Physiotherapy 92 (2006) 122127

Discussion

An overview of podiatric biomechanics theory and its relation to selected gait dysfunction
Paul Harradine a, , Lawrence Bevan b , Nik Carter c
a

The Podiatry and Chiropody Centre, 77 Chatsworth Avenue, Cosham, Portsmouth PO6 2UH, UK b West Gloucestershire Primary Care Trust, UK c Queen Alexandra Hospital, Portsmouth, UK

Abstract This paper introduces the foot function approach used by podiatrists in the treatment of lower limb musculoskeletal dysfunction. The aim is to demonstrate how podiatric theory has evolved its own perspective of mechanisms relating to normal and abnormal locomotion. Three individual podiatric paradigms are discussed, and a further theory allowing a working simplication of theory is introduced. Finally, an example of gait abnormality is discussed in relation to podiatric and physiotherapy perspectives. An insight into podiatric theory should enable therapists working within this eld to develop a more holistic and multidisciplinary approach. It is the view of the authors that a closer working relationship between physiotherapists and podiatrists with an interest in movement dysfunction provides a better quality service for appropriate patients. 2005 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Keywords: Gait; Podiatry; Theory; Dysfunction

Introduction Specialists in physical medicine have developed systems of assessment and treatment to identify and correct faulty postures and patterns of movement [15]. These methods fall under the umbrella term of muscle imbalance. By definition, muscle imbalance can be described as a deviation from a theoretically optimal posture or movement by a disproportional effort from muscles working around a joint or joint series [6]. In relation to gait, this can result in abnormal stress through the kinetic chain causing deformities, pathology and symptoms. Podiatrists have also developed systems of assessment and treatment to identify and correct faulty postures and patterns of movement. This perspective focuses on how biomechanics of the foot inuences the function of the lower quadrant. Theoretically, any abnormal foot function leads to pathological stress and microtrauma over time. With apparent justication [7], management of certain musculoskeletal pathology

has been widely accepted by the podiatric community, with treatment aimed to improve movement dysfunction. Concomitantly, in-shoe appliances known as orthoses have been developed to address these issues [8]. As a specialist in gait dysfunction, the podiatrist should be able to incorporate the knowledge of muscle function and testing to understand the possible multi-aetiological causes for abnormal gait. The same could be said to be true for the physiotherapist, with neuromusculoskeletal practitioners requiring adequate knowledge in the assessment of footbased abnormalities.

Podiatric theory Podiatrists have been treating gait-related symptoms using varied theories and therapies since the profession began to develop in the 18th Century [9]. The following section of this paper presents an overview of the three main emergent podiatric theories. A unifying approach is then introduced that can be used to understand the role of the foot in gait dysfunction.

Corresponding author. Tel.: +44 2392 373737. E-mail address: podiathing@yahoo.co.uk (P. Harradine).

0031-9406/$ see front matter 2005 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.physio.2005.10.003

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Subtalar joint neutral theory The subtalar joint neutral (STJN) theory is based upon the premise that a foot is functioning ideally when the STJN position occurs just following heel strike and at the end of the midstance phase of gait. This model of management seeks to identify foot morphology that is abnormal, e.g. forefoot varus, and to prescribe an orthotic device to prevent subsequent abnormal joint compensatory motion, e.g. excessive subtalar joint pronation [1012]. It may be fair to assume that this method of podiatric assessment and treatment is the most popular biomechanical approach to foot function, used worldwide by both podiatrists and other professions [1315]. According to the STJN theory, the orthosis is designed to balance any foot deformity with angled wedging applied to a rigid bespoke shell. Prescription protocol requires a cast of the foot in a non-weight bearing neutral position [16]. The cast is then posted with an intrinsic forefoot post to place the bisection of the heel at the required angle. The degree of posting is arrived at by taking the value of the patients neutral calcaneal stance position and subtracting a set number of degrees in order to allow normal pronation [16]. The height of the subtalar joint axis is used to determine the amount of pronation to be allowed. To maintain the posting and shape of the orthosis, only rigid materials are recommended, such as acrylic or carbon bre plus an acrylic rearfoot post. The shell is cut to 25% of the width of the rst ray. Critical review of this theory leads to questions in terms of reliability of joint position measurements, validity of the underpinning STJN position and a lack of outcome studies specic to the prescription protocol [17].

shell thickness, heel raise, etc. is done without reference to the forefoot to rearfoot relationship or the axis height as in the STJN model. Dananberg [22,24] also cites the use of shell modications such as cutouts beneath the rst ray and specic forefoot extensions to encourage medial propulsion. Critical review of this theory leads to questions in terms of reliability and validity of video gait analysis and in-shoe pressure system assessment. Although both are now seen among practitioners as the most reliable and quantitative method of assessing gait, reliability and validity should not be taken at face value, with research questioning both reliability and absolute accuracy [2527].

