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More than you ever wanted to know about the foot. MAJ Joel L. Shaw Sports Medicine 24 May 2007. Overview. Describe foot and ankle joints Joint actions during running Related pathology How to prescribe running shoes. Foot function. 1. Accept vertical forces during heel strike

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More than you ever wanted to know about the foot l.jpg

More than you ever wanted to know about the foot

MAJ Joel L. Shaw

Sports Medicine

24 May 2007

Overview l.jpg

  • Describe foot and ankle joints

  • Joint actions during running

  • Related pathology

  • How to prescribe running shoes

Foot function l.jpg
Foot function

  • 1. Accept vertical forces during heel strike

  • 2. Absorb and dissipate these forces across a flexible mid- and forefoot during pronation

  • 3. Provide propulsion as the foot becomes a rigid lever with resupination and toe-off

Articulations l.jpg

  • Subtalar

  • Talocalcaneonavicular

  • Calcanealcuboid

  • Midtarsal

  • Tarsometatarsal

  • Metatarsophalangeal

  • Interphalangeal

Subtalar l.jpg

  • Triplanar

    • Supination vs. Pronation

  • Bones: inferior talus, superior calcaneus

  • Alternating concave-convex facets limit mobility

  • Ligaments- talocalcaneal, interosseous talocalcaneal, cervical

Subtalar joint l.jpg
Subtalar joint

  • Supination

    • Inversion by calcaneus

    • Abduction by talus.

    • Dorsiflexion by talus

  • Talar abduction causes external rotation of the tibia

  • Position of most stability

Subtalar joint7 l.jpg
Subtalar joint

  • Pronation

    • Eversion by calcaneus

    • Adduction by talus

    • Plantarflexion by talus

  • Talar adduction causes internal rotation of the tibia

    • May increase Q angle

  • Increased flexibility and shock absorption

Subtalar joint8 l.jpg
Subtalar joint

  • Clinical significance

    • Mobility

    • Shock absorption

    • Stability

Midtarsal joint l.jpg
Midtarsal joint

  • Functional joint- includes talonavicular and calcaneocuboid joint

  • Triplanar supination/pronation- primarily DF/PF and abd/add

  • Navicular- highest point of medial arch

Midtarsal joint10 l.jpg
Midtarsal joint

  • Assist pronation/supination of the subtalar joint

  • Maintain normal weight bearing forces on the forefoot

  • Control/communication between rear foot and forefoot

Metatarsophalangeal joint l.jpg
Metatarsophalangeal joint

  • Biplanar- mostly dorsiflexion/plantarflexion with 10 degrees of abduction/adduction

  • Dorsiflexion- allows body to pass over foot while toes balance body weight during gait

  • Plantarflexion- allows toes to press into ground for balance during gait

First ray l.jpg
First ray

  • Functional joint

  • Bones- Navicular, 1st Cuneiform, 1st Metatarsal

  • Plantarflexion at late stance to assist 1st MTP dorsiflexion

  • Peroneus longus and abductor hallicus brevis muscles

Plantar fascia l.jpg
Plantar fascia

  • Causes tension along the arch

  • Supination facilitated as arch heightened

  • Windlass effect

Windlass effect l.jpg
Windlass effect

  • Webster’s: machine for pulling a rope around a drum. Pulley system to lift anchor in a boat.

Windlass effect15 l.jpg
Windlass effect

  • Tension in the aponeurosis secondary to toe extension elevates the arch by acting as a pulley around which the aponeurosis is tightened.

Ligaments l.jpg

  • Spring ligament

    • Tension wire which helps maintain arch

    • Helps rigidity during propulsion

  • Long plantar ligament

  • Plantar aponeurosis

  • Short plantar ligament

Function of arches l.jpg
Function of arches

  • Stability

    • Distribution of weight

  • Mobility

    • Dampens shock of weight bearing

    • Adaptation to changes in support surfaces

    • Dampening of superimposed rotations

Running gait l.jpg

Stance phase

40% of gait cycle

2 phases



Swing phase

60% of gait cycle

2 phases

Initial swing (ISW)- 75%

Terminal swing (TSW)- 25%

Running gait

Running gait19 l.jpg

Double float

Stride length

Step length


Velocity=stride length x cadence

Running gait

Running gait20 l.jpg
Running gait

  • Kinematics vs. Kinetics

    • Kinematics- motion of joints independent of forces that cause the motion to occur

    • Kinetics- study of forces that cause movement, both internally and externally

      • Internal- muscle forces

      • External- ground reactive forces

Ankle foot kinematics l.jpg
Ankle/foot kinematics

  • Ankle joint

    • Dorsiflexion/plantarflexion

  • Foot joints

    • Triplanar

    • Pronation and supination

Running gait ankle kinematics l.jpg
Running gait- ankle kinematics

  • Absorption and midstance

    • Rapid dorsiflexion (response to increased hip and knee flexion)

    • Decreased plantarflexion in running decreased supinationcause of increased running injuries??

