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Pathomechanics Study Guide

Axes and Planes of Motion:


3 cardinal planes: frontal (inversion/eversion), sagittal (flexion/extension), transverse (abduction/adduction)
motion around an axis occurs perpendicular to that axis

1st ray (no phalanges): almost parallel to transverse plane


45 from frontal and sagittal planes, no transverse plane motion
inversion/eversion and dorsiflexion/plantarflexion (not a pronatory/supinatory joint)

5th ray: triplane axis


supination/pronation

central 3 rays, IPJs, MTPJs: parallel to frontal and transverse planes


only sagittal plane motion flexion/extension
(MTPJs also have dorsiflexion/plantarflexion about vertical axis)

Midtarsal Joint:
Longitudinal parallel to transverse and sagittal; frontal plane motion
Inversion/eversion
Oblique parallel to frontal; transverse and sagittal plane motion
Plantarflexion and adduction/dorsiflexion and abduction

STJ: triplane axis == supination (Dflex, Abd)/pronation (Pflex, Inv, Add) joint
Passes from post-inf-lat to med-ant-dor
16 from sagittal plane and 42 from transverse plane
most motion frontal and transverse, sag = least
2 bones (Tal, Cal), 3 Jnts (ant, post, mid articular facet)

Ankle: triplane axis


8 from transverse plane and 20-30 from frontal plane
supination/ pronation with most motion in sagittal plane
(trochlea of talus locked in ankle mortise)
most stable in dorsiflexion

Open chain Kinetics Swing Phase, all motion subtalar, talus locked in AJ (tibio-talar articulation)
pronation= Dorsiflexion, Abduction, Eversion
supination= Plantarflexion, Adduction, Inversion
Closed chain Kinetics Stance Phase, weight-bearing
Pronation = calcaneus Everts, talus Adducts and Plantarflexes (opposite)
Supination= calcaneus Inverts, talus Abducts and Dorsiflexes(opposite)

STJ neutral, MTJO and MTJL are oblique to one another


STJ pronated, MTJO pronated, MTJL supinated = parallel, unlocked, mobile adaptor
STJ supinated, MTJO supinated, MTJL pronated = very oblique, locked, rigid lever

Compensation:
Normal compensation is rxn to uneven terrain (SJT adapts)
Abnormal compensation is rxn to function abnormality and causes pathology

Hypermobility: excessive motion at joint; motion occurring when it should not

STJ neutral: STJ neither pronated/supinated, but allows for 2x as much supination as pronation

Leg length discrepancy is not normal

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Pathomechanics Study Guide
Gait Cycle
Contact Phase = time btw heel-strike of WB limb & toe off of contra-lateral [CL] limb
@ heel-strike Body weight [BW] = force is 15% greater than BW

Most important factor in dissipating shock is Pronation


Other factors = Calcaneal fat pad, knee menisci, knee flexion, trabecular bone, muscles

Forefoot contact- @ 10% of stance phase


In prep for heel-strike entire extremity internally rotates, however the knee is slightly flexed which
creates a slight external rotation of the tibia and foot relative to the femur. However, the pelvis and femur
continue to internally rotate as a whole.
STJ responds to internal rotation by pronating. Due to the leg internal rotation the talus aDducts and
plantar flexes, while the calcaneus everts. As a whole the entire foot dorsiflexes, everts & abducts.

When calcaneus hits the ground it is supinated 2-3 degrees. Total calcaneal frontal plane ROM = 6 degrees.
STJ pronation MTJO pronates lowers medial longitudinal arch
ROM of 1st ray ROM is 11* dorsiflexion & 11* plantarflexion = 22* TROM

End Contact/Midstance = toe-off of opposite limb


@ end contact foot is maximally pronated
**The external rotation of the weight-bearing limb ENDS pronation & INITIATES re-supination
***Peroneus Brevis is the strongest pronator of the foot
***Tibialis Posterior is the strongest supinator of the foot
Simultaneous firing of these two muscles stabilizes the STJ & MTJ
*we dont rely on TP for initiation of resupination

Event Summary leading from pronation to supination:


1. external rotation of WB limb
2. PL pulls down the 1st ray to transfer weight from lateral column to medial column, and pushes up the
arch b/c of windlass effect
-Windlass effect - results from plantar fascia tensing up, which results from digit dorsiflexion on the mets.
3. Toe break = shape of metatarsal parabola. The lateral angulation of the lesser mets encourages
supination of the foot when toes are dorsiflexed, which explains the supination of the foot right after toe-off
4. Hallux dorsi-flexion allows the met head to roll up onto the sesmoids, the abductor hallucis adds to
this force. This extends the 1st rays length to nearly the same length as the 2nd met.
5. *The Hoopshire maneuver (more of a gesture really) determines if the foot is flexible enough
to transition from pronation to supination. To do it, just pickup the 1st toe while the patient is weight
bearing. If the foot is flexible the arch height will increase.

Midstance begins with toe-off of opposite foot & ends at heel-lift of WB foot
When the STJ transitions from pronation to supination the STJ passes through neutral twice. The second
time (at around 50-60% of stance phase) its in neutral the thigh is exteed 10*, knee is fully extended & foot is
dorsiflexed on the leg 10*. **This is the only time the knee is fully extended in the whole gait cycle.

