Chapter 32: Biomechanics

Normal Values
Criteria of Normalcy in the Lower Extremity
Adult Biomechanical Examination
Common Structural Variations
Planes of Motion
Axes of Joint Motion
Angular and Axial Deformities
Anatomy of Gait: Activity of Muscles
Observation of Gait
Subtalar Joint Measurements
Subtalar Joint Function
Midtarsal Joint Function
BIOMECHANICS
Normal Values
1. Quick reference chart of normal biomechanical finding s:
Part Birth Position Adult Position
Thigh/Femur/Hip Angle of head and neck of femur=150° At age 6 years=125°
(frontal plane) (angle of Inclination)
At age 6 years=0
(transverse plane) Externally rotated 60° At age 6 years=10°
Femoral torsion (angle declination)=30° Past puberty=100°
Total range of motion=150°
Knee (Birth) (1&1/2-3yr) (3-6yr) (7-puberty) (puberty-18) (over 18) (over 60)
Genu Varum Straight Genu valgum Straight Genu valgum Straight G. valgum
Genu Recurvatum=5-10° At age 6 years =0°
Externally rotated=30° At age 6 years=0°
Frontal plane rotation=5-10° At age 6 years=0-5°
Transverse plane rotation=5-15° At age 6 years=0-5°
Leg/Tibia Varum(approx. 15°) At age 18 years=0-2° varum
Tibial torsion at birth=0° 1 yr=6°, 2-3 yr=10-15°, 5-6 yr=18-23°
Malleolar torsion at birth=0° 5-6 yr=13-18°
Rearfoot At birth= 10° varus approx. At 6 years=2-5° varus
Talocalcaneal angle=30-50° At 6 yrs=25-30°
Calcaneal inclination angle=approx. 14° At 6 yrs=20° approx.
Talar declination angle=approx. 30° At 6 yrs=21° approx.
Calcaneal stance @ 1 yr=5-10° 5 yr=3-8° 8 yr=<2° external rot.
Dorsiflexion=45° approx. After age 18=10V min
Forefoot Varus 10-15° (birth) At age 6=0-2° varus
Metatarsus adductus=15-35° (birth) Adult=15-22°

Criteria of Normalcy in the Lower Extremity

1. Nonwelghtbearing:
a. Malleolar torsion should be 13°-18° externally rotated
b. Ankle joint dorsiflexion should be at least 100 with the knee extended
c. Ankle joint plantarflexion should be at least 20°
d. Total STJ ROM should be 30° (with 20° of inversion and 10° of eversion)
e. When the STJ is in neutral position, the calcaneal bisection should be
parallel to the bisection of the lower 1/3 of the leg and perpendicular to the
supporting surface
f. When the MTJ is maximally pronated and locked the forefoot should be
perpendicular to the calcaneal bisection and parallel to the supporting surface
and the knee on the frontal plane with the hip neutral at 0°
g. There should be equal excursion dorsally and plantarly (5mm) of the 1st ray
from a level equal with the 2nd metatarsal when the STJ is in its neutral
position and MTJ maximally pronated
h. The 5th ray should have equal excursion dorsally and plantarly from a level
equal with the central 3 metatarsals when the STJ is in its neutral position and
MTJ maximally pronated

2. Weightbearing:
a. The distal 1 /3 of the leg should be vertical
b. The knee, ankle, and STJ should lie in transverse planes parallel to the
supporting surfaces
c. The STJ should rest in its neutral position
d. A bisection of the posterior surface of the calcaneus should be vertical
e. The MTJ should be locked in a maximally pronated position about both its
axes
f. The plantar plane of the forefoot and rearfoot should be parallel to each other
and to the supporting surface
g. The central 3 metatarsals should be completely dorsiflexed and describe a
plane parallel to the supporting surface
h. The 1st and 5th metatarsals should describe a common transverse plane
with the central 3 metatarsals

Adult Biomechanical Examination

1. Non-weightbearing assessment:
a. Ankle dorsiflexion:
i. Taken with the patient supine
ii. The minimum ankle joint dorsiflexion that is necessary for normal
ambulation is 10° with the knee extended.
iii. Dorsiflexion is also measured with the knee flexed

NOTE* If the amount of dorsiflexion is less than or equal to 100 whether the knee
is extended or flexed, then there is an osseus or soleus equinus; if the amount of
dorsiflexion is decreased only with extention, then there is a gastrocnemius
equinus

b. Subtalar joint ROM: to calculate neutral position

i. The posterior calcaneus is bisected as is the posterior /distal 1 /3 of the leg
ii. The foot is dorsiflexed to resistance, the MTJ is pronated and locked against
the rearfoot, and the rearfoot is supinated maximally and pronated maximally.
The total ROM is measured with a goniometer (or tractograph) placed parallel to
the bisection of the lower 1/3 of the leg
iii. The STJ neutral position is defined as that point that divides the medial 2/3
of motion from the lateral 1/3 of motion

NOTE* Calculated neutral position= eversion - total ROM-3

For example:
From an examination there is revealed to be: 20° inversion + 10° eversion = 30°
total ROM. So following the formula from above:
Neutral position= eversion (100)- TROM-3 (100)= 0 °
A positive number means a valgus or neutral position, while a negative number
means a varus or neutral position

iv. The minimal STJ ROM is 8-12° for normal ambulation

c. Midtarsal (forefoot):
i. The foot is held by the 5th metatarsal and dorsiflexed to resistance and then
slowly everted until the STJ reaches neutral position
ii. The plantar plane of the rearfoot should be perpendicular to the calcaneal
bisector
d. First ray:
i. Dorsiflex the foot to. resistance and bring the STJ into its neutral position,
stabilize the 2nd-5th metatarsal heads and grasp the 1st metatarsal head and
move it in a dorsal to plantar direction to resistance (this distance should be
about 5 mm or 100 to either side of its resting position and its resting position
should lie on the same transverse plane as the lesser metatarsals)
e. Malleolar torsion:
i. Reference marks are placed on the malleoli, the knee placed on the frontal
plane, and a measurement made with a gravity goniometer
ii. Normal malleolar torsion is 13-18° externally rotated
f. Hip motion (transverse plane): internal and external rotation of the femur
i. The hip joint functions around its neutral position, in a transverse plane,
with the femur rotating the same number of degrees from a neutral position
(same with the hip flexed and extended). Total range of internal and external
rotation must be equal to be considered normal
ii. Mark the patella or the femoral condyles and measure internal and external
rotation with a goniometer
iii. A normal hip rotates 45° internally and 45° externally from a zero degree
starting point. This results in a total ROM of 90° and a neutral position of zero
(from the neutral position, the hip rotates 45° in each direction)