Tissue stress theory This model is based upon assessment of the moments across the subtalar joint and methods of changing these to decrease stress upon anatomical structures [2832]. Injured structures are identied and pathology is related mechanically to foot function. This approach emphasises physical laws including Newtons laws, elastic/plastic deformation, levers, moments, etc. The tissue stress theory emphasises the concept of kinetics rather than the kinematics of gait. The central concept is that it is not the pronation or supination that causes harm, but stopping the pronation or supination. Foot-related musculoskeletal injury is treated via orthoses to reduce the abnormal forces upon injured structures by applying appropriate moments to the subtalar joint [30]. The choices are, therefore, forefoot or rearfoot posting in valgus or varus orientation. Posting is not dictated by the STJN position but by the magnitude of pathological moments. In contrast to the STJN theory, a change in magnitude of forces is required to reduce symptoms rather than a change in joint position. Large degrees of posting can be used, up to 510 , along with forefoot extensions that are also posted in varus or valgus orientation [33,34]. At present, there are no outcome studies available that use the tissue stress theory exclusively. Therefore, as yet, no conclusion can be established regarding the clinical efcacy of such orthotic modications.

Sagittal plane facilitation theory Dananberg rst published his theories on sagittal plane facilitation in 1986 [18]. This theory highlights the importance of the foot as a pivot that rocks forward from heel to toe allowing adequate hip extension. Dananberg proposed that this hip extension allows a normal stride and therefore an efcient and erect gait [1822]. He [23] cited ankle equinus and functional hallux limitus as examples of pathology that restrict necessary foot movement in what he terms a sagittal plane blockade. Ankle equinus is stated to be a lack of 10 of dorsiexion beyond 90 , and functional hallux limitus is dened as a rst metatarsophalangeal joint that has a normal range of motion structurally, but which for any number of reasons, is unable to dorsiex adequately in gait. Although this theory can be used to explain foot pains and abnormalities, Dananberg highlighted the effect on more proximal posture-related problems such as lower back pain [2123]. The method of orthotic prescription is one of trial and error using in-shoe pressure system measures and video gait analysis. Therefore, the means of determining the posting,

A unifying theory It is fair to assume that no clinician would continue to use a theory that was not working to relieve their patients symptoms. Therefore, there must be benecial aspects of treatment from the STJN, sagittal plane facilitation and tissue stress theory perspectives. There may be a common underlying corrective mechanism, or there may be more than one way to improve symptoms with the use of orthoses. The authors, therefore, present a theory to explain normal and abnormal foot function which can be used to unify and explain benets reportedly obtained from the three previous theories.

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Mechanisms for foot stability Motion in the lower limb should be thought of as an upsidedown pendulum of the body passing over the planted foot [35]. In effect, humans walk by pulling themselves forward over the weight bearing foot, and this pull is mainly provided by the opposite limb as it swings forward [36]. However, for this to occur, the foot on the ground must allow the smooth passage of the body over it, essentially acting as a pivot. This pivoting is done through three rockers; the rounded heel, ankle dorsiexion and the forefoot extending around the digits. These foot-pivoting motions allow us to place a foot in front of the body and transfer our centre of mass forward and over the stance limb. Vitally, it allows adequate extension of the hip and therefore a stride with the torso remaining upright [35]. These rockers need to be correctly timed to coincide with motion occurring proximally, e.g. as the centre of mass advances and the hip extends, the heel must lift appropriately. Failure of the rst metatarsophalangeal joint to extend at this vital moment will impede heel lift and limit hip extension with consequences up the kinetic chain [1821,23]. For appropriate timing of the foot rocker motions, it is essential that the foot is stable under load. Calcaneocuboid joint close packing is an important mechanism that confers stability and is seen in the human foot. Normal pronation of the subtalar joint leads to close apposition, or close packing, of the articular surfaces of the cuboid and calcaneus [37]. Just after forefoot loading, the peroneus longus begins its phasic contracture, which aids in rotating the cuboid upwards against the overhanging process extending from the body of the calcaneus, further compacting the joint. This has the effect of tightening the plantar ligaments and stabilising the midtarsus. The continued contracture of peroneus longus on the stable midfoot allows smooth transfer of load from lateral to medial across the forefoot as the foot progresses. Transfer of load from lateral to medial coincides with weight transfer to the contralateral limb. Calcaneocuboid joint close packing is therefore a prerequisite to normal propulsion as it gives optimal transfer of load to the rst metatarsophalangeal joint and in doing so facilitates the windlass effect. The windlass effect was rst described by Hicks in 1954 [38] and has more recently been described in depth from a biomechanical perspective by Fuller [29]. The anatomy involved with the windlass effect is the medial slip of the plantar fascia and the medial arch. Proximally, the medial slip of the plantar fascia originates from the medial tubercle of the calcaneus, while distally, it inserts into the sesamoid bones and the base of the proximal phalanx. During weight bearing in a foot with a normal structure, dorsiexion of the hallux will tighten the plantar fascia due to the plantar fascia being wound around the rst metatarsal head, analogous to a cable being wound around a windlass [38]. This effectively draws the head of the rst metatarsal and calcaneus together, shortening the foot and raising the arch (Fig. 1). This medial longitudinal arch raising