When Peroneus Brevis [PB] pulls at the insertion of the 5th met base, which pushes the cuboid into
calcaneus. The Soleus simultaneously pulls on the calcaneus, which creates an opposing force to the PBs effect.
In sum the forces compress the lateral column, thereby stabilizing it.
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Pathomechanics Study Guide
The Peroneus Longus [PL] requires the lateral column to be stable so that it can use it as a pulley to
plantarflex and evert the 1st ray. It also helps to PL redistribute weight medially and helps hold the foot in
supination.
Once the foot is supinated it is Momentum that initiates heel-off**.
Propulsion begins w/ heel-off, ends with toe-off
In order to propel forward the 5 segments of the forefoot must be locked, which is accomplished by
supination. This tightening effect stabilizes the independent 1st & 5th rays. The intrinsic muscles of the foot act
to maintain a locked position of the mets.
65* dorsiflexion of the hallux
Must achieve 65*
PL plantarflexes and stabilizes the 1st ray
As the 1st ray is plantar flexing the hallux dorsiflexes
Helps create the supinatory rigid lever
Plantar flexion of 1st ray, dorsiflex of hallux compreses hallux against 1st met
Forces the arch up and stabilizes the whole foot
PL plantar flexion keeps the forefoot on the ground during resupination
During the latter parts of propulsion the intrinsic musles take over
There force keeps the foot stable for propulsion
Sesamoid apparatus:
Tibial and fibular sesamoidal ligaments and collateral ligaments
Attached to head of the 1st met and held in position by intrinsic foot muscles
Also held in place by the cristae of the 1st met head
The 1st met using the sesamoids to extend its length
Therefore the 2nd met must be more distal or cant roll forces medially
A long fist met will cuse jamming of the 1st MPJ leading to hallux limit.

Hypermobility of the 1st ray


Pain in the ball of the foot
High 1st met put leaves too much pressure on lesser mets
Often 2nd met in painful

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Pathomechanics Study Guide
Phasic activity of muscles
Muscles can be stance phasic, swing phasic or Bi-phasic
Ex: TP tendon transfer to attempt to correct drop foot
The foot needs to dorsiflex during swing phase, however TP is stance phasic, so it cant actively
dorsiflex out of phase. TP is the strongest supinator of the foot, but now that its been moved,
there is no other muscle to oppose the PB (strongest pronator). This will lead to foot Valgus.
PL and PB can be used b/c they can change phase more easily.
PL is a better muscle to transfer b/c it planterflexes the 1st ray, and since TA isnt
working to dorsi-flex the 1st ray b/c it isnt working.

Antagonism: can occur in phase of out of phase


In phase: Muscles work simultaneously to stabilize a joint
TA, EHL, EDL, PT all dorsiflex but TA antagonizes the pronatory effects of the others.
PB and TP - PB strongest pronator, TP strongest supinator
When they fire together they stabilize the STJ and MTJ during contact to prevent
xs pronation. And during, midstance to prevent xs supination
Out of phase: Ex. Gastroc soleus and anterior crurals do opposite actions in different phases

Length tension ratio: A variation in length will affect muscle tension ability
Types of muscle contraction: Concentric shortening contraction
Eccentric - lengthening contraction used to decelerate
Isometric = no change in muscle length
Isotonic = no change in muscle force, but length changes
Muscle Groups:
Abductors: Gluteus medius & Gluteus minimus
Fire during contact at heel strike
Trendelenberg sign = weakness of abductors
If Hip dips 5 deg. towards one side then the Gluteus medius is weak on WB side
Adductors: Adductor magnus, brevis, longus, & Pectineus
WB limb Adductors fire at toe off of the opposite limb to pull/rotate the pelvis forward toward the WB
limb (essentially internal rotation of WB limb). They also cause internal rotation of the swinging limb.
They also can cause external rotation of WB limb, which aids in resupination of WB foot.
Cerebral palsy causes adductor spasticity and therefore scissors gait
Quads: Rectus femoris, Vastus medialis, lateralis, intermedius
All are decelerator muscles of contact phase, and are knee extenders during swing phase
*Rectus fermoris only one that fires during toe off, which aids in flexing the thigh on the pelvis
Runners knee: hyper pronation leads to lateral patellar deviation, secondary to internal rotation of the leg
Chondromalacia of patella ensues
Hamstrings: Semimembranosis, Semitendinosis, Biceps femoris
Fire just before contact to prevent snapping/hyperextension of swinging limb
Fire during contact to stabilize the knee joint
Cerebral palsy will create hyper-innervation and cause perm. Flexed knees
Foot Supinators: TP, FDL, FHL, Achilles tendon
Foot Pronators: PB EDL EHL
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Pathomechanics Study Guide
Lateral leg muscles: Peroneus longus, Peroneus brevis
PB - primary function = antagonize the supinatory action of Tibialis posterior
Stabilizes the STJ, MTJ and the lateral column of the foot
Passes above the peroneal trochlea on the lateral side of calcaneus
PL stabilization of the 1st ray.
Passes below the peroneal trochlea
Both tendons are situated in a retinaculum
If injured/weak then it causes popping peroneal syndromes
PBs stabilization of the lateral column allows the PL to have a pulley to plantarflex and hold the
1st ray on the ground during re-supination
Peroneal tendons in ankle reconstruction
Use PL because supination lead to lateral ankle sprains
So weaken the supinator PL not PB
Use of PB will leave the supinatory action of Tibialis anterior unopposed and will lead to
an increase chance of ankle sprains in the future
Peroneal tendons in drop foot surgery
Both of the peroneal muscles are split
PB is halved and sent to help PL
PLs free half is attached to the dorsal intermediate cuneiform
PL can undergo phasic change

