisamphasizes the impo afcc
oflhe firs!metatafsal,the cavusdeformilyis reduced.lf ol a thoroughbiomechanical evaluationpriorto surgicalre-
I osleolonv hrd bee^ ured Io realr8nrhe ,a!€,r€d
the cavu! deformity wolld mosl likely relurn as the

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
rigure 3.88. M€cthnical Estunction associaredwith a plan.
tarfler€dfor€foot,Whena nolm:l metatarsal declin€ansleis
present(A), the ankle will readily supply $e range of
dorsiflexionnec€ssary for noncompensaled frnction durm8
latemidsiance (B).Howevef,whena plantar{lcxed forcfornis
p.esent(C), lhe entire r€arloot is liked posterio y, and the
ankle, lvhich typically posseisesa maximum oi 20'
doaillexion,is oftenurableto allowthe l€Eto rcachvenical
cocoMJ
figure 3.89. when sL€ssedsuperiorlyaod injeriorly,lhe
.oruenital dorsiflexad first metalanal will display €qual
(D).Ttrisforcesth€ knte intohyoerexlension
rnd
to inrpingementexoslosis,as th€ :rntcriortip of lhe low€r
tic lir eud..eoflhe tibiareoeatedlv
collidesw$ the
thel,rlus(rld,l.Theplantadlexed
lorcf(x)ldelomilymay
BrealLhar evenwirhconrpensalory hyp€rcr1€nsionofth€
(D, rheheeli, t]nableto makegrolnd contacl,andth€
vidlnl may walk rnd standwiih $eisht suppoftedenlilely
at
OCCg
rangosot do|si ard plantarmovement(A) while theacquird
d€formitywill Foss€se asymmorricalmolcm€ni patt€rnr(8),
 Chapler'thrccAbtromslMotlondlrlrg lheGaiaCycle 105

xedposirionoi rhc firsl metata$al.(A dorsalbase coexislerceoI variouscombinalions of forefooland reaJ-

iri is oiren presenL.)
Assominglhc doninexedlirst too! defbrmitieswould be lhe rule, ratherlhan the excep'
is associalcd wilh an evcned hccl Lhalis able Lo relurn Lion.This idea was consisrentwiti tbe foo! survey by
vcni(alto(iri0n.lrearmcnr shuuldioclude a func- McPoil et rl. (1) in lhal nearly857, of thoseindividuals
onhoriclhal minimizcsrhe deareeof r€adboreveF possessing sublalarand/ortibiofibularvaromalsoposscssed
inverLing the calcaneus, tbc orthoticwill imprcve sometypcof forcfooldcformity(eiiherforefootvarus,fore
n€chanical eificiencyof peroneuslongusas a firsr ray fool valgus,or plantarflexed first ray).While the combina-
fiexoranJ ma) po'enuall)corcJt rhc dcru'mn)), lion of a renrfoorvaruswith a lorefoolvalguswasthe most
wilh thc incorporatbnoi variousmaripulalivetech- commonlyseencoupledmalformatioo (whichshouldnorbe
neccssary to breakany sofl rissueidhesionsthat suryrising,consideringthe mutuallydepcndertnalureof
limilingfirsLray motion. lhcsedcfomides),virlually any combinationoI forefool
lllh€ heeihadbeenfixed in a oefmanenllveverted and/orrearfooldeformitymay coexistto8ether,j.e.,a lbrc-
(as jn msny rigirl tlaL lbot deformilies), ortholic ioot varuswith a piantarflexed lirst ray, a fearfooivarus
would be inef{ecljvc in reducing Lhe melalarsus wirh a forefoolvans, a rcarfootvaruswith a forefootval'
elevatussincc dorciflcxion of thc firsl ray is neces- gusanda plantarflexed 6fst ray,eLc.
to accommodate the cvencd calcaneus. As a generalrule,odhoticmanagemett in lhesesitua-
Conscrvative treatmenlmay alsobc ircflbctivewhen tions requi.esputtingthe foot in ils reutral posilionand
wiLha largccongcnilaldorsiflexcdli I rn), since lilling in the spaceberweenthe foot and horizonral(109).
melatanalis ollen so elevatedlhal il is unableto Allhoughrhesimplicityot thrsrul€ givcslhe inpress;on
inLorheposilionnecessary ior a normalpropul- tharorrhoticmanagement for combinrtionsof defeclsis a
'fhereforc,Lhe dorsalposteriorshifi of the firsl relalivelyuncomplicared proc€durc, !n actualilyir canbe a
alangcal joint's |ransverse axisdoesnor occur, confusingprocessof trying to decidewhicb deformily10
lhehalluxis unable1odorsifl€x beyond35': halhx lim- posrandwhatpostangl€sto use.'l'hcfollowingseclionwill
with compensatory hyperexrension of thc inleF rcviewtho paftomechanics andortholicmanagemenl asso-
joinrmayquicklyfollow. cirted wilh the mor€conmonly se€ncombinalions of de-
Sudrssfulmanageme of a large!$ngenilaldorsillexed
ny may necgsitalea plantar baseclosing w€dge os- The rearfoot eoruslforcfoot vdrus defomit!, 'l[e
ro rcalign the 6lsr nretalarsalwith lhe less€l individualwitb rhiscombination oI defordiliesis proneto
Unfonunalely, all tooolienthesurgeon ignores ot injury throrgholt thc eDtiresiancephasebecause the rcaF
doesnol rec.,gni/elhe dorstflexedfial my detormiti foot varusdeformityroquiresrapidcompensatory subtalar
lalesonly on $c deformed mclarars.Jphahngealjoinl. pronalionduringlhe earlyportionsofslancewhile lhe fore'
rhis oeur, lh€ fi$t Detalasal joint deformity will ibol varusdctbrmi1yfequirescompensatory slbtalarplona-
rclumsincelhe biomcchanicalcausefor detormityre- lion durirg thelatterponionsofsrance(Fig.3.90).
uochanged (3). It ir hadbcer oneof Lheless€rmetalaEals Treahent in this siluationrequirestakinga ncutral
dolsifleied, surgical rualignment is typically not nec- positionimpression thataccurarely captures thelbrefootde-
sincoa doEillexedlessermclata$aldoesnol DredisDose formity, th€nfabrioatingan orlhoticlh?t car controlbolh
ngealjoinr ro dcformilyand onscrualivc the rcariootand forefooldelormities.fiis can bc accorn-
wilh m{nipulationto mainlainth€ full rangeof plish€din eirherof two ways.The 6rsLand nost common
tlsal pla arflexion, coupled with relDmmcndalions lbr approach is ro postth€forefoolso asro bfingtherearfootto
vi$ a spacious toe box, will usuallyresultin a complet€ vertical(l.ig. 3.91A),thenadda s€paratc rearfootpost(re-
oiany |iymploma!ology. fened to as an extrinsicrearfootpost)lo tilt tbe erdre or-
ThecxcepLiotr is wbenrhedorsiflcxcd meLalaaal is un- thoLiclarerally(Fis.3.91B).
effectivcly parricipate in thcdislribution ofgroundrc- Tbe only flaw with rhisapprcachis rhatbecause the
lorces,thcrebyexposinglbe ncighboringmclata${l rearfoo!and forelbolpostsreston differenlplanos(dotled
lotaumr.Conservalive tfeatment in tfiissiluationsrm- linesin Fig.3.918),$e orlhotic,whenplacedon a flat sur
ftqunesplacinga srnallmelatarsal padproxirnalto the face(or moreirnportantly, whenplacedin a shoe)will have
murararsal hcad.lhurcby shilring groundreacrive a "rock line," wherethe entireonhoticwill lip lron being
i at fromthoneighboring metatarsal hoadsandonlo supporlcdsolely by lhe rearfoolpolt to being supponrd
of thc involvedmetatatsal. solelyby Lheforefootpost,depending on which sidcof thc
linepr€ssur€ is beinsptaced(Fis.1.92).
OR[rorrc MANAGEMENT FoR V Rrous lI you comparethe localionof thc averagerock line
C0MBTNATIONS or REAR!0ol AND on anorthoticwith separate rearfoolandforefoolposlswith
FoREFoor Dt!'oRMl t'IEs rhe normal pro8ression of vertical forces(Fig. 3.93),il be-
comesclear thar the rearfoolpost becomesnonlunclion{l
Becausc 98-37o of thepopulationpossesses somodo- alter early midslancesincethe enlire or$otic w;ll have
tibiofrbu larvarum (1), il shouldbe expecledlhatthe liltcd mcdially(evertcd)onlo lhe lorefootpost.Clinically,
 H€dsrnk€ H6€lllfi

fiSure 3,90, Stan€ephale motiom wlth a combinalionrcarfootveru/tor€fmt val|rsdctonnily.

FiSur€3.91.(A and B) Useof ld€- A

p€nd€nlfor€foot and reartool po3ts.

fi8ur€ 3,92. The rock line on an o{hotic

wilh indep€ndenl fo.efoo! ad re.rfoot
A
Po$ts,li p€ssureis appliedpotteriorto the
rockline(A),theentileonlloticwill renon
lhe rea oot post.Conversely. if pressu.e
appljeddntcrio.to the rockline(B),th€or-
is

tholic will rcck mediallyonto the torefoot

K^_r
"[5f--L*'*

Fiturc 3.93. (A) tocation of average roc* linq (8) normal

progreesionof forc.r dujinS ttanc€ phas€. TO = roe-ol' HL
= heellin: rrt = lull fo.efootloadiHS = heelsr ke.

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
posted,lhe forcfoolpostwould lbrcelhe subralarjoinlink'
a pron.itcdpositionthc momentlhe individuals pmgrcssion
of forcespasscdth. rock line on rhc orthotic.
ClcBrly,lhis is norrhegoalof orrhoticrherapy. A com-
monmisconccprion lharhasb€comest:tndard pnclicc in rhe
fabricalionof orthoticsis rhe bclicf that rhc practili{ner
shouldfully poslbothrheforcfootandr€arfootdeformity.
In the prcsenccof a combinedrearfootvarus and
fotcfool valgus,this practic€is padicrlorlydangerorsllnd
is responsible for rnanyiatrogenicinjlries sinceduringlate
midslanceandearly proputsionlhe positionof lbc subtalar
joint is delermined solelyby $e forefootpo6t.Ifan individ-
ual with a 5" rearfoolvan s and u 50 forefoolvalguswerc
fully postedon ihe tbrcfoot.thc 5' postwouldftainlainthc
$ubtalarjoinli a pronatedposilionduringheel lifi, which
would,o[course,be detrimenral (Fig.3.95A).
In thc prcsenceof equal forefool and rcarfool defor-
mities, thc forcfool deformity is n€ccssaryto allorv the sub-
talarjoinl to reachits mutral position(Fig. 3.958) and
shouldaccordinglybe l€fl alone.h shouldbc mentioned
thar ther€arc €ertainexc€prions to this rule.as it is rrcca-
sionallynecessary to ovcrposlthe forefoolbetondsubtalar
joint neutralilyin orderto successfully rc,solyesymplons
associatcd with a chronici y invertedheel,e.9.,rccurrert
inversioninstabilit' or a rccalcilrantrarsaltunnel syn-
drome.Ir facr,Valmassy(110)advoc{t€smurin€l}posling
combincd rcarfmt varus/forcfool valgus dcformilies wllh
sufficient forcfoot valgos posting to brinB thc rc{ffool to a
verticalposition.He cmphasizcd tllatwhenthisis nol possi-
blc bccause of a limitedrang€of subtalarjointmotion,the
forefootvalguspostshouldbe of sumcienthcight(o m i|l-
tair thesubtslarjointin its maximallypro0ated position.
Because of dreporemislforiarrogenic injuies associ-
ated wilh rhis tccbnique(specificrlly,planrff fasciitis.
springligamentsprais.soleusslrain,aDddecreased $abi-
lizalionassocialcd rvilhialonavicular incongruity), rh€h.ge
forefootposisshouldbc usedwith caolioo.
Figurc3.95.rh€ .ombinationof a s' A
r€arfool varu3rvilh a 5" forefool val-
86. Useof. forefootpostin thiecas!
would tuc('rhe subtala.ioinr iSI,/)
into a pronatedpositionrhe moment
the individunl'sprosression of forces
passed anleriorto lhe rock linc (A). lf
,efi unpostcd,the 5'forcioot valSus
will aliow ihe 5'r€a ool vafusto
r€acha ne|rrralposirionby heel liil
{8).
H€6lllll
Wlen lrealitlg combinatioDs of rcrrfool vrrus
for(fDorvalgusd€fonnities, a foretuolposl is uscd
ily when tbe size of thc forcfool dcformiry exo:edsthc
of llte rea.fr)otdefonnity.fie cxactdegreeof the
posrshouldtheflbe de(ermioed by subrrncring lt|e
anglefrom lhe forcfootangle-
Ftrr examplc,ar individuAlwith l| 4" rcii oot
and a 9" forcfool valgus would receivca 5' forcfoot
polirto protectagainstlalernlinstabilityand mai
:rub':rlarjointin a ncutralposilionduringhecllill. In
lionr requiring borh rcarfoor lnd fo.efoor posting(
8" rJarfoorvaruswith a 12' forcfftI valgus).the
posr is still detcrmincdby sublractingrhe rcadoot
from lhe foref(rctangle(in thiscasc,4'). only nowa
r{lc extrinsicreartoolpostcanbe addedto control
joinr molionsduringthe contaclpcriod,i.e..s 2.
po!{ would allow 6' of subtalarpronation.Thc
rcirfool andforefqrl ooslswork well in thissilualio[
the rcarfoot poil controls subtalarjoint motionsduriog
conrircrperiodand,oncc fie rock Iine is pass€d,thc
poslpmr€crsagainsrl{reralinsrabiliryandmaintsins
ler rleutralityduringhcellifi.
Thc only drawbackwirh the rcchnique ol
lhc Lcarfoot anglefiom thc forefootanglcin ordcrto
lninr thc sic ofthe forefoot F,st is lhal it rcquircs
imprcssiotr ofthc fool in a non-ocutmlDosition: the
rnglu capiuredin the cast should rcflecr lhe sizeof the
sire(lpost.not rhesizeof theaclualdeforrhity.
To demonslrate $is point picturenn individual
a 4' rearfool varu.\ and a 9" forefod valgus.The
cas!in this situslionshouldcapture5', not 9" of
valgu$.This is accomplished by uiing lsssprcrsure
ha(!inglhe lateralcolumoduringthc casting
thc lull 9' of forefoor valgu$had bcen caprurcdin thc
prcs.ion.useof a 5" lbrefoorvalgusposl would
the rcarfootin positionof4" inversion,whichwould
plerelyblock the rangeof subialarpronation

absorplion(whichwolld eventually
resultin iatro,
injury).
Be.ause a non-neutral
impressionhasbeenusedin
on,ir is lheorlhoricposl.nor lhe sh€ll,thalplay\
pnmaryrolein controllingjoinl rnotionsduringstance
In all siluaLions
ir which lhe for€foolpostis noi in-
to bring lhe rcarfoot lo vertical, thc laboratory
beinfbrmedof yourtfe men!plafls.
Therea4ontearusBexible
pbntarflexedfrrstru! de-
(ftA. J.96J. Sincosublalarcompensation for the
va!!sdefonnilyoftenforcaslhe firsrray abovethe
lransvcrseDlaneof lhe less€rmetatarsals.
orlhotic
t for this combinalion resuifesbolh the use ofa
bar post to accommodale lhe Dlantarfiexed first
headanda rearlborvdrusooslto orevenL exces.
periodsubtalarpronatioD.
Thercarfootvarusposris invaluablein lreatingth.
inedrearfoolveros/llexible plantarfiexedfirst rat de-
beca{se,in additiol]to prcvenlingexcessive subta-
prcna$on, il also aclslo increasethe mechanical
of peron€uslongusas a first ray plartarflcxor,
€nablesthis muscle lo protect more effectively
do.siflexion
andinvemionof thelirsl melat3rsal.
FiSur€
3.96.rool r€arfoolvarusflexlbleplantarflex€d
wilh a combination
'notions
rigure3.97.Footmolionswith a €ombination
rearfootvarutriSidplantarflex€d
Chnpl€!Thrce Abnornsl Motlondurlng lhe Grlt Cycle 109
If suhalarjointpronalionduriDglale midstance/early
propulsionis a concern,an alternateposling techniquc
would be to placethe desiredrearfootposl beneath ie fore
Iool and have the rea.foot posted flat to stabilize the in-
vertedorlholic shell.Also, a first ray 6!t-out and sub 1
balancefor lesionshouldbe addedlo accomoodatethe
plantarflexedfirst metataJsal.This orthotic could conlrol
subtalarand first ray motionsduring lhe entire shnc€ phase.
The reatoot veiatbigid plaatarflaxed fftt rat de-
IomilJ OiC.3.92), Becausethe rigid plantariexed6rst
ray deformily mailllairs lhe rea.fool in aEinvened position
andpreventsthe subtalarjoint from pronatingduringmost
of slancephase,orlhoticmanagemcnt .equiresthe addilior
of a 2-5 bar postwith a sub I balanc€for lesionto accom-
modatethe lirst metatarsalhead and to allow for a condn-
uedrangoof subtalarpronation.Rearfoolpoststypicallyarc
not neededsincecontrollingexcessjve subtalarjointpmna-
tion is mrclya concern.
The fotefoot varus or forcIoot valsus with a plan-
tuflexed f'st mJ defornio. Treatmentof rhis combina-
lion requircs use ol the appropriate forefoot post (as
measuredwith lhe secondthroughfif$ mctataffrl headsas
fte reference)with a first ray cut-out addedlo accorrno-
firsl raydelormity.
filJt raydeformily.
I l0 FOOTORT}IOSES
endOlherFormsof CoN€wativeFootC]!re
date the plantarnexedfirst met3rars{l. lf tbe planiarflexcd
first mc|8tarsal is $mincxible or rigid, a sub 1 balance
shouldalsobe coNidercd.
An outdaled techdque for tr€arin8 a combinatiorl
forefoot varus/f,erible plantarflexed Rrsl ray requires
dorsinexing the plantarffexcdfirst ray into a midline posi-
tion (i.e..levelwilh thc less€rmetatar$als)u/hilethe neutrat
posilion cast is b€ing takcn.Becrusethis maneuvorrisk in-
advencntsupinatiolof lhe forefootaboullhc longitudinal
midrarsaljoint axis. lhis techniqueha6 for the mo$t part
becnaba'ldoned (42).
VARIATIoN n MRIATARSAL LENGTH
The relative lcngths df the differcDt metalarsalsare
readily evaluatedby planlarflexingthe digit6 flnd Doringlhe
F,sitionsof the dorsalmetalaNalheads.Ideally,an imagi
narylineconnecting ihedistalmetatarsal headsshouldform
a smoothparaboliccurve(Fig.3.98).In mostfeel,lhc rcla-
live lenBhs of the metatarsalscranbe erpresscdby rhc for-
mula bl>3>4>5 or bl = 3>#5 alll). Becrusethc
second melatarsalis lsually th€ loogesl it is exposedto
Sround-rcactiv€ forccs during both high and low gear
push-off,with largeamountsof pres$recenrereddirectly
bencaththe secondmetabrsnl head as thc transition from
low gearto high gearp!sh-of[ &aurs.
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
figure3.98.ld.al alitnmenlof th! metalarsal
heads.
(pre\umably du€ lo th€ larger forccs on the hallur
lo lle less€rdigits).
Fortunately. cventhouBhlhe s€condmeratanrl
app!ais slenderand frail. i!$ ovcrallouLlineand
tion of densecompactboneallowsil lo cff€ctivclyma
profulsiv€ forces.Funh€rmore,the secondlarsomc
arli(ulalioo seems to be sp€cifically d€signedto
thesc large forc.,s, as lhe basc of the secondme&
wcdqed into . relatively rigid socket betwqln lhe
andlateralcrnciforms(Fig.3.99).This anaromical
nti)n seavcsas a locklng mechanismfor the entire
somelatarsal complex(115).
Civen lhc fact that the disribution of srou
forc.s is dependcnt or lhe rclativc l€ngrhs of
mektarsals. il se€msreasonablcto assumethal at
sivel!'long or shorlmetatarsal wouldsubjectirs
headto a resDective increase or decrcasc in Dressurc,
The Eloogat€d SecondMetrierssl
The most commorly s€en varialion io
longlh is an elongalcdsecondmctatars{I,i.e., rhc
mel.,rarsalis even longcr thao usual.wkh irs
heatl projectingdislal to Lhcideal parrboliccone
3.1{)0).lf this melatarsalis cven slighlly elongat€dt
metrtarsnl head is sub.jecl€dlo trcmcndousforcasss
Figure 3.99. The iecond tarsomelat rsal arli.ul.lion
Lisfrnnc'sioint), Note how the baseot the seohd metal
is tirnly stabilizedagainstth€ noighborin8mebtaKak
cune,to,ms.Eecaus€lhe planlar s rface o{ lhe s€cond
sonx'ratnrsaijoiot ir reinforcedby the slrongplanlarI
and ,,n exlensiooof the tibialis porteriortendon (106),I
partnularlyeffecriveat rcsisrin8
th€ doEilleclory
creak'dby Bround'reaciiv€forces.

3.100,An elonSatcds€cond mclatrrsal. lModified
CoLrldlS (ed).The Foot Book.Baltimare:
Wlliams &
1988:220.)
irom low-8earlo hiSh-gear push-oft.The result.
in prassure
andfriclionDroduc€s a characteris-
inkactableolanlar keratosisbensatbthe second
head(insetA, in Fig. 3.100)andmaybe a causr
mctatarsalgia(64) and/or planlar wans, i.c.,
stimulalesgrowth of rhis virus ('l l7).
Also, an elongatediecond motala$al often produces
toc dcformity as comprcssiol from a tight toe box
lhedigil.(Bccruscsboes e fit from hcello ball,
sccondmelatarsal is rypicallynor rakeointo
ioll.)
Trealmonlforan elotrgal€dsecondmetatalsalmayin-
th. additionof cushioningmalsrialsplaceddirectly
lhs Dainfol meiahrsrl head (materials such as
(Spcncol\,ledicalCorp., Waco, TX), poron, and/or
maybe invaluablein reducingshearforces),the
mrlatar$alpadsplacodproximalto the metatarsal
(Fig.3.101)and,if necessary,
anorthoticro accom-
anystrucLlraldeformitythat might be responsible
increrscin pressurebencath the second mctatarsel
a8., a forcfoot varus deformiry. Recommendations
alsobe madefor well,fittine sho€s rrt do oot com-
thc disraldigit and, if sympromswarrarr, a Thomss
rockcrboltom m8y be addedlo lhe outer sole of rh€
iclp rcducc pressurcbeneith the metatlrsal head.
rdditionsarediscussedin a later soctior.) Of cours€,
isl rharrhe individualwith an elongatcdsecoltd
avoidhigh-hceled shoesatrdhavethehyperkera-
trinrncddowniegularly.
Tte ShortenedFirst Met{tarsal
causefor pain beneaththe secondmetatarsal
& excessivelyshortonedfirstmetatarsal.
lt hasbcer
lhal rhis dcformity,which was ori8inally de.
by D0dleyMoflonin 1935(119),allowsfora redis-
Chlprcr Thrcc Abrodrrt Moiior du.lr8 ln€ Grll Clcl! I l1
FiSur€3.10r. By distrlbutinS
wei8hlaw.y froh the central
met.ta'3al heads,evena lmall metataF.l prd may de€.€ase
pl.nlar metararsal
h€adpressure:by asmuchas50Yo(118).
tribution ol prassure away frcm thc shorrcned first
met8trrsalonto the neighborings€condmctataNal.
Allhough lhe clinical sigrificance of a shonenedfirsi
mctstarsalhas been questioned(120), recent invesrigadon
(l2l) has corroboral€/ MortoD's th€ory io thar pcak pres-
sure measu.€mentsraken b€trerth the s€cond metstafisl
head while lh€ patient was walking were significantly
greater in individuats posscssidgModon's foot structl|fe
(i.c., tie firsl mehlarsal was 8 mm or more shorterthan the
secondmetatarsal) than rhey were io a controlgroup.ll
should bc clarified that a shorl fi$t metatarsalby its€li does
nol conslitutcMortoo'sfoot strlcture.A tru€caseof Mor-
lon's foot struclurewill paesentwilh a short fifst melstalsal,
a lhickenedsecondmetatarsal shaft,anda hypermobile firct
melatarsalwith posterio.ly displacedscsarnoids(Fig.
3.102).
Bccauseof its shon€r len8h, lhe first metatarcalin
this foot typc is only ableto psrticipareio tbe pmpulsivepe-
riod l.ansfcr of forces by exc€ssivclyplrntarnexing abour
$e nd ray axis (Fig. 3.103). h hasbeensuggestedthat this
incleas€dranSeof 619 lay planlarflexion may predispose
the iDdividual with Morlon's foot sEuctur€to degeneral;ve
chmgss al tbe jocdon of rfie firsl a[d second melalarsal
bascs(122).
ln somcindividuals, the first metatarsalmay be so se-
verely shorteoedlhat the first ray is uoable to plantarflex
throughthe rangenec€ssaryfor the first metatalsalhead to
mainllin gound conhcr dudng midpropllsio[.(n should
be retuembered itrat firct ray planhrnexioDis usuallyless
than10:) This beingthecase,thefirst oetrtarsalis unable
to participatein the disfibution of g.ound-r€rctivc forces,
and thc neighboringsecondmetararsalh€admay be chroni-
cslly traumatized.Furthermorc,tbe sublalarjoinl will be al-
I | 2 FOoTORTHOSES
andOtherFormsof Conseruative
Fun Csre
figure 3.102. Morton's fooi slru.ture.
Sscondnelatalsal
Fitrre 3,rm, ln orderto demonitrdte the efiectof a sho.t-
sed fi6r meblaBal, this illustrarion ui€s an analogy in
which ice creamnicls of variour l€ngllls ar€ usedto repro-
lent the fi.st and s€condmelalarrab. ln seriesA, becausethe
iilst melatnsalis only sliBhtlyshorcr th.rn the second
nretataual, lhe rangeof firslrry plantarfletion
neces5afy f
lowcdto pronatethroughlArgerrargesofmotionduringthe
propdlsiveperiod,as the mediaiforefootis no longerstabi-
lizedby an eflectiveperoneus bng s muscle.
Treatmentin this situationreouiresthe Nddilionof a
platform(rcferredto asMorton'sext€nsion) plscedbeneath
the filst mctataBalhead(Fig.3.104).This extension allorvs
th€first mclatarsalhcadlo participatein the distribudonof
grcund-rcactivc forces,whichin tum allowsfor a lessening
of prcssurebeneathlhe secoodmetatarsalhead,a decrcnsed
rangeof propulsivep€riodsubtalarpronationard, by alhr!-
the iiBi and scond metatarsalheadsto nraintain8rcund
lacl is mininlal. However, when the ll6t met:tarsal
markedlyshortefthan the $econdlas in B), a exteme&
of firn ray plnnlar{lexjon
h necessary
for the ikst m€ta
h€arlto mainlain8roundconta€!followinah€ellilt.
ins lhe fi$t metata$alto a$ume more midlinc
minimizesstrainon th€lirsl larsoftetatarsal
articulalion.
TruveI atrdSimons(12]) described a surprising
IionshipbelweenMorton'sfoot structu.€andtigger
in lhc mBsseterandtemDoralis musculature. Thes€
gatorsclaimedthatby correctingfauhybiomechanics
ciarcd$irh thistootrype.Morlon'scxtcnsionmayaUow
ao irnmediateimpruvement jaw op€ning
of interincisor
asmuchas307o.
A word of warnitrg r€gardingthe useof Mortont
 ChaplarThrc€ Abrornrl Motlon durhg lh. Galt Cycl€ 113

fi8sre 3.104. (A and 8) Morton'3e{Gniion. Comparcfirst ray motionswilh and without this addition.

Whileproperuseof thisplalform$ay bc essential maintaifltherearfootin an invertedpositionduringterminal

a true Morton'sfoot successfullv. morc often stancephase,which allows a moderalclylelgthenedffrst
IoL it is incorectlyuscdlo treala leDslhsned second mclatarsal to plantarffex
duringlh. propulsive period.
(A lrueMonon'stbot structureis acluallyquite Arother techriquethat is usefulin treatinga length-
Tfie inappropriateusc of a Monor's extensionm.y encd lirst melatarsalinvolves fabricating an onhotic with a
rn sesa$oidilisand, if conlinued,could evenlually large rearfoot varus post, theB adding a kinetic wedgr b6-
to degeneralivechrn8cs al the dorsal first mctrlsr- nerlh lhc forcfoot Thb addirion, which is dcs$ibed in
joinl s€coodary to impaired fiIst rry rnorcdetail iD a later s€crion,requiresplacing a soff, lrian-
Becauseof this, Morton's extensioDshould gularly shapedpiece of foan boncaththe first metalarsal
!e cotrsideredNftercareful slatic and dynamicevalua- hcadwhile the remainitrgmetalarsalhcadsarc support€dby
(Ahhoughthir addirion moy bc uscful in rrealing a dense.ubber. According to Dana[be.g (124), the softer
painbcnearhthc sccondmclatarsalhead .) materhl pla(td beneathlhe fusl metatarsalheadallows the
TheElongotedFlrst Mctrtrrsal lirsl ray to plaitarflex and evert duriog propulsion,thereby
lesGeninglhe poteotial for first metatarsophalangeal joint
Afnal causefor polenlialinjuryoccurswhenthefirsl deformily.
is thelongesrmetalalsal. As the individurlwilh lf thesemethodsare incffective and hallux limitus de-
i(y movesinrc propulsion.dere will be an in- formiry conlinues to be painfll, a rocker bottom may be
in the snounl of prcssurecentercdbeneathlhe first addcd to tie sole of the shoc (s€e Fig. 3.132). Unfonu-
head,and ground-reactive forccswill prevent the nalely, Rool el al. (3) cl.imed thst when a|r elongatednrsl
of first ray planlarnexion rccess.ry for the dolsa! metatarsalhas resulled in a halhx limitus defodnity, con-
slifr of fte ffrstmetatarsophdangerl joinl's lraos- sewstiv€ attemplsio restor€hallux dorsifl€xion are useless,
is (3). This offen leads to subluxation of the firsl and tbe deformily will contiouc to progrcssunlesslhe 6rst
langeal.ioillt,wilh the eventuaidevelopmenr melatarsalis surgicaly shorten€d.They rccomoeodedsur-
limitusdeformity. gicauy short€ningth€ first melatarsslso tbet iis distal tip
Cnlsewativ€lreatment of thc lengthenedfirst linesup witb lhedishlrip of the thirdm€latarsal (assuming
is alwaysdifncullandsholld includetechniques the third metataasalis not exc€ssivclylengthenedor short-
theindividualto maintaina low gearpush- ened),while simultaneously altoringthe declioationangle
lhe propulsiveperiod.This may be accom- of tbs 6rst metatarsalso tbat its metatarsalheadrestson tho
muscularlyby having the patient consciolsly commoo tral|sverseplsoe of lhe less€rmeala!$ls. Failure
his or her gait patlcrn 10 maiotaina lov/-8earpush- to cbaogeOc declhatioo argle will result i! lhe formatio!
, by usiogan onhotic with atr oxtendedrc!u- of a m€tatalsusprimus elevatos.
posrro mainrainthesubtalrrjointin atr invcned Il should be noted that tbis approacbs.ems a bit ex-
drring early propulsion and/or by cutthg thc solc lrcmc sinc€the hrbilual t|seof a low gcar push-off,coupled
shoealongan exis thst parallelslhe bis€ctionof the with s rocker bottom sboe, will succcssfullyalleviate the
andfifth melalarsal h€ads.All of lhesetechniques svmDtoms in almostall situatiorls.
 andOlherFoms oi Co$eruativeFootCare
I 14 FOOTORTHOSES
LEG I,ENGTH DISCRIPANCY
bB lcngrhdilcrepancy(LLD), which is dividedinto
functionaland strucluralcategoiies, is a commoncauseot
injury (19. 125).Me,ssier andPitiala(19) demonstrated rhat
slrucruralleg lenglhdiscrepancies $eaterthan0.64cm (1/4
incb)predispose to plantrrfisciitis while RothbanNrd Es-
tabrook(126) claimedlh{l funclionalleg lcngth dislrep-
ancysecondary to asymmetrical pronationis ao etiological
faclorin thc developmenr ofscialica.
It is extrcmely imDorfantlo differentiate a sructural
leg lenglh discrepancy(which represenlsa tl\€d osseous
inalformslion) from a functional leg length discrepancy
(which is nost oflen lhe resullof a"symmetrical pronalion
and/or sofl tissuecoltractureitr the p€lvis/spine), sinc€
lreatmenrfor the$etwo cotrditionsis differcnt-Unfodu-
nat€ly,differcntiatinglhesdlwo defonDitiesis nol always
easy.ln many cas€s,structuraland functioral leg lcngth
discrepancyoccur togclher. one maskingthe actual degee
of theorher(Fis.3.105).
To help differenliatesLructural ftom functionalleg
lergth discrepancy, scver{l examinttiontechniqueshave
been developcd.Thc most accurateof thes€ tests is the
scanogram. This techniqueinvolvestakinga scriesof x-
rays with the centralray injtially level with the femoral
head,thenwith theribialplateau,andfinallywilh th€ anlle
mortise.Informltionfrom lhesex-raysgivesc)(actinforma-
tion regardingthc lengthol thefemursandlibias.
An alternatemclhodof x-rayevaluationinvolvespo-
Fkrre 3.r0s. Maskingof leg l€nglhdiscrcpanci€s. In A, a
Iunciionalleg lenSthdiscEpancvon the left (whichis scc
ondaryto asymnrclracalprcrarion),coupledwilh a slructu6l
leg lengthdiscrepancyon the riShl(whichh the rctult oi a
sift,ning th€srandingpatientwirh rhefeetdrrectly
thelemoralcondrl€s,i'Jithlhesubtalarjointmainldned
neurralposirion(whichshouldbc mainlained muscularly
the paricnt)andthe A.S.I.S.'sequidislant liom lhe
An \-ray takenwith thc cootralray parallello lhe
heauswill give fairly accllrate informalion regarding
relalivelengthsof the lowerexlremities(ahhoughit is
ablr Logive exact informalion regardinelen8lhsof tfic
murs and tibias). Regardlessot which x my prccedute
used to detect leg lenglb discrepancy,the subtalarj
sholld alw{ys be maintained in lheir neukalpositions,
rhe iemoralneck anglessho ld alwaysb€ m€asur€d
cornoar€dbilateralh since these are colnmon causes
funerionaland structurallcg lcngthdiscrepancies,
livclv (Fi8.3.106).
If exDosure to x-rav is a conccmor if costis
tive. structuralleg lengti discrcpancyma! l c iden
\^ith manualexaminalion techniqucs. Thc mosl
mcthodof evaluationis to positionthe patientsupjne
mcir.urc rhedist0trcesfromrheA.S.l.S. to rhcmedial
olus. Uofo&rnalely,asymmetrical muscletensionmay
the fclvis, thercbymakingaccuraterneasuromcnt
To il.ld to rheproblem,Rothbarta d Eslabrook (126)
tbat supirc measurernerls for determiningleg lcngth
creprncy should be avoidedsince pressurcftom the
iaint tableflexesthesacromwhiletensiorin thehip
simrluneouslycxrcndsthe innominales. thereby
ing r slruclural leg length discrepancy.Becaui€of i
racv wirh supinenleasurem€nls, Ford atldCoodnun(
shod aenur),Eivasthe app€amnceofsymmet.icalles lengthsr
In B, the ri8id plantarflexedfi6t ray on the riEht
funcronal lon8 leg on that side ihat hides the ri8htshod
 Cha e.Three Abnor|notMotiot durhg tte Gall Clcle 115

fl8ure 3.106.A3ymmelrical femor.l neckanglcsb a com'

mon c.u!e to. strucloralleg knSlh discr.Pancy.

Fi8ure 3,107, Allh' test, Ihe exam'

iner manually aligns Ih€ Asls's ro
tharthey rcrt on the $me flontal and
llansvelse piane (A), Ih€ m€dial
malleoli are ften placed to8ether,
and femolal leneths are evaluatcd
lrom above (8) while libial lenSlhs
arc determin€d by comparinS lhe
lev€lsofthe libial plaleaus(c).

' i1,,i

lesslhan l/4 inch be

tha!leg lcnglhdiscrepancies latc swing phase(which re,sullsin an incteaseir vertical
11281and lateral[129] gound-reactiveforces),many pa-
Morcaccurate evsluationof struclurallcg lengthdis- lieotswiil attempllo modifyihpact forccsby slowlylowe.-
requiresthat thc examircr combine informatiod ing the shorterleg lo th€ groundvia eccentic contraclionof
several dilferentmanuallesls.To beginwith, lhe rela- $e contralaleralhip aMuclor musculature.This produ6s
of the fcmurs and libiar can be evaluatedwith chronic slmin on thescmusclesand mly causehypetmobil-
lest(Fig.3.107).Findiogsfron lhis cvsluationcao ily of the lJ-Sl articuhtion, as the body of lJ rotsteslo-
bc compared with informationfrom e weighl-bearing wardsthe €xcessivelyloweredhip. (Normally,tbe pelvis
ion,whercinthc lcvels ol the vrrious bony land- droF!only 4 or5'during rhemiddleportiorof swinSphase
canbeobservcd fromfrontandback(Fig,1.108).ltr- and retumsto neutralby heel-strike.)Also, in an attcmpl lo
from Ois evalualion,when coupled with stabilizc against the increas€dlateral shear forces at hecl-
from off-weighl-bearingand/or x-ray measure- stdke, some irdividurls develop an oul-toe gail pallern on
enablcsrhe pfactilioner to differenlialc slruclural the side of lhe shon lcg. ADothercommor pattemof com-
funclional legl€rglh discr€pancy accuniely. peosalionfor a leg lcnglh discrepancyoccurswhen the indi-
vidualhyp€rexlends the kneeand invertsthe sublslarjoinl
Pathomechsnics on lhe side of the shortleg- Wbilc bolh of thesemotions
may be helpfrd in ihat $ey bring the heel closer lo lhe
As relal€dlo its effect oo gail, lherc are many ways groulld during latc swirg phase,tbey may also be dama8iog
patietrtmay comp€nsatefor a leg lenglh discrepancy. in tbat hyperextcnsionof the knee imprirs the quadricep's
ftc shon leg hss a longcr dislanc€lo fall during abilitv lo damDenvertical forc€swhile inversionof the sub-
r16 FOOT ORTIIOSE,Sand Othor Form6ofc.'nscrvative Fool Car€
Figure3.108. W€ight-bearin8evaluationfor le8 l€ngth die
€.cpanci6.The patienlis carclullyposnioned with bolh feet
direcdybeneaththe sreatertrochanterr. The leveloi the me-
dial malleoli(A) canthenbe comparcd to deteanine whether
asynrmelrical subtalarp.onation(or supinalion)
is a causeot
functionalleglen8rhdiscrcpancy. Ncxt,thetibialplateaLrsare
compar€d(B) to d€lerminethe relntivelengthsof lhe lib,a!.
Io compare{emorallenSlhs, thefin8edipsare plac€don top
talarjoinlcreatcsa functionalrearfootvarusdeformilylhal
incrcrsesthc ftnge and sFcd of subtdlrrjoint pronaridn
presenldoring the contactperiod-
It ;s alsopossiblelhat conpensaiionfor a leg lcngth
discrepancy may produceinjuryoo the$ideoflhc long leg.
Bccausethe krng leg moves through a larger arc during
swing phase(130), the individual offen attemplslo decrease
the radius of this arc by flexing the kn€e.This motion may
sigificantly incr€rs€coEprcssiveforcesal the patellolemaral
adiculatioa.Furlhermore.it is nol urcommonfo.lhe individ-
ual to britrgthe lotrgleg closerto thegroud by narimally
pronatiogthesublalarjointon thalside.While Saoner€t al.
(131)nol€dan averageverticalchangeof only 3 mm asthe
subtalarjoint moves from a n€utral position to a pronated
posilion,it is possiblefo. subtalatjoint prooationlo com-
pensalefully lor structural leg length discrcFncies of 1/2
itrchor mofe.ln somecases,th€ hesdof the taluswill ac-
lually makegroundconlact.kodcally, Hiss (132) claims
thal this makesrhe foot more stable.as Dhntar conlact
with the laiar headservesss a poinl of supportfor the un-
stabl€medialcolumn.So, even thoughil is a commonly
held belief that the greaterfangeof subtalarjoitrt p.ona-
tion occurson the side of the skucturallyshort lcg, it is
quit€possiblethal an evengr€alerrang€rvill occuron the
of the g.eatertochanteB (which can be iound by havinS
pati.nl tlex and e\tend the hips),and lheir r€spfttile
are ioled (C). The levelr of lhe porteriorsup€rioriiiac
(PSlss) with lhe patientstandins
areevaluated erccl,lhen
90" xi the hip. Finallv,the levelsoI lh€ ilia. .f€stsrhould
conrpar€d(D)i and any devlarionof dle lumbar spine
ve ical shouldbe noted (O.
sid( of the long leg if tie individlrl attcrnptslo lelel
pelvis.
Treilmentin rhissilualioorcquirc\placinga hecl
ben.ath the shorl Icg and, it Lheraige of subtalarj
prcration on lhc long leg side reoains unchanged, an
tlotic may bc necessary to controllhe exaggented
ft i' of particulrrinlerestlhal \orick and Kelle'
noledthatthe additionof a z-mn{hick functional
produc€da 4.8-mmelevalionof t}e anklcjoinr'scertr
masssecondaryb superiorrepositioningof lhe taluson
calcxneus. Because of thissiluation,lreatmenifor combi
tion. of structuraland tunctionaldiscrepancies requi
caretulpre-andpostevaluation to ensurethatprop€r
tionhnsbe€nattained.
Treatment oJ Struetural $. Fanctional
cies. If a structurallcg lengthdiscrepancywere Fescnl
itsell,fteatmenlshouldconsislof placiDg$e
size(lfiee,lifi beneaththeshonleg.Theactualh€ighl
hcel lifi is bestdetermined by placingiifts ofvar'ous
bene.lththe shorlleg andreevaluating alignment.The
heel lin will levcl the iliac crcrl ard, more im
brins the lumbarspineto vertical(l23)- This lechnique i
surprisingly accuraletbr ev€n subdeleg lenglh discrepaD,
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

FiSure 3.109. The eff€c15 of asym-

metrical subtalar ioint pmmtion.
txcessiverutrlalarioint pronarioD(A)
causesth€ lower o(tremity to inteF
nally rorale (B) and dmp inferio'ly
(C). This, in turn, increass tensile
$rain on the lliopsoasand pariformis
muscles(D) and leadelo a narrow,
ina of the Breater sciatic notch
Ithelebyprcdhposingthe €ntrapmenl
oi lhe sciatic neN€). Also, as rh€
lorer extrcmitydops inferiorly,the
ipsilateralinnominatek lowered (l)
and, a5 is consist€ntwirh Fryene's
l.w, the body of 15 rotatestoward
the f!nctionally shodenedie8 (D. As
a rc\ull, the lumbar spineatempts to
suai8hten ilseli by latelally llexin8
towad ihl: long leg (C, on inseo,
which compresses the lateralasp€cts
of the discs on that side and forces
the lacelr oo the €oncaveside into a
hyp€rcxtended or clos€.packed posi-
tion {srar5l. Over a period of years,
theseactionsmay lead to a varietyof

mum rangeof motion,porenliallyinjuriouscompensation reqliring frequenlbendingand lifting,lhc 30'rangcof

may occurcls€wftere in rhe kincticchainand,brthe mcta'
bolic co6t of locomolion would incrcase,as greatermuscu-
lar effort would b€ requiredto producca smoolh lrtrnslation
of thebody'saenlerof mass-
While the lossof cvensubtlemovcrhents betwecnrhe
tar$ls mighthe responsible for compensatory injuries,it is
the hrger more mobilejoinls lbat are more likely to pro-
ducepalhologicalcompensation. The followingis a lisl of
the mi[imal rangcs of molion necessaryfor noncompen'
satedfunclional thevariouslowerextrcmiryarticulalions.
The hip masamlatc a mini','un of 15-20',fet 30",
and extenl I0'. Conditionsresultingin thelossof sagi nl
planemolionsal dc hip are mosl destrucdvesince they
may be rcadilycompensated thf by eitherflexionor exrcn-
sionof th€lumharspifle(Fig.3.1l0). An increased rangco{
spinal fl€xion is particularlydaogcro$ sinc€ numerous
sludieshavedcmonrilnledthalrepealedflexionoffie lum-
bar spin€candamagelh€ arnularwall oflhe intervenebral
disq allowingfora posleriormigmlionofthe rucleus(139,
140).Forlunately, whileevenslightlimilationin fiip flexion
may damagethc disc duringBportingactivitiesor actionr
Rcxion necessaryfor ideal Iocrmotion is scldom lost,
comperlJabry sPinalflcxiondurirg the gail cycleis
This is not the casevith hip exlensionsince
teoathrosisand/or hip nexor contraclureoften limil
ranAcof hip e{cnsion to 50 or less.This may lerd
chn.ric flcet \yndromeor evcn a dynamiclatcral
litcnr)sis
3s lheetrlirelumbarspineis oftenforcedinto,
pci:\lendedposiiionduringlatestancephase.
While decreasesi|| iransver.scplanc rnotionsare
deslructivethanthcir saBitlalplanecountcrpsns, $ey
murt br evelualcd. At slower\p€edsofwalking.
tion for decreas€d hiD rolalion mav bc associated
asyfrmetriel shoulderrclationand ann iwing (l4l).
specdsindcase,the asymmetrical8lm molions
morr exaggeraled.and the effon required |o move
pch is rvith ils rigidly altachedf€mur becomc$nrore
able Also, thereis an overalldecrease h stridelcngti,
an aMucto lwist of the rearfoot is oflen Dres€nldu
heellift.
me knee dust extcnd 180' dnd ler a minimM
 Abmrmrl Motlor dr.ibg lhe crta Cyctc I 19

Fiture 3.1t0. A limired ranre of hio

flexion prodocc' compenratory soimt
flcxiondurloglat. sr{inr.nd errtv srance
phrrc (A) whil€ dctreasedrante oI hip Gr_
rcftron pnoduc€|comt,eni.tory ipinat hr-
Fr€rten3ion during rhe proputsivepefiod

B provideanple groundcl€rrancedurinEnidswin8,th€ indi.

vrouarts lorcc{tto circumduct0,eeorireswingphas€lower
crtrcmiry.This is accomplished with gr€armusculsrellon
via.forcefulcontractionof lhe contralateral gastrocnemius
anogluteusmediustrtusculalure (whichIunctionlo etevare
rheceder ofmassandebducrth€swing
!,haseinnodnalc),
rhe ipsilalcrrlquadratuslumborum(whjch lilrs rfie 5wins
phaseinnomioate)andmostimporrantly, vigorouscoorraci
uon ot rhc-ipsitabralhip Rexors(whichpull lhe s$ing tcg
forward).Inlnaner al. (l4l) notetharan adcquate rangeot
10,
knee flexion is the single most imponanr d;termiDanl of
gal.
3.llt, loit p.ior to heet tifi, lhe,:nse ot rnu€ The ank:le matt dorsinex o ninitu m o! IO.. The
rion is lrually limitedto lff o. tejs (A). Howeve,, ankl€ .
reachesirs maximaltydorsiRered posiriotrJuslpflor
i.lim,redidngeoI knecerrcnsion,, p,"i"ni to hcel lill. Thc_greare.
irl, ,r," $c rargc of hit extensiondurinS
15lorcedlo rlorsifhiex(ssrvety. lat€ midsknce(as wirh runningand speedwalking),rh;
grearcrlhc rangcof ankjedorsifls\ionncces$ryto
com_
pensalc.If the alkle is wable ro move throughthe full
Iihc kne€is unablero fully exlend,excessive tensxe rangenecessary to compensate for hip exteosion,the foot
are plecedon thc posteriorcompartmcnlmusctes wrrrattemprtosupply
theremainingrangeby pronaringthe
lrrly soleusandribiatisposrcrior)as lhc ,nkt€ joinl subralarjoinl. This acrior rihs rhc obtiquemldtarsaljoint
,Inro an excessively dorsjfforedposilionduringrhc axrsInroa morehorizonklposhiontharsllowsrheforetool
period(Fi8.3. l). The iDd;viduat wid $is to dorsiflexmorccffectivelyabourlhis sxjs(Fi8.3.112).
ity.ofienavoidsthe Ialler hali of stancephaseby Whilc subtatar andmidrarsatjoinrpronalionauowtor
rcly liftingth€heet.
Sreateramounlsof forefooi dorsinexion, tles noveoents
lf he indjvidurlwereto posscss lessrhan50. ofknee may be destructive,as tftey unlock the ta$als as verttcal
(whichis reladvclyuncommon), ths m€raboliceosl forc€s p€ak, I'revcnt lockirS of the calcaDeocuboidjoint,
mouonwould bc greally increasedas, in orderro anopreventtlreapproxinationof lhe aoteriorandposterior
120 FOOT ORTI'IOSES{nd Other Forns of ConservativeFool Care
Figure3.1I 2. with the subtalar,oint in its neulr.l Position,
rhe obliqre midtarsalioint arie allows ior muchfor€foor ab'
dtlc7ion lanov A). However, when th€ subtaiarjoin! is
il
//
U
oA -
titure 3.r t 3. Whenan ad€quaterante of ankle dorsiflerion
is or€s€nt (A), inertial forces a$ociat€d wlth the toNard
pro8rersionof the centerof mas!act to prertr€tchthe Poste-
rior calf musculaIu.e,lhereby allowing for the evenlual re.
turn of this€nergyduringth€ propulsitep€riod.lf the ankle
afld foor arc unable to supply lhe necessry range of
dorsiflexion (0),the heells pr€nraturely
liftedtom theEround
pillars nornally associated
wilh a tutclioning windlass
If for anyrersonthe sublalsrandmidtarsal jointsare
unable to fully compensat€for thc limited range of antle
dorsiflcxion,the individual will be pr€disposedto a
metararsal slrcsssyndrome(142).as incrtiallorcesassoci-
pronated,Lheoblique midla6al joini axis shiflsinio a
horizonlal position,ther€byallowinB for s.eiter
foreiirot dorsifl€xion (anot!,, 8).
(aff.w) and, s is consistentwith Newton's lhid law,
forc.i arsociatedlvith elevalinglhe centar o{ masstxl
now dive th€ lonBer metatarsalheads into the Sround{llat),
the l,eel do€i nol immediatelyllfi from the 8rcundG5
weal€ned tricepstulae), a recurvatumstres5is applied!o
posn'riorkne€ (C), which may eventuallylead to a Eenu
aredwrlh fonrard progression of the body will
drivc th€ melahrsal heads into lh€ Frund (Fig. 3.1
Huglrs (143) demonslraledthat a decreaserD
greallyincreases
dorsrflexion the potentialfor
mehtarsalstressfracluresas soldierswith limiled ranses
dorsjllexion w€r€ 4.6 limes fiorc likely lo d
 ChapLcrThree
Abrormd Motiordu.inAtheGaiaCycle 121

$lrcsslrrclures lhan lhcir morc flexible counLer- individual'sabilit! ro absorbshocksinceit inhibitsboththe

cushioringeffect associated vr'irhtalar planrarnexion and
ln additunto $ese Droblems. a resrriclionin ankle the connurent iDtematribial rotatior associaledwith lalar
ion(whichis rcferredto as an equinuscondilion) adduction(which is necessary for kneellexion).The indi-
slsodamageth€ anbrior talotibialadiculation,as lhe vidual may atlemptto compensat€ lor Lhereducedshock-
edgeot theanteriorribiaofteocollidesintothesul' absorbingcapabilitiesby dampeningvertical forces via
Ihedoasltalarneck.ll rhcrcis onlya sligh(limila. cxcessiveankle phniarflexion(which strainsthe anterior
in ankledorsiflexion, thc disraLtibiofibllararticulation compalmentmusculature) or by avoidingheel'slrikealto-
allemplto accommodate thc mlus by gappingaderi- gcther,i.c.,switchingto a forefootslrik€patternallowsthe
, (Thisarticulation rnaygapby asmuchas 1.5mm antc- po$eriorcompartmenl mus€ulature more time lo dampen
11441.) Ilowevcr,the abilily of{he syrdesmotic distal
r a iculationto accommodate the dorsiflexing lI rhe individualhasthe misfonuneof possessing dn
is al besllimiled arlylosed subralarjoinr (as occurswilh rdple ?rthrod€sis
Ovcrtime,repeated contacroI the Lalarneckandthe and cenain tarsalcoalitions),in additionto a vanety of
libiaresuhsin a bonyreaclionwilh tie eventuallor high-impaclsymplomsassociated with diminishedshock
of an impingemenr exosroses (Fie. 3.I l4). absorptioncapabililies,the anklejoinl often becomesa
(145)sLated that'1hisredctionhasan advers€ sourceof chronicpainsinceil is subjecledto trcmendous
lhan a prol€ctivc ellect in that lhc more bone that is torsional$trainsas $e subtalarjoint is no longerablc to
u p .rh c m ole e/ s il) ; m p i n g e m c n,'rc e u N ,a n d \" a v i - conventhecontactperiodinl€malrotationofthe shankinto
cycleis formed,rosultingin gradually increasingdis- readool evelsion.This resultsin large torsionalstrains
." He also statedthal the pain associatedwith beingappliedto theanklemortiseaslhe shankspirson bp
exostoses is rcrdily cxacerbated by acliaili€s of the immobiletalartrochl€a.
lhe demandsfor ankledorsiflcxion,suchas Bccause shankmotionoccursin a dir€clionparallel!o
ming,walkingup hills,andprolong€d squalting the ankle'saxisof molion,jl producesa shcaringforceca-
lhe subt larjoint m,.slpronate 4" and supinale t2" pableof producingmuchdamage.If ankylosisoccursin a
thenestftl position. Becausesubtalarjoint prona- child, nalure,via fic Heuler-Vollmannprinciple,has the
is re body'sprinary shockabsorbing syslemand be- ability lo compensate by conv€rtingthe asklc into a ball'
3n adcquatc range of sLibtalar joint moiion is and-sockel join! that is betler equippedto lranslatethe
l b t r hec onv c r s ion
o frrrn rv e rs ep l a n es h a n kma - transverse planeshanimotions(141).Ir facL,a r0-yearfbl-
into{rcnlalplancheclmolion$,a properlyfunctioning low-up study of childrctrsubj€cledto triple arLhrodesis
join! lhat possesses a minimumof 4' pronationis lbundthat397, of lhe childrenshowedevid€nceof a ball-
itthc individualis to remaininjury-fr€e. and"socket anklejoint(146).Unfortunalely, the adullis un
A rangeof lessfian 4" pronaliongeatly impairsrhe abl€ to accommodate thc tnnsvcrseplanc shankmotions
wilh lhe lbrmadonof a new articulalion,and sevoreos
teoarlhrosis of theanklejoinl is oftenthe finalsequelaof an
ankyloscd subtalar joinl.
The anklejoin! is not the only articulalionpredis-
posedto injury with an anlylosodsubtala.joiflt. In a well-
writlen article descdbing the pathomcchanicsassociatcd
wilh a peron€alspasticflatfoot,OutlandandMurphy(147)
described a seriesofjoinl interactions i. whichankylosisof
the subtalarjoint pmducesan exostoses aloDgthe dorsal
talar head.They referenc€da peruooalcammuoicationre-
garding cinefluorograpbicfilms in which dorsinexioDof a
foot witb a normalsubtalarjointis accompanied by an ap-
preciabledegroeof forwardgliding of calcaneus benealh
thetalus(Fig.3.115dandB). This lbrwardelidc contin €s
until ne the etrd of ankle dorsiflexionwhen motion is
checked,presumablyby capsularljgaments.Then, as the
final raogeol anlle do$iffcxion is reached,an uplvardglid-
ing motionis seedbothat thecdcaneocuboid joht andtbe
lalonavicular joinl as lhe upperponion of the navicular
movescephalador the talarhead(Fig. 3.115C).Through'
out this process,the intenpacebetw€enthe headof lhe
tiSure3.1r4,Theimping€ment exostosis (l). talusandthenavicularacetabulum remainsconstanr.
122 FOOTORTHOSESandOtherforms ol Con*rurlivc FbnrCarc
fiSur€3.115.Seetcxt for explana-
tion.
As pointedoul by Outla and Murphy,lhesemo-
lions do not occ$rwheo the subtalarjoinl is xnkyldsed,In
this situation,the normrl glidirg of the calcrneusbcncath
rhetalusdoesnot occor,rnd rhemidlar$ljoinr functionsff
a hingewith ankledo.sifl€xionaccomprnied by a narrow-
ing of the dorsaltalonavicular jornl marginsas thc shary
uppercdgc of lhe nnvicularimpingesupoo the ialar hcld
(Fig. 3.115D).Whenthe subtalarjoinlis complelelyanky"
losed,talonrvicul8rjoint remodellingoccurs,in which a
characleristio exo$bsesformsalonglhe talarlread nd ncck
(insetin Fig.3,lt5D).
While a completcr€striclionin subtalarjoint motion
may resullio dramatichonychsngesir theanklcanddeigh-
boringtanals,evena slight restrictionin subtalarmotion
may leadro il|jury,as lhe fool is oftenunablcto srtainfull
plantigradecontactwith thc ground..ds noled earlier. if thc
subtalarjoint is unableto move lhrough a rarge nece\sary
to compensatcfor a specificfoot typ€, it is relened to as an
unc,ompensatcd venjion of lhat foot type.The mostmmrhon
exampla\ arc th€ uncrmp€rFated re foot and forclmt
varusdefornitics (Fig. 3. I I 6).
ln addition lo producir|g atr acqoired plantrrflexcd
first ray deformity, lhe rq\ar!:!edsubtrlrr motion mighl also
be responsiblefor knec injury as,in an atlempl to brin8 thc
medialplaniarfmt to theground,thenedial knseis gapped
with a valgusslresswhile the lateralknee is comprcsscd
(Fis.3.117).
Engsbergand Allinge. (148) notedrhal
oftcr atetuptto comp€trsatc for limilcd subtalarmotiorl
wlllingwith awiderbaseof gait.Whilethismaylcss.n
pokntial for kneeinjury. it prcduccsa lesscflcctivc
patrcrn,asthebody'scenterof rnassis displxced funh€r
erallyoverthe stancephas€leg (which$trainslhe
mediusand the peimeal musculature), and rhe
angllar momenturnpresentin thc lowerbody as'
sNte for via excessive abductionof thearms,
lndividualswilhlimiledsubtalarnorions!re alsc
disposcdto interdigital neu ris and/orstreis frucrureof
lesscrmektarsals,as lhe foot is maintained in a low
pusl.{rfflhat Eactionslhc inrcrdigiralnervesand
the ground-reactive forces supponed by ft€
melirtarsal heads.Because of (hcir abenantdisribudon
pla rar pressures,individuals wilh unconrpcnsated
typcs typically presenrwith diffuse hypcrkeratutic
bentaththe lateralmetarrisalheads.
Allholgh ir is poGsiblet) have an un
for€lt,otvalgusin which the sublalarjoinl lacks
supinalionlo brina the latcralforefootto thc ground,
shurtion is rarely seensiice the rangeof subtalar
supinationis almott alwayssuflicientto bring lhe
forelbot to the ground,
The mAftanal joint mtl.tt atlot+ lor 6' ol
pldne motion. If ihe midtarsaljoint is unableto inved
n)inrnrum of6" (whichoccursprimarilyaboulthc
 Chrprcr'three Abnomal Motlondudrg l[. Grlt Cycle 123

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

nalmidlarsaljoitrrixis), rhesubtalarjoint is unableto movc

lhrouBb an adequaterange of pronation wiftout comper-
satory dorsiflerionand inve6ion oI thc firsl ray (Fig.
3.118),Wher the first ray movesthroughils full mngeof
motionnnd is oo longerabl€to compensatc, sublalarjoint
pronationcomesto an abrupthrh.
The ha ux '//'usttlorsw a minitnum ol40". Al-
t though 65' of hallux dorsiflexioo is necessaryfor ideal
propulsiveperiod function, as liltle as 40' of haliux
dorsiRcxion witl still allow the individualro movcthrough
lhe €arly stagesof propulsioDwithoul injury. When the
inffexiblehalluxachi€vasils fully dorsidexcdposition,the
individual ofien choosesto rcrminarclhe propulsiveperiod
by prematurelyfiexirg rheknee and hip.

