Foot and Ankle Biomechanics

Jeffrey D. Towers, M.D.,1,2 Christopher T. Deible, M.D.,1 and Sara K. Golla, M.D.1

ABSTRACT

With the advent of imaging advancements there has been renewed interest in
the foot and ankle. However, many of the basic functions and biomechanical considera-
tions of the bones, joints, and specialized tissues of the normal and dysfunctional foot and
ankle remain unfamiliar to many radiologists. This article focuses on the basic biome-
chanics, normal alignment, and common alignment disorders of the foot and ankle that
are relevant to radiologists.

KEYWORDS: Foot biomechanics, foot alignment disorders, ankle biomechanics

TERMINOLOGY GAIT AND BIOMECHANICS

Although clinical and anatomic descriptions of alignment
have evolved with somewhat disparate terms, most terms
can be applied to the standard three-axis, X-Y-Z coor-
dinate system. Using this system, the description of mo-
tion can be agreed upon by rotational movement about
these axes (Fig. 1).1–5 It is important to note that the
movement of the foot and ankle is multiplanar, and these
individual components of motion occur simultaneously
in a coordinated and synchronized fashion, not as indi-
vidual movements in isolation.
Motion in the sagittal plane, about the horizontal
or X-axis, is described as plantarflexion and dorsiflexion.1–5
Varus and valgus are the terms we use to describe move-
ment in the axial plane, or rotation about the cephalo-
caudad Y-axis, and refer to either medial (varus) or lat-
eral (valgus) alignment of the distal portion of the
structure relative to the proximal. Abduction and adduc-
tion may be used as well, but some landmarks for these
terms refer to the body and some to the center of the
foot, resulting in confusing situations (e.g., abductor hal-
lucis is really an adductor). Inversion and eversion are
terms we use to describe motion in the coronal plane, or
rotation about the anteroposterior Z-axis. Supination and
pronation are often synonymous with these latter terms
but may also refer to motion combining adduction, plan-
tarflexion, and inversion (supination) or abduction, dor-
siflexion, and eversion (pronation).
OF THE FOOT AND ANKLE
There are two things the foot and ankle must do: be-
come flexible to absorb load and become rigid to act as a
lever arm. A brief review of the gait cycle underscores
these tasks (Table 1).1–4,6 The walking cycle can be
roughly divided into two portions, the stance phase in
which the foot is on the ground and the swing phase when
it is off the ground.
The stance phase comprises about 60% of the
gait cycle and is initiated by heel strike.1–4,6 Transfer of
the body load to the foot, which must be absorbed to
prevent injury, characterizes the heel strike portion of
the stance phase. Load is absorbed in the skeletal sys-
tem by angular motion of joints resisted by muscles in
eccentric contraction, that is, contraction occurring while
the muscle is lengthening. It is directly analogous to lever
arm shock absorbers that were used on British sports
cars prior to the advent of telescopic shocks. Accord-
ingly, flexibility is paramount for accommodating load
in this phase of walking and occurs in the knee, ankle,
and foot.
As stance progresses, the body mass continues to
move forward over the fixed foot and initiates toe-off,
the second portion of the stance phase.1–4,6 This portion
of the stance phase requires that the foot become a rigid
lever arm to support the load generated from the ankle
across the metatarsals that propels the body forward.

Biomechanics; Editors in Chief, David Karasick, M.D., Mark E. Schweitzer, M.D.; Guest Editor, Jeffrey D. Towers, M.D. Seminars in
Musculoskeletal Radiology, Volume 7, Number 1, 2003. Address for correspondence and reprint requests: Jeffrey D. Towers, M.D., UPMC Health
System, Department of Radiology, 200 Lothrop Street, Pittsburgh, PA 15213. 1Department of Radiology; 2Department of Orthopaedic Surgery,
University of Pittsburgh Medical Center, Pittsburgh, PA. Copyright © 2003 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New
York, NY 10001. Tel +1(212) 584-4662. 1089-7860,p;2003,07,01,067,074,ftx,en;smr00280x
67
68 SEMINARS IN MUSCULOSKELETAL RADIOLOGY/VOLUME 7, NUMBER 1 2003

A B
Figure 1 (A, B) Foot and ankle motion.