Deep posterior muscles: Tibialis posterior, Flexor Digitorum Longus, Flexor Hallucis Longus
Collectively fire at 15- 20% of stance phase; Peak during propulsion; drop off after toe-off; Supinatory
TP - Antagonist to the PB (TP is strongest supinator) and supports MTJ
Inserts on tuberosity of navicular w/ slips to all other foot bones except talus
Runs under spring ligament and supports head of talus
Hyaline cartilage behind medial malleolus allows tendon to glide
TP tendon dysfunction:
Pain along TP tendon, with severely collapsed arch on weight bearing
*Test: look at calc. make pt stand on toes. If tendon is snapped then calc will not invert
Shin splints- hyperpronation leads to increased pull on TP strain and tearing insues
Kidner foot type children with enlarged navicular tuberosity
Possible os tibiale externum
Joint between os tibiale externum and navicular becomes ruptured
TP insertion becomes unstable Hyperpronation ensues; Tx: Tendon graft
TP and drop foot surgery: TP cant change phase, so dont use it
FDL - 2nd compartment of laciniate ligament
Becomes part of master knot of Henry and sends 4 slips to lesser toes
Stabilizes digits on supporting surface
If prox and mid phalanges are not stable, FDL will cause toes to buckle
Quadratus plantae inserts into lateral side of FDL
Counteracts oblique pull of FDL & prevents buckling / rotation

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Pathomechanics Study Guide
FHL - Passes btw 2 tubercles on posterior process of the talus, & through he 4th compartment of laciniate
Passes directly under the sustinaculum tali and into the master knot of Henry
Supports head of talus during resupination
Primary function of FHL is resupination** Secondary is hold down the hallux
Associated with injury to the os trigonum, esp in Ballet dancers.
When en pointe planter flexed foot will rub FHL tendon on os trigonum
Dx: dorsiflex halux while foot is planted & palpate behind ankle causes PAIN
Pain indicated fractured os tibialae externum

Superficial Posterior muscle group: Gastroc, Soleus, plantaris,


Complex is slightly supinatory, Fire @ 10-15% stance & peaks prior to toe-off
Gas/Sol stabilize knee during propulsion, Soleus can help extend the knee during weight bearing
Achilles tendon inserts on the middle 1/3 of the calcaneus
External rotation during development twists Achilles Tendon
Tension of the complex sends force into the cuboid, which stabilizes the lateral column
Club foot (talipes Equino Varus) - TP and Achilles Tendon are tight
Achilles tendon is the major deforming force that keeps the foot plantar-flexed & supinated
Equinus = <10* dorsiflexion at ankle.
Pts. compensate with hyperpronation, which Unlocks STJ Foot never resupinates & is a-propulsive
Usually only gastroc needs to be resected not entire Achilles Tendon
Cerebral palsy: Superficial posterior leg muscles hyper-innervation ankle plantar-flexion
G-S complex must be Dx: Either short or spasming
Spastic should not be lengthened b/c will only get shorter
Tx = move Achilles tendon toward the talus on dorsum of the calcaneus
Achilles tendon rupture:
Watershed area: 4-5 cm above insertion w/ decrease nutrient supply
Thompson test = legs hanging off table, squeeze calf and see if foot plantar flexes
If it doesnt flex the tendon has been torn
Tx. stitch tendon together and place patient in gravity equinis cast.
Anterior leg muscles: Tibialis anterior, Extensor digitorum longus, Extensor hallucis longus, Peroneus tertius
**All are biphasic firing during first 25% of stance and throughout all of swing
Prevent foot slap
TA - can help supinate the foot as it is dorsiflexed at the ankle
However pronatory force of EDL EHL AND PT counteract this effect
As foot prepares for toe off TA pulls 1st ray upwards
Creates a strait ridged beam for toe off
TA paralysis: PL pull is unopposed and 1st ray is plantar flexed Irritation of 1st IPJ
Foot cannot be dorsiflexed enough during swing
EHL may be moved to TA insertion to aid but peroneus longus is a good choice
EHL is the strongest dorsiflexor** of the foot bc/ of most distal insertion (Greater lever arm)
However TA must elevate 1st ray before EHL pull can be effective
Contributes to extensor hood of 1st MPJ - allows EHL to buckle the hallux
Extensor halluci capsularis - small capsular fibers resembling articlaris genu
Useful surgical landmark
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Pathomechanics Study Guide
EDL - Four tendons to distal and middle phalanges & extensor hood
Can extend the toes and create a rigid beam supporting surface

Anterior compartment syndrome: caused by leg trauma


Pressure occludes blood supply and is very painful
Surgical emergency must relive pressure to prevent necrosis/foot drop deformity

Intrinsic muscles of the foot: Start to fire during resupination, 35-40% of stance then continue through toe-off
They do not help maintain the arch during static stance; Interosseoues ligaments do that
1st plantar layer: Abductor Hallucis, Flexor Digitorum Brevis, Abductor Digiti Minimi.
*general rule 1st plantar layer intrinsics oppose the 3rd plantar layer intrinsics

1st dorsal 2nd dorsal 3rd dorsal 4th dorsal


Medial 2nd toe Lateral 2nd toe Lateral 3rd toe Lateral 4th toe

Abductor hallucis - Inserts into medial sesamoid, joins with medial head of FHB
Primary action is hallux flexion**
Stabilizes 1st met in plantarflexion by pushing proximal phalanx against it
Provides retrograde force on 1st met so it can rotate up onto sesamoids

Tarsal tunnel syndrome Pain/tingling along the pat of the medial and/or lateral plantar nerve
Hyperpronators are at high risk, b/c it compresses the Portopedis
Porto-pedis = ring where posterior neurovascular bundle passes as it enters the foot
Between calcaneus and abductor hallucis