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

figurc 3.l 18.Whenthe rnidtarsal

,oinl is unabl€
to inverti minimumof 6", cortinued$btalar
p.onarion (A) can o y occur ;f lfie fi.st ray
dorsifl€re:andinverts{8).

and abruptaM do€snot changewith r.peatedhold"

strerches, A classicexamDle of a bonvrestriction canbc
by gentlyauemptingto hyperextend theulnohumeml.i
Ajoinr's rangeof motionmayalsob€ ljmitedby
dyslunction.In this situation,rfie normalelaslicend
a,sucifiedwirh accrssirgrhcparaphysiological spncc is
placedwith a lirm, tellseerd-play.As defircdby
(15(l),joinr dysfunctioorepres€nts a loss of lhe
ranseof involuntarymotionooirt play) of whichall
ovirLljoints arecapablc.Hc alsonotesthalthcseinvolu
mo\ementsarea necessary prercqsisite fof a full r
pail-freefirnctionrlvolonlarymovcmenr.
Althoughthe exact naiureof joint dystuncLio!
maiJrsconlroversial, rhemoslplausibleth€orysuggesrs
it is due1()Mhesionsin lhe perisrticular coDrective ti
thar iiltrir accessto the joint's paraphysiological
Manip'rlallon
(15lJ.Becaus€ a joinl s .Ncrallmnge.\f moljonL\
tigure 3.119. RarBc oJ motion ayailable to a dia.throdial denton thesnaller accessoly motions(152),lossoflhc
ioinl' lf an examlner were io move a joint lhfou8h ii, full mphysiological nnge of modon may irhibil lne
ranseof molion, an elasticbani€r would be fell at the end of rolling. spinning,and gliding molions rccessaryfor
its pEsive €n8e oi mov€ment.This barrier nomally pos- joinr lo movethroughils tull rangcof movernent. To
sess€sa sprinSy end f€el that crn be evalualed by genlly pou d $e problem,because of discomfbnas\ociatcd
siressinsthe ioinl. (A classicexample of this cndj€€l is lhe Lheindividualoftenlearnr
tensingthe librousadhesions,
springy rcsistanceassociatedwiih long axis lractron ol a
avoid using the dysfuDclional ioid, which only seNes
m€lacarpophalangeal ioinl Th;s end ran8e reetswithin the
limii! ofthejointt anatom'.rl.ange of nrolionnnd.an be ac-
peryletuate the rc-slrictiolr.
cessedvia €areful mnnipllatlon. {Adapled from Sando, R. Anotherpossible.albeitpoorly uflderstood cause
Som€physicalmechanismsand elfectsof spinnladjuslments. jojn! dysfunclion relatesto subluxarion of a hypcrmobile
A n n Sw i ssChir opA s s o.19 7 6 ,6 r9 1 .) tiorlriion. Becamelhe abnormalapplicalionof ground
acti\e lbrcc in a nechanicallvmalfunctiorns foot
lead!to it laxityoffte rcstraining lig0menls, subluxalion
oneor mofeoJ thetanalsis not unqlmmon.
LnJortunatelt. evenslight:subluJ|ation m!! leldto
Whenajoint's rangeofmotion is limit€dby muscular funclionalmalalisnnentof axesthat actsto lirnit fu
contractu.e. lhe elrslic barrieris diffioh to access, andthe molion.Thi:ris anxlogouslo how tilling ooe hingeon
endrangeis soft andconslantlychanging.The easiesteay door even2 or 3'will drasdcallylinit the rangethat
to idenlifya muscularrestrictionis to perfbrmrepeathold- door wiu oDen.Becausethe arlicularsurfaccsarees1e['
relax siretches:If lhe rangeof motion ircreasesslightly tiall! frictionless, a subluxarioflcould initiallybe rcducedl
wilh eachsuccessive stretch.therestriclionis muscular. simtly by rnovingtie joinl rhroughits full rangeof notion:i
In conlrastto thissiluatioD. if thejoint'srargeof mo- Pressurc on opposingarlicularsurfaceswill causethesub-
tion is lirnitedhy a bony restriclion,the end rangeis hard luxario to reducein ord€.to allow for a pa.allelism of thek
 chapterTnrec Abmrmll Motlonrlorirg it€ GslaCych I25

axe\.The samcrhingwouldhappenif thedoorwrLh r€fered ro as PNF techniques,or muscle energy proce-

qtalaligned hingeswere forc€d open, assumingthe dures,consistof variouscombinatiorsof slatic strelchesap-
wefenol secured roo dghllY. plied in coniunclionwilh alternatingcombinationsot
As relatedlo the body, however,ground-reactive antagonisr and agonisl contractions. A ljsl of possibls
arer€l€Iltlcss
in th€ir maintenanc€
of a sub]uxatiotr, AMRTB is describedas follows.
lhe involvedjoint's rangcof motronremaioslimiled Matinum resistance hoA-relax stretchet. This
lo lhemaleligncd peria.ticular
axes.If untreated, adhe- lechniquerequirestharIhe examinergertly slrelchthe de-
fDrmIbat con!1fl the one-rime hyp€rmobilejoi0t inro shed muscleto its fully lengthenOd position.The palienl
jlejoint, thenisometrically leDsesthe musclewith maxlmumeffon
Acaordingto Hiss (132),IbesEperiaiicular adhes'ons for apploxinately10 seconds while the examinerprovides
ho refers1o as "nalure'scement")produce'loint resistance.On releasing tension, the muscle is g€ntly
th8lirlcrfereswith thc synchronyof pivoling,bal- srrerchedro its new end posirion,and lhc processis re-
andthedistributionof lhe movingloadin walkrDg." peareduotil musclelenglhgairs oo longeroccur.
notes lhatil is nol uncommonfor hypermobile pronatcd Lewit kchnique. This slretching procedureis iden-
lo havcone o! more of the rarsalbonesbecomalocked ricalro rhemaximumrcsistaflce hold-relaxstetch,with the
Bbnormal position.This is amlogousto how a hype.- exccptionthal only genrleisometricconrsctions are used.
glenohumeral joint may eventuallybecomelocked Mflhnic subilizatian. This strelchingtechniqueir-
*ozenin lhe upperponioDofthe glenoidfossa, volves altematecoDractiors of agonislard sntagonistmus-
Oncetheexactcauseof limitedmotionhasbeeode- cle group$ while the examinermainlains the isomelrically
ined,fie appropriate treatmenlprogramcan be initi- telsed rsuscleal the limit of its availablerangeof molion.
. Thefollowineseclionswill describetrealmelltfor the CRAC techaique (conlracl, nlax, agord contrac-
condidons limirirg rangeol morionin the lool and lior). As tle nane implies,lhis techique involveshaving
Fora rnoredelaileddescriplion ofmanurl techniqucs lhe patienlisometrically tensethedesiredmuscleal the end
wilh kncc and h;p dysfuncrioo,the inter€sled of its fully srretch€d position(Fig, 3.1204).The muscl€'s
is referred to olhersources (150,153-15?). aotagonist is ther contracted with tull efion agarnstresis-
tanceprovidedby the practilioner(Fig.3.1208).(Notothat
Restricted Motiol Resulting from Lheuseof rhe ierm "agonist" in lhe tille rcfers to agonistsof
MuscularContracturr the motion, not agonistsof tle stretchedmuscle.)The de-
siredmuscleis thenstretched ro iN new end-position (lig.
Resisusce to a stretchresullsfrom tensionon thr ac 3.f20C), and the proc4ssis repeaEdunlil musclelength
conlractilccomponerls and lhe passiveresistive (vis- gainsn0long€roccur.
ic) components(158). The llexibility oflh€se tislles While the us€ of AMRTS is widely advocaledbe-
tusually b€ improvedlhroughLheuseof variousactive cause they mote quickly increasemnge of motion
Dassive musculalurc relaxaliontechniou€s.The aclive (159-162)and irnprovethe ability of the myotendhous
rclaralionrcchniques (AMRTt. which are also junctionsto resistteflsilestrains(163),morerecenlstudies

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,

fiSur€3,123.Ant€.iorcomparlment stretch€s. Tibialisante' resur in halluxlimltusor h.llux rbductovalslr,as llBt

rior is strctch€dby plantarflexinS the anklewhile contactinS planfa{le}ion durinSlhe propulsjveperiod nay bc block€d.
thebaseofthe fid metata6al (A).txtensorhallucislon8ueis is al'o possibl€lhat conlracturein extensorhallucit
nrclchedby planlar,lexinB the ankl€ and then matima'iy will rrcdu.e a plantarlleted
firstr.1ydeiormity,as the
planrad€xin8 thehalluxby prcssiog on thedistalphalanx(B). pr€s,ive forceseneratdat the halluxmay pruducea
Extensor dighorum longus and p€roneui ledius may & gracl,:plantarllectory
force at rhe fi6t metata6al
strelched by maintainingtheankloin a plania.rlexed position Conrrnclurein ext€nrordiSitorumlon8usis lessd.lma8in&
and applyi.Epressure to .listalphalanges (C).Notethal lhe tho{r1hit may,eruk in the developmenofdiSitalcon
laredlfibe'' olextenrordrEirorum lonrlre{includrnBpefoneu( with hrperenenrionol the lesserm.\atafsophaldnSeal joi
lenius)maybe iccesredby simultaneously InwdinSlhe rcar' Perpetu.lingfaclorsr'llbialisaniefiork chronically
footwhileplantarlle)(irg andadducllngthe fore{oot.
Effecbof and rishtenedin individualswith cxcessiv€lowcrin8of
contracture:Contracturc In libialisanteriormay producea while the
mediol Iongitudinalarch upon weiSht-bearin8
lunctionallv dorsiflexcdfnn ravor cvena funclionalfotefool di8illl llexoE may be chroni€allyconlracredin indlvld
varusilthe conlracture is severcenough.Thisnay evenlually presi,n{inswith plantarflexedforefrcl.
r28
 chapLer'thr€eAboormll Motlon durhs the Grit Cycle 129

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.

To preventpossiblciatrogcoiclow backor kne€in- ankle dorsittexionhas produc€dplasticdoformityof the

, lhe individualwilh a unilarerallydecreasedrangeof midtarsalrestrainingligamonts.In lhesesiiuations,it may
dorsillcxion
musrb€ lreatodwirh bilatcralheellifts. be n€cessary lo us€an onhoricin addhionto theheellift in
Il shouldbc slressed that excessivesubtalaror mid- orde.to controlsubtalarandmidtarsaljointmotionsfully.
joint prunationfesultingfrom a decrcased nnge of The Sat'talar Joint. Subtalarjoinl motion may be
doBiiexionis not treatedwilh a fool orthotic.If an limited by bon] restrictionsthal block pronalionandlor
scre inadveaenrlyprcscrib(dto lrear compen- supinalion. The most conmon causeof a bony restriction
sublalaror midlamal p.onation and thc decreased that limils supinationoccurswith the triarticulat€d subtalar
ofankledorsiflexionwasrot lroatcdwith a heellift, joinl. This anomalyoccursin approximately 367oof lhe
ic injurywouldmosrlikely resultas the lissuesbe, population(173) and producesa resticLionthat prevents
!e mediallongilldinal arch would cl)llidc inlo the oF condnuedsubtalarjoint supinationwhen lbe anterolaleral
shcll as the ibol continuos to compensalefor thc facel of the calcatreuscotrlactstie anterolaleralfacel of lhe
anklemotion.This often resulNin neuropraxia ol
media!plafllar ncrve dnd/or contusionof the abduclor Anotherexampl€of a bony restrictionlhat limits the
rangeof subtalarjoinlsupination
is therudim€nlary lalocal-
In nost situations,
lhe addidonof a hcel lifr allows canealbridge.As describedby Harris(174),the rudimen-
lle rcstoration
of propersublalarandmidlarsalmot;ons. lary talocalcanealbidge consislsof an abnormalbony mass
in ccltainsiruations,
rhc sublalar and midtarsal projeclingfrom the sustenlacuium titli llat blockssupina-
contilueto pronateexcessively despitcuseofthe heel lion whenthe lip of this nass impingesthe medialsideof
This mosl oflen occurs when the decrcascdanklc the talar body (Fig. 3.129).Tbis bony anomaly,which is
is associatedwith other structuralmalforma, very difficult ro id€ntify wirh convontionalx-ray rech-
(suchas the lorefoot varus deformity) or, when pro- niqucs,aclsas an osseousblock ftat maintainsthe heelin
pronalionassocialed with compensation for limiled
130 FOOT ORTHOSESand Olhcr Formsofconscrvative Fool C re
fi8urc 3.125. Ho.n. stn{de.. All of the ponerior compnn-
mentmusclesmay be siret.hedwilh a {andardcalf nrcl.h
(A).8y placin8an an8ledpieceot corkor a foldedwashcloth
beneathlhe medirl forcloot(B),the lat€rallibersof the sas-
trocnemius musclemav be ltretched.h h oossiblelo rlrctch
rhe medialfibersof lhe sarnemusclesinrplyby placinglhe
weds€underthe latcralforef.t)t.the medialfiber.of loleus
ard tibialirp(rsteriorshouldalsobc strctched wilh rh€wedse
underthelateralforefoot; onlyfte kn€eshouldbe majntained
in a sliShtlyfle,(€dposilion lthe lateralfibec atP strctchedin
positioo 8 r,/ilh lhe koee th.)€d. The diEilal flexotscan be
strctched by placin8alowelbeneath thedi8itswhilepertorm-
in8 bent kne. calf stretches (C). Peroneurl.'n8usjs best
stfetched by placinSa tcnnhball benealhthe firstmelatarcal
headsandthenhavinsthepatienlfle,(thekn€es{D).An nlteF
natemelhodof str€tchin8 pe.oneus lonSusis lo havethe pa'
tient aMoct the hios 45". ade.nallv robte lhe lower
ertk milies,andsli8htlyllex theknees:a Bentlestrelch
be f'.lralonglheoutcrleg.Theanle.iorcompadmenl and
intri'1sicmuicl€! can be strelclEdby havinSthe patienrrit
a ch.rirwiththeanklecrossed ove.theoooosile kne€,The
fcrc,t muscles nraythenlte str€tched asdescribed in
3.12, and -1.124. Anothermothodoi str€tchins lhe a
comr)adment murclesjs lllusrraled
In [. 8y partially
bodt weiShtontothc plantarflex€d .nkles,the an|erior
partrnent muscle!aregraduallylenslhened. Thelaleral
of e' rensordigiiorum lonAu5and p€roneustertiusmaybe
cesr(d by adducting the Iorefeel fd'rowi in E) whila placi
towrl L'nderthe toas will increaseIhe amounl of
plac,.don all of the diSilalextensors.
Of course/lheee
only a few ofthe potentialhomeetrelches,
.s a knowleige
each muscle'soriSin and jnsedionwill allow the practil
to pn"s.ribe any of a va.iely of slretchcs.
Chapte.Threc Abnormal Motion d.rhg the GaiI Ctcle 131

Figure 3.125. comparison of the dorsal lalus in a normal foot

(A) and in a foot possessinBa tlatteo€d lalar trochl€a (B)
Note how lhe llattenedtal& dome is lesrcurved,and lhe nor-
nlal concavesudaceof the tala. neck is ab5€nt.Thi! deformity
producesa bony block lhat limn5 ankle doEiflexion as rhe
thickencd Ialar neck collides wilh the distrl libia. (Modjficd
hom phoroaraphsftom Root MC, Orion WP, Weed lH. Nor
mal and AbnormalFunctionof rhe Fool,LosAngelesI Cllnical
l 97Z.l
B i omechani cs,

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
Flgurc3.128. Thefoot in A is unabl€
to dorriflex the anlle beyond th€
90' marlr and th€ lubtalar and mid-
larsalioinrswill rnosllilely cornp€n"
satc for $rh defornit by promting
durin8 lat€ stancephale. Nole how
the additionof a hel lift allowsthis
foot to movesafelyinto jt! propul,
riveperiod(B).
figure 3.129.The rudimenlarytalo.alcanealbridg€. lhe
bony massprojecllnglronr the sustentaculum rali ads as a
bonybloct thallimilssubtalarioinr (Adapted
supination.
from
Haffis Rl. Ri8kl valBu(foot due to lalocalcaneal bridge.I
BonelointSUG1955,37A(l):169-183.)
In ddition to anomali€sthat limit supinarion, theru
arcalsovariousbonyblockslhat limit therangeofsubtnlaf
joinl prondion. Bccausethe useof rriple subtalaranhrode-
sis is exleosivcly usedfor various rnedicil conditions,suF
gical fusioo is the most common crrse of restrictcd
pronation.
Othercauscsincludevarioustsrsalcoalitions(which
aredescribed in moiedetailin a latersoction)anda congen-
itll anomalyin wbich lhe l€adingedgeof the lateralprucess
of the talusrbuls lhe siousrarsi(175).This particularmal-
formation oflcn resulrsin an adhesivecaosulhisof rhc sub,
ralarjoinr(175).
Becauselhe various bony Rsrictions often prevert
lh€ foot from making full plantigradeconr ct wirh the
Slound,rreatmcnlis to accommodate lhe bony rcstrictions
by argling or po$ing the onhotc so as to bring the orthotjc
she up ro the high sideof tfie foot (Fi8. 3.110).Alrhough
the postedorlhotic will not chatrgethe faulty biomechanics
of lhe foo!,il will reducethe risk of injury bothto rhe nlc-
dial knee and to lhc planlar Iateral surface o{ the {oor by
disuibulinggound-reactive forcesovera largerarea.
Fir'i MetalarsophalangealJrinr. The characteristjc
degencralive changesassociated wilh hallux limilus otlcn
producea bony block lhal limi6 hallur dorsiflexion (Fig.
3.131). While manual techrques to restore hallux
doBifiexion a.e indicatedwhen bony changesrre
rltemptsto malipulateinto a signific{ntbonyblo.k
onl! accelerat€thejoint damage.Hiss (l 32) callions
ffaiipulating tbc first metara$ophalangcal joint when
limitus is pres€nt, statingtftat "every time thc patient
step the metatarsophalangeal joinl is manipulated(too
ir facl) and h is this activerhotionof rhc.ioirl lhat keet6
Pro(essSoing b€causeof lhe excessiv€buildup of
Trealmentin this situationrequir€sthc useof a steel
or rocker bottomshoeto decreaselh€ dorsiflcc@y
joint (Fi9.3.132).
on lhe6rstmetalelsophalongeal
lf the halhx limilus deformily is tbe resulrof
chanically mauunctioring foot (i.e., inpaired firsl €y
tarflcxioo secondary ro sublalar joinl pronation),
apprcpriate orlhoticmustbe pr€scritedin order!o
lish the propulsivc pc.iod donral-posteriorshift of the
veffe melatarsophalangeal joint's axis.Surgical
to rcmove the cxostosesfronr the dorsal first
hcadsshouldonly be considered if@mpr.hensive
ativf caic hasfailed.
RestrlctedMotiotrResultiagfrom Joirt
Dyrfutrclioo
Ille useof manipularion lo improvctunctionin
joinrs of the feel hasa long and inrercstinghislolv-
40Oye&s ago, tbe early boneseters of Englandclaimcd
b€ paniculffly effeclive ar reducing foor and handpaitr
manipulatirgsubhxalionsin the ranalsrnd cirpals(1
In firct, ihese booesetteNsingled our manipulatio$of
smJll bonesof lhe handsandfect us on€of si)
for whjchtheirtrcatments wereprrticula.lyeffeclive.
t he imporianceof manipulatingthe foot *as even
knowledgedby D.D. Palner (177) who, in his l9l0
"Th( Science,An and Philosophyof Chiropractic,"
lhat: "57, of all diseasesare causcdby displaced
othcr thar the venebralcolumn,morecspecially, tlose
the |a$us,m.latarsus,andpfialanges." While thisnay bo
somcwhqtof an overstatemcnt, thc clinic efncacyof id.
juslivetechniques to improvefunctionis readilyeppareto
anyoneskilled io lfteseprocedurcs.
The various mobilizalional and manipulariveprocc.

F.
3.130.Lorxcredrcmilv motion $,ith limiled srblaht
Theindividualmostoflenrpendsall of stance
wih weight suppoded benealh th€ lateral Iool 6ta. in
3.131.A dorsalerostosison the fint metatilsal head
limilshallurdoniflexion.
usrd to br€akdowr lhe collagenffbral cross-linl-
wifi pmlongeddisusdimmobili"ation and
thc normal accessorymotiols necessaryfor a
dovc lhrouShits full rangeof motion. In a detailed
beatinB histolog.icalchangesassociatedwith im-
Wooel al. (178)providedquartitative
evi-
ChaprerThreE Abnonnrl Motlon dfflng thc Gsll Cycle 133
stre.s(B).Thevarus
A) or Bapslhe medialkneewith . valSus
posl (C) prev€nrrcompenralorykneemotionsand distributes
plantarpressuresover a larEerarea.
tiSure 3.132.Addirion of i stc€l shanl ot rocket botlom al-
lo$,e for a pain-f.ce prcpullion, ev€n In thc pr€senceoI
ankylosh.
dcnccthal mobilialion do€s,inde€d,b.eal down lhe colla-
gencross-fibercformed during imDobiliz tion.
ln addition to being csse irl for [offesl.icted rarge
of motion, the restoftriod of a smoothend-plsy allows the
artiorlations of the feet to dampcnground-rcac ve tbrces
mor€ eflectively through lhe naturalspringinessor elastic-
 134 FOOTORTHOSES
rnd Olh.r ForBsof Conscrv.tivcFoolC!ru
ity associated wilh srr€ssir8healthyconnccliverissue.lliss
(132).who hashadrhe€xp€ricnce ofadiusringseverathun-
drcdtholsandfccr,stat€dtharallholgh ir canrakesmonths
to restoremotionto an old fibrotic foot ("il lakesa lot of
poundinglo drive a nail into hardwood").somerimes even
thc slightesincrcasemovcmcntcr! oftenspcll the diffcF
ence belweenpnin and completerelief. Figures3.134
through3.157illusrale the variousmanualtcchniqnes for
jointsof thefool andrnkl€.
Nole that theseprocednres nre not intcndedto repre.
sentr cookbookformulafbr manipulation. Rather,by cou-
plilg a thoroughunderstardingof anicular archit€c1ore
with lhc cxpericnce gainedby palpatingmotionbanien in
thousands of fcet.the pracrilioneris encouraged {o modify
the line of drives,corltsctpoints,and forccsin wtys tbal
beslsuir€achparicnts individ$alneeds.Mairland(179)de-
scribesfive gradedoscillations that may be usadwhile per-
forming theseprocedurcs(Fig. 3.133).
Th€ d€cisionofwhethcr ro mobiliz€or manipulatcis
dependentupon the practiti{)ner's experiencewith thcse
tcchniques.Becaus€an improperlyappliedmanipularion
may potentiallydamagethe joinl, ttseof a higb-velocily
lhruslshouldonly be aticmptcdby thoseexpericdced wilh
suchlechniques, AllhoughCood (180)chims that cavira-
tion or crackinglhe dysllnctionaljoinl is ncccssaryfor
trealmentto bc completelysuccessful, lhis claim is un-
founded.
Theonly diffcreoqrbetwcedmobilizrion andmanip-
ulrtion is thal manipulation oacursso rapidlythatit gcneF
atcsa negrtivepressurc capableof pullinggasesout of $e
liynovialnuid.(Cavitalionrefersto th€proccss of crearinga
cavity,in lhiscrsc,a vac[um.)Because mobilizationoccurs
morc slowly,thc vacuumneverb€comes strongenoughto
riSure 3.133. (A{) The fiv€ Eradedoscjllaliors useddur;n8
manral lhcr.py. / = small ,mplilude movernentnear the
staning positjon; /l = larSe amplitude movement irear the
na{in8 position; tl/ = lar8c amplitude movenent endin8 nl
tho alasticbar.ier;/V = small amplitudemov€nrenrborderinB
the elastic ba(ier; V = manipulation:: smrrll-anrplilude, Joirl.!. All of thescjoints shouldposscss an appreciabL
high-velocilylhrusl accessin8the paraphysioloBical
spaccbur elasticsplinli whenstressed io long axi$extension.To per-
nol exreedingthe dnaronri(allimit o{movem€nt. fo.nr $i! oraneuvcr on a meratarsopha langcaljoint, theex-
pull gas€sout of the synovialfluid. However,ir h not
cav,fationlhat produccstbe favorabi€rcsponse, bur
th€ breakingof collagcncross-fibrilslssociared wilh
seprrl|ionol joint s|]rfaces.
'l'h€ frct rhai mobilizario etfecrivclybrcaks
cro\s-linkswas demonstrated in the srudyby Wooct
(l7il) in whichthe fibroticjoinh weremobilizedartic
of I cycle of flexion/ertcnsion evEry 5 scconds(hrcc
cles were performed,with the majorityof charges
ring duringthefirstcyclc).
Although clinical expericnccsoggustslhat marl
lion morc quickly restoresmotion, this hls ncvcrb{cn
clusively dcmonstrded.In fact in many siluatiols,
joinrs of thc fcet arc so tighlly articularcdrhatclen
higlr- velocity lhrust of manipulationcsnnotcrearg
sufllcienlscDaration ofthe articularsurfaccsto crvitatc
joinr. This is padicularlytruefor theintercrneiform and
navicular-cuneifom arliculaiions- ln thelicshuations"
bestto takethe ad\.iceof Paris(l8l), who suggesrs
lizirlgthevery stiffjointsnndmadpularinB thcslightly
joinls. Usingthis approach. ir is not uncommon for m
lr€n]clyfibrolicjoint ro bccomcso flexibletftar,ovcr
thc ioinK cnn be cftecriv.ly manipuhr€dwith I mini
It shouldbe norcdrlul themostcommoncaose fof
jur,! aisociarcdwith ma0ualtechniquesis failureof
praditionerto evaluatemotionbanicrs properly.I
idenrifving{ hypernobile.ioinrprior to manipularion.
is {spccirlly impo ant witl rhe ralocruraljoint, w
mant practitioners roulinclyincorporatelongasis
lationas prrl of a poslinvcrsion sprainlrcatrnent regi
CIh^ ;s mo6llilely besusc thc poppingnois€
witl this manipulation givcs borh the prflctitionrrand
pati(nt a sensethat som0thing lhlll wrs 'out of pla@"
now "iri place.")
Bcc0uscrep$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.
Mrnipdallve Thchniques
The M.talarsophalangeal and
 ChaplerThrqeAbmmd Modondurbgrhe G.il Cycle 135

sholldfirmly grasplhe proximalphalanxandgrad- should possessan af,preciablcamount of inferior glide of

tracliorrhcjoid in longaxisextension (Fig.3.134).Ii lhe dislal articulalionon the proximal artictiation.Con-
dysfunclion is present,a shorlfast thruslis delivercd versely,the €nd-rangeof doEiflexionshould inclld€ a
theend-mrgeis reached. slightsupeior glide oI the distalarticulationon the proxi-
TIes€ jo'nls should als^ bc c!alu2rcd by routing rhe mal articulation. Unfonunately, digitaldeformityoften re-
phalaoxon thelixed m€lalarsal. lf a hardendfeel sultsh contraclure in lhe dorsalmetatarsophalangeal joinl
on rotatingthe phalanx,a manjpulationnay be capsolethalljmitsthorangcofinferior gljde.This is paflic-
by sinultancously rotalingrhephalanxwhileap ularlylruewith clawloe deformity.
a dynaftic thrust in long axis exteosior. Nole thai i! lf this gliding notion is limited,lhe manipulation il-
uncommon for lhe toesin a chronicallypronated foot lustraredin Figure3.136may be performedin which lhe
iretolslionalmaniDulalions to rcducothevarusDosr proxiroalphalanxis planlarflexed by the thumbwhile the
of theproximalphalan8es. This lesLposilionis also indcx6ngerdrivesthemetatarsal headsuperiorly. This ma-
whenevalualing medialandlaleralsidetill. nipulation,which is accomplish€d wiih a genllesqu€€zing
As illush-ated in Figurc3.135,lalcrallilt al thc second molion,maybe facilitaledby tractioningtheproximalpba-
langealjoinr is chcckedby tractioningthe lallx in longaxisextension andby pcdormjngseveralhold-
I phalanxwith lhe right hard while simultaocoully relaxstretches prior ro dcliveringthe sdjustmenl in orderto
ng it on rhe stabiliaed metaratsal hcad,which i. relax the digital exlensofmu$cLrlalur€. NoLethal supedor
conlacled on ils dorsaland planiarsurlaceby rhe glide ar rhe meralar€ophalangeal joinls is iarely lost and
andindcxlingerofthc left hand.lijoinl dysluncLion when r.slriction in this motion is notedal the iDterpha-
a mmipulalionis pcrformedwirh rhe lefr hand, Iangealjoinrs. it maybe reslored wilh simplclon8axisma-
tkough the melatarsalheadwhile the righi hand nipulationperformedwhilc stabilizingthe moreproximal
t o r r ac lionand a h d u c ll h c p h a l a n x '.l o e v a l J a t€
joints in medial till, rhe hands are switched, and the It shouldalso be noted thal an invaluableform of
rcatmcnt lbr metatarsophalangeal joid pain is to add a
j ol i nLc
Th c nr ( r dr dr s uph a l a n gd(anld i n l e rp h a l a n g e a compressive componentwhenevalualingthejoiors.As de-
aho be cval0aledlbr superioFinleriorglide. On scribedby Maitland(182),lhisprocess irvolvesposirionirg
il\ tullran8eol planlarflexion.
eachol rhese
ioint. lhc digir in a midrrngepositionandaddinga compre.ssive

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
Figure 3.136. Infqior Slide of proinal phalarx on
figur€ 3.137. Superior-inf€rlorElideb€l\!€en lh€ diatalmelalnrsals.
forcewhile simukaneousty applyinga sm$ll-ampliludc ab-
duction-adductionand/or rotalional motion. (Theseniove-
nlenls ar€ applied in an oscillatory manner*ith a rangeof
motion no! to exceed lf.) Becrus€ this procadureis per-
formedwilh thedigit in a midlincpositio[ neithert]lejoint
capsulcnor the slabilizingligameDts are stretchedin fny
way, therebygivitrg the practitioler ioformathl that could
trothavetrcenaltainedwilh noncomprcssive lests,
fie class;ccxamploof when this prog€dureshouldbe
usedis on lhe individual presentingwith a stubb€dtoe. Nor-
mally,sucha prtientwill repottno Painon P:Lssive teslinS,
but fte addition of |] compressiveforce will often praduce
excruciating pah. fiis beiogthecase,lreatment wouldcon-
sist of small-amplitudeoscillatory motionsperformedwhile
genrlycomplessing thejoint.As patietrlloleranceimProves,
the compie\sivefo.ce is graduallyinqeas€dunlil the syEp-
toms are gone. Repeatedtreatrnenb,which arc rcadily per-
form€d by the palient at home, arc remerkablyeffecliv€ at
reducingpainrssociated wirh thisryp€Dt injury.
--.".rt
Allhoughlhe exactmcchanism for fie surprising
cessrateof this treahent is unclcar.it is Dossiblethal
ular.onof mcchanoreceptors in lhe subjacent bone
pain cycleassociated with rcflexsympathetic i
Manhnd (152) staredthar the joints mosrofian
trearment with compression are the fiIst
langcaljoinls, th€ hip joint, the glenohumeral joint,
patellofcmoraljoin1, aad thc carpometacarPal joinl of
thunlb.
The Dislal IntcflwtatarsarJarits. No.mdlly,a
perior-inferior gliding moliol is prosentbelwecna]l of
nretrtarselheads.Becaus€the c€nlml hetatarsalheads
slabilized by the sronge-rt ligaments, inlermetrlarsal
tion is least belween thc second and third
slighlly greaterbelweenthc neiShborirgmctatarsak,
srcaLestbetweenthe fourlh and fifth metatarsals. Th€
of moveme may be evaluatedby graspingthe headsof
jacent metatar€alsbet\peenthe lhumbs and index
andrltematelyshearingupanddown(Fie.3.137)
 Chagter
Three AbnormalMolion durhg the G.it Cycle 137

Anodcrmethodofcontacringthemetatarsals is illus- to the $neiforms, superior-inferiorglidiag motionsat these

i$ fte insetin Fisure3.137.lf motionis re*rict€dbe- tarsom€lalarsalarticulatio0sarc besl r$tored by vigorously
anyof thc metatarsalta Crade4 mobilizalionis mobilizitrg the proximrl metatarsalswith the grip illustratcd
to paticnl lolerance.Il is of clinical InFrest thal in rhe hset of Figure 3.137. It is also possibleto mobilize
superior-inferaorglide between lhe second and thesearticulations with a grip similarto the one ilhsuated
nelataNals is a commoflcaus€for intermetatarsopha' in Figurc3.138in which the left handsecurelystabilizes
lbursilisbelwdenrhetbndandlourth mehtarsals. the proxinal cun€iformwhile the right hand vigorously in-
The Ta6ometata^ol Joints. Thesejoin6 may be vsrls and cverlslho forefoo!, therebydorsiflexing and plan-
wilh anyof sev€raldiff€renlmaneuvers. Firsl,su- taricxing the dcshedtar$ometatarsal aniculation.
inferior glide is checked b) slabilitng cach
's proximallarsalandaltcmatelydorsiflexing and
thedcsircdmetatarcal.
For examplc,in Figure 3.138, the cuboid-foufih
aniculationis atabilizedwith the left handwhile the
of lhe founh mehta.salis stressedin doEiiexioi/plan-
A restriclcden&rangeh superiorglide betweenthe
or fiIth larsometatanal artiarlationmav b€ madDulated
fie dorsal cuboid while applying a dynamic
lhmlgh lhe plantarbaseol the itrvolvBdmelatanal.(A
(x)nlactmay also usedon the planlarmebtarsal;se€
ConveNely,inferior glide at the founh and fiffh
jointi may berestoredby sabilizing theplanhr
with lhe centcr6ngefwhile thrustingdownwad upon
rnelatamalbalc (thenar cminen€f contacti see Fig.

Becalselhecenualmeularsalsarcso lirnlv anached

Figure3.139.Manlpulation io reitoresuperiorElidero th€

fifth tarsonetalarsalarticllation.

.l

,l
',.,,i,i
.
".?",^
',1

3.1i8. Fvalualionof ,upniorinfer;or Slide at the riSut€3.140.Manipulationlo restoreinf€riortlid€ to lhe

melalarsal
articulatibn. frflh tarsomel|tarsil articulation.
138 FOOTORTHOSES
andOtlcr Fornsof Con$rvlrilc FootCirc
With regardsto thc fir$ larsometatarsnlrrticulation. a
very efieclivemethodof rcsloringiotbriorglidc is wilh lhe
manipulaljonilluslralcdin Figure3.141.In this mrnipula-
tion, the patientis supineas th€ practjlioncr'srigh! ftand
conkcts the first melala$al betw€enthe middle phalaru of
lhe indexfingerandlhe them.€mincnc€. Theleft handthen
"hooks" the medial cuneiformwith thc third finger and trac-
tions upwardly (black anow) as lhe righl hdrd beednsto
planrarflex A$ thcjoinr reach€s
the first metararsal. its erd-
range,the palm of lhc left hard wmpssccurelyover d1c
dorsal midfoot.
ThDmanipulalionis giver with thc lefr wrisl exrend-
ing (lherebyprovidingtractiooingoo lhe mcdialonciforo
lpwardly via cootactwith the third finger) nd thc righr
wrist rsdiallydeviaring(whichallowsthe thcnareminencc
to plantarflexthc nrst metalarsal). 'l'he praclitioner'schest
is directlyoverthepatient'sfoot so thata long axisFaction
may be appliedduringthe manipuiali('n. lnt€restillgly,Hiss
(132)not€dth8tjoint dysfunctionin thc firsrtrrsomeratarral
articulalioo. which is almoslalwaysprescntin a cbronically
pronatcdfool is a commoncausrofdcsc.scd proprioaep-
tion.
An alernatc mcthod of restorinBinferior glide at thc
iirct tarsometatarsal aniculalionis lo contactlh€ dorsallirsr
melata:':ialwilh the centerfingcrwhjlethe palmarasp€c1of
thc oppositehaodcontaclsthe plintar surfaceof thc secood
ti8ure 3.r4I. Manipolation to reslore inferior Blide lo fi'.l
larsom€latarsalarliqrlation.
mel" a$al (Fig. 1.142).By graduallyincrcasing lhc
ing lorcebel\recnthelirstandsecondmetataKals. rlc
litionercanbuild up to a dynamicthrusrwilh whichth€
metrtarsalis planlarflexed ad evcnedwhile the
merrtarsalis slabilizedagaiostrhe prlm of the left
Thi\ processmay be repeatedlo ra\lore inferior glide
of lh€ t?rsomebtarsalaniculaliorrs simply hy movil8
conractpoints latelally,i.e., conlactil|8the plantar
metrrtarsalwhileshearing thedoNals€condmetatars|l
riorly, etc. Noto thal this manipllationis invaluable
anemPingto reducea fun.tion l forcfootvarus
Supcdorglide at lhe tarsonretatrrsalarticulario0s
becvaluated andteatedhy posirioning the handsasio
ur€ l.l43A. By plecing lh€ pisiform of thc riehl
agein$theplarltar6.stmerararsalshaff with thepalrnar
face ofthe lcft handcontactingthe dor$lsecond
shati.a sheariogforceis developed by cootfitctiog lhe
lomlismusculaturc (thcpractitionrir chesljs tosition€d
rcct! overthc paticnt\ tooDlhlr drivesrhefirst
sup.riorly and the second metatarsal infcdorly
3.14.1B).
This nanipulationmay bc rcpeated al anyof rhe
sornctatarsal
afliculationsandis particularly usefulwhon
temnling to rcduce a lunctional planlarflexedfir8t
atd/sr funclionallbftfool valgusdcformity.11should
bc r'ot€drhdt ir is possibl€ro resronja rcstricred nng.
Fi8ure 3.142. Altenate nanipllalior for rctorint iofcrior
Slidc at la$otn€Lt ]3.l aniculatiorb,
 chaptcrTtrec Abrormi Moltooduriq iftc G.il Cyctc 139

K9

figurc 3.143. (A{) superiorgli& at ta.somet.la.saland inr€darial ioinls.

inversionwith this tuanipuklionby moving the

pmximallyover the midfootand generating a force
drivesthe cunciformsupwardand rhc cuboiddown-
Cig. 3.143C).NoretharmanyFactitionqs preferlo
tE SripsilloslJor€d in Figurcs3.143DandE whenper-
ingth€semanipulations.
Porhaps lhe most effeclive treatmenrfor rcstoringsu-
Slideat fie tarsometalarsaland interlsrsal joiots is
$c manipulalion illustraredin Figur€3.144.tn this
lation.0rcleft handdorsifiexes md invertstheDrox-
fils|metalarsal whiletherighl handis shoaring theme-
!m irferiorlv.To manioulate lhe inlertarsal
*nd
a iculalions, thc handsare movedproximallyso
conlacllhe cuheiform-navicular articulatiorsand lh€
aniculation, respectively.Il is alsopossiblcto
inlcriorglidear th€seaniculalions simplyby rcven-
posilioosandaclions.
Th. Midltrso! loiltk. Like rhe lalsomelal.aJsalaod
joints,rbe midtarsaljoinls shouldalso poss€ss
ior gliding notions. In additiol lo the sheaF
ip!lationilluslratodin Figure3.144,sup€rior-inf€-
gliding motions may also be resLor€dwilh the
ionillustrated in Figure3.145,
In thisprocedure. the leir handslabilizesrhehcel by tigure 3.ltl4. Slperior-inferior Slided laEom€rabrs.l artic-
nrm cootacrproximal to the midtatssl aniculations !l.tiooi.
140 FOOT ORTHOSESand Other Forns of Conscratv€ Footcd.c

al tlre midtarsaljoinl is illuslratedin Figuro3.147.

lhe rhumbof the right handsrabilizeslhc dist0l
the rhenareftinenccof theleft handdrivesthroush
solareralforefootftlack a[mw) whilc $imu
verling tlc forefoot (white anow). By v rying
pojDrs,this adjustment may be uscdon any of rhe
and is pafiicularlyeffectivcfor resloringilf€rior
thecentraltrrsomctaiarsal joinls.
tn additionto superior-in{erior glidc. diflorcnt
lypcs wi pr€s€nl with a los\ of olher gliding motiorlx
cxarnple.thc navicul|r in an individu whh a rieid
varusfool will ofteo be maintaimd in an adducted
tharr€sultsin the hss of lateralElidcof thenavicular
FiSur€3.r45.Superlor-inf€dor the |alarherd.This motionmay be restoredby
Elideal lhe nidiaaal iointi.
the Inlarheadwilh the liD of the lhumbwhile the
han,labducts lhe forelool(therebyglidingth€navicular
€rallyacrossthe talus;seeFig. 3.148).This procedurE
alsob€ us€dto glide rhecubo;dlaterallyoverrhesbbi
calcrneus(Fis.3.149).
Ir is alsonol uncommonfor an individualwitha
vereiy pronatedfool to presentwith an in{biliry of
cuboidto supinaEon lhe calcaneus. (This is b€cause
cubr'idin a pronaledfoot h mainuiredin an abduckd
doniflexedpositionfor so long thal capsulrr
pre\entsplantar-mcdial glidingof the cuboidon lhe
neu(.) Ttis being rhc cas€.calcaneocuboidsupinalion
bc r$lorcd via themanipulatiorilluslralcdin Figur€3.
in \ hichthe riShthrnd evertsth€calcaDcus (pisiforn
tacl on mcdialcalcaners)while lhe l€ft handplan
andrnvenslhe cutDid(Disiformcomacton lderal
Thir motion is pcrformedgertly, a$ if one h
cla!. Ir is noteworrhylhal ltist (132) claimcdrhat

rigure 3.146.rigure €igtrl of the nidtirsai ioinl.

'nobilizatlon

whiletherighl handcrcatesa strongsupcrioFioferior shear-

ing ibrceon thefixatedrcarfoot.Mennell(150)emph8sizes
that thc thumband index lingor of Ihc lefl handmusi bc
carefullyposilioncdoverthenrvicularandcuhoidto ensurc
thal$e shearin8motionis produccdat lheproperjoints.llt
goeson to slatethat the lrresilienceof the fool to tale up the
strcs\esand strainsof tunction" largely dependson the su-
perior-inferior gliding motions of lhc cuneiform txrncs on
thenavicularandthemvicrlar on thetalus.
A gencralized manipulatioD that is very effecliveat
restoringslperioFinferiorglide al the midtarsi joint i! il-
luslratcdin Figure3.146.To pc orm thisInaripr]lation, the
left handsecurelystabilizesthe calcancus while thc right
hand grasps lhe forefoot. Thc righl hand ther moves the
forefool through a figure-cight patt€m while the letl hand
continuesto stabilizethe fixatedrearfoot.This manipula-
tion is very effecliveal resbringthe linritCdmngeof mid-
ta$al modonrhatofienresultsfromcastimlnobilization.
A norc specificadjustmcnt for ro$loringinleriorglide tiSure3,147.Interio.glldeoflhe cuboidon thecalclneur.
 Chtprcr Tn,ce Ahortul Motiotr durtrg th. c.lt Cycl. 141

3.148. tileral Slide of lbe navicular on thc talu!.

fi8ure 3.t 50. SupiEtion of the clboid on rhe celoneus.

(132) notcd thal thesesubluxarions,wbich are usually ir a

plmtar diredion andproduc€pain with dorsalcompresrion.
may be correctedwirh rhe adius|menlilluslralcd in Figure
3.151.
This manipulalion involves posilioni[g the standing
palie so &at tbesoleof the foo! is preseolcd to thepracti-
tiooer.Contrcrpointsaretlrcntakenby crossingthethumbs
bencalhthc subluxatod tarsal.The adjustment is thengiven
by driving the tbumbs supedorlythroughthe involved
larsal while slightly pletrbrflexiog the forefoot. As the
thruslis giv€n,the foot js broughtdownwdrdto helpopeo
lhe tirsals, and the wrjsts arc relaxedso as rlot to injurc the
ankle mortise.Also, when performing thi6 adjuslrnenton a
subluxatedcuboid (which NeweUand Woodle ltt3l claim
i is mainbined in an evertedposition secondarylo contrac-
lrre of lhe percneuslonglls muscle),lhc contactpoint with
lhc thumbs should be madc bencalh the Dlantrr-medial
cuboid, and $e line of drive shouldbe in a supcrolateraldi-
3,149. taleral glid€ of lhe oboid on th€ calcancu!.
reclior in order to reducelhe rotalional comDonentof suF
luxatedc!boid.
It is of inreresrthal Eiss (132) clained rhat liublu*-
joint dystunclionis a commoncaus,e ofrecuncnl .kd'@boid may oilrrgorirlt{tluital n.ulitia e n oofipnsres
anklesprain. tho.li$nl tiLatairiiativGrind r'!t alro Rd$rlti! ahtonic pltn
I! Ndditiorto lhe gliding motionsalr€adydescribed, brndnb {her hb+d.Ptadirf {6d+ a!,,rhe q@dtlrur pLtrtllr
l(150)notedlhsl lhcreis a wide rangeofintertarsal Euiclo,rnayib6n idiitdi y todiusfd,
c (usuall, sup€rioFinferiorir direcrion)thsr The Sub,atu,Ioiat. While John McM. Meonell re-
beappreciatcd clinicallyutrlesstherehasboenlrau- pcsledly demonslrateda krowlcdgc of functional anatomy
$bluxalionof oneof rhe bonesuponanother."Hiss lhat was far ahe{dof his time, perhapshb greatestcontribu-
 142 FOOTORTHOSES d OihcrFormsof Cors!ryativeFoorCare
riSur€3.r5r, Reduclionof phntar
tion ro fie 6eld of manipulativerehabilitation was his de-
scriplionof subtalarjoint turction.While otheranatomists
in the 1950sand 1960sdiscussed subtalarjointmotiononly
as il relaledto p:rssiverangesof inversionllnd eversion,
Menn€llwasdcscribingsubtlerockrngmotionsbe$*eenlhe
talusand calcaneus that absorbshearforcesrl heelstrike
and to€ off and act to prevenl injury about th€ arkle com-
plex wh€n the foot/ankleis sprainedor srublred(150).lfl
lact, Mcnnell(15{l)staresthalif lr werenot for thescinvol-
untaryrockingand glidiog motions,"fiacluredjslocations
alouodtheanklewouldbecoftmonplace."
Thesejoint play movements, which consistof lDng
axisextensioqforwardandbac*wardgtidc,atd m€dinland
lsteralside rill. may be elicilcd in the folloring manner.
Tle supinepntienlis positjonedwith the hip aMuctedand
extemallyrotaied.wilh the kneefl€xed90", and wirh the
anklein its neutmlposition. Whilesittingonlhdedgeofthc
-examining table, the practitioner plac.s his or her back
wth llre wristrelaxed,
ganlly snapth€ wisl androol.
againsllhc palionfsdistalthighwhile firmly Srabbing
fooL.tusr belo$theankle(Fig.1.152). Thecxamrnet
leans back againstthe patient'sdislal felnur (A)
mairlaining alongrhelong,\is ol rhe
.r counrc'force
(B). This longaris forcEis transferred equallylhnugh
web\ of bolh bands.whereit ooensthe talocruraland
lar juints in longaxisextension. is prs
Ifjoint dysfunction
senl.fl dynamicthrustis anpliedal the end-range of
This positionalso allows ibr evaluntionof
glidf oI thc calcaneus beneaththe talus(whichwas
ousl! illusiratedin Fig. 3.115).By srabilizingth€:
taltr' rith lhe righl hand,the eraminer'sleft hand
glid(s rhe calcancusforwardbeneaththc talus(C) whilo
mairtaininga long axis taction on the joinl. Backwad
glid. canb€ evalualed by reversinghandaclionsso thcleff
handserves s the stabilizerwhile lhe righthandglidestha
salcrneuspostcriorly(D). It is pos-sibleto cvaluntelalenl

Dainlaining the longaxislracrionwhilc €verring$e
(E). Medialrih. which is frequentlylosr tollor{-
irversion sprainof $e anlle, is cvaluatedby inverting
s wilh theripsof thc lesscrdigits.U joint dys-
is notcdin anyot tlc\e tcslingpositions,a gentle
ipulationmay b€ performedby conlinuinglhe lesl
whilesimultaneously lr0clionlng on thcsublalar
carc mustbc laken whcn performingtheseprocc-
aslhe practitioner car gencralca surprisinganount
sxis truclionby l€aningback inlo the patienl's
An elt.rnrtemolhodfor adjuslingthcsuhalar.ioinrid
or laleralside tilt is illustrarcdin Figure3.153.
mainbioingthe subrala.joint in loog axis lraction,
lih maybc resioredby havingthe palm of the rjght
evo lhecalcaneus while the lcft handdriveslfuoush
(theteb)shearinglhe calcrneuslaterallybencalh
To manipulate$e subtalarjointio mediallilt, thc
lo$ilions andmovemensare reversed.
Alother manipulationfor rcsloring lorward glide of
benealhtheralusis illustratedio Fieure3.154.In
ChaglcrThre€ Abnonnrl Motlotrdu.bg tbe Gllr Cycle 143
Figure 3.152, (A..O Evaluithr of
subt l.r ioini nolions.
rhis adjushenl, tbc plantarhe€l is stabilizedby friction
fton the cxamjning table wbile lhe crossedthumbsapply a
postefiorshearforce throughrhe talus.Inilially, a force is
appliedgeDlly,causi0gthe talusto glidepo$eriorlyon lhe
fixa1edcalcaneus.Whenpedormedpmperly, a smoolbelid-
ing morionshould be fek, and the forefbot shouldLtt
sliShtlyoff $c examiningtable.At thejoinfs end-rang€, a
springyend-playshouldbc roted as the cross€d thumbs
pushinto theelasticbanier.lfjoint dysfunctioois presenl,
s€veralshortdyDamiclhrustsmay be appliedal this end-
rango.
The Taloc ral Joitta, This joint shoold possess
both long axis exlensionand anterior-posleriorglidc. l-ong
axisexrensiormay be cvsluat€dwith the samelestiogpro-
cedureusedin Figurc3.152or, morecommonly,by hook-
ing the talar neck wilh crossedfingeB and lrrclioning
inferiorly(Fi8.3.155).lfjoint dysfunctionis notod,a dy-
nlmic thrust is applicd by lracrioning tbe joint ir loDg axis
cxtensionwhile slighdy radirlly deviaiio8 tbe wrists (black
ar.ow). Anrerio.-postc.iorglide of lhe talocrunl joiot may
be evalualedas illustrarcd in Ficure 3.156. A loss of either
144 FOOT ORTHOSESand OtherFofts of Consepalive Foor Care
Figur€3.153. Manipularionto restorclateraltilr to lhe subla-
lar ioint.
Figur€3.154. Manipulationto redore fo^r,ard glide of the
cal.ane{! beneathlhe talus.
Figule3.155. long rris ertcnsionoI the talocruril ioi
Figure3.156.Evaluarion
of ant€rior"post€rior
Blideal
talocruralioint
of thcsemotions rray usualy be restor€dby vigorouslymo-
bilizingthejoinl in thistestposition-
Distal Tibiofibular Joinr Although this is a fibrou$
syndesmotic joint, ir shouldstill possess
a clinicallyappre-
ciable lange of atrterioFposteriorglido (Fig. 3.157).Dys.
funciion in this joint may be addressedby gradoallyj
incr.asing a Grrde 4 Eobilization until lhe desiredrnotiot
hasl)cenrestored.Note that motion in the distai tibiofbular
 ChaplerThlceAbnordolMotio. durlngtheC.it Cycle 145

specificangle,while olhersare rapidly adaplingand dis'

cbargein bursisto signalchanges in acc€leralion
or tension.
The musclepropriocepro.s consislolthe musclcspin
dle and rhe Colgi tefldonorsans(GTOS).Spindles,which
areprcsentlyconsider€d to be the mostimponantreceptor
for kineslhcticawareness (184),are locatedin parallclse-
ricswith contractilemuscle6bcrsandconsistof fllidjilled
capsules 2 lo 20 mm long,crclosing5 12 smallspecialized
m0sclcfibersrefenedto as nuclearchainand nuclearbag
fibers.Collectively,thcy are refenedto as intmlusallibers
(sceFis. 3.158).
The nuclearbag fibersarc very sensitiveto slretch
and,via primaryafferenis,relayinfomation regardingdy-
namic cbangesin mosclelengrh,i.e., phasicresponses.
Convcrsely, the nuclearcbain,which is innervaledby bolh
annllospial and Iloworspraynsrve6ndings,relaysinfor-
mationrcgardingthe staticposidonof muscleffbers,i-e.,
lonic rcsponses. The sensilivityin which thosereceplofs
will discharge canbe preselby activatingthegamrna-motor
neurons:by producinScontractionat thc polarefldsof lhe
intrafusalfibers,thegamma-motor ncuronsincrease tension
on thecenlralportionsofthe chaitrafldbag(panicula.lythe
3.157. t\alualion of anlerior-po\lerior glide at lhe bag), pnducing a leightcnedscosilivily to a changein
icnglh(Fig.3.159).lhe procelsof seningspindlesensiliv-
ity via gamma-motorneuron activity is reterredto as
bilalerallylo gel a reltr-
sho ld alwaysbe compared
Thc gamma-motor neuronsmay alsopaoduce volun-
lary movomontvia an ind;rect palhway known as the
NEUROMO toR CooRDrNATtoN gammaloop.In this palhway,signalsflom the pyramidai
ANDPROPRIOCEPTION tract,which in a moredirectpathway\tould traveldircctly
to ths c-molorneuronsto producemovem€nt,activatelhe
Thisis uncot the murc imporranlcrireriafor normal gamma-molorneuroosto rcnsepolar ponions of intrafusal
sincca wcll-coordinated p?ti€ntmry be ableto tol- fibersto thepointof stimulalingtheirafferenrs. This in turn
evenlargestructuralmalformalionswithout injury, serds n signal back lo tbe cord, which lravercesa tuonosy'
thc uncoordinaled patjenlrnaybe consrandyinju.ed naptic palhway 10activatethe appropriate tx-motorneuron,
heorshercspond\ lo e!cn minorchangc\ in tcrrainwith Allhoughlhis obviou$lyoccu$ at a muchslowermle,stim-
polenriallyinjuriousmovemenlpatteras.An ulalion of th€ gammaloopsysremis associated with a
example joint
ofthis is rhedesrructive changes as- greal€r controlol muscularactions-In mosrsihations,vol-
witb the seurolrophic arthropalhies, i.c.,Charcot's untarymovementsarc accomplished by a combiffirionof
direct and indirect(via gammaloop)aclivationof lhe a-
Whileneuromotor coordination mavbe imDaired sec- motorneuronsrelered1oasalpha-gamma coactivation.
lo rpper ot lower motor neuronlesions,a much while activalionof spindleafferentswill result in
lik€lycauselor dysfunction occurswhcneitherdisuse reflexconlractionof the neighboring musclefibers,activa-
irjurydamages lhe sonsoryreceptors so thatrheyar€no lion of the Golgi tendonorgans(which are locatedin fie
sbleto provideenoughposirionsenseinlbrmationlo lendonfibersnearthe musclelendonjunctions)will pfo-
thede\iredmolorresponse. PosiLion scnscor propri- duceaulogenicinhibitionor relaxalionof theinvolvedmus-
iveinformatioo is supplicdby neuralinpuloriginating cle. Becausemusclesare capableof producinggrealcr
rcceptors locatedin Lhemuscles,tendons, joinl cap- coDkaclileforcesthan tbeir own slructuralmakeupcan
andotheraslociatedde€ptissues. Th€sepropriocep- withsland,theGolgilendonorgansplay a protecliveroleby
are calegorized into three differeot groupsrmuscle inhibiling contraclion(and facililating the antaAorisl),
, proprioceptors of the .iojnlsand skin, and shouldlhe conlractiletbrce becometoo geal
inlhineandneckproprioceplors. As a group,proprio- Although lh€se roceprorshave relatively low thresh-
relayconstdnrinformarionregardingsralicanddy- olds (i.e.,the cTOs locatedin a cat's soleusmusclewill
icjointpositiors,i.e.,someof thesereceptors areslow dischargewi$ an appliedfo.ce of lesslhan 0.1 g l2l5l)
adaptalld dischargeonly wh€n the joinl is held at a thcir inhibitoryeffectmay be offsetby the annulospiral ac-
146 FOOT ORTHOSESard O$er Fords of ConscNarivcFool Care

TypellRber(AU)
tmmftowe,sp€y endhg
Gammamoro.neuronsto nrEf!$lmus.le lbe6
Alph,rmoto.neuronto €xlralusalmuscletiber
ExtraflsalmusclelDer

Typo la fibor (Ao) lrcm

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.)