NOTE* Other examples of hip ROM:

a. InternalNOTE*
rotation
When
= 55°there
external
is a variance
rotation=in35°
the degree of neutral position between the
Total ROM= flexed
90° 90-2=
and extended
45°, 55°(int)-45
hip position,
=
10° this
therefore,
indicates
neutral
soft position=
tissue abnormality
100 limiting
internal hip rotation. This abnormality is called internal or External Femoral Rotation
(from neutral
Example
position,
of athe
15°hip
internal
rotates
femoral
45° in position:
each direction)
Internal rotation with hip extended=
b. Internal45°
rotation=10°
external rotation
externalwith
rotation=
the hip40°
extended= 15°, total ROM=60° therefore,
Total ROM= neutral
50°, 50-2=25°
position with
10°(int)-
the hip
25°=-15°
extended=15°
therefore,
internal
neutral position= 15°
external Internal rotation with the hip flexed=45° external rotation with the hip flexed=45°,
(from neutral
totalposition,
ROM=90° thetherefore
hip rotates
neutral
25° inposition
each direction)
with the hip flexed=0

NOTE* Lack of symmetry in total ROM between the flexed and extended positions
results in asymmetry of the neutral position measurement. This indicates soft
tissue abnormality at the hip.

2. Weight-bearing assessment:
a. Angle and base of gait:
i. The angle and base of gait are necessary to measure NCSP, RCSP and tibial
varum. This allows for standardization and reproducibility of values
ii. The angle of gait is the number of degrees that the foot is deviated from the
line of progression of gait (mid-sagittal plane of the body). Normally the foot is
between 7°-10° abducted from the line of progression
iii. The base of gait is defined as the space between the malleoli during
midstance (normally 1 & 1 /2 inches)

b. Neutral calcaneal stance position (NCSP):

i. Defined as the angular relationship between the calcaneus and the ground
with the STJ in its neutral position and the patient standing in the angle and
base of gait
ii. The calcaneus is bisected, the foot is placed in STJ neutral position, and the
angular relationship between the calcaneus and (perpendicular to) the ground
is assessed

c. Resting or relaxed calcaneal stance position (RCSP): This is measured with

the patient standing in the angle and base of gait with the STJ in a relaxed
position. A measurement is taken of the number of degrees the calcaneal
bisector deviates from perpendicular with the ground

d. Tibial varum: Measured by placing the goniometer on the bisection of the

lower 1 /3 of the leg, with the feet in angle and base of gait, and the foot placed
in the NCSP

e. Gait evaluation: Things to look for

i. What is the position of the calcaneus at heel strike?
ii. Does the foot pronate excessively?
iii. What is the position of the calcaneus and foot at midstance?
iv. Is the heel lifting at the proper time?
v. In propulsion:
 Is it vigorous and active?
 Does the hallux participate?
 Does the foot roll medially?
 Is there a plantarflexion of the ankle?
vi. Is the knee joint on the frontal plane at heel strike, internally deviated, or
externally deviated?
vii. Does the knee joint flex and extend normally or not?
viii. Does the pelvis function around the transverse plane or tilt excessively to
one side?
ix. Does the patient lead with one side excessively?
x. Do the arms swing symmetrically?
xi. Are the trunk and head in the sagittal plane?

Common Structural Variations: Signs and Symptoms

1. Rearfoot varus: A condition in which the calcaneus is inverted relative to
the ground with the STJ in its neutral position. Symptoms:
a. Callus, plantar 4th and 5th metatarsal heads
b. Tailors bunion
c. Haglund's deformity
d. Inversion ankle sprains
e. Adductovarus 4th and 5th hammertoes
f. Mild HAV deformity
 NOTE* With rearfoot varus the changes during gait are as follows: The knee
would function fully extended both at heel contact and during midstance.
The leg may be somewhat internally rotated at heel contact, and some
internal rotation would occur if STJ motion were available from this point.
During the latter half of stance phase normal external rotation of the leg
occurs. Position of the heel at contact would be inverted. If the rearfoot
varus is not fully compensated, the heel remains in an inverted position. The
STJ is normally supinated at heel contact
2. Rearfoot valgus: A condition in which the calcaneus is everted relative to
NOTE* Rearfoot varus is not a major pronator. It only allows pronation until the
heel is vertical
the ground with the STJ in its neutral position. Symptoms:
a. Callus, plantar 2nd metatarsal head (occasionally)
b. Fatigue muscle of foot and leg
c. Arch pain
d. HAV deformity

3. Forefoot varus: A structural abnormality in which the plantar plane of the

forefoot is inverted relative to the supporting surface and a vertical bisection of
the posterior surface of the calcaneus when the STJ is in its neutral position
and the MTJ is maximally pronated and locked (rearfoot is normal).
Symptoms:
a. Callus, plantar 2nd, 4th, and/or 5th metatarsal heads
b. Muscle fatigue in foot and leg
c. Tailor's bunion
d. AdductovaruS 4th and 5th hammertoes
e. HAV deformity
f. Plantar fascitis/heel spur syndrome

NOTE* With forefoot varus the changes to the gait cycle are as follows: During
gait the individual with compensated forefoot varus functions with the knee
internally rotating during forefoot loading (contact). The external rotation of the
knee that occurs later in stance phase is decreased. There may be some
reduction in the amount of flexion of the knee during stance phase because of
the pronated position of the foot. The knee would be fully extended at heel
contact and midstance. Following heel contact, normal ankle joint
plantarflexion occurs with smooth contact of the forefoot. At heel contact the
calcaneus is inverted. The heel everts during the stance phase of gait as the
forefoot loads. The STJ will be in a pronated position through the rest of the
stance phase of gait

4. Forefoot valgus (plantarflexed 1st ray with compensation by MTJ

longitudinal axis supination): A structural abnormality in which the plantar
plane. of the forefoot is everted relative to the supporting surface and the
posterior bisection of the rearfoot when the STJ is in its neutral position and
the forefoot is maximally pronated and locked about both MTJ axes (the
rearfoot is normal). Symptoms:
a. Callus, plantar to 1st and 5th metatarsal heads
b. Tibial sesamoiditis
c. Muscle fatigue in foot and leg
d. Flexion contractures of the lesser digits
e. Lateral knee strain

5. Forefoot valgus (plantarflexed 1st ray with compensation by supination

of the STJ and MTJ longitudinal and oblique axes): Symptoms
a. Callus, plantar to the 1st and 5th metatarsal heads
b. Tibial sesamoiditis
c. Flexion contraction of the lesser digits
d. Lateral knee strain
e. Inversion ankle sprains
f. Haglund's deformity
g. Intoe gait seen in children