FDB - Originates from the medial tubercle of calcaneus,


It sends 4 tendons to lesser toes that separate to let longus tendon pass at MPJ
Acts to produce plantarflexion force on middle phalanx (Stabilize Proximal phalanx)
Heel pain syndrome [HPS] - Pain at plantar surface of the calcaneus
Causes: Arthritis , trauma, fracture, neoplastic activity , tarsal tunnel , baxters never
entrapment, infection , calcanel apophysitis in a child gunshot wound
Important to determined if mechanically induced or due to an above cause
Dx: pain from squeezing sides of heel could be stress fracture or HPS
Plantar fasciitis - FDB may pull on calc and create a heel spur; can rub plantar fascia
Heal pain in children is mostly associated with calc. apophysitis
Posterior growth plate inflammation from hyperpronation or rep. trauma
Pull of achilles tendon Achilles Tendon is cont. w/ plantar fascia in children but not adults
Tx. NSAIDs, Injections, hyperpronatory correction, in 5% may need surgery
nd
2 Plantar Layer: Lumbricles, Quadratus Plantae
Lumbricales - originate from medial sides of the FDL tendons
Run plantar to deep transverse metatarsal ligament** (Only one to do that)
Insert on medial aspect of extensor hood, Flex the MPJ and extend the IPJ
Provide stability to hold the proximal phalanx down during propulsion
FDL requires proper function of the lumbricals to prevent buckling of the toes

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Pathomechanics Study Guide
Quadratus plantae Medial head origin: from medial surface of calcaneus.
Lateral head origin: from inferior surface of the calcaneus
-distal to lateral calcaneal tuberosity process, & long plantar ligament
Insertion: lateral side of FDL to neutralize medial pull of FDL
Prevents adductovarus (curling) of toes

3rd Plantar layer: Flexor hallucis brevis, Adductor hallucis, Flexor digiti minimi brevis
FHB - two headed origin; Med: PL tendon sheath, Lat: cuboid and lateral cuneiform
Insert into sesamoids
Adductor hallucis - transverse & oblique heads - Both insert on lateral sesamoid
Entire sesamoid apparatus acts to put retrograde force on 1st met
Allows for rolling up onto sesamoids during propulsion
Flexor didgiti minimi brevis
Stabilize proximal phalanx of 5th toe against the ground

Hyper-pronation makes the 1st met drift medially


Pull of adductor hallucis pulls hallux laterally Creates HAV
Sesamoids pull on tibial collateral ligament & form Bunion Creates bony prominence
Surgical removal of the sesamoids
Creates a dynamic imbalance between the muscles that control the function of the hallux
Tibial sesamoid removal
Adductor hallucis gains mechanical advantage =HAV
Fibular sesamoid removal
Abductor hallucis gains advantage = hallux varus from medial pull
HAV mostly in Pronatory foot type, but also in compensated equines, flexible forefoot valgus, downs syndrome ect.
Rheumatoid could also contribute
Painful loss of cartilage - can be repaired surgically with implants
Keller procedure = Removal of base of prox phalanx
May result in cock-up hallux if intrinsic insertions are damaged
Hallux wont purchase and then lesser mets get stress fractures
4th plantar layer: Interossei (4 dorsal 3 plantar)
Dorsal insertions
1st dorsal 2nd dorsal 3rd dorsal 4th dorsal
Medial 2nd toe Lateral 2nd toe Lateral 3rd toe Lateral 4th toe
Plantar insertions
1st plantar 2nd plantar 3rd plantar
Medial 3rd Medial 4th Medial 5th
Interossei and lumbricals work together to stabilize the proximal phalanx of the four lateral toes
Chain of stability command proximal phalax-lumbricals/interossei
Middle phalanx- brevis tendon
Distal phalanx - longus tendon

Gait analysis:
Normal angle and base of gait is 7-10* abduction (Children shouldnt have high arches)
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Pathomechanics Study Guide
Development of Lower Extremity:
Torsion twisting along the long axis of bone
Rotation twisting occurring at joint
Angles at Birth: (All angles relative to frontal plane)
Head and neck of the femur are angled 60 posteriorly (or external rotation at hip)
30 internal femoral torsion (knees face externally) relative to the femoral condyles
Net rotation at birth of femoral condyles is 30 externally
Angles in adult
60 reduces to 8-12 of external rotation at the hip joint
30 internal femoral torsion reduces to 8-12 relative to the femoral condyles
Net rotation nearly 0 (knees face straight ahead)
During development knock-knee is normal at certain points but in toe is never normal
2-4 Straight
4-6 Valgum
6-12 Straight
12-14 Valgum
>14 Straight
Children will not out grow in-toe, talar facets molded by age 3
Delayed torsion creates in toe (posteriomedial heel wear on shoe)
Very flat feet
May be caused by sitting in reverse tailors position
Tx with orthotic

Deformity Biomechanics Clinical Presentation/Tx


Rearfoot Varus Caused by: Genu Varum, Tibial Varum, Talar/subtalar
varum, tibial epiphyseal varum
Uncompensated -No motion available at STJ so first ray plantarflexes -WILL NOT develop hallux limitus or HAV
Rearfoot Varus and everts to compensate through P.L. action -May develop Cock-up Hallux
-mets 1-5 in valgus compared to calcaneus, 2-5 -Keratomas under met heads 1 and 5 and
perpendicular compared to calcaneus pain under 1st met (tripod postion)
-lateral heel and shoe wear -bipartite tibial sesmoid (tibial sesmoiditis)
-Charcot-Marie-Tooth -High-arched foot Lateral ankle sprains
-Peroneal Muscle Atrophy -lateral heel pain medial displacement of fat
pad
-digital contractures intrinsic muscles
maintain contractures
-Lower back pain and lateral knee pain
Tx Orthotics (medial rearfoot post) with
forefoot extension, lateral Dutchman heel, deep
cup orthotic, Dwyers osteotomy (remove wedge
of bone from calcaneous), tibial sesmoiditis
remove tibial sesmoid but TIGHTEN ALL
STRUCTURES as not to create HAV