organsproduc€s only facilitalion,hdiciiing thatthej

ing cffect of the Golgi rendonorgao can somchowbe
celhd. lt secmsthat althoughlhe CTOSsupplythe
rrith const nt feedbackr€garding the forces actirg on
muscle!they may produceinhibitiononly when
ouslvhightensionIov€lsarercached.
Urlike the mlsclc proprioceptors (GTOSand
dles).joint dndskir proprioceptors trrvcl dl lhe wayto
concr irnd,becausetheir receptors conneclwith so
inlerneurcns, ftey are able to favorabtynodify aclivity
all li-nbs.norjr$ in lhe ,,rimulared limb.In addirion.j
and skin rcceptorsalso havea facilitatoryeffecrupon
rigur€ 3.1s9. Srimolationot the gamma neuronspro- vestjbularapparatuswhich, by enhancingactivity
duce6conlraction ar the pola. ends of the 'noror
intrafusallib€rc sDecificmotorneurons. actsto stabilircth€exlremities
(arrows), which .reat6 a hei8htenedsensirivity in these ing the gait cycle by slimulalinsthc r€quisitenruscles hi
fibers, a5 the nu.l€ar regior is now tensed.(Modifiedfrom connrcl with moreforce.
GowitzkeBA, Miln€rM. ScientiflcBasesof HumanMove Wlen properlyfunctiooing,the vnriousjoinl, skiq
ment.Edl. Bahimore: Williams& Wilkins,1988.)
and ruurcle proprioceplorswork togctherlo supplyrhece|I'
lral n€rvoussystemwith a constantba[age01 sensory in=
tivity associalcd \rith voluntarymovomenr, In facl. success Iornxtion regardingbody posilion md movements.In ws,s
with strcngth training depcrds upor Lberbility of the ath- tbatl|restill poorlyunderstood, the centralnervoussyslsm
leie io leam how to inlibit inform.rtion from Golsi refldon analyzesthis infotuationby comparingit to a deskedFit-
orgrns successfully. lern lwhich nature,codditioning, andpa$ expeder€es l|ave,
Itr a st0dydelirealirg irte.acliors betweenannulosp! estahlish€d) and producesan appmpriatemotor response
ml ad GTO fibens,Hlfschmidl(187)tbundthata stimuhs The cycle is thenimmediatelyrep€rled,wherein€achrc-
sufficientto excitebothlhe annulGpiralandColgi tendon sponsris anslyzedandthemovcments areline-tuned.
 Three AbnormalMotioDduringtheGNitClcle 14?
Chapter

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

becausc of a previoussprain,the extensibiliwand function of scnsoryinfomarionsuppliedto thecenlralnervous

of the dystsophictissuemay tre resloredwith cross-fric- tem. This result,in lum, has a facilitatoryeffecton
tional massage. This lcchniquc,which involvesstroking vesribularapparatus (which inprovcs motor activity)
massagein a direction pcrpcodicularto lhe sprainedliga- mar evenblocka chronicpaiopattemthatmayb€
ment'snaturalfiber odentadon,will lheoreticallylengthcrl atinqan injury,i.c., stimulatiooof the facrerAp fibets
thefibroticscarlissucrhatis impairingtunctian. sponsibl€ for transmitting infornation iiorn
Wh€n done propcrly. cross-fictioral massagefavor- prqrrioce ors will "close the grle" to th€ slowcrA6
ably stimulatespropriocoplors and may producea tempo- lypr nbe:sresponsible for painlrammission.
rary anesthesia thai is hclpful in identifyirg the involved A prrfccl erampleofhow p|in anddecreased
tissue.When done impruperly,cross-frictionalmsssage oceltion may pmduc€a chronicpain patternoccurs
mayproduccatrinflirmmatory reaction(with resultingfibro- refl(\ sympatheric dystrophy.Ahhou8hrhe €xrcl
sis)andmay evendamagethc Colgi tendonorganslocaled nisnrremainspoorlyunderslood, il is believ€dtlul
in themu$cletendonjuncrions (197). tive Inpul associarcd with a relativclymild injury
If the proprioceptivcsyslcmis mallunctioningbc- the i cmuncbl ncuronsin the grxy malterof lhe
causeof repeated microtraum!associated with a mechani- The$ neuronslhco inhiatc a reverberating cyclethrt
cally malfunctianing toor,an onhoticshouldbe considcrcd ciles the antcdor hom cells (producing musclespasm)
in an altemptto improvcthc mcchanicaleffciencyof thc latcrxl hom cllls (pioducingsympatheticvasomotor
supponinSnuscles(which less€nsthe irilation of the ab- sudomoror responses). The incrcasedsympa$etic
normallystess€djoints)andro r€establish the normalpro- char'temav perpctuatc lhe d),suophy,as it l€adsto
grcssionof forcesalongthc plantarfool. By improvingthe changcsin the involvedbone and connectivetissue.s
progrcssion of forceA,thc orthoticactslo reeducate lhe cen-fu(ficr stimulateItrenociceptive affcrents, rhercby
tral nervoussyst€mns b lhc idealpaltemsfi)r muliclere- the rkeady hyperexcitedinlernunciNls. As explain€d
cruitmeflt.Theeflicacyofonhoticsin favo.ablystimulating K6 (198),the per;pheralaffercdtsand abenanl
proprioceplionwas dcmonstrated by Novick and Kclley theticdischargebecone'.refl€xivelycolpled to lhek
(133),as theynoredonhoticsrhatareableto d€crease cal-tual derrimeflt."By stimulntinglhe fasrerposilion
caoealcversion by 2.4" during stalic stanc€will decreasc joinl proprioceptors immcdiatclyafieran iniury.meni
calcaneal evexiionby 4.2' duringthc gait cycle.They sug' lion is ofiennbleto brcaklhis dangerous cycle,thereby
gestcdlhatIhedecreff€drangcof calcaneal eversiondurinS venrinBthecharaclerislic lrophiccharges.
locomolionresultsfrom "improvedtactil€and proprirrcp- hr addirionto lhc uscofcro\s-fricrionalmasrrge.
live feedback"duringdynamicfunction. ' orth,'ses. andmanipulation to improveproprioception,
Thoughrarelymentioned,it is slso poss;ble$nt thc fl al. (199)recommcdedvariousproprioceprive
proprioceptivs syshm may bc dAmageds€condarylo dc- cular f:rcilitationexerciseslhat incorpontespecific
crcascdoutputfrom periarticularproprioceptors lurround- and diagonalrnolions(Fig. 3.160). Becauscthese
ing hypomobile joints.The imporunceof suhlleintetursal niquc.requirea trainedrssislanlto pertbrmthem,tbey
motionsin maintaining balrnccis evidcnccd by rhefad thnr of s{,ncwhatlimitedvalue.Pe apsthe simplestand
individualswith cedainrarsalcoalitionsareunableto elTec- eficctive melhod for .edevclopiflg lh€ proprioc4ptivc
tivelybalanceon onefoot.WhilethisreFresenls an cxtrcmc lem is wilh home balancc board exercises(Fig. 3.
situalionin which thcjoinl is ankylosed, it €mphasizcs thalThesc cxercises,which may b€ made progressively
propriocepdvefuoction cannol be considercdfully restored difticullby p€rforninglhem wirh ooeleg,andfinally,
until eachjoinlcanmovethroughits full availablerangeof eycsclos€d,restorekinesthetic awarcncs$ by slressing
prioccptivepathways. This typeof exercisesystemhas
In additionto limiting prop.iocepriv€informalion, advanlagcover conventionalexeacises lhal rcquire
fliss (132)claimedthrt a hypomobile joint producesa cer- scionscffort (e.9.,isolonic.isokinetic,etc.)in thrl it
laio degre€of "tissuclcnsion"thatforceslhe individualtr) vrtes the subcorticalpdlhwayswhich. once lrrincd,wi
aherlhe progression of forccsthroughlbe planlarfurt. l'his operirrc on an auronaricbaris(200).
situation,accordingto Hiss,interfercswilh the synchrony Becausecompensation for even minor injury trtry.
of pivolingadd balancingmovemcntsand,over lim€. re- lri&r(r a newslateofcenlrallygcneral€d molorconlrol.
sults anan abnormalDatlernof molor rccruitmentlhnt is rehahiliralion p(rcess should attempr 10 resolve the acutc
evenlually .eprogramm€dinlo lhe certrel nervoussysiem. stagcas quicklyas pos$iblewirh l€chniqu€s tharmi
Hiss(132)clannedtlal the only effeclivelreatnenlin this scarr!ngrnd mainhinrangeofmotion.Variousgaittraining
joinls
situalionis to re\toreflexibilityro rhe dysfuncrional exerc;sesshouldbs incorpo.alcdlo ensur€tbe synchromus:
with theappropriale manipulativc procedures. interrctioDof all body scgmcnts, therebyprevenring dan.
It appearsthal not oDly do manualtechniqucsde- flgdlo tb€pruprioccptivc syslom.This mry be assinplcrs
creasepolenaially desrru(:live
compensrlory f, ovemcnlpat- insurclinglhe paticnlto walk with a normalprogression of
terrsbut lheyalsoscrvcro incr€ase thequalilyfid quanlity force i,e.,makeinilial hccl contacralongthc literalcalc."

3.160.PNf oatterns.insls A and I demonslrateme
PNFpatr€rn:fie patient is inslructedro ahemalely
rflex and inve.t lhe loretool (A) and dorsillex and ;nve.t
|tfool a8ainetresielance providedby the practitioner.A
.omplicatedserie, ot movem€ntsrequkesrhal the pa-
alt€nalebeMeen plantarfleiin8and inve ing one foot
lhe opposirctool is doniliexlhSand evertlng(D).
ChaplerThree Abnormsl Moilon dorlng tbe Grlt Cycl. 149
Throughout theprocess,
thefootthatis planbrflexinEir main-
lain€dwith the lowerextrcmityin an exlernallyrotat€dposi-
tion while &e oppositelowerextr€milyis internallyrctated
(ar.ows).lFormoreinfomalionon ihes€andotherPNFpal-
terns,lhe lntereeled
readeris efeiredlo VoesDt, lontaMK,
Myec BJ.Proprioceptiv€ NeuromlscularFacilitation. Ed 3.
Philadelphia:Harpef& Row,l98s.l
tiBure3.t51. lalanceboardex€r[i.es,In lhe earlysta8es ol
the patientis inslructed
rehabilirarion, to sit nextto the bal'
ance board with both f€er contactinSthe outer daes of lhe
boad. TheparientthenDtat€sthe boardso lhateacheect{on
ofthe periphery conladstheground,It thierangeof motionit
too painful,theanrlethattheboardtlhr frcmhorizontal (usu-
ally 16")can be modifiedby placinSmatazines ben€alhlhe
ed8es.(Medialandlateralplacement will rcd'rcelhe ran8eo{
inveGiory'eversion while mainraininglhe full ranSe oI
A5lhe patientimproves,
do6iflexion/plantartlexion). themag-
azanes a€ rcnloved,andtheexercise is r€p€ated with lhe pa-
li€nt slandinB,proSfessively brinSingthe ieet towardsthe
cenlerof the boatd.Ev€ntually, this ex€rcis€may be per
formedwhile thepalienlstandron one ler with eyescloeed.
For paniclladylaBe patients,it is possiblero inceasethe
anSlethatthe boardtihsby placinga maFzinebeneathlhe
150 FOOTORTTIOSES
TndOlhctFo.msof Con*ryativeFmt Carc
neus!progressalong lhe laleralcolumn duiing the rnid-
stanceperiodand,nnallytraverseth€ metatarsal hcadsand
roll off the halhx to terminatethe propul$iveperjod. lf su-
perimposcdbody weight makesearly rctum to acrivity
difficull lhe palient should be encour.g€d ro walk waist
de€pin a swirEsing pool.
Anolh€r altcmative would bc !o have thc p.'ltienr
march or g€ndy bounceon a homc minftr.a'poline: poisi-
ble variationsars limilcd only by the practitioner's imagi-
nation. ln chronic cascs,it may be o€cessary!o have thc
patieni p€rmln€ ly alter his or her gait pitt€m. For exam-
plc. ar individual with a rigid lorefoot vllgt$ deformity and
hamme. to€s may have to develop s high gcar push-olTin
order lo avoid irritaling a chronic itrterdiSitalneurids.Also,
individuals wilh recalcilrantq canealstressfracturesmay
have lo developa forefool sfike patlem in order to less€n
ground-reaclive forces beneath the h€cl: Civanagh and
kfonune (201) rcted thal shock scord arc often halved
when experimeotalsubjccls swilch from a he€l strike ro a
mid or forefoot strike paltem.
Il should be not€d that a forefool strikc pattem may
markedlyaggravaiean achillesrcndonand/or planiarfascia
injury. With lheseinjories,it is bcsl to hrve the padent
maintain a rearfool strikc patlera and, if nec€ssary,to
shonenhis or her lc[gth of stide is order to reduceforces
during the propulsivepcriod-Whilo recommendations to ci-
ther increaseor dccad.see patieot's nalural stride lengtb is
u$ally associatedwith a I or 2% ilcrease in the mctabolic
cosl of loconotiofl (202), the polential benefitsassociated
with a .educed.ateof injury usuallygroatlyouweigh any
metabolicpenalties.
Muscur-{n STRENGTE, PowER, At\D ENDURA cE
Perhapcno ropic in $e field of r€habilitativcfix)t care
ha5 been the center of morc controversytha lhe role of
strengthedng excrcisesio lhe mainlenanc€irnd develop-
mcnlof lhe mediallongitudinalarch.Over4l) yearsa8o.iD
an articledescribingthc etiologyand lreatmcnlof tftc hy-
perhobile flatfoot, Harris and B€ath(203) arguedthar mus-
culsr stren$h wlrs not ihe most imponant facloa in
maintaioingthe shapeof the nedial arch (lhis was rhe mosl
widely accepted view at thattime)aodthala poorlydeve!
opcdarchwasfte rcsultof bonyabnormaliti€s ill the tarsal
bones(primarily i|l thc subtalarjoint) thrt matss them
strocturallyrnable 10supportbody weight. They statedthat
rhe muscularmechanismsrcsponsiblcfor Inaintainillg thc
alch are for occ.sional us€otrly, sincr. unlikc hony and lig-
amentousrestrainli they are unable to function rnr€mit-
tirgly. Tbey supportedthis b€lief with the observalionrhal
feet that are complelely paralyzrd with poliomy€litis oflen
havelittle deformity.
This is nol to say that muscularsupportof the mcdial
longitudinalarch is noi irnponad. On thc contrary,a r€cent
study by Hannab end Robbitrs (Z)4) dcmonstratedthat
harcfoolrunningproduc€d an increased tonein the
foor mlscLrlature (panicularlyflexordigilorumbrcvis)
rcsuitedin $o incrcased heightof the medialarchar
sured or laleral rveighl-t'€aringx-rays. Ahbouehlte
tive importrnc€ of muscular vs. oss€ous suppoat
mai,rtainingthc medisllongitudinal archr€mains
is reasonableto statc that th€ dcmandsplaced upon
mussularsysted vrry inveN€ly wifi lhe bony
i.c.,an individualwith n singl€aniculatodsubLalar j
gojng to rcquiregreatermussrlar supportthansi
witlr a lrianicularcdsubtslarioinL wheremotionis
prinrarily by ioiot incongruily. [t most bc cmphaized
lhere is a limit to the suppon affordedby the muscdar
tcm. As staledby Perry@05),"Even with maximrl
lar lu[icipalioo, tbe capabilityto rneetthe valgus
impos€don the foot is lidrited,providings strong
for lhe careful selcctior of footwear and th€ addilion
add.dsuppon."
In mostsilualions. wh€nan individualwirha
ically dalfiuctioning foot pres€nts with muscle
strcngthening cxercisessbouldinilially be avoided,
the musclesarc almost always overworkcdand w€ak
fatiirue.The prcmatureincorporationof a
proPnm will ovcrloadlhe alrcadyfatigucdmus.les
mdl p€rp€t ate a fauhy movemcnlpsltern iII the indivi
who hssleamedto compensale for rbcchrcricallyslrai
nusculatur€.This bcingthc case,the first srageof rh€
habilitalionFocessis to slrelch$e overworked
genrlY.
As notcdby Janda(206),Lhr posruralmusclsc,
aslibjalisposterior, soleus,andgastrocnemius, arc
larl\ proneLotighlcningwir}| fatigue.This is troub
h lhat tbe faligrcd and tighlenedpostu.sl musclewill
producereflexinhibilionof theanragonistic phas'c
(pafliqrlarly peroncuslongus and tibialis anterior)w
necLlle\s to !ay, crealesa confuscdstateof motor
Becrus€ of this, stretchesfor the farigued and
posturulmuscle3shouldhe incorpuratedsimu
wilh strcngthenilgexercises for the weake$ed andI
enedphasicmusCles.
The cla$ic examplcof how posturalandphasic
cles work logerhcr to produc€ fo{rt dcformity occurs
fte lypermobilesubklarjoinl: lhe overly mobile
joirt often requiresmore musfllar stlbilizalionthan
pos(uralmusclcscrn providc.As a result,lhc$e muscles
liglc and dghtco, which in turn producesreciprocalinhibi.
tion of lh€ antagonistic Peroneals. Sinc€ even sligh
weikness of pcrcncus Iongus will allow for an incrcas.d
rang. of sublalar pronation s€condarylo dec.e&sed shbi-
lizarionoflhe fir$ ray.thesrbtalarjoinlis allow€dto movc
throughan even grcaterrange of pronation,which stresse$
the libialisposlerior,soleus,andgastrocncmjus mus.lcsto
the poi at which they cln no longer st8bilizc lhe fe8 ool.
Thii placeslhc forefool into a constantlyinvenedposition
relalive to the rearfool,which may evenllally bccomefx€d

solttissueconlracrurc. This conditionis re{erf€dto as a
ionallorclootvarusdeformity.
Unlikcthc true{orefoolvarus,tlealm€,]lol lhe (unc-
a.lforcfootvarusdeformitvdo€$nol rcouirea forefbol
(whichw uld only mdinrainrhc dcformiry).Rether,
shouldconsistof a well-dcsigned programofma-
ionlo restorclhc rangeof lirsl ray plartarflexionand
oversion, strctchesfor the posteriorcompartment
ure,er€rciscsfor lh€ Dhasicmusclesaod an or-
lo minimize the rangeof sublrlar joint eversaon
ichwastheoriginalcaus€ oflhe defornity).
Whilewcakness may be sccondary to a mechanically
ing foot, ir may also b€ the end-rcsultof pro-
immobilization. As demonstmted by l,eBlancet al.
immobilizationhas differeflt eff€cls on differeot
groups.Afrcr a s-week periodof horizontalbed
thercwasno chanBein muscleareaor strengthin the
dorsiflexors (asDeasured with MRI ard Cybex2 dy-
while the ankleplantar{l€xors!particularlylhe
rusandsolcus,suffereda I2al reduqionin mass
r267, redlctionin strenSth. This studyenphasized th€
of strengthoningthe postcriorcompa menr
rc afterevcn brief periodsot immobilizalionor
3.162. Abductor h.llucii. Ieslr The examinerforce-
alemptsto abduct the hallux aSainslpatienl resistance
(Thisdirectaonis rcvcE€d to test adductor hallucis).
i prclon8cdwcJkne$ ol the aMuctor hallu(is mus.
may rcsull in hrllux aMuctovalsu, defolmity, lon8utis occasionally
f'd ray delormily,and/or an excessrve
lh€ mediallongiludinalarch-Weaknessot addu(tor hallu,
is €lely seen.Flercr hallucisbr€visand longus,TestsrTo
fle)(orhallucisbrcvis,rhe examinerauemptsto dolsiflex
proximalphalanx a8ainsl patient .eristan€efcenter,A).
halluchlongur is teftd by applyinSrhe sametorc€ be-
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
ie mainlainedin a fiexed position when kning llexor
llucislonSur.Waaknesr:A weakileior hallu.isbreviswill
Ior clawinSof th€ rrear toe and lessenedstabilityof ihe
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,
ChrptcrThrceAboorn.l Motiotrdurlnglh3Grll Cycle 151
Followiog is a series ol illuslrations (Figs.
3.162-3.165)thal detailthe variousmanusltestsfor mus-
cl€softhe foot andleg.Also discussed arethepossiblesid€
cffcctsrssociaredwith prolongedweakness. lt shouldbc
stresssdthal in additionro evaluatingftese musclcs,the
pnctitionershouldalso evaluatemuscularstrcngthalong
ftc entirckineticchainsinceweakness of a moreproximal
musclemay delrimentally affect foot function, e.g., a weak
piriformismusclemay allow for excessivctalaradduction
andproducea chronicallypronatedfool (172).
Onc€ it has beer determined$ar muscle weakness
from faligue is oot a factor, strengdeningexcrciscscan be
iniliated. Th€seexercisesare readily performed by having
lbe palientduplicatethe mmud muscls tcsts st home.
Thes€exercisesmay be dom isomot.ically (changingjoiol
anglcsapproximaaelylf after cachcontrsctionto allow for
sufficicnt overflow) o. isotonically (either ecccnrricor con-
centriccontraction). TravellandSimons(123)rccommend
th4i muscleswitb triggerpointssbouldnol be isonelricslly
cx€rcised andlhat ioitially only the eccenlricportionof an
isotoniccoDtraction shouldbeemphasized.
A popularmethodof isolonicexerciserequiresmov-
ing lhe musclethrougha rangeof motionaSainslresistance
providedby difrerent sized rubber bandsor surgical tubing
bilizationol rhe medialforcloorduringthe lauerhalfof the
prcpulrivep€riod(e.8.,,econdmetaia.$lnressr.acturc. cap-
sulitis,et..)andfor hyp€re,(tension
ofthe fi|srinleehalanEeal
ioint. SranEely enoush,complet€paralysis of flexorhallucis
foLrndin longdistancerunnels.Flexor
lowerinB diSilorumb'evi! and longus.Tesls:Stren8lhin llexo,digito,
rum brevisir evaluat€dby applyin8a doBifleclorylorce b€,
neathlhe middlephalanaes of the patientt ,econdthrough
fifrhdigits(.rgho.Thelonsdisitalflexorisevaluared by apply-
in8 thesameforcebeneaththe distalphalan8es whil€ main-
tainin8 lhe interphalangeal joinls in a flexed position.
As sus8estedby Robbin,et al. {189),weakncs,in
thedi8ilalflexol,mayallowfor a loweringoithe medlallon-
gitudinalarch and for chroniciniury to the metatarsopha,
lanSealjoinrs,as rhe d;sraldigilsarc unableto effectiv€ly
I s2 FOOTORTHOSES
andOIherForms
of Cons€nativc
FootCsrc
Figurc3.163.tumbricales. T.str8y contactingthedorsaldis-
lal sudace,ot lhe distalphalanges, the examincratlempGlo
plnnta lexthediSibwhilestabilizing thefootIr the rnetataF
sophalanSeal ioinb t/efr.Waakness: Weakness ofthis muscle
ofien results;n diSitaldetormity.Ext€nsor diBitorumbrevis
and lon8u3.Test:Thesemuscles..e t€:ted toSefier (l72i by
posjlioninSlhe foot in a slightlyplantarflex€dpositionwith
lhe examinerarremptin8 ro planta/lexrhediSirsbv applyinS
prcssurealonSthe doEnl surfaceof the t6 (cctler). Weak'
(Fig. 3.166).Olherconmon homeexerciscs are illustralcd
in Figurc 3.16?. ln all situatiors,an ex€rcbe program
shouldatlemptto duplicalelhc sp€edof conlraction, joint
angles,and lypesof conllaction(i,e.,ecccntdcvs. concc -
tdc) thar the musclesare O be functionally stressed.The
essiestway to do this is with barefootwalkidg.As the pa-
tiont improvcs,theexercisos canbe mad€moredifficuhby
having lhe patienrpedorm rcpeat sidc-to'siderunning
drills, progressively tiShtcr"figure8" drills, voriousplyo'
metdc cxcrcises,aloog wilh Cadoca mateuvers(Fig.
3.168),In udditionto increasing srenglh,thcscmovemcnts
producelhe cooKlinated,svochronousmtl\culir interaclions
thal are essentialfor full recovery.In silualionswhere large
dctbrmity ,nd/or proprioceptivedefcils are pres€nl,il may
be nccess{ryfor lhe patienl !o wear o.thotics $d/or prolec-
tive wrappingto preventreinjury.
In ccalainciases,a given musclcruy not respondto a
strcngtheningprogram. Possibl€causd for this include the
continued prcsenceof aciive trigger poinrs (which impair
lhc musclc'sability to recruitfibers),joint dysfunclionin
the ncighboring articulalioDs(two separdtesludies (209,
210)demonstrAted tbatmobilizationofa hypomobileartic-
ulationmry produceimmediatestrenglhgainsio the sup-
poningmusculalure), andor nerverootcntrapnrcnl.
As nolodby l.ee@r1),oneof the firstsignsofnervc
ruol irrilolionis an acceloralcd fatigabiliryof the involved
muscle.l hisdccreased endlrancemaynol hc apparent with
nejs:ThenDstcommon problemassociated wilh weakn€ss
thcs,rmLrscl€s
is a clawinBoi the lessefdi8its.Extreme
nessmavreeultln r mild droojoot. ExteNorhallucis
ard lonSur,Tests:lhe pati€ntrsisrs a plantarfledory
appliedal the proximalphalanx(r6lin8brcvis)andlhen
di{il phalanx(testinglongur)lral,a).Weakness: Be€aus€
tennt hallucislonsusis an imponantankledo6iflexo,,
ner<rn thes€mus.lesmay rsull in a drop'foo!.
a singlc tull effon musdecontraction(as is usedin
nelrrologicalassessments) and musi be evalurtedby
ing the involvedmusclero the poinl of faligue,then
parirg rhe 6nal Dumberof repctilionsto thc -
sidc.The neurologically induccdfatiguemay bea sourcc
chrooic fool injury and treatmenlmusl be dircctcd
resl)ringoptimslspinalbiomechanics: in ordgrfor an
cisc progra to be €ffec{ive,one must first idenli{y rny
all tnctorslhatnay be perp€tuating
thewcakness,
ExcEssrvr/ABNoRMAL
MorroNs
Becauseof the extrem€sin ground-reactiveforces&F
sociilted with locomolion, the most rcliable protcctiol
against ahnornlal or excessivemolion is a well-desigoed
skelctal system. ldeally, the articulations of fte foot ur
fornred in such a wa:. lhat they funclionally int€rlockard
rcmrin stable even wilh lhe superimposedstress€sof
wei$ht-bearing (215).
Thereare,bow€ver,numerouscongenitalanonalies
that signific"lntlyimpair rhe ability of bony restraininS
mechanisms lo resis!exc€ssivemolion,
The most significanl of lhesr congenilal anonralie$
occrrs in the subtalarjoirt. As describcdby Hafiis ald
Beirh (215), an architecturally slablc subtalarjoint will
fornr in sucha way that the headof thc lalusis positioned
direLllyoverthc atrterioretrdof thecslcaneus. ln thispos!

3.164.Tibialisanterior. Te5t:The examinergra5pslhe
s medialfore{ool(jusl dislal to thc insedionof tibialis
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
againtlpalienlresittance{/eftl-Weakncss:The mon obvi'
floblem nssociated wirh weak4essof tiblalisanlerioris a
. Aho, the lorefooroflen "slap!" lhe Broundloudly
n8 th€ conlactperiod. Rooret al. (3) noled lhar exlreme
oi libla is anteriormay allow rhe anlagooislicp€F
longlslo cfealea planta lexed fi6r ray defomity. Tib-
tterior.Ten: The mon common tesl positionh to have
ienradducrand planrafflexthe forefoolwhjle the ex,
, with a medial midfoot .omacL anemptsto dolsillex
ev€dlhe fool lcenrerl.Could {208),who claimed{ha ib'
posterior is probablythe most overlookedmusclein tha
in l€rmsoi muscularrtrenSth,suggeslstestingthh mu!
iirnrlygratpinEthe heel and having the palient rcsjsl
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 $
20lb, otpressure,tibialisposterior5houldbe conridefed
Weakness: Pfogressive lowerinSof the medial lon8itu,
archwith lhe possibledev€lopmentof a functjonalfore,
wrus defomiiy and/or dorsiflexedfir$ ray. Peroneus
andbrevis.TesterAsn group, lhe pelonealsaret6ted
inEthe pati€ntwirh lhe lorc{ootsliShtlys!pinated
plantarflexed,and inve cd) (flgh). Againrt reris-
prcvidedby ihe examiner {contact point on dorsal,
lfifih metdtar5al),lhe patient attempc to abducL
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^
ChapterTlrce Abnormal Molior during the Glit Cyclc 153
peroneuslonguswilh the test pos tion illtjltrat€d in B. In lhk
tesl, the palient h positionedwith the forcfootslightly plan
tadlexed and evertedwhlle the examinergraspsthe medial
iorefoor.Agalnn maximal rcsistanceprcvided by the palienl,
the examiner alteinptsto doBiflex and inved the forciool.
Weaknels:A weak peroneuslonrus allows for the develop'
menl of an acquireddorsiil€xedfirst ray, as the medial fore-
Ioot is no Jon8erdabilized during lhe prcpulsiveperiod. fhis
may eventuallylead lo defomity at the first metatarsopha
langeaijoint. Weaknessio peron€usbrevk is also trcuble
some,as il allows for the developmenrof a flnctional rearfool
varusdeiomiry as the mll5clesresponsiblefor inve(in8 the
tubtalafjoinr ovelwh€lm lhe weak€nedperoneahduring late
swin8 phase,allowing he€lsrfike to occur with the reartoot
exce,sivelyinvened.tlhe foot will behaveidenricallyto one
wlth an olseousrcadool varu defomity until slrenglhis re-
storcdto the lateralcompa.henl muscles.)Also,weaknessin
the peroneahmay resukin chronic invesion anklesprains,as
peronels brevis i, unableto everl lhe laieralcolumn, iorcing
Lhefool lo roll lhrcu8h ils popukive period with the rea oot
excessiv€lyinverled as a low gear purh'off i, majnlained-
Thi! movemen! paltern may eventually lead to interdi8ltal
neuritis,recufientankle sprain,and/or laleral hip pain as the
Bluteusmedius muscle fire5 vigorouslyin an attemptto dis-
place thc center of massmedially towad, the stancephase
l.E
154 FOOT ORTHOSESand Orher Foms of ConscrvativeF@r Carc

Fi8ur€3.155.Soleosand g.stro€nen ui. Tesls:Soleusis eval' com )aredbilateralJy. Weakness:Awea&ness of these

uated by posirionin8th€ patient in a prone positionwith lhe
knee fl€x€d 90'. (Ihis position minimiz€sihe abiliiy of gas,
trocnemiusto efe.tively assjsiin resirtlngth€ t€st motion.)
The examitrerlhef contaclsthe posteriorcalcaneusand plan-
hr forcfootand attemprsto dorsirlexthe ankle againstparient
rcsistance cO. se.ause the gastrocnemiusis such a strong
muscle,it k b€si evrllat€d by having Ihe patientp€.lo'm re-
p€at sin8le leg-heellaiseswhile standinSlri8hir.lhe n!mber
of rep€tilionsnec€ssiryto prcduce mild {atigue should be
is a|nost alwavs associatedwith a markeddelav in hel
Th;. ofhn reruhs in the delelopmenr of cras toe derorr
and/or an a.quired plantarflexedfkst ray defomity, as
lonA digitnl flexors and peroneuslon8ns (which are all
lremcly weak ankle plantadlexoE),ttempt io initiarch€el
durirg lat€ nridstance(3). Becnusegastfocnemius crosses
kne joint, weakrcss in 'hi\ musclc one'' re(ullr in geru
curvrtum andor rccurrentkn€einiury.

l:loxor
hallucis
longus 'llbiarisantoior

Figur€3.166.8y anchoring endofan excrciseband,lt is posrible

thc opposite
anymusclcin lhe hody.
 Chatrer Threc Abnomrl Moaiotr dorlngthe Grlt Cycle 155

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.)

tion,thc lalarhcadrcceivcsfirm supportliom thesustentac-

ulum tali, which is broad.rounded.andru s forwardlo thc
anleriormarginof lhc cnlcarcus(seeFig.3.169).This paF
ticularformationallowsfor muchstabilityin thatsupcri -
posedbody u,0ighlcompresses andlocksrhelalusonb rhc
calcan€us. thorcbypn)tcctingagainslexcessivc
molionwith
littlc or no stressplaccdon thercstminingmu$cles
andliga-

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

f$rlhermediallyanddownward,eventuallyleadingto 50' of ibrefootinversion)whileconiracture of theposterior

complete collapscof tbe midtarsaljoinl. (Nornally lhe calJ musculatureusually mairtains the ankle in a
ive forcefrom the navicularallowsfor grsatorsta- plantarflexedposition (e.9., ne8ative 25o of ankle
in lhe modifiedball-and-sockel taloruvicularjoint; dorsiflexion, asmeasured with the subtelarjoint in n€utral,
Fig.3.19) is no! uocommon).Haffis and Beath(203) emphasizedfiat
Furthermore.the adduct€dand olanlarflexodtalus im- the decreasedrangeof ankle dorsiflexion is not lhe causeof
rhewindlasseffecl oI Lheplantarfasciaad allows the hypermobileflatfootdeformity,but probablydevelops
-rcacliveforceto crearea jammingo{theuppermaF because"lhe structureof thc foot and tho laxity of lho tarsal
ofthc unslable larsusas the undersurfac€s of the,sear- join$ deprivc tbc tendo Achillcs of tensionstress€s,which
collapse(Fig. 3.171).Becausethe supporting rormallywoltd facilitateelongation of thesetissues."
ald ligamentsa.e unablelo resjslthe progressive Becau$ethe stressesplaced upon lhe muscular and
of the tarsalstthe lalar headoflen coniinuesils ligamenlous restraining mechaDisms areso geat, individu-
rr)igraliolt
lndl il eventuallynakesgroundcontacl. alswith lhis deformityoftenleamto avoidstrenuous sports
finalresullis a hypermobile foot thalpre$ents wilh an or heavy activili€s.Ahhoughsymplomssucb as painfui
andabducted forcfoot.an ever@dheel.andan un- joiots and/orfatigoedmusclesmay be delayedindeffnitely
fi$l ray. wjlh a scdeitary life-style, thcy mosl oicn begin by lie
Harrisand Beath(20J) claim thal the architecturally oarly teen$afid may be evidenlas early as 5 yearsof age
sublalarjoinl with its incomp€rent sustentaculum (203).Becausethereis a srong tendencyfor this subtalai
h the primary etiologicai faclor responsiblefor th€ de- anomaly1obe inherited,rhe conditionis oftenrecognized
ot lhc hlpermobileSatfoordeformity.This paF by a parcnt afflicted with the samedsformity. It cannol be
nalformation,which may also be secondarylo ovcrstatcdthat €arly recognitionof tbe hyperrnobilcflalfoot
ital ligarnenlous laxily, will alwayspresenlwilb a deformityis essentialsinceit i! often possibleto correct
al medial longiLudindl arch otf-wcight-hearing thal lhis deformity wilh lhe useof custom-moldodoihotics lhat
y collapscs uponsrdnding. The forefootin thissil maidtaiDbory alignmentduring,growthycars(2r7). (Nol€:
oftenmovesthroughextcme rangesof invcrslon irealmeotof tbe child'sfoot will be discussed in delailin a
sb d u crion( hc m iLlr ar la l j o i nmd
r ) a l l o w to ' a ' m u c ha s latersection.)

Fiture 3.171.Normally,rhe plantat

fascia h.s a t€nsion banding efiecl
(A) thal allo$$ imposcdfor€es(B) to
inducc slabiliry by interlocking the
larels. When the tensionbandin8
effe.t of the plantarfasciais absent
(c), impos€dforcesproducea .ol
lapleof the ta6als{D),with thodor
sal rLrr{aces b€ing cornpresred (t)
while the planlarsudacesare dis-
tracted(r). {Modifi€dfromVo8lerH.
Siomechanics ot lalipesequinoval-
8us. iAm PodialrMed Assoc1987;
7711):212a.l
!58 FOOTORTIIOSES
ard OlherFonnsof Consrative FoolCare
The hypermobileflalfoot deformity can be idenrified
by theextremeloweringof themcdiallongitudinalarchon
weighFbearing, thechronicallycv€rtedheel,rhedrasrically
increasedrangcof lorefootinversion(with $e concohi-
lantlydecreased Iangeof anklcdorsiflexion)and,mostim-
portan y, by lhe medial displaccmcntof thc talus relativc lo
thc calcaneusduriog static slance.A supcrior/infbriorx-r.y
servesasa llseful index for dcterminingth€ degreeof defo.-
mity, as it demonstmtes a shadowwbererhe headof the
talusis not supponedby the ant€riorcalcarcus(e.9.,com-
palc the shadedareain Fig. 3.I 70 ro the shadedaftn io Fig.
3.169).
To be comprehensivc, trcatmeotof this subtalsr
anomalyshouldincludovariousmanualtcchniques lo !d-
drcssany soft tissuecontractlrrcsassociat€dv./iththis defor-
mily. and an orthoric,which actsas a physjcalbarri€rro
prevcnl excessivedisplac:emeolof the lalar bead.Allhorgh
lhc onhoticwill not conectthe dcformilywhenusddaller
osseousmaturity, it cao greatly reducestrain placed upon
lhe supportingmusclesandligamcnts, asit basicallyaclsas
an extrinsicsustentaculum lali.
Whcnapplicablc, fl rearfoolvaruspostshouldbe used
LoreDosilion thccenterof massof thecalcaneus benenrh the
canterof massof tfte talus.This posl rhay be invaluable,as
il lc\senslhe lengthoflhe leverann affordedbodyweighl
for pronalingthe subtalarjoint, which in tum altowsrbe
muscularsystemto becomcmore effectiveat conlrolling
subtalarmotioos.fie uscof a forefool varuspo6tshouidb€
pr€scribed with caulion, as prolonged sublala. pronalion
oftcn rcsultsitr lhe develoDment of a funclionalforefoot
varus whcrc the forefoot deformity is mainhined by sofl
lissuccontncture.Useof a forefoolva s postin thissilua-
lion wolld only maintah the forefoot deformity and rnay
cventually lead lo progr€ssivcdeformity of th€ first
mehhrsophelangealjoinl.
Thc most imporlantclinical conccmwhen d€aling
Fi$re 3.172, Ite id€.| ,irsl t r-
lo'ndataFal arliculation allows for
a midline position of lhc fir.l
detilarsal (A). lfobliquity ofthe flrsl
tarsomehtarsaljoi is prcsenl (B)l
lhe ti|5l melatalsalshiits into an ad.
wilh a hypemobilcflalfootis how to accommodare rh!
crer\ed rangeof anklc dorsifl€xion.Becau,(c the
ftnllc ofankledorsiffexion is almostalwaysassocialcd
a p.|lhoiogicalrangcof compensarory midtarsaljoint
tion. it is imponantthatthc practitionerinco.poral€
pmllriat€ly sizedhcel lifl and/or useonly dle soflcr
shellr as useof a rigid shellwithouta he€llift a
wals leadsto iatrogenicinjury as the pronaringmi
collidesinto rhc onhodc shell.Also, arcmDr.\should
ways b€ mad€io leDgth€tlthe achilles rendon(the
joinl mustalwaysbe in a [eutralor supinated position
pcrli)rming calf stetches) and $rengther th€ s
mus.ulatrreGfflicolarly dbialis posterjorand sbd
hallucis).
The liypcrmobile First nay
In additionto fauhyfoot functiooassociated wilt
anorrnloussublalarjoint. anolherosseous
thalnllowsfor abnormalnotion is obliouitvoflhe firsl
somNtatanal (Fig. 3.172).This panicubr d€forniryid
throsbackto th€ primitivr arborralfout. *hcre
skills, nol mechanical $ldbility,was thc pdmary
Evolutionaryremodelingof lhe foot necessilated a
migr.rtionof th€ fiN ray in order to allow a morc e
propulsivep€riod(218).
lf deformity of the firsr tarsom€tata$aljoinl
lhc lirsl r.y to b€ meintaincd in ao adduct€dposition,
6rst mcratarsal headwouldbe unableto b€arweicht
tivelv sinc€.unlikethe sccondmctalarsal- it is nol
slabilizedby rn osseouslocking mecha[isnr.Nolc
whcDthc firsl metatarsal is in a midlire posirion,il crrl
efferlively stabilizedhy rhe supponingmusc|llaturc
first ftelatars?l hasstronccr musclesallachedlo il lhan
ot the othermetararsals [219])and by ligamcntous
monrsto the securedsecondmetalarsalbese(the bascof
 Chapff Throe AbnormolMo(on durlry Ihe Golt Cycb r59

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
Fi8|lre 3.174. The dorsal b.3e exorosisfrl4sel)may produce
leno.ynovitis of ext€Nor hallucis longusafld,/o' brev;sand
may re€ul{ in entlapmenl neuroparhyof the de€p p€roneal
newe where it paisesbemath th€ cxt€nsorhallucir brevh
t€ddon(IHBT). Th;senr.apment neuropalhy may b€ clini-
callyrletected by a posiiiveper(ussionsign(Inel's tesllper
fomerl at rhjs junction andlor by a decrcasedvibratory
sensdtwopointdiscrimination at $e fksl dorsnlweb spaee.
(Adnptedfrom LeeDellonA: Deappercneallerve entrap-
menton th€ dorsumofthe lool. FootAnkle 1990i 1l (2):
73 7a.l
cecdr€arfooimotion,i.e..2"of fearfoot€vcrsionwillbc a€'
companied by 8' of inlernallibial rotation.Convercely,an
axissitunled20"ro the transverse planewill alk w for largc
amountsof rearfooimorionwilh relalivelysmall 1lnr('unls
oI iibial rotation.
when a high nxis of motionis pr€sent,the b$'ci leg
is p'edisposed ro ifljury,asevensmallrangesof r€arfoolin-
versjon/cvcrsion mayresultin potentiallyinjuriousamounts
of torsioflalstrainsbejngplacedupon thc Iower lcg. The
low axismotionhastheoppositeeffectio lhat thelowcrleg
is mostoftensparedfrorninjrry, but thefoot maybe chron'
icr y injured,.rsit is forccdto movcthroughlargerangcs
of frontalplanemolion.
Trcatmenlfor both lh€ high and low axis of notion
rcquiresI slrong,wellcoo.dinatedmuscllarsys&mro help
controllhe abeflantfrcntaland trAnsverse planeof motion
of thc hccl andtibia.While orlholicsmay be invaluablein
FiBUre3.17s.ltt€ splayfoor detomity. This defo'mity
i.leFriliedby th€ substnntialincreasein intermetntaEal
pad cularly betv/eenthe itsl and second(A) and lhe
and li{h {8) metalalsals.(Thesean8iesare typicallyless
Rooteral. (3)claimed
l0.rnd s', r€spectively.) thatthi,
nrit\ resulislromeith€rabnomalpirpulsivcperiod
o{ rl,p {,brdlrr jojnr or lo,, of Ln, rion in tl.e t.rn$er(o
nrus(le.TheywentoDto sratethatanenrplsto lalt the
gfeslionot lhisdeiormityby climinalinS
th. abnomalp
tion arc dc{ned to fail if the filsl nret ralsrl angle
14'.rnd ire fifrh ray is jn bluxalion in a pronated
(as lvidenced by a concave lateral border ol lhe ii
met,rtafsal
shafton a dolsiplanl.r i{ay)-
conlrcllingmotionassociated with a low axis of
rhc) aie lcsshelpfulwhend highaxisol molionis
sincutlrcrearfootin thissituationmovesthrougfisuchsm8ll
r$nfesof morionrhato.rhor;cconlrul is usuJilynor indi-
cat€d.In somecases,however,lhc hjgh axjsof molioni$,
associal€d with a normalor evenincreased rangcof subta-
lar lmnation. which makesonhotic controlessential for
minjnizingtorsionalstraioson Ih€lowerleg.
Veltictrlly Displaced Obliqtre Midta$al Joint Aris
Ir addilionto variatior in positioningof tlc rubhlrr
joinr axis,it is alsopossiblethatanicularanomalies in lhe
rnidrarsal joint may allow for a vandlionir positioning of
rh€obliquenidrarsdjoinraxis.Nomally, thcobliquemid-
tarsll.ioifltaxis rcsts5l to th€ IrnNvcrseplaneand57'!o
thesrgittfllplaneard allowsfor relativelyequalarnounls of
 ChaplerThree Abnormal Motion drrlng ihe Gsii Cycl€ 161

uction and dorsinexioniplaotarfrcxioo (Fig.

76).Howcver,variationin articulargeometrymayallow
a morevcrlicaldisplacemenl of the ohliquemidtarsal
laxis-Tbehighobliqucmidtarsaljointaxisallowsfor a
inc.€ase in transverseplanemotionof thc forefoot
uction/adduclion) with a corrcspondingdec.eased
of sagiltalplanemorion(dorsiffexionhlartarflcxion).
positionof lheobliquemidlarsal joinraxiscanbe de-
clinically by evaluaringlic luleralconrourof rhu
uponweighr-bearing. If rhe high oblique midtrrsal
axisis present,thc forefoolwill abdrcrexccssively,
a characlcristi.ansulationat thecalcaneocuhoid
(Fis.3.177)
Tlo highobljquemidlarsaljoinl axismay be respon-
for injury,asil allowsfor a medialdisplaccmenl of lbe
relativcro the calcaneus (Fig. 3.178).Thi$ unfortu-
y supp)iesbody weighl with a lorger lever arm for
ing lhe subralarjoinr, which 0suallymairtainsthe
in a pronatedpositionlhroughoolthe cnlke stance
. Also,lhe nearlypuretransveNe plaDemotjonoflhe
may produceinjuly during propulsion,as il may
llow lhc normallocking of lhc calcancocuboid joinl
for.tabiliLy:becauseabducrion of $e forefoolal
lhe clboid to shift latera[y, ir is possiblethat rhe FiSut€3.175. Nornrally,the oblique midlarsalioint axis
(OM,A) allowsfor relaiiv€lycqualamounlsoJtransverseand
id mayescapethe anatomicaloverhangof (he calca-
s.ghtal planemoliom.
tis, therebyprevenlingthc calcaneocuboid joint from
ingdudnglatemidstance (216).The fool rheflbehaves
o flexiblelcver arm thatwill bucklewith the forcesof

To mokemattersworse,because lhc ravicular$imuf

abduclswilh the cuboid,the talai h€admay es-
m€dially from the navic{lar acetabulum,ofleo
io! rhcconplerecollap$eof rhc mediallongiludi-
arch.Signsandsymplomsassociated with thisfool type
a markedloweriDgof th€ mediallongiludina'arch
weighrbearing (with aouteangulationof the lateral
mrrginzl prolif€runon ol rhe lsleral calca
id joint, chroniclibialisposteriorandtibialisante-
tondinilis,plantar frsciitis, spring ligamentsprain,
knecpain,diftusehyperkoralotic lesionbenealhtie
andlhird mctatarsalheads,and a hanmcring of the
digils secotrdaryto a bowing of rhe nexof digitorum
Geferback10Fig.3.34).
Onhotic managemenrir rhis situarion is often
It becaus€, even with proper shoegcar, excassive
werscplan€motionof lhe forefootmay continue,and
tissues ben€at!the mediallonsirudinalarchare ofter
intolhe orthoticshell.In facq manypraqidon-
thal the high oblique midtanal joiDl axis defes or-
conlrolandthattreatment
failureis a rule,rarherthan

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
Figure3.178.Normally,th€ talus i! posltionedalmostdi-
reclly over th€ cal.aneus. th€rsby supplying body weisht
with a r€la$v€ly $mall l€v€r rrrt for prorating ifie sublalar
ioint (x in A). However,whena hishobliquemidrnaalioint
axisis presenl(B),abductbnof th€ forerootoccrjrswith si-
this, a neutralposition c$titrg lechniquemusl be used,dnd
ihe de$kedrearfoot and forcfool posts should be addedro-
getherandplacedbencaththedistalmedialaspedofthe or-
thotic sh€ll. (Renemberlhat it is lhe orlhoiic shell rhai
capturcslhe rearfoot-to-for€foolrelationshipand thal place-
ment of the postnercly delcrmineshow long the orthotic
will remainfurctional.)
To give an example,imaginea patientwilh a high
obliquemidtarsaljointaxisthatrequhesa 3" tbretbotvarus
postanda 4'rearloot varuspost.[f the ortholicwaspo$tcd
in Ihe usualmanncr$ith scparate 3 and4' postsplacedbe-
rcath thc forcfoo! ard rearioot, rcspectively.the subtala.
joinl *ould pronatean addilional4' as the pad€nt'spro-
gressionof forcespassedanterior to the rock lin€ of rhe oF
thotic (reLr back to Fig.3.92). This world auow tb€
forefoo{to abductand the mediallongitudinalarchto col-
lapsejustas thc foot wasappnnchingils propulsivep€riod.
Thc individual mighr cornplainthal tle disral ortholic
seemsIo shifl medisllyand/orthe ortholicshellis digging
inlo thesorltis-sucs bencathltc arch.
Hicc (222) sugge,qls that symf)tomsin Lhissjturrion
could havobeenavoidedif a 7 for€footvams posrwere
addsdto tbedisralmedialshellithispostanglcwouldfnsi-
tio! rhesagitlal bisecrionof the rearfoolso thal it is invr.rtcd
4' from perpendicular,which wollld allow for contanued
conlrolof lhe sublalarjoint until earlypropuhion.('Ihis k
essentia! for successful managcment of this dcformity.)ln
multaneous add!.tion of rhe rcallool (anot)rs),
f.n medial displacemenlot the ralusrclative
neu.(a/rowfi in I andC).ThisIn rumsupplies
with a much morc eiicctiveleveram for
l ar j l ri nlfX i n c).
almostallsituations, therearfootof theorrhotic
be posted8arfor stabilityand,if neces$ry, a
posi to solcusmay b. addedlo ,llow for
coDtrolthroughout rhcpropulsivcp€riod.
In situations in which lhere is no forefool
and rhe individu:rlpr€senrswilh s combination
varusa highobliquemidlsrsaljointaxis(whid
licularlydiffcull combinarion lo rrer!),rhedesi
posr\hould \lill hc phccd brncalhrhe forefoot
conrnu€ lo conlrol motioo duringt€rminal
The useof the varuxpostplacedbeneath thc
shelr is invaluablewhen rreatingthis dcformity|
repositions (h€talusdirectlyoverthecalcaoels,
fectlvelydecreases the Ievernrm atrordedbody
trorrling thc suhtalar joinl.
ln additionto foot onhoses. lhe useof 6r!|.
ive shoegear(with wellfitting he€lcrunlc$),
vari,i s proprioccplive andsrengthening
ally necessary to trert a high obliqucnridlarssl
succfssfull!.Th€ pfltientsholld be encouraged lo
orlh ric" bv Lran\leffing rheprog'ession of forc€s
later.rlcolumnand initiatinga low gearpu
proFLrlsion. Also,bc.ausclhechronically evened
ciatrd with thisdeformityoftenprcduces a
foot varus dcformily,manipulationof the lar$l3
alwivr be qJnsidcredbcforcprescribing a

TRENtrslN LowER ExrREMrrY
ALIGNMENT
rclarionalpalternsof the lower cxlrem;ty
signiticanllyfrom thoseof tfie adult. During
rnd adolescenc€, lhc femur iibia, and fool un-
sDecificlransformalio0sin the lransverseand
lharwill hopefullyallow the adr l ro wnlk
srrajgltgai(pattcm(i.c., lhe yo|lngadult
with an approximate I' toe out gail paltem),
bejngncarly perpendicularto the grourd al
These developm€ntal chargeswill be disdssed
;b€ginningwith thoseo€curingin lhekansverse
FiBUre planealignment
3.r79.lde.l Iransrerse
Chapter'lhree Abmr'[!l Motion duriry ih€ Grlr Cycle 163
Tranov€rsePlaneAlignmetrt
h rheinfant,thefemoralheadis posirioned in lhe ac'
elabuhm so thnt the femoral neck is angledapproximately
60" posrerior to the fiontal plane (panel I in Fig. 3.179).
Note that in patrgl2, the femoral neck is interflally rotated
35" lo the transcondylaraxis oI the distal femur. This angle
is referred to as rhe argle of femoral anreversion.(lf the
femoral neck were extemally rotated relative to the distal
femur, it would be refered to as femoral rettoversion) Be-
csusethe 35' angleof femoralanteversionPanially negates
the 60' posteriorpositionirg of lhe femoral head and neck
in thc acetabulum,the lraDscondylaraxis of tbo kneejoirl is
extslftlly rotated25' relativc ro the ftodal plane(panel3).
Adult
in inFrnts.ndadulis.
164 FOO] ORTHOSES
andOtlterFonrsof Con$Narilc loot Cflre
Panels4 and 5 of Figure3.179dcmonsrrate thal tbc
proxinal and distalaspectsof the tibia are well-aligncdin
the infant,i.e..thercare0'of Libialtorsion.II is importanl
to nolethatlhe degr€cof Libialtorsionis dillicull LocvBlll-
atewirfiouta CITscnoor MRI a lhaton average,thede-
greeoftibial torsionis approximately 5'less lhanth€anglc
be$een thc transmalleolar axis aod the bisectionof the
proximaltibir. (Comparelhe do(ed linc in panel5, which
r,rptesenls thr rransmaller,hrurjs,tu l||e\oU.tline';n pan-
cls4 and5, whichreprcsent actualtibialtorsion.)
Panel6 in Figure3.179 illusuatesthe nolnlal talar
neckanglewith aespcclto the supeaior articllar sltlfac4of
the body of the talus.This angleincreases frcm 20' in the
fetusto 30" in theirfant (223).Sircethe entircfoot follows
the ncckof the talusvia thc arliculationwith the navicular
(223),Ihetalarneckangleis an impodanl,albeiloltenover-
looked,comporcntof transveme plancalignm(nt.
By coftbioinglhe v{riousanglesfor eachsegmenlin
$e lowercxtrcmlry,the{veragedegreeoi toc-inshouldbe
apprcxinulely5" (i.e.,the rfllarneckin pan€l6 deviates5'
mediallyfrom the sagilralf,iane).This is corsistenrwith a
sludyof 70 inianrsby Bleck(223)in which rhemeannor-
mal internalrotationoflhe f(}olwilh reference to thelineof
progrcssion was4.4 1 1.7'.Bleck notedftat rheinFrnally
rctaicdposilionof thc loot jn newbornsis usuallynol no-
ticcdbecauscmostbabieslic wilh theirhips cxternallyru-
uted. h fac1,the prewalkingchild who is forcedlo stand
will often turn his or her feeloul by noarly90'(224).This
shouldnot be considered abnormal,as it occursonly be-
causethe hips nre nlaximallyextemallyrotaled.ds the
child beginsto walk on its own, the normaltoe in partern
beconresmoreapparentas all segmentsof the lower ex-
tftmity rolatc into their n€utralposirionsduring slance
phalic(223).
The idcal ransvcrseplanealignmentprtternsir th€
adult are illusiraledir paflels7-t2. Noreth l in panels7
and8 thc femoralneckis now positioned in thcacelnbulum
approximalely12' posteriorto rhe frontrl plane,.rnd the
angleof fcororalanteversion hasreducedfronl 3,t' to 1l
(8-l-5' is the norm).This allowslhe transcondylar axisoI
rhcdistalfenlurto be positionedin theftonlalplanc(panel
e).
While completederotation ofthe femorll neckgencr'
ally occurs heforc thc ageof 8 (225), Bleck (223)olaimed
lhat the majorreductions in femorfllantevcrsionoccurduF
ing lhe first3 montbsof infarcy,as ext€nsionandexternal
rolalion of the femur (which are neccssarylo redlcc con-
lractureoffie h'p flexorspresentat birih) producean cxteF
nai fotalionallorque on lhe proximalend of the femur.
Decause thisendofthe {emuriscartilaginous andis 6xedlo
th€ rigid diaphysie,the exlernaltorqucstreinacturlly ro-
tatcsthe femoralneckrelativelo theshaft,producinga de
creasein the angleof femoralanteversion. Apparenlly.this
iwist occursin ihe subtrochanlericregioDwherethe plaslic
carrilageof theproximalfemurinterfaces with the
aphrsis(223).
Another importantdevelopmental changein
nrdrl occursin lhe tibia. By comparingthe relalivc
tionr of thc proximalanddistaltibia in panelsl0
you will notcthatlhedisrallibiabecomes externally
2:'{o ihe proxilnsltibin by adulrhood. (Thc
axis.which as mention€dis approxinately5' grexter
the degreeof libial torsion, is position€d27 to thc
plare.)Jay(226)notesthatrhedistalribia rotrrcs
at d lateol I 1.s"/ye{r.t}is is clinicallyusefulin
i|tg lheide.lldegreeoftibial torsionat a givenag€,in
10-teaFoldchild shouldpreseotwiIh appfoximalely
extr-rnallibirl lorsion.wi*r a transmall€olar
axisof
marclyl5o.
The fiDal developmenral€hangelo bn disc sscd
cun in lhe talarneck.Fromtulancyto adulthood, lhc
dial devialionof the lalar neckshouldreduc€lrom300
l8'. with lhc najoriry of lhesechangesoccuffingby age
(22:). Notjcein panel12 that afLeraddingup thevs
tfn\verse planealignmenls,lhe adull shouldprescnt
an r nproximarc40rocdur pdrlemwhenrll segmcnrs are
neuLmlali8inrne. This angleof toeout is oftendcl
incrired. a\ mosr peoplcextemrlly rotarclheir hip\
ordcr to provide later,rlstability during slowerwal
While lhe developrnental lrendsoudinedin Fi$n
3.179 repr€sentideal ontogenicpalterns.various
snd/ordevelopmeDrladom ma),eitherimpairor
alc rhc rotutionalde\,elopment at an) or zll segmcnts
ol rh6
lowcr extremity.While suchtorsionrrldefbrmities may
casi'rnallybe inherite4theyare morecommonlyd€ve
menral and typically resuh from faulty
posirioning duringlhe latermonthso[ pregnancy (224).
(22(.)nolcdthat in(rauterine constraints nre morclikelylo
detrimeorally moldthefetaltissues$hen rightuterine mu$
cl€sarepr€senl(aswith a firsl-bornchild)or whe! a large
f0turor multiplefelosesar€presenl. Also, excessively
dgfu
abdo$inal musclcs,a snall pelvis, a proninentlumbat
spinc.uteiire fibroids,or any feml malposition(suchai l
brerchor Fansversc lie posidon)all may impairnonnilrc-
lari(lnof thc limb buds.The rcs!ltafitto$iooaldcforrnities
arc 'rflcn nrrinrainedby va'iou\ sirling:rndslccningpos-
turc\ tbala('tto pcrpeluate orevenproducelmnsvcrce plane
(Fig.
nrall,ositionins -1.180).
In approximalely S-15f. of thc populalion,rotational
pall(ms of infancywill persistbevondskelclalmalurily
(221). If lhe toe oul gai! patlen persistsin(d adulthood
(whichusuallyis the resrrltof fernoralrelroversion [228]),
rhe ndividualis prcdisposed to injury brcauscoI lhc in-
crer\c in pronaloryforcesplacedupon the sublalrJjoint:
nornrally,whenrhe foot landsin , straigbrposition.sheir
forc.s act to crcate a plnnlarflectory moment arolnd the
ank,! axis.However,whenthe foot landsin a loe oul gait

3.1E0.Sle€pin8and sitrin8po6tu.€' thal m.y pcrp.lu-
o. Produc€varioustorsional d€fonnitiei. (A) Pronefrc8
Abelsexlernallolationdeformilyat hios,exle,nallibial
and valrus he€ls.(8) Prone,hips extended,feel ad-
, Abets inlernal libial to.sion and varus heels. (C)
hipr flexcd,feet adducted.Ab€rsexrernalmrarionde-
ilyal hips,internallibial tolsion,varu!heels.(D) Sitting
uctedfeet.Abctsinrernaltibialrorsionandvarusheel!.
Si[in8withfe€r.bducled(the"television posirion').
Ab€tt
shearlbrc€sare appli€dmoreperpendicular to the
axis andcan ftercforc generatea strong pronatory
It is for thisreasonthatindividualswith lffge.angcs
rolation!r lhe hip arepredisposed to medisllib-
rtoss reaclions(229).
A loe out gail pancm m-ayalso pr€disposeto inj!ry
it allows for a prematuremedial displacementof
Dornalprogr€ssion of venicalforces(Fig. 3.181).This
bodywci8h!with an effectiveleverarm for main-
lhesublalarjoint in a pronaledposilionthroughout
andpropulsivep€riods.Accordingto Davenpon
excessive subtalarpronationassociat€d with a toeout
tallcmmayevcDtually resultin lossoflhe mediallon-
arch,adapriveshorEningu[ the p€roneals,im-
ChapLerThrcc Abnornd Modor duing lh. G.it Cycle 165
excessive externaltibialtoAionandval8usheels.(F)lailo/s
posilion.Abetsexternalrolationdefomityat hipeand vaflJe
heelt. Wilh rcsardto thesesittinSand sleepinSposturcs,
Swanson et al. (227)sratedthar'the sleeping
positionwhich
is iniliatedat birth and shodlythereaftermay becomea
difficuhhabjt10breakandftay carryoverinlotho sittin8and
playportures andeventually intolhe walkingposiurerof the
child."
pingomentof the talusupon the lalelal aspecrof the ca!
canorlsulcus(whichoftcn leadsto a flaneningand broad'
enillg of the lateral talar process),and a nafowing of the
poslerio. ialocnlcrreal facet Also, the first melatarsalhcad
may also be damagcdas the individMl "rolls off' the m6-
dial forefool; this forceslte firsr ray into a dorsifiexedand
invened position aod may predisposeto libial sesamoiditis,
dorsalbas€exostosis,enddorsonedial bunion pain. It is for
lhcse reaso[s thal Macconaill and Basmajian(228) claim
lhal toe out gait psttomsdetrimentallyaffect meanlevels of
musclcactivity muchmorelhan toe in patterns.
In lhe adult,a toe iD gartpaltemis relativelyharm-
less,cveflthoughit forcestheindividualio naintaina lolx-
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.