6. Metatarsus primus elevatus: A structural abnormality in which the 1st ray

has a resting position above the plane of the lesser metatarsals. Symptoms:
a. Callus, plantar 2nd metatarsal and hallux IP joint
b. Fatigue of muscles of the foot and leg
c. Dorsal bunion
d. Hallux limitus/rigidus

7. Equinus deformity (adults): Symptoms:

a. Corn, 5th toe
b. Adductovarus deformities of the 4th and 5th toy
c. Fatigue of the muscles of the foot and leg
d. HAV deformity
e. Plantar fasciitis/heel spur syndrome
f. Neuroma symptoms
g. Contracture of all the digits (extensor substitution)
 NOTE* The gait variations seen are as follows: The compensatory changes for
equinus are an early heel-off with the knee slightly flexed throughout the
stance phase of gait. The knee will be somewhat flexed at heel contact, the
flexion might increase during midstance, but it never fully extends at heel lift.
As the leg swings forward, it actually becomes hyperextended relative to the
femur and then begins to flex, and is flexed by the time the heel contacts the
ground. Rather than being an actual compensatory mechanism for equinus,
this seems to protect the knee from abnormal stress in a fully extended
position. In severe equinus the knee may go into hyperextention during the
stance phase of gait (back-knee function). The ankle will be at 90° at heel
contact unless the equinus is severe. Following foot flat, the ankle will then
dons flex to the limit of its ROM, at which time heel-off will occur (the earlier
the heel lift, the sooner the load to the forefoot, the more stress induced
symptomatology there is. The STJ will typically be neutral or slightly inverted
at heel contact.
8. Forefoot supinatus: A relatively fixed supinated position of the forefoot
relative to the rearfoot with the STJ in its neutral position and the forefoot
maximally pronated and locked about both MTJ axes, caused by soft tissue
adaptation. The MTJ ROM is typically decreased secondary to soft tissue
contracture

Planes of Motion
There are three planes of motion in the body, one perpendicular to the other
two, corresponding to the three dimensions in space. The position is one with
the body erect, elbows extended, palms facing forward, _and feet slightly
separated and parallel
1. Sagittal plane: A vertical plane passing through the body from front to back,
dividing it into right and left half. The cardinal plane divides the body into equal
symmetrical halves

2. Frontal plane: A vertical plane passing through the body from side to side,
dividing it into a front and back half. The cardinal frontal plane passes through
the center of gravity dividing the body into equal but asymmetrical halves

3. Transverse plane: This is a horizontal plane, which passes through the body
from side to side and from front to back, dividing it into an upper and lower
half. The cardinal transverse plane passes through the center of gravity and
divides the body into equal but asymmetrical halves

NOTE* It is these planes of motion that are used as coordinates to describe

where the axis of motion lies and what motion will occur around the axis
Axes of Joint Motion
1. Either single or triplane joint motion:
a. An axis can be defined as an invisible line around which all motion takes
place
b. The axis of motion is always perpendicular to the plane in which the motion
takes place (the motion takes place in one plane and the axis lies in the other 2
planes)
c. The frontal-transverse axis is horizontal (its motion is sagittal plane), the
sagittal-transverse axis is horizontal (the motion is frontal plane), and the
frontal-sagittal axis is vertical (the motion is transverse plane)
d. The majority of joints in the lower extremity are hinge-like, therefore when
motion occurs around a joint it occurs by rotation about an axis

2. Position of the joint axes:

a. Single joint motion: The plane of motion is perpendicular to the axis of
motion
b. Triplane joint motion: The amount of motion that can occur in that plane will
depend upon the degree of angularity the joint axis makes to each individual
body plane
 NOTE* The greater the amount of degrees (up to 90°) between an axis of motion
and a cardinal body plane, the greater the amount of motion that will occur in
that body plane

3. Motion of specific joints:

a. Hip:
i. Transverse plane axis (controls sagittal plane motion): Controls the
movements of flexion and extension. The range of hip flexion depends upon the
position of the knee:
 When the knee is extended the hip can flex 90° (active flexion) and 140°
(passive flexion)
 With the knee flexed the hip can be flexed 120° (active flexion) and 120°
(passive flexion)
ii. Anteroposterior axis: lies in the sagittal plane and controls the movements of
abduction and adduction
iii. Vertical axis (controls transverse plane motion): controls internal and
external rotation
b. Knee:
i. Frontal plane axis (controls sagittal plane motion): Controls the motion of
flexion and extension
 Active flexion of the knee with the hip joint extended can result in 120° of
flexion, and 140° with the hip joint flexed
 Passive flexion of the knee may attain a range of 160°
ii. Longitudinal plane axis (controls transverse plane motion): Motion of internal
and external rotation
 Active internal rotation has a range of 30°, while active extended rotation
has a range of 40°
c. Ankle: The primary motions at the' ankle joint are flexion and extension in
the sagittal plane
i. The axis of the ankle joint passes lateral, plantar, and posterior to medial,
dorsal, and anterior passing through the tips of the malleoli. It is deviated from
the frontal plane due to malleolar torsion
 The range of dorsiflexion available at the ankle joint is 20-30°, while the
range of plantarflexion is 30-50°

NOTE* Due to slight deviations in the transverse frontal axis of the ankle joint we
will see transverse plane motion of abduction and adduction

d. Subtalar: The axis is oblique to all 3 body planes which allows for triplanar
motion (pronation and supination). Pronation allows the motion of abduction,
eversion, and dorsiflexion. Supination allows for adduction, inversion, and
plantarflexion
i. Subtalar joint axis passes from a plantar, posterior, lateral direction to a
dorsal, anterior, medial direction. It enters the heel and exits through the
dorsomedial surface of the talar neck
ii. The axis is directed 42° from the transverse plane and 16° from the sagittal
plane
iii. As the axis is deviated 42° from the transverse plane positioning it
approximately equidistant from being completely vertical or completely
horizontal, and equal amount of transverse and frontal plane motion will occur
(i.e. Equidistant from both the frontal and transverse planes)
iv. Additionally, as the axis is deviated 16° from the sagittal plane, this allows a
minimal amount of dorsiflexion and plantarflexion
v. The normal values for passive ROM from neutral is 20-35° of inversion to 10-
15° of eversion for a total ROM of 30-35°

e. Midtarsal: Has 2 axes of motion which allow for triplanar motion

i. The longitudinal axis passes 150 from the transverse plane and 9° from the
sagittal plane. It passes dorsal, anterior, medial to plantar, posterior and
lateral. It enters the calcaneus and exits medially through the 1st metatarsal-
cuneiform joint. Since the longitudinal axis is more longitudinal (close to the
transverse-sagittal axis) its permits frontal plane motion of inversion and
eversion. The normal ROM is 4-6°
ii. The oblique axis passes 52° from the transverse plane and 57° from the
sagittal plane. It enters the lateral aspect of the calcaneus (plantarly) and exits
the talonavicular joint (dorsally). The motion that occurs is adduction and
abduction, and dorsiflexion and plantarflexion. Inversion and eversion does
occur, but is minimal