Running gait foot kinematics l.jpg
Running gait- foot kinematics

  • Subtalar motion determined by muscular activity and ground reactive forces

  • Midtarsal motion determined by subtalar position

Running gait midtarsal joint l.jpg

Calcaneus/talus supination

Increase midtarsal obliquity

Lock joint

“Rigid lever”

During propulsion and ISW

Calcaneus/talus pronation

Parallel midtarsal joints

Increased ROM

“Mobile adapter”

Mid stance

Running gait- midtarsal joint

Axis of transverse tarsal joint l.jpg
Axis of transverse tarsal joint

O'Connor FG, Wilder RP: Textbook of Running Medicine, McGraw Hill Companies, 2001. Page 13.

Running gait foot kinematics26 l.jpg
Running gait- foot kinematics

  • Absorption

    • Pelvis, femur, tibia internally rotate

    • Eversion and unlocking of subtalar joint

    • Pronation of midtarsal joints

      • Allows mobility and shock absorption.

      • Able to adapt to ground surface.

    • Plantar fascia- relax medial arch

Running gait foot kinematics27 l.jpg
Running gait- foot kinematics

  • Propulsion

    • Pelvis, femur, tibia externally rotate

    • Inversion/locking of subtalar joint

    • Supination of forefoot

    • Plantar fascia- increase medial arch stability and invert heel

    • Metatarsal break- promote hindfoot inversion and external rotation of leg

Running gait foot kinetics l.jpg
Running gait- foot kinetics

  • External forces- ground reactive forces

    • Vertical- 3-4 times body weight

    • Fore-aft- 30% of body weight

    • Medial-lateral- 10% of body weight

    • Newton’s third law

  • Internal forces- muscle forces

External forces l.jpg
External forces

  • Foot strike pattern

    • Forefoot Midfoot Rearfoot

Rearfoot striker l.jpg
Rearfoot striker

  • 80% of runners

  • Initial contact- posterolateral foot

  • Center of Pressure (COP)

    • Outer border of rear footprogresses along lateral borderthen across forefoot medially toward 1st and 2nd metatarsal head

Midfoot strikers l.jpg
Midfoot strikers

  • Most other runners

  • Initial contact- midlateral border of foot

  • COP

    • Lateral midfootprogresses posteriorly (corresponds to heel contact)rapidly moves to the medial forefoot

Evaluation of running injuries l.jpg
Evaluation of running injuries

  • Training log

  • Shoe examination

  • Arch appraisal

  • Gait analysis

  • Running shoe prescription

Training log l.jpg
Training log

  • Weekly mileage

  • Transition point

  • Increase in distance or intensity

  • Increase in mileage >10% per week

  • Change in terrain or running surface

Shoe examination l.jpg
Shoe examination

  • Current running shoes

    • Age (days and miles)

    • Replacement frequency

    • New brand or model? (change biomechanics)

Shoe examination35 l.jpg
Shoe examination

  • Outsole wear

    • Lateral heel vs. inside heel vs. lateral sole

  • Midsole wear

    • Heel counter tilt

    • Midsole wrinkling, tilt, or decomposition

Shoe wear l.jpg
Shoe wear

  • Based on foot strike pattern, initial contact, and center of pressure

  • Neutral gait

    • Wear on lateral aspect of heel

    • Uniform wear under the toes

Shoe wear37 l.jpg
Shoe wear

  • Overpronator

    • Excessive wear on medial portion of heel and forefoot

  • Underpronator

    • Excessive wear on lateral heel

    • Wear on entire lateral portion of the outersole

Arch appraisal l.jpg
Arch appraisal

  • Standing arch contour

  • “Wet test”

  • Static evaluation=running evaluation?

Biomechanical function l.jpg
Biomechanical function

  • Required functions of locomotion

    • Adaptation

    • Shock absorption

    • Torque conversion

    • Stability

    • Rigidity

Biomechanical assessment l.jpg
Biomechanical assessment

  • Video gait analysis

  • Always base on running gait, not arch height

  • Evaluate shoe wear

Gait analysis l.jpg
Gait analysis

  • Behind- location of heel strike, foot motion during single stance, foot engaged at push-off