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Pathomechanics Study Guide
Partially -Partial motion available at STJ, calcaneus can evert but -Inversion (lateral) ankle sprains common
Compensated not enough -Pump-bump develops posterior lateral
Rearfoot Varus -at heel strike lateral column unlocks surface of calcaneus retro-calcaneal, retro-
-most of weight bearing on lateral side Achilles irritation
-Tailors Bunion bowing or splaying of 5th
met (adductovarus) result of hypermobile 5th
ray pronating
-soft corn on web of 4th interspace
-callus between 4th and 5th met head
depending amount of medial weight shift
-pinch callus on medial side of hallux
-may be MILD HAV
Tx Orthotics (medial rearfoot post), NSAIDS or
steroid injections into BURSA NOT TENDON on
calcaneus, break and fix 5th met or perform
osteotomy for Tailor bunion correction

Fully- -Pronation at STJ equal to amount of varus at heel strike -Pump-bump develops posterior lateral
compensated -Forefoot completely on ground and can bear weight surface of calcaneus
Rearfoot Varus -Unlocking of STJ and MTJ via pronation creates -Hallux Rigitidus/Limitus DJD of joint
hypermobile 1st Ray (functional elevatus) leads to -Will only develop HAV if ALSO has metatarsus
jamming of 1st MPJ adductus
Elevatus: -Have longitudinal arch even though
hyperpronating
-Callus submet 2
-Hammertoes, pain on ball of foot (anterior
displacement of fatpad)
Tx Neutral position orthotics w/ medial
rearfoot post, Injection of corticosteroids @ 1st
MPJ or surgery
Metatarsus -Structural Elevatus: intrinsic problem of 1st ray causing Causes: congenital, post-traumatic, structural,
Primus Elevatus it to remain elevated in a fixed position. iatrogenic (base-wedge osteotomies of the 1st
-Functional elevatus: occurs secondary to hypermobility met), DJD, forefoot orthotic posting.
of the 1st ray. Reversible.
Structural elevatus can be seen on a weight-
bearing stress lateral hallux dorsiflexion view if
the 1st ray is elevated.
Helbings Sign Medial Bowing of the Achilles caused by everting of
rearfoot and abduction of forefoot. (Compensation of
rearfoot varus, forefoot varus)
Rearfoot Valgus -Calcaneus is everted at heel stike -Ankle Valgum agenesis of fibula, deformed
-Genu Valgum (knock-knee), Tibial Valgum, Ankle fibula due to fracture or premature closure of
Valgum, Calcaneo-Valgus (flexible flatfoot), Tarsal epiphysis
Coalition (no inversion when patient stands on toes) -Tarsal Coalition Peroneal Spastic Flat Foot
due to tight peroneus brevis (pain at sinus tarsi)
Rearfoot Valgus -Calcaneus hits everted and cant invert due to internal -Bulge on medial side of foot (talar head and
rotation of leg navicular tuberosity)
-Leads to severe pronation -callus on medial side of hallux
-STJ pronates maximally unlocking MTJ causing arch to -callus/corn on lateral side of 5th digit
drop (adductovarus of 5th toe)
-Longitudinal axis inverts creating Supinatus, oblique -sinus tarsi absent in lateral view
axis drops arch radiographically
-forefoot abducts on rearfoot -HAV, arch pain, knee and lower back pain
-note: abduction of calcaneus looks like
eversion
-Tight plantar fascia heel pain
-If calcaneus stays everted when on toes
Rupture of Tibialis Posterior
Tx Cant use neutral position orthotics, Use
Soft orthotics, DSIS, wedge osteotomy of tibia
if Ankle valgus and young patient,
epiphysiadesis
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Pathomechanics Study Guide
Forefoot Varus -Due to abnormal position of talar head and neck
relative to body
-During development normal for talar head and neck to
undergo valgus torsion
Uncompensated -Mets 1-5 are perpendicular to calcaneus while mets -Lateral shoe wear
Forefoot Varus 2-5 are in varus -callus/keratoma submet 5, sometimes 4
-1st ray plantarflexes and everts to bring forefoot down -Callus/keratoma submet 1, sometimes
(still see good arch) extending to 2
-Tailors bunion with soft corn
-Possible hammering of 4th and 5th digits
(adductovarus)
Tx orthotics medial forefoot (anterior) post
Compensated -STJ pronates unlocking MTJ, pronates longer into gait -Helbings Sign
Forefoot Varus cycle -No arch
-Hypermobility of the 1st ray occurs -Everted Calcaneus upon weight bearing
-Extensor Digitorum Longus acts unopposed by plantar -Abducted forefoot on rearfoot (too many toes)
interossei causing hammering of toes -Bulge on medial side of foot (talar head)
-Callus/keratoma submet 2
-pinch callus on medial side of Hallux
-HAV
-Hammerdigits
-can lead to equines (contracted Achilles due to
chronic hyperpronation)
Radiography (weight bearing)
-Talocalcaneal angle increased
-Calcaneal inclination angle reduced
-sinus tarsi absent
-anterior break in cyma line
Tx orthotics medial forefoot (anterior) post,
DSIS (if hyperpronation is severe)
Forefoot Valgus -mets 1-5 are everted to calcaneus -callus submet 1
-after heel strike calcaneus everts rapidly creating -bipartite or fractured tibial sesmoid -
supinatory rock inflammation
-creates cavus foot -Lateral ankle sprains (sinus tarsi syndrome)
-tibial sesmoid is first part of anatomy to strike after -Lateral knee pain, sciatica, lower back pain
Flexible Forefoot heel strike -hammertoes
Valgus -Pump bump
-Cavus foot when non weight bearing but flat upon
weight bearing
-May develop juvenile HAV
Equinus -Normally 100 of dorsiflexion with knee extended and -ROM deteriorates as we age adult with 50
15 with knee flexed (isolating soleus) occurs at the
0 dorsiflexion may or may not have symptoms
50-60% point of stance -prancers syndrome in children walk on toes
-measuring the amount of dorsiflexion by placing STJ in even with plenty of dorsiflexion
neutral, MTJ max pronated and locked, grabbing 4th and
5th mets and dorsiflex
-important that the arm of the tractograph only reach as
far as 5th met tuberosity so you dont measure the MTJ
dorsiflexion
Uncompensated -Primary, congenital condition -Patients will walk on their toes
Equinus