These seemingly contradictory tasks of flexibility
and rigidity all must occur at the correct times within a
stance phase that lasts about two-thirds of a second in
normal walking.
NORMAL ALIGNMENT AND
BIOMECHANICS
The overall configuration of the foot and ankle from a
lateral view is a truss with a short posterior and long an-
terior joist forming the longitudinal arch.1–5,7,8 A ten-
sion arm along its plantar surface joins these, the plantar
aponeurosis, and is dynamic rather than static being at-
tached to the plantar plate at the metatarsophalangeal
joints forming a windlass mechanism. From an antero-
posterior view, a series of angled joints are evident, with
valgus at the hindfoot-midfoot junction and varus at the
midfoot-forefoot junction. This Z-configuration allows
angular motion in the horizontal plane. In coronal sec-
tion, the foot is relatively vertical in the hindfoot, with
an asymmetric arch becoming shallower and more hori-
zontal as the forefoot is approached.
Ankle
The ankle has an articular configuration of a conic sec-
tion held in external rotation to the tibial plafond, with
the foot internally rotated with respect to the ankle.1–5,7,8
It provides the majority of plantar and dorsiflexion and
considerable internal rotation in concert with the subta-
lar joint. It is stabilized by the deltoid ligament medially
and the lateral collateral ligaments laterally. Its asym-

Table 1 Lower Extremity Activity During the Gait Cycle

Pelvis Femur Tibia Internal Rotation External Rotation Internal Rotation

Ankle joint Plantarflex Dorsiflexion Dorsiflexion

Plantarflex
Subtalar joint Eversion Inversion Eversion
Choparts joint Unstable Increasingly stable Unstable
Intrinsic muscles Inactive Increasingly active Inactive
Pretibial muscles Active Inactive Active
Calf muscles Inactive Active Inactive
Cycle Heel strike Midstance—Toe off Swing

metric surface provides greater stability in dorsiflexion
and greater mobility to inversion and eversion in plan-
tarflexion.
Subtalar Joint
The subtalar joint usually has three facets and provides
eversion, inversion, and internal rotation. It is stabilized
by components of the deltoid and lateral collateral liga-
ments, the interosseous ligaments of the sinus tarsi, and
by its lateral capsule.1–5,7–10 The lateral position of the
calcaneal posterior process with respect to the talus pro-
vides a lever arm for eversion (pronation) during heel
strike and midstance, whereas the sustentaculum tali pro-
vides a lever arm for inversion (supination) in late stance
and toe-off (Fig. 2).
Transtarsal (Chopart’s) Joint
Plantarflexion and dorsiflexion are major components of
this joint, which has a variable range of motion, depend-
ing upon the degree of subtalar rotation and version, and
is largely responsible for providing flexibility or rigidity
of the midfoot.1–5,7,8 During heel strike, pronation (ever-
sion-valgus) of the subtalar joint makes the rotational
axes of the talonavicular and calcaneocuboid joints rela-
tively parallel, increasing the joint’s range of motion. In
late stance phase, supination (inversion-varus) moves the
articular surfaces into a relatively antiparallel arrange-
ment, increasing rigidity of the midfoot.
Intertarsal Joints
The naviculocuboid, naviculocuneiform, and intercunei-
for joints form a variably pitched roman arch in the
midfoot, which is altered by the dynamic alignment of
the hindfoot.1–5,7,8,11 In addition to the relative flexibil-
ity or rigidity of Chopart’s joint, the intertarsal arch be-
A B
Figure 2 (A, B) The mitered hinged configuration of the subtalar joint provides linkage between pronation of the foot and internal
rotation of the ankle during loading.
FOOT AND ANKLE BIOMECHANICS/TOWERS ET AL 69
comes shallower by hindfoot pronation, increasing its
flexibility, and steeper in supination, making it more rigid
in preparation for toe-off.
Tarsometatarsal (Lisfranc’s) Joint
Lisfranc’s joint is relatively rigid, with some capacity for
varus of the first ray.1–5,7,8 Strong ligaments traversing
intertarsal, tarsometarsal articulations, and a mortise and
tenon configuration of the second ray contribute to a
transverse arch and longitudinal arch that support the
metatarsals in toe-off. The peroneus longus attachment
to the lateral base of the first metatarsal provides dy-
namic resistance to first ray varus and excessive prona-
tion of the forefoot during toe-off.
Metatarsophalangeal (MTP) Joints
A metartarsal break angle from the second to fifth ray
metatarsal head defines the angle of dorsiflexion of these
joints (Fig. 3).1–5,7,8,12–17 Beginning at the lateral toes,
loading moves medially, ending between the first and sec-
ond ray. The plantar plate helps to prevent intermetatarsal
divergence during loading of the forefoot. In addition,
progressive dorsiflexion of the MTP joints during toe-off
activates the windlass mechanism of the longitudinal arch
of the foot by the connection of the plantar aponeurosis
to the MTP capsules, which progressively steepens the
anteroposterior arch during forefoot loading, adding fur-
ther rigidity. Dorsiflexion reappears just before the next
heel strike, during which it is actively resisted with load-
ing of the hindfoot, further absorbing load (Fig. 4).
Plantar Fat
The plantar fat in the foot is especially compartmental-
ized with swirls of fascia surrounding lobules of fat, with
superficial microchambers and deep macrochambers (Fig.
70 SEMINARS IN MUSCULOSKELETAL RADIOLOGY/VOLUME 7, NUMBER 1 2003

A B
Figure 3 (A) Metatarsal break angle. (B) A long second toe alters toe-off mechanics.