f. First ray: Consists of the 1st metatarsal and medial cuneiform

i. The axis of motion passes dorsal, medial, posterior (enters the medial aspect
of the talonavicular joint) to plantar, lateral, anterior (exits third metatarsal-
lateral cuneiform area
ii. It angles approximately 45° to both the frontal and sagittal planes and
slightly from the transverse plane. It is a triplanar axis, with most of the motion
in the sagittal and frontal planes in a 1:1 ratio
iii. When the first ray dorsiflexes, it inverts and when it plantarflexes it everts.
For every degree the first ray dorsiflexes it also inverts 1°. The first ray axis is
now a pronatory axis. The ankle, STJ, MTJ (longitudinal and oblique) and fifth
ray all possess pronatory-supinatory axes. The 2nd, 3rd, and 4th rays as well
as the digital IPJ's are all uniplanar and produce sagittal plane motion only
 NOTE* The digital MPJ's contain 2 axes, a transverse and a vertical. While the
vertical axis allows for transverse plane motion, it is the transverse axis which
allows for dorsiflexion/plantarflexion to occur. The transverse axis moves in a
dorsal-proximal direction with MPJ dorsiflexion. The first MPJ must allow for
65% of joint dorsiflexion. The joint acts as a ginglymus joint for the initial 25°
of dorsiflexory motion, and acts as arthrodial joint with the first metatarsal
plantarflexing for and MPJ dorsiflexion after the Initial 25°
iv. The average ROM is 5 mm for dorsiflexion and 5mm for plantarflexion

NOTE* The term "degrees of freedom" refers to the number of axes a joint has.
While the ankle and most joints of the foot have one degree of freedom, the
MPJ's and the MTJ each have 2 axes and thus 2 degrees of freedom

g. Fifth ray: Consists of the 5th metatarsal

i. It has an axis of motion from proximal inferior, lateral to distal, superior

medial and angles to all body planes
ii. It angles 20° from the transverse plane and 35° from the sagittal plane,
therefore exhibiting triplane motion. The degree of sagittal and frontal plane
motion is large, and transverse plane motion is minimal
iii. When the 5th ray dorsiflexes it also everts and abducts (pronatory axis)
h. Lesser rays: The central 3 rays along with the IPJ's, have axes that are
parallel with the frontal and transverse planes, therefore will have motion only
in the sagittal plane
Angular and Axial Deformities of the Lower
Extremity in Children
1. Definitions:
a. Torsion: is the twisting of a long bone on its longitudinal axis
b. Rotation is an axial change in the limb due to changes at the joint
c. Anteversion is an anterior axial change in the femur with relation to the head
and neck to the distal condyles (refers to rotational and positional changes of
the limb at the hip)
d. Antetorsion (femoral): Refers to twists in the axis of bone. It is a twisting of
the head and neck of the femur on its own body axis while the portion of the
femur on its own body axis entering Into the knee joint area remains (more or
less) in a fixed position, lining up with the lower leg

NOTE* Normally, antetorsion at birth is approximately 390, and eventually

untwists to 12°
NOTE*
by adulthood.
While the Ifbony
antetorsion
femur isisuntwisting
greater than
after
it should
birth, there
be is a simultaneous
(femur does not
inward
untwist
rotation
enough),
of the
then
thigh
we(anteversion)
have one of thein the
factors
region of the hip. The bony
influenceing aexternal
pigeontoe
twisting
gait (torsion) is being neutralized by the inward rotation of the
thigh to align the extremity for forward progression

e. Retroversion: Is a lack of normal torsion in the femur, less than normal by

10-12°

2. Axial Deformities:
a. Tibial torsion: Normally 18-23° (external) in the adult. Measured by malleolar
torsion which is 5° less
i. Etiology: Soft tissue origin? osseous origin ?
ii. Treatment: The decision whether to treat or not is determined by the degree
of the deformity (if any), and the age of the child. In the infant with rigid tibial
torsion, serial-above knee casting is effective, followed by maintenance with a
Ganley splint or D-B bar

NOTE* The actual amount of tibial torsion cannot be measured, so therefore we

measure malleolar torsion. From birth to 1 year it measures 0° to 10° (external),
1 year to 5 years it measures 8°to 13 ° (external), and 6 years to adult it
measures 13-180 external torsion

3. Femoral torsion:
a. Anteversion (medial femoral torsion): Is an axial deformity within the neck
and shaft of the femur, resulting in a medial functioning knee
i. Normal femoral alignment at birth is approximately 35-40° of anteversion,
which gradually derotates to the adult alignment of 12-15°
ii. Any delay in this progression should be considered abnormal and treated
owing to positional imbalance caused by soft tissue constraints and the
adaptability of the epiphysis to external forces. It is usually seen is the older
female child and manifested by the "reverse tailor's" sitting position
iii. With this, there is a persistent medial effect of the femoral growth plate
iv. Examination reveals excessive medial angle of the femur associated with a
limited lateral range of motion suggestive of femoral anteversion
v. Treatment:
 In the older child who presents with a knock knee conformation and who,
on examination, shows excessive medial femoral ROM, treatment initially
consists of change in sitting habits
 Later (if necessary) a Ganley femoral derotation splint (this splint is of
benefit in the 4-8 year child with excessive medial ROM)
 In true persistent osseous anteversion in the older child a femoral
derotation osteotomy or epiphyseal stapling may be necessary

NOTE* The treatment approach to femoral problems has been difficult since any
splinting device attached to the feet or legs is nullified once the knee flexes

b. Retroversion (lateral femoral torsion): Felt to be a continuation of lateral

rotated position of the femur in infancy. Lateral ROM is excessive. Often found
in females, usually obese with heavy thighs. The gait effect is knock-knee

4. Angular deformities:
a. Knock knee (genu valgum): An angular problem found more often in the
obese female child, it also may be associated with coxa vara, and is often the
visual result of the proximal axial problems of medial and lateral femoral
torsion. These changes are often associated with torsional changes of the lower
leg and valgus foot deformity. Depression of the lateral tibial condyle in
persistent knock-knee in the older child may also lead to soft tissue strain often
reflected as quadriceps and calf pain. This can lead to DJD in the adult

i. Etiology:
 Physiologic
 Medial femoral torsion
 Lateral femoral torsion
 Anteversion syndrome (Kleiger)
 Trauma: microtrauma (Hueter-Volkman law of epiphyseal response to
pressure states that increased pressure across the epiphyseal plate will
decrease the rate of growth), direct trauma, infection
b. Bowleg (genu varum): May, be associated with coxa valga
i. Types:
 Physiologic: noted at birth
 Rickets: result of vitamin D deficiency causing a disturbance in the
metabolism of phosphorous and calcium
 Osteochondritis deformans tibiae (Blount's disease): an angulation is
noted only at the proximal tibia causing a characteristic "beaking" of the medial
tibial plateau. This disease shows fragmentation of the proximal tibial
metaphysis and may not become evident before 24-30 months of age.
Additionally, infants with a metaphyseal-diaphyseal angle of 110 or greater
(created from the intersection of a bisection of tibial and a bisection of the
femur) will eventually develop Blount's disease