The toe in gait prttcrn is moreof a problemin children,|ls

theyleamto "correcf' thedeformityby rbductingthe fore-
foor upon the readoot-Alll|ough il giv€s the appearanceof
a straightloe gail patlern,lhis methodof compensation is
de$tructivc,rs it may p€rmancntlydamag€the a.chitcclural
stabiliryof ihe fml by obliteralingthe m€diallo.gitudinal
arch.In facr,it is not uncommoofor a child ro outSrowthc
primary torsional compoo€ntof the toe in, only lo bc lcft FiSure3.182. CniS's |esl. The examinetSraspsthe
with a permanentnat fool d€fomity (231). ankle and olates lhe femur (A) until the oppo.ite hand
Bccauseof the potential for d€foinity. C{illiet (94) paks the Breat€rkochanteras beingpa.allello the eranrin
claimslhat a loc in gait pallen should be encoutrged and tabl,(B).8y notingth€ positionofthe tibia rclalivelo ltrLi
nol discouraged or corected, as it allows children lo bear it is pdsibleto deteminethed€8r€€of fumoralanleor
weighl on the lateralborderof the foot, wh;chcauscsthe version,i.e.,in thascase,lhe fenroralneckis anleveded
(Parliallyadapt€dfrom MaseeDJ. OdhopedicPhysical
foor to supinarc, thcrebyallowingfor thc devolopmefll ofa
sessnrent.Philadelphia: Safidet' l9a7: 252.)
[unction{lmcdiallongitudinalarch.
Trcatmentfor thevarioustorsionaldeformiticsis dc-
pendenton lhe tocataon of th€ deformityandtheag€of the
child.The segmcnlor regmenlsresponsible for a to€ irr or
out gail patt€rn canbe idsnlifiedwith anyof scvcraldiffcF
entevaloationtechniques. To beginwilh, a bricf geitevalu-
stion should bc performcd to determine thc prescnceof
f€moralantevcrsioo: [f lfte kneejoint poitrlsinwardlyrela-
tive to thc lid€ of progession, theo femoral anteversionis
present.Tfiis will prodocea toe h gail pallemunlesscom-
pcnsaroryextcmal tibial torsion is present.It shouldbe
notedthalil is notuncoDmonfor multipl€deformities lo ei-
rher negateor amplify otle another,e.9.,femoralantever-
sion wirh external tibial lorsion producesa relatively
straighlgait pattem,whilc femomlanleversion with medial
talartorsionand/orintcmallibial lorsionDroduces an cx-
treme toc in gait paltem.Thc gait evaluationshouldbe
compl€tedby recordingthc approximate deviationof each
lool relativeto thelineof progr€ssion.
The posilionof thc fcmoralneckrmy alsobe cvalu- Fiture3.I83.Determining rclatived€treeof inlemalander-
atedwilh the child Dositioned Dronewilh lhc knce R€xed temil femoral rotalion.
 chaptorThrcc Abnor-al Modon du ng the Galt Cycle 167

Tlc diagnosisol cxce,ssive femoralanlcversioncan

$!de if tfie ranseof inlernal rolatiotrexcreds70' andthe
of external fotation is Iess than 25" (224). While
use the telm "intemal fenoral torsion"
'nvestigators
ote a pathological rang€ol anteversion (i.e.,inlemal
rorsionexistswhenth€degreeof venionor twjstin
ongboneexc€edsby more than 2 SDs the norm for lhat
group),lhis rext has delib€ratelyavoid€duseof this
because of discrepancics in the lheratureregaiding
andinconsistencies in fte term "torsion":internalor
libiat toniion does not denolepathology while in'
or external femolallorsiondoes.Also,bccause vatia-
in joinl laxity may alter values for norm (224),
ecliveadjustmenls muslbe madeifthe overallrangeof
ionis excessive GreaEr rhan110) or reslrictcd(lcss
?5').
If excessive iemoralanteversion is present,the useof
nodmcalions, twi6tercables,andnighl splintsshould
dkcouraged sincclhey do nol alterthe natura,historyof
conection(233).In fact, twistercablesonly sewe
thedevelopme of a pathological rangeof ex-
tibialtorsion(2a3)while thc useof nightsplintsmay
in aseoticnecrosis of thefefioral heador hio disloca-
iflhc respective externalor intemalforccproduGdby fiSur€3.184.M€a$r.inB tibialtoEion.(Modifiedf.oma pho-
deviceis cxcessive(234, 238). Allhough oxcessive tographin Ble€kEE.Developmeal o(hopaedics.lll. Tod
anleve$ionwas al one lime blamed for the devel dlels.DevMedChiidNeurcl19a2j24: s33 s5s.)
I of ostcoarlhrosis, bunioflformalion,flal feet,low
pain.and impairedarhleiicperformancc (235),$ese
hav€lotrgsincebcendisproved(236). shouldbe conparedto lhe child's age.(Rememb€r that the
Conser!arive L,carmcnt shouldconsistof rc€onrxLen- distal tibia extemallymtatesf.om a slarling position of 0' at
for changcsin sitlirg andsleepinghabitsthatn€u- birthapproximalsly 1-1.s"/year.)
or revcrse fte torsional deformiry. Also, physical If evenslight tibial rorsionis present,rccommenda-
iviliessuch 3srolleror iceskatingandcross-country ski- lions should be made {or chaiges in silting or sleeping
areofltcdvc ways to t€achI child to funclion with the habils(i.€..habiluaUy sitlingon adductcdfect is a common
ia n morcmidUneposition.Classicalballellessors,as causefor interna!tibial torsion).lf geater lhan5' of tibial
astheyareinitiatedbefDretheageof 11,may aclually torsionis prcsentbetweertheagesof6 and12 monrhs,coF
for a reduclionin the degreeof femoral anlcve$ion reclion may be possiblewith serial long leg casts (which
(Samma'co llll'l cautioned rhar if an excessive exl€nd from the toes to above the lmees). Approximalely
is fofced on lhe adolescentafter lhat age, the r€sul- oDceevery 4 week, cifcurfer€nlial cuts are made at the
increos€d rangeof motionis due ro micmscopjcrup- proximalribialjutrction,and Lhedistalaspectof the caslis
of lhe anleriorhip capsulc,not chargesin the degrce rotated 2 cm. This p.ocessis repeatedseveral times urtil
anr€version.) correctionhasbeenachieved.
Finally,althoughlhey do nol altcr the progr€ssion of Although the elficacy of nigh! b.aces has nol b€en
ant€venion or r€iroversion, fooronhos€sshouldbe thoroughlyevaluated, mostaulhorities rocommend theirrse
ideredif excessiv€ sublalarpronationis prcsent.Be, betweenthe ages of 16 months aod 3 ye?Js.The Innger
ofan unacceptably highrateof complications, surgi- CounlerRolationSystem(Fig. 3.185)is padcularly well-
inlervention shouldbe avoided(223). toleratedby lhe child becauseit allows for rccip.ocal mo-
Evaluation of tibial torsionrcquiresthatthe child sit lion o{ the right aod lefr lowe. exlremities, eoablmg the
cdgeof ancxaniningtablewith ths kneesflered9ff. child to crawl (238). Whenushg night b.aces!csie musl be
godometer is theous€dto measurethe rslationshipbe- taker to maintainthe sublalarjoirtin an invertedposition,
tlc lransmalleolaraxis of the ankle and the as failure to do so woold allow lhe €xtemal rotalional force
lar aAisof the knee (which, for all ptaclic:l pur createdby th€ bracelo abductthe forefooL rhercbydeating
is represerted by lhe edgo oI the lable; see Fig- flatfootdeiormily.
Thedegr€eof tibial torsionis thendelcrminedby While mosl aulhodliesclaim that intemaltibial tor-
ing5" from lhe formedangle.The rcsulrantnumber sion is themostcommoncauseofa toe in gaitpattern(224,
168 rOOT ORTHOSESand Olhd Fom\ of C-onseruative
Fool Care

Figure3.185. The LanS€rPdiatric Cofiter Rol.tion syst€m.

(Modifiedirom a photogrnphin The Lan8erCloup Newdel-
ter. DeefPark,NY: LanSerEiomechanics Cro|/p,May 1987;
l4 {2)r1s.)

226),Blcck (223)claimslhat whenmcasured csrefully.io-

Iemal tibial torsior is a rar€Dhenomenon and lbat medial
talar torsion is the most commoIlca!6e.lt is possibleto de-
terminclhc degeeof mediellalartorsionby nreasuring lhe
thigh-fool angle as the patient lics prone wilh thc knees
flexed90" (Fig. 3.186).B€causctftis angt€rcprc$ents the
combinedde$eeofboth libial andtalartorsion.thcapprox-
imat€anglc of medialtolar to.sioocan be determined by
noting thc differetrcebetwecnthe proviouslvdelermincd
degre€oftibial torsionandth€thigb-fooranglc.
For exampl€,an adultwith 22" of cxtcrnaltibial tor-
sion and a thigh-footanglcof +4" will pos*ss appro',i-
mately18'ofmedial ldlarlorsion(asin panels11and12 in
Fig. 3.179).Iderlly, sincemedialtalar torsionrcducesas
extemaltibial torsioni creascs, thethigh-footangleshould
graduallyincrease ftom approximately -l0f in th€ 6 y€ar
old to +4" in the adult. (Urfonunately, d€lails regardingthc
exact rateof derotationarc scaotadd unrcliablc.)
If excessivemediAl lalar toBion is present(i.c..
geater than3k0o in the infantand 15-20"in 3- to 6 ycar
olds),recommendations shoull b€ nadc for changes in sit-
ting rnd slccping pastures,and night brac€sshouldb€ con-
sidered. Cfhese are partiorlarly useful for G to
l8-month-oldinfants.)Also, twistercablesmay be an ef-
fectiveform of lreatmenlwhen usedon 3- to 6-vear-old
chitdrcn (223\.
Iniercstiqly, foot orthosesand/or shoe gedr thar in-
hibir midtarsalpronationaboutrheobliqo€axismay impair
the normal reduclion in the degreeof medial talal torsioo,
AcslrdinSlo Ble.k (223),at'duction of thenaviculardurinS
stancephasemay be neccssary to pull th€ neckof the talus
laterally,thcr€byreducinglhemedialangulation of thetalar
neck- Becauseof this situation, foot onhosesthat disallow
the normal ranSeofmidlaNal proEationsho|lld be avoided,
andody flexible,straight-lasted shoesshouldbeallowed,
Of course,if dest.uctionof ihe mediallongitudinal
arch occurs secondaryto €xcessivesubtalar or midtarsal
joitrt pronatio[,rhen a padially controllingfoot orthosis
may be rcce&sarylo preventpermanentdefoamity.Becius€
FiSure3.186. Meaiu.iry lhe thigh-foot angle. The
ioint is placedin its neulralposition,aod lhe forcloolie
depessedwith the irdex finger.The thishjooran8le(X)
me;iu.ed at thc inielsectionof a line rhat parallel,lhe
mid and forefoo!(A) and thc continuation
of a linerhit
Fcr\ the lhifh (8). This an8le is noted ar posiliv€if the
fool is abducledwilh respectto the lhiSh bis€clionlas in
illusration),whercai a neaativean8le indicai€sthar the Jo|e
fool is adducled.care musl be l;rkenwhen markin8rheloo{,
as Liilureio maintiinsubtalarn€utality will rcsuhin
eror lvhile lhe prosen.eof a lorefootdeformity,such
met,rtarsusadductue.will aho rclulr in inicclratc measue
menr-ln lhecaseot forctoolmalaliSnment, accurale rn€aslie
merrmaystillbeachieved by bisccting thercar{ootonly.
lhe ,rngleof medialtalarbrsion bccomeslixed by nge6,
fun.lionalfoot o hos€safterthatagcmay b€ invaluable in
maintaining a normalmediallongitudinalarchunlil lhefoot
rcaches skeletalmaturiryduringth€earlyt€ens.
Alrhoughir hasonly briofy bretrmcntioned, it is alsn
possiblelh&tan in toe gaitpatternis theresultof a mekhr-
sus Jdductus.ln this cotrdirion,which is oftcn mistakenly
rcfcrrcd |o as metat?lsusvarus, thc metatarsalsarc angled
mcdially,relalivelo the longitudimlbiseclionof ther€ar-
foot.Because lhe medialangulationmayoccurareilherlhe
tarsometatarsal or midlarsaljoi[], someinvestigabrs distin-
guisl behveenmetatalsusadductusand forefdrt adductus
(Fig 3.187).11is pGsible io categoizethe cxlentof a
metrtrrsus or forcfmt adducrushy nodng whcrc thc longi-

3.188.In lhe nornal foot, a line bis€crin8rh€ h€cl
pa!6bctweenlhe s€condend lhi.d di8its (A). lf a mild
or for€fooladduclls is Drcsenl,lhe line will pass
rhc lhid di8,t. In modcra'c ad mrrked del'ormrlies
bhection of the rca oot intersecrswilh tle
headsGig. 3.188).Also, the lexibility of lhe
shouldbe evaluatedby passivelyabdllcliogthe fore-
agairstlhe slabilizedrearfoot.If rhe dcformity is flexi-
thc forcfool may be abductcd bcyond midline; if
ir csn bc movedto midlineonly, and a rigid
nitycannotbe movedto midline,
Unfonunatcly, thereis no clear-culcritedafor detcr-
ry which doformitics continuelhroughosseo0s matu-
: often,a markedsemiflcribledeformityresolves during
whilea mild flcxibledcformitymaybecomeper-
As a genomlrule, it is suggesledthat mild deformi
receiveno lreahcnt other lhan recommendalionsfor
in sirtingandsleepirgpostorcs, weariogshocson
Thce Abnorm.lMolloDdErtrstheCrtt Cycl€ 169
Chapt€r
rl8ure 3.147. (A) M€lata.sosadducrlb; (B) for€fool adduc-
(C and D), the heelbis€ctorwill passbetweenthe thkd and
foudhand tifthdigitr,respectively.(Modifiedflom BleckEt.
D€veloomeotal onhooaedics. lll. Toddlers.Dev Mcd Child
Neurcl1982:24r513-555.)
oppositefcet and e gentle slretching procedurewbere lho
parcnt abducls thc forefoot rgai$l the stabilized heel.
Thesestrelchessholld b€ Dainrainedfor 40 secondsandbe
rep€ateda minimum of l0 lioes daily-
Becauseit is difiicult lo correcta metatarsusadductus
or forofoot adductosaft€. idancy, it is suSSesled that mod-
erateandmarkeddeformitiesb€ treatedwith serialplasler
casts(proferablybefore8 monthsandideallyrt theageof4
mooths).This tr€atment involveswearing a plastercastlhat
mainlainstheheelin varuswhiletheforefoolis moldedinto
abductioD.Two or thre€of thesec3sls,chatrgedevery I or 2
wcels, areusually suffci€nl lo achievecorection.
While ma6y investigalorsfeel lhat conscrvativetreal-
ment in the form of casts, bnc€s, shoc gcar, and/or
170 FOOTORTHOSES
andOtherFormsof Conreryativ€
Footcsrc
strclchesis no longercffectivcafte. the age of 2. Slaheli
(224) cl: ms thal a long leg cast may produc€conection of
fte dcformilyif us€dbeforelhe ageof5. Openliveconec-
tion is pracdcallyneverappropriateb€{aus€poor resultsare
commonand becausearl untreatedmetalarsusadductusha$
little porenlialfor disabiliiy.A poin! of intercstis rhat a
meratarsusadducliis defonnity is often mistakd for a hrl-
lux adduclusor "s€arcbingtoe" in which hyperactivity of
the aMuclorhallucismuscleprodrccsa dyoamicadduclion
of thehalluxduringgait.
Because ofthe potedrialforperman€nt impairmcnr, it
is imponanl lo difierentiate a melararsusadductusfrom a
club foot deforrnity(ralipesequircva s). Uolike metalar-
sus adductls.a club foot is chaJacterized bv an anvelted
heelthaldoesnotevenlo ftidline anda nonrcducible anklc
equious,Thesccombineddeformitiesforce the child to
$and with full body weight centeredbencalhthe fifth
mclalarsalhead.This condition,which reprcscnls a defect
io prenataldevelopment. requhesimmediate llastercastirg
to reducethe forcfool vsrus and adductusand, aftcr thcse
haveb€encoffected.fte equinus.If the canttrcstmcDtis not
successfulduring the 6rsl 4 monlbs of life, surgical conoc-
tion may be neces$ry. A complet€descriptionof rhis con-
dilion is well beyondlhe scopeof this texl. Sufticc it to say
that whethersurgically trealedor not, lhe clubbed foot is a
comnroncausefor un@mDensalcd rearfoot varus deformi-
ties.
In addition lo osseouscausesfor to€ in or toe out gait
patterns,il tu also possibleihat, despileideal oss€ousalign-
ment, solt tissuccontractureio the thrgi or p€lvis may pro-
ducean alteredgait paltem,For exanple,contracturc ofthe
medial hamstringmusculature will forc€ thc enlire lowcr
extrcmity into an intemally rotatedpositionduring late
swing phase(which is oflcn maidtaincdtlroughout fie
stanccphaie)while c.rntracrurc o[ rhe biccpslemorismus-
cle will havetheexactopposileeffeci
lf ir hadbeenlhe iliopsoasmusculature that was ab-
normally shortened,the lower extremity will oflen exler"
oally rotsteduring the propulsivcperiod,as tbc spineis
simullarcouslyforcedinlo hyperextension. Also, children
who sit in the tailor'$posirionwill oftenpresentwith con-
traclure in the hip exlemal rotatorsdrar producesa loe olt
gaitpattern.Itis clearthalcomprchensjve evaluation of ror-
sionaldcformitiesshouldincludeexamination for adaptive
shorteningof all the mu$clesin lhe lowcr cxrcmity and
D€lvis.
ln closing lhis sectionor tratrsvers€plan€ defonnily,
it shouldbe cmphasizedthat th€ role of foot orlho$rs is not
lo conecl an osscousmalformalion, bul rathet to prevcnt
dcstructionof the medial longitudidalarch tiar might olher-
wis€ have occuaredduriog growth years.A common treaF
mentregimenis to nsea poly€thylene ortlolic shellthatis
formcdwith longlateralandmedralflangesanda dcepheel
seat(se€Fig.6,3),A minimum5oreadootvarusposlis rcc-
ommendcdto preveniabnormalpronation(231),Bernlse
lheseorthoticswill prevenl€xcessive abduction of thc
foor.pare0tsof childrenwith toe in gail partems
informed thal the onhotics might actually increase
p€aranceof lhe loe in defonnity and lhat lfie prrpos€
onhot;cis lo mainkinthe itrlegrilyof tbemedial
nal arch whilc normal ontogeny hopefully allows thc
sion0l defonnily to resolvcilsrlf. Be.auscthcy
normaldcrctarionof rbe forefootaboutrhc lonei
idtarsaljoint axis, foreloot va s postsshouldbe
in children lessthatr6 yerJsold (239).
Althoughsomeorlhoticlaboratories recomm.nc
gait plates be us€d to rreai rorsional defomities
3.189),thes€deviccsshouldb€ avoidedwith rocoul
miticsandareofoueslionable valuewith toe in
sincctheresulta propulsiveperiodpronation. altiorgh
suallyappealing io thepar€nts,will nol facilitateco
ofl[e deformity.
Comprehensive conservativecareshouldalways
cludcrecommeldatiors for changesin sitlingandslccl
posrures, alongwith recommendations tbr hornc
andexercisEs. Evonif ineffective,rhesecxcrcises give
parclls a senseoi control and may easeanriety ovcr
evclllorldevclopment of th€ deformily.Slecpingin ! si
lying posilion with a pinow placed b€nealh the head
maintain spital aligtrmetrtshould b€ encourag€d,since
pre\ cnls aspirationwith regurgitatiodwhile also D.in
ing rhe limbs tu a neulBl position (240).This tx sition,
sidei ahemakd afler eachfe€difl& is panicularly i
durng thc 6Kt 3 monthsof life whenflovementsare
mal anddelormitvis morelikelv lo be maintained.
soncl al. e2A chim thatchildr€!who slecpin a sidclyi
positionmostofietrgesenlwith theirlegsplrall€land
inlernalor extemalrotalion.
Fiture 3,189. Thegait plat€ for toe in defornities. Byextend-
in8 r rigidorthoticshelldistallybcneathihe tounhandfifth
m€htarsal head,(A), the child i, unableto €fiectively push-
off withoutabductinslhe for€footin oder ro roll olf ol the
 ChaplerThree Abmrmd Motion durirg the Gait cycle 171

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.)

Finalrccommendations shouldb€ madefor sboegear: Althoughit is lesscornmon,it is alsopossiblcthalab-

lastsshouldnol mairtainthe de{o.mity(i.e.,lhe child nomal developmenl of the lowerextremity$,ill rcsultin a
mektarsus adductusshouldDot be w€aringa curve- genuvalgrim.While the mostcommoncausefor thisdofor-
shoe),andthe solesshouldbe flexible.As notedby mity is renalosreodyslrophy (13),it may alsobe the resull
(?41),it is nol unusualfor a child'sshoelo requirc of infection,tumor,trauma,o. variousparalyticconditions.
bendirgforcethanthe child actuallyweighs.ln hit Accordingto Kling (13),treatmentfor childrenlcss$an 7
uationof sole stiffn€ss,this irvesligator demor-strated yearsof agemay be safelyignoredunl€ssthe condilionis
variousshoesrequireanywherefton 4-70 lbs of pres- asynnetrical, excessive(i.e., the tibiofemoralanglc is
robendarrheball-A sriff-soledshoeforcesrbecrawl- ge.ter tban 15"), or if the chitd presenlswith a shon
childlo progresswilh an ;n or out toe pattern(Fig.
andmay delayons€rof walkingfor wceks(21). A Children with a genu valgum secondaryto trauma
solsdshocmay also increaselorsionaldeformityin maybe treatedwith a knock-knec bracrthatshouldbeworn
walkingchjld,as it inhibitsdorsiflexionof the toesal fo! approximately 1 year.Bleck (223)clairnedthat 1% of
metatanophalangeal joinls. This effectivelyincreases
genuvalgumdeformiliespersislbeyondlhe ageof 10.If at
lengthof thefoot,andthe child ofien developsa !o€ in thisagethe malleoliaremorelhan3 inchesapartwhenlhe
locoulgail pattemin orderto roll off the medialor lat kneesare positionedtogether,then staplingof the medial
aspect of the shoe(therebyshorteningtbe functronal distalepiphysisshouldbe considercd. As with torsionalde-
of thefooo. formities,fool orthos€sfor individualswith geru valgum
are recommerdedto provent deformity of the foot during
Frontal PlaneAlignmcnt growthyears.Gouldet al. (243)notcda signifcanlcorrela-
tiofl betweenthe presenceof valgrs l(8cesand hyper-
In addilionto the specificchangesoccurringin the pronaledfeer.They statedlhat all of the subjectsio theh
rseplanc,il is also essentialthat cedaindevelop- study who presentcdwithout valgus kneeshad normal
changcsoccur in the frontal plane that allow lhc arcfies.The modi3llongitudinalaJchis predisposed lo col-
tobenea.lyperpendicular ro rhegroundarheelstrikc. lapsein lho presence of a gonuvalgumbocause thoseirdi-
ideallrorlal olanedeveloomental trendsarc desc bed vidusls walh with a wide baseof gail lhat allows body
3.191. weight to fall medrallyto the talus, therebycreatinga
As notedin the secliondcscribinslhe rearfootvarus strcngFonatoryforceat the subtalarjoiot. Tie samebio-
ity, defectsin fronlalplaflealignmenlmay occurif mechanical scenarioalsoexisiswilh rearfootvalgusdefor-
walling is initiated whon the physiological rnities(Fig. 3.193),in exlremelyobesoindjvidualsand iD
is al hs peak.Becauscmosl casesof tibial or gcnu womenduring the 3rd trimesterof pragnancywho walk
reducespontareously, lreatmentbeforcthe age of with a wide baseofgait.
months is seldomnecessrry(13).If after 18 monlhsthe Orthoticmanagement in all of ihesesituationsis to
varum has nor irnproved(i.e., rhe m€dial ger underthe proDatorylbrce trom aboveby usingan ex-
condvlesare morethan4 cm aDartwhen lbe me- Lrinsicrearfoorpost with a higb medial heel cup and a me-
maueoliare placedLogether, and showa dial oulffare oD the Dost.(Theseadditions are describedin
'adiographs
beakingof {he proximallibial metaphysis), ihen a the laboratorypreparation section.)Gould(245)noledthat
right splin!shouldbc considered (Fig.3.192). the rearfoolvaruspost shouldslowly reducetbe genuval-
 172 FOOT ORTHOSESand Other Forns of (bnsenarivc FNr Cn!€

Physlologicgenuvalgum L6gsslraight
wlth Protecliveloe in

Figure3.r9r, fronlal planedevelopnent

of lhe lowercltremity.(Modified
fronrTachdjian
Mo.
Ped;atric
O(hopedics.Philadelphia:
9aunders,i 972i146i.)

gum deformity.po$iibly becauseil externallyrorates$c

tibia, therebyallowingfor improvedfunctionalalignrnenr
al thc knee.Langer(246)suggesredthateffectiverear cnl
may requirechangesin shoege.arsuchns addinga medisl
outffareb the heelof the shoeand.ifnecessory.rei.tbrc-
ing the m€dial{spectof the heel counterwirh stiffening pressure
ofl the medialplantarheel,which is alreadysup-
 Ch&ptF'lhrcEAbDormdMotiotrdudrg theGEitCycle 173

shouldnot be posledandshouldscrvepriDaiily as supports

necessaryto prevenldostructio!of the mediallongirudina!

Development of the Mediol Lotrgitudiml Arch

Thi lasl Ferequisircfor normalfunctionis liat on-

logenyallow for lhc development of a functionalmedial
tongitudinalarch.Not only is deflectionof themedialarch
trec€ssary for adequale shockabsorption but theresuaining
ligamentsthalstabilizelhe archareinvaluableduringloco-
motionsincetheystoreandreturnelasticenergydlrin8 rh€
early and later periods of stancephase,respeclively.
Could er al. (243)srudi€ddevelopment of the medial1oll-
giludiral archin 125 beginningwalk€rsard notedthatthe
1.192.rh€ Danishnightsplinlmayb€ usedto correcl developmenlof a neutralarch requiieda wetl-developed
erc€isive physiological varum,Unfortunat€ly, lhis splinl sustentaculum tali (Fig. 3.194),a hcalthylibiali! postsrior
ichmaybe worn unrila8el) is inefiecrive al lrcaringthe terdon and muscl€,aDadequare deltoidligamsnt,a non-
I fom ol Blounf! disease,which typicallyprodlces constricled achilles lendon and 3 properly placed inferiot
varurnin obeseblack maie, belweenthe aeesof s and calcaneo[avicular ligament.Theseidestigatorsnoledthat
Su€icdl coiiection with valgus osleolomy may be lhe thedevelopm€nt oI lhe arch,whichwasprovento be acc€l'
ly way to maintainnoma mechanicalalignmenlrn these eratedwilh the useof archsupports,is not completeunlil
(Adapled fromslountW. Tibi. vara:osl€ochondrosis aff 8. They also noted that
hyperpronation(nosl often
ns tibiae. In; Adams JP (ed).Clnenl Practicein Or
secondary 10genuvslgum)was lhe rorm for 5 yearolds.
S ur eer yS.l.Loui s :C .V.Mo s b y ,1 9 6 6 :l 4 l -1 5 6 .) 'fh;s discreditspreviols an€cdolalreports,claimingthat
yourger childrcn possessa h€altby medisl longitudhai
arci thatis oblireratEd by a fal pad.
As with fronlal and (ansverse plane malposiLiotrsof
lhe lower enremity, variouscongenitaland/oadevelopmen-
tal factorsmay impairdevelopment ofthe mediallongiludi-
nal arch, lhe.ebyresullingin lhe fornation of a flatfoot
dcformily.The four mostcommontypesof flatfootdefor-

\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.

r.\;
b;
35.
3.195.M€a$r€mcnlof lhe laleral talomelalarral
(A)Nomal; (8) modeBtedeformily,{C) severcdefor
(Adapledkom Bodelon RL. Hypermobile flatfootin
.ClinO r r hopRela te d
R e sI9 tJ 3 i 1 8 1 t7 1 4 .)
Beclusetheimprovemcnlin lhe talometstarsal angle
istsevenefierlhe onhotichasbeendiscontinued, it can
tha! thesgare permarerl o$seouschalges, as is
with rhe bws of HeuteFvolkmann.Davis.anu
lff,lfthe deformityremainsunchaoged despiteconstant
of theorthotic for sev€ralyears,and the severityof the
tendoncontacturc remainsunchan8ed,surgery
beconsidered. (particularly
AJthrodcsili of rhesubla-
shouldb€ avoidedwheneverpossible,as the pro-
of cioice is {n achilles tendon length€ning wilh
of the calcaaeusto align rhe h€cl (252). Afler
coneclion,thepatientshouldconijnueto wearthe
ChapterThreeAbmnnrl Moaioddurhg the Gall Cycle 175
13 yearsof agein females
foot o{hosesuntil approximately
and15 yea$ in males.
References
L McPoil TG, Krecht HG, Schuil D. A su*ey of tool Lypesin
normel femslesbctw€entte ,ga oI 18 !trd 30 ycaB. J Or
lhop SponsPhysThcr 1988i91406-409.
2. Hlavac H. Compenssledforefool vans. J Am Podiar. Assoc
l9'l0;6OtZA-233.
3. Rool MC, Orion WP, VveedJH. Nornal aDd AbnorBal
Functio! of the Fool. Ls Angolcs: Cliniel Bioncchanics,
t9n.
4. SalenlusP, Vanlk! E. The develapmertof rhe tbiofemolal
adglein children.J Bore Joitrt Surg-1975;57Ar 259-261-
5. Yochun TR. Rowe Lt. Elserrirls of skeleul ladiology. Bal'
tinore: Willians & Wilkins,198?:1014-
6. CockshotlWP: Dsctylitis aDdgrcw1hdisordeB. Br J Rediol
1964;36r19.
7. WatsonR.l, Bulko li, MeaasH, er al. Hand-fool syrdromc jn
sicklEcell discaseitr yourS children.Pedialrics1963i 311
975.
8. BatelonEM. Tht relalionship betwe! Blourfs dileaseard
bor legs.BrJ Radiol1968;41:t07-114.
9. Bathf€ldCA, BeighionPlt. BlouDt'sdiseaso: a rcviewoI e!i-
ologiei factors in ll0 padenrs-Clh Odbop 198; 135:
29-33.
10. KesselL. Arnotdions otr $e eriolog dd ftardent of tibia
vara.J BoneJoiotSura1970;52B:93 99.
11. Cook SD, LayerniaCJ, au.re SW. A biomechanical alysis
of thc etiology of tibis vai|. J Pediat Onlop 1983; 3r
12. Golding JSR, MacNeil-SmithJDC. Obsefla$onson thc
etiolo8y of tibia vmi. J Bone Joinl Surg 1963i 45Bl
32V325.
13. Klirg TF. Argular deformities of lhe lower linbs itr chi!
drcn. OrrhopCliD Nort! AD \987i 4: 513_'21.
14. ScrantonPE, ct al. Suppon p[Ese kircmrrics of the foot. ln
DatemsnJE, Trou Aw (eds).The Foot atrd Anllc. Ncw
Yort: Thieme-Stmllon,1980.
15. Viitasolo JT, Kvist M. Sone biomechaical aspectsof the
foot andtnkle ir athlet€s wi$ andwilhoutshiDsplinls.Am J
SportfMcd 1983;ll: 12:F130.
16. Cla*e TE, lredenck EC, Hamill CL. Th€ cffec6 of shoede-
sign pardetels on reafoot co[lrol in running. Med Sci
SponsExerciso1983t15:37G381.
17. JaDesSI. Bstcs tlT, Ostenig LR. hju.ies !o runn6r. An J
SporrsMed 1978j6:4ff50.
18. BrcwnLP,Yavonky P. Lacodolorbiomeclunics andpatbo-
mechanjcs:a review. J Onhop Spons Physfier 1987;L7.
19. M€ssjerSP, Pillala KA. Etiologic lactors secisrcd wi$ se
lected runnitr8 injuri..s. Med Sci Spons Exercjse 1988; 5:
501 505.
20. CsvaraghPR, et al. An evaluaiion of rhecffectof onnotcs
on force distribution ard rearfootlnovcme doring ruMir8-
Paper presentcd ar rh€ American Orthopacdics Soci€ty
SponsMedicincMering, kte Pircid,I\Y, 1q78.
21. Innab yT, Man! RA. Duvrjes Surg€ry of the Foot. St.
lnuis: CV Mosby,19?0.
22. Malh€sonGO, ClemenrDB, McKeEie DC. Stres fiacllres
176 FOOT ORTHOSESandOlhcr Form$of Cbnsdvativc Fml cltrc
in atltlcrcs.
A srudyofl20 cas4s.Am J SponsMed 1987rt5:
46-58.
13. RieggcrC. Mechadcalprcpcrtiesof b1,nc.ln: Oould JA,
Davics cI (eds), Onhopaedicand Spons PhvsicalThenr,y.
Sl. tluis, Mosby, lgljsi 3-19.
24. Luner LD. F@t rchtcd hee prohlemsin rhe bng dhrrnc€
ruonor.FoolAnklc 1980:lr lL? 116.
25. McKcMieDC, Clcncnt DB. TauntotrJE. Rutrnirgshos,or-
thotiGandinjuris. SponsMed l9E5:2:334-147.
26- Noblc CrA.Uiotibirl bandfriction syndoFc in runr.a. Arn J
sF)ns Mcd 1980;8:232-234.
27. D Amio JC, RubinM. The induence of f nonhGosonrhc
qundic€psEngle.J Am Podiak Mcd As.oc 1986; 76:
337-339.
2it. Kcgerreis s, Malon{ I', Johrsn 1.. Thc dirgonal medirl
plica:an und€rcstimarcd clinicaler(ity.J OnhopSponsPhls
Thcr 1988;9: 305-309.
29. HrlbcniHll. aycsWC. Patcllofeoorrl$ntacl pressurei. J Datcllofcmoral
BoncJointSurg1984i66,{:715 724-
30- Mrnlcr JT. Movrmenlsof thesublalarand tr.nslers lanul
joinls.tual Recl94li 80:397-409.
31. CarricrPA JaniganJD, SmilhSD. Wcil l"s. Mo on s neu-
rulgia: a posrible contriburingcriology. J Am Podia!_aAssoc
1975r65i 3lJ-321.
32. kng.r S. WernickJ. A PracderlMadualfor a B$ic AI-
prcachlo Bbmcchanica. New York: LangerAcrylichbora-
k'ry,1 9 72.
33. D.hlc KH. Mucller M. Dcliuo A, Di{mondlE. visuat ss
scssm.nt of fool typc lnd rclatioNhip of foot ryp€ t,r lowcr
exlrcmityinjt|ry.J OrlhonSporrsPhysThcr l99l; 2: 71.
14- Hhvac HF. Thc Foot Book. Mourtain Vicw. CA: World
PublicadoN,r97?: 187,
35. TauntnnJE ClemcnLDB, McNicol K. Planl.rrlisiitis i'l
runncA.a stud:/of4{) cnscs.Med Sci Sporlshercisc 1980:
2: 137.
36. NcalcD. Hoope.C. ClowcsC, WhilinSMF. Adult fool dis.
orders.h: Ncale D (ed). Commor Fool Dilorde6 Diasnosis
snd Matugemc : A CcncBl Clinical Cuidc. Minbu.Bh:
ChurchillLivingstone,l98l: 56 57.
37. CehlscDCM, Se8erA. SelcctcdnEasurcsDi angulardis-
placrmcnt,$renathlnd tlcxibihy in subjcchvi$ ard sith-
out shinspli s. RcsQ E\c.c Spodl9m:5l:4'lHa5.
18. MannRA. Biomcchrricsofrunnins.l'r:tack RP(cd)-Sym'
posiumof rhe Fot {nd lag i. RunningSpffts. St. t uis:
Mosby.t9E2:28.
39. BatesBT. OsterDigl,R, MflsonB. Footortholicdevi€N k,
modilvsclected aspeckoi lo\rcrextemity m(jchani6.Arn J
Spons Med I 979: 6: -j38-341-
40. Smilh LS, ClarkeTE, Hrmill CT, SrntopictroF. The cffects
of l,oft lnd smirigid onhotiG upon .earfoot movemcntin
running.J Am PodistrMcd Asoc 1986i76122?-233.
41. Snrs CW. TaunlonJE. ClemcnrDB- Achillesrendon disor
dca in runrcrtsr rclicw. Mcd SciSponsHxcrcis f930i 4:
?3t-241.
42. Schoctrha6HD, .lay RM- Cnvusd.fonnilies.conspalive
managemcnl JAm PodiariyAss 19E0i5:2]5-238.
43. D AmbmsiaRD. Odhoticdevies in runninginjuries.clin
SponsMed 1985i4: 6l l-618.
44. EgSoldJF. Onlrlics ir lhc prcvarlionof rurncr's ovcdNc
injrries.PhyssporlsM.d l9El:9: 124-128-
:li. Novick A. K.llcy DL- Posilionand movomcnlcfirns6
lhe loor
'rirh orthoticinreNerriondurin8 rhc loadinB
sp(,n* ofgait. J OnhopSponsPh),sTher l99O:7:l0l
Donatclli& HulheriC, ConawayD, Sr. Pieiie R.
chdnicr footonholics:. retruspccrive sludy.J Onhop
PhysTlcr I988:612{)5-212.
4?. S(rausWL Crcwlh df lhc huma! foot af,d i$ eloruno
\ignilicl|ncc. CbnrribEmbryol1927i101:95.
48. McPoilI CamcmnJA, AdrianMJ- Anabmicrl
tic ofthc lahs in rclntionro forcfmr dcformitics.IAm
diauMcd Alsoc 1987:7: 77-81.
49. l'a\ HR Podopcdiarlic\. Bnltimnr€:Wrtlinnr<&
19t10:59.
50. CoplsnJA. Rotalionalmo on ol ihe l$cc: a corparisol
normaland prcnatinSsubjccrs.J Onhop Spns Phys
| 9li9i l0: 36(>-369.
51. ribcrio D. lhc cffcct ol e,(ccssivrsubthr p(,Mrion
nrchanics: 0 rhcorerjcdlmodct.J
SporisPhysThcr I987i 9r l6(!165.
5:. Chnc' J. Orthoricconlrelof groundrcucliveflrces
running(a prclinitraryrcport). Orrhot Proslher1984;
l2 4tl'
53. C.vagnaCA, DosmanB. Mlrgada R. Positivcwo* doncby
r pcviously slierchcdmusclc.I Appl Physiol1961,; 2,1(l)l
2t.
C{v{gnd CA, S ibe.€ Fl', Mlrgada R. Efiecl of negadvc
!!ork o rhc anount of positjveworl peformedby rn
latedf,usclc.J Appl Physiol1965:20(l):157-la,{1. 'so-
55. Vu.phy rc, BaxrerDE. NeNc cnrrupmenr of thc tod and
Jnklein ru.ncts.Clitr SporrsMed 1985:4:753-?63.
56. Pzylucki H, JonesCL Enlrapmenl reurupathyof lhd mus
.le branchof thc lalcBl planrsrnctvc:acauseof l$clpain.J
A m P odi arry A ssocI981:7l rl l 9-124.
Newcll SG. Millcr SJ. Conscrvntiv€lr.armenrof plrn!&
|as.iilk. PhysSporbmedi 97715: 6li-7J.
58. Shith S. Faligucpertuftalion of th€ qlc.reui Fool .nd t g
Fnncrion. Dccr Pa.k. NY: Lrngd Bioncchanics Cn'up,
l 9l t9:4:2.
59. WilliamsPL. SmibcnJC, Cox ll, MilchellR, Klc!)elnML.
Imrgi,rgstudy ot the pdrf{l lcel syndromc.Fool ,{ntk
l 7i 7:745-349.
(f,). I lugler LY. Biom€.hankal analysi\ of lh. foot ard anlle for
lEdisFFition b d€veloping srrcssfracrurcs.
J O hopSpons
P hysTl er 19851 3:96 101.
6t. Rossm. Thc rclafionship otahnomal foo! prcnstionb hal-
Itrx abducrovalSusapilor study-ProslherOnhol lln 1986i
tqt 12-78.
62. rordanllH. BrodskyAE. Kell€ropcr.tionfor hallnrlllgus
rnd hdlti riSidus.A$f,AA.ch SurRl95l; 62:586-596.
61. RogeB WA, Joplitr RJ. Uallt|:\ valgus, weakfoor afld te
Kalleroper€tiotr: !n end rcsultrludy. SurAClin Nodh Arn
1947i2111295-1302-
i) ConnorPl- B8xlerDE. Dcvelopmenrat dicoilcrs:adul
loot.lnr GouldJS(ed).The FoolBrx)t.Buhimorc:Williad\
& Wilkins,1988:207.
65. Vlnn RA. Sur8cry of rhc For. Ed 5. Sr- liuis: Mosbt.
r986.
srbotnick SL Biomcchani6of lhc sublala.a'ld midrarual
rDinh.J Am PodiarryAssoc1975:65:756-'164.
llaberl- Winftrop 1.,WeincrSS.aiomcchaiicalnndingsi'r
 chapl€rThrce Abnortnsl Modon durlng theCait Cycle 17?

a E.door suNey of tilh loe abndmalilies.I Am Podiahy 91. S&!aia. SK, TopoMian LK. Alatomy and physiology of
Assoc1975il: 20G213. the exlensorappararus of lhe loes.J Boneloim Surg 1969i
68.MannR, lndan VT. Phasicacliviryol intri.dc musclcsof 5lA(4):669-679.
rhotoor.J Boneioint Surg| 96+ 46A(3')t469481. 92. Bo.delon RL. Surgiql and CoDsewaliveFool Carc. Thoru-
6r. OlancyJ. Onholicconlrcl of groundleadive forccsdurinS lare,NJ:Slaok55.
running(a peliminary rcporl). Orthor PnxthEt 1984j 93. Bojsen-Moller4 FlagstadKE. Plrntarapon.urcsisand in-
}1 2 4 0 . LerMl archi|eclur€ of the ball of the toor. J Arar 1976;
?0.Cmhod G. Sciqlic pain and the feet. Ann SwissChnop 121(3):599 {11.
Assoc1971ri:207-213. 94. cailliel R. Fooidd Ankle Pain.Philadelphia: Davh,1968.
?1.N.kcnoKK. Scraricncryc enrapment:rhe pni(omis syn 95. BellsLO. MortoDhdeta|a6aigia:neuntisof thefounhdiai
droDe.J Mls.uloskeletalMed 1987iFcb:3!37. tal neno.McdJ A usl 1940;11514515.
72.Buh! l\.{J.Non'w€ignlbcaring casrimpr€sionsfor thc con- 96. RalhbunJB, MacNab I. The dicrovaslular palt€rnof the ro-
slructionol odholicdevices,J Am Podblr tus@ 1977;67: taLorculf. J BoneJoinl S$rg 1970;528: 540-553-
7S0-795. 97. Ljungqvist R- Sub€Dtemlls padi.l ruplure of the Achilles
13.Bojsen-Molle! F. Calc e@rboidjoinr md srabilirl of thc letrdon. AclaOnhopScardSuppl1968:118.
loigitudinal8rchof lhe foot at higbatrdlow gee pusholi J 98. Lanbed KL. The weight-b€arirg function of lhe fibula. J
Anal]979i 12q 165-176. tsoneJoinlSu.g1971;534(3):507513-
74 S8arlato 'lE. A Compendiumof PodiarricBionech6oi6- 99. tinge! S- Prutlem of rbe rnorth. In: Foot md b8 Funclio!.
San Francisco; Cal'fonia Collegcof PodiatdcMidiciDe, DccrPdk, NY: li.ger BiohecbaricsGroup,1988;l 14-
1971. 100.SubohickS. PodiahicSpo s Medicire.ML.Kisco,NY: Fu'
?5.txlter LD. C.!us foot in runres. Foot Ankle r981r 1l tum Publishing, 1975.
2U 224. 101. RoncaraliA, McMullenW. Codelats of low backpain h a
?6.DwyerFC. The presenrstalusoI rhc problsn oI pcscavus. geno!.lpopulation sanplq a mulri discipli.arystudy.J Ma
ClinO hopRelatedResl975t1l6tz54-275. nipulativePhysiolTlter198813:158-164.
l?. IrrivjcreJY, MiladiL, Duholss€tJF,Se.ingeR. Medialp€s I02. Denslow,Kon 1.Third In|ematio.alSeminar,Th€ Inrema-
cavusin ohildren:a surdyoffailuresfouowingDwyer'sprc- rional FedeElionof Oinopredic Madpulative lhempisls.
cedurc. Re! Chir O lopcd 198,5;71:563573. V ai l ,C O:1977.
. Bruckne! J. Varbrionsin lhe humansubklarjoitrr-.1Orrhop 103.Wosk J, VolosninAS. hw back paiD:ens.Native tr€al-
SponsPhyslhcr 1987;8:48994. mc.t wilh arLificialshockabsrbers.Arch PhysMed Rchabil
?9.Schocnbaus HD, Jay RM. Cavusdeformnics,conscrvative i985:66: 145-148.
managemcnl. J Am PodialryAssoc1980i70:235 238. 104. D Ambrosia R, Drcz D. PrevcDtionand T.ealDenl of Run-
80.Build€rMA. Mar SJ. Casehhrory of a palienrwirh low ninBlniuries.Thorofare, NJ: Slack,1989.
backpainand csvusfcci. I Am Podiafy Assoc 1980;6i 105. Lutter LD. O(hopedic maragemenlof runnels in lhe f@t
299-l0t. ard ankle.tn: Bar€manJE, Tm[ AW (eds).The Foorard
81.Caneialosi CP,SchallSJ.The biomechanical aspectsofan- Ankle. New York Thieme-Slraiton,1980.
&norbrsallutrnslsyndrome. J Am PodiaryAssocl98q 70: 106. Bojs€r-Moller F. Anatomy of the folefoot, nomat and
291 292. pathologic. Clir OnhopRelat€dRes1979;142:10.
82,Radin!L. Taual turn0lsyrdrcme.Clin OnhopRelaredRcs 107.ClvanaAhPR,RodgeFMM,IiboshiA. Prcsssre distributior
1983:r6l-170. uder symptom'f!€e fecl during barefoot standing. Foot
83.Wapne.KL. ShalkeyPF. The uscof niShrsplinrsfor trea! Ankle 1987i7:262J'16.
memof a re@lcirEntpla.rar lascinis.FooLAnkl€ 1991; 106. Langer S. forcfoot valgus, plantarffexedfilst ray.
l 2 (3 ),1 35. Ciarificarionplesso.Ir: bnger Biomechanics N€wsletter.
,8d CsnierPA, JaniSan JD, Smilb SD, Weil LS. Monon\ reu- Dee! Park,NY: hnger BiomechadcsCrollp, 197714; 2-6.
olgia:a possible cont.ibutin8oriology.I An PodiabyAssoc 109.Schusrer R. Footrypesand lie inndeac€of environmenr on
1 9 7 56j 51315- 321. rhe foot of rheIorg dislancerunrer. Arn NY Acad S.i 19?7:
, t5. Banlingbd JW, SnyderR, MichaudT. Morotr s neurom. 301,881i 87.
J Manipularive PhysiolTher1997;5:317-i22. I I 0. VdnNy R. Orlhccs. lD: SubohickS (Bd).Spois Medici@of
186 Carcll RL. VertebrarePal€ontology and Evolution.New tho Lower E{tEmity. NN York Churchill Uvirgslo&q 1989:
York:Frce0an:469. 432.
i'E7.MortonTG. A pecrliarand psinlul afflictionof rlE fourrh 111.Wood Jo.es F. Suuclue and functior as seenin the fool.
rnebhEophalatrgeal aniculation.Am .l Med ftj 1876j71: lrndon: Bailliere,Tindall,& Cox,1944.
3145. It2. Betts RP, Fmnls CI, Duckwonh T. Analysis oI prosure ad
B$sley CJ, C.irtre) PC. lhe inle.met6!.sophDlangeal lordsundertie fool. PanIl. Qunlirariotrof lhe dynimicdis-
bu$-ils siAnificanoc in Mo(on's meorsalBia. I BoDe uibution.Cli! PhysPhysiolMeas1980;1:113-124.
JoinlSurg1980i628: 184-187. 113.GricveDW, RashdiT.Pressure6 undernorltlalfeelin st?nd-
ColdmrnF. InrermeralaFial nd@ma: lighrdndelellrcnDi. inA and walki.g as measuredby foil pedobarography-Ann
crorcopicobscrearior.J Am PodisrrMed 1980;70r 265,276. RheuBDis 1983;43: 816-318.
CowanD, JonesB, Robinsotr J, PollyD. Mcdiallongitudinal 1)4- GrcssTS, Burch RP. A mechanicalmodel of melabrsal
anh hcighland iisl of tnining assoliatedinju.y. Mcd Sci stressfraclure during dislar€e .unning. Am J Spons Med
Spo sExercise1989;?:60. l9&9i 5. 669 6'74.
178 FOOT ORTHOSESand Otlter Formsof CooservaLivc
Fool Care
I I 5. Teitz Cc' Spod$ medicine conccms in darce and gymnas-
ri6. P€diarrClin Noni A[| l982aT). 1399-1421.
116.could Js led). Thc Fml tsook. Ballimore:Williams &
Wilkins.1988:220.
I | 7. ClovcrMG. Plartlr w.lts. FoolAnkle 1990;3: 172-178.
llE. HolmesGB. TinmcrnnDL. A oumlitativc.s*ssmentol thc
effecl of mclslarsnl pads on plantar prcsiures. F@t Aitle
l99O:l: 14l-145.
ll9. MononUL TIe HumanFoot.New Yorl: CollmbiaUnilcr-
sity Prcs, 1935.
120.HaEisRI, BeathT. Ttc sbon ffd mclatarsal, il$ idcidencl:
snd clinical significnnc4. J Bona Joinl Sllrg l949i 3lA:
553-565.
l2l. RodSeaMM, CavanaghPR. Prcssurcdilributiotr in Mor-
bn's foot strudure.Mcd Sci SponsE,crcir. 1989:21(l):
r:2. iosrey nC. Stalic disordersof lhc anllc and foot. clin
Symp1 957i9185.
123.Tmvcll JG, SimonsDC. Myofa$cialPair and Dysfunclion:
thc Tiaser Poi' Manlal. Ballimorc:Willinms& wilkins,
1983:lt2.
124. Dandberg HC. t ner b fte edilor. Thc kinetic wedgc. J
An PodiarrMed Assr t9r88,78{2).
I 25. SubotDickSI- Th€ biomcchanicsof running: inplicalions for
rhc prevenlionol loot injEie$ Spons Mc{ 1985i 2:
l:l{-153.
126. Rolhbad BA, Lslabrook L. Exc.ssive tronation: a major
biomechanicnldcrcrmirant in thc dcvelopmentof chondro-
and pelvic lists. l Mdipulativc Physiol Tter 1988;
'rrbcia
5:37!379.
127. Ford LT, GoodmanFG. X'rar sludi.s of lhc lumbosacml
soirlc.SouthMedJ 1966:59: ll2!1128.
128. PorlcrfieldJA. Th€ sacroiliac joim. hr Colld IA D{viesGJ
(eds). Onlopaedic af,d Sports Physicrl Theapy. St. bui$r
Mdsby,1985:555.
129. Schoir D, Addd M. Pidore P. Effccrs of he.l lifrs on Cround
reactivc forcc pa(cms in subj€ts $,irh slruclural leglcngth
discrepan€ies.PhysTher 1989:6q 4r-.48.
130. Prcss SJ. A rcpon or clinical applicdions ol clJmprr.ls in
analysisof g8il spin',Iimbalanccs. ChimpracrSportsMcd
1987il:30.
I3l. Sanner\4fi, PageJC, TolboeH& €t al. A nudy ol rnkl.
ioinl height charEeswilh s{btnl$joiol motion.J AB Podia-
tryAss l98l; 3: 158-1 6 1 .
132. His! JM. Functionol Fool Diso.den. t s Anscl€s: The Oi-
ford Prers, 1949.
133.NovickA, Ke'ly DL. Positionandnrcvemcnr chanses of rhe
lool with oniodc inlervenliondurint the loadingresponseof
gail. J Onhop SponsPhysTher l990t I t (7): 3{ll-312.
134. Cyri&r J. The Te,(book ol OnhopedicM€dicine.Vol I. Ed 5.
lrndon: Bailliiire,Tindrl, & Crisell, 1969.
135. Taillnrd W. Lombar spire a leg lcngth inequality. Acu
OnhopBelA1969:35: 601.
136.SubordckS. Ca5ehisroryof Mil{lerrl shonlcg wilh athlclic
ovcrusaitrjury. J Am PodiatrMed Aasoc 1980:5: 255-256.
137. Redlcr I. Clili@l sigriliqne of ninor incqu.litis in leg
lcnglh. NN O eani Mcd SurAJ 1952; 104:3tlE-312.
138.Subornicks. skiing injun.s Ir SubolDicts (ed). spons
Mcdicine of rhe I-o\r€r Extrcmty. Nec/ Yorkr Churchill Liv-
ingstonc.1989:611.
t3c. HickevDE Huki6 DW. Rrlationbelwefl thc strucrur.
rhcdnulus librusisandlhejunctionand failurc{frh.
vcdcbBidisc.Spirc l98O;5: 106-115.
l:10.Scbultz AB, Watwick DN. B.rkson, MH, Nn hcmsotr
Mechsnicllpropcniesof humanluobar spi.c notion
men(s.Pon l. Responies in flexion,extcrsior,lareBl
i.g andtorsioo.J BiomechEng 1979;l0l: 46-52.
l:r1. Inne VT, RalslonHJ, Todd F. Htrmd w.lking.
Williatns& wilkirs. 1981.
r42- Lillich JS, B!)(ter De Coftmon torcfoot problcns in
ners.FootAnkle 1986171145-151.
l4l. Hugh.sLY.aiomcchstricJanalyrisof Lhelml,nd,nkb
predispo$ilion rodcvelopitrg$trcssfractures.IOnhop
PhysTh.r 1985;3:96 101.
144.CloseJR. Sone appli@lio$ of lhc fumtioml anatomyof
adl. joint.J Booe.loirlSurSI956:J8A(4):?61-781.
145.O'Donoghu. DH. tmpiryemcnl cxoslos€sof the talus
tibia.J BoneJointSUrt1957i-l9A(4):83H5?.
146.Adclaar,RS, Dmnelly EA" MeunicrPA, StellingFtl,
vardDF. A longrermsrudyof tripleadhrcdcskin
(PrccecdingB of th. Anerisr Ac.dcmyol OnhoFdic
se,itrs).J BoncJoi! S!€ 1976;58A: 724.
t47. OudandT, Murphy ID. Tle pdhomccta 6 of the
spasticflatfoot.Clin Onhopl963:Z1:6+-73.
148. E CshelaJR, Allinaer TL- A funclion of thc
jojrt duringrunningsupporl.Fod Ankle l99U;2i93-%.
sandozR. Somephysi.almcchanisms aodfffccrsof
adjustmcntr. Ann SwissChiropAr$c 1976i6:91.
150.Mcnnell L Joinl Pain.Boston:Lnth BrowL l%4.
l5t. RahlmanoJF. Mechrnisrnsof int€rvedebraljoint 6)6rior:
literaturcreview. J ManipulativePhvsiol Tler 1987;
t77-187.
152.MacconailMA Basmajian lv. Musclcsmd Movcmenrs:.
Basis for Hu'natr Kincxiology,Baltimo.e WillianE&
WiUiN,1969.
153. Scbafer RC, Faye LI. Molion Palpation dd ChnopEdic
Technique-Principles of Dynamic ChimpBctic H|lntiryton
B€!ch, CA: Thc Motion Palparionlnsitute, 1990.
154.Iladmcr WL FunctiotrEl Sofi TissueExamination ard Trcd-
mcnt by M$ual Methods.Crilhe6burg,MD: A$pcnPut-
l i stc6,1991.
155. Xaltenhorn FM. Mobilization of thc Exftemity Joit|t5.o!lo;
Olaf Norlis Bokhadel, 1980.
156. Greennan PE. Pnrcipl€s of M.null Medicin.. Baltnnotlr
williarn$sndWiltins, I9E9.
r57. Mritlrnd CD. Periptenl Manipulalion.Lotdon: Brllrts
158. Condon SA, Huton RS- Solcus mu!.le elcctmnyo8nphjc
acrivit, aod ankle doninerior mnge of molio! durirS tou
smtching pmced{rer. PhysTh.t lgn i 67| 24-30.
159. Moore MA Hu(on RS. ElectromlogBphic inve-rtigation of
mus.le strerchingtecbriques.M€d Sci SponsF.x€rcisc1980i
5:122-329.
160, Prerrice WE. A compairon of stalic strcr.hing and p.n.f.
stElching for improvitrBhip joint Relibility. Athlctic TniF
iry l9a3i 1: 56-59-
16l. SadySP.Wo.har M, BlankcD. Flexibilnyhining: ballis-
dq static or propioc.ptiv€ neuronuscularfacilitarion.Arch
PhysMsd Rchab r982i 6:261-263.
162. TanigaM MC. CoBpansonof hold-r€laxprocedlrc rnd pas'

