THE NEW BIOMECHANICS

VS.

Sponsor Paris Orthotics

THE OLD ROOT THEORY

DOUGLAS H. RICHIE JR., DPM SEAL BEACH, CA

www.ParisOrthotics.com

NEW YORK

www.SealBeachPodiatry.com

Podiatric Clinical Conference

OBJECTIVES
1. Review pertinent clinical concepts of Root Theory 2. Present new, conflicting experimental evidence 3. Propose clinical applications of these new insights

Criticisms of the Root Theory

1. Reliability of clinical measurements 2. Dynamic subtalar joint position 3. Criteria for normalcy 4. Single axis model It behooves the podiatry profession to first of all establish a common nomenclature which is specific in its meaning so that knowledge can be accurately transmitted. Secondly, the foot must be classified as to its various functional and structural types, with specific clinical methods for measurement and evaluation so that one foot type at a time can be given detailed study to further our knowledge of the problems we face. 5. Frontal plane rearfoot motion significance 6. Kinematic patterns of RF motion 7. Static measures = dynamic function
McPoil and Hunt 1995, Michaud 1997, Keenan 1997, Levitz and Sobel 1997, 1998, Payne 1997, 1998.

Merton L. Root, 1963

Criteria for a Normal Foot

In the individual with normal lower extremities, the following conditions exist during normal static stance upon a level surfac e (ground). I. The legs in the sagittal bisection of the calcanei are perpendicular to the ground (vertical) and parallel to each other in both extremities. II. The subtalar joints of both feet are positioned at their neutral positions. III. The midtarsal joints are locked in their fully pronated positions. IV. The full plantar surface of the forefoot of each foot rests upon the ground, all metatarsals bear weight, and the plantar surface of the forefoot parallels the plantar surface of the heel.

Root, ML, Orien, WP, Weed, JH: Clinical Biomechanics: Normal and Abnormal Function of the Foot, Vol 2. Los Angeles, Clinical Biomechanics Corp, 1977.

KINETICS
Forces acting on a body part
There is also no evidence that the posterior bisection of the calcaneus is perpendicular to the plantar surface of the calcaneus, which is used as the reference plane for the frontal-plane forefoot deformity.
Payne CB: The past, present, and future of podiatric biomechanics. JAPMA 88:53, 1998

KINEMATICS
Timing and movement of a body part

Kinematics of Rearfoot Motion

As the midstance period begins, the leg begins to externally rotate and the subtalar joint begins to supinate . Just before the end of the midstance period, subtalar joint supination moves the foot into a slightly supinated position. Pronation of the foot is abnormal if the amount of pronation, during any period of locomotion, becomes excessive or if any pronation occurs at a time when the foot should be supinating. When treating the foot, the objective of functional orthopedic therapy is to reestablish normal motion and position of the foot during the stance phase of gait.
Root, ML, Orien, WP, Weed, JH: Clinical Biomechanics: Normal and Abnormal Function of the Foot, Vol 2. Los Angeles, Clinical Biomechanics Corp, 1977.

Abnormal compensatory pronation of the foot is the most common cause of pathology within the foot. Abnormal pronation of the foot is defined as abnormal pronation of the entire foot which occurs at the subtalar joint. Abnormal pronation of the foot usually refers only to abnormal subtalar joint pronation, but, rarely, abnormal ankle joint pronation may also be included.
Root, ML, Orien, WP, Weed, JH: Clinical Biomechanics: Normal and Abnormal Function of the Foot, Vol 2. Los Angeles, Clinical Biomechanics Corp, 1977.

Normal Rearfoot Motion

2 opposing views 1. Achieves neutral position before heel off Root, et al

Should We Control Calcaneal Eversion?