Anatomy of Gait: Phasic Activity of Muscles

The human body has evolved bipedalism as the most efficient means of
locomotion. Bipedal gait is a repetitive sequence of alternating movements of
the lower limbs; one complete sequence represents a gait cycle
1. Subdivisions of the gait cycle:
a. Stance phase (62% of gait): The period of ground contact and weight support
of the foot
i. Contact period (27% of stance and 17% of the entire gait cycle): initiated by
heel strike, the fully dorsiflexed foot Is lowered to the ground as the body moves
from a posterior position to one more directly over the foot. The key locomotor
events of contact are:
 Subtalar joint pronation (for shock absorption) which is normal pronation
 Subtalar supination (closed chain, begins at the end of contact)
 Internal rotation of the leg and femur (concurrent with STJ pronation)
 Full loading of the metatarsus is completed by the end of contact
 Peak vertical ground reactive forces occur for the first time at the end of
contact (the first of the two periods where the ground reactive force rises above
body weight during late contact phase
 The foot functions as a mobile adaptor in contact
 Internal leg rotation initiates STJ pronation
 At the end of contact the STJ begins supinating and it is initiated
primarily by the posterior tibial and is aided somewhat by the other calf
supinators and leg external rotators
 NOTE* At the beginning of weightbearing, during the entire contact period, the
STJ pronates in order to make the foot more flexible and, as such, a better
mobile adaptor to variances in terrain.

ii. Midstance period (40% of stance): Foot flat begins midstance, when it singly
bears the body weight (single support), and the alternate foot is in the swing
phase. The key locomotor events of midstance are:
 Conversion of the foot from a mobile adaptor to a rigid lever for
propulsion. The primary condition for a rigid lever to occur is STJ supination
(when this does not occur you have all types of problems (i.e. flatfoot). This
leads to a poor propulsive unit
 A decrease in vertical ground reaction force to about 75% of body weight,
but begins to increase again prior to heel lift
 Continued external leg rotation
 The contralateral limb is in swing phase
 STJ supination as a result of external leg rotation and the supinating calf
muscles (especially the posterior tibial and swinging limb). The foot passes
through STJ neutral shortly before heel lift. From this point on, the STJ is
supinated

NOTE* During midstance the STJ is still pronated but starts supinating to convert
the foot to a rigid lever

iii. Propulsive period (33% of stance): Continuation of the forward shifting body
results in heel lift and the initiation of the propulsive period, whereby the
weight is shifted to the forefoot and at the end, opposite foot regains contact
with the ground by heel strike. The key locomotor events of propulsion are:
 Continued STJ supination which increases skeletal rigidity and creates a
rigid lever
 Continued external leg rotation
 Second peak vertical ground reaction force (about 125% of body weight)
 Shift of forefoot weightbearing from lateral to medial
 The opposite foot begins to bear weight just after lateral to medial shift
and by toe-off the opposite foot is in full contact phase

b. Swing phase (38% of gait): That portion of the gait cycle when the foot is off
the ground. During swing the foot pronates first and then supinates. The key
events of swing phase are:
 During swing, the foot is transported from one step to the next
 The leg continues to externally rotate momentarily after toe-off. Then it
begins an internal rotation during the swing
 Pronation of the foot to aid ground clearance and then resupination to
prepare for contact
 Ankle joint dorsiflexion, and hip/knee flexion to shorten the length of the
leg (there would be a tremendous amount of pelvic motion during gait if there
were no mechanisms to flex and shorten the leg length)

c. Double support: Both feet are in ground contact at the beginning and end of
each stance phase in the walking gait. Both feet are on the ground 25% of the
gait cycle (0-12% and then again from 50-62% of the entire gait cycle)

NOTE* In running gaits, the swing phase proportionally increases in duration, an

instead of stance phase overlap, the limbs overlap in off-ground motion in a
period of float; i.e. there is no double support phase during running, also there is
an airborne phase with no ground contact and there is never more than one foot
in ground contact at one time

2. Hip and knee motion:

a. Motions in gait: At toe off, both the hips extended and knee is flexed while
the limb Is posterior to the body. At heel strike the hip is flexed, the knee
extended and the limb forms a lever for the movement of the body onto the heel.
During stance the limb extends at the hip as the body moves over the
stationary foot. Internal rotation of the limb continues from swing phase into
the contact period of stance. In midstance, the limb begins external rotation as
the opposite side of the pelvis and hip shift forward and medially rotate during
swing phase of the opposite limb b. Swing phase muscle action:
i. Hip flexors:
 The primary flexor of the hip is the iliopsoas which is activated shortly
after toe off: it is comprised of the iliacus and the psoas major to form a
common muscle belly
ii. Hip stabilizers and rotators: In swing phase, the hip on- the swing side has
lost support from the ground; it needs to shift body weight medially to the
stance limb and to resist downward tilt. The unsupported hip, therefore, needs
greater muscular stabilization in swing phase than it does when supported in
stance
 Transverse stabilization of the unsupported hip is produced by the
erector spinae on the swing side
 The hip abductors (gluteus medius and minimus) pull down the pelvis on
the supported side, and lift and level the pelvis op the swing side. Their primary
function on the swing side is to abduct the-thigh
 The medial hip adductors (adductor longus, adductor brevis, adductor
magnus, and pectineus), stabilize the hip and thigh (with the abductors) in
both stance and swing, and they contribute to flexion, extension, and internal
and external rotation of the hip
iii. Knee extensors:
 The quadriceps femoris (rectus femoris, vastus medialis, vastus lateralis,
vastus intermedius) is a biarthrodial muscle acting on hip flexion and knee
extension at the same time. The quadriceps is the only extensor of the leg, and
in the walking gait, extends the leg near the end of swing (this extention is
decelerated by the hamstrings (semimembranosis, semitendinosis, biceps
femoris)
iv. Knee flexors and hip extensors:
 The hamstrings, prior to heel strike, exert a flexor force on the leg,
decelerating ongoing extension, and extend the hip in early stance. The
semimembranosus and semitendinosus medially and biceps femoris laterally,
are synergists of each other in stabilizing rotation at the knee at heel contact.
The hamstrings also stabilize both the hip and knee joints at heel strike