siec mobilizationon incrcasin8nusclc length.Physlhe!
1912:1:'725735.
SalBnMR, Ganet WE, SeaberAV, GlissonRR, Ribbeck
AM. The rolc ot warm-upon muscularinjury prevenlion.
Am.JSponsMcd I988i 16:123 r29.
Suzuk'S, FluuotrR5. Postcontractile motoneuron
prcduced by nlscle afl.lont activrrion.MedSci SponsEx
qciseI976t4:258 264.
EldrcdE, UuxonRS,Senh JL. Narureof persisdng
in alferetldischargcfrcm mlscle followirg ils conkactio..
PrugBrainRcs1976i44:157 171.
MoorcJC.Tbc golgilerdono€an: a ieviewandtrpd5le.
! Oc.tplhe! l9a4:4:227 236-
Asnnd PO, Rodlhl K. 'fhc Textbookrrf Work Physiology.
Ed2. NowYork: M.Graw-ltill, 19?(1.
Holr ND (fefcrened in Altar I4J). Scien@of Srrcrching.
C.hampdiSr, II-r HtrmanKireticsEoolG,19881
Shnis} WD, Hubley'Kozey CL. Neurophyriolo&/of
strclching. In: D'Ambros'aRD, Dre" D (eds).Prev.nlion
andTrcarmcnlof Ruriig lnjuries.Thorofare,NJ: Slach,
1 9 E9 .
Godges JJ, MacRaeH, hngdo! C, Tinb€rgC'.MaccmcP.
TheefiecNof two slretchinAprocedureson hip rrngc norion
andSail ecorony. J Onhop Spons Phys Ther 1989;9:
350357.
SapcBa AA. Quedenfeld TC, Moyo. RA, Butler RA. Bio-
physjcalfactorsin Bnge of,morionexeruise.Phys Spons
Me d1 981; 12: 57 65.
Keidau !P, KendauMccee, ti. Mwcles, lesring and
Fu nrnn
. E J3. B alr im o rcW: i l l i d n s& Wi l l i n ., Iq 8 3 .
Brucknet J. Variarions in the hunar sobml,rjoinl-J O hop
SponsPhysThcr 1987i8:489-494.
Ilarjs Rl. Rigid valgrs Ioor dre lo lalo.alcnneal
BoncIoitrrS!181955;374(l)r169-183.
wagnerFW. Pclsonalconmunication.ltr: BordclonRL.
Surgic2land ConservaliveFoot Care.ThoDfa.c, NJ: Slack,
1 9 8 8: 111.
Schoilz ElI, Cydaxl. Manipulrtion:Pastand Presenr.
don:WilliamIleincmanrMedical Books,1978.
PalmefDD. The Scierce,Art and Philosophy of Chirc!.ac-
lic.Ponland, OR: PoalandPublishing, 1910:56.
WooSL-Y,MauhewsJV, Aleson WH, Amiel D, Convery
FR, Conncctive tissuerelpons€lo immobililyiconelatrve
studyof bioBcch&icaladd biochemic{tmessuremerts
lromalandimnobilizedrabbilkqees.AnhridsRheun1975;
l8t 251-264.
Mairlaid GD. Vcflebral Manipularion.Lnndo.: Buuer
wo d hs1986196,
, 107 .
CoodAll. Spinaljoint blocking.J Mdipulalive Physiol
TheIr985j8; l- 8-
ParisSV. Spinalmrnipulalive$erapy. Clin Onhop 1983;
1 7 9 :5 5- 61.
MaiuandCD- Th€ htpodesisof addingoomprcsionwhen
cxanining{nd reatingsynovialjoirls. J OnhopSporlsPhys
Ther1980j2(1):7-14.
Ne*c1lSG,W@dleA. Cuboidsyndrome. PhysSporlsMed
1981i9:7116.
CoodwmCM, lr4ct-lo\kc)DL, MdrLhew\PBC.The persi!
lcrccof apprcc'abl. kincslhcsia afterpal,lyzingjoinla-ffercnls
burpresetuing musclcaffeenrs.tsmir Res1972;37r32o.
ChaptcrThfce Abnorbd Morior dlrirg the Gsll Cyclc 1?9
185.Nerter F- The NervousSysrem.PaIt One. Anatomy and
PhysioloAy.West Caldwell,NJ: The CIBA Colleclionof
Medial llluslmlions,1983:1985.
186.GowilzkcBA, Mil.er M- ftieDliRcBasesof Hutun Mole
menLEd3. Baldmore:Willians& Wilkins,1988.
discbarge 187-HdfschnidlHJ. Demonslralior of autogenicirhibilion and
irs signjncrnc€in hume volunhrymov.nonl.In: CrsnirR-
(cd).MuscleAffefenlsaddMolor Conlrol.Ne{ York; lohD
charges W i l ey& S ons,1966.
188. O'ConnellAL, Gardrcr EB. Urde6tandingthe Scieminc
Bases oJ Human Movemenl. Ballimore: Willirms &
Am Wilkifls,I972.
189.RobbinsSE, Couw Gl, HannaAM. Running-r€lated injury
provenrion thrcughiDnareimpacFmoderating behavior.Med
Scislorrs Exercise1989;21(2):130-139.
190-BrcmmrJM, LawrerceJS,Ma'll WE. Degenerativc arthrilis
89. in a Jamaicannral populalion.An. Rheud Dis 1968;27:
32G332.
191. L€nlcllGL, Kalzmd [, Wal|elsMR. The rclalionship be-
rwecn ouscic tunctionand ankle srabilily.JOSm 1990i
1i (12):605-611.
192. AndcrsonO, CdllnerS. O! lhe feedback conlfoloflhe cat s
hindlimb during loomorion. In laylor A, ProcnazkaA
(eds)-Muscle Reeptors rnd Movemont.New Yort: Ox{ord
Unive,siryPrels,1982:427 432-
193. RowinskiMJ. Afiere't neurobiology of lhe joinl. In: Could
JA, D€viesCJ. (cds).Oinopaedica.d SponsPhysicalmeF
3py.St.lruis: Mosby,1985:5G'63.
194. Frc€ma!M, DeanM, HaDhm L The etiologyand prclen-
riotr of functiodal if,srabiliry of rhe fool J Bone Jolnt Sllg
1965;478:67H 85.
195.Billek SawhneyB, WhilneySL, SawhneyR. ,{ssessmcnt of
bridgo.J slaticbalan@.In: OdiopaedjcS€ctionPosterPrescntations
ar ihc 1991ConbinedSectionsMecting.J OrthopSporls
PhysIller 1991j13(5):252.
196.CyriaxJ. Textboakof Onhopa€dic Medicirc.Vol 2, Ed 11.
London:Baiuiiire'Tindall, 1984.
l,on- 197-Caiiick FR. lrcturc noresfrornNYCC diplomareitr $eurol-
o8y prcaram.Nov.1987.
198.Kon IM. Neufobiologic MechanisnN in Manipulativo TheF
apy.New York:Plenun,1978:247.
199.VossDE,IortaMK, MyersBI. Proplioceptive Nesrom{sct
lar Facilitation. Ed 3. Philadelphiar Har?er& Row,1985.
of 200. LisbensorC. Active muscularrelaxalioDlschniques.Palr
Tw o.cl i ri Gl appl i c.don.JMP I 1990:13(l ):5.
201. CavanaghPR, Lafonune M4. Cround .eactionforccs in dis-
tanccrunDing. J Biomech1980i13:397-406.
202. Cavanagh PR. The biomechanics of lowerextcmily acrioD
in distancc runninL.FoorArkle 1087:lq7-216.
203-Haris RI, BeathT. llypemobile ffafoot wirh shon tcndo
achilles. J BoD€JoinrSuig 1944;30A(l):116 r38.
204. RobbjnsSE, Hsnm AM. Rumirg{elrted irjury preveniion
lhrorgh barefooladaplalions.Med Sci SporisExercise1987;
l9(2):148-156.
205. PeiiyJ. Anatomyandbiom€chanics ofthc hirdJoot.Clin OF
lhopRelarcdRes1983;177:9-15.
206. Jarda V. Musclcs,centml ne.vousmolor regulationatrdbacl
probl€ms.I.: Kon IM (ed).The Neurcbiologic Meclanisns
ir MorjpuladvcTherapy.New York: Plcnum,1978:27-41.
2Ol. IaBlanc A\ Gogia P, Schneid€r V, KrebsJ, SchorfeldD,
180 FOOT ORTHOSFSand OrherForns of Coffew{livr Fmr C|re
Eea.. H. Calf mus.lc afea nnd stredgthchnngeslftcr frv6
weeksof horizonrdlbed resr.Am J spons Med 1988i 16:
624429.
208. Gould N. Evaluationof hype.prondtion md pes platrusjn
adulrs.Clin OrthopReletedRes1983il8:37 45.
209. Cibulka M, Ros SJ, Delitta A, SitrscoroD. A @mpdisotr ol
hvo lrearnenls for hamstring stains, Phys Ther lgli4i 64:
750.
210. Mnckte DS. Ass@ilted facloB in recuficnl grcir !d h.m.
s1rin8ir.iuries.Br J spons Med 1982j 16: 3? 3S.
211. l-€e DG. Tennis€lbow:a marualth€rapist\pcBpecfive.J
OrrhopSForrsfhys Ther 1986;8:!34 142.
212. At€r l- S[erch and St&ngthen.Bos(on:Houghtoi-Miffiin,
1986.
213. Aubrey BJ, Bernardone JJ, ConnollyTJ. The prospectivc
ev&luarion of inlasivelnd non-inlasiverrearfrmlprotocols
for planlar fa\ciilis. RehabilResDev Pros Rep 1989i50.
214. Se|oJl- BrewslerCE, tnmbardoST,TiboneJE.Rehabilira'
tion of rhe kne€ afier arredof cruciareligaDent r€coBtiuc-
tion.J OltltopSpodsPhysTher 1989iIl(l):8 18.
215. Houk J, Henneme E. Response of golgi eodon orgaff to
aclive conlraction oI the soleus musle ot the cal. J Neurc-
physiol 196?i30r .!66.
216. VoglerH- Biomechanics ofralips equinovalgus. J Am Podi'
itr MedAss 1987177(r):21 28.
217. BordelonRL. Hyp€rmobileflalfoo!iD €hiidrcn.Clin Onhop
R€latedRes196l; lttl:7-14.
218. OlsenTR, SeidelM- flre €volulionary b6is otsomeclinicat
disorders ot the hum?n fool. A cosptr.lvc auNey of lhe
livirg p.imales.Fool Ankle 1983i3: 322-341.
219. Hutun WC, Dhanedrdn M. Thc mccltanics of normsland
halluxvalgls feer-a quantir ive study.Clin Odhop l98l;
157:1-13.
220. re Dollon A. Deep pomncll mrve enlrapmcnton thc doF
suh of thetoot.FoolAokle l990i ll(z)t 73-78
221. Hicks JH. The mcchanics of lhe l6ot. I. The joinl$.J ADaa
1 9 5 38i 7 : 345.
222. Hice OA. Onholic tiealndnl of teel havhg a high obliqucmid-
lars,l joinr t\is. J Am PodialryAssoc.1984i74111): 5?7-582.
223. Bl€ck EE. Devclopmental onhopaedics. lll. 'roddl€rs.Dev
MedChildNcurol1982;24r533-555.
224. Srancli LT. Rotationalproblcm of the lowo! ortremity. Ol.
thop Clir North As 1987i t8(4): 503-5 12.
225. FabryC, MacEwetrGD. ShandrAR. Tosiotr ofthc fonnr, a
fbuolv-upstudyin mrmrl and sbnormalconditions. J Rotre
Joid Surgt973i 554: 172G173E.
226. Jay RM. ln-toosecondary to hedirl fibial toaior. Fet dd
I's Funclion.DecrPar[. NY: tanger Biomccha'i€sCrorp,
1 9 8 9 li (4) : 8- 14.
227. SwaosonAB, OreenePW, Allis HD. Rolationaldeformilies
of lhe lower extrcdily in childrcn aDd lheir clinicul
signiflcance. Clin Onhop1963:271157-175.
228. Macconaill !.tA, Basnajiai (]J. Muscles ed Movemenrs.
Huntington, NY: Kii€gor.1969.
229. LilctucdrJ, KEiahbruD E, PhillipsRL. Analysisof sclccred
aligntneniof rheloweroxmrnityasrelatedto theshinspljrt
syndrome. J Am PodiatrMedAssoc1976:69(3):211-217.
230. Divenpon J- Tic prthomechanicsof rhe flatli|ol defoinily.
Fod andLf,aFuncdon.DcerPark.NYr lrngcr Eiomechnn-
i(\ croup. 1988:l(r): 7.
231. Schoennaus lt. To6ionul abnornaliliesin podi.rics.
and bg funclion. Deer Park.l.{Y: Irnger
C oup 1988;l (l )r l l .
232 MaB€eDJ. Onhopedjc Physic{l Assessncnt.
Saunde6,1987:252.
231 Fabry O. McEwen GD, ShandsAR. Torsioo of lhe
lolloq-up studyin nomal anJ abnomalcoDdnion\.I
.toinrSurg1973;55A:1726.
:14 Td HR. Ddech posed lo lhe hiFj of infer( by
splinlsusd ro rrealintenal rolrrionof rhc legs.I An
alr Assoc 1975;65(r): 5,1-56.
235 Alvik I. Incr€aed alleveBion of thc femoralncckL! lhe
signof dysplasia coxae.AcraOs 1960i29: 301.
236. Sr.hcli LT. Lippefl F, D€nortr P Fcmordlanreleision
physi.alperformance in adolescence
andadultlife.Clin
rhopt977:l29t 213.
SsmmarcoGJ.The dancership. Clin SponsMed
.185-498.
238. Valmssy RL Upc L Falconer R. Pedia|ric
modalilies of the lowef exrrcnn). J Am Podialr Med
1988;78(2): 69 -80.
239.Spener A. Pr.ctical Podiaxic Onhopedic
Cleveland, OH: Obio C.llege ot PodidricMrdiciie. I
124.
24\t. SchocnlausHD. PossKD. Tbc clinical ard pEctical
in hcatinStorsionalproDlemsin childrcn.J Anr
Assoc1977;67(9)1 62.
?41. Schusler RO.'l!e effeclsot moden fool gear.J An lodirtr
Ass l9?8:68(4):235.
242. Tachdjirn MO- Pediatric Onnopcdics. PhiladclphiarSau-
de6, 1972:1463.
243.Gould N, MorelandM. Alvarez R. Trevino S. Ferwick J.De'.
velopm€ntof lhe childk arch.FoorAr*le 1989;9(5):?.{1.
244.l$nan RE, lnman vT. Anrhrouometricstudiesof lhe hum$
lbot andankle.lull Prostnet Res,Spring1969-
245. Corld N. Positionalanonalies and early paltem*of gail ln:
GouldlS: Thc FoorBoot- Sahinore:Willialns& Wilkin!,
1988:128.
246.lzngcr S. Genuvolgum,obesity,prcBnancy andlosi.gmn'
|ml of FoDarior The tanger Biomechanics Newslelcr.
bnger Riomechanics Group.Deer Park: New York.Ma!
l987i 14124.
Innan VT. Th. rointsof rheAnkle. Baldmore:Willians&
Wilkins,1975.
248.Adelaa.RS,WilliamsRM, GouldJs. Consenilalmnvcxpes
valgus: resulls of tut early omprchensilc relcrsc and a re-
vicw of ongenilal venicaltalusaI RichnondCdppledChil-
dren\ llospildl and the Univctsny ot Alabida i!
Bidningham. FoolAikle l98q l:62.
24s. M.Cillicuddj DV. JonesET. HcnringerRN. The eadl
tre mentof lalipescquanovarus wilh udhe.sivelapir& OF
lhop.dics1980i3131.
250. 6ould N. llatfool: spa\lic.In: Could Ji Thc
BallimoreWilliams& Wilkils. l9tl8: 185-
251- SrbohickS- Footinjuics. In: SubohickS (ed).Sponslvcd-
icinEof rhe lrwer E*tremily.New Yo.t: ChurchillLiving-
stone,1989:2t8.
252. BordelonRL. Hypelmobileflatf@l in cbildrun.CompEhed-
sio!. evsl$tiotr rnd treatmenl.Clitr Onhop RelrtedRes
1983il 8l r7.
 ChapterFour
BiomechanicalExamination
Succ€ssfulmaEagemefltof any biomechaaicalabnor-
nrlity requiresa thorough evsluation of the entire kinetic
in in wbich the various argular relationships,rangesof
and dynamic interactionsare carefully measuied
rccorded. Sinc€impropermeasuritrg techniquesleadto
treatment,Factirioners shouldbe sufficiendy skilled
nat theexarninationvields accurateandreDroduciblerc-
tdls. This chaDterwil review the comDonetrtsof a biome-
examination,as divided into supirc, prone,
anddynamicevaluations.
SUPDTEEXAMTNATToN
Tlis examinationshould begin by motion palpating
variouslower extrcmitv adculations. The Dresenceof
dysfuncrion shouldbe noled,andany tuatioosshould
Bertlyoobilized. In addition to relaxing the patienl,this
to reduceany functioflal deformities that dight ad-
aifect measurcments.The relalive lengths of the
are then determinedby plantarflexingthe digils
notingthe locationsof the dorsal metatar$l heads.A
gonioheteror tactograph is then usedlo measuro
ran8eof hallux doainexion(Fie. 4.1). Of interes(,a
correlationexistsbehveena decreasedrangeof hal-
Ill,xdorsiflexionard platrtarfasciapain (2).
After lhe rangeof ballux dorsiflexion hast€en noted,
posiiionof the first metatarsalheadandrangeof fust Iay
nay then be evaluated(refer back to Fig. 3.68). At
time.it is alsopossibleto evalual€theraDgeof forefoot
ion evailable about the longitudinal midtarsal joint
(Fi&4.2).
The rangeof ankle doisiflexion is measurcdby rest-
orc armof a go:fometer parallel to the fiblla while the
arm paralels the plantar lateral foot (Fig. 4.3).
Beasuremeotsbouldbe taken with the knee exrcnded
flexed to differentiate between sastrocnemiusand
contacture. If significant muscle tension i! noted
ths evaluation, the measurementsshould be r€-
after soveral hold/relax stretcheshave been per-
This givesa mor€accunte readingof ihe degse of
dorsiflexionavailableduring locomotion.
While a lirniled range of a*le dorsiflexion may be
for injury secondaryto midtarsalcomp€nsatiotr,
(4) nol€d that an exaggerated range of ankle
(i.e.,geater than 15"with kneestraightand20'
lhib klee 0€x€d)may also be rcsponsiblefor irjury sec-
tfuda.ryto inadequatemuscularstabilization.He emphasiz€s
181
that in this situarioD,treatrnertshouldconsistof strengthen-
in& ard nol stretching,exercises,For similar rcasons,an
exaggeratedrange of anlle plantarflexionmay also be re-
sponsiblefor injury secondaryto inadequatemuscularsta-
bilization affordedby an ovedy fiexible tibialis anterior(5).
Messier and Pittala (5) noled lhat a range of ankle
plaDtarfiexionexceeding60' is a good deteminant for pre-
dicting plantarfasciapain.
Slructural leg leDgthdiscrepanciesBhouldbe ovalu-
atedby using Ali's test (seeFig. 3.107) and atrteriorsupe-
rior iliac spjne (ASIS) to medial mall€olusmeasuremenr!.
lf nece$sary,various maNal techdques should be used
prior to recordingthesemeasurementsiD order to rule out
iDclional leg length discrepsncy.A series of treatments
anal/orhome strctchesmay be nec€ssarybefore it is possi-
ble to accuratelydifferentiatea structuraiftom a functional
leg lenglh discrepancy.
The degreeof tibirl tonion may be evaluatedby posi-
tioring the femoral condylesh the ftontal plane and mea-
suringthe tlansmalleolarpositioo (Fig. 4.4).
The range of i emal and exlemal femoral rotaliotr
shouldtbenbe recorded.If the ratrgeof .xtemsl femoralro-
tation is limited when the lower erhemity is sraight, rhe
measurementGhouldbe repeatedwilh the hip flere4 as
coDtrscturein the a{erior bip capsulewllj producea less-
ened range of extemrl rotation that dramatically ircreas€s
as ihe hip is flexed. (Flexion rcducesteDsioDotr the Y liga-
metrtof Bigolow,) Also, if koee itrjut is presetrt,the rango
of tibiof€moral rotation should be evaluatedwith the knee
flexed in varioos positiors. Rememberthat ercess subtalar
pronalion produc€sa laxity of the hee-restrainjng liga-
mentsthat resulB in an ircreasedrEDgeof rctation, panisu-
larly when the kflee is flexedbeiween0 atrd30" (6).
The rangeof knee flexion a$d enension shouldlhetr
be recorded:genurecurvatumis often associatedwith ankle
equiflus,\,r'hileflexion contractureat the knee often rcsults
in achillestendinitis and/orplantar fasciapah secondaryto
the increaseddoaiflectory rquiremeds placed upon the
snkle.Tightnessin the hanrstringmusculaturecan be ovalu-
atedby performiogstsaightleg raise! wilb va.ying degrees
of jntqnal ard €xtemal hip rotalion. A tight medial halr|-
slling will result in a lessenedsuaighl leg raise when |}e
hip is exlemallyrorated,while a rightbic€psfemorismus-
cle will restricl the heighl of a straight teg rais€ when lhe
hip is intemally rotatod.SuchcotrAaduremay be responsi
ble for an in or out toe gait pattem, as pfevioush men-
182 FOOT ORTHOSFSmd olhe. Formsof conservarivcFoot carc

riBrre 4.r. Measuringhallur dorslflexion

with a goniom€ter. Nole thal unlessthe fi6t
metata6ophalnn8e€l ioint has been injured,
lhe ran8eoi halluxplanbrflexjon De€dnot be
mearured/ as this is a vesrigialfunctionlhal
seryesno purposein locomotion li).

I !*,
il'l
il
't!,t'
u:t.

figur€4.2. M€asoring forefootinvertionaboutlon8itudinal

midtarsalioint a s. Wrthth€ root placedin ils neulralposi
rion.theexaminer theheelwirhonehandwhilein-
stabilizeq
vcrtin*the forcioolwilh the orh€r.Therelaijonship between
th€cenlnl lhre€nretal.nalhends.rndlh. planiarhsl isthcn
nored.Uniodunately, melhocls ior quantilvinfjtilsi i.ry rnd
nr dtaE;rlmotionsare i€lati!€lvinexa.land needto be im
pmved (3). o| note, Klaveet al. (23) reeonllydemonslraled
lhsl It th6lirst ray dorsillexesmor€lhen 9.3 mm abovethe figure4,3. Measurin8 Whiletalonavicu-
ankledorsiflexion.
seoond metatarsal,lh€ Indlvidualis llkoly to clevelopbunion lar conBruency h maintainedto prevenlmidtalsal
conpensa"
pain (the avehge range presenl in thek asymplomalic tion. the for€{ootis forced lnto a maximallvdorsitlexd
populationwas 5,3 mm). posilion,ard the measureinumberoldeSrees is recoded.

Tltc6ral po(ion ofthe supin€examshouldincludca
ovalualionof r!usclestrensth.
PRONE EXAMTNATToN
T}e patieolis plac€din a proneposilionandihelower
ity is rotakdto bringthc posteriorsurfaceofthe cal-
inlo the frontalplane.(This may requireplacinga
towelbcn€athth€ contralaleral oelvis.)The calca-
is Lhcnbisededby pincbingthc planlaraspecls of the
andlaleralcondylesanddJawinga line that is peF
to the line counectingtbesepoints(Fig, 45).
plantarskinconlollrshouldnot be usedasa reference
bisecting the heel,as a chronicallypron ed ioot will
thd pldnlarheelso lhar lhe skin appcrrs inverledrel
lo the plantercondyles-(The oppositcis lrue with a
icrllysupinated reaJfoot.)
Also,althougbil hasbecomestandadpracticeto bi-
lhecalcaneus u$ingthe medialard lateralsurface,slbr
thisDracticeshouldonlv bc consideredwhenthc
oI !h€fat pador thjckness
oflhe skin negatesbisecting
calcaftusvia palpationofthe planrarcondyles.Because
ouline of the Dost€riorcalcancusmost ofteD forms a
id, marking lhe calcaneusby bisccLioglhe medial
latemlsurfaceswouldproducea line thatdevist€sfron
perperdicllarbi:eotionof thc plantd condyles(Fig.
Sinceit asthelocaiiorof ihc condvlesthatdctemrutcs
phasemotion ol lhc subhlar joint, lhe condyles
ChaprefFour Blome.hrnlcrl Eirmlnatlon 183
Figure4.4. Measu.ing tibial tolsion.
The leg ie rotatedunlil lh€ postedor
lemoralcondylesrestpafallelto the
eramininStable(A). To ensurethat
thecondyle,arepositioned prcperly,
the€xamineruhould sliShtlyllex lhe
patienl'skn€€. When the femoral
condyles areparallelto thetable,the
kne€ will move straiShlLrp.A eo-
niometefmaylhen be usedto mea-
surelhetansmalleolar position(B),
shouldalwaysbe the referercepoiris. II the medial and lat-
eral surfacesof the calcanBusmusl be used,bony deformi-
ties($ch as Haglund'sdeformityor atr aboormallyshaped
calcaneus) shouldbe ignored.
lt cannotbe overstressedthal adequatemarking of rhe
calcanealbisectionis cssedialfor properevaluationand
lrealmetl,as an incorlectbiscclionwould produceelfor in
bolh the reerloot and forefoot measur€men1s, e.9., the r€aF
foot biseclion in Figure 4.6 thal usesthe nedial and lareral
contoursof the calcareusfor references(dashedline) givcs
the impression of a combincdsubtalarvaiunvforefootyal-
gus delormilywhile lhe lrue bisection(solid line) clearly
demonstratese neutial forefool and rearfoot,
Once the cslcaneushas beon marked,the distal one-
third of the leg may be bisecled.The alignmontbelweenthe
post€riorcalcaneusand Lbedielal leg may now be mcasurcd
(Fig. 4.7). Although Rool et . . (7) originally mainlaincd
that the neutralposition of the subtalarjoint should be de-
terminedby noting the overall rangeof motion available to
thesublelarjointandthenplacingthecalcsneal bisectionin
a position lhal is one-third of the way from its fully
pronatedposilion,this techniquehas b€en all but aban-
donedb€causevadalion ir sribtalarrangeof motion nakes
for muci inconsistency.
Also, wbile most authoriliee recomftend measuring
the raDgeof subtalareversionwith lhe patientin a pronepo-
sitior, more recent investigation demorslrates that off-
weight-bearing neasuremenls of subtalareversionare nol
184 I'oOT ORTflOSES and Othcr Poms of ConservatlveFoot Cere
Figur€ d.5, Eirerling lhe calcan€us.With the foot main.
lainedin ils neulralposition,theexaminervisuallybis€cl!the
medialand laleralcalcaneaicondyle!{solidline) and th€n
drawsa line perpendicular to rhisone on the palient'sheel
(dottedlin€).To fieethemarkinghand.whil€maintairin8 the
laterrl(olumnin ill lockedpo\iiion,lheseatedctamincrures
r knee to apply pressurebeneaththe foudh and fifth
metataBal heads.Thelransitionfrom handpressure to kn!€
p€ssurcrhould be qmooth,with no changein forefootor
rearfoolreldrionlhips.
valid (8). Becauseof this, thescmeasuremenls, which are
useful when evalualing uncompeffaled foot types, should
be perforded during ststic stanc€.(t nanzacl al. [9] notcd
a 37% increas€ in sublalarcvcrsionwhenits ra[ge i6 mc!-
suredin a weighl-b€aringposition.)
Atler subtalaralignmenl hasbeen.ecorded,the fore-
foourearfoot reladorship can be rrcasured(Fig. 4.8). Eveo
thorgh rhis measurcmentrcquircs eyeiry th€ v$iots rela-
lionships betwe€othe measuringarms and the plantarforc-
foot and rearfm!, even inexpcrieocedpaaciilioneasare ablc
lo achicve a high d€gre€of consistencyitr thesemeasure-
mcnts. ln fact, Kaye and Sorlo (10) demoostratedthrt four
oul of five examin€Iswere able (o correclly ideotify forc-
foot rclationshiBwfthinl'.
An important poinl of concem regalding forefool
mcasulementsis the frequency with which practitione.s
Fitur€ 4,6. UdnEthe n€dial and lat€r.l srrfacer of lhe
c.ncur for ref€rcnc€s(A and 8) u{ally re3ultsin e hc.l
!€clion thil ir inverlcd {C) rclative lo tfi€ kue bk€cdon
find forcfool vrns deformities. AlthouAh presetl in
than9% of thc pop laiion (l l). mrny e:perienced
tioners rcoolt forcfoot varus deformiti€s in exc€ssof
of lhe prtient population. Bums (12) offers a possiblc
Dlanationfor this by sratirg; "It s€eds most cliniciars
ing .tt pronated fcel think rhd forcfmt varus is rhc
prob(blecause,a with this precondilioning sel in
mind.il is mucheasierto find a forefootvarus."
An incorrect m€asurementof a forcfoot varus
mh] mayb! theresuliof variooserrorsin examinalion.
mostcommonmislakescanusuallybe frscedto €ithcrimd-
equrteloadingof the fourth and lifth metala$al h€adswhila,
phcing the foot in its neutral position or to an inco&ct
markingof theposteriorcalcaneus, c.g.,lsing a Iincthatir
parallel lo the lateral surfac€of ihe calcane||owhenbisccl.
ing rhc heel will result in a false forefoot varus neasun.
menr. as lftis line will be everted relative lo thc thrc
bisedior. Also, determiniry the neutralposition of ftc s b.
talar joint wirh the merhoddcscribcdby Root et al. (4 is
like,v to prodsce a fals€ forefoot varus m€arurernent, ss it
is not rncommon for the irversiorveversio[ mtio of subtelf
morionto be4:1,insteadof theideal2:1.This resullsin thc
foreloorrearfoot relationship beiog measuredwhile thc
subtrlarjoint is bei[g held in a supinaledposition.Becius.
of a de'ireasedpenilelism of the midlrrsal axcs,this resuhs
in ! lilse for€foot varusmeasurcmenl(Fi8.4.9).
Oth€r lactors tftat may result io atl incorect forcfool
vonr{ messur€mentinclude the presenceof a dorsinexad
first ny and/or a functional forefool varus deformily. If
 Flgure 4.7. Mcaaurlng neutral subtelar
allgnnenl. To beglnwlth,the low€rleg is bls€cted.Thls
requiresli|st palpaling, lhenbiseciinga 3-inchs€clionol the
tibiaandlibulaiuslproxllnaltothe nallooll(A). The malleoli
shouldnotbe us€d,andasymmgldcal musclemassandthe
achllleslendonshouldbe lgnorsd.Thg longltudinal aris of
lhe loot is thenpoeilloned pepondlcularto lho lloor andlhe
dsgr€eol subtalarvarumislhen m€asulodwhllemainlaining
lool neutrallly.lt shouldb6 stressedthat the lrnportance ot
lhis angle is ollen ovsrated as it is relatlvely small
compar€d lo th€ degroeot llbiofibularvarum.
Anolherlmpodantconsid€Btlonls lhat s€veralsludies
(24, 25) have domonstlalsdpoor inlerrator retiabilitylor this
measulefienl. lnconslslgncles wllh lhis moasuremenl can
almosl alweys be relatedto difticultiesassociatedwilh
bisectinglhe low€r legi i.e. lailure to positionthe tool
pgrpendicular lo the lloor anci/ordllllcultieswith visually
biseclingths lowerlagon obesepeopleoll€nallowalor non-
teproducible bisocllonlines.Theseproblems,however,may
be minimized wllh praclice(e.9.,h is somelimesnecessary
whon evelualingobeseindivldualsto bbect lhe low€r leg
watha linethal is parallello a panicularly slrelghls€ctionot
lhe distaltlbia)as exporienced €xamln66 ar€ capablool
achievinghigh levelsol int€ (26) and int€ral€r reliabilily
(27). Ol note, ll has b8en rocgnllydemonstratadthal a
simplequalilallvemeasuremonlol neuAalsubtalaralignmenl
(1.e.,notingil the subtalarjoin{ is in varusor valgus)hss
d6monstml€dan acceptableinl€rraler roliabillly wlth varus
cleform;tiesb6ingcor€lated wlth a prevloushbtory ol mgdial
libial6tresssyndrome(28). Frirlhormoro, Powersat al. (29)
demonstraled thal IndlvidualaposaeEoing e sublalervarus
dolormily (as measurodoff-w6ighl-beadng)were more likoly
io pr€s€nlwilh reaopatollar painlhan a conlrolpopulalion,
Theso researcherswero also abl€ to obtain accEptable
levelsol inlrarat€rrellabllitywhen takingthis m€asur€msnt.

F{gure 4,8. MeasurinS lorefoot

al;SnmenlWith the loot mnintained
in ils neutnl position,one ann of a
Soniometer h placedpa€lle to the
plantarforcfoo!while the olheralm
is rcslingperpendicula' to lhe cal-
186 FOOT ORTHOSESatrdOther Forlnsof Cottewaliv. Fooi Car€

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

is anvdoublas to lhe oosilioDof lhe nrsrmelatarsal
hoad,the pmclitionershould use only rhe ccritrulthr€c
hcadsfor reference.
Also,a suspectedfunctiona]
varusshouldbe vigorouslymobilizedprbr to msa
rheforeiool/rcarfoorrclationship.
Wilh the forefoot maintainedin its ncrlral position,
enl of the metatarsalsshould then be rccorded,{nd
Iallgcof 6rst ray dorsiflexiofl and plantadexion should
noted. Hip rang€ ot motion is readily €valuared by
ing theknees90' and observirgLibialpositionsas the
is maxjmallyintcmallyandexlemallyrotaled.The legs
tien st.aigbtened,
and thc rangoof hip cxtcGion and
nexionis checked.Notethanwhenevaluating hip ex-
ion,onchandshouldb€ placedovcr thc sacrurnto cn-
6a[ motion is coming only f.om th€ hip and nol
compcrsalory sacrojliac
or spinalexlension.
A sus-
leg len$h discrepancy shouldbe evaluakdand,if
specificmusclesshouldbe checkedtbr conlrac-
The final ponion of the plone examshouldinclude
I cxaminalionof planhr cal'uspatterns,
asthesepaF
provideinvaluableintbrmationregardinglhe degree
shearandcompressive lbrccsprescrtdurirg slancephase
4.r0)
STANDTNG
Ex MINATTON
Thepatienlis askedto stand,andthc iDiegrit)of thc
longitudinal archis nokd on andolfweighrbearing.
informaiion is usefulin jdcntifyingvariousfoot types.
eromple, an individualwith a fo!€footvarusdeformily
classicallypresentwilh a lossof the mediallongiludi-
atchbolh or and olf weighcbearingwhile lhe rigid
frtsrray de{ormitywill r}pically rcsultin a
ial lorsitudinal arch thal is elevaled bolb on and off
.h.jaring.Allhoughinterrarerreliabrlitylor evaluat-
archh€ightis low (13),rhisinfornatior shoirldslill be
asit he'pscorroborale olherexaminarion lindings
leslstheinlegrityof thesubtalarandmidtarsalreslrain-
qamen$.
Onemelhodlo quanrifychargesin archheigbtmore
ro measurcthe navicularditfe,entialas the
noves's
ftom iis neutralDositionto a Dositionof felaxed
stance. (ThenaviculardiffcrenlialrefersLothechange
heightoI lhe naviculartlbcro3ityrelativt to lhc floor.)
mothod allowsfor quantifiablechang€sin archheight
Thepraclitionershouldthenslandbehindthe palienl
notelheamounlofshanl rotatiooasthepatientactivcly
andevefisthe r€arfoot.As mentionedpreviousl!,a
subhlarjointaxiswill allow muchlibial rotationwith
ly insignificanl
amounlsof obligatorycalcaneal in-
cr\iun,shrle a low subralar
Joinr ayic will have
opposite effect.The rangeof sublalarjoint inversion
chaptorFow EloloecharicalEx{minarior 187
andeversionmay now be measured by placiogthe subtslar
joinr in irs neulratposirionand notinSthe locationof the
calcanealbileclioh relativeto the ground. The Prtient is
rhenask€dto eyen the heelmaximallyand lhe changein
angulationis noted. The procedureis reversedro measure
rhe r.nge of inversionand is repeatedbilaterally. This
positionalsoallowsfor neasuremenl oflhe weight-bearing
neutralrearfootposjtion,lhe neulralsubtalarpositionand
the subtalarjoint angle presenldurin8 relaxedcalcaneal
slanceandsin8lel€g stance(s€eFig.4.ll).
The slanditrgevaluationcodinueswitb observalion
oI lhe lateralcontourof the foot dudng relax€dstanc€:a
vcnicallypositioned joilll axiswill result
obliquomidtarsal
in an aculeangulalionat the calcancocuboid joinl (refsr
backio Fig. 3.177)while a foot wjth an inadequate suslen-
laculumlali or singleaniculat€dsubralar joint will prcsonl
with a sraight lateralcolumn,despjtethe m€dialdisplace-
mentofthe |alusrelativeto th€calcareus.
The possibleeffectsof a leg lenglh discrepancy
shouldbe notedby checkingfor lateraldeviationof the
spine,as well as the levels of the iliac cr€sls,grealer
troclanlers,tibial plateaus,and medial malleoli.A fuoc-
lional leg length discrepancysecodary to asymmeHcal
pronationwiil resultin an excessivelowerinsofone medial
mallcolusrelativeto the other.The standing€valualioncan
bc complctcdby performingan equinuscompensation !€sl
(F'g.4.12),a modifiedRomberg'stest,and by nolingdis-
placemenl oflhe fal paduponweight-beadng (Fig.4.13).
Fl!!B a,ll, 6y pl.cltrgltr. pd.nt In lh. pFp.r .n!b .nd b... ol q.ll
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.
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
nllrEr .ubr.I.r ns.unmnt.i .r., . l.ur dasd |omr |.! vem du.
. 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
ln ..4 2lLlr h 6fis i!'t{nr. ti. drhlm ol ft. c.lc!mu. .l h4l
arrui {alhoish rh. &ru.i Do.hlon ol rit .drtoor .| hld .lrlh. v.d.!
d.!.ndhg uro. tetd rsn d .D*1, be ol !!B !t$!ft, .nd $. u.!
ot onftoric.: ..d.. onhollcr lncr.tx th. dsd ot L..l@l lnv.r.lon
gtunr .t hsrlirlt whrb .mnoftdlnc .-|Nl.d l30l .nd . dldd
b... ol s.ll Ptl m.y .Lc|lu Edoor hwtul.n el h..l .t'|r.). Afi.r
nollft d!. ..ulral r.rnoo! rorltlon, tha slghr.ba.rlna NLrl .u!l.l!r
l.hr angl. c.h b. nd|{r*l by nodq tlf, .nd. tom.d b.lwFn lh.
crl..dl .nd lo* l4 bh.c{da lht mOl., *nlch .hould mrct' lh.
otl-Flcht.borlnq 6uuomnl, l. th.n om..urd.. th. p6ll.nl lkrl
moer ro . r.lu.d ddbh lknb dlc.dl .i.nc. F.nlon 4d tlnrrlv ro .
shor. te !nc. oGrrlon, Ai noi.rt bv llcPoll .nd comlrall (32), rh.
us-h r.iin.d by lh. F.rloot .nd lour l.s dunng .ln!|. h! .lim. (E)
sda .. !n Indlc.lor ol ft. d.gr* ol n.rlnuD Mdron po*lbl.
durlngfrx.g ldlh4ch ryDlony$. .ubtd.r lol rlll pM.l.lo.n.nd
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
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
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
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

fiSure 4.13. Normally, rhe infracalcanealf.t pad will

to.n' ndially and lar€r.lly upon *riShlt€arin&
tor no apprerirutr 2s% r€duclionin heiSht.lt a clinl
inla,6tinE thal individuals presentin8wlth heel pain
oner allowior as muchas a 50% rcductionin thc heirhl
the irr paduponwcitht bearinB.
Thismdyresulrin injury
the infracaltan€albuEa and/or nredial calcanear
($tar)asthe plantarcalcaneosk forcedto dissipaleground{G
fiSure 4.12. E$rinus(ompcnraliont€d, As wilh measurin8 activeforcesovera smallersurface aroi. Theabilitvot th€td
subtalareverion off-rvei8hl"bearin8, nreasuring ankledorri, pad lo dampenBrcund-rcactiveforcoelessenswilh a8e(l
flexionin .rn off-w€i8ht-bearinSpositionmay not accur.tely and rcpealed trauma(15).Also,Joryenlan and B
rcflectlhe availableanse of mollondurinsambulalion. To (15)nolelhat the fet pad,which absorbsshock].1 timet
confim lhe cffectof a linliledran8€ot anlle dorsiflexion as possesses
thansorbothane, anopenplexusofvoinsrhatt
measured off-wei8ht-bearing, the palienlir askedto stind col]rpresslofol the tr1dto €nhancethe counteGfavilational
rs
with kneesexlended andthesubtalar joid in its rcutralposi-
lion. TheexAmlner lhen placee linge.sbenealhthe midtarsal
joinl andaskslhepatientto ilex th€knees:a tru€€quinris thal
is secondary to a bonv festriction or soleuscontracture wilj
prdur.e comp€nsatofymidlaBal motionas lhe proximaltibia lionsof a $cond, with multiplestructuralinteractionli oc.
nov€s lorward with kne€ tlexion. Convers€ly,conradure in currlngsimullaneously. To clmpound ihe problem,m.ny
ihe gastrocnemjus musclewill producecompensatory mid- paticntswill clnsciollsly or unconsciouslymodify ihcir gait
tarsalmolionas lhe skaiShtened lorer ext emily is moved patlomwhenlhcy kDowsomeone is watchingthcm.
With lhesefactorsrakeninro consideration,it is easy
lo scc why gait obs€rvrrionsarc frequeotly wrouShlwili
inaccuracy.as eveothe most expcricna€dpractitionershevc
DYNAMTC Exa'm{.{TroN to a\'oid seeingwhal they want lo s€€.ln fact, somcindivid-
ualsclaimthc eyeis an inadequate lool for gsil evalu.tiol
TheBailevahalionbasicallyscrvesasa double-check (16) To sinplify theseproblefis.andrc cnsurethallhevi-
syslemto confitmyour ncutralposilionm€asuremcnts, i,e., sual examinationyields dinicslly signinca[tresuhs,it is
a patiet|lwith a 10"forcfoolvarusdeformityshouldrcnain suggesledthal one concenraleon singling out isollted
pronated lhroughout propulsion with th€ rearfool eycrrcd evenrsduring lfte gait cycleas thcy occur in onc spccific
duringheellift, etc. In ordei to perfomrthis evaluarion. a Dlancof motiofl,
clear, level walLway is necdedlfiat is a{ least 20 fecr long. For examplq after havingthc piticnt wrlk up ard
Kecpin mind thrt lhc gait evalualionis the mostdifticult down lhe walkwayuntil he or she is relaxed,one should
part of thc exam, as many movementsIale place ir faac- note the prccise ftontal plane position of thc calcsnelsal
 chaplerFour Blom€ehlnlcalExlmlrrlior 189

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

sion injuries,i.e.,slre$ fractureof the dishl tibia,

synovitisof theankleor knee,clc.
As the foot movesinto the latter Dortiooof irs
siv. period.the shifl into a hi8h-gerrpush-otrshould
ro(d as Ihe rearfoot slighdy evertsfuom its invened
rior l.inally,by observingthepatientas heorshe
wardsthe exsmine.,ore can evaluateths positiorof
lirsr ray during leminal proptllsion.lf the sublalnrjoirt
mains pronaledlhroughoutpropulsionwith the firsr
maintaiocd itr a dorsiflexed and invefied positaon
slrcrnsthe medialbandof theplantarfasciaas seen
sidc vie\\,), ir is suggested rhat tfie ratrg€ of
dor.iiflexionbe measuredduring static slance,witl thc
lalnr joint rnainlain€din the appmximateposiiion of
lion present during tormfiral siance phase. This
ide|tify a f|lnctional hallux hnilus lhat mighl oltr
hare bsenoverlooked.
Evalualionof the swing phaseleg shouldincbde
ing Lheapproximaterangesof hip and kneeflexion,as
Ls he rangeof ankie dorsi8crionnecussary ro
gr, rnd clerranccdoring midswing.ll rhould be
bercdthat tibialis anterioris ur ankle do$iflexor
earl! s\ring phaseand a forcfool inveflor during lale
phx$e(m).
tigure 4.14. The glut€usmediusSail pattern. (Modlfied The swingphrsesbouldid€allyeDdwi$ thefoot
frcmHoppenfeld S.Physical[xamination
oithe SpineandEx- siliL,nedso thst the rearfootis sligitly invenedandthe
trcmities.
NewYork:Applelon-Century-Crofts,
1976:ll9.) fool is fuuy invertedprior to heel s{rike.Also, theswing
iDnominateshould shii from its low€red posilio0
midswingto a neutralposilionat heelstrike.It should
notfd thatfinal portionof swingphaseis anothcr
tiftc to evaluatethe effect of structural leg length
ancv: the swing phaseleg oftetr appean lo drop an
sivcamountpdor io heelstrikeor thesideof theshod
The gait evaluationmay now be concludedby
tie distf,nc€beh,/eeneach fool during atr averaBe
i.e..by notingthe baseofgait. Tibiofibularva.umcan
be nrcasurcdby placing the patient io the averagcbass
anglcofgait andmeasuring therclarionship bclseen
s€clioDof lhe distal leg and tfie ground(Fig. 4.16).
funclional tibiofibular varum is pr€sent(e.g.,contracture
th€ tduckrr musculature tesultingin a cross-over gait
lern). appropriatemeasurdssholld be taken lo rcduce
sofr lissue imbalanc€.
In addition1(]the visual informalionobtrinedal
time of the €xamination, many practitioners opt fol
nrorcrcliqbleinformalionob€inedwiih various
malDgraphy equipment. For purposes of mq$udng
period eve6ion of the rearfoot, standardhomevideo
crar are efleclive(theserecord€rs shootapproxinalely
franreshec)as the sublalarjoinl noves throughils
ranfe of morior during the first 507, of the cortacl
lhen hasa dwell at ils end-pointthat rllows lbr
men\ur€nenr(16). Also, this equipn€ntallowsfor
Figure4.r5. Thetlutsus maximui gait palte.n, (Moditied moLlor analvsit of the comDl€xstructuralirteractiom.
f.omHopperfeldS.Physical oftheSpineandEx' iniormationobtainedvia videoevalualionrnayalsobe
Exnminatign
tremities. ry'Crofts,I 976:I 39.)
NewYorkrAppleron-Ce.rlu valLllble, as it allows for pre- and posttreatment
 Chapterlour BiomechanlcllExatDlnatlon 191

g3i!

iig'lrea.16, Mealurin8libiofibularvarum.Priorlo record- cred essenllal,il is nd{ ncceisaryto maintainrubtalarneutraL-

inBthismeas!rcment,
thepaticntmusrbe positioned wnh feel ily when takingthk measurcment, a5bestrcqull9are achieved
in lheploperanSleand basaof gait.Ahhouehonceconsid- with the fool in a rcnin8 calcanealnance posilion(21).

is0ns, a fratufclhat is parLicularlyusefulwhendealingwirh rbe nr'l meralalsophalatrBcal joinr i, runnciswith planrar

Solllissuecontactures, fasciitis..lOrthopSponsPhysTher 1987;8(?):357.
In addilionto video equipmonl,many practitioncni 3. Rodge6 MM, Cav$agh PR. Pressuredhr.ibulior in MoF
bdvecometo rely on morc sophislicated mcthodsof gail ron'sfoorsftuctu.e.lved Sci SponsExerc1989121(r):23.
suohas tle EDG (clecirodynogram). 4- BlakeRL. CommonSportsInjuriesandThek Tr€atment. Fool
blaluation This de-
and t-eg lilnclion. Desr Park, NY: kngcr Biomechanics
vice,whichwasd€vcloped by Langert-aboratories, consists (jroup,1989;9(3):7.
of7 planta!fool s€nsolsthst accurately m€asurcsho€/lbot 5. MessierSB Pntah KA. EliologicfactoBaGsocjaled wilh sc-
intcdaces al eachsile.Ailhoughunablelo measure absolule lected rulning injurics. M€d Sci spons trxerc l98q 5:
toice,theEDG suppliesreproducible inlbrmalion.€garding 501-505.
dutation of time thalcachsensoris exposedto pressure, 6 CoplanlA. RotadonalnoLiodof rhe knee:a conparhonof
l5 wellassubtlechanges rel4tedto relativeincreasesor de- nornal ald proraling slbjecb. J odbop spods PhysTher
in pressure (22).This informationis cunically I989r10:366 369-
as it allowsfor numericalquantification thal may 'lse-
be 7. Rool MC. Olion WP, Weef JH. Biomechmicar Examina(ot
d lo an esrablished norm.The signiticance of th;s ot ths [oor. Vol. L Los Angeies:Clinjcal Biomeohanics,
cannolbe understated, as the EDG allowsfor 1971.
iv€ pre- and posltrealment 8. Snith-OricchioK, Haris BA.Intenalerrelhbilily of srblabr
evaluation.FurGermore,
rcltral, calcaD€alinversjonand evesion. J Onhop Sports
s€theequipment is portableandcarriedby Lhepatieni
PhysTher1990i12(r): 10.
wiresconnecllhc sensors to a nm packanchored to the 9. LatanzaL, CrayC, Karthe!R. Closedve6usopen kinematic
I's bell),biomechanical datarelativeto foot/shoeor cbajnnealurenerts of sublalarjoint evc$ioD:impiicalions
canbeobtajnedin vi uallyanyenvironmenl- foi clinicd pnclice. J Onlop SponsPhysTher 1988;9(9):
s 310.
10. K.ye JM, Sono L.\. The K squa.e.A new biomelltanicll
l. HhsJM.Fuictionalfool Dhordels.Los Angeles:The Oi neAsu.inedelicc for thc toor endankle.J An Podiar Assoc
1979;69(1)r 58.
2rCrcishlon
DS.Olso'rvl". Evaluarionot rargeof motionof 11. McPoilTG, Kiechr IlC, SchujtD. A surveyof looi ryposjn
192 FOOT ORTHOSESand Othcr Foms ot Cons.ffadve Foot Crrc