CONTROVERSIES
When does STJ achieve neutral? Rearfoot angle vs RCSP

2. Remains at resting position until heel off McPoil & Cornwall, 1994
Pierrynowski & Smith, 1996 Mosseley, 1996 Liu, 1997

Controversy
Root et al.: RCSP & NCSP calcaneus to ground Others: Rearfoot angle calcaneus to leg
Figure A & B: The resting calcaneal stance position is determined by measuring the posterior biscetion line of the heel to the ground with the foot relaxed.

NCSP

RCSP

Fig. 3. A plot of the mean pattern of rearfoot motion as well as the mean angles for RSFP and SJNP for the 100 feet. The two unmarked lines represent plus or minus on standard deviation from the mean pattern of rearfoot motion.

Subtalar Neutral = Normal?

Nine subjects Three dimensional treadmill analysis Max eversion at 44% of gait cycle Neutral STJ position at 66% and 74% of gait cycle
Pierrynowski , M.R., Smith, S.B.: Rear foot inversion/eversion during gait relative to the subtalar joint neutral position. Foot and Ankle 17: 406, 1996

Subtalar Joint
When does pronation end and supination begin? 36% of gait cycle
McPoil and Cornwall 1994

44% of gait cycle

Pierrynowski, 1996

What initiates supination?

Independent Joints Independent Axes

A B

Figure A, B. The subtalar joint is moved to its end range of inversion (A) and eversion. (B) Motion and excursion values are recorded.

Figure 1-33: From the neutral subtalar joint position this foot inverts 20 when the subtalar joint is fully supinated and everts 10 when the subtalar joint is fully pronated. This foot has a normal rearfoot, and its full range of subtalar joint motion, measured in a frontal plane, is 30.

Clinical Measurement
Calcaneal Inversion - Eversion 15 cadaveric legs Unlocked vs locked tibiotalar joint Manual vs radiographic measurments

Taylor, K.F., Bojescul, J.A., Howard, R.S., Mizel , M.S., McHale, K.A., Measurement of Isolated Subtalar Range of Motion: A Cadaver Study. Foot and Ankle Intl 22:426-432, 2001

Clinical Measurement
Calcaneal Inversion - Eversion This study demonstrates that the clinical measurements of calcaneal eversion and inversion did not correlate well with radiographic measurements. The contribution of the tibiotalar joint to apparent subtalar motion, as measured clinically and radiographically, was found to be one-third of the arc of motion.
Taylor, K.F., Bojescul, J.A., Howard, R.S., Mizel , M.S., McHale, K.A., Measurement of Isolated Subtalar Range of Motion: A Cadaver Study. Foot and Ankle Intl 22:426-432, 2001

Axis of Motion of the Pedal Joints Fact vs. Fiction

In this model, the subtalar and midtarsal joints have been described as dual screws connected to the talonavicular joint in opposite directions. This model introduced the concept of the position of the subtalar joint. The range of motion of the midtarsal joint is controlled by subtalar joint position. In a pronated subtalar joint, the two axes of the midtarsal joint are in a more parallel orientation, increasing the range of motion. In a supinated subtalar joint, the two axes of the midtarsal joint are in a more oblique orientation, decreasing the range of motion. - Justin Wernick - Russell G. Volpe

Valmassy , R: Clinical Biomechanics of the Lower Extremities. St. Louis, Mosby-Year Book, Inc. 1996

Bi-axial Model of MTJ

Refuted by:

Van Langelaan (1983) Benink Lundberg

(1985) (1989)

Should We Control Calcaneal Eversion?

CONTROVERSIES
When does STJ achieve neutral? Rearfoot angle vs RCSP Independence vs Interdependence of joint movements

The tarsal bones together form an articulated ring of bones. The talus articulates with the calcaneus, the calcaneus with the cuboid, the cuboid with the navicular, and the navicular with the talus: a socalled kinematic chain with only 1 kinematic degree of freedom. Under weightbearing conditions, this kinematic chain acts as a mechanism in engineering terms, if a motion is imposed upon one of the links, the other links are also forced to move.
Huson A: Biomechanics of the tarsal mechanism. A key to the function of the normal human foot. JAPMA 90:12, 2000.