NOTE* The gluteus maximus (the largest and most powerful of lower extremity
muscles) contributes to hip extensor stabilization

c. Stance phase muscle action: In the contact period, those muscle groups that
decelerated and stabilized these joints at heel strike continue to perform these
functions until the foot achieves full foot support. At midstance most of the
weight-support functions are managed by bone and ligament, requiring little
primary muscular action. As. the body moves over the standing foot, the limb
externally rotates in all segments down to the ankle. This rotation is a reaction
both to subtalar supination and to medial rotation of the opposite limb swing
phase. After the stance limb passes beneath the hip joint, the hamstrings are
again activated to help extend it

3. Ankle motion:
a. Motions in gait: Functions on a pronatory/supinatory joint axis with the
majority of motion consisting of sagittal plane dorsiflexion and plantarflexion.
Any rotation of the leg carries the talus with it when the foot is off the ground,
and any subtalar action involving the talus affects leg rotation when the foot is
weight bearing
b. Dorsiflexors: Dorsiflexion occurs from late contact to the propulsive period,
whose action is the result of kinetic forces of the body moving over the limb.
The 4 anterior crural tendons pass anterior to the transverse axis of the ankle
joint, and therefore dorsiflex the ankle. Distally, the tendons pass to either side
of the subtalar and midtarsal joint axes where the tendon passing medially
(tibialis anterior) exerts an inverting force, supinating the STJ and MRJ axes.
The tendons passing laterally (EDL, peroneus tertius) exert an everting force
(these apply a pronatory force to the STJ and MTJ longitudinal axes). The
anterior crurals function mainly during swing to dorsiflex the foot to clear the
ground. The toe extensors begin to act at the end of the propulsive. period,
when they help stabilize the toes. They are joined by the tibialis anterior and
peroneus tertius, and together lift. the foot at toe off. After heel strike, they
decelerate the foot while it is lowered to the ground.

NOTE* The tibialis anterior is the main dorsiflexor because of its insertion at the
base of the first ray, and acts together with the EHL in elevating the first ray
and hallux above the groung during swing (its insertion is also medial to the
STJ and MTJ axes making it an effective supinator, and invertor during
dorsiflexion)
 NOTE* Summary of anterior aural function: They become active at toe-off to
dorsifex the foot. They remain active throughout swing, and show a peak
activity at heel strike as they decelerate the forefoot as it strikes the
ground. They are active for the first 10% of stance
c. Plantarflexors: Consist of 6 muscles divided into superficial and deep groups
(superficial: gastrocnemius, soleus, plantaris) (deep: tibialis posterior, FDL,
FHL). The tendo Achilles passes 2 cm posterior to the STJ axis giving it
more leverage to act on the ankle than any other muscle (supinates the ankle).
The combined action of the triceps surae (2 heads of the gastroc and the
soleus.) together with the deep plantarflexors, produce 4 times as much power
as the combined dorsiflexors, and mainly act on the fully loaded limb in single
support. The tibialis posterior is the strongest invertor and adductor of the foot.
The plantarflexors begin to function in the contact period and continue through
midstance and into propulsion. They act to decelerate the momentum of the
body as it moves across the fixed foot dorsiflexing the joint. The gastrocnemius
also resists hyperextension of the knee prior to heel lift

NOTE* Summary of posterior aural function: The, triceps surae are active during
the middle of stance phase. They begin to fire during contact and terminate
during propulsion in order to achieve heel-off

4. Tarsal joint motion:

a. Motions in gait: The definitive feature of the contact period is progressive
loading of the foot from its initial contact at the heel, along the lateral border, to
full foot support. At this stage, the foot is undergoing pronation, and the leg
continues to rotate internally. These joints are characterized by their flexibility
(if the MTJ is unlocked, the 1 st ray is not stabilized). By midstance, the weight
is progressively more medially distributed as the body center of gravity
continues to move over it. From the lateral border of the foot, weight is shifted
medially along the metatarsal heads. The stresses on the foot now require
rigidity in tarsal structure to transfer weight to the forefoot. As the STJ begins
to supinate, the leg, with the hip and the thigh, externally rotate. This
supinatory process involves the windless effect as the foot proceeds through
propulsion.
b. Tarsal stabilizers: In midstance, the soleus, gastrocnemius, and tibialis
posterior are the prime movers to supinate the foot with concurrent external
rotation of the leg. The peroneus brevis and longus (lateral crural ms.) are
inactive in the contact period and only begin to act well into midstance and
early propulsion. The peroneus brevis is the prime evertor (pronator) of the foot.
The peroneus longus exerts a force on the first ray, pressing the first metatarsal
to the ground as well as on the intervening tarsals. The combined result is a
compact tarsus. The continuing secondary action of the soleus and supinating
tendons from the posterior compartment, maintain pressure on the lateral
border of the foot. This maintains a fixed position of the cuboid, which acts as a
pulley for the peroneus longus tendon. At the end of midstance, the heel is
lifted, and the cuboid is released, permitting the peroneus longus to act more
directly on the 1st ray as body weight is lifted from the lateral metatarsal heads
5. Forefoot motion:
a. Motions in gait: Stability in the forefoot begins to develop in the latter part of
midstance when the foot is supinating, the MTJ is locked, and the tarsal and
metatarsal bones are in a close packed position. At heel lift, the foot forms a
lever from the plantarflexing ankle joint to the met heads that form its fulcrum.
The MPJ's are transversely stabilized while the toes are firmly braced against
the ground forming a stable platform for the fulcrum. The loaded extension at
these joints activates the windless effect of the plantar fascia, which is
stretched by its attachment to the MPJ and hallux

b. Extrinsic muscle action. The FHL continues to act almost until toe off as the
hallux is the last part of the foot to leave the ground and requires a longer
period of stabilization than do the lesser toes. The tibialis posterior and the
peroneals compress the metatarsal bases as well as the tarsal bones. The
peroneus longus stabilizes the 1 st ray through the propulsive period