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.
13.JonesB. CdwanD, RobinsonJ, PoIy D, Bcrey fl. Clitrician reliabilltyIn e clinicalsotting: Subtatarand anxte
nssossmenlof adiul k,ngiludinal arch from photogmph. fieasor€msnta.PhF Th€rl98g; 68:672-677.
MedSci Sp() s Eierc 1989:21(2):60. 25. PiccianoAM, RowlandsMS, Wonel T. Ro eb ily o,
14 P€rryJ. An.lomy nd biomochaniG of Ih€ hindtbol.Clh Or and closed kinetb chatn subtstar jotnt n6ural ;06
tbopRehtedRes1983;lZ:9. and naviqiar drop |€6t. J Onhop Spods phw Ther
15. JorgenscnUfre, Bojse'FMollg F. shek lbforb€t'cy of f.c- l8 (4): ss3558.
tols in thc ihoe/heel inlcraclion-wilh sp.cial iocus on thc
r o l e o tthehec lpad. F ootA n k l cl 9 8 q rq (l l ):2 c .t. 28.AstromM, AfvldsonT. Allgnmonland joinl molionIn
nomallool. J Oihop Sport8PhysTher1995;22(5):
16.CavanaghPR. Thc shoo-ground inteface in runnitrg.ln: 222.
Mack RP (ed). Sy'rposium of thc Foot and bs in Rudnng
2T.tiiamond JE, Mueller MJ. Dolitto A, Sinecore
Spons.St. Louis: Cv Mo6by, | 982: 3G{4.
Betiabilltyol a dlabett loot €valuafon. Ph'ls TIte
17. Clmphcll KR, GEbircr MD, Havlhorne DL Alcxarule. U. 6s(lo)r 797.8@.
Th.cc-dinr|nsional kincmrricof,.|!sis of tibir!cilcan.rl mo- 28.SomnorHM,Vallentyne
rions.llring rhc supnl)nphrscot gdir.M(l Sci SlDrrsE\cre
SW. Eflsctot loorposruro
lheIncld€nce
ot m€dlatbtalstres6svndromi.M€d
!0 1 t9 ::l ( : ) :s ll8. SportsEx€rcise
1995i27(6):BOO-Oo4:
l$. Schucttr RC. Clinical Biumcchrnicr.MusculoskellulA,i-
t,on{ .nd Reetiins. Ed. :. Bdtinrrc: Willirn\ .\ 2g.PowetaCM,MatfucciR, HanptonS. neadootpostuB
wnhprlef|rlemoralpain.J OrthopSpo !
subi€€16
Wilkins:I l-1. Therl0g5;22(4):15tt59
l1r.Hopsntr'ld S. Ph),sicrlExnnrinrti(rrul'th! Spincrnd !\-
llemiU$ NewYor\: Aptl.lotr-Ccntot-C'ntis. | 976:| 39. So.Feltnar ME, Macra6HS, Macbs PO et at.
tlaining €lt6cl6 on rca.toot molion du ng runnlng.
2{1.Eosmjiln JV. Dtlucu CJ. MusclcsAliv.: lIeir Fun.rl)n\ Scispo.b Ererclse1994;26(q: lml-1o27.
RevcnlcdhvElcctronvognrphy. Ed.5-B,ltinr(tr!:Williinr\&
Wi l L i n s. 1985. 3l.William8KR, Aff. JL Chang|gsin dlstance
ll- McPoilTG.lkbuit D. K.cchtllc. A R)mplrisn oflhre po- nlschanba dug to systomaticverialions in runnlng
sirions usedn'.vduatc tibirl larum. J An Podi{tr MrU IntJ Sporbgiomechl9Sl;7:7690.
A sso c.l 9 u8: 7d( l) :2: . 32.McPoll,TG, Comwell.MW, Relallonship bstw€en
22. StuckRM. l\.,looru JW. Plrwnrdl:aD AC. Fofc{surderthc h l- stalic angl6s ol the rsadoot and lhe patlern ol
lur Sidurfqn rlhh sur8icll rnd onhoricinrcrvcntiun. J Anl moliondudngwalking.J Onhop SporlsPhysTh€r
PodirrrMcd A{soc l9l'ri: 71l(t)):465. 6. 37$375.
SS.NawoozantLiOA.CookTM. Salznan CL. The efied d
loot orlhollcaon lhre€-dimonsionalknomellcaol the l€0
and roarlool dudng runnlng. J Orthop Spons Physlh€t
1995:6:317.327.
 ChapterFive
CastingTechniques
Afi€r aheexanination has beencompletedard ii has
bsetrdeterminedlhat use of foot orthosesis indicaled,the
tlactitione.must now decide which castitrgrechniquebest
tuits $e patie 's biomechanicalneeds.Becauseth€ most
@mmoncausefor orthotic failure is iocorlect positioning
'ofthefoot during the caslingprocess(1), it is esse ial rhat
$e negativcimpressionbe accurate.Surprisingly,thereis a
fair amourtof controversyregading which t€chniqueEost
rccuralelyallows for ideal functioni Someauthoritiesclaim
veighl-bearingcastsare necessaryto captureplastic defoF
'ottion of the soft tissueswhile others advocar€$at notr-
rv€ighl-b€aringplastercastsare superior,as they alow for
,daximalcontrol of motion,
In orderto clear up someof the coniusion,rhe follow-
.i!g se€tionswill r€view th€ principles andproceduGsasso-
rcistedwilh each of the various techniquosand relato this
:idormalioDto lhe clinical objectivesinvolved ir making an
lorthotic.The advantagesand disadvantagesassociatedwith
facl lechniquewill be snmm,'i7€d al the etrdof eachsec"
lion. The final decision as to which techdque should be
jiur.dis basedupon reaunenl goals, examinationfindings,
.endthetreatingdoctor's €xporienceand/orprefercnce.
Theprimary castingmethodsare oudin€das follows:
1.lul-weighcbeariog polystyrenefoam step-in.
,2 Neutralposition, semi-weight-beaiingpolyst,.renefoam
$ep-ln.
i3. NeutrslpositioD,off-weight-bearingplaslercasls.
14,Harg techniqueplastercasts.
5. I!-shoevacuumt€chdques.
Fu,-WErGET-BMRTNG PoLyslyRENf, FoAM
STEP-IN
Method
The patienl is instructed to stand in a tray of poly-
lqftm foan with full-weighl equally distributed between
jtnthfeet.
Ralionale
laboraiories advocatingthis techniqueadvocatethat
it is superiorto all otbers,as it crptures the degreeoI soft
llilFredeformalionassociaredwith static stance.This iDfor-
prtion is lhetr usedto choosea specific height for the me-
Eiallorgitudinsl arch.
193
Dircus6ioo
The conceptof ooting plastic deformity in a casr is
valid, as it provi&s information regardingthe i egnty oI
lhe boly and ligamentousrestsairing mechanisms.How-
ever,the needto vedfy this information witb a weight-bear-
ing cast is oi questionable value since it may morc
accwatelybe measuredby noling the navicular differedial
as the foot shifts ftom its neuual pGition lo its resting
slance positioo. Furthermorg full-weighlbearing casting
tech$quesalso capturea pictureof the foot in its fully com-
pensatedposition: since resistanc€ftom the polystyrene
foaD caosesthe plantar forefoot atrdr$rfoot to shift !o tbe
same tnnsverse plane (which obliteratesflexible forefoot
deformiti€s),it forcesthe midta8al joint to collapseanden-
ablesa hypermobilefirst ray to doNifiex and invert. An or-
thotic fabricatedliom such an jmFession maintains all of
tbe positional pathologies associatedwith this aberrant
compensafion,
Note that sone labomloriesclaim ihey prefer a com-
pensaledpicture so lhe moalialarch caDbe built up ftom
that position. However, without the foot in Aod of them,
the orthotic laboratoryhasno ideawhereneuual position is
and,thereforc,must guessas to the idesl afth heightftc€s-
sary for corr€ction.Suchnorspecific buildup of the medial
longitudhal arch risks undorconection (with contitrued
symptomatolos/) or worsc, overconectiotr,which Eay be
exlremely deshuctive, as an oversized arch support ran-
dotr y invens the entire foot. This may Ieadto a varioty of
injuries, as inversiotr of the forefoot offen preventsplan-
tarflexion of lhe first ray during propulsion (which may
eventuauy lead to desl ction of the fi$t melalarsopha-
lansealjoint) while inversiotr of the rcarfoot may prevent
d€fection of the midtanals ad lhit lhe rang€ of sublalar
pronationnecessaryfor shockabsorptior
As notedby Robbinset al, (2, 3), excessivcbuttess-
ing of the medial loogitudinal arch may p.oduce proprio-
ceptive de6cil6 (pol€ntially producjrg a neurotrophic
arthropathy)and,by stimulating cutaneousreceptorsunder
the nedial longitudinal arch, may eve ually lead !o injury
of the metatarsalheadssecoDdaryto impaircd muscularsta-
biuzation. Furthermore,Olancy (4) sratedthal becauseat
exaggoraM medial arch sup?ortwill block the storageand
eve ual retum of elastic energyduring the contact period,
the long ard short digital flexoN may be chronically
straioed as they attempt to compensatefor lhe wealened
calf musculatureby firing vigorously dudry midstanceand
194 FOOTORTHOSES.md
OthcrFormsof Cor*rvarivc Fmt Carc
propulsion(i.e.,tibialispo$tenoris espcciallywcakcncdby
lhecomplctcblockageof rearfootevcrsion).An excessively
high nich supportmay alsodamagothe tissucsdircctlybc,
nerlh themediallonSirudinal arch,asil maycontus.lhcab-
duclor haliucismuscleand createa bowsrringeffccr thar
increascs tcnsilcstrainplacedon lhe plaDtarlaicia (5). An
€xc€ssivclyhigh arch slppon may also producea ncuro-
praxiaof thc medialandlar€ralplantarnervestfut caDtakc
4-6 we€kslo heal,evenaft€rthearchsupponhasbeenre-
noved(6).
For the above-mendoned reasons Roorel al. (7) ca!-
tionedagainstnonspccific buildrp of thc mediallongirudi-
oal arch. Thcy claimed thal althoughsuch inscrls will
initially .cducc syinptomsassocialcdwith ligamcntous
sprain(lh€y reducelensionon the strelched mlcaneonovic-
ularligamcnt),lhey shouldalwaysbe avoided,asrheynuy
eventuallylc|d to permanenl osseous deformityof thc Ilrst
joint.
melaiarGophalangeal
K€epi0 mindthatlhe maingoalofo(hotic thcrupyis
to allowfor 0onconrpensaled lunctionaboutalljoinls oftlrc
foot and ankledur;ngall phasesof stance.To accomplish
lhis, the laboratorymusl reccivea modelof the foot in its
neutraiposition.This positior seryesas a rcfercncepoilt
for id€alfunctionlhatenabl€s rh€onhoricto mnlrol morion
pr€ciselvaboutrll axerduringlhc conlac! flidstance,and
propulsive pcriods of gait: lhe rearfoot posl and calcrneal
inclineanglcof thc orthoticshcll will conrrolsublalarmo'
lion duringcontact period:thc reafootposlandmedialarch
supponwill controlsublxl|r and midlars.l motionduring
midslancc (thearchis loweredto allowfor defiecliorl ofthc
midtar$k necessary tor shockabsorptionand propriocep-
tion); and forcfootpasting(if needed)@ntrolsmidtarsal
undsubralrrmovemcnts duringthe propulsivcp.dod (and
indircclly,during6wingphase).
By properly posling lhe rcarfaol and forefool seg'
mcntsdurinSlhn vark'usperaods of sta0cephase.a well-
madc ortholic enablesthe medial longitudinalarch lo
supportilself,withoutunnecessary buttressing via cxkinsic
suppods(8). Laboratoriesthar insisl on tullweighi-be.ring
caslslypicallybas€theirevaluarion or staticfunctiol.with
supportof the medialarch the prinary goal of lreatmcnl.
This approachis outdaredand inapFopriate,as it allows l'or
effectivecontrol of abnorrnalfool tloction only during
midslance:the arch suppon is nonlirnciionalduring rhe
contactandproprlsivcperiodsof gait, as lhe archdoesnol
firmlyconlactlhe fool duringlhesepcriods.
Thc inabilityof arch supporrsto effeclivelycontftrl
biomechrnical abnormalitieswasdemonstrated in a Dartic:!-
larly interc$tingstudy rharcomparedthe effecliveoess of
archsuppo s andfunclionrI oflhotics(i.e.,semi.igidplastic
orlhoticshcllswilh denserubberposts)(9). Th€ arthorsof
tbissludydemonsrrated tharafierfailurewirharchsuppoas,
81.274oflhc 35 patienlshadsuccessful resolutionol symp-
tomswhcntrcatedwith thefunclionrlorlhoses. This clearlr
dcnu)nstraied
thatan effectiveorthoticmustdo mrch
lhrn mcrelysuDport
themedial:rrch,
NEUTRAL PosITtoN SEMFWEICHT,BEARTNG
P0LySTYRENE F0AM S'rf, P.IN
Method
Wilh thepatientslandingnert to thcexamining
lhe tcet are positioftd at their prdpcr rnglc andbascot
rs (ictemincdduringthcgaitcvaluation. The paticnris
asl.d lo sit,andtbepractitioner placesa trayof
foalnunder€achfoot.While mainlaininetalonavic.lrlar
gru.ncy, a firm dowtrwardforc-eis applied, 6rst on top
the knee.ften on too of the meta(arsal headsa d to€s
5.1).The linishedimpression muslbe al lcasl2 irches
so rharthe ldboratorycan lill it with cnoughpiasrcrro
trin ,n ad€quate posilivcmodelof lhe palicnr'sfoor.
lcclrniqucmay rlso be pcrformedby wrappingthcpati
fool in plast€rasit r€stson u softfoamb.d.
Ratiolrale
Maintainingthe subtalarjoim in its oeulral
lhe lat'oEtorya refcrence
poinrfor idcalposirion.
8iv(s
Discussiorl
Tlis t€chtriqueaffords a f|tst, simple, atd
melhodfor crpluring a pictureof the fool with ideal
joinr positioning.Because a semi'weighcbcaring imprarsiotr
is osed,ther€is adequate displacemcnt ofthe plantarsofrlii-
sues.which n€gatesthe needfor nlling-outor "firdging'
arcundbordersof th€ cast,0s is necessary with all oft.
weight-beArjng techniqu€s. Schuslor(10) claimedthatany
mo(lificalionof lhe posirivemodelto allow soft ti$,!ue e,(-
prrrsionupon wejgbt-bearing is guosrworkand shouldbe
avolded.Schuster (10)alsoclaimsthatsemiweighl"bearing
tcch iouesdlow for a moretolerablcorlhotic.
l]|e only dra$backto thislecfiniqucis rhalit disrors
flex,bleforefooldeformities(particularlyrhe flexiblcforc,
fool valgus and phntarflcred first ray), as resistanceftoo
lhe polyslyrene foari causesthc plantar forefoor to shift
fuxr ils ocutralposition.While Schu:iter(10) maintained
thal semiweighlbearingimpressions arc ablc ro captlrc
forclootrearfootrelationships accuratcly. this hasbccnre-
ccntly disprovedby McPoil cl al. (11), as they demoF
slrarcd tllat ooty ncu|Ial pGsition off-weight-benrilg
techniques wereableto duplicatcfbrcfoovrelrfoor rclarion,
$hipsaccurately. Because of lbis.semiweight-bearing tech'
niqrcsareusedprimarilyir lhe lrcatmcnrof rcrrfborvarus
deformiliesand/orrigid dcformities. (A rigid lorcfootvnrui
orvrlgus will norshiftfrom ils fixedposirionuF)nmeeting
reshtance frum thepolystyrene foam.)
The s€mi-weight-b€aring rcchniqucs are parricularly
 chaptcrfive CsstlnsTechniques195

individralsandthe lstloratorydoesnot allow for ad€quatc

soft tissucexprnsion,the edgesof the orthoticshell will
oflen dig inlo ihc patient'splantarsofl tissues.)Schustcr
(10) claimcdthatthe averxgcfoot will lengthen57r,widen
l1dl. at theball and 139,at theheel,andthonavicularwill
drop8-10 fnmuponweight-bearing.

NtrUTRAL PosrrroN OFF-WEIGIIT.BEART,\G

PLASTER CAsTs

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

5.1. The neulralposhionsemi'weight-bearing

tbr lreatiflg€quinuscondilions(ii is oftendifficultto

ne how muchto lower tbe nedial lonsitudinalarch
usingoff-weight-b€aring techniques) andfor individ-
whoscfoot structurechangesmarkedlyuponweighl
(lf otf-wcjghl-bcaring
te€hniques areuled on thes€ Figur€s.2. Then€utralpo3iiionfoot.
 196 FOOT ORTHOSESsnd Other Foms of ConscwativeF@r Crrc
Figure5.3. Off-wei8hl.bearingplalt€r c.dlng t€chniquer.
fitur€ 5.a. Off{.right-b€dint
pla.tcr cartingrechniqE.
finger (Fig. 5.3). The plsstcr strh is lhcn submergedidto a
tray of werm water (for appmximatcly3 saron&), gendy
squeczcd,andrcmovedfroft rhewater.Tbc plaser ofParis is
th€n mixcd thoroughly thtuugh the clolh by rcpeatedly
squeczing thewer pla.sterrtrip in the palmof thehand.It is
imponant that rhe fre-eend be drmly hold throughou this
proccss.asdoing so allows unfoldin8of thewerplasrers8ip.
Once the plastcr hasmixed with the cloth, the plaster
slrip is opcn€d,andthc upperborderof tle strip is foldcd aF
Foxamfltely l/4 inch, therebycroarioga lip along the endre
upperedgefFig.5.4).The plasteris thenappliedlo thefoot
by wrappingit aroundthe heelaod'tscking" it downto lle
lop of the tirsr and lifth metatarsalheads(Fig. 5.5). The
brnging plastcr is then smootftedag|in$ lh€ m€djal arch
(Fig. 5.6), then overlappcdby the lalersl strip. The smattv,
shaped nat that forms ar the base of the heel is lhen
smoothedsgairlsr the c{sr (Fig. 5.7). The secoDdpiece of
plasreris applicd by drapingir over rhe torcfoot (the plosrer
on thc dorsal foot is tacked againsttbe prcvioussrrip) and
folding it as illusrared in Figures5.8 and5.9. The patiert is
the. askedlo relax,and lhc tor€fool is loadedby pr€ssingup
on the founh and 6fih mehrffsal he6dswhilc mainlainillg
talonavicular congnencywith theoppositehand(Fig.5.10).
Bccauseof thc dangersassociatedwith capturing a
supinaredimpression,ir is suggestcdthal , slighl aMuctory
forcc be uscd while loading rhe metatarsalhcadsrnd tid
tirlonavicular corgruency be nainlaircd in i posiliol i[
whjcb thc hcad of the lalos is slighrly mor6 palpablcon it6
medialside.The foot is heldin rhispositionwhilelhepla6-
ler hfidens(for approximately 2 minutes).
An ahematemethod of loading thc forcfool is witu
the suspe$ion rcchniqrc (12, l3). This popular
requireslhar lhe pmctitiooer fir ly glrsp the proxinal pht
langcsof the fourth and fffrh digits b€twe€trthe lhunb and
index0nger (Fig. 5.11A).The foiefool is rheolo.dedby
g€nlly plantarnexing tle fourth {nd 6fth digirsuntil they
parallel the long axis of rhe foot (this allows the respcctivc
metrlarsal lrca& lo dorsili€x slighlly, blacl armw in Fig,
5.llB) whilc simrltaneouslyapplyinS at| upwardrnd
slighlly larcral forcc in ord€r to lock rie calcrne&uboid
joinr. Tfuoughoul this process,lhe to€s are rrsctionedin
long axisexlcnsion(therclaxedfoot is actuallysuspcnded
fmnr tle rable),which allows for proper elongalionof rhe
Dlar(arsofi tissues,
The flished cast is renoved by pirching the skin or
the dorsumof the fool (white anows in Fig, 5.12)and
pulling down on the h€€l-The pradidoflerthencarefully
pus}es the casl forward, geotly shaking it until the c!s1
glidesofl thc forefool(Fig.5.l3).
The accuracyof the negrtive inrpressionmay nowb.

Ftute 5.6. Off-weighl-bearingplaslercaslin8t€chniqu€s.
ed by placing the imprc,csioD on a level surfaceend
$!e frontal DlaneDostrionof the h€el: if a forefoot
is present,the bisectioDof lhe reaifoot should be
if a neutralforofool is pres€nt,the rearloot sholld
verticil; if a forcfoot valgus or plantarflexedfirst ray
presont, thebiseclionsiould be inverted(Fig.5.14).
The most importantcriterion to considerwhen evrlu-
lhe rcgative model is thar lhe plaster impressiot
metchin ev€ry derailthe shapeof rheneutralposition
(Fig. 5.11. DevialioD ftom the anti€iparedfoot shape
commonly.esulLsfrom insufficient loading of lhe lal-
column (which gives the false iftpression of a
lateralcolumtror foretoorvarus),tsking the
wii\ the subtalar jctint supinai€d or pronated
Ch+ler Five Clsdrg Techniqu6 19?
Figllrt 5.s. Otr-weigtt-bea.ingplas-
rer castin8lectmiques.
Figure5.7. Ofi-w€i8ht-bearin8plaiter castingt€chniqu€s.
(whicl will resul in a falseforefoot varusor valgus,respec-
tively), and/orfauhy useofthe suspension techdque(in-
appropriate do$iflexion oI the toes vi/ill rosull in a
plantadexed laleral colurDnwhilg excessivepressure{rom
the thenaremiftnce may producea false forefoot adductus
sealndaryto InadveateDt supinationof the forefoot aboutthe
oblique midtarsaljoint ar(is). If for ary reasonthe neutral
foot and negativeimFession do not match, the carl should
Rrtionale
This techniquecapturcs a pict{re of the foot in its
most stableposition: the subtalarjoinl is in neutral and the
198 FOOT ORTHOSESsnd Olher Forns of CollsewariveFoot cN

figur€ 5.9, Off.*€i8ht-b€arin8plart€r casting

rlgure 5.8. Ofi-tal€igh-bcaringplader caldngr€dniques.

fiSure 5.10. Off-w€ight-bearirBplalter calting tecftnique!.

A
+q^)
l+ t
t-CQrhu
p;*'""*
t\
t\
'q$

technique.Note lhal whenone

figwe 5,11. Thesuspeoeion mebtnrsalheads uponlhetecondol
andshouldnotencronch
us€sthismethod/thethumhshouldalwaysparall€lthe less€r thiftldlgiB(13).

Figur€5.12. Ca.l r€molal.
Figure5-r4- Evalualingforefoovr€arfoot
crlcateocuboid joirt is in irsclose-packed
position,thereby
slaliliTingthe forefootagainslrhe rearfoor.This giveslhe
lrboratorya refcrcncepoinrfor idealposilioningof all ar-
ticulations.
Discussion
'nis is the mosl accuralelcchnique[or capturing
iorcfootfearfoot relalionships(11).An oflhoticnadc fron
Uisirnpression allowstbr precisecontol of morionduring
rll periodsofslancc.The only problemwith this tcchnique
is lhatil requirespracticebefbreaccuratcreproduction of
thencutralfool is possiblc(particularlywilh lhc suspension
thatplaslerbe add€d(o the pos-
) ard neccssitatcs
iliveftodEIlo alhw for softtissueexpansion uponv/eight-
ng.
IIANG TECHNIQUE PI-ASTER CASI
MGthod
Thistechriquerequircstakinga plasrcrcastwhilethe
nt li€ssupinewilh rhe foot and leg restingin a com-
ChapbrFile C{sdng Techniques 199
figurcs.13. Castr€moval.
r€latioDlhips.
fortable posilior. Thcr€ is no loading of the forefool or po-
sitioningof lhe sublalarjoint duringthecastingprocedurc.
Rationsle
It hasbeensuggestedthat a negativeimpressior made
usingthis Iechniquecloselyduplicateslhe contoursof a
neulrallypositioned
fool.
Discussion
Allhougb the hang techniquewas popular in the
1940s, il ha$for lhe mosr part beenabandoned.Tbe rcaso!
for thisis thattheincrcased tensioncommonlyfoundin the
musclesr€sponsiblefor deceleratingsubtalarand midtanal
pronalionhavea t€ndency1I)maintainthc restingfoot in a
positio' wherelhe forefootis invetcd aboutthe longitudi,
nal midtarsaljointalis while tie rearfootis supinated
about
thesublalar joint axis-
Unlgsssubstantial aremadeon thepos-
rnodirications
itive impression(which would seriouslycompromiscthe
accuracyof theposilivemod€l),an orthoticnolded to this
200 FOOTORTHOSES
ard OtherForDsof Co6ervatvcFml ClI€

figure s.ls. Criteriafol evalualingnegatlvecasts(14). l)

Thefronlalolaneporitionot the heelshouidbe wilhin 2'of
lhe m€asured forefooy'reartooi
relationship. 2) -Ihetransvece
olanerelationshiD beMeenthe forcfootand rcarfootshould
exactlymaichthe patienl's fool, i.e.,an individualwilh a rec'
tus loot shouldpresenrwith a stralshtlat€lalcolumn(A),
while an individualwilh a melatarsus adductusshould
demonslrate a medialan8ulation of ihe forefoot(8). 3) lf the
suspension techniqueis ured,lh€ thumbprint, which should
alwaysparallelthe sulcus{C), shouldnot conlaclthe thid
disit,andthethenar€minence shouldnotbe imprinted on the
laGralaspecLol th€ c:ist.Also, rhe folnh and fltrh digirs
shouldba fteiiherdoEiflerednor plantarflexed (D). 4J The
contourof the lat€ralar(h (f) slmuldduplicat€thecontour.,f
the Datienltneutlaloositionf@t. 5l Examination of the int€'
rior of the can should.evealwell denneds*in lines,andthe
DlartarimDre5sion! of the fnit and iifth metaLalsal heads

Figures.16. In'sho€vacnm cast

t€chniqu€.When performingthis
caslinA t€chnique,Valmassy(13)
reconrmendsusinS a loose"fiftlng

lnpression \eouldmaintainthe ertire foot in I supinal€d
losidon. nentioncdpreviously,lhis
As may resullin a vari
ctyof injuries.Also, bccausethis tcchniqucmakestro ac
lempllo loadlhe lateralforcfool,il caplltesall functional
fooldoformiri€s 0hc mosr commonbeing lhe funclional
Iorcfoolvarus)that arc typicallynol tfeatcdwith posting
techniqucs.
Bccalsclhc problcmsassociated wilh lhis techDique
fiNybe avoidcdsinply by mainlainin8the fool ils neu-
'n
lril posilionfor the 2 minulesir tak€sthePlaster to haden,
it is suggcrlcd lhal the hanglechniquebc complctclyaban-
doncd.
IN.SHOE VacuuM TECHNtQUES
Method
'thc fool is wrappedin plasl€randplacedin a plastic
b!9.Thc caslis thenvacuum-molded 10lhe palienl'sfoot
yhilchc/shcis wearinga spccificshoe(Fig.5.16).A varia-
lionofrhistcchnique involvesvacuum-molding a hcal-mal-
e onholic shell (usuauyPlaslazote)dircclly lo the
's footashc/shesirson anexaminingchair.Thesub-
joinl is typicallynaintainedin its neulralposilion,and
lbrufootmayor may nol be loaded.
Rstional€
'lb preciselycoo$ol motion,lhe onhodc mustcon-
borhlo lhc palient'sfoot andto his/hcrshocgcar.
,form
Discussion
Theconceptrhatan onhoticmuslconformlo lhe pa-
's shoc g€ar is parlicularlyvalid when considering
wirhextremehcclsandcurvedshanks.Il an onnolic
c fmm a neulralDosilionimDression is worn in sucha
lheshellwouldbe forcsdro bendor rock at lhe hiah
inr o[ lhc .hank. rherebyirriralinStissucsbcnca(hlhc
joint. Alrhoughusc of $e vacuumtechnique
avoidthisproblemas il captures a picturcoflbe fool
ir restsin theshoe,rhislcchniquehass€riousdrawbtcks,
it mosloftencaDtur€s a oiclureof lhe foot with the forc-
addrcted andrhemidlarsaljoinr supinarcd (13).
This risksiatrogcnicinjury from ovcrcorrcctioo un-
subnanliulmodilicarionsare madc on lhc podtive.
whileBrownandSnirh (15) claim rharir is tnssiblc
crplurcforefooUrcarfoor rclarionshaps accuralelywilh
lechoique, it seernsunlikcly sincelhe soleof the shoe
to ndinlain the phnlar lbrcfoorand rcirrfoolon lhc
ChapterFive CrltL8 Tettriques 201
CAD.CAM TECHNIQUES
Mcthod
CAD-CAM is an acronymfor Compu@.Aidcd DesiSn-
Comput€rAid.d Manufacturing. In lhe past, this
tcchnology was utiliz€d primarily by lhe automobil€
induslryas the CAD could only bc run on very largeand
cxpensive comp!tcrs. Fortunalcly. advances in
microcomputcrtrchnologyhair sllowcd for morewidcsprcad
useof CAD-CAM tecbniques.In fact,aurornatcd onhoses
arenow b€ing manufacturcd by morethan15labs,
Basically, the proce$ involves using mlgnetic
rclonance(MR). whiteliEhtor laserto scanan imascof lhe
padenfsfool (or casointo a computct.Accordingto Black
(16),the MR methodinvolvespassinga maSneticficld
acrossa ca$ and rccordingthc image. The imageis lhen
compared to ovcr 10,000previouslyrccord€dcaslsto selecl
lhe mostrppropriarconhoticshape.This informadonis
thensentto a milling machinefor productionof the final
onhoric(whichis lypicallymadcfrom a fai.ly riSidplaltic).
The while light recbniqueinvolvestakinga numberof
phorographic imagesthal are analyzcdand modificd by a
compurersoftwarcpfoSramthat inrcrpretsits lhaPe and
ultimaielymills a device.
By far, the mostsophisticatcdmeftod of CAD-CAM
technologyis the laser scanncr. Developedby John
Bergmann, DPM, the processinvolvcspassinga laserlight
sourceover a patient'sfoor or cast (he palienfs foot is
usually maintaincd in its neulral position usinB lh€
suspension techniquc).As the lascrPesses overlhe foor.a
videocamcrarccordsthe image, Bccausethe camcraand
laser are positionedat sp€cific angles,it is possiblelo
calculate the x, y, and z cooadinatcs at any gavcnpotnt
alongthe enlir. surtrc€(usually,
datasamplings arcrecorded
at 2 mm inrcrvals). The compulcr thed analy?csthis
informaiionandcreatesa Sraphicdispl.y of lhe foot on a
The nexrstcpinvolvesmanipulating the graphicimage
ro allow for soft rissueexpanaionwith weiSht-bcaring
and/or for thc addition of vhtuslly any modification
including balances, forefoot platforms, pockel
accommdations, de€phell cups,ctc.
Oo.:ethc imag! hasbeenmodified to the dcsired shaPe,
it is senlovcr a computernetwo.k!o a milling arca. The
milling machinercsemblesa drill pressthal cxactly
duplicatesthe final computerimagaout ofan iniermediat€
material (usually war). This intcrmediateservesas a
posilive model upoo which any shcll material may b€
molded.e-g..lcath€r,Pl.sEzotc,graphiic,etc. If a Plasiic
orthotic is dcsircd,first lhe lop is milled lo fte desircd
shaDe.thenthc msterialis inverted!o nill the bollom. As
with designingthc supcriorsurface,it is polsibleto mill th€
plantar surfacc inlo any shape,lhcreby incorporaling
inlrinsic/extrinsicforcfoot and/or r.arfoot posts,medial
grind-offs.etc.
 Ch{ptc,Fivc C{riin8Techrtques
.ln addilion ro MR, white liShl and las€r scanning,
anorhcrlropularCAD{AM lechniqueis conhcrdigitjzin!.
This methodinvolvcs having lhe padenrstep on a trsy
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
computc.rnalyzesrl|c infonr'adonandproducesa 3D image
that can bc modificd. Thc final inagc is rh€n senrro a
milling machin€andconvenedinlo an onholic. prcs€rrtv-
onhoticsm0nufacrurcd wi$ rheconracrdigirizingr€chniq;e
arelimitcdto a comDr€ss€d EVA maerial
Rstionrle
CAD-CAM technologywas developedto providc
proclirionefli
wirh r fLstandaccumre
melhodofduplicaringa
patient'sfool andpreciselymodifyingjt to conlrol rnolion
!n or rcdistributcprassore,
Dlscussiotr
when pcrforminga scan,the paticnls fool fiay bc
mainlaircd in a neut al off-weight-besdngposilion (as wilh
thc ltscr optical scan)or n scmi-wcight-bcaring or fuil-
wcight-bcarinS position (as with contact digitizing
r€chniquc!). B€caus€som€critics point out $rt lhe off-
wciSht-bcrring inprcssiofls requir€ substallial modification
of thc positive model (this is true \r,helhe. a lascr scan or
plastcr casr is takcn), Bergmaoo Orthoiic Lrborutory
providesa glass plaacro compressthe patienfs foot dudng
thc scrn (thereby duplicating a semi-weiSht-b.aring
imprcssion).
ln rrgards to onhodc producdoo,a mqior criticism
of someCADCAM labs.elalesto the limitcd sclcclioool
shcllmarcrialsii.e..MR lechniques aretypicallylimhedto
the rigid plasticswhile labs utilizing contactdigitizcrs
providconly compressed EVA. (Alfiough labsproviding
contact digitizers correcdy point our that it is not the
matcrialrhit mrkes an orthotic funclional.it is thc post
angles.)B€cause laserscanning incorporuiesan intcrmcdiat.
model.the practitioner may choosefrom thesomemateriols
availablewith nanual productiontechniques. e.9.,laather,
gmphire.ctc,
Another cilicism of CADCAM devicesrelatcs to thc
acctrracy of the milling machims. Someof th. catly CAM
systemsrequircdconstanlrecalibralionot the comPleted
onhodc *ould be differeol than the ooe displaycd on thc
compurcrscrc€n(his couldresultin iatroScnic injury a! on
incorEctly slopedan:h would conuse thc con$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
north. Of notc, in the nor too disuni folurc,
millinS mnchincswill be available(tbiswill
dily tumov€r).
RefercDces
L Arotr'nD. Snith C. Vacuumcasrinsli'r lid
PodiatrAseF 1976:66(li):581.
l. Robhnrr
SE.Hrnn. AM. Ru|ln;n!-relurd
injury
throush brrefrxn adaplarnhs. Mcd Sci Stioni
l 9(l ):148-156-
r. RobbinsSE. Cdu$ CJ. Hann! AM. Ronni
prcvcnrionrhrou&hir.atc arnl)uct-modcrurirg
Sci Sporls&erc I989i ll(l): l-1lrll9.
l. Olrncl J. Onhoticcontrcl ol grolnd rcactio0|
pmpulsionr u prcliminrryrcpon.OnhotProflhcrI
5. Crm cll JW. InmanVT. Treahrelrof pknut
calc ed splj| wirh llc UC-BL shor ins{n.Clin
IntedR cs1974i103:57.
,,. W3llcrlF. tlindftut rnd nidirnn prcblcnsul rh'r
Mick RP (cd).SyrnposirNot the Foorlnd Lcg in
Spo s. St-L.uk: Cv Mosht. I98l:?1.
t. Root MC. O'ion w?. W€ed lH. Nomrn and
Flnction ol tfte Fool. Los AnAclcs:(tinical
1977.
il. l)'Amica JC. Pre$ribD! lb.'r onhoies:thc
pr.cess. Foor and leB func|ion. Decr Park,
mcchanic\ Croup19|n: l{l):3.
\). Virrk M. Kcrkc P. TEalm€nrof rcjtion l anomars
fool sifi i tundionnl s4ponive inla!. O hopadc
l9E9: l:7(l): l5-: l.
Irr.schusrcr Ro. NeurBlplaflarimprersion
cnsr-ncrhod
tior!l(. J Am Podia,r
Ai-$c 1976:66{6}411.
I L McPoilTO.SchuirD. KrcchrHG. Comm.isonafrht!.
ods usedlo obhin a nertml Dld\|cr toor ihur€ssion.
l:. tsurrs MJ. No!-weiehlbrarii8clsl irnprcssi('rs
for
sllucri.n of .flhoric dclrce\ J Am Podutl Aso
0 7 (l l ) : 7 9 0 .
Lr. Valma\svRL. AdvrnuAcsanJ disadvanrrgcs di
J An P(nliiu A!\oc . IeTq:6q(l:t. 7tl?.
ing rechniquc..
I L RossAS. JonesL. Non-weighlbcarg negarilccasl
ti()n.J Am PodiatrAssocl98li ?2(12):634.
l\. Broln D. SmirhC. Vacuumc&sringi(tr fuaronhors,
Podia! Asroc 1978:66(8): 5ll:.
16.Black E. Automatedlab technoloqy.
l*si 4n-7A.
 ChapterSix

Laboratory Preparationand Orthotic

Fabrication
Although the praclitioner ne€dnot be familiar with all inainsic forefoot posl. Allhougb it has nol yet beefl dis-
slagesof orthotic fabdcation, a cu$ory understandingof cussed, a forefoot deforrDity may be trealed efther by
lbelsriousmalerials,postingtechniques, andorthoticaddi- adding wedgesto the exterior surfaceof the sh€ll (rcf€rued
tionsis nec€ssaryfor the clinician to prescribethe most ap- to as extrinsicforefoot posting)or by makitrgmodificaliotrs
Fopriate orthotic- To familiariz€ lhe reader wilh this to the shapeof the positiveimpressionso tha! rhe she[ itsef
bfornatioL this chapler will review each step in fte is able to cotrlrol the forefoot deformity (referr€d to as in-
po{es$of manufacturing anonhotic. trinsic forefoot posting).
In order to i rinsicaly post a forefoot, two small
MoDrFIcATroNoF PosrrrvE MoDEL nails are driver hto the positive nodel just proximal to lbe
fust andfiftb metahnophalaog€aljoint8, IJ a forefoot varus
To begin wilh, a positivemodel must be obtained deformity is Fesent, lbe nail beneath the ifth motatar-
fromthe negativeimpressioD.This is accomplishedby po- sopbalang€al joinl is driven to a point wh€reit ir flusb with
l.gitioringthe negaliveirnpressionso tharthe bise€lionof the lhe castwhile lhe medial nail is drivel only deepenoughso
r$rfoot is venical (!vhich, when forefoot deformity is pre- that when restiDgupright, the bisectioDof the hecl resls in a
r&nt,requiresplacuB a w€dgeunder rbe medial or lateral vonical posilion (Fig. 6.2A). U a forefoot valgus deformily
Betaars3]h€ads)and,then pouringa mixlure of plasterand is g€sent, the medial nail would be driven flush while the
\rat€rinto the negativeimpression. laleml nail capiuresthe forefooadefomity.
Afterlhe plasr€rhashsidened(whichrequiresapprox- A m€talarsalpladofm is th€n madsby addingplasterto
ifirtely 5lo l0 minutes),the negativeslipperis toin off the plantar forefoot (covering the nails and €xtending ovqr
,andtheplantarsurfaceof the positive modelis smoo&edby the headsof ail $9 metararsalsiFis.6.28). The positivc
impression is ihenp)aceduprighionio a sheerofwax paper,
wet-rubbing it wilh a wire meshor wet sandpaper,The pos-
and th€ medial and lateralsidesof lhe melatarsalplatfom are
itivecrst is then placedupright and gently rubbedin a cir-
pack€dright (Fig 6.2C). Wh€nthe plasteris semi-dry,the
roljir motior against the table. Tbis determines the excessis removed,leavinga 2-cm platformthat maintains
lweigirbearirg contact points of the ffrct metatarsalhead
lhs exact height necessaryfor full correcdonof the forefoot
rld the planrarheel (Fig. 6.1A and B). The weighfbearing defo.mity (Fig. 6.2D). To allow for adequatesofl tissue
pointben€aththe firsl metatarsalheadseavesas a refgrence displaccmenton weighr-bearing,additional plasteris placed
for determhingthe outline of the ortholic shell, as a mark is along the cntirc lat€ml aspectof the poBitivcmod€l (refened
lpla.€d1 cm proximal lo this point, therebyindicating the to as the laterslexpansion).Also, ldditional plasteris added
reedialdistal border of the shell (Fig. 6.1C). A horizotrtal beneathfie m€dial longitudinalarch in order to allow
iine is lher extcndedfrom this point acrosslhe plantarsur- qdequat€defl€clion of the midtarsaljoints during the contact
ftce of the positive casl unril ir bis€cts with the fifth pedod. Althoughthe lsb typicallyaddsl/4 inch of plaster
n€latamal shaft(Fis.6.1D). A mark is thennsde 1/2 cm to the arch area (referred to as an MLA fill-in), the
practition€rmay .equesl€ilher an l/8 or U2 inch fill-in to
poxiinal lo this intersectionlo iDdicatethe distal latenl
'lordcrof lhe ortholic sheu(Fig. 6.lE). allow for a grsateror lesse.amountof midtarcalmolion
duringeffly stanceDhase.
The laleral edge of the orthoric is dererminedby ex- Finally,the meratarsal plalform;s smoolhlyblended
rtordinga line laterally from the w€ight-bearingpoint of the into (hearchcontour(Fig. 6.2E),and a 3nall region of plas-
:heel(B) to a point approximately14 mm fiom the support- ter beneaththe lateralcolumn i6 6led away to onsutea con-
rilg surfac€ (Fig,6.lF). A line connecting this point to th€ stantpronatoryforce or lhe fffrh Iay during gait (Fig. 6.2F),
Feviouslydetermin€dmark located proximal to th€ fifth An orlhotic she that is nolded to this model will h6ve a
uohtarsalhead(E) servcsas a refercnceline for the lateml betrdat its distal m€dial edgethat aloll,s the she to suppo(
:apoc!of theorthotic shell. the forefootvarusdeformity intrinsically, without the useof
addedw€dges(Fig. 6.2G). Nore that if a Iorefoot valgusde-
INTRI.ISTCFoRDFooT PoynNG formity wele present,the bend would havebeen in lhe dis-
tal lateralportion of the orthotic she[.
If forefoot posting is desfed, it is no\r possible to A point of clinical concernrelatesto how far back the
i|Dake modificationsthat allow for whar is referredto as an metatarsalplatform shouldbe blendedinto the arch. In mosl
2\t3
Fi$rre 6.1. Delermihingtie outlin€ of an orthollc
shell (seetexl). (A-F). S€eiext.

Fig$e 6.2. (A-H) M€thodfor Intrinsi.atly Fosling te foretoot.

204
 ChapterSh l,$honlorJ Prrp$stion ad Orthotlc Frbricttlor 205

Lheplalformis blendedso lhat il mergeswith fie

iilualions, thoses. This is ootto saythattbereis ro differcncebelwecn
ccntcrof themetararsal shahs(blackdot in Fi& 6.2C).This thcseodhoticmaterials.Smithet .1. (2) comparcdthe vc-
bcingthec.se,rheinrrinsicpostwill remainfunclionalunlil locily aodrangeof rearfoolmotionbotweensubjcclsusing
0E carly propulsive period when the progressionof forces identically postedsoft atrd semirigid ortholic shells. Thcy
p$s disralto rhis point.Someorthoticlaboratories, how- nolcd thal while both lypes of ortholi€s decreasedvelocity
cvcr.recommcnd thatrhemeratarsalDlatforrnbe blendedas of pronationby l5%, the s€nirigd shel more eff€ctively
|rr backaslhenrvicular(Fig.6.2H).This crcatesproblcms, dccreas€dthe ranae of calcaneal eversion. The clinical
rs fte formedorlhoricshell will be unablcto controllhe significsnccof this infornation is thal either material may
forefoot deformitybcyoDdearlynidstance,as the frrstray be usedwhenthegoalof trEaimenr is merelyto slow down
will activ€lyplantarflerir orderto ftake groundcootact. the vclocity of rearfootBotion (as with a medial libial
Because of this, ir is sugg€stedlhat inrrinsicposls be stressreaclior associaledwith a rearfool varus deforrnily).
blendedno morc proximally than lhe c€nter of lhe However,$hen conrollingthe ran8eofpronationis a con-
nelararsalshafts. ccrn (as with a halluxabductovalglsdeformitysecondary
to a collapseof lhe mediallorgitudinalarch during mid-
SHELLSm-xcrroN stanccandpropulsion), thenuseoflhe morcrigid materia's
is ifldicaled.
With thc intrinsicpostingcomplolsdand lhe final A word ofcautionregardingthe useoflhe moreriSid
rnoditicalioos madero rhc posiiivemodcl,lhe practilionor sh€llsis rhalbecause thesematerials areso controlling,fiey
|nuslnow decidewhich materialis to bc usedfor the oF mustbe moldedto a positiveimpression thatexactlyduPli-
tholicshell.Themorecomnonlyusedmalerialsincludeth€ cetcsrhe patient'sneutralposirionfoot. If an error was
lclylic roh0dur(a rigid, glasslike material),the semirigid madoduringthe castiflgprocess,it is nore likely to pro-
graphitelaminatesand thermoplasdcs (polyethylencand duceiat.ogenicidjury when usingthe lessforgivingrigid
tslypropylene), and rhe very soft ,nd compressiblc poly- shclls.Bccauseof this, the oovic€sho ld inilially stick !o
cthyleDe foans (e.g-,variousdensiliesofPlastazole). These sofler shells unlil he or she feels comfortablewith casting
materials havelhe abilily lo decrease shearforc€s,redislrib- tecbniques.Also, experi€ncc has demonslrat€dthal the
utebodyweight,.nd/or altermolionaboutlhe variousaxes fasteran individual prcnates(as occurswilh proFioceptive
of rhcf(x{ and lnkle. The decisionas lo which mal€rial deficits or musclewealoess),the less likely hc or shc will
shooldbc uscd is based upor examimlion findings (foot be ableto toleratea rigid shell.
nolions,patientweighl,€tc.)andlrcatmcnrgoals. Aftcr thc materialhasbeenselecFdfor the shell,it is
As a generalrule,th€ sofi€rmaterialsarc uscdwhcn formcd dircctly over lhe preparedposirivenodel. lf a
conlrclof morionis not a concernandthe primarygoal of loarhershellis to be used,it is fusl saluratedwilh waterand
trcalmenl is lo decrease shearforoeand/orrcdistribule body molded lo the positive model, lhen lllowed lo air dry for
wcighlawaytrom painfulplanlarlesions(aswith diabetic 24-48 hours,The mor€popularthermoplasticsandgraphile
individuals). Ortholicsmadefor thispurpo$earereferredto lamioates aremoldedby fu$ placingthe chosenmatcrialir
!5accomnodative dcviccssinceno atlemplis madeto all€r a convection ov€n(whichmakesit pliablefor pressing) and
molion.Theseorthoticsare iypically madefrom negative immediatelymolding the heatedshcll over thc positivc
imFessions takcnwith lhe foot in its comp€nssted position, modelin an onhoticpress.Otrcethe shell hascooled,il is
is wilhful!weighl-bearing t€chniqucs. removedfrom the pressand lrimmedto tle desiredshape
Convcrscly, thesemirigidandrigid matcrialsareusrd (Fig. 6.3A-N), Not€ thar thc thermoplasticshells are
vhunconlrollingabnormalmo!emenlis rhc primsrycon- availabf€in l/8, 5132, and3116inch lhicknesses (the lab
cctn.Sochonhotics,whicharecat€gorized asfunclionalor- chooses a shcllthickn€ss baseduponthepatientsweight).
tholics,are designedto allow for near neukal position ExrRtNslc FoREToor AND TIp
function o[ thc subtalarjoint, which rccessitales thal only PosrrNGTEcHNreuEs
tcutnl posirioncastinBtechniques be us€d. Wirh lh€ outlinc of lhe shell properlycontoured,a
An imporlantfaclorto considerwhenchoosingmate- forefootdeformitythat wasnol treat€dwith intrinsicpost-
rills is lhatil is nol so muchfte choiccofshcll malerialthat ing techniques may now be addressed with eitherextrinsic
drlermines wherheran odhotic is functionalor accom- posringor tip poslingr€chniques. Thc tip postis thc easiest
modrtive, as il is lhc shap€of the impressiofl lo which the mefiod of Ireadng a forefoor deformity, as it merely rc-
sllellis moldcd(i.e.,ls thepositiveimpression madefroma quiresprcssinga fingertipdown ifl the cenl€rof the heel
ncuualpo6itioncasr or full'weighr'bearinginpression?) s€al so rhar eilher thc dislal medial or laleral cdge of rhe
&d lhc amounl of forefoot aod/or rearfoor posliog used. shclllifts offthe table.CIhemedialedge$ll lift up wirh a
Thiswasdenofftratcdby McPoiler al. (l), as they norcd forcfootvarusdeformitywhile the lateralcdgewill lifi up
no differcnc€in cenlerof pressurerecordingswhen lhe wi$ a forefootvalgusdeformity.)With rheshellslabilized
slmesubjecN!,,/oreflexible,semnigidand then rigid or- in this position,a heatgun is usedto warm the elevded
206 FOOT ORTHOSESand OrherFom ot Con\ervsriveFoorCsrc
 Six Iahorrtory P.eparatlorrnd Ortho{c fsbd.tlion
Chapr€r 207

edge,allowingil to bccomeso pliablethat it drcpsto rhe

Fgure6.4. Iip poslinSa forefoolv.rusd€formilr.
supponingsurfac!(Fig.6.4).Tbe shellproximallo th€bent
cdgenow servesasa poiol of conlactthal supponsthe fore-
fmt deformiry.A well-madetip post accomplish€s th€
sane thing as an intrinsicforcfoot post, only thereis no
nocdto ater lle positivemodsl with a mehla$al platform-
The 6nal methodof postingthe forefool is thc cxtrit-
sic post.As illusxatcdin Figure6.5,rhistechliquerequircs
lirst scu{lirg the djstal plantar edge of the orlholic shell
0ape is uscdlo protcctthe proximalshell IAI) aod lhen
gluing th€ posling malerial to the shell (B) . A finn cr€pc is

tigu.! 6.5, M€thodfor ertriftically poltint Ih€ forefooi.

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

figure 6.5. Ihe compr€.lible posr

to !{lcur Beeid6providin8conrln-
ued conrol of subt.lnrmoliondur-
in8 the prcpuliive psiod, thi!
additionlessensrhe sk ol iat.ogenic
iniury by suppo inS the melalarsal
headsaA) therebydistribulin8 prci'
sureawayfrom the distaledSeof the

lhc mo61commonlyuscdmatcrial.Thc pnstis $en ground

in such $ way thhl il brings thc rearfool to wrtical (C). Crit-
ics of this lechniqueclaim thal lhc cxttinsic malerial often
cracksoff lhc shell and Illc addedbulk fidkes for difficulty
with sho€fit.
In si(uationsr€quiriry large forefool posts,a common
pracliceis lo panially conect lhe forefoordeformity with ao
intdnsic post and thedadd the remainitrg|rumb€Iof degrees
ncc€ssaryto brinS the hecl lo vedical with atr exFi[sic post.
For example,a 12' forefool varus defomilt may have 6'
buih intrinsicallyiotolheshellvia a po6lingpladorm,while
the remaining60 of varusposlitrg is addedexlrjNicslly. As
a rule,limirationssssociated with shoefit prcvenruseof a
forefoot varus po$ gr€ater rhar 9", while for€foot valgus
postsshould not excecd6'. Also, ifa largEforefoot post is
indicated,it is suggestedthat a comprcssiblepost to sulcus
be addedso that lhe distalorthoticshell doesnot dis into
themetalars.rl shafts(Fig.6.6).
IN"rfl NsrcREARroor PosnNG
With the forefootpostingcomplered, it is now possi-
ble lo post the rcarfoot.As wirh for€foot posts.thc rcrdosl
poslsmay be appliedeither €xtdnsica y or intrinsically. As
de,scribrdby Lundeetr(3), a true idrinsic r€arfoot posl re-
quiress€ctionitrglhe posirivemodel to lhe axis of the suhta-
lar joint and mtating thc rearfoot s€ction into lhc desired
degr€€of valgus or varus (Fig. 6.7). The crcasein th€ F)si-
live model is lhen blendedsmoolhly with addiliond plaster
to pneventthe formation of an armoying edgo lhat would
olhcrwbc be molded into lhe shen. This t€chniqu€allows
fairly lrrg€ deformilies ro be postcdwithoui affecti|lg how
the devicefits inlo the sho€.
An easier,rlheit less€fleclivemethodof postingis
tbe modified intrinsic technique-Tbis methodof posling re-
quhespllcing the hecl of thc moldedplasticshell onto s
ligure 6.7 Ih€ biari.l intrinsic post. Prior to moldinS
shsl to the positive,th€ castis s€ction€dand rotatedsoes
caprurcthe delh€dof rcalootpostinS (Modi
inirinsically.
Iron LuDdeen RO. Polyae{tiolrl r,iaxial postrnS.
^
pro(castor incorporatingcouectionin foot onhoser,JAm
dian MedAsroc1988;78(2)i55.)
horirontal sanderand grinding the desired angulationin@
ttc shell (Fig. 6.8). While lhe modifed inrrinsic posl allo\li
fo. n nic€ shoc fiL il is .elatively ineffective al mnlrolling
motion bccauselhe ba.scof sllpFn provided by thc intrin-
sic lost is loo nafiow: whencverprcssureis cenlcrcddislr!
or medial aothe planlrr 8rind, the odhotic will rock mcdi-
ally. thcrebynulifying tfie eff€ctiveftss of thc post.
This is not to say thal the modified iotrinsic posris
oot us€ful- When placed io a shoe \rith a firm, iat inn€r
solc. this posl scrvesas a proprioceptivelool that allowsthc
prli( nt to fccl thc trarsition from the cotrl.olling laleralpor-
tion of tho dcvice to the unangledmedial portion oI thc de-
vicc (Note lhat even thoughil ir unangled,thc medisl
porlionof the orthoticstill prevenlslhe sublalarjointfrorn
pmnolingbeyondheelvertical.)
 ChaptcrSir btorrlory Prcparluo! rnd Odhodc Ftbrtc{ior 209

Figurc 6.8. Thc modificd inlrinsic

rearfootpost.Theplantarheelol theor
thoricshell is Broundflal (A). lheJeby
maintaininS fte rearfoolin th€ desired
angle(8). Unfodunalely, the detr@ of
poslingis limitedby lhelhicknessof the
shell.

EXTRINSIcREARpooT P0STTNG to conlrol motion duriry lhe propulsive period by Placing

the desirodr€arfootposrb€neatbthe distalmsdialedgeof
Whil€ rrueintrinsicand modifiedinlrinsicposb arc the orthoticshel or by addinga comp.essible postto thc
occasionally usedfor ulntrolling subtalarjoinl motion,by sulcus.
farthemosrpopularmclhodofpostingis the extrinsicrear- The decisioDasto tie exactnumberof degreesthat at
footpost.This post is fabricat€dusingth€ samegdnding orthoticshellshouldbe postedis a malterof conlroveny.ll
nethodusedfor lhc modifiedintrinsicpos! only now lh. hasbeensuggestedthal the rearfootpost arglc shouldequal
pla0taraspectof rhe heel is reinforcedwith extdnsic post- rh€ tolal degrcesof r€aifool varus dcforhity aod that the
irg mat€rial(Fig.6.9). rangoof subtala!prooationoec€ssaryfor shock absorPtion
One of $e mosl imponant characteristicso[ the ex- shouldbe suppliedby addioga 4" ot 6" biplenargdnd to lhe
tsinsicrearfoorpostwith regardslo ils ability to control mo- plaotar surfaceof the readool post (6). The theory behiDd
tiotr during shnce phase rclat€s io how far lhe posting thc biplarrr g nd is thal lh€ uoalleredaspcctof lhe rcarfoot
nalerialis extendcddisrallybeneaththe shell.Notually, posl maintainsideal oss€ousnlignment while the biPlanar
lic extrinsic rearfoot post extendsapproximalelyono-half grild enablesthe orthotic (and tbercforelhe subtalarjoint)
ilch distalto the cenrcrof rhe heel seat,which maintrins to evert lhroughthe exactrangenecesslryfor ideal futction
thcenljreonholic in irs postcdangleunlil lhe progre$sion (Fis.6.l0).
offorcespasses distallo lhe rock line (seeFig. 3.92).Oncc Unfonunately, thislogic is inconsct,cvcndangerous,
these forcespassdistalto this linc, the entireonhoticwill ss the biplanargrind basicallybehaves ss 3 shor!extnnsic
cvenonto ils distal medialcdgc (or forefootpost,if pre- rearfool posl lhat maintaidsthe heel in an invertedposition
s€nt),nakirg thc r€arfootposl nonfunclional. during €arly co[!act, delayingponstion utrtil lh€ early mid-
Asdomonstrrted in Figure3.93,theslandard extfinsic stanc€period.This is parlicularly dangcrouswhen you con-
rcarfootposl is cffcctive only until the early midsianccpe- sidcr rhat lhe majority of promlioo occurs during the first
riod.If desired,it is possiblelo request€ither a short rear 50% of the conractperiod (4. A fllly posledorthotic wilh
footpost(whichtypicallyends3t lhe ceolerof theheelseat irs biplanargrind ess€rially blocks suhalar joinl p.omtion
or sligh y proximal lo lhal poinl) or a long rearfool post at a rime when it is oeededth€ most: during lhe ea.ly con-
(whichcxtelds approximatcly3/4 hch distal to rhe cenlor tacl p€riod. This risks iatrogenic iljury from decre?sed
of the hc€l scal). Becaus€the short rcarfool post basically shock absorptiona predispos€sto koee injury, as il pre-
Eovesthe rock line prorimally,an orihoticmadewith this venls lhe rangeof talar adduclion necsssaryto accommo-
po6lwill control nlotiononly during the contaclperiod, date the internallyrotatioglower extremity,i.e., inenial
{,ith the ortholiceverringonto ils distaledgeduring lare forcesdrivc the intemallyrotati[g lbrhurinlo the immobi-
conlact. This nay be helpfulwhen tr€atinga0 individusl lizedribiawhich,togetherwith the talus,is heldslalionary
witba compensated rearfoolvarusdefomily who hasa his- by lhe rearfootpost. This may cventually producclaxity of
lory of r€correntinveGionanklo spraiN (which would the ligamentsresponsiblefot limili||g tibiofemoral rotation.
tnakemainlsining the reaIfoot in an inveded posirion dur- The industry-wideuseof biplsnar grinds with exldtr-
ingmidstanccperioda conlraindication). sic rearfootpostsmost likely exphios anccdotalrepons re-
Conversely,a long rearfoot post displaccsthe rock hring rigid onhodcs(rohadur)lo krcc inilries. Nole thal it
lift distally, therebyallowing for impmved contml durirg is not the firmnessoI lhe shell lhat p.oducessuch injuty, it
lie lstter half of stencephase.Of $ursc, il is also possiblc is $e inappropnateuseof ar oversizcdand riSid post that
210 FOOT ORTHOSESand Orh€rFoms of ConseNatile FoorCrrc
Postinqelevator
riSure 6.9. M€thod fo. fabricarin8 an extrinsic r€arfoot
varuspost.Theplant&proximalodhoticshellis scu{fed, and
an extrinsicposris gluedso tharits distaled8€reetsapproxi-
mately1/2 inch distalta rhecenre.of the heelseat(A).The
ed8esof the postarerh€nfil€ddown,andthe heeii5 placed
on a horizonlal,ander(8).Thedistalodhori.i! pasitioned on
a supportingplalfom (C).andtheed8eol theonhoticsh€llis
angleda sp€cificnumberofdegre€s with analullrinumwedse
(D), Th€ heelof lhe odhoticis then firmlv oressed into the
sander, which allowstheolantarrearfootoostto stabiliz€tbe
€nlireodholicshellin lh€ desiredof varus(E}.lf theonhotic
is lo beworn in drerssho€s,it is frequenllynacessary to usea
postingelevator to ensurethatthepostwillresrflatagainst the
heel sealof the shm. for exanrple,it lh€ exb'insicrcadoot
postwaegroundor)a levelsurfaceandtian placedin a h;gh
heelshoe,the Dlanrar surfaceot theoostwouldb€ unable1o
adequalely conlactlheheel,thercbyn€ealinsthe post'sabjl-
ity to control rcarfootmotions(Fl This probl€mcan be
avoidedby placin8the orthoticon a postingelevatorwhen
B ndi!]Elhe rcarfoolpost{C), By duplicating rherelarionship
betweenlhe planlarheelsea!and foreloolof the shDe,rhe
postinselevatorallowsthe entirereadootpostto sit flolh
asainstlhe heelseatOhe tinkhedposrin C lvould{it par
hctly intoshoeF).As a Ben€mlrule,shoe!wilh l/2-, 1 , and
I l/2-inchheelsareaccornmodaled by using4-, 8-, and 12-
blocks the necessarfrangeof stlbtalarand midlaruaipro,ra-
tion necessaryfor shockablorpdon during the early contact
period. The najor probbm $sociared with incorporatioga
biplanargrind is that althoughit doesallow for subtalar
pronation,rh€rangeit allowsis too little (a 4'gdnd allows
only 4" of rearfootmolion,which is not cnoughto ade-
"rM Th6 ertrinsic reartootposi
stabilizbsthe enlireortholic
sn€ in th6 dosir€ddegres
mm posting elevatoE, lesp€ctively.However, rs
stratd by RossandCumick(s),lt is notsomuchthoheiSht
the heellhat deteminesrhe sizeof the postingelevrtorai it is
the ,rngulationof th€ heel tlope in the shoe.An exampledi
this s illusrr.@din H. Despirethe height of its heel,an ol.j
thoti. for this shoeshould be sround ilat becausoof the aclr&
an8!larionof the heel seat.Eecauseof thk, the heightol tfid
posling elevalorshould be selectedlly placins a flat bar(t
tonsLredepressorworks well) illrsh againu rhe hecl seatand
notirl8rhe dktance be&een dr€ bar and the point \ahe€fi6
odh,,ri ,w i l l end (l ). Thi sdhl rnce repre:Ff| \rhei dea hei ghi
of thr postingelevator.In addilionto usinBa postinBelevaloi
it i5 rlso polsiblelo allow for inrprovedshoefil bv raquenini
thc redloot pod be Sround inlo lhe sheli (r). lhis
modrficationsi8nificantlyreducesthe bulk 01 llle extrinrie
pon by decr€asin8lhe hei8ht thal the odhotic will raisetho
heel. The stabllityilnd resiliencyoi the rearlootpou nay k
imprrved by addinsa medjnl or lateralflafeto the Dost(() fto
,onl rnl ex,e{ i ve p' o.a' i on o, supi nati on.
rcspF(l i vcl y)
dd
by ninlotcing the posl mat€ri.l wirh nylon s(rews (L). Bet
causr the mosl common postio8marerialk a comprcssible
crepc,the plantarrud,ce ofthe pon is usuallycoveredwltha
thin, high'densityplaltic in order lo pre\,€6texcessivew$rl
{Thisis referre.d lo as a "post-protector':)
quakly absorbshock),and it atlowsthis molionlo occui
too l:rLein the gait cycle.(By midstance all pronalorymo-
lionsshouidhavcended.)
The problens associatedwith biplanarSrindsarefur
rhercomplicatedby the fact thal dreability oJ theorthoricto
rock medially is dep€ndenlupon the firmnessof lhe sole.ftr
 ChapLerSi3 hborstory PEp!rulion and Ortholic Fal}'icalioD 211

Shell Invsrtedtour degre(

4
Foufdegreesol pronalion

Flgure6.10. The blpl8nar grind. ThB distal medial
podionoi lhe extinsic rearfool posl correspondingto
lhe shaded a'ea (A) is ground lo a deplh of
approximately4 mm {lhis is a gradualgrindlhat p€aksal
lhe distal medial corner ol the post g). Accordioglo
Weedet al. (6), rhe biplanargrind allows lhe rearlool
posllomainlainperfectosseusalignment duringtne conlacl
periodii.e., when weighl is cenler€d posteriorio
lhe axis of the gind (C), the readoolpost mainlainslhe
subtalarjoint in an inverledposilion(D) whileallowinglhe
sublalarjoinl 10 pronatethe four degreesnecsssarylot
shock absorptiononce lhe progressionof lorces are
centereddistallothe axisol the biplanargflnd(E). (Adapted
lrom We€d JH, Hallif, FD, Ross SA. Biplanargrind lor
rearloolpostson lunclionalorlhoses.J Am PodialrAssoc
1978;69 (1):35.)

ample,an individualwith a 4' subtalarjoint varunr,nn 8c

Iow€rtilrialvarum,anda normalbaseof gaitwouldrequire
a 4'rearfoolvarusposl(4 pius il rninus8) in orderto ailow
rhesubt.rlarjoinl to pronaterhrougi an 8" rangeof motion
duringrheconradpcriod.By usingthis merhod,lhe subra-
la. joint would have alrcadypronatedthroughils idsal
rangebefb'elhe medialcalcaneus strikeslhe shell.Al Lhat
lrme.theorrholic $oJldacLli) hl,)ckonl) rhLexce\srve n)o-
lion. allowinglbr lhe ideal rang€n€cessary for shockab'