Figure 1. An osteoligamentous dissected specimen of the foot exarticulated at the ankle joint. The dorsal capsules of the talonavicular and calcaneocuboid joints have been removed. The foot is held in the neutral position corresponding with upright standing.

Figure 2. The talus has been moved as it does in supination of the foot while the calcaneus, cuboid, and navicular are kept immobile. The talar head has left the navicular socket laterally, creating a wide gap at the medial side of the talonavicular joint.

Because of the complex mechanical relationships between the tarsal motions and between these and other complex motions in the tarso-metatarsal joints, the use of axes of rotation as tools for a reliable quantitative clinical evaluation of foot function has no firm basis so far.

Huson A: Biomechanics of the tarsal mechanism. A key to the function of the normal human foot. JAPMA 90:12, 2000.

HINGE AXIS?
VanLangelaan E.J. A Kinematical Analysis of the Tarsal Joints. Acta Orthop Scand 54: 204, 1983

Lundberg et al. Kinematics of the Ankle / Foot Complex: Plantarflexion and Dorsiflexion. Foot and Ankle 9: 194, 1989

Six cadaver specimens Axis-finder rod LED path photography MRI serial cuts Single axis, at tips of malleoli

Singh A.K. : Kinematrics of the Ankle : A Hinje Axis Model. Foot & Ankle 13:439, 1992

Traditional Biomechanical Exam

Static Measurements Open Kinetic Chain Calcaneus is Point of Reference

The assessment of the range of motion of the subtalar joint is done in a non -weightbearing position, but there is a difference between the weightbearing and nonweightbearing range of excursion of the calcaneus in the frontal plane, indicating motion in the joint. Static measurements are used as part of the biomechanical assessment of patients, but in light of these reports and other work on the reliability of the measurements, their usefulness must be reconsidered.

Payne CB: The past, present, and future of podiatric biomechanics. JAPMA 88:53, 1998

Figure A: With the patient standing in the angle and base of gait and the subtalar joint held in its neutral position, the angle of the bisection of the lower leg relative to the ground determines the tibial position.

Figure A & B: The resting calcaneal stance position is determined by measuring the posterior biscetion line of the heel to the ground with the foot relaxed.

 PT Tendon removed Spring ligament removed

CKC
Universal Joint
Rotation
PT Tendon removed Spring ligament removed

Torsion
Transmission

Tibia: Dominant
Lever

The Myth of the Subtalar Joint

Should We Control Calcaneal Eversion?

CONTROVERSIES
When does STJ achieve neutral? Rearfoot angle vs RCSP Independence vs Interdependence of joint movements Importance of STJ control of LE

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3 Myths of Podiatric Biomechanics Calcaneus = Subtalar Joint = Foot

1. The calcaneus controls the subtalar joint 2. The subtalar joint controls the foot 3. The foot controls the leg

Frontal plane movement of the calcaneus has been the primary indicator for measurement of foot pronation in studies on foot orthoses, while control of excessive foot pronation has been the primary objective in the prescription of functional foot orthoses. - William R. Olson

Figure 1-44: Closed chain pronation of the subtalar joint. Pronation of the subtalar joint in the weight bearing foot results in eversion of the calcaneus , and the talus adducts and plantarflexes relative to the calcaneus . The leg follows the talus in a transverse plane and internally rotates. In a sagittal plane, the leg also moves to some extent with the talus. As the talus plantarflexes , the proximal aspect of the tibia moves forward to flex the knee slightly.