c. Intrinsic muscle action: The main function of the intrinsic muscles of the foot
is to transversely and axially stabilize the digits against the metatarsal heads
and against ground reaction forces. All intrinsic muscles begin to contract in
midstance and most continue throughout the propulsive period. Transverse
stabilization of the toes is accomplished by the plantar and dorsal interossei.
The dorsal interossei are bipennate and 4 in number, originating from the
corresponding adjacent sides of their respective intermetatarsal spaces. The
first dorsal interosseous attaches medially into the base of the proximal
phalanx of the second toe while the 2nd, 3rd, and 4th attach laterally into
digits 2, 3, and 4. The plantar interossei are unipennate. These three muscles
attach medially into the 3rd, 4th, and 5th digits and originate from the medial
aspect of their respective metatarsals. Their combined action resists
displacement of the toes to either side. Transverse stability of the hallux is
provided by the abductor hallucis on one side and adductor hallucis on the
other side. The abductor digiti minimi mimics the function and attachment of
the dorsal interosseus on the lateral side of the 5th toe. The FHB, FDB and
flexor digiti minimi brevis act synchronously with the long flexors, stabilizing
the toes against the ground. The flexor digiti minimi brevis attaches laterally
into the 5th toe, as a unipennate muscle and functions with the interossei to
provide transverse plane digital stability. The interossei are stance phase
muscles and function to plantarflex the MPJ's against the retrograde
dorsiflexing buckling force that accompanies the FDL and FDB contraction. The
axial tension of the FDL is aided by the quadratus plantae. The lumbricals are
4 muscles originating from the medial aspect of the corresponding FDL slip,
and attaching medially into the base of the extensor hood of the lesser toes, as
they pass plantar to the deep transverse metatarsal ligament. These have been
described as swing phase muscles, stabilizing the MPJ's plantarly while
assisting in extending the PIPJ's and DIPJ's, limiting excessive swing phase
contraction. This provides a stable insertion to allow the EDL to be an
important dorsiflexor of the ankle during swing phase of gait
 NOTE* The greatest combined effect of all these muscles is achieved in
conjunction with the extensor expansion mechanism, which links the
IPJ's & the MPJ's
NOTE*in Summary:
each toe soThethat
abductor
tensiondigiti
on theminimi
long and
extensor
EDB become active at about
extends a row30%
of digital
of stance,
joints
theatFHB,
a time
abductor hallucis, and FDB become active at about
40%, 50% and 60% of stance respectively, and the interossei become active at
about 25% of stance. Activity of all these muscles ceases near toe-off

d. Muscles acting on the 1st ray and hallux: During supination in the
midstance period, the peroneus longus is uniquely significant in plantarflexing
the 1st ray. The FHL assists in supination during the earlier part of midstance,
plantar stabilization of the, metatarsal head together with the action of the
peroneus longus, and stabilization of the hallux in propulsion

6. Summary of joint motion during gait:

a. Hip joint motion-sagittal plane:
i. Contact: hip extends from flexed position
ii. Midstance: hip continues to extend
iii. Propulsion: hip flexion

b. Hip joint motion-transverse plane:

i. Contact: internal rotation of the thigh in the pelvis, corresponding to internal
leg rotation with STJ pronation
ii. Midstance and propulsion: external rotation of the thigh on the pelvis

c. Knee joint motion sagittal plane:

i. Contact: flexion (the major shock absorbing mechanism of the body)
ii. Midstance: body weight passes over the knee, so there is extension
iii. Propulsion: the knee flexes again for pushoff

d. Knee joint motion-transverse plane: Corresponds to supination and

pronation in the STJ
i. Contact: with STJ pronation comes internal rotation of the tibia
ii. Stance: external rotation of the tibia on the femur

e. Ankle joint motion-sagittal plane:

i. Contact: plantarflexion until midcontact
ii. Late contact to midstance: dorsiflexion
iii. Propulsion: plantarflexion

f. Subtalar joint motion:

i. Contact: pronation
ii. Midstance and propulsion: supination

g. Midtarsal joint motion: There are 2 separate axes

Longitudinal axis Oblique axis
i. Contact: Supinated Pronated
ii. Midstance: Fully pronated by heel lift* Pronated
Ill. Propulsion: Remains pronated and locked Supinates
 NOTE* Longitudinal axis pronation during midstance* is very important for
normal propulsion. Negative plaster casts are taken of the feet with the
longitudinal axis of the MTJ in pronation
Observation of Gait
1. Stance phase:
a. Posterior view:
i. Contact:
 Heel contact is inverted but rapidly everts
 Contact is slightly lateral to the midline of the heel
i. Midstance:
Posterior bisection of the posterior of the heel goes from everted to vertical
i. Propulsion:
 Posterior bisection of the heel inverts as heel lifts

b. Lateral view:
i. Contact:
 Posterior portion of the heel strikes the ground with the foot dorsiflexed
on the ankle
 Plantarflexion of the ankle begins slightly after contact
 At contact the knee is extended and flexes rapidly for shock absorption
ii. Midstance:
 Ankle dorsiflexion of 5°-10° as the body weight passes over the planted
foot
 Knee returns to full extension
 Late midstance heel lifts as the trunk passes over the planted foot,
literally peeling the heel up from the floor
iii. Propulsion:
 Ankle plantarflexes to facilitate toe-off
 Knee flexion as the trunk advances further

c. Anterior view:
i. Contact:
 Forefoot is markedly inverted as the heel contacts the ground
 Leg is slightly inverted
ii. Midstance:
 Forefoot has everted bringing the metatarsals to the ground. The forefoot
is loaded 5-4-3-1-2 or 5-4-3-2-1- depending upon the metatarsal length and
muscle functioning
 Leg is slightly internally rotated
iii. Propulsion:
 Marked dorsiflexion of the MPJ's
 Lateral digits lift-off first
 Body weight passes through the center of the hallux
 Leg externally rotated
2. Swing phase:
a. Lateral view:
i. Trunk muscles advance the leg forward
ii. Ankle dorsiflexion to decrease leg length
iii. Hip and knee flexion to assist in shortening

Subtalar Joint Measurements

1. Open kinetic chain measurement and neutral position calculation: In
the non-weightbearing patient, the bisection of the posterior distal 1 /3 of the
leg is the point from which calcaneal inversion and eversion are measured.
a. Example 1: The calcaneus can evert 80 from the leg bisection and invert 22°
from the lebisction. The total STJ ROM is 30°

To find the neutral position of this STJ we need to find the point from which
there is twice as much supination as there is pronation. In this case the
neutral position is 2° inverted, as from this point there is 100 of pronation and
20° of supination available

Total STJ ROM X 2= Inversion from neutral position

3
Inversion from the leg -MINUS- Inversion from neutral= Neutral position

30°(total ROM) X 2= 20° 22°(inversion from leg)- 20°= 20 varus

3
b. Example 2: Calcaneal inversion= 32°, calcaneal eversion= 7°, total ROM= 39°
39°+ 3 x 2= 26° inversion from neutral, 32°-26°=6° varus