'Iher€is someconc€rnthat maintainingthe rearfoot

in a conslanllyinverlcdposilionduringstaticslancewillre
sulr in ihe dcvelopmcnlof a functionalplanlrrllexcdfirsl
FIgure 6.11. By €xce6stvety inverting the ray nnd/orfunctionaltbrcfoolvalgus(Fig. 6-l1). How€vcr.
roarlool during statlc stance! a targ6 resrtoot lhis is nol a considcralion since,aslongasthesubtalarjojnt
varus lrost may allow for ihe devetopmenlot a is albwcd to proratc8', the forefootis ablc to cvert6' bc
ruoctlonal loretoot vatgus deformity larrows).
Anolher lmporlanlconsderationis thatthe roarlootpost yondneutralsecondary to the increased rangeof mjdlarsal
should neverbe so higt-tiat the knee,whenflexedd,.jring joinl motior lrssocirt€dwirh rhe proratedpositionof the
sGficgance,rotates extemaltothe saginalptane. subklarjoint. 'fhis meansthat the r€arfootvaruspostmay
bc ashighas6'(althoughii is scldomnecessary to postthe
sofierdiplastedsncakers or shoeswilh soft heelseals,lhc reartbolaranylhingmor€Lhan4') wilhourfearofcrealinga
hlenl pollion ol the cx(rinsicrcarfootpost acrually!inks l nctional forefoolvalgus dcformity.lf a large rearfoot
inrolhc shoe,negalingIhc abiliryof Lhebiplanargrind ro varusposris dcemcd (Blake [8] claimslhe rear'
alkrwfor lh€additional of subralarpronation. foot va.uspostmay be 'recessary
as highas 10'), a compressible post
'ango mcthod delermining
A safer,morecflbctive of lhe to sulcussholld bc addedto supporlthe medialmetalarsal
sizcofLher€aribolvarusposl is lo tind thetotalof therear,
loot!ams deformity(i.c., addsubtalarvarum.lower tibial In situarionsin which thc total rearfootvarusdefor-
varumi andanyvarun associated gajl par
with a cross,ovef mily is lcssthan8', bul €xaggerared p.onarionis srili a con-
hrn)andsublraclcirhcr6 or 8' fronl thisnumbcrin order!o cern(e.8.,individualswith a verricalobliqu€midtarsaljoinl
allovtor an adequale rangeof subtalarpronalion.For ex- nxis, singlearliculatedsllbralarjoinl. or hypcrmobilelirsl
21? FOOT ORTHOSESlnd Ot$er Fonnsof Conservalile Fool Cde
FiSure6.12. Ihe 0" r€arfoot post ctabilizeslhe heel in a
vertical Dorition.
ray), the rearloot shouldbe postedar ff (Fig. 6.12), and the
rarg€ of excessivepronalion would now be cootiolled by
theorthoticshe[, not the poslangle,i.e.,supportofthc me-
dial longitudinalarchin thescindividualsis hclpfulh con-
trollingtheoveiallrangcof molion.
ORTHoflc ADDrrroNs
With the orthotic shell posting the desircdnumberof
de$ees, it is occasiomlly necessaryto rcinforce bencalh
thc medial longitudinal arch rvith a filler lnalerial to protect
agaiosrshell breaksge.Although the strength of a thermo-
plastic sholl usually obvirles ihe ne€d for r€itforcemen!
cerlaio sitoationsdictate that addilional support be adde4
c.g.,iflhe orthoses wer€ro be wornby obes€patients or pa-
lients involved in high-impact spoding aciivities. Also. if
an ac€ommodativeshell had beenchosen(suchas leatheror
low-density polyethyl€ne),it is rcc€ssary1'] altach a filler
materialto the Dlantarsurfacein ord€r to rcinforcr the arch.
The sh€Uand attachedfiller marerialar€ codplcted by
grifldiflg the bordersdown to the desiredshapr andwidth.
Besideschoosingftom different shell and filler mate-
rials, an orthotic can be funher modified by addingatryof a
vsriery of top covers and/or additions.Thesemodilications
are outlined as follows.
fop aorers. Ths most commonly used top covers,
which may be extended!o the proximal mehtalsal heads
(covering only the orthotic), to fte sulcus (cnding al lhe
baseof rhe roes),or ro the distal toes(tull length),ar€ typi-
cally nade frorn glove l€ather,Spenco(a neoprenefoam
with a thifl layer of nylod on ils rpper surface).vinyl,
nylon,or anyof a varietyofsynthetic$ed€s.With lhe ex-
ception of Spenco,top covcr matcrials are mosl olten lay-
eredwith eitbera 1/8- or l/16-inchpicceof PPT(r very
resili€nt open-c€llfoafi availablc from the Lange. Biome-
chanicsGroup, Inc-, Dcer Park, NY) or Plaslazote(a
conrprcssiblcclosed"cellfoam} The layeredmoierial
be uddedfrom the distal edgeof lhe orthotic shellto ttrE
tal rdge of the cover (refened to t]s sn extensiod)or, it
run hen€alhlhe enlire lengthof the top cover.
Forexag]ple, a vi0yl top covu maybe requested
a l/s-inch PPT enension to the sulcus(ir \thich case
the vinyl will cover the onhotic while a clmbi
vin\ I and PPt are extend€dfrom the dislal edgr of
thoric ro the baseof the toes).Or, a vinyl/PPT lop
tie rulc$ may be requcsted,which would consistof !
eredvinyl/PFTcombinationbeingextended from lhe
of rhc orthoticto the baseof the ioes.Note lhal iI is
possibleto requsstlhat a bottom coverbe addodbetreath
entireorthotic,Bottomcovcn areusuallyusedlvilh
mo(r(ive ortholicswhcreliller ndtc|ials wo0ld
bc susceptibleto wear.
H""1r,ft. Hcel lifls may bc invaiuabLe in tie
menrof a multitudeof condilions.ln lhc toalm€rtof
lenglhdi$crepancy, a heellii will level thepelvisand
creirselateral shearforces on the sidc of th€ short l€e
Heel lifis mry also be osedbilatorally to treat injuries
ciai.rd with compcnsatioitfor a decreasedrang€of
dorsiflexion. While uslally madeftom rubberor cork,
lifls can also be mad€ ftom more sho€k-absorbrne
als. \uch as PPTor sorbolhane,in order to morc
lreaL a high-impact foot (e.9.. a" uncompensat€d
varusor a rigid fo.efoot valgusdeformity).
The abilitv of PPT to lessen imDact forc€s
dernonstrated by Millgromet al. (10), as theynot€d
gencdc flexible orthotic with a 3" roarfoolvaruspost
U8-inch PFI heel Iift decreasedthe incidenceof
stres hacturesir milildr) rccruitsby 8.1q. This is
tcnrwilhthefindings by Voloshin (ll). whonoedtbal
coelrtsticheel lift6 decreasedthc ampliludeof
oscill{tionsduringwalking.
Furlhermore.becausesome pcoplc adrpt to
cusljoning by decroasiagthe velocity of kne€ fiexion
heel'strike (12), shock-absorbingheel lifts may alsobe
benrfit in treating rerropatella anbralgias. (Allltough
dcn,.\nsrrsled by Niga et al. tl3l, it is not ncccssary lo tF
placclhc standard EVA iNole foundin runningsho€s
the moreerneosileso6othaneinsoles.as thc stock
src iusl a.\ effective al reducing vertical fbrc€s al hed!
strjke.)With regardsto treatinginjuri€sof theachille,s
dor. I-€e et al. (14) concluded that heel lifts csn be rd
etTectiveform of rreahenl, asprogressivclylargerheellifb,
producclinear decreasesin EMC activity of lhe nedi.l gaF
Regardlessof the porentialbenefits,heel liffs should
slwxvs bf prescrib€dwith caution, as they produceatriq-
creaseh venical forces bilaterrily (9) ,nd $ay initiauy in:
ctea,iethe range of subtaiar pronation during the eodact
peiod (15). (Note that there is much confficline inforor-
rion rcgarditrgthe effectsof heellifts on conlactperiodsltb-
 ChaplerSjx LeltoraaoryPrepamtior a.d OrrhoticFab.i$tion
talarmotions tl6-181.) Also, becnoselhet displacethe
body'scen(croi massanreriorly,h€€l lllis may producea
tacelsyndrcmeohe lumbarspinehyperextends lo ac€onr'
modate lhe displaccdcenlerof mast and/orprecipitatea
painfrltor€footcondilion.asa greaterpercentaSe ofweight
isnowborneby rhemetatarsal hcads.(Bccaus€ ofthis, heel
Lill5mayacluullyaggravare d plsntarfasciapfoblcm.)
Barposls. A b poslis a flal forefootpostthalmay
effectively dccrealcpressureon the meralanalheadsby
suppon)ng tho metalarsalnecks.It is commonto requesla
2*5 bar postwhcn lreali:rga pl,lnLarllcxcd firsl ray. Notc
thatwhen tr€atinga larged€fo|mity,1lcomprcssible 2-5 bar
losl maybe cJ(tcndcd lo rhesulcus.
BalanceIor Lasion. This is an invaluableaddition
plovidingcustonizedcushioningfor painlul bony or soft
lissrcprominonccs. The praclilionermarkslhe lesronon er-
therrheparicnr'sfoor (bc ink will transpos€ onrorhecast)
or on a diagramlocatedon the laboraloryorder lbrm. A
custonr doughnuf,U-, or J-shapedpad is lhen contorred
ijoundthe lcsionand altachedbeneatlthe top cover.Th€
Iinishedbalsnccallows for a redislribuiionof pressure
awaylrom lhe ;nvolvedprominence. The mostcommonly
uscdbahnccs.which are usuallymadeirom cork or PPT,
arcilluskated in Figure6.13-
ln siluationsin which a painlul lcsionis locatcddi,
rectlyovertheortho(icshell(suchasa prominentcalcanerl
condyle), ir is possiblcto build lh€ balancefor lesiondi,
recllyinLothe orthoticsbell.This addition,rel'erredlo as
ligur€6.13. Ihe variousbalanc€sfor lesions.{A) Thc slb l
bal,ncelor lci on (aka "dancer'spird") is lsed to ac.ommo-
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 )
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
pla0larflexed iirsr .nd liflh r:ys o{ten .tsociated wilh cavus
loorlyp$. (C and D) Thc ho6eshoepad ac(ommodationmay
b0 lscd to ac.ommodaiea cai.aneal sp!r, a pl.ntadlexed
lesscrmelalarsa,ir promincnl plantar condyle ltnset)or a
planlarwirr, e., l)eLausL'prossure stlmulalesgrowrh oi llre
virus(19),an)' iddlrion that dccreasesprcssurebeneaththe
213
pockel accommodalion,reqoircsadding a small amounl oI
plasterdireclly over lhc correspondinglocationon the posi-
live mod€l (Fig.6.14A)- The shell Lhalis molded ovcr this
modified posiliv€ model will have an indentalionor pockel
lhat distributespressureaway fron lhe painfol lesion (Fig.
6.r4B).
Morton's ex.ension.An l/8-inch platfornr is
shapedliom cork or c.epcandplaccdbeneatb the top cover
;n orderto supporra short6rslmctatarsal (referbackto Fig.
3.104).Pleasenolc thai this addidonshouldrot be us€dro
trcatn longsccondm€ratarsal, which is moreapproprialely
t.eatedwilh metatarsalpads.toe crests,and/ora sub2 bal-
Kinetic \)edE. Developedby HowardDaltanbcrg,
DPM, thisadditionrcquiresaddinga dcnsccrcpccxtcnsjon
ben€arh the secondthrcughfifth notatarsalhcads,whilc a
softerlriangularlyshapedpjeccof PPT is placedbencalh
lhe fi$t metararsal hcad.Accod;ngto Dananberg (20),tbe
soller malerialplaccdbcnealhthe medialfore{ooralbws
thefirsl melatarsallo "plantarfl€xandev€rtduringperoneus
longrs activity,"thercbyallowingfor the dorsal-posterior
.hrftof Ihc fir{rmcrdarsophalan8eal ioinr'srransveFe axi(
that is neocssary for the hallux to .eachits full .angc of
the logic for this addilionis questjon-
Unfortunately,
ablesincelhe mosl commoncausefor irnpairedlirsr ftry
planlarnexionduring propul$ion is excessivesubtalar
pronation.
Becausethc sofl mat€rialplaced beneath th€nte
wan (s!ch as a bar pon, melatarsalpad, to€ cren or sub
metaratsalbzldnce)is c inicrlly indicared.(E) An accessory
navi cul ar,
w hl ch may be atachedto l he parcntnavi c!l arvi a
a synchondfosis, ofle. rcquiresproleclionfiom t-"nsil€,shear,
and comp.e$ivc forces.This may be accomplishedby addinB
a U-shapodbalanceto a laGe medial flanSe.Thi5 balance ,
ueualy ueed in conjunction wiih the approprirte rearlool
dal tt to etuu' vJru\ po,ri _ oroer l o m.r' ni /F c\rers,\c
subtalafp.onalion that would otherwiseinitale lh s Dtseous
214 FOOT ORTHOSES8nd Oth.r Formsof Crft€r/ativc Foot carc
FiSurc6.14. (A and B) Thc pockeraccommodation
Fi8ur.5.15. (a) Hearll (B) sromach-,and (Cr tldmydraPrd metatarsalPad!.
dial forefoot may actuallyencouragesubtalarpronallon,the
kin.lic wedgehaslhe pot.ntirl to createlhe exactcondition
il was designedto prevent funcdonel hallux limilus.
This is nol lo say the kilclic wcdge should never be
!sed. 16 siluarjons in whicb &formity of the finl melatlr_
sopbalangealjoint is secondaryto a lotg firsl melal3rsal,
lhe linelic wedgemay allow for lhe ihproved raDgeoI RrsI
ray pladarflexion nec€ss5ryto prev€nt conlinued dcfor_
mity. (As long as il is us€din conjunctionwiih a long rcar_
foot vaaos post id order to prevenl €xces.\ive subtalal
Dronation.)
Mctatorsl pads. Thesc pads, which ar€ ry?ical]i
madc from eithor spongerubb€r, felt, or PI'I, allow for {
redistribution of pressureaway from the metatarsalh€d(b
by sopponidglhe dislal metalarsalshafu (21). As a re$ L
metntalsalpadsmay tre an effective form of trcatt|entfor
€longaledsc$trd rnctatalsals,plantat keratose.s,
interdigilrl
oeurorhas,inletrnetatarsophalangcalbursitis, Planlaiwatq
rod/or plamadexed l€ssermetatatsals.To be effective,th!
metrtarsal pad, which q)m(}s in a variely of shapesad
size( (Fig. 6.1t, shouldbe positionedjust proximal lo thi
me{irtarsal heads,
 chapkr si\
Dccausccachpersonrcspoodsto pad placamenldif-
fercnlly,il is oftcn ncccssary10 have lhc metatarsal pad
shifted proximally,di$rally,medially,or lulerallyin ordor10
frndrbe exact localionthal povides rhc best resulrs.ln
somesitualions,il is lccessary 10 use a temporary
melatarsal padandallowlhe palientLoexperjment with size
andlocutio!.Whcn the idealpositionis iocated,a perma-
ncnlmclalarsal pad may be atlachedb€neatilhe top oover
of Lheonhodc.
It shouldbc stressed thatwhenthc goal of trealment
is to reduc€pressurebeneadrthe first metalarsal head(as
wilh sesamo'di1is), ii is Decessary that a largemelalarsal
padbe usedsincesmall metatarsal padshavono effeclor
Educingpressurepaltcms bcnealh the hallux or SrsL
head(21).lf it is oeccssary to incoryoratc a largc
'ilelalarsal
metalarsal pad,the prrcritioncris caulionedagainstusing
thehardrubbernalerialssiroe thcymay irrilatcthe cenral
bandof lhe plarlar fasciaandmay evenproduceheelpain
secondar) lo 3 how(tring(ffecrun thcplonLar lascia.
Io. crAts. lhis additionis usedin th. lreatmenlof
hammcr andclawloc dcfolmities.llysupportirgtfieccntral
ponionso{ lhc sccondthroughfifih digils,toc crestsfunc'
lion lo rcducepressurebeneaththe melalar$xlheadsand
distaltoesbydistrjbutingpressure ov€ra largersurlacearea
(Fig.6.16).Also,becausc 1oecrcsrseftecrivelysrabilizerhe
distalphal$gcs,their additionhelpsimprovethe propul
sivepcriod functjonof flexordigilorllm longus,whichis se-
verclycompromised byiigilal contracturcs.
Pleasenotethdl i djvidualv{riationir lhe angulalion
ol lhe secondlhroughlilth mclatarsa]s makesidealplace'
oenlof loe crcstsd;fficult.A helpfulmethodfor onsuring
properpositioningis to initially prescribe a vinyl top cover
wirha Plaslazole extoosionro thc toos.Aftcr 2 wcoksof
wear,lhe lessermctatarsal h€adsvill form a groovein thc
llastazore rhaLallowsfor cxaclplacemenl,
InterdiCiul plugs. LJsedto tr€al a painful irler-
l.sbomtory Preparadonrnd Odhotic Fsbrlcrtion 215
motatarsophalangeal bursitis,this teardrop-shaped addition,
whicfi is placeddir€ctly betwoenthe involvedmetal.rsal
heads,aclivcly opel)sthc inteispacetheoretically allowing
for a reduclionof shearlorceson thebursa(Fig.6.17).
Becausethis additionmay polentiallyiDcrcas€ com-
p.essive fbrces at the ncighboring inte$paces, and may
evenresultin entrapment of the iDlerdigitalnewe belween
theplug'sdorsalsurfac€aodthe transverse metatarsal liga-
menl,il is suggesl€d lhat the interdigitalplug be usedonly
asa lastrcsonin rhetreatmenl of a painfuliflterspace.
CuboU pad. This small pad, which is placed di-
recdybeneadrlhe cuboid,is typicallyuscdonly wilh pre-
fabricatcdorlhoticsasa way to accommodate plantarflexed
fourrhandfifth rays.(Theshellofa custom-molded o.thotic
will naturallycontourtheplanrarlateralfoot,lherebynegal-
ing the ncedfor this addition.)Carc must be takenwhen
prcscribinga cuboidpadas inapproprjate usemay resultiD
a prcmature lockingofthe calcaneocuboid joinl, whichmay
potenliallysprain$e midtarsalreslrainingligamenls,con-
tuselhe quadratus plantaemuscle,andmay evenproducea
neuroprax;a of the lateralplanlarnewe (which is chrori-
callysheared belweenthepronalirgcubojddrd the pad).
h is worthmenlioningthatsomeonhoticlaboratories
pol lhis additionon all of thcir orthotics,clairningit sup-
portsthe "lateralarch-"For obviousreasons, this approech
is discouraged.
SPORT-SPECI!rc VARTATIoNS
Besideschoosingfrom the previouslylisred addi-
tions,i1 is oflen necessafyto furthermodify an orlholicso
thalit mayaccommodate the biomechanical demandsasso-
ciatedwirh a specificsporl.For example,a tenris playc.
with a rearfootvarusdeformitywouldbe posteddiffcrently
$an a longdistaoce ruflnerwilh rhesamevarusangulation.
Basically,unidirectional sportingactivities(suchas walk-
FiSure6.16. 8y supportinglhe en-
lire digit(A).toecreslseffedivelyre-
ducepr€$ure b€neaththe metalarsal
headsanddistaldisils/s.arsl.
216 FOOT ORTHOSFSrnd Othe. Formsof ConseNaliveFoorcare
plug.
Figure6.17. Theint€rdighal
,.)opo;;
ing and running) arc typicaly trealedwiih semirigid shells
with maximum amountsof r€arfoot and if necessary,fore'
foot pos{ing. lf lhe running athlete strikes th€ ground in a
to€-heel s€quence.the rearfool post shouid be placed be-
neaththe forefoot anda compressiblepost to sulc(lsadded.
Also, in order to meet the training requirementsof a long-
distancerunner,it is suggcsted thatth€ mediallongitudinal
arch ifl lhese individuals be reinforc€d with either PPT or
cork and thal a compressiblcposLto sulcusbe usedlo pro-
tectagainstpropulsive periodinjury.
B€caus€weighl of the orthotic is a legidmateconcam
1o lhe runningathlete(be€ruseof the lenglhof lhe lcvcr
arm ro the hip, each10Og addedto thc foot incre$€sthe
aerobicdemandsof runniflgby 17o[22]),.nany distance
rumers orefer to tlaitr h the heavierthemoDlasticorthoses
atrd race in the lighter Plasrazoteor graphile laminates.
Sprinling athlelcs also have specilic treedsin lhat they re-
quire controlof lhe excessive rearfootmotionsassociated
with speedwork (contr|ry ro previo$ reports.sreed work
is associatedwith an increasein rearfoot molion [2] that is
wors€nedby the fact thal racingflats are lessablelo control
sublalarpronationI23l),while alsorequiringthe id€alrear-
foovleg alignmeDtneccssaryfor thc achillestendonlo mrx-
irnallyparticipate in an explosiv€propulsivcpcriod.
Becauseof these concem$,it is suggesledthat or-
lhoses fbr ihese athletes incorpont€ larBe rearfool posls
with compressiblc postsextend€dbeneaththe melatarsal
headsin order to more effbctively control notion during
eirly andlarestrncephnse.In fact,to controlthepropulsive
periodmotions{ar the longestpossiblelimc, Sisfley(24)
suggesled extendingthe compre$sible poslsall th€ wly 1o
thetoes.Because of thelimitedspaceandextremelastsfre-
qu€ntlyseenin racinBflats,it is rccommended thal {latsbe
sent10the laborfllory for customfilting of the ortholic.
Aootber unidirectional sDortthat reouircs accommo-
datid. is lace walking. Becauseof their extendedlengt[
sr (lc, tbeseathlelesmaintainthcii heelson thegound
suchlongperiodstharit is not unuimmonfor desc
uals to requircas mt|ch as35' of ankledorsiflexionto
for noncompensated function. Sinco this rangegreatly
ceedsthenorm,theoseofbilateralheellifts hasb€€ome
rulc ratherthsn lhe exceplion.d\ wilh olher unidirectional
sports,theseindividualsrespoodbestlo fully posledoF
lhotics made from non-weighl-bearing mutral posiliotr
When dealing with athl€tes involved in multidilto
lionrl sporls, however,the exacropposit€situationoccu$,
In ord€r to allow for the various c'uts. Divots and lalenl
molemenlsnocessaryfor theseathietesto 'feel" theplayiig
\urf.rcc.il i5 customary to uses€mi-weight-bearing impr.$
sion Icchnique,s with minimrl rearfoorposting(0" is themosl
conrmonrequest)ir conjunclion wilh thc soft Plastrzoleor
lea{hershels (allhough graphite is an excellentaltemrtivo
becNuseof its ability to flcx in rhe frontal plnne).lf nece$
sar]. lhe forcfoot deformity may be tully or partislly pothd
(i.e.. while a foreloot valguspost nuy be es.senlial for slebil.
iiy with lateralmotions,a larg€ forefoot varuspostmayini.
tat€ rhe diskl firsr melata$al shaft and posdbly producean
invc$ioo aokle spmin during ihe propulsiv€F€riod).Mih
mulridirectionalsport! that includemuchjumpiry (e.9.bas.
kctblll, vollcyball,aerobics), full lengthtopcovem&e usad
and additional shock absorbing materiols are typicrlly
placcdbeneafrthe metatanalheadsard heel.
Co|l is a multidircctional soort that Drovidesao inter-
esringbiomecbanic8l dilemmabecause of its asymmetrical
rcquirements:the riAhl foot of the righl-handedplayern$l
be able to pronale Ihrough a large range during the end
stageof the swing. while the left foot requirc-sfirn digital
stabilizarion pith prolectionagainstlatemlinskbility(Fig,
6.18).
 ChaFcr Sir
Figure6.18. root motionsduringthe end-stag€ of a golf
slroke.Notice how lh€ ritht fool is Inaxim.lly pronated
*hil! Ihe left fool is inv€.t€dwilh its diSilr cliwing or g.asp-
F8|lre 6.19. A libial va?um detomity will totc€ the fier lo
sl.ndon lh€ outride o{ th€ ski. Withercl {28) noted that 80%
ollhe slicommunity has this prcblam.(Adaptedfrom Mathe-
sonCO, MacintyreJC. Lowar le8 varum alignmenlin skiing:
mlationshiplo foot pain and euboplimalpe oman.e. Phys
SpodMe s d t987; t 5( 9) :t 6l. )
l-rbonlort PrtFntion .nd Odhotic Frbdcrilon 21?
in8 in an allemptto Saina "to€ hold."(Modifiedftom pho-
rosraphs in Segesser W (eds).Th€Shoein Sport.
B, PfoffinSer
Chicaso:YealbookMcdical 1989:125.)
Publirheri,
Onemcthodlo accomplish thisis to usea thermoplas-
tic sbell postedat 0' rearfootbilaterally,wilh a kinelic
wedgeplacodon the riglt odos€s (whichallowsfor con-
tinuedsubtalarpronatiorduring the drive) and loe crests
added bilalerally to improve propr;oceptior and stabilize
the digils. If forefool posts ar€ indicated, a compressibl€
postto sulcusshouldbe usedto dist buteprcasure ontoth€
melala$alhcads.It shouldbe mentionedthalWilliamsand
Cavaragh (5) bclieve that ortholics fm golf€rs shouid be
postcd with the rearfoot io valgus h order to provide
great€r slability and reduceshear force during the swing.
They suggesled lhat the righl-handed golfer havea lateral
flare on the left shoeanda medial flarc on the right shoe"ro
facilitaleBndsupportlhe rolling movemeDts of lhc feel."
While the conceplof adding flares to irnprove $ability has
mcrir, the routine ircorporation of reafoor valgos posls
cannoib€ recommended as it would most likely produce
symploms associaled wilh excessive pronation.
Athleles involved in edge sports(such as skiirg,
hockey, and ice skrtinS) typically requjE orthotic therapy
lo accommdatc even mild varus defordily of fie leg and
fool. h a beaulifullywritteoanicledescribingthe biome-
chanicald€mandsassociatcd with skiing, Matbesooand
Macintyr€(27)statedthatlhe ski bootseryesasa rigid me-
chrnicalextensionof the lower leg thal forc$ lh€ individ-
ual wilb a tibial vcrumto ride on th€ Ialenl edgeofrhe ski
(Fig. 6-19). This prcdispos€sto injury and/or poor p€rfot-
mancein thai the skier is more likely to fall by crtching the
outsideedge.lt also.equiresthat tums be iniliatedwith a
hoppingmolionthatservesto unlocklhe lateralcdge.
The first stcp in accommodatingthe tibiel varum is to
make the approprialecorrection in the cuff of the ski boot
218 FOOTORTHOSESandOtherFoms of Consew.livcloot Que

tenrialfor retropatellaarihralgin(whichis extremely

monin th€ski communiiy).
Theseprcblemsmaybe avoidedby prcscribjng
rhoricwith fuII forefooland rearfootpostinga$d
lowcdngof the mediallongitddinalarch.Nolethat
fierc is no heelstrikcin skiing,il is no! necessary
to
the (H" of profttion nece$ary for oormal shock
tion ls the goal of ortholic therapyis Io align the I
trenrityso lhat I vexical line drawnfrom lhe midpoi
lhe palellafalis directlyoverlhe s€condtoewlile thc
staldsin a fifictionalski posiiion.Thefully posted
whi,ibshouldincorporate a compressible postfo sulcus
a toi) coverto thetoes.ennbles(heskierto cvcnly
thc rrpsatrdlails of the skis while alsolllouiDg for
acc(ss b the inn€redgesof lhe skis (therebyless€ning
pot(nrialfor kneeinjury).To ensurelhc ofthoticdoes
roci, in th€ boot, the plantarsurfac€sof th€ foretbot
rearlrootposrsshouldalwavsresl on dre sanle
plarr:.
Thi! mry be accomplished by placingthc d
forefoot dnd rearfoot oosts benearhthe distal onhotic
ther' postingthe rearfootflat to slflbilizc the heel.Mat
andMacintyre(27) starcdtharthe dequacyof thepost
glesmry be lestedby plachBan ddilionalvaruswedge
FiBure5.20. Ihe cuff of th€ sti bool nay be anSledla.erally nealh the medial forefoot while lhe skicl $taudsin
lo accommodarea tibial v.rum. (AdapGdtrcm Mathelon funclional posirion. lf the origiral post angles
CO, MacinlyrcJC. Lowetie8varumaliSnmcnt in skiinS:rala- ins!lficient,tfieskierwouldfeelmorestablewiththe
tionshipto fool pain and suboptimalpcrformance. Phys
Soorls Med1987j15(9): l6l.) C-onversely,if urc skier complainsof disconfort m
outwardmlling of the knees,the built-uporlholicis
(Fig.6.20).Unfortunately, whilethisadjustment accommo- poslcd.The authorscldimthal advanced skiersar€remarl;:
datesthe bowedtibia, it also allows the subtalar joint to sbl! sensitiveto €ver subtlc changcs in post angulalion,I!
shifl into its pronared pos;rion (arow in Fig. 6.20). This is is n(,leworthy that because lhey lacl the angulation necee
deleterious a
in that when standingin functional ski posi- sary to ac€ommodaic various forefoo!/rcarfoot deformities,
tion (kneesflexed,arklesdorsiflexed), thc tody's centerof lhe duslom-moldedo(hotics sold in ski shops,re of litthl
gravity r€stsdir€ctly over the metatarsalhcadsand thc lips valLrcto fie more advancedskicr and/orindividudls will'
andtailsof th€ skisareconrrolledevenly rhro ghout a tum sign ilicanlvarus deformity (27).
via a conlinualshift of Dressuebetweenthe heeland the Thebiomechanical reo$irements associated wilh bikel
metatarsalh€ads.In order lo control the distnl ends of the ridirg aresjmilarto sliing in thal because tlere is no heol-,
skis,the fool mustfunctionas a iigid beamwith thesubta- srrile or toe off, lhc goal of trentmcnl is to improve func-
lar joirl bcing mamtaincdin a neulral position with the tionrrlalignmontoffte patella and allow the fool to function
nidtarsaljoinlIockedandslable. asr rigid lever.Thecyclislpresenting whh exc€ssivesublai
If the subtalar joint is pronated, the midfoot wiii lar trcnationoftendemonst.at€s exag8erated medialdevia-
buckle as pressure is shifted ftom the h€elsto llle melatarsnl tion of rhe kneoduring the power slroke and ckonic muscle
fieadsand the distal €ndsof thc skis can ol|ly be controlled frriSue in $e arch secondaryto an inat,ilily to effectively
via pleatmuscular effon (27).Furthermore, whenthesubla- rranstr forces through an unstablemidtarsaljoint. Treat-
lar joint is maiotainedin ? pronatedposition(which is menl wilh so appropriately sizedpost will both improve
amplifedby tighrfittingski bootswhich Eattenthe medial funcriodal alignmenl of the knee and allow for the locking
arch), ir i$ often impossibl€to gain accessto lhe inner edge of rhe midtarsaljoint rcccssaJyfor the {ool lo effeclively
of the ski without inlernallyrotatitrgthe lower extfemity trnn$€rforcesduringthepowerstrcke.
and cr€alinga valgusthrustat the knee(Fig. 6.21).This The improved biomechanical efficiency associated
mayresultin faultyupperbodyrotalion(th€lorsot rnsinto wilh properly postcdonhoucsv.as clearly demonstrated by
the hill makingcoufierrot.rtion difticult),sideslipping(the Hjcc ct al. (29), as they noled that tfie samefive cyclisls
tail endof the ski often wa,\besout due to unequaltrp to lail werc able 1o consumeless oxygtln and maintaio a Iowd
pr€ssure),excessivemuscularcffort rnd aa increasedpo- beanrateas lhey performedal , given submaximal work
 ChaplcrSir liborator! PreprBtion !trd Orthotic F bricallon 219

tigure 6.2r. Eic€ssivepronalion resrlls in

an s(aggerat€dint€rnal rotalior of the entire
lower exrremity and pelvis {A). while this
may allow the medial ed8eofthe ski to carue
a turn, it is associatedwith a "washing-oui"of
th€ lail (B), wider lurns, and an increased
senseof muscularefiod, as the upper toco
musrcounreffotaiefor rhe nexr tum. (Adapted
from MalhesonGO, Macinlyrc jC. Lower le8
varum ali8nmentin skiinS:rclationshipio foot
pain and suboplimalpe.fomance.PhysSpodt
Med 1987;l s(9):161)

rltc whilewearingorlholics.Because toe-clipsmaintainthe IN-Orfl ctr FABRTCATToN TDCHNTeUES

fore{oorin a Iixed posilionwirh the centerof pressure lo-
caleddirecllybcneathfie melal^rsalheads,il ;s imporlan! So far, Lhediscussion oforthoticfabricationhasbeen
rhcdesiredreadooland forcfootposlingbe combincddnd limiled primarilyto the role of the comnerciallaboratory.
placcd benealhlhe forcfoolwith a compressible postto sul- Ilow€ver,it is also possible10 usevariousin-otficetech-
cusaddedlo supporlthc m€tararsal heads.Note that be- niquesto manutacture effective,inexpensive onhotics.
€auscsomccyclingstroeshavecontoufedbottoms,it may Th( most populartcchniquclor manufacruring in-
bcneccssary 10havethecyclistswitchto a diferentshoe.lf officc orthoses is thc directmold melhod.This mclhodre-
thisis a concern,it is possibleto complelelyavoidusingan quir€shealinga layeredstrip of Plaslazole in a convection
in-shoe c'nholicby addi'g a speciticallydesigncdfcplrc€' oven lbr approximately 7 minures(rhe edgesIift up and
menrpedal. drop whenthe materialis r€ady).The hearedPlastazot€ is
Wilhoul doubl,lh€ alhleticactiviiythal prescntsthe the! plac€don a block of high-densilyfo3m and directly
mostdifficullieslbr orthoticmaragencntis balletdancing. moldedto lhe patienl'sfool. (Thepatientis wearinga sock
Because of the limircd conJines of thc balletslipper,it is to DreveotblrrrN.)The formedPlastazole is then cut and
neccssary ro fabricatean orthoticin whjchonly lhe forelool groundinto thedesiredshcllshapcandif indic{tcd,various
is postcd.Allicd OSI l-aborato.ies (lndianapolis,IN) sug- top covcrs,additioffi,balancefor lesionsand/orpostsmay
gestsusinga semiflexibielhermoplasLic shellwilh an ex- thenbe added.lt is imponanl!o nol€thatlhe inherertcom-
Irinsicforcfootpostandsuederopcoverthatis h€ldin place pressibililyof Plasiazote dictatesthat forefooland/orrear-
wilh an elasticbandanda lhong.This ortholic,which may foot poslsb€ evaluatedall€r 2 weeksof regularw€ar to
includcnreklarsulpads.bar posls,and/orbalancesfbr l€' delerminerhe reed for possiblereinforcement. Becauseof
sions(daocersfrcquentlyrequirebalances benealhthc firsl lhe accommodative natureof th€ Plastazote, thedireclmold
andfifih metatarsal heads),nay be invaluablewhenlrear- orlhos€sareparticularlyeiTective whentreatingjndividuals
ingmclatanalskcssfia.tures,capsulitis, inlcrdigitdlneuro- with inflammatory arthrilisor diabeles
mellilus.
mas,and/orplaniarf{sciitis. In tacl, because of their tendcncyfor plantaiulcem-
Of panicularin1€rest wilh rega.dto rreatingballet lions,N,{ueller et al. (31) suggeslrhaldiabeticswno are ln-
danccrs, Miller et al. (30) recendydemonstraled thatmodi- sensitivelo a 5.07SemsWeinsieinmonofilamerl,possess
fyinga slandardtcchniqueballetshoewirh l/8-irch PPT lcssthan5" ankledorsifiexioror havelessthan30' subtalal
cxterdedftom lhe be€l to rhe meratarsals, 1/16-inchPPT rangeof motion,shouldbeginlr€atmeniwith accommoda-
extended undcrthc toes,and a high PPT archsupponwas tive footweardesignedto l€ssenplaDlarpressurepoints
ablelo successtully redislributepressureaway from the coupledwith mobilityexercises andeducalionin foot pro-
overworked and often injuredfirsr and secondmetatanal
b€ads withoutcompfomising the dancer'ssubjeclivecom- In additionto treatitrgarthrilicand diabeticindividu-
iorlandleel lor thefloor. als,lhe direclmold Phslazoleorlhosesmay alsobe helpfd
220 FOOTORTHOSES
ando|herFoc of co.s.Nrtivc Footcare
riBur€ 5.22. The Eiopedal(Bio+ons, Mill Vallcy, CA,
whlch b ured lo replaccthe existint p€dal, may provide up
to 12' of forefoot varur or val8usangulation(A), 5' of In o.
out.toe positioning(8). and structural leg length dirc.eprn-
ci€sofup to 1 inch.
FiSure6,23. By t pering thc €dtes of l€lt Btripsor Plade-
zote, pa(€"in onhotica may be t|s€dto treal foi€foot valtu3
deformitiB (A), tor.foot varu3{B), and r€arfoot va.osdeaor-
in lreatingathlercsinvolvedin cuttingsporls(psnicularly
basketball and soccer) wherc a more funcliooal onhotic
mighl nol b€ tolemlcd- Tfte only drawbacksto the direct
mold metbodsare that they are time-consuming(they take
an)ryhcrefrom 25 minules to 2 hours to fabricate,dcpend-
ing uF)n the individual's experienc€)and the processrc-
quircs the |lsc of noisy, fairly expe$ive machircry. Also,
becaus€lhc choice of msterialsis limited to the clos€dcell
polyethylenefoams(lhes€are lhe only shells that will read-
ily mold to lhe patient), the finished orthotics arc not rery
duftble and must be re€valuatedevery 6 months for po6si-
ble reinforcemenlor replacement.
A simoleallernativelo thedrect mold mcthodis the
paste'inrechniquc.
This technique involvesshapingvrrious
accommodativcrnalerials(usualjy felt, Plastazoteor PP/T)
into different Ftostsand/or balanc€send fier gluing thcsc
fo.ms otlto the bottomof an inncNole(eitherthe patient's
presenlinnersoleor a genericSpencoor PPTimersole msy
be usad). Figure 6.23 illustrat€s the more conmooly os.d
modificalions,
W E€vel€d
milica(C),(ModjfiedfromMcPoilTC.The€obrapad-ano.-
thori( dltehativ€for the physlcalth€rapist.
, OdhopSporb.
PhY\Ther1983;5(1J: 10,)
Despite their r€latively simple design, pasle-inor"
Ihoricsare able to effectivelyreduceboth thc rangoand
specdof subtalsr pronatiotr (32, 33). .ds with diftcr mold
tcchniqu€\ lheseonholics should be cvaluatedbirnnualt
for poAsiblereinforcementor replao)mcnl.
Refercnces
l. McPoil TG, Adrian M. Pi.lcc P. Effccts of foot onhos6 od
renl.r of pessl're patem ir wom.n- PhysTtcr 1989;69(2):
2. Smilh t,S, Clffke TE, Hamill CI- SantopictroF. The efi€cts
sofl and s.mi'rigid odhos.s upon r.srfoot novened ir
',I
trn'dn& J An PodiarrM€d Assoc 1986i7ri(4): 22?.
3. l.undcenRO. Polysclioral Iriaxialposting.A ncw process
ror incorpomting corection in fool orihoscs.J Am Podiatr
Mcd Assoc1988i78(2):55.
4. .lor8€nsenU. Bojset-Moncr F. Shoct absorbcncyof factolsjn
rhc sho€/hcelintaftclion-wilh sp.cial focui otl ralc of thc
l|eelpid. FooiA*le 1989i9(ll): 294,
5. l{oss AS, Gmick KL. Elevator relcction in rcarfoorFsted
('nnoss. J AE Podiatr Assoc 1982i72\\21:621.
 ChaplcrSix kbo.rlorx Prcp.ntion a||d Onho{c F brlcltlor
6. W€edJll, Rarlifr FD, RossSA. Biphnd grird for reanbor
po$son luncrionalo boscs.J Am PodialrAsc 1978;69(1):
35_
?. Clvatra8hPR. The sh@-troundinledaccin running.In:
Macr RP (ed).Symposiumon the Footand Leg itr Runnint
Sporls.Sr.Iruis: Cv Molby, l9lizr 3tL44.
8. BlakeRL, Commonsporrsirjuries dd their Lealinenl.ln:
Foola.d Lrg r!.clir)n. DecrPark,NYrti.ger Bionecharics
cro u p ,1 9 89i
l( 3) ?.
9. SchuitD, AdrianM, PidcoeP. Bltccrsof heellilts on trcund
reactivcforcepauernsin subjechwirh structuralleg lcn8rh
discrepancies. PhysThcr l 9il9;69: 4l -48.
10.MilgromC, Gjladi M, Ka$htorH, €r al. A prospedivesrldy
of Lbceffeclola $hock-absorbirS onhodcdeviceon the inci.
denceofstrcs liacrurcsin mjlilaryrcctuns.FootAnkle 1985;
6( 2 ):1 0 1 .
ll. Volshin wJ. l.w back pain: conepative {.@rmenrwith
anifcialshfrk !b$6er!. Arch PhysMcd Rehabil1985;66:145.
lZ McManor'lA, er al. Orouchorunnirg-J Appl Physiol198?i
62: 326 337.
ll. Nigg BM. Erccl ot viscoclasric sh@ ireles on ver|icll im-
pacrlblccsin hcclroetunDinS. Am J sportsMed 1988j16(1)1
70 76.
14.t* KIl, Sh'ch JC. MauclianoA, Sni€horcwskiT. Elcc-
liodyosraphicchanges ol lcg nuscl.s in wone!: thorapoutic
inplicalions- Arch PhysMcd Rchabil1990;71r31 33.
15.Ni*c Sport ltesearchRcview.Rearf@rstability.Ileaverron,
ORrNike,Nov/Dec.1989.
16.BalesBT, OslcmiALR, MasonB,JamcsSL.Lwcr extrcmity
fu.ctionduringlhc supponphaseofiurring. h: Asmussen E,
Jorgersetr K (cds).Biomechanics VL Baltimore:Univcsily
17.ClarkTE, FredcrictEC,llamillCL. Theeffectof shoedesiSn
on rea.t@tcontlol in running.Mcd Scj SpoasExerc 1983;
15:3 ? G3 81.
lE. Slaoff A, Kaelin X. Pronatiorand sporl shoedesiSn.Inl
NiBeBM, Kerr BA (eds),Biomcchanical Aspeclsof Spons
Shoesand Phying Sudaces.Ctnada: Uriversily oi Cal
Sa i y;1 4 1
3 51.
19.GloverMC. Plantorwaris. fool Ankle 1990;11(3):l?2.
20.DamnbergHG. L€tlcrro lhc cditor.The kineticwedge.J Am
Podiar'Mcd As$@ 1988i?8(2).
221
21. HolmesGB, Jr,-nrMcrnan l-. A quanlitativcas$sme of
Lheetl€cl of neta{aGal padson planur prcsures. I@l Ankle
1990i1!:141145.
22. Frederi.kEC. The cnergycost of lord cadiagcon lhe feol
duringrunning-In: Wirer DA! er al. (cds).Biom.chanics IX.
Champaign,II-. Hud Kirel 19E5:295-300.
23. Hanill J, F!€edson Ps, Bodaw, Rcichsman F. Erecrsof sh@
rypeon cardiorespi.alory rcsponscs ard rea.footmotionduF
ingtrcadmillrunnins.MedSciSponsExerc1988;2qt:515.
24. SisncyP. Triathlonsand asso€iatcd injudcs.ln: Slbohick S
(ed). SporrsMedicineof the t-owcr Ertrcmily. New York:
ChurchillLivinAstone, 19E9:637.
25. Williams K& CavanaghPR. TI|e n€chanics of fool actaon
during rhe golf swing ard ill|plic3tiors for shoedesign. Med
Sci SponsExerc1983:l5(3) 24?.
26. S€ass€r B, Pforidaer w (eds). Thc Shoc in Spon. Chicago:
YealbookMediel Publishcrs, 1989:125.
27. Matheson GO, MacintyreJC. Lowcr lcg !a.um aliellmenlin
skiing;rcladonslipro foot painlnd suboplimalpe.fomae.
PhyssporrsMed 1987;15(9)i163.
?8. WitherelW. lI you can'l sli psnllel, canl. Skiing,January
t9'1',t.
29. Hice GA, Kcndrickz, WccberK, BrayJ. The effccl of fool
o hoss on oxygonconsumprion whilecycling..l PodialrM€d
Assoc1985;75(10):513.
30. Miller CD, PaulosLE, Pa.kcrRD, FishellM. The bauertech'
niqueshoera preliminary study of clcven diffcrcody modined
balld lechlique shoesusirg forc€ and pressureplates. Fet
A r* l c 1990;11(2):97.
31. Mu.ll€r MJ, Diamod JE, D€liuoA, Sinac.rcDR. Inselsiriv-
ily, joi nobility andplanlarul@ls in pati€nlswiti diabetes
mellilus.PhysTher 1989;69: 453-458.
32. NigS BM, bthis, Segesser A, er al. Sponschuhkonellur€n.
Ein biomcchanicslerVergleich vor dr€i veFchi€denen.
Sponschuhkonckturer Z Onhop1982;120:34-3v.
33. Clark€TE. FrcderickEC. Hlavsc HF. Effectsof ! sofl oL
thc'ticdoviceotrrea.I@tnovehenrin runninS.PodialiSports
Mcd 1983!l (1):20.
34. McPoil TC. The cobla pad an orlholic alt€rnali!€lor lhe
physicaltherapisl.I OdhopSpodsPhysThcr 1983;5(1):10.
 ChapterSeven

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
SHoE GEAR
Possibly the most important factor to considerwh€n
fabricating an onhotic is thal th€ ortiotics are only as func-
tionalastheshoesin whichtheyarewom. As demonstrted
by McPoilet al. (4), a well designed shoe,evenwifiout an
onhotic, hasthe ability lo favorably aker the centerof pres-
surerccordings in individuals with fore{oot varus detbrmi-
lies. Unfortunat€ly,the reverseof this is alsorue, in rhnta
poorly desigftd shoe may serve as ar exlrinsic sourceof
pronalion. Becau-seof this, the paticnt should be educared
&sto lhe proper choiceof shoegear.
The mor€ irnponad qu"lities ro look for i! a shoein-
clude a firm, deepheel countertiar closelycontoursrhe pa-
tient'scalcareus(this rnayrequireaddingfelt to the inner
aspectsof the heel counter), a sfiong shank that does not
flex upor weight-berring (th€ shank is rhe se{tion of the
shoelhat co(esponds lo thc medial longitudinal arch), and
a spacioustoe box that does not compressfte metatarsal
heads(Fis. 7.1).
Wheo being fit for a shoe,the patient'slargerfoot
shouldbe tneasured(oddly enough,a studyof 125individu-
als indicatedthal the foot oppositethe domhs,rt hand is th€
fiSure 7.1. Compon€nb of a well-nEd€ shoe. The he€l
counler should in securely{it may b€ necessaryto balanc€
Haslund's deformity wrth fell), and its lrise.tion should be
veftical to lhe supponinSsortace.(Poorquallty conlrol often
allows for an asymmekjcalhe€l counterthat is ekher iovefted
or €'€.ted rclalive to the table top; see A). Also, the shank
should lt able to rcsisrforcelul comprcssionwjthout deform
inC (B), and ir should be angled in such a way that when the
heel eat is compress€d(C), the plantariorefootlifts no mor€
thar a few millimeters(D). (A-P instabilitv is presenrif th€
larger of the two fu almost80% of $ose evaluared [5]I
lh€ lengthof the shoeshouldbe deLerminedby the
of rhe metatanal headsi the widest portion of the
shouldparallel the bisection of LhemRtalarsalheads.
patjenthasan Egyptia! fool-type with i|s long first lo€
thal this refersto th€ length of fie big toe, not to tie
of rhe first m€tatarsal),tb€n the dislal roe bor should
evdlmtcd lo make$urelhat it is not compressingrhe
which if it happcnsmight precipitalea hallux
glls deformity.Aiso, to allow for adequateftonlal plane
bili y, lhe planlarsurfaceof lhe heelsbouldbe tairly
(unlikemostwomen's&oss shoct)andshouldbe
when exc€ssivesigns of wear are present, The patj
should always be informed that the orthotic may &
significantly changewear pattems(which sr€ secondary
abrasionand not vertical forcss) and may actuelly
vafirswear whena large rearfootvarusposris used(l).
In addition to choosing from the various
changesin shoe design, ceiain casesrequire that a
sho. be modified by a cobbler in ord€r to b€lteraccom!*r
datc a specificfoot typc. Thc more (xrmmotr
ared€tailedin Figore7.2.
Whenever possibl€,the patientshouldbe encouraged
'@
foreti)ot lifts more than this.) Th€ toe box should provide
ample spaceso ar nol to compressa doEomedialor lal€ral
bunion. Becauselt allows for Breaterreparationof the oppef/
Blucherlacins may be n€cessary to acconrmodalethe b!lkier
odk'ses (q. If th€ patienl complain! thal his or her lool is
didi[8 tblward on the oilhoti. (which often occuB whenheel
lifts ire used),a slrip of adhesivefelt may be placeddlonsthe
und..surfaceo{ the tonEuethat Eentlyprcsses the Jootponer
orly onto the odhoti., thereby prcl,entin8slippa8eand im-
 ChapterSclen O hotlc Dispeffir8 Sho. Ge|r, atrd Cliricsl Pmblem-Solvirg
A
tigure 7.2. 5h@ modification. (A) By suppodins thc
neialaf,al neckr, a Thomasba! may de(€ase pressurebc-
neathlhe mchtars.l heads.(8) A s(hosterhel w€d8e it use-
lul wher hcel lifts grcaler lhan 7 mm are requi.ed. (C-t)
Decomprcs5ion pad, mdy be usedlo disi.ibutepressu€away
tom a vrricty of bony prominence,(in€ludinsdoBomedial
and ateralbunionsand HaSiund'sdeformiiy).(D A wins-heel
may be ncldedto rein{orcethe media heel while a varti$
wedBemay also bc incoporated inlo tho heel itself(G).(Note
Ihat €xremal modilicarionsof shoes aro nol as effeciive at
controllinsmorionas iniho€ onholes16l.)(H)An overly flex-
ible rhank may be rcinforcedwith a filler m.terial while lhe
225
addiiion of a rcckeFbotlom(l) allows the palicnt ro prcceed
through rhe prcpuhive period withoul bendinSth€ metalar
sophalangeal joinls. {Thismodificationis oftenessentialwhefl
trealinghallux i8idur deformiti€s.)The final modificationrc'
quiresmakinSclrs in the sole of the sho€ in order to encour
age a hi8h or lolv 8ear push'off (r): A hiShgeaf push'ou
,hould be encouraSedin an individlal with a risid forefoot
val8u, and recalcilranl nlefdigilal neuritis while a low Sear
push-offrhoujd be encourasedin an i.dividual wilh a hallut
abduclovaJgus defomily as$ciated with ex.essivepropul!ive
226 FOOTORTHOSBS
andOthe.Formsof ConscrativeFootCarc

to wearrunningshoes,as advances in materials technology (8) nolesa dircc! correlationbetweenmidaoleduro

coupledwi$ l.uge varialionin shoedesignallowsfor ac- (densily)atd the rangeofsubtalarproialion(Fig.7.5).
commodation of a widervarietyof fool types.For example, Beduse softer midsolesimproveshock
the praclitioncrmay reconm€ndeithercurvcdof slraighl- while lhe firmermidsolcsmoreeffbctivelycontrolmotiofl
Idrtcdsneakers in orderto accommodate a m€tatarsusad- it llLs bccomeslandaldpracticcfor manufacturers to
ductus or metatarsusrectus(Fig. 7.3). Th€ praciitione. bin( a softerlateralmidsolewilh a firmermedialmidsole,.
shouldBlsomale rccomdendalions for eithersliP, comb! Refcnedto a duodensity midsolc,thc softermaterialon.
nation-,or boa.d-lartedsneakers(Fig.7.4). the ateral side softetrsimpa.l forcesand decreascs
lt€ ini..
The useof sneale$ is also paeferablc to shoesbe- tial velocityof pronationwhile lhe firmcr materialon thc
causeil is possiblelo modify sublalarnotion at heelstrike m€d;alsideprovidesproteclio|lagainstexcessive pronatiol.
by choosinglron differerldensitymidsol€s, e.9.,Frederick Thc duodensitymidsoleessentidlycrearesa funclio0al

A B

rigure 7.3. The last refers to the fool-shapedhigh-densiry
polyelhylene moldthata ,hoeis conslruct€d around.Ar prc
sefl, shoesnreeitherslrrilrhlor cutue-lasted.
A ltrai8ht-laned
shoaiswell-alirnedin lheiorcfootandrearlool nndshouldbe
rccommended fof individual,with rcclusfool types(A),On
lhe cantfary,curve-lasled shoesare anSlednrediallyal the
ior., oot and should be recornmendedoDly for individoah
with metata6usaddu.tus(E). (Theinadvertcnluseof a curve
lasl(alshoe by nn individual with a melatarsusrccrusr!o!r
oftcr resultsin a painful adventitiousbu6a lomins ovcr rhe
dorsolateEliifth n)etalarsal
head.)

B
Figurc 7.4. A board-lasl€d shoe {A) har a hard fibrous
board on its iflncr slrfice that Drovidesstabililv and is more
appropriarefor individuals who overpronat€ (7). Unfonu-
nately,the boar.l'll5te{lshoe is ,tiffe. and may pr€cipnalean
achilleslendon ini'ry. In a slip-laltedshoe (8), ihe upper is
stitchedinto a one-piecemoccasin;rnd thenglued lo lhe sole.
Theseshoesprovide les. stabilily but are lishter, morc ilexi'
ble, rnd roornierin the toe box (makinSth€m an excellenl
cho,e for nrdividlralswilh cavus fool lypet. Ihe combina-
liof l,rslshoe(C) providesthe besl oi bolh worlds by provkl-
inH rcirdoot rtability with a bodrd-lailed he€l while
mainriininBilexibilltywith a ,lip-lisled forefool.lhis is a nic€
.onll'ination when lreatingindividualswith rear{ootvaru,de'
 ch.pier Seven Orthotic DisprtrsiDg,Sho. Gerr' .nd Clhidl
Duromeler
tshoreAl -Had
FiSure7.7. Ihe n€galiv€posleriorfi€€l flare.
rearfootvarus posl thal ha,sbccn prcvcn lo be effective in
conrrolling rearfootmotional hccl-strike (9).
ln addhionLochoosingfrom differenldensitymid-
soles.rhc amountof srlblaltrrpronalionpresentduringthe
contactperiodmayalsobe moditiedby varyin8rheamount
of lareralheelllarc.As demonstrated by Nigg andMorlock
(10),a largelaleralflare incrcases the lengthof lhe lever
armb€(wecnthc subtalarjoinr axis and lhe ground,*hich
produccsa concomilant incrcasc in both the rangc aod
speed of initialsobtalarjointpronalion(Fig.7.64).The au-
lhorsalso d€nonstraledtlal a negaliveflare effecrively
le$sens lhe lergth ofthc lcvcrarm (X' in Fig.7.68),which
p.oduces a concomilartdccrcasoin lhc rangcandspe€dof
initialpronalaon .
The samebiomechanical principlcappliesto the n€g-
ativeposreriorIlare(Fig. 7.7), in thal it shonensthe lev€r
arn belwe€ntle anlle joint aris and the grourd, lhereby
lesseningthc vclocity and range of initial ankle
Pmbl€n-Solalo8 227
ti8u.e 7.5. Relatiofthip belu€en mid$ol€ density and mari.
mum p'onarion. (Ad:pred fmm tredeick tc. The Runnins
Shoe:Dilcmmasand Dicholomiesin DesiEn.In: SegesscrB,
Pfotrn8e. w (edt. Tha Shoe in Sport. ChicaSo:Yearbook
Medi ca P ubl i rhers.
1989:l l .)
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.
plantarflexion duringheel-st.ike. (This modificalionsholld
b€ consideredin all recreatiornlaodcompetitivewalkersas
a melhodof rcducingstain on the anteriorcomparlmenl
musculature.) Il is alsoimponantto notethatwhilc a largc
lateralflaremay initially increas€velocityof pronrtion,a
largcmedialflareeffectivclyreduclslhe rangeof pronation
by actingas a physicalba ier thal blockscxcessive motion
f8). This is also lrue of sneakers that haveextra midsolc
matcrialplaccddirectly bcneaihthe medial longiludinal
arch(11).
On€ of lh€ fiost importanlqualitiesof a sneateris
lharlhe h€elcountersecurely{abilize the rearfool.In addi-
rion ro mainlajningthc fat pad(which protectsthc planlar
calcaneus from injury),a well-lormedheelcounlerhaslhe
ability to lessenmusculoskeletal uansienls,decrcascacdv-
ity in the quadriceps andtriccpssuraemuscnlaturc, andrc-
duccv0, (12).tn addition,thedeeperbeelcounleFpres€nl
in mostrunnang shocsallowfor a better6t with theortholic.
(Notethattheslockibsolepresenlwher lhe sn€akeris pur-
chasedshouldbe removed,as it may adverselylilt oI angle
rheonholic.)
Thelinal stockmodification thatmalesrunningsho€s
preferable 10a standard shoeis theupwardcurvcof thcdis-
ral nidsole(Fig.7.8).Refcrrcdto asa toe-spring, lhc supc-
rior angulationof the midsole basically rcpres€ntsa
modifiedrockerboltomthatservesto shortenlhe functional
lenglhof the shoewhilc also allowingthc melatarsopbs'
langealjoi lo move througha lessened rangeof motion
228 FmT ORTSOSESrtrd Olner ForE! of corservativc Fool Carc
Figure7,a. Mary runnint rto€6 havea 3up€rioranSulation
of th€ dirral mi&ole lhat .llo$3 for a moie €fficient propul
siveperiod.
dudng propulsion. Bec{usc of these improvemcnts,this
modification is invaluable in the trertment of achilles tcn-
dinitis, plantar fasciitig metatarsal$ress syndrome,ard/or
halux limilutrigidus.
In all cas$, the practitioncr should try to match the
patient's foot typ€ to 3 st €cific shoe.For example,paticnts
witt rigid fool iypes typicdly rcspond best to slip-lasted
sneakerswith thc softest possiblc midsoles. Becauseof
their ability to dccrea.rcbolh thc rangeaod velocity of sub-
ialar prcnation at hecl strikc, individurls with a reartoor
varusdcformity respondbest to a combinationlast sn$ker
witb a duodcnsitymid.role,a 3ff medial flarc, and o rcga'
tive laterEl flarc, (Bccalse tbey are not yel commercially
avrilrble, il is ncccssarythat the leterrl flare be oodified ci-
ther in-offce or by sendingrhc sneak rs !o an onhoric labo-
ralory.)
For patieots pres€nting$/ith ext eme ra.rgesof cal
caftal ev€rsion(e.9., individuals with large forefool varus
deformitiesor ob€scpetientswith hypermobileflatf.et), ad-
ditional supporl may bc afforded by a midsole that is rcin'
forcedbenealhthe rocdial longitudinal arch, coupledwlth a
pladic external hecl rtabilir.r. Although NiEg et al. (13)
d€moNhated lhal .n cxtemal hcel stabiliur may actually
increasethe initial velocity of pronstioD,tbis fact doesnot
Table7.1'
SPECITIC
PTOBLE PROBATLE
CAUSISAND CORXFCIIVIACTIONS
'tS:
to€lion of Dtuconforr PocsibleCeurer.nd Ralional.
Bunionpainincreas€s
with use a. Largerearfooy'forefool
varus
postliftingth€mcdial
{orefoot (andbunion)ink)
outwcigh tic beneficial eff€ct of a stsble, vcrticxl
CUNICALPRoaLEM.SoLVr c
Regardlessof how thorough your cvalualiotris,
will ah,ays b€ crses in which a patient's respodsero
nrorrtis lessthan wirnderful.Fortunrt€lv.it is
posrible to determine in .dvancc which patiena wifl
spo,rdpoorlyto lreatmenr, asth€majorilyof thes€indi
als will have larg€ roarfool rnd/or forefool
.igi(l cavus foot types (which are notoriorsly difffflill
trear). congenilally limited amountsof snkl€
(cq||inus conditions ofien dcfy orthotic
and or advanc€dstages of soft lis.suedsnage (whict ig
oftefl dilncdl to rcsolve€venwith the most thoroughrcle.
bilit ivc pro€?dures).Patier s with thca4problcmssholld
alwlys be informed in advanceihat th. onhotic may oot
producea subsbdial r€ductionin symptomarolo!ryandtllat
il is io do way a cure-rll.(Howcver,rhereis alwaysOc
plen\ant exceprionto rhe$erules in which a patiotrtwilh
largc alruqurai deformity lnd seeftingly untcatablc
amounrsof soft tissue degenaEdonwill hrve a completo
resolutiodof all symptofis.)
Unfornrnal€ly,therc arc also olher instancesin whicl
palicnls wirh seeminglymanagcablcdcformitiesare unable
to \\'ear ibeir orthotics for morc than r f€w hourswithoot
discomfon. Althougb the lisl of possibl€causesfor tr€et-
ment failure is long (and would inchde faully mca$rc-
merts during cvaluation,poor calting lechriqlcs, Iabonlory
crror, incoFect selecdonof materials,and/or unanticipated
proFrioceptivedeficitsthat arc not respondingto the rehabil-
itative progtam),it is offen po$sibleto determinclhe sour(t
of tle problemby relatinglhe locationo{ lhe disconfon
to thc sp€cificsof the palient'slbor typc and tbe typeof
orthoticfabricated.
Teble 7.1 (rdaptedfrorn rei 14) relatessFcmc prots
CorraclivcActlon
a. R€evaluate needfor poning.
lfthe poil anglerarecorrect,
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

Localionot Discomfort Po$ibl€cau3e3

andRatlonale Cotr€ctiveActlon

Seiamoidpain conlinues a. Not enouShrearfool a. Consider increasin8 Posl

despiteuseoI odholic.
conkol;th€prlaent antl€s and/orusint a more
lo pronale
continues controllingorthotic.To
excesively,thereby contrclpropulsive Period
comprcssinS thesesamoids. pronation,$e readootPosis
may be plaed ben€alhlhe
distaledBeof th€ orthotic,
andthe solesof the shoes
maybe cutto allowfor low
SearPUsh-off.