Valmassy , R: Clinical Biomechanics of the Lower Extremities. St. Louis, Mosby-Year Book, Inc. 1996

One method of estimation of correction for the severe pronator is the 5-to-1 rule Five degrees of plaster correction produces 1 of calcaneal inversion (rearfoot change). Measurement of the patient presents with an RCSP of 10 everted on the involved left side. Utilizing the 5 to 1 rule in an attempt to bring the rearfoot back to a vertical position, a 50 degree inverted orthotic correction should be ordered. - Richard Blake

Valmassy , R: Clinical Biomechanics of the Lower Extremities. St. Louis, Mosby-Year Book, Inc. 1996

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Controlling Calcaneal Eversion Effects of Functional Foot Orthoses

AUTHOR Clarke et al. Cavanagh Rogers et al Smith et al Taunton et al Sims DECREASED EVERSION 2.5 2 per 6mm wedge 1-2 1.2 1-2 2

Simms and Cavanagh noted that although studies have claimed that foot and ankle symptoms are usually dramatically decreased with the use of foot orthoses, the objective improvement in rearfoot motion is considerably more modest, suggesting that therapeutic success is not necessarily due to restoring the foot to what is functionally considered normal. This raises the possibility that foot orthoses are effective for reasons that are not entirely clear.

Payne CB: The past, present, and future of podiatric biomechanics. JAPMA 88:53, 1998

Variation in the spatial location of the subtalar joint axis affected the overall biomechanics of the foot during weight bearing activities.

Therefore, during many weightbearing motions, the foot may approximate a relatively rigid unit with all the bones of the foot rotating around the central pivot of the talus at the subtalar joint axis.

Kirby KA: Subtalar joint axis location and rotational equilibrium theory of foot function. Journal Am Pod Med Assoc 91:465, 2001

Kirby KA: Subtalar joint axis location and rotational equilibrium theory of foot function. Journal Am Pod Med Assoc 91:465, 2001

Finally, Husons theory on the constraint mechanism of the human tarsus, which has been supported by the tarsal kinematic research of Cornwall and McPoil, and the roentgen stereophotogrammetry studies done by Van Langelaan, Benink , and Lundberg and Svensson are all consistent with the current authors theory that the subtalar joint axis is the primary inversion/eversion axis of the foot.

STJ: Pivitol Joint?

The authors believe that the finding that the magnitude of navicular (midfoot) movement is greater than that of calcaneus (rearfoot) illustrates the importance of the midfoot for typical foot function during walking.
Cornwall MW, McPoil TG: Three-dimensional movement of the foot during the stance phase of walking. JAPMA 89:56, 1999.

Kirby KA: Subtalar joint axis location and rotational equilibrium theory of foot function. Journal Am Pod Med Assoc 91:465, 2001

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Figure 1. An osteoligamentous dissected specimen of the foot exarticulated at the ankle joint. The dorsal capsules of the talonavicular and calcaneocuboid joints have been removed. The foot is held in the neutral position corresponding with upright standing.

Figure 2. The talus has been moved as it does in supination of the foot while the calcaneus, cuboid, and navicular are kept immobile. The talar head has left the navicular socket laterally, creating a wide gap at the medial side of the talonavicular joint.

The tibiofibular talar unit does not function independently of the subtalar or midtarsal joint but acts cooperatively in closed-kinetic chain performance. The complex movement pattern known as supination and pronation of the foot must occur in concert with talar movement in the ankle housing unless spontaneous or surgical ankylosis has occurred in the ankle
Vogler HW, Bojsen-Moller F: Tarsal functions, movement and stabilization mechanisms in foot, ankle and leg performance. JAPMA 90:112, 2000.

Talar positioning on top of the calcaneus is determined by ankle movement and midtarsal joint motions and varies depending on whether these are open- or closed-kinetic-chain events. Changes in any one of these joints alter the position and function of the others to varying degrees.

Vogler HW, Bojsen-Moller F: Tarsal functions, movement and stabilization mechanisms in foot, ankle and leg performance. JAPMA 90:112, 2000.