NOTE* Another method for calculation is: Total ROM- Eversion = Neutral
3 2.
If the resulting number is (+), then there is a varus or neutral position
If the resulting number is (-), then the resulting number is valgus or neutral
Closed kinetic chain measurement and neutral position calculation:
a. Example 1:
Maximum calcaneal inversion 12° (right), 150 (left), maximum calcaneal
eversion 6° (right), 3° (left), tibial varum 1 ° bilaterally
i. To calculate neutral position: Total ROM 18° bilaterally
18+ 3 x 2= 12° 12°- 12°= 00 (right), 15°- 12°= 30 varus (left)

ii. To calculate NCSP: Add the tibial varum component to the neutral position
measurement
Tibial varum is 1 ° (left) + 30 varus (left)= 40 rearfoot varus (left)
Tibial varum is 1 ° (right) + 0° (right)= 1° rearfoot varus (right)

iii. To calculate the RCSP: Since these values indicate a rearfoot varus
component, this individual will compensate at the STJ to bring the calcaneus
perpendicular to the ground, by using all STJ pronatory ROM that it needs (the
pronatory ROM of the STJ is 1/3 the total ROM or 6°).
On the right the NCSP= 1° varus so the RCSP= 0°
On the left the NCSP= 40 varus, so the RCSP= 0° (using 2/3 available pronatory
ROM)

b. Example 2:
Maximum calcaneal inversion 16° (right), 15° (left), maximum calcaneal
eversion 2° (right), 3° (left), tibial varum 30 (right), 2° (left)
i. Calculate the neutral STJ position:
Total ROM (right)= 18° Total ROM (left)= 18°
18-3 x 2= 12° (bilateral) inversion from neutral
16°- 12°= 40 varus (right), 15°- 12°= 30 varus (left) neutral position

ii. To calculate the NCSP:

Tibial varum 3° (right) + 4° varus neutral (right)= 7° rearfoot varus NCSP (right)
Tibial varum 2° (left) + 3° varus neutral (left)= 50 rearfoot varus NCSP (left)

iii. To calculate the RCSP: Know that 1/3 the total STJ ROM is 6°. 7° rearfoot
varus (right)- 6° (1/3 available pronation)= 1° RCSP (right)
5° rearfoot varus (left)- 6° (1/3 available pronation)= 0° RCSP (the STJ still has
1° more of available compensatory motion left)
 NOTE* Forefoot varus is compensated (mostly) by STJ pronation, and minimally
by some MTJ pronation. If the amount of forefoot varus is 3° or less, the STJ will
only compensate that sped lc number of degrees. lf, however, the forefoot varus
is greater than 3° the STJ will (usually) maximally pronate to the end of its
ROM. Therefore it will pronate more than the number of degrees required to
bring the forefoot's medial surface into contact with the ground. The reason the
STJ maximally pronates with a forefoot varus deformity greater than 3° is that
once the calcaneus is everted more than 3° the force of the body's weight
pushes it to the end of the STJ's pronatory ROM. If, however, the STJ cannot
completely compensate the forefoot varus deformity, then and only then will the
MTJ pronate to help with the compensation (on the longitudinal axis), leading to
first ray dorsiflexion and inversion

NOTE* In a rearfoot valgus greater than 2° the body weight on the everted
calcaneus will cause the STJ to pronate to the end of its ROM. A rearfoot valgus
of less than 2° does not change the STJ position from the NCSP. If a greater
than 10° rearfoot valgus exists, the head of the talus will usually plantarflex
toward the ground before the STJ completely pronates. While this produces a
severe flatfoot, the STJ may not be pronated to the end of its ROM

Subtalar Joint Function

During the gait cycle, the STJ functions during the weightbearing (closed
kinetic chain) and nonweightbearing portions (open kinetic chain).
1. Open kinetic chain (OKC):
a. During the 1st half of the swing phase, the STJ pronates, and during the last
half of swing the STJ supinates
b. In OKC function, the STJ pronatory and supinatory components are
exhibited exclusively by the calcaneus (with OKC pronation, the calcaneus
abducts, everts, and dorsiflexes)
c. In OKC motion, the calcaneus moves around the talus, which functions as
an immobile extension of the leg

2. Closed kinetic chain (CKC):

a. In CKC the STJ motion, the calcaneus and talus both move, the calcaneus
moves only in the frontal plane (inversion and eversion), and the talus moves in
the transverse and sagittal planes

NOTE* The bones of the STJ move around the STJ's axis of motion, and if any
motion takes place in a bone which is proximal to that axis, the motion will be
in the opposite direction of the named major motion.

b. In CKC STJ pronation, the calcaneus will still evert, but the talus will
plantarflex and adduct
c. In CKC STJ supination, the calcaneus will invert and the talus dorsiflex and
abduct (the talus abducts and dorsiflexes because it is proximal to the STJ joint
axis) (transverse plane talar excursion reflects the transverse plane movement
of the leg)

NOTE* During the contact period (STJ pronation) the calcaneus is everting, while
the talus is plantarflexing and adducting. During midstance and propulsion the
calcaneus is inverting while the talus abducts and dorsiflexes (STJ supination)

d. Internal rotation of the tibia is associated with CKC STJ pronation, and the
converse is true with CKC STJ supination

e. The 2 major functions of CKC pronation are shock absorption and adapting
to uneven terrain

3. Measurement of STJ motion:

a. There is really no good way to measure STJ motion in all 3 planes, therefore,
the frontal plane motion of the calcaneus is used as an index of STJ motion (a
bone distal to the STJ axis)
b. From the STJ neutral position, the normal foot can supinate twice as
much as it can pronate. The average total ROM for the STJ is about 30° of
calcaneal frontal plane motion (minimum normal STJ ROM is 8-12° for normal
ambulation)

Midtarsal Joint Function

Although triplane motion occurs about both the MTJ axes, some planes of
motion are so small as to be clinically insignificant
1. MTJ function:
a. Motion about the longitudinal axis will occur primarily in the frontal plane
(inversion and eversion)
b. The oblique axis allows primarily for sagittal and transverse plane motion

NOTE* Since 2 planes of motion occur about the MTJ oblique axis, it is necessary
to know which motions are coupled. As the axis is a pronatory/ supinatory axis,
the following occurs by necessity:
a. With plantarflexion: adduction also occurs
b. With dorsiflexion: abduction also occurs
 NOTE* The MTJ's total ROM is dependent upon the STJ's position. The axes of the
articular facets are just about parallel when the STJ is maximally pronated. This
allows for a certain congruity to the 2 joints (T-N and C C joints). As the STJ goes
from a maximally pronated position toward a more supinated position, the axis of
the 2 joints progressively diverge from one another, congruity is lost, and with it
ROM decreases

c. The MTJ longitudinal axis has an average ROM of 4°-6° (ROM of the oblique
axis is unknown)

d. When the STJ is maximally pronated, the MTJ's ROM is increased and the
forefoot becomes mobile. When the STJ is maximally supinated the MTJ's ROM
is decreased and the forefoot inverts with the rearfoot