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Pathomechanics Study Guide
Compensated -EDL will excessively dorsiflex the digits in order for -collapsed arch due to excessive pronation
Equinus them to clear the ground -heel pain due to stretch of plantar fascia on
-Hyperpronation the oblique axis of the MTJ ,makes up medial tubercle
for lack of dorsiflexion -arch pain due to collapsed arch
-early heel rise -lower back pain
-shorter stride -Calf Pain
-juvenile HAV
-hammertoes
-may see calcaneal apophysitis (due to Achilles
and plantar fascia stretching

Forefoot -Lateral view metarsals are superimposed on each -compensated equinus can cause this
Supinatus other
HAV - most common cause is mechanical (hypermobility), Bunions can also be caused by an inflamed
often associated with elevatus. As the STJ pronates, the bursal sac, deposition of uric acid (Gout),
forefoot moves laterally, which creates a lateral pull on genetics (Downs Syndrome - atavistic
the Hallux, due to the movement of the MTJ-oblique axis cuneiform, predisposing to a bunion).
in the transverse plane. The Adductor halluxis pulls on
the hallux and the sesamoid apparatus, movng the base
of the proximal phalanx ad the sesamoid apparatus Patients bear more weight on the 2nd met head,
laterally. As the hallux drifts laterally, there is a angular and develop metatarsalgia and keratoma sub
retrograde force from the proximal phalanx that pushes met 2. Contracture of the 2nd digit puts a
on the first met head, moving it medially, and increasing retrograde forece on the 2nd metatarsal, which
the IM angle (normally 8-10deg). As the 1st met drifts exacerbates the lesion.
medially, it pulls on the tibial collateral ligament,
causing the bone on the medial side of the head of the Bowstringing of FDL holds the hallux in a lateral
1st met to proliferate, creating a bunion. position. Correction to straighten the toe makes
the tendon of FHL tight, possibly creating hallux
Hallux is parallel to the lateral side of the foot, leading limitus/rigidus.
to intrinsic fatigue of muscles and a loss of plantar
stabilizing force on the digits, resulting in digital Juvenile HAV in severe pronators, compensated
contractures, especially the 2nd toe, allowing the hallux equinus, significant forefoot varus, torsional
to abduct more and more. The latter toes curl in an abnormalities.
adductovarus condition due to the pull of FDL without
the neutralizing force of QP.
Hammerdigit Results from instability of the digits during propulsion. Metatarsal head flattens. Capsular and
Syndrome They occur in hyperpronated and cavus foot types. ligamentous contractures at the MPJ. Anteriro
Caused by intrinsic fatigue. Longer pronation fatigues dislocation of the fat pad, resulting in visible
the intrinsics fullness at the toes.

Cavus Foot Causes: -Calcaneal stance position is perpendicular or


- Uncompensated Rearfoot Varus (higher Arch) inverted w/ medial fat pad displacement
- Uncompensated Forefoot varus (lower arch) -Reverse Helbings Sign
- Muscle imbalance -Prominent EDB
o Weak P.B., Strong T.P., Strong P.L. -Hammertoes
- Limb length discrepancy (unilateral cavus foot, -Cock-up Hallux
and HAV on other limb) -Callus lesion submet 1 and 5 maybe 2-4
- Forefoot Valgus -Pump-bump
Spinal Dysraphism, Charcot-Marie-Tooth, Friedrichs
Ataxia, Roussey-Levy Syndrome

Warts: pain on lateral compression, same width all the way through to the dermis. Pinpoint bleeding on
debridement. Keratoma: pain on direct palpation, narrows as you go deeper into the dermis.

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Pathomechanics Study Guide
Current Theories of Foot Function
Root STJ Neutral Foot Morphology Theory
Optimally functioning foot should have the STJ in neutral position during midstance.
Frontal plane morphology abnormal.
Orthoses: balance frontal plane deformity.
Dananberg Sagittal Plane Facillitation Theory
Foot acts a sagittal plane pivot that smoothly rocks the foot through the gait cycle.
Equinus and hallux limitus produce a sagittal plane blockade, reducing this motion.
Orthoses: first ray modifications, including cut-outs, forefoot extensions, and kinetic wedging.
McPoil/Kirby Tissue-Stress Theory
Symptom reduction by reducing abnormal forces.
Orthoses: higher degrees of forefoot and rearfoot posting. Reduce pronation by limiting medial movement.
Whitney, Whitney, and McGuire Triplane Balance Axis Theory
Recognize that foot and lower limb deformities exist in one or more body planes.
Lower Extremity Axis of Balance: body weight thrust exerted vertically from each hip in bidepal stance.
Axis should ideally pass centrally through the supporting foot structure.
Normal sway displaces and returns balance.
Goal: reduce foot imbalance and high potentially ulcerating pressures.
Digital Reaction Patterns:
Posterior balance cause toes to retract.
Anterior imbalance produces contraction deformities such as mallet, buckle, and hammertoes.
VFAS: Realignment and casting occur simultaneously to align the segments of the feet in all three planes.

Compensatory Effects of Foot Deformity


Frontal Plane Foot Conditions
Forefoot Varus - inverted Forefoot relative to the rear foot when STJ is neutral &
the OMTJ is locked and pronated (because when STJ is pronated, the LMTJ is supinated, and the
OMTJ is pronated). When the STJ everts the MTJ inverts. Tx: with medial forefoot wedging.
Forefoot Valgus - everted Forefoot relative to the rear foot when the STJ is neutral &
the OMTJ is locked and pronated. Occurs b/c inadequate MTJ ROM, to compensate the STJ
must supinate to bring the forefoot to the ground. Tx: with lateral forefoot posting.
Rearfoot Varus - Varus tibia or calcaneus is inverted when the STJ is neutral, & OMTJ is locked & pronated.
(Tibial varum/subtalar varus) If STJ has enough ROM it will evert the rearfoot to
compensate.
Medial rearfoot compensation.
Calcaneal Varus - Isolated structural inversion of the tuber of the calcaneous.
Tx: Use rear foot lateral wedge to compensate for the lateral deformity.