Two Lever Theory

The ankle connects two unequal levers, the leg and the foot. The longer lever contains only a pair of bones, the tibia and fibula. The more massive tibia conveys most of the body weight directly on the talus and acts as a solid lever in ankle injuries. The foot, on the other hand, is composed of numerous small bones intercepted by joints, which weaken it as a lever. Kelikian, 1985

The subtalar joint provides most of the transverse plane motion which is necessary at the distal extremity to allow internal and external leg rotation during the stance phase of gait. The subtalar joint pronates to allow internal leg rotation and supinates to allow external leg rotation.
Root, ML, Orien, WP, Weed, JH: Clinical Biomechanics: Normal and Abnormal Function of the Foot, Vol 2. Los Angeles, Clinical Biomechanics Corp, 1977.

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Two Lever Theory

Between these two unequal levers (unequal in bulk, length and strength) lies the talus. When the foot is dorsiflexed at the ankle, the talus becomes firmly lodged in the tibiofibular socket and serves as part of the proximal lever or the leg
Kelikian, 1985

Transverse Plane
Internal rotation of tibia = Internal rotation of talus

Tibial Rotation During Stance

Tibial Rotation During Stance

Max velocity of tib internal rotation = 7% of gait cycle Max velocity of tib external rotation = at toe off Max amount rotation of tibia = 12 internal Total range rotation of tibia = 17

25 Subjects

External markers 3-D motion of foot and shank

Nester CJ., Hutchins S., Bowker P., Shank rotation: A measure of rearfoot motion during normal walking. Foot and Ankle 21: 578-583, 2000

Nester CJ., Hutchins S., Bowker P., Shank rotation: A measure of rearfoot motion during normal walking. Foot and Ankle 21: 578-583, 2000

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Angular displacement
10 5 0 -5 -10 Ang 2 Ang 1 Ang 4 Ang 5 Ang 3

Toe off time (one gait cycle)

We found that external rotation of the shank (indicating supination) began much earlier, at around 16% of the gait cycle. This is most likely a consequence of the fact that motion of the shank in the transverse plane can occur at the ankle and mid-tarsal joints without any change in the angle between the heel and shank in the frontal plane .
Nester CJ, Hutcdhins S, Bowker P: Shank rotation: A measure of rearfoot motion during normal walking. Foot and Ankle International 21:578, 2000

Nester CJ., Hutchins S., Bowker P., Shank rotation: A measure of rearfoot motion during normal walking. Foot and Ankle 21: 578-583, 2000

degrees

4 2 0

Rearfoot Tibia

When does External Rotation of the Tibia begin?

Percent of Walking Cycle Avg. Internal Rotation Authors

Angle (Deg)

-2 -4 -6 -8 -10 0 10 20 30 40 50 60

17% 25% 16%

7 7 7

Levens et al Reinschmidt et al Nester

Stance Phase Duration (%)

Cornwall W., McPoil G., Footwear & Foot Orthotic Effectiveness Research: A New Approach. Foot/Ankle 21: 337-344 1995

Movement Coupling
1. Inversion of heel begins at 50-55% of gait cycle
Kepple (1990) Mannon etal (1997) McPoil & Cornwall (1994) Pierrynowski and Smith (1996)

Movement Coupling
How can the tibia externally rotate while the calcaneus remains everted (does not move)?

Tibia can internally rotate on talus Rearfoot complex can internally rotate as one unit on the forefoot (transverse plane MTJ motion)

2. External rotation of shank begins at 16% of gait cycle Levens et al (1948)

Cornwall & McPoil (1995) Reinschmidt et al (1997) Nester (2000)

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Tibiotalar Delay
The talus does not immediately follow
internal / external rotation of the tibia.

Ant. Talo-Fib and Sup Deltoid have to

tighten before talar motion is observed.

Lateral rotation of the lower leg in the stance phase of gait allows a slight delay in transmitting this transverse plane rotation to the foot. This action is believed to be related to that of the horizontally aligned ligament fibers that surround the ankle and talus that must absorb these forces before transmitting them

Huson A, VanLangelaan EJ, Spoor CW: Tibiotalar delay and tarsal gearing. J Anat 149:244-245, 1986

Vogler HW, Bojsen-Moller F: Tarsal functions, movement and stabilization mechanisms in foot, ankle and leg performance. JAPMA 90:112, 2000.