  • Side- gastroc-soleus flexibility, great toe dorsiflexion

  • Treadmill-based analysis

  • Force plate analysis

Neutral gait l.jpg
Neutral gait

  • Level Heel Throughout Gait Cycle

  • 90 Degree Medial Angle Throughout Gait Cycle

Intrinsic abnormalities l.jpg
Intrinsic abnormalities

  • Pes cavus- abnormal supination

  • Pes Planus- abnormal pronation

Supination l.jpg


Late stance phase

Provides rigidity, support, propulsion

Facilitates lower leg external rotation


Minimal pronation at subtalar joint

Little drop of medial longitudinal arch


Abnormal supination signs l.jpg
Abnormal supination- signs

  • Lateral Leaning Foot Surface Placement

  • Inflexible Foot

  • Callus- 1st and 5th metatarsal heads

  • Clawing of 4th and 5th digits

Abnormal supinators l.jpg

Stable and rigid foot

Lacks flexibility and adaptability

Poor gastroc-soleus flexibility

Achilles tendonitis

Plantar fasciitis

Poor shock absorption

Tibial and femoral stress fractures

Abnormal supinators

Pronation l.jpg


Early in stance phase

Provides flexibility, adaptability and shock absorption

Facilitates lower leg internal rotation


Continues throughout stance phase


Mild overpronation signs l.jpg
Mild Overpronation- signs

  • Slightly Greater than 90 Degree Angle Throughout Gait Cycle

  • Medial Leaning Foot Surface Placement

  • Some Ankle Instability/ unstable position

Severe overpronation signs l.jpg
Severe overpronation- signs

  • Significant Medial Leaning of Surface Foot

  • Great Instability

  • Excessive internal tibial rotation

  • Increased medial stress

Overpronators l.jpg

  • Patellofemoral pain

  • Popliteal tendonitis

  • Posterior tibial tendonitis

  • Achilles tendonitis

  • Plantar fasciitis

  • Metatarsal stress fracture

Arch height will produce different levels of flexibility l.jpg
Arch Height Will Produce Different Levels of Flexibility

  • Normal feet:

    • are flexible as they grip the ground and become stiff at push off

  • Flat feet:

    • are flexible as they grip the ground and remain flexible at push off

  • High arched feet

    • are inflexible and do not adjust to terrain well, but provide a good base for push off.

Running shoe design l.jpg
Running Shoe Design

  • In an attempt to minimize injuries, running shoes need to provide:

    • Cushioning

    • Motion Control

    • Support

Anatomy of the running shoe l.jpg
Anatomyof the Running Shoe





Anatomy of the running shoe54 l.jpg
Anatomy of the Running Shoe

Heel notch

Lacing system


Heel counter


Anatomy of the running shoe55 l.jpg
Anatomy of the Running Shoe

Flex Grooves

Split Heel

Anatomy of the running shoe last curvature straight semi curved and curved l.jpg
Anatomy of the Running Shoe Last (Curvature)Straight, Semi-curved and Curved

Anatomy of the running shoe57 l.jpg
Anatomy of the Running Shoe

  • Lasts (Shoe Template)

    • Board

    • Slip

    • Combination

  • If you cannot remove insole, remove shoe…it is of poor quality

Stabilizing features l.jpg
Stabilizing Features

Support is added to the inside or medial portion of the heel to counteract the foot rolling inward (pronation)

Running shoe selection l.jpg
Running Shoe Selection

  • The three basic types of running gait based on ankle biomechanics are: over-pronation, neutral and underpronation

  • Shoes should be bought to accommodate your running gait, not your arch height!

Shoe prescription l.jpg
Shoe prescription

  • High arch- curve-lasted, cushion shoe

  • Flat arch- motion control or stability shoes with firm midsoles and straight to semi-curved lasts

  • Neutral arch- cushion or stability shoe

Orthotics l.jpg

  • Effectiveness

    • Gross, et al. 90% with symptom improvement

    • Schere. 81% with complete symptoms relief

    • Blake and Denton. Reduced pain associated with plantar fasciitis by 80%.

Orthotics62 l.jpg

  • Motion control

    • Control excessive pronation

  • Shock absorption

  • Pressure relief in specific area

    • Plantar heel or great toe metatarsophalangeal

  • Redistribution of forces away from area

    • Metatarsal pad for metatarsalgia/Morton’s neuroma

Orthotics63 l.jpg

  • Adjunct to rehab and training modification

  • Return athlete to full function

  • Prevent further injury

  • Functional orthoses

    • Alter foot function

    • Guide foot through stance phase

    • Promote biomechanical efficiency

Orthotics64 l.jpg

  • Start with soft temporary orthotic

  • Over-the counter prefabricated devices

    • Most athletes report improvement

  • Incomplete improvementcustom orthotic

High arch orthotic l.jpg
High arch orthotic

  • Dropped forefoot

  • Plantarflexed first metatarsal and forefoot valgus

  • Decreased subtalar range of motion

  • Plantarflexed first ray, unstable cuboid

  • Peroneal cuboid syndrome

Pronated foot orthotic l.jpg
Pronated foot orthotic

  • Flat medial arch

  • Unstable rearfoot and excessive motion of plantar calcaneal fat pad

  • Weak plantarflexion of first metatarsal head and weak “windlass” effect

Common mistakes l.jpg
Common mistakes

  • Only looking at standing gait

  • Failure to evaluate various needs of different runners

  • Need of different orthoses for running and everyday activity

Summary l.jpg

  • Understand normal foot biomechanics- pronation vs. supination

  • Evaluate with functional arch and shoe wear

  • Signs of abnormal arch

  • Match shoes and orthotics to running alignment- correct shoes and over-the-counter inserts first