Saggital Plane Deformities


Ankle Equinus = less than 10 degrees of ankle dorsiflexion. b/c of shortening/tightness of Achilles tendon.
Will compensate by rearfoot eversion with STJ pronation. Tx: Orthosis management w/ heel elevation.
Talipes Calcaneo-Cavus (Combined Cavus) - Combined posterior & anterior Cavus.
Ankle joint is dorsiflexed while the forefoot has equinus. Weakness/paralysis of calf muscles will
produce this deformity. Clawing of the digits occurs. It increases pressure at heel and forefoot
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Pathomechanics Study Guide
Orthosis management: Centro-plantar foot support and cushioning fore & rear foot.
Anterior Cavus (Forefoot Equinus) - Fixed congenital deformity or acquired neurogenic disorder where the
forefoot is plantarflexed on the rearfoot. Ground reactive dorsiflexion of the forefoot causes STJ
pronation (pseudoequinus). Orthosis management: cavus heel elevation.

Lateral Column Cavus - Lateral column of the forefoot is plantarflexed (indicated by Too many toe sign)
Ground reactive forces will cause dorsiflexion of the lateral column, rear foot eversion, and medial
column inversion (to keep the medial foot on the ground). Treat with medial foot wedging and cavus
heel elevation.
Posterior Cavus - Congenital Osseous where calcaneal body is elongated, neuromuscular conditions will cause
ankle dorsiflextion. Ground reactive forces cause forward shift of body balance and is associated with
digital gripping. Orthosis management is distal heel elevation creating a negative heel.

Met Primus Equinus - Fixed rigid congenital deformity where 1st met is plantar-flexed on the cuneiform.
Can also result from Charcot-mare-Toothe. Compensation via STJ supination as ground reactive forces
roll the foot laterally (because of the plantarflexed first met is being dorsieflexed. This leads to an
increase incidence of lateral ankle sprains. Orthosis management: depressed first met cutout and lateral
valgus wedging to further eliminate supinatory force.
Met Primus Elevatus (structural) - Fixed rigid congenital deformity where 1st met is dorsi-flexed on cuneiform.
Can also occur via STJ pronation causing hypermobile of 1st ray. Compensation occurs with increased
hallux dorsiflexion due to decreased MPJ dorsiflexion (Hallux Limitus). Orthosis management: help
medial imbalance. Use Mortons elevation to bring ground up to dorisflexed metatarsal.
Met Primus Elevatus (positional) - Can occur secondary to STJ pronation. Compenation with dorsiflextion of
hallux IPJ due to decreased ROM at MPJ (Hallux Limitus). Orthosis Management to realign first ray
with kinetic-wedging with a sub-metatarsal cut-out (Ok this doesnt really make sense to me but Ill look it up).

Transverse Plane Deformities


Metatarusus Adductus - Metatarsals adducted at Lisfranc Joint. Usually compensated with out-toeing (mets
adducted and toes abducted). Usually produces lateral imbalance with STJ supination (ankle sprains)
(Has compensated Z-foot type). Orthosis Management: reduce lateral imbalance with valgus wedging
and deepened hell cup with extended flanges for greater tranverse plane control.

Lesser Tarsus Adductus - Congenital strucutural deformity with adduction of midfoot. Compensation with
STJ pronation. (Comepensated C-foot type). Produces a centro-lateral imbalance (ankle sprains).
Orthosis management aimed at centrolateral imbalance with lateral midfoot valgus wedging.

Midtarsal Joint Abductus - Result of abnormal foot pronation. Other influences include Kidner foot type,
TP dysfunction, peroneus brevis spasm and medial limb torsions. (Will have too many toe sign). Has
marked abduction of forefoot and medial ankle deviation.
Orthosis management: deep heel cup and medial heel skive technique.

Calcaneal (Tuber) Adductus - Congenital adductus of posterior calcaneal process. Protrusion of medial heel
(Peaking heel). Compensation with STJ supination and inverted rearfoot (causing lateral imbalance
ankle sprain) Orthosis management: with lateral valgus posting for the lateral imbalance

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Pathomechanics Study Guide
Biomechanical Exam
The examination should include: Morphological triplanar evaluation, Arthometric Evaluation, Postural
Appraisal, Gait Assessment, Radiographic Evaluation, Shoe Assessment

Examination
1) Determing Hip Neutral Position - Transverse hip plane ROM is determined and is either normal, internally or
externally positioned. Use formula to find Neutral position = Greatest ROM - (Total ROM)/2. ***ON EXAM!

2a) Frontal Plane Knee Alignment - Note any medial or lateral deviation of the tibia on the femur.
2b) Transverse Plane Knee Alignment - Genu Varum = bow legged condition expected to patients base of
gait & will tend to cause STJ pronation. Genu Valgum = knock knee condition that will base of gait &
induce STJ supination if there is decreased malleolar torsion or increased medial hip rotation.
2c) Sagital Plane Knee Alignment - hyper-extended patients leg to the max ROM. Patients with greater 10
degrees of extension may exhibit back-knee posture =genu recurvatus).
This is condition is accentuated if patient has co-existing ankle or forefoot equinus.