Transverse Plane Movements In Gait

Ankle
18 15 McCullough, Burge Nester

Midtarsal
10.6 Nester

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Foot & Ankle International/Vol.21, No. 3/March 2000

Ankle vs STJ
Transformation of leg rotation into calcaneal eversion-inversion, and vice versa, has been suggested to occur mainly at the subtalar joint. When this is true, subtalar joint fusion must result in a significant loss of movement transferred between calcaneus eversioninversion and tibial rotation. However, as shown previously, it did not.
Hintermann B., Nigg BM: Influence of arthrodeses on kinematics of the axially loaded ankle complex during dorsiflexion/plantarflexion. Foot & Ankle 16:633, 1995

Fig. 5 Movement coupling between calcaneal eversion-inversion and tibial rotation for the five test subjects (mean curves of three repetitions). The dashed line represents a theoretical 1:1 coupling from the calcaneus to the tibia. HS (heel strike); MS (midstance); TO (takeoff); SD (mean standard deviation in the horizontal (x) and vertical (y) direction)

Stacoff, Nigg, Reinschmidt, 2000

Considering motion at only one of the three, i.e. the subtalar joint, is unlikely to describe the eventual motion which results from all three in combination since it does not account for factors affecting the other joints.
Nester , 1997

Ankle, Subtalar and Mid-tarsal joints

Rear foot Complex
Downing, 1978 Nester, 1997

Tarsal Mechanism
Huson, 1991

Ankle Joint Complex

Hintermann, Nigg, 1994

Ankle Joint Complex

3 Segments: tibia, talus and calcaneus 2 Joints: ankle, subtalar
Universal Joint: inversion of calcaneus = external rotation of tibia eversion of calcaneus = internal rotation of tibia

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CKC
Universal Joint
Rotation

Torsion
Transmission

Tibia: Dominant
Lever

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Functional Foot Orthoses

1. Do not change skeletal alignment 2. Change input signal to CNS 3. Modulates muscle activity

Nigg, Benno: Foot Orthoses Do They Align the Skeleton? Prescription Foot Orthotic Laboratory Association, International Conference Foot Biomechanics and Orthotic Therapy. Nov. 2001

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Shin Muscle Activity On Various Sport Surfaces:

An EMG Study By: DOUGLAS H. RICHIE, D.P.M. HERBERT A. DeVRIES, Ph.D. CLIFFORD K. ENDO, D.P.M.

JOURNAL AMERICAN PODIATRIC MEDICAL ASSOCIATION VOL 83, No. 4, APRIL., 1993

ECCENTRIC vs. CONCENTRIC PHASES

- Two separate counters - Kistler accelerometer triggers timing circuit - Concentric phase begins at g Max through mid-swing - Eccentric phase begins at mid -swing through contact and g Max

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Stationary Run
Eccentric Phase Leg flexors lengthen immediately after foot touchdown Concentric Phase Leg flexors shorten immediately after g Max during propulsion

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Conclusion As the surface becomes harder and impact increases, the overall eccentric activity in the posterior musculature of the lower leg increases. This may be partly due to pre-activation of these muscles prior to foot touchdown.

Prior to footstrike a pre -innervation phase of muscular contraction occurs allowing stiffness and elasticity to the leg. As vertical impact increases, preactivation of the muscles increases.

Gollhofer et al. Int J Sports Med, 1984 5:19

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Where Do We Go From Here?

1. Re-design podiatric biomechanics curriculum 2. Emphasize importance of joint interdependence and foot-leg interdependence 3. Prioritize clinical & laboratory research 4. Beliefs must be based upon sound scientific methodology

Where Do We Go From Here?

The field of foot orthopedics, and to some degree foot surgery, is a conglomeration of theory, techniques of treatment, and treatment modalities that are too frequently not based upon scientific fact. Merton L. Root, 1963

5. It is o.k. to say: I dont know

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