Fig. 1. Simple model demonstrating the windlass mechanism.

is synchronous with subtalar joint supination and so ensures that the foot motions coincide with external leg rotation. As the rst metatarsophalangeal joint is larger than the other metatarsophalangeal joints, it is far more effective at tightening the plantar fascia as it dorsiexes. However, a less ideal situation can occur where propulsion occurs via the lesser metatarsophalangeal joints. This leads to the load not transferring from lateral to medial but staying lateral. The plantar fascia is not wound as the heel raises, so the calcaneocuboid joint stability is not maintained and the foot becomes unstable [37]. The arch may therefore lower at heel lift when, in fact, it should be rising with supination. In addition, a reverse windlass mechanism has been proposed [39]. During heel strike, the leg rotates internally and the subtalar joint pronates. This unwinds the windlass, the arch lowers and the foot elongates. In this situation, the plantar fascia becomes taut and applies a plantarexory moment to the phalanges, stabilising them against the ground (Fig. 2). This, in turn, applies an advantageous compressive force longitudinally and resists excessive pronation moments. The plantar ligaments, namely the calcaneocuboid (long and short) and calcaneonavicular, are also placed under greater stretch as the arch lowers, increasing compression across the midtarsal joint. Thus, with the reverse windlass, calcaneocuboid joint close packing is pre-empted, resulting in essential midtarsal stability. To summarise, the sequence of

Fig. 2. Simple model demonstrating the reverse windlass mechanism.

P. Harradine et al. / Physiotherapy 92 (2006) 122127 Table 1 Period of gait Contact Phase of gait Heel strike to forefoot loading Stance limb function focusing on foot function The rst rockerthe round underside of the calcaneus Internal leg rotation Subtalar joint pronation Reverse windlass mechanism Increased tension within plantar ligaments and spring ligament

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Midstance

Forefoot loading to heel lift

Continued reverse windlass mechanism Continued increasing tension within plantar ligaments and spring ligament Calcaneocuboid joint close packing The second rockerankle dorsiexion Initiation of hip extension Initiation of subtalar joint supination External leg rotation The third rockerhallux dorsiexion First ray propulsion Windlass mechanism Continuation of hip extension

Propulsive

Heel lift to toe off

foot movements that confer essential foot stability are demonstrated in Table 1. Failure of the foots ability to act as a stable pivot There are three main functional possibilities where this can occur in feet otherwise demonstrating normal joint ranges of motion at the subtalar joint, midtarsal joint and digits: 1. Failure of calcaneocuboid close packing. This may occur if there is inefcient ring of the peroneus longus or an inefcient windlass mechanism. Instead of the cuboid moving upwards and close packing into the articulating surface of the calcaneous, it remains plantarexed or even plantarexes further. This destabilises the midfoot and impedes the peroneous longus muscle. The midtarsus is therefore unstable at heel lift and unable to resist the bending moment applied by heel lift. The possible lowering of the arch at heel lift causes subtalar joint pronation to occur, rather than supination. 2. Prolonged reverse windlass. This occurs as a result of excessive pronation moments at the subtalar joint. These excessive moments may be due to myriad causes, such as a forefoot varus, tibial varum or weak lateral hip rotators. The resultant prolonged reverse windlass results in drawn out plantarexory moments at the rst metatarsophalangeal joint when dorsiexion should be occurring. Such plantarexory moments will therefore impede hallux dorsiexion and so reduce the ability of the foot to propulse through the rst ray. Pressure would remain lateral, engaging the foot in inefcient propulsion [40]. This, in turn, prevents the arch rising due to the lack of a windlass mechanism. 3. Functional bony jamming of the rst metatarsophalangeal joint. Dorsiexion of the rst ray impedes the ability of the rst metatarsophalangeal joint to extend [41]. Pronation will lead to dorsiexion of the rst ray via increased ground reaction forces medial to the foot [42]. This will