3) Frontal Plane tibial alignment - Tibial tuberosity directed vertically, the frontal plane alignment of the lower
2/3s is observed for abnormal bowing greater than or equal to 5 degrees (Tibial varum is what you are
mainly looking for, Tibial valgum is very rare and normally the result of injury). This will cause knee
bowing and the STJ will evert (pronate).

4) Malleolar Torsion - Tibial tuberosity is vertical. Place one thumb on top of the lateral malleolus while other
thumb is positioned along the mid-line of the medial malleolus. The thumbs should be at an equal level
(then the malleolar torsion will be within normal limits of 13 and 18 degrees. If the thumb over the
lateral malleolus is lower than the one on the medial malleolus, it is indicative of increased malleolar
(tibial) torsion with an increase in the patients angle of gait with greater STJ pronation.

5) Ankle Dorsiflexion - STJ held in neutral, then the ankle is dorsiflexed. The amount of dorsiflexion is
relative to a vertical bisection of the lateral leg as represented by the peroneal tendons. It is performed with
the knee extended and flexed. Must have at least 10 degrees ankle dorsiflexion*

6) STJ Neutral = (Total ROM)/3 Eversion ***

7) Midtarsal Joint Neutral - Put STJ in neutral and load the forefoot (pronate and lock) and observe the fore-
foot to rear-foot relationship. A forefoot varus means the STJ must pronate to compensate (can lead to
bunions and hammertoes), a forefoot valgus means the STJ must supinate to compensate (can lead to
submet head 1 and 5 lesions and lateral ankle sprains).

8) First Ray Neutral - Place thumb and index finger on 1st met head and other thumb and index finger on 2nd
met head. With STJ neutral, plantar and dorsiflex met head. Should have 10 mm dorsi & plantar flexion.
Dorsiflexion of 1st met will result in STJ pronation and hallux limitus/rigidus. Plantarflexion 1st met will
result in STJ supination with increase in ankle sprain.

9) 1st MPJ ROM - move Hallux to end range of dorsiflexion noting quantity and quality of motion. 1st MPJ
must have 65 degrees of dorsiflexion. Lack of 65 degrees = hallux limitus, no dorsiflexion = hallux ridigus.

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Pathomechanics Study Guide
10) STJ axis determination - Usually determined via eversion and inversion.
Lower axis feet have calcaneal eversion and arch lowering with pronation.
High axis feet have lesser amounts of calcaneal eversion and arch lowering with pronation.
Compensatory findings will be of a transverse plane nature (medial deviation of the ankle).

11) MTJ axis determination - Put STJ in neutral. The motion about the oblique MTJ is determined by moving
the forefoot through its full range of motion. Normal MTJ motion will demonstrate equal amounts of
transverse and sagittal motion. Higher axis orientations will have greater transverse plane with increased
talar escape and an increased cuboid abduction angle with abduction of the forefoot (too many toe sign).
Predisposes foot to Tibialis Posterior Dysfunction Syndrome.

12) Make a Triplane foot assessment to try to predict abnormal compensatory patterns

13) Stance assessment - Should confirm predicted findings of morphologic exam of STJ & MTJ axis orientations

14) The Gait Assessment - Should be predictable with respect to the angle and base of gait, rear-foot position,
compensatory patterns and pathological findings.

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Pathomechanics Study Guide
Benefits of Foot Orthoses
Theory of Function:
Reactive forces (kinetics) imposed on the foot by the orthotic plate rather than by its influence on motion
(kinematics) may play a more important role in the beneficial therapeutic effects.
Neutral Position:
When joints are aligned in their neutral position (STJ), the muscle-tendon complex is in its optimal
mechanical position where muscles are in their ideal relaxed state being neither elongated or shortened.
This is the reason that people can easily lose balance with hyper-pronation conditions when any pressure
is applied to their out-stretched arms (fall forward). Due to the Tibialis Posterior lengthening and stress
with pronation, it is at a distinct disadvantage to overcome the challenged postural imbalance. When the
foot is supported with any arch supportive device, the persons balance and stability appears to be
miraculously improved.
While the orthotic is static, the foot is still dynamic
Goal: reduce pathologic loading forces on the injured structural components of the body, and promote more
efficient dynamics of the body during weightbearing activities.
Dependence: orthotics reduce muscle and joint degenerative changes.
Shoe choice: shoes are essential part of orthosis therapy.
Orthoses are assistive rather than corrective. At risk of recurrence/progression if they go for peiods without
their orthoses. Patients become more dependent as they become older and lose flexibility and muscle strength.
After surgical correction: greater risk of recurrence without management.
Yearly checkups
Non-weight bearing casts preferred so that you dont compensate for compensation.
Modifications:
Orthosis balance position. Corrects rearfoot varus/valgus.
LMI: STJ pronation will produce medial deviation of the lateral malleolus. STJ supination will produce
lateral deviation of the lateral malleolus.
LMI = O represents STJ neutral where the lateral malleolus is collinear with the lateral heel fat pad.
Metatarsal Head CutOuts: for off-loading.
Length: patient preference, for shoe type.
Heel Cup height: depends on rearfoot and midfoot control wanted.
Heel elevation: for equinus, achilles tendinitis, LLD, anterior cavus.
Heel cushioning: PF, Calcaneal heel pain syndrome, calcaneal bursitis.
Metatarsal pads/bars for sub-met pain, neuroma
Bunion Flange: reduce irritating pressure from shoe, reduce forefoot splay.
Mortons Extension: reduce 2nd MTPJ pain with short or elevated 1st mets. Prevents medial imbalance
and dorsiflexion of the first ray. Reduce hallux rigidus.
Kirby Skive: reduce calcaneal eversion, AAFFD from PTTD.
DMO Charcot: protect prominences at risk for ulceration.
FHL: produce cast with a properly aligned ray through first ray repositioning with PF of 1st met.
Met Primus Equinus: 1st met cut-out and offloading.

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