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.

Diltalendof oftdic a. Ov€rlyrensilivesofttissues a. Hav€ pariefltwearthick

enension(padicularythose 5ocb untilthe sofl tissues
can accommodalethe
ext€nsionor simplYtaper
the planlarsurfaceof th€
extension.Anothercon-
siderationis to havethe
palienl rcst a flal Sp€nco
insedover lhe orlhotic.
(Thisalso s€rvesto cushion

Dorsal5lh a. LargeforetootvalSuspost a. Havecobbletsttetchlhoe

lifrinalatemltorefoolinlo Searover 5th mebtarsalhead
(e.pe€i.llyi{ a tailo.'s
bunionis p.esen0,
b. A largeforefoolvarusport b. Reevaluate pogtangletrif
causinB ihe patienttoslid€ correct,consider addinS
lat€rallyoff the ortholic, Spencotop cov€rlo
iammingthe5thm€tataGal preventslippag€or have
headinrotheshoe. palientins€nfeltslr;P
unde.ton8ueof shoe.
c.lncorrectuseof a curve- c. Swit.hto straiSht-lasted
lastedshoein patienlwilh

Do6al f tsr meralarlophal a. lncoiiectule of a lorefoot a. Re€valualen€ed fol

anSealjoint pain .n.yof
IiKt inlenhalan8€aljoinl
varusPost.ThePosling forefoot varus post.
materialprevents$e nor
maiplanta lectorymolions
o{ the fkst rnetatalsal
necessary fora firll mngeof
halluxdoreifl exion.The
inre.phalanSeal ioinl may
be iniurcdas il hypeF
extendrto compenerefor
thelimitedmetataBophalangeal
230 FOOT ORTHOSESand Olher Formsof Con*ryllile
Locarion of Discoirfo.t
lniediBital
de3pileuseof ortholic.
Medjal arch pain develops
M€dial Lrorderot orlhotic
diSSinginto ,oft lissues.
Foot Care
Table7,1 ---eontinued
PossibleCarees and Rarionale
b. lncorreduseof Modon's
extenrion,whichalsolimits
lhe planlarfl€ctory
movementsof the fnsr
c. Castwastakenwith torefoot
.r. Suspe.ldouble-crush
syndromef.om entaPment
i n | l rs a l l l n n € l o r s p i hc
(particslarlyif lhc inteF
dlgital pain is bilateral).
b. Patient.orn inuesto wear
I ithriitthG shoesor overly
flexibleshoesthai allc'w for
a rangeof digita| .iorsl'
florion drat kactionsthe
interdigiLal nerueaEainsl
the rransv€lseliS.rment.
a. Re?rfoolvails ponin8 is too
hiSh.
b. Inadeqxate(r€ngth,
flexibjlity,and/or
c. Incorrecichoiceof maleriaI
(panicul.iriyii riBklrhell is
usedfor dsid toot Lypel.
d. FuJlarchheightusedwith
equinus{ootrype:15the
midla6rlr anemptto com
pensalefor limikrd ankle
do$iflexion, the planur
medial arch i$ conrpress€d
e. Negativeimprcssionis laken
with lhe subtalarjolnt
a. tabofaiory e(or: failu.eto
lower arch lor equinusfoot
b. Inadequill6slro.'g.ar:
patientrullin8 over
.. Inadequitele,'elsoi
p'oPriocepllonand/or
d. OveryeiShtpatienlwith a
raGegeDUvaEunr.
b. Reevaluat€
needfor
Morlon'sextensioo.
b. Switchto shoeswilh B
nrorespaciourtoe box and
sliffersoleslhat lcssenthe
ran8eoi digital dolsiflexion.
Also, arbtle chan8esln the
posilionof metatarsalpad
may havea dramaticefiect
on reducinSinterdiSilal
a. Reevaluateneedfor
postins.Considersofier
b. Increasefrequcrcy of
treatm€nGand/or home
rehabprocedures.
c. Consid€rchanginB
materirisor add s.rfllDp
cover to presentorthotic.
d. Add tempoary bilateral
heel lifis. halt: laboralory
lower the medial lon8il{d
inalal.h, ard/or usesofter
e. llav€ laboratorylowe. a.ch.
Considerrc.astingpntient.
a. Have laborabry iower arch,
add bilateralheel lifts,and/or
useroftero.lhotic!-
b. changeshoegearand/or
remakeodhori. wirh
c. Addrelelvith approprlate
rehabilitarioniechniques.
d. Remakeorthoticwith
nredialflanse,reinforce
thoe 8ear,strengthen
intrinsir mrls.ulalLrre.

Lo(alion of Discomforl
Planlar
fascia
l/media
I ar.h
dis.omfonconrinuesdespire
Planlarfid matararsalshatl
painat disralendof odhotic.
Tiss{esovor melataGalpad
be.omeuncomfonable.
Tanometrlalsalpain afrer
urinsbalancetu lerion
benea$a painful melatal,al
Medial,ponerio.,and/orlareral
heelpainal edseof heelcup.
ChapterSevci Orthollc Dlspersitr& Sboc ce!r,.nd Clidc€l Pmblcm.Solvlng ?31
Pocsibkcaus€sand Ritionale
a. Too linle controlor rissues a. Consider ueinSmore
too inflamedto toleratea funclionalo.lhoticand/or
funclionalortholac. usclow-dyetapinS
procedures \,vithonholic.
b. Inadequalenren8lv frcquency
b. Increase of
tfearment and/orhome
prcceduf
rehabiliialion es,
c. Inco(ecl diagnosisof Considornighl brace.
mechanicalfool p;in. The c. R€questappop,ia(elaborn,
sercn€Ealive spondylo"
arthropalhiesoften poduce
symptomsal the medial
lube(xity of the calcaneus.
r. Laryerearioovforofoor a. Reevaluateneedfor posl,
varusporl lihinAmedial ing:ifcor€ct, havepatienl
wearlhickpaarof so€ks
accommodalenew les! or
sendto laboratoryand adda
compressible pon to sulcue.
CThi,disrrib!re,weightoff
themetararsal neaksonlo
lhe m€tatal5alhead$.)
b. Labofatolyerror lhe medial b. Relurnto labo.rloryfor
dislal edte of devicetoo long. adiustment (orjuslErind
ed8edown in office).
a. Nomal padol brcak-inas a. Proceedmorcslowlywilh
lrssuesaccommodalenew break-inand/o'werr rhick
b. Metatarsalpadsloo larScof b. Returnto laboratory
for smaller
PoorlYPositiooed,creatinS andlofsofterpads,or for
bowstrlngeffeclon (entral repositionin&
band of plantarfaeijia.
a. Nomal parl of brcak-in. a. Proc€€dmor€slowlywilh
break-in.
b. B.lancetoo deep,allowinS pa(iallyfill
b. Havelaboratory
Ior excessi!€planta lexion balance,
rcmovelI
of involvedmetalarsalhead
(therebyrtninin8 rhe
prcximalla6ometalar5al
a iculation).
a. l( thelaboralorydoasnol.allow a. Inilially,makesurclhe
for sufficienr
dhplacemenl of shoet heelcounter i5film
calcan€al lat padwhen andsnu8(consider adding
modjlyinglheposilive feltto theinsideof heel
modeloI an otf-weirht- counte,andfeathefrhe
b€arinB impression, lhe ed8€of heelseatar point of
cdte ot ihe odhoric heel iftitalion.lf nece5rary,
eettwillbecomea sourceof relum to laboraloryfor modifi'
chronicirrilationasit di8, calion{alwayspinpointfte
inlolhedirplacinS 5oft painfularea by mad(inglhe
tistles.Also,tho€swith edge)andconsider
 232 FOOTORTHOSES
ondOrh€rFornsof cons€rvariee
FoorCare

TabL T.1 --aontinued

Locarion ot Dilcomjod Podbl€ Guse. .nd a.tion.l.

inadequaE he€lcountef rcqueslinga deeperheel

mayallowfor exc€ssive seatto allow for impro!€d
displacemenrof thefal pad conrainment of rhefarpad.
and may theretorebe a

discomfortat theedgeof
the otthotic.

PlaotaFbieralsudacc a. Thlr is ffequently.normal a. Pfoceedmorcslowly

Planta.-medial surface
Parlof lhe brcak-inproc€ss,
a5a Eafoot varuspostwill
redlstributea Breater
p€rcenraSe of v€rtical forces
towad rhelareraiheel.
a. Too linle conrml.{The
pat|entcontinues to
Pronat€excessively/
jamminSthemedial
condyleintoorthoric.)
{Overpostinswilh €arloot
varuswed8ewill compress
andkdlatethemedial
planrarheei.)
c. H€elhejghtof odolic is
shiftingweighrto rhe
forefoot,ther€hystressinS
plantarlasciaand,in tun,
ilsoriginon themedial
tuberosily.
ihrou8hbreak-in.If
dilcombn conlinues,
r€evaluatene€dfor rea oot
po6lin8or us€lofter
materialfor shellor posr.
a. hcrear€ Poslan8le,ch€{k
shoegear,srlengrhen
gastocnern iuvmlelsand
libialis postedo..
b. Reevaluateporrangle;
consldcrsoil€rp6rin8
c. Testby havinSparienrwalk
on to€sfo.l0 rec:if
heelsympromsincrcas€,
remowh€elliftsand8rind
the |earfootposb inro rhe
shells.

Lateralheelpain aredSeot a. Palientslide off orrhoric a. R€evaluateneedfor posr.

lecondarylo largevarus ConsideraddinSsp€nco
coverto Prevenrslippa8e.
AIso,checktir ot h€el

Achilleslendinjtis
deve,opsor
contanu€s,derpiteuseof the
Soleusstraandevelop.wirh
a. Onhotic undeFor oveF a, R€€valuate
postar|8les.
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
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

Locationof Dircomforl Po$ible caus€sand Rarionale

its ve.lical posil{on.The

soleusm!5clc is constanlly
strainedas it attmpts to

venical by liflin8 the entire

medialtoot up rnd over the
ove6ized lorefootvalgut

MediallibiaLnressrcaction a- Reevaluate postan8les,

conrinuesdelpite u(e of orlhotic selection{consider
m.'rc contrcllingorrhoric),
shoe8ear,and castlnS
technique.{Con5iderne!lral
posilionte.hnique.)
b. Inadequateanounts oi b. Reevaluate tieatment
slrcn8th,flexibiiity, and/or

c. Problemnol mechanical, c. Reevaluateparient;

rul€ out valculardisorder. considerrcfelralif
{Noierlf rhlombophlebitis
is prcsent,a blood pressurc
cuff wrappedaroundthe
(a l fw i l l p rc d u c ep a i nw hen
intlaledIo 40i0 mm Hg.
Myositiswill not produce
paii evenwhen lhe.L.ff is
inflaredto 120 mm Hg.l

Peroneus
lonsusand/orbrevi5 a. Normal pan of break-in a. Slowdownbrcak-ina^d
discomforr
dd{lops wilh as p€fonealsdllemptlo pe6n€al
ncorPorate
accommodalefearlool

b. flcessive reaifoorvarus pon angles.

b. Reevaluare
pod nrainin8 peroneus
btevisas it attemplslo
bring the 5ubtalafjoint
back lo its neukal po9ition
c. Inconert useof iorefool
varusport: lhe fa! ty posi
invensforc{ootdurinSlate
midslance,ther€by
unlockinSlhe midtacal
ioinl. PeroneusJons'rs,by
v i d u e o f i c i n l e n i o ni n to
the baseof tha iilst
metalarsal, atlemptslo
slabilizeth€ nridta$alsby
forcef!lly plaota lexinBthe
fifsl metatalsal(which
worJd evert th€ forcfoot
and lock the midtaBal
join0. Howeve.,rcsistance
hom lhe poetpreventsthi5
aclion and is thercby
rc5ponsiblefor chronicrily
5t.aininBthh m!scl€.
234 FOoT ORTHOSESand Olher Fonni of Consewativ€Fool Care

f able7.1 -continued
Locatior ot Dircomtort Po!6ible Caus€sand Rarional€

Medial knee(typlcallya pes a. Too lilrle conllol; the a. Reevaluatepostangles.

anserinebulsitk) and/or
retropatelladiscomtud
continueclespitelse of
sLrbtalarioint contjnu€sto Considera moreaonkollinS
prcnat€exc€s5ively. This onhoticind checkshoe
mostfrcquentlyrcsultsfiom g€ar(especially
lhe fii of
us€of an overly{exible
shellwith a hypermobile
fool type and/or inadequale

HiSh-impactsymptoms a- lnadeqlateposlingoI risid a. lDc.€asepostanglesas

continue,despitet se of
forefoot valsuVplanbr need€dand consideraddin8
tlexedfiretray, allowin8for shock-absofuinB material
codjnlFd sripinatory
comp€nsationby rhe
subtalartoint.

High-impac!symptoms a. Normalpartof break-

developwith odhotic:
typically,lateralkneepain
(a diifusebony ache)
and/orchronic sicrolliac
insrabiliry.
in as a. Poceed morc siowly lvith
accommodatenew sresses
b. Toomuchcontrol;the b. Re€valurteposl an8les,
olthoticisdisallowing lh€ conljder havjnglab low€r
amounlof sublalnr the medialarch(o. recast),
promtionnecesary1o andor switch to a softer
abso6shoct.Th'emay
resultfrom exccssive
rearfoo/iorctootvants
poslinS, bulty casting
t€chnique (especiallyii

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
list may seem intimidatitrg in sizc, rcmemberlhal break-in
problemsrequiring morc $an chargesin shoegoarare rela-
tivelyuncommonand,re readilyavoidedasth€praciilion€r
becomes proficientwith the principlesof biomechanics
and
orthotic fabrication.
RefeIttrces
L Novick.AhKelleyDL Posirjon andmovcmenl chslg$ of the 7. NlcKcn?ieDq Cbnenl DB. Tr mlonJE. Rordng rhoes.oF
fmt with odlrclic intcrrcnlior durirg lhc loadirigrssponsof
gan.J OfthopSponsPhysTher1990;I r(1: 301-312.
2. Don{tcltiR,HulbcnC,ClnawayD, St.Picrc R.Biomo.brni-
cal foor odhossra retrGpccrivcstudy.J OnlropSpds Phys
Ther1984t10(6)1 211.
3. Awbrey BJ, &mardone JJ, A)nnolly TJ. Th. prospecriv{
tvnluation of invosive a'rd doo'inv$ive lrealmenl prolocoh
ntr phdar rasciitjs.RehabilResDev Prog R€p 1989150,
4. Il.Poil TG. Adrian M. Pidox P. Efe.ts of fool orrfioGcs
on ccn-
ler of pr€ss!ft yattemsin wo[len. Ph'6 Ther 1989i69P): 149.
J. Brum I, Sp€ncerA. Limb donin.nc€rils rclalionship to fool
lcngtt!. J Am ?odiatr Assoc 1980:70(10):505-507.
6. RnseCK. CoF€.tion of $c prcn?rcdfoot. J Boo€ Joinr Slrl
(b) 1962i44: 642.
rhoricsard injur;e.s.Spons Med 1985;2: 334-347.
8. Fddc.ickEC.Thc runningshoe: dilcnnas anddichoromies in
dcsigr. Ihr SegesserB, Pforlineer W (eds). fte Shoein Spod.
Chica8o:Yedbook Medic.l Prblisier$, 1989131.
9. Nigg BM, &ltlsen 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@

tut^ps.rqqord Fctolt3 pr5,licf eoqs€uFq.tlElJ ]|tortlo ueA3Sr.gilqJ

 Index
Pagenumbcrsi[ italics deootefigures;thosefollowed by "t" dercte tables.

Abduclbn, 2, .l'J Iong rrds cr(l€nsio!of, 143,1{4

ot mctaralsophilang€.ijoints, 13- t4, I3-14 madpulatior oq 143-144,.l{-/
of midlarsaljoinr, r I itrjrry associ*ed with, 13
of sublalf joint, 9 durhS midllarce Fno4 33, 3J
of blos,31 noiions in conracrpsiod, 27
Accommodativedevices,205 osseousblockhg nechsnisn for, 7
Adduotion,2. J-5 p3ir du6 to forcfoot valgusdefomiry, 88
of metararsophalanAial joinls, 73-14, 1l- t4 pla atne\ioli of, 7,8,27,29, rl4
ol midlurel jojnt, I I naximal,3E
mlrsculu dccelqrlion of, 54
of talus,29,156-157 positionar iecl-sEiko, 27
Ailis' t.st, 115,llJ, l81 rangesofrnotion rc.€ssrry for nonconpensatedgait, 119-121.
Andomy,1-Z 120-t21
sa8inalphft moliols durinS8an cycle,4,
ankl.joinl, 7, 7-8 A.kylosis, of subtah joiol, l2l-122
ffth Ey, r1-r3, 12 Anlerior sopcrioriliac spinc!53
firsl r8y, 1l, 12 Arch suppons,ioappropri € us. ot 147
inleQhalsngealjois,14,14 Arthritic foot, 219
metararsophalangeal joirts, l3-14, l3J4 Anhmdeslsprocadureq175
midt rsaljoinr,rl, lJ-r? Adiculations. S.€ stc{,if c.ioiits
s.cor4 $ird, rnd founb nys, 11 Axis of bolion, a 5i
subllldjoi ,9.r0,9-r1 fot NJrl€ joial?,74, 19-22
inldaclion of forccs, 14'24.S€" arsoForc€(s) defrition of, 2
for i erphrlarg.al joinls, 14, 14
plan€sof motion,2, 2.6, 7 for mclatarlal h€ads,37
obliquc, 3?, 37
cllclrleat hclinc, 63, 63 t anslrsar 37, 37
of fcmoralantclersion, 163,'164 tor mehl$sopndargenl jointt 13,13
Q,6r lratrsvrrsc,Zl-24
acnical,23-U
tNlom.hrdsal,17+175,t75 for didrff$l jotur, 1l, l r, 19
lhigh-foot168,t68 lonsitudiruI (UtuA), Ir, ,9-2I, 28
libiofbular, 59 forcfoot prclltion ato{, 3+35, 37
tuH! joirt in for€footvalgls dcformity, 79, ?9-80
,ris of motion for, 7, 7-8 d$luring fo.efoot irveNio! about, l8l, 182
shifliogof, 7,8 obliquc (OMJA), ll, 20'2J. 28
dotslB.xion of,7, 8,44, 119-121,120-I2t phntarfl€xedfilstrry defornily .nd, 94, 9J
cff@ts of limitnions i|l' 12&121 supinstionabout,33-34,J4 37
st crd of midstanccpc.iod, 33 venicrly displrc.n, 16&162, 16r-162, lrr
cxaggerarcdnngc of, 181
mcaswmenl of, 181,la2 frah,r\-t3,12,21
muscular decel€ratior of,33, 3{, 54 fitsr,Ll, 12,21-22
reslrict€dmolion duc to osscousblock, 126, 129,t3l- s.co , rhird,ad forrth, 1I
132 for s|Iblalrrioi4 9, -14.19-22
duriog swing phasc,38 dclermining posilioDof, 159-160
fo' warhnS and rundr& 1I ? m.lposilioucd,159160
cvafuatingaDterior-postcriorg,lideof, 143,144
funclionaldatomy of, 7, 7-6 Balancebolrd .xcrcis, 1{9
hypcrmobility dueto forefootvaru3d.fomirt, 76 hlan .s Ior l€sions,213,21J
irtcactioos with hip dd lnec durina aair, 4l acc€ssorynavicll&, 213
invdsior sprrin of, 87 hors.sto.pad,2IJ

237
2J8 INDEX

Balsnccsfor lcsiors -.ortt!/?./ n. utftl posnionseni-wcighr-bcaringpolysryrc.efi,amslcp.itr,

pockttacconnodation,213.214 n4-195. Igs
st'b I bdlance("dancer'spdd"),?1-l (liscussionof, 194-195
sob 1,5bala're ("doublcdanccfspad ),2.I-l disro.lionoffl€xibleforefootdeformiLics
by, 194
Batlctdaocirg.2l9
ntiomle lbr, 194
B& posls,101-10?,.lrtto?,213 C avi l i ti on,134
BicyclcridinA,2l E-?19,22,
Biomcchanical exaninadon.1llI - I 9l
dymBic, 188'191,l9lI19/
prcnc,183-187,144,/.% doNiflexed
proxirnal rl{nx in,85.A6
slanding.187,147'184
supinc,I8l-181. /82 /a.? n.urcmrsculer disease!nd, 77-78
B ipi a fl a rgn d,?ljg2l l, 2ll suhuld jonn in. 77,78,82
Blount'sdkcase,58-59 C l nt,r ol gravi l y,2
B oncs,l ,/ Cenr.rofmas, (arslationduringsride.4?
Charlot\ join1,145
dueto flcxiblcplsnlaricxcdffrslrdy deformily,99 Clas toes.74. 135,/-t4
llikt s Ounionelte) dr( lo li8id forcfoolv€lgosdeformily,85,46
dueto fletible focfool velgusdcformiry,84 dui Lorigid planbncxedli6i ray deformity,100,10./
duelo plantad€xed,irsl raydeformiry.96,100 Cliiirul problen-solvin&::8r-234r.22&'234
Bursilis achillestcndinitisdespitcuscof onhoric,232t
intemetaraMphalangeal. 6t b!dion painindcrscswithuie oforthotic,228t
duclo fl.xibte lorefootvalgusdefomiry,84, 84,85 do6al lilh metatrisalheadpain,229t
dne(o planrarflcxcd li6l raydcfoI|Dity,96,99. 1 ) dorsallirslmclabrsophalmge3l joinr p i. ind/or lii'l
intcryhrlangcal joi paindevelops wnh onhoric,229t-
relrocalcaneal.
62,62. 67.d7 130r
hitsh-inpacr symptomrcoDtinue dcspitcuseof onlotic, 2341
C.lcancoc'rboid joit't, I I hilt impaclsymplonsdevclopwilh orDolic.234r
uis durinSsublalurjointprcnation.?9.J0 inrlrdigilalneurilisconlinrcsdespilctrsrolonhotic,2301
dysfunction of, 1,lo-l4l ldl$!lhcel painrl edgcofhcclcup,?321
forcloor lalgrls doformhy and,77 meriial,Dosrcrior. and/orlaterulle€lpninaredgeolhe€lcup,
forefoorvarusdeformirvand.64 271r-232t
lackirg calc.ineanpracess.77 rnfdialarchpsindevclopswith onhotic,230!
lockingot 3l-33, 35..16 rnfdialboder oforrhori.diggirg intosofl risues,2301
rn(dialkneeand/orrorropatclla djscomfondespirelse of
Calcsneonavi.ular
conlilions.I 74 orrholic,234r
rdfdialtibialsr6s r€actioncoltinuesdespircuscDfonlD c.
ilignmenlbelweendistallegand,l8l, /,u 233t
biseclionof, I83,184 plrn aI distale.d ofonhoricextension,2291
de.otation duringe3rlychildhood..58 pa n on planlar-larcral surfae ofelcaneus,l32l
cxcsivc inveBionof. 58 pal.ron planlaFmcdial surfllceof calcaneus, 1121
obscPrtionof i-rontrlplancrnovemcnls oq 189 percncus longusand/orbrevisdis.omtortdevclopsqitlr
prolonAcd cversionof, 67'68 orrhoric.33t
Cano.l| exercises.I52. /56 plrntir fasial/medi!1mh discomfonconliruesdespileuseof
Cas{ingIechniques, 193-?l)l onbol i c,23l l
IUUweight-b@iDg polyslvrene
foan step-in.193'194 pl!nrdrlirsl metalaMlshaftpdinal djslalerdof onholic,
discussion of, 193-ls4 2l l r
e moidpainconliiu€sdespileuseof odholic. 22eI
rationalefor, 193 sermoid paind€velops \r'ithoilhotic,229t
hangtecbnique phstcrcasq199.?01 sol.usstnirt develops wirh onitolic,23?t-23J!
dislussionol 199-201 laForEtala$lpdtr aJlcrusingb!lan.. for lesionbcneath
painh melallrsalhead,231t
ratiotulefof. 199 lis\uesov$ melanmalpadbe.one lncomibrtrblo.?3lt
in-rhoevncuud techniqlls.2rar,20|
discussioo of, 201 !s. ncraraBusadducru\170

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

Conl8d period,2?-3t . 28--1./ Eve6io!,2,3-4

of aboid, 35, J6
inilislinpact forcesd!rin8, 27 of la|6lal colu|n4 37
nidtatsa!joinl motio. duing, 29 of midlarsal joint, I l, 47
subralsrjoinLnolion during,27-31,29-3] proloaged,of calclncus,67{8

aclilc muscularrel3xalionlcohniqueslbr, 12J,125-12, fi ftb.13

paisivemuscularrclaxsrioD rechniqles
lor, 126 fi rst,11,47
restdctedmodon dllc to, 125126
Convcxp.s valeuE 174 rDeasurenc of, l83-r84, l8?
Coordination.&? Neummotorcoordination Exrcnsiotr,2, J
CRAClechrique,,25, 125-126 of hi p,44.53,118
Oaig'stesr,.166 of knee,53, 1l8- I 19,.r./9
Crossjdcrionilmassagc, 148 Bxtcnsorexpmsion,20
Cross-overgairpa eii, 190
Cuboid,I,12 Feis.slift, E9

arSle ot tcmoralanrcvcEion,163, 164

supinalion on calcaneus.
140-141,
141 derolirio8 of f€morsl rcck, 164
Cubo i d
p .d ,215 dclemioing dcgrccof anteveFior or €riovcEior of, .166,| 66,

fcmool retrovcrsion, 163,164

tronlalplanemolionsdurirg gaitcycle,.16
Danishnight-splint, l7l, /Z intem|lletnoraltolsion,16?
DeoomFessiorpaG, 22J lotarionof, 48, $,5a
Dolpcchcsprinciple, 71 cornpcll$tory inlemsl femoral ro|ation,6T
Developmetrral rrendsin lowercxt.emilyalignrnenr, 163- delerminiry rclaive degreeof, 166,166
175
lront8lplanealignmcnr,l7]-173. 172 .ffcct oo pelvis,6l
mcdiallongltudinrlarchdcvclopmenr, l7l-175 excessive sublala'joint pronstionand,61,61
li0nsvcrs.planealignm.nt,/6J, 163-171 meas@rnenl oc 181
Diabcricfoor,219 rranyerse planc molionsduring gair cycle, tE
DiSils Fibula,/, J3
abduclionandddduction of. t.t-I4, 13-14 "Firut€ 8' drilh, r52
conrrlcluresd!€ ro rigid planrarflexed lllst ray defoflniry. Flatfootd€formny,r?3-175
100 convexp€svatg$s,174
varus.ndvalgls posilionsof, 14./.t hypcnnobik,r57-158,174-1?s
Distalinlcrmelatarsaljoinl manipulation, /.16,136,137 perongal spastic(riEidRatrol), u4
Dkrallibiofibula.joinr lilipes calcancoval8us(cotrs.niral tla|fooo, 174
mmipulatiotr of, 144-145, J4J l l cxi or,2,J
duringmidson@pgiod, 33,JJ of hip,44,53,55, l18
Dorsl bascclosing wcdgc osrcotomy,102,lrJ ot kree,2g,30,zn,44,53, 51, 118-119
lbrce(s), 14 24
wilh dotsinexed firsrme|atarsal,103,105,159,/60 appliedp3n€'rdicllsrto a,iis,14, l5
du€to pkntartlcxcddnt ny dcfomily,99 rohrionalard nonrolationllcomponcnts, 15,/J
Dolsifloxion,2,4 chanclcdslicrof, 14,.14
ot anklejoint,1,8,1t,ll9-121, !20 12l
arerd ot midsb.ceperiod,13 delennining magnnudc of, 17,17
musculard@elerarionof, 33, J4 54 detemiriry mtalional aid nonrctarionalcohporetrts of, 17.
rcsriclcdmotiondueft, osseous bloct, 126,129,r-il t8
dlringswjnephrse,38 doorhin8eanalogyof, 15,r5-J6
for walkin8andrunnnrg,117 cffectiveproduction of motionby, 1415
ot ha l l u r,123 fiicrional,14 19-20
ot Dcrarar$phalangcal joints,t 3, 45 grcund-rcactivc, 18,la
oi midralsai joi.l, 1l in co acrperiod,2?
de|ernitring magniiudcof, l & 19
l i tth ,l 3 lomal ad shcldng coDponenl. of, 18
ti Br,1 1 , 38, J 8
second, thid. ard founh.ll in!$action of, 20.22
lrcahenl ol, 103'105,ld4 fof abductorhallucls,22
for adductorhallucis,2.1
"Doublcdancclspad,'2ll for flexor diSitorum brevis,2-l
Do$le-linb suppoa,43 lor ffexor digitorum longus,22
for ffcxor b.llucis brevis,22
Elecrrcdymstan
GlDc), l9l for flemr hollucis longls,22
Equinuscompensatiol
tcst,187,18, for gastrocremiN/solcus, t9
240 TNDEX

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

measuring rlignrncnrof, r 84, l8t knceRcrio extension.

r'o I
plantarflexcd,103, /Ol
For€fooladduclu6,.i69, 169-170 ix'i,'ili"::",i:"1,Y"***" I
pelvicrilr.,r0 I
cxtri\sic, m5-208\ 20 7-20I dcvclopmeoral rends ib low€r€"ueni'y alisnmen'and.163.
inrrildic,203-205, 204 I
Fo.cfoorvallus d.fornily, 6J, 77-9| , 78-9, dFarionof.27 I
in civtlr foot, 7?-78, 78 .l'(cr or musculest'cnsrh.now<r,sndcnduftnc.on. I5o
defrilion oi 64 I
cliology of. 77 d,tcr ot ncuomord cordim'ion Ntrdprupnoc.ptionor 144
flrxibl., 78-80, 78{0 |
siansmd $ynptoms of, 83-85,8415 €\.rluationof. l8&l9l I
onholic lnrnageme ol 9G9l, 9O-9t c\fBsivcr'abnonil motionsin I52. 156 I
pathomechlnicsof , 78-83 hyp.rnobile6.sray. 15&159,lJ8.l6, I
patLms of.lmpensrbn for! 78, 7a hypcmobifcsub|'laljomt. t 56-157,156-l5tl I
nElposirio'Ed joint axis,159-160
subtala! I
wilh rcorfoot vrrus, 107-lt)9, ,ltl8 vfftic:lD djsplacedoblhK midtaNljoinr sxis,16{1162.
rigid,?8, 7& 80-82,8r I
signsandiympto'ns o( 85{9,8s-t{) lirrl lranslationof€nter of massdurin& 42 |
rigid pl0nlarficx.d nrst ny deronnity an4 100 fr"ntalpld. oolids drrine.46-..7 |
Forcfoorvdgus posr.90-91, 90-91 gr.,phicsuhmsr'ot 4J
I
FoEfoot varu6deformily, 6.r'-76.6+77 iaimunTritrges ot motionneessuy for noncompcnsssd
gri'.
c8lluspoltco with, /86 I
confficlingular rnd tibislmotionswirh,66,67 ljl,kL,ll9-121, lm-121 I
defnitionof, 64 hnl l ux,l 23
etiology or, 64-65 hi p,| 18..l t9
funcrional,l5l knc!,118-119,119
inconc4l rn€asu.emcntof, I ?4, ,86, t87 midtar${ljoint, 122-123,124
&ncccxlcnsion!nd,6&67 \ttbtallr joi^t, 121-122,I22-l 2J
onnoft mrnagcftcnr of! ?6-77 hrrclc tunctior drring, 52-55
p.thomechnics of, 65-73 lbdftlor h,llucis, 55
por. i.l injuries aseciated wirt. 65{6 rddrclor hallrcia 55
prcvalcnccof, 64, 184
wi$ M{od v8rus.105-107, 116-107 citensor dignorun lolgus. 54
signsand $ynploms of, 73-76. 7+ZJ cxlcLeort llEis lonAus.54
lbncc phas.molionswirh,66 flcxor diAiloEm brcvii 55
progr€-{sionof forcca,68, 69 flexor diailodm ldgus, 54
unconpcnsnlcd,9J, 122,.12-t neior halucis brevis, 55
plantarffcr.d firsr ray deformily duc to,95,96, 1)6 nexorhrlucis longus,54
Forcfootvaruspost.76. 76-77, 158 grstrocnemi!\ 54-55
glutcusmaxinus,52
devefopmenrof lower crtremity alignnl€ntin, ll l-173, 172 qluteusmediu., 52-tl
motionsin gail cyclc,.t6-42 h3mstrinA.r, 53
Full forcfootload.2Z28 iliocoslllis luDboBm. 52
Functionalo holics. 205 iUopsoas,53

Gaitcycl., l, 28.Se/ al.roSraiccphar; Swint pha*

cause-sof sbnormalmolion dunng
forcfoor vrlgus deto.mily,6t 71,91, n9,9t peroncoslongN, 55
 INDEX 241

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

flexor diEitorun brevis

efteclof forcfoolvarls defomiryon, 67
!cl'viry in rormaled SauooredDerso.5.7j
etrcd of blrefoot ruming on, 1j0
i r onla l p l a n c m or jons dur ina g a i l c y c te ,4 Z
fun tion dunl8gail cycte,jI, j5
r uncxo n a tn ar ohy o! t l, I t _12 relationship ro axesof fool,2J
2{4 INDEX

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

Mlsular relaxalionrechniqucs msrerirls,?05

actire,125,125-)26 sbapcs, 205,216
conmc! rclax, agonistcont.acrion(CRAC) s!rcrches,l2J, spon-sp€cific varitlions,215.219
1 2 5 ,r 26 brlld dancin&219
Lcwil lechniquo, r25, 126 bike tidi,ng,218-219,220
maximumrcsislance holdielaxstrctches,
125 aolf,216-217, 2l 7
yhmic shbilirntion,125 Bulridi€dioml spo.ls,216
mlerior@dPmrmenlsrrelches,/26 raccwalkitrg,216
.!nni ng,215-216
inlrinsicmusclenrctches,i29 skii'og,Zl 7'218,2 I 7-2I 9
laleralcompanmeor srErches, ?28 lnidn dional $Pons,215-216
pas si vc,126
po!tcriorcompadrnenrslrerchcs,127 casli4 lechniqu€s for, 193-201. Se"ato Caslingt€chdqucs
of combintlioDsof rdrfoot and torefoot defoflnitics, l05'l I O
lorcfoot vms or vrlgs wilh plelarflcx.d 0rst lay
Navicular
difierential,187.193 defomjty, 109-ll0
rcartoolvas/Rexiblc planlurflexed filstny deforDity,109,
to abductor
digiti quinti,68,68,75 t09
inledigiral,82,6.1,8? learfoot varus/forcfoorvalgusdeformity, 107-109,/06
re.rfool varus/forcfootv6rusdefornily, 105-107,/06-107
mcdialcalcaneal,
68,68 reaitoot vduvrigid plularflc,(ed ffrsl ray d€formity, 109,.i09
medialdoMl clbneous.97 @nParcd wilb arcl suppon5r194
of elongatedfi6t lnclrlasal, I l3
ol elongnted secondmcraursal,111,ll.1
dccp,c.tlapmentrcuropathyof, /60 tor fenoral antcvcrsionor rctrolcrsion, 167
supcrfi.lal,entmprle.tncurop.thyof, 81,E2,87 of forcfoot valgusd€fomity, !}G9l, 90-91
of forefoot va.usdgformity, 76, 767?
la&ra 1 ,82, 8J of frcntalplanedcformirics, l7t-U3
3floct ol for€lool varusdeforDity otr, 68, 68, ?5 ofhypc nobile firsl ray, '159
of hyp.mobile fl.lloot r74-175
cffectof torefoorvarus
defomny on, 6E,6E,75 of bypeffnobile subtalarjoirt,158
libial.E5 of lsg lenglhdiscrepancy, 116-l 17
posedor.entrapmetrl ncuropath,of, 8r'82 oflinir€d ankledorsinexion ductobonyblo.t, 126,l29,lJ2
Ncuromotor coordimlionandprcprioception, 144-150 of limned $lblalsr joidt moriondu€ to bory bl@l, 129,l-u
Nculralpositiodfoot,195 for malfuncdo ing proprioceplivosysr€m,148
Newtoi\Third L3w, 18 of malpositioned subtalarjoiniaxis,160
Nuclsrrbag6bels,145,146 of peroieal spaslicRatfool,174
Nucle chainnbe6, 145,/46 of plarlarfex€dfi|s(ray deformiry,l0l-103, 1OlJo.i
ofplant ffercd forcfoot, 103
Onholicdispen$ing. 223 of planurflexed less$ melatalsds, 103
br€3lin8 in orthotic, 223 lo preventdcstruclionofmedial lonAitudinalarch, 168, 170
dclemini.gonhoticaccurucy, 223 of Earfool var6 dcformily, 62-64, 63
cvaluatin8 orrhoiicsgainsrpalienl'sfoot,223 ofsho encdfilsl Inclatllel, 112113,JIJ
O horidtabriqrion,203-230 thaldissllowsnormalrangeof midi{sal prcnaIor, 168
acconmodalivevs. tu.ctional orthorics,205 of tnnsvels4 planedcfomiti.s, 170
o(r.insic forefoor ard rip postine tcthniques,mS -208,207- 208 of venicrllydisplaccd obliquenidlaBrl joint axis,l6l-162
extdnsicrcarfoorposting,209-212,2 I 0-212
in.oflicelechniques, 219-220,220 Palelhrsrabilizadon,
.16,17
dirccrmoldmethod.219-220 Pclvis
p tc-in n tlo4,22n.220 cffectof inrem.lfcmoralmralionon,61,6l
int nsicforofoo!postin&203-205,204 eveluslinS molionsof, 189
intdnsicrcadoot pGring, 208,208-2d9 iionlal plBnemorionsduin8 Sait cycl.,46
modilicalionof positive model,203, 204 lar€Fl displa@m.rr of, 4l
onhoricaddnions, 212,215
balance fo! lesion,213,2,1J,214 tilt ot,40
barposrs,2l3 transver$ plarc motioB d$ing Sait cyclc, ?8
cu b o i p d a d, 215
h € cll i l s, ? 12- 211 lacral,E?
intcrdignal plugs,215,2.r6 nedial,?5-76
tioctic wedgc,2l3'214 Pcsvrlgus,conver,174
DetltaMl p.ds,ll l, J/.1,2r4,214.215
Mo on'scxlcnsion,/./J. ?13 Pl.na of molion,2, 2.6, 7
ro ccBrL \, 215, 2lJ
biplanarmotioD,2,J-6
pdnciplcsof onhodc desiar, 63 |d denotclixedposirions,2,.r-J
"rccl lire" on onhotic,105,106 frontal,2
shellsdcclion,205,216 in gait cycl., 46-47
2Z16 II,IDEX

Pla.es of motiotr-.rrnir&ed .f iistcd by cccentric(r.rnrract

sati|lal,2 io'l of anrcrior@mFlnmcnr
mu$lcs.2?
nB it cycle,44-45 rerrrictionof, 7,8
ol ralus,29
i! gait clcle, 4(t.?9
rriplanarmolion.2, 0. 7 Plit ,l bandsyrdromc,6l
Platrtar bax clGrngwedeecsleoromy,t(rr Plv.netic.x6rci.!s. t52
rirntar c.ttusF ems./d6, t87 PNf ex.rcise$. Se. Propri@.prive
ncurcmusotarfacilirariof,
erecr of forefoor varusdefomity on, 68, &9 Poclcrlccomnodation, 2 rl, 2t4
effecr of rea.foot varusdcformiry orq 6, Po\ ethylcncfoa4 :05
\trainduero planradcxedfi6| raydefomiry.q9.09 Pohp.opylctrc shclts,205
rensionbandirgeltectof, t5z Posr.*inlfib!l boder
windlasseffecrof. 34,.?J.82 .\posure lo proputstveforc€s,ll3. 8J
Plasrarfrlciiris. I t4 in planrdfrexedfirsrrsy dcforniry,g,l
Pletar prcssurc disrrihrdon,/00 PW 2t2
Plantarffcxcdtusl raydcforniry,93-t03, /J/ o{ tor€foor0boullo'|girudinatsxis
acquted.93.122./5? of midroNaljoinl,j4-35,37
or nridtafi.tjoint,3U,4J, 49. I 19
duc ro Raeid paratlsisorcxrGmewcakncs!of onhosesftfl disrllop mmrl EnAc of, t68
grnmcncmius,94 or \lbralarjoinr,9-10.27-31,29-3t.47, 19, tt9. t?l-t2l
ducto fllccid paralyskor cxrrcmeweakness
oftibiulh compcnsrtirS for leg lenglhdts.repancy,tI6
duc lo hyp€rionicity of pcroneusIon8ls. 9+9S dentritionof, 60
ducro neurmuscut.rdkordcrs.96 eft@Isof, l./a
duclo utrcompenssred icart(rrror forcfoorvarusdcformitl, forefmt varusdefomlryand.65.67,66
95-96,95-96
halluxlb.ludovalgusduero, 72-73
duc lo we.al(ncs\of a ricic nus.tes responsihlefor iliotibi.l b.od fri.rion syndmneand..'
srabilnngptantarp.oximathaltuxor o hcrurcof intemalf€moralrorarionatrd.6t.6/
cxtcnlorhallucislongus,96 lowe.libialitres faclurcs!Dd, 6l
clinic{l rienificnncro,l q:i mcdial lfte injuries doc t(r, 6t
onhotiB for, 62_64,6.1
conpcn$torysubratarjoinr duc ro.q:l-94.9t
supinarion porc ial itindes associaredwnh, 6r, 6r}6t
hr\t fuy lnd nidta$aljoint motiorconrpensarrnSfor.9l-94. rcarf@tvarui deformity&rd.59,60
relmpatruapainand.6l
doNal brsc closing wedgeosteoto..nytor. t02, i0-l sninsplink and,6l
rrcrcasinAb forefoorvalgusd€fonnily. 9l
callurpsuemwirh./a6 ir midswins,38
foor otionswith,96,97 rclurionihlpof midsoLdlnrity to. 226,227
rcarloorv.rus wirb, I 09. 109 ralonavicular
_ and.ntcancocuboid joinr axesdu.ing,29,J,
srSnsandstmpromsof, 9E"99 Prcpdoccprive.euromusular
wilh forcf@tvarusor valgus,t09-l|l) f.cititationcrcrcisB,t2J-t2.6,
va-ljo,149
msniplhrivcrechniqusfor, I U2-10;l Protrioccptivc ncuromuscntar tacititarionpaflrrns./.r9
o rohc managernenl of,101-tot, tol -t03 Prolrftreplive systcn,145-150
pathoDcchani6 of, %-98, 97-9.t lrnss-friction.l massaBe for stimut.rion of. t:lE
tigid,96,97
calluspaucmwith, tE6 cnus.60f,l:17.148
rearfootva.us with. 109, tr9 chronicpain &rcociarcdwirh, 148
si$s ard sydpromsof, cq-t0t) ,lctrctcdby modiRed Roobcrr,sresr.t47
stanccphasemotionswirh.t8,98 .{fccrs oi 147
weiShl-bearine poinrss,ith./00 maoipulalion for, t4a
.emillexibl€,96. 97 onioliG for, 148
foot moriotrswirh, 97. 9ti inr,hction olpmp'ioepro6. t46-t.U
s'9! lnd symplomso( 9r, jo',,1andskinprcpdocepto6,t46, t47
m' slc proprioclpros,145-t46./46
ot anklc joint,1, 8. 27, 29, 1-l Prup pe.iod, 27, 28,33-J8. J4,.'7
'lsive
ex'ern0l lcg rotationdu.irg, 33,
of metalaMphalangcal joinrs.r, 4j fln.ilponionof, 37-38 -?4
ofmidtarsaljoirt.t l to, rh andfifrhDclar!ftal! lcavinssrcunddurine.35.Jo
hc(| lift duri.E.3J,14
fiflh. t3 larJralcolum tundionduring,15.36
li6l. I L,36-37.JZ 45..t,e a/lo ptftnrarflcxcd
fsr oy mNltrlcnance of mid$rsattockin8|nechantun during,35,"?6
pl3oldrflcr(ion ol li$t ravdurinS,36-3?,J7
sec-ond,rhird. and founll I I widlass efied ofplanrarfirra durins,34.J5
Pumt brnp.62,62. tt?
 INDEX 24?

Rearfoolv.rus/forefool valgusdctohiry, Ifi-109, loE

highgcar,17, lE9 Rqrfoot valltforefoot latt]s defotl]niry,1O5-IO7, 106-107
shocmodilicarions lo cnoouqgc,22J Rearfoorvarus/planrarflexcd fi rsr ray deformily
low gcar,37, li2-83,189 nerible,l09, i09
shoctnodilicalions ro en@ola8e,
225 nEid,t@, t09
Re.rfootvdus posl 63, 6.', 158,171-172
R ace
w.l ki n g, 2l6 Rcflcxsydpalhelicdystrophy, 148
"Rock li&," 105

nccessdylor noncohpcnsaled gail, 117-123 joinr, 132,1.1.t

lbr bonybbck of firstmeldarsophalatrgcll
a n k|.,1 l9' ) 2l. I 20- I 2I for €lon8ar€d frtstmerara|sal,113
h a l l !x,123 for eloryaled s4ond meulaisal, I I I
hip, 118,t.19 Rohadur shetls,205
kn e e ,l 1 8119,/ . / 9 Romhrg'sresr,modified,14?,187
lnidtarsaljoint, lzz-tz3, I24 R oB ri on,2,J,7
stbtzlatj.int, 121-t22,122123 ot fedur.4a, 53,54
ofhi p,l tB
diflcie.riaringcauscsof, 123-125,.i24 otpelvis,39,{8
ducto joinr dysfurclion.l12-134 ofti bi a,4&53
duclo mlscularcont cture,125126 Rubbcrbander(crcise!, 15t , ./54
dueto osseous block,126-l32 R unni ng,215-216
anktejoint, t26, 129, t31.132 knnning sh@s,226, 226-228,2U
nr$ metahrsoph.hngcal joinr, 132,t.?3
subLalarjoinl, 129,132,.?J2JI Sagiltalplanc,2
manipulalive lcchniques for, 134-145 notionsin gail cycle,?4.45
Roys Schuslcrheel{edg€, 25
fifih, I1 13,.t2 Sciatica
drle ro forcfoot varusdeformily, ?6
alis of no{ion for, 11,12 duclo leglcn$h dis{xepancy. il4
co mPo n c nr s of , ll "tals! lJ," 76
"S€atchinS loe,''170
in forcioinvarusdeformity,68 Sesmoids.22
Ironblplanemorionsduringgaircyclc,47 injury doc lo plantarflexcdiBr r.y dcforrniry,97
frndional anarcmyof. I l, ,2 larcrsl displrcemcntduc to h?!u,( rbductovalgus,70-71, 7i
hyp|rmobile,158-159,/56-16, painful,229t
Sninsplinrs,6l
plantarflexedfilst raydofomiry,93-103,93- 103-Seeobo Snockabsorprion,27-29,J0, 38
Planbrncrcdfid ny dcfomny Sbocs,224-2?8. .te a/soOnhodcmlnagernonl
plrnlarflexiondudngpropulsiee puion, 36-37,37,45
sagiuslplanemoliotrsduringgrit ctcle,4J for clo||8rredffr$ melalallal,113
doring$inB phase,lli, Ja tor.lonSarcd s.cord me(alarsal,I I I
lolll couapscol, ?59 titting oI, ZZ4
sond, lhird,andtourlh,I I fo! hypcrmobile ti6t ray, t59
llcalmcrtofdo$iflexior of, 103-105./04 impondr qualitics of, 224, 22,
rrcllmcnrof planrarnclion of,103, /04 tater,l n al tt,rc oI, Z2'l,227
marchjng lo patienfsfoot type,228
"a ucrny twki oi,65 for mclal.i.usadducrus, l7l, 226,226
alignmetrt
wirh forclbot,64 for mchlaBus reclus,226, 226
nant ngalignnenrwirh sublaldjoinlin iellualposiLion,
16T, midsoledensilyof, 226,227
18? Ndifrcations of, 224,225
negativcposl€riorh@l ffarc of,227, 227
cxninsic,249-212,2l O-2I2 sNarels (rurnins shoes),?26,226-224, 228
i tinsia,2Ou,208-209 erilT-soled, 171,.I7l
Rcartoorvalgusdcromity, 171,./7-l fot vcrticallydisplaced obliqle midtanaljoinl ,xis, 162
Read@lvarusdclomity, 56-6.t, 5&64 Sildng posturel .165,l7O
Blou.fsdiscascand,58-59 Skiiag,217 -2r8, 2 t7-2II
dcn n i ti ooni, 58 Sleepinepostrrcs,/6J, 170
s.e akcrs,226, 226-22a,226
criologyof,58-59 Sp€nco,212
onholicmanag€ment of. 62-64,6J Spird ncxior/e,(lcnsion, l l8, I/9
pathomcchaoics of, 59-62 Spon-sp.cilicortholics,215-219.
phntarRcxed -tseabo Orrholicfabricslion
fi6t ny defomity.nd,99 Stancephase,l, 27, 2a
porenrial
injudcsassoci.tcd wirt, 60, 60-6t
sjeisandsymproms of,62 notionsof,27-38
slace phascmotionswjth,J9.59 as closeddain molions,27
umompcns.r€d. 9J, 122,l2J con|.ctpc.iod,2?'31,28-.il
plhhdlercd Jl|srEy def(trDnyducro,95-96,96 wilh forefool varusdcfomity. 66
248 INDEX

low€r tibial srr!.s!fmdurcs .od. 6l

modonsof-drirt rd oedial rnecinjud.s ducro.61
midstenceperiod, 27. 28. 3133, J.l-3J onhodc for. 62i4, 6t
propulsivetEriod, 2?, 2a, 33-18,Jr-J7 porenrialiniudcs associrredwith. 60, 6&61
wirh rcader van$ deforniry, Jt esrfoot varusd.fonniry aid, 59-m, @
normal prog.€ssionof forcesduring, 69 rcrrop.relh Prin !nd, 6l
Straightlcg raisilg. l8l shiDsplints and,6t
StenSrhenint exe.cis.s.150-l 52 increding in forefmr valgls dcfordity, 91
at home.152,./J5 at midswing,38
incr.asitrg difficully of, 152.,fJ6 rclarions$ip of midsoledcnsi,ty to,226,227
lbr shockabsorplior. 27-29
iiotonic.151-t52,,1J4 lbr surfaceadaprllion, 29, J0
lackol rcsponsc ro, 152 Il onaviculsrlndcalc"nco(uboidjoirlaxesdurin&29,J0
mtlscletgtiDg for, l5l, /-rlJJ4 rargesof modon neclss!ry for noncompensared gair, 121,122.
122 123
anlcrior @mparl6ent, r2ri rc\rrictedmodondueto oseousblock.129.t32, i.?J$
conract relax.aSorasl (CRAC),l2t 125-t?6
conrmcrurc shrclunlly $able,151 156
s!.tale varum,58.J8
inttusicmlsle,l, suninarionof, 9,10,3 t, 3/ -32. 47, 19,l2t-t22
lateralcomparh.rr, /26 compcB.tirg Lr plantarfloredthst my defodiry,9l-94
tlwir techniquefor, ll5, 126 in lbref@r valg6 dcfomity, 80-82
maximrmesisraEehold{clax.t25 "supiraroryrock,"80-81,8./
suLsical nbion o( 132
po$tcriorcomPanmenl, /27 rran\vcrse planemolion6 dulinggditcyclc.49
rhythmicstabilizelion
for, 125 rui,niculated,78,I29
varlationsin a&romt 0f, 9,9
joint, 32
oI c.lcaneoluboid
ab obliquer\is of F idt.rs.l joinq 33.34 J4,17.4i
joinr dtstunctionduero, 124.125 'ur
ot .uboidor cJciners. I zl.lrI 41, /4/
or metatamph6langcal joims, 13 ot didra6.l joirl. 49
Subt8lsrjoinl ol iobfalffjoitrt,9-rO.31.J / -.12,47, 19. r2t-122
in forefdt valAusdefomiry, 80-82
'supi..tory!ock."80-81. 8./
adbesilecrpsulirisof, l.l2 Susp:nsionrcchniquc,196..r98
mkylosisoi l2l- 122 Susrrdraculum rali,I56, ,J6, 173./Zl
dis of motionfor, 9. .lr,82 Swinqphaqe, 27,28
determ'ning positionof. 159-160
malposift,ftd,159-160 du,dl i onof,27,38
posilionallariidon in, itIL ?4 IE7 gnrundcledanceof lorcfootduring,38
in cavusf@r, ?7,78,82 midswinB,SS
in conta.t period, 2?-31 mdions of, 38, Ja'39
det€rminheneutralposirion of, 183./{i5 neuronoror@rLrcl o!: 38
effect of positionir8 on p.roneuslongusfulctior. 36, J6 rs oper chain morions,27
effecls of resirictcdmovclncnt ot, l2l-t22, t 22-t 23 mNcle functionsdD.ir& 38, J8
prirnary turdiotr of foor and anlle drdng, l8
mcAurcmenr ot 183-114,187
frontalplarc motiorsdudnSAaitcycle,4Z
frnctional.nalohy o( 9J0.9-ll corg.nitallywide,126,/3/
hypermobihyof, 150.156-152lscl58 synovitisor chondronalacie of, 66
invcsi o D ol9, 35 TaliFcsql@reovslg!s,174
duclo leg lergrhdiscrcpancy, I 15-I 16 Talip.scquimvhrus,170
nGurcmenr of, 187 Talo(rlca&albridge,rudimen$ry,129,.1J2
joinl play dovemen$of, 142 Talo(rursljoilr. S"" AnHejoinl
manipulation ol 14l-143,/?.t-l4r' Talonaviculdjoi , 11,157
in midslanc€ p€riod,3!,33 axi' dsiDs $blalar joinr Fonation,29,.?0
osscousblockirg mechanismfor. 9 fotufoorves defomiryand,64,67,62
position at heelatrilc, 27 Talus.r
pro|l3riorof.9-r0,27-ll, 29-31,47, 19,ll9, r2r r22
compensari.Sfor lc8 lengrhdisretancy. I t6 adducriorof, 29, 156-157
drdior displaccm.nl duc to rcRrf@rvarosdefo.niry, 60
definniono( 60 de\ elopDenhl ovcno|arioi of rccft oi 77
cffats of. /./8 ffarcnedt.lar t.ehle ,126. r3l
forelmt v!ru! dcfoKiry and,65-67,66 plarlarflenon of, 29
halluxabducrov{lgus ducr0,72-73 Tannrconlirions,132,148
ilioribialbafldfriclionsyndromean4 6l pe(,realspasticflatfootducro. 174
internalfemomlroulior and,61,61 Tals,Ltunnel$yndmmc, 82
 iNDtfi 249

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