limit the foots ability to pivot over the rst metatarsophalangeal joint, leading to sequelae as described with a prolonged reverse windlass mechanism. The resultant effect is similar to that of a structural hallux limitus. Orthotic prescription utilizing the unied theory The fundamental reason to prescribe functional foot orthoses is to improve symptomatic gait dysfunction caused by failure of calcaneocuboid close packing, prolonged reverse windlass or functional bony jamming of the rst metatarsophalangeal joint. It may be argued that previous podiatric theories achieved this with combinations of negative cast shapes, varus or valgus posting, or modications in orthotic width. For example, the orthotic prescription according to the tissue stress theory would reduce the prolonged windlass by using varus posting. Sagittal plane facilitation theory would reduce functional bony jamming of the rst metatarsophalangeal joint by using cut outs in the shell beneath the rst ray. The STJN theory may improve both of the above abnormalities by varus posting and a shell cut to a narrow width beneath the rst ray. The STJN, sagittal plane facilitation and tissue stress theories would all aid the windlass mechanism and so improve calcaneocuboid close packing. It can therefore be demonstrated by the simple examples above that all three theories can be conicting in nature and yet correct in treatment by utilising a unifying theory.

An example of common gait dysfunction highlighting the use of the unifying theory Flexed trunk/attened lordosis Clinical features Sagittal plane assessment of gait demonstrates a exed trunk and attening of the lumbar lordosis. This is often exaggerated in gait from the static posture. Hip extension

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is restricted and the knees fail to fully extend prior to the swing phase. Common presenting problems Chronic lower back pain, anterior knee pain syndrome. Podiatry approach/perspective If the foot is unable to function as a sagittal plane pivot due to a prolonged reverse windlass or functional bony jamming of the rst metatarsophalangeal joint, the hips ability to extend over it becomes impeded. However, the trunk will still be anteriorly progressing and ex forwards at the lumbar spine [20]. Moving the centre of mass anteriorly also enables easier progression of the body if the hip is unable to extend without restriction. Over time, the lumbar lordosis reduces and kyphosis can develop. Physiotherapy approach/perspective The proximal features of this gait may be classied by physiotherapists as having a at back posture with posterior pelvic tilt and associated muscle imbalances [3]. The posterior tilt in midstance and the relative position of hip extension leads to a limitation of further hip extension as would be required in the late stance phase. The reduction of lumbar lordosis may be hypothesised to result in non-optimal force distribution to the lumbar spine. Clinical relevance Low back pain can occur due to increased vertebral disc shear with a decrease in lumbar lordosis. Failure of hip extension also leads to a lack of momentum being established for the swing phase of gait. In these instances, the iliopsoas muscle may overwork in an attempt to re-establish some normality to the swing phase. However, as the limb to be lifted weighs approximately 15% of total body weight, it presents a signicant load on the iliopsoas structure. Kapandji [43] has proposed that when the iliopsoas res but the femur is xed, the lumbar spine will side-bend and rotate. These actions shear the intervertebral discs and so create an environment that has been shown to induce intervertebral disc herniation [21]. In addition, with this lack of hip extension, there also tends to be a concurrent lack of knee extension [23]. The resultant bent-knee-style gait can increase retro-patella forces and be part of the myriad aetiological causes of anterior knee pain, particularly if combined with excessive internal lower limb rotation at propulsion.

the podiatric approach. Gait dysfunction may have a multiaetiological background, and therefore understanding of the podiatric and physiotherapy perspectives should be encouraged. Clinical reasoning may then be enhanced through consideration of the various causative factors for gait dysfunction and the development of presenting clinical features. It is the view of the authors that a closer working relationship between physiotherapists and podiatrists with an interest in movement dysfunction provides a better quality service for appropriate patients. However, this conjecture has yet to be supported with research.

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Conclusion This paper has introduced the three most common podiatric theories relating to lower limb pathology. A theoretically applicable amalgamation of these paradigms has been presented, allowing therapists a more simplistic perception of

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