5).2–5,7,8,18,19 The structure works to dissipate load, par-
ticularly over the bony eminences of the heel and metar-
sophalangeal joint. The fat structure works best when
more of its surface is loaded, as when shoes are properly
fitted with a tight heel cup, which allows more of the
lateral surfaces to dissipate load. With poorly fitted shoes
or injury, the fat cells may become inflamed or fibrotic,
leading to abnormal loading of underlying bone and ar-
ticular structures.
Normal Gait
With heel strike, the lateral position of the posterior pro-
cess of the calcaneus causes pronation (eversion-valgus)
of the hindfoot with internal rotation of the ankle.1–4,6
The knee and hip also internally rotate in response.
Pronation allows greater mobility of the transtarsal joint
by making its surfaces relatively parallel, which allows
dorsiflexion and widens the cross-sectional arch of the
midfoot, allowing greater flexibility. There is progressive
midfoot valgus as loading continues that is resisted by
the medial flexors, especially posterior tibialis. The wind-
lass mechanism is progressively unwound against resis-
tance by extensor muscles, further absorbing load. As
midstance progresses, the tarsometatarsal joint allows
some varus and dorsiflexion of the first ray, further ab-
sorbing load.
In preparation of toe-off, the flexor tendons con-
tinue to contract as the load on the heel reduces, pulling
the hindfoot into supination (inversion-varus) by action
of posterior tibialis.1–4,6 This makes the trantarsal joint
surfaces more antiparallel, and hence more rigid, and
makes the cross-sectional arch steeper and more rigid as
well. As toe-off progresses, the medial flexors are matched
by contraction of the lateral flexors, which stabilize the
first ray through contraction of peroneus longus and
maintain position in the lateral column by contraction
of the peroneus brevis. Intrinsic flexor muscles also con-

A B
Figure 4 (A, B) Windlass mechanism of the longitudinal arch. At toe-off progressive plantarflexion of the MTP joints tightens the
plantar aponeurosis, increasing the height of the longitudinal arch and providing greater rigidity.

A B
Figure 5 (A) Sagittal and (B) coronal MR images of the heel pad demonstrating load distribution.
tribute to forefoot rigidity, and the windlass mechanism
is tightened as MTP flexion proceeds.
COMMON ALIGNMENT ABNORMALITIES
Alignment abnormalities are best derived from clinical
measurements and weight-bearing anteroposterior and
lateral radiographs. Non–weight-bearing radiographs and
sectional images may suggest alignment disorders but
often over- or underestimate deformities.
Pes Planus
Defined by the talometatarsal angle pointing plantar-
ward, planus feet generally have components of planus
and valgus and are often referred to as a planovalgus de-
formity (Fig. 6).2,5,7,8,20–24 They are more flexible than
normal and therefore can absorb load well. Their pri-
mary problem is in becoming and/or maintaining rigid-
ity in toe-off. In the middle-aged patient with progres-
A
B
Figure 6 Lateral radiographs demonstrating (A) normal align-
ment and (B) pes planus with talometatarsal angle pointing
plantarward.
FOOT AND ANKLE BIOMECHANICS/TOWERS ET AL 71
sive, painful planovalgus, posterior tibial dysfunction is
usually present and the degree of deformity correlates to
the degree of tendon tear and lengthening.
Pes Cavus
The high-arched foot is characterized by a talometa-
tarsal angle pointing dorsally and usually has varus align-
ment as well and thus is often referred to as a cavovarus
deformity (Fig. 7).2,5,7,8,20–24 It is more rigid than nor-
mal and thus is prone to arthrosis from the inability to
absorb load. Heel and MTP loading may be excessive
with plantar fasciitis and forefoot fat fibrosis.2,5,7,8,25 Ad-
ditionally, in individuals who are active in loaded plan-
tarflexion (such as ballerinas en-pointe) cavus at Lis-
francs joint may lead to abnormal longitudinal load in
particular.26,27 A major consideration in the cavus foot is
neuropathy.28,29 In the forefoot, excessive varus may allow
greater than normal loading of the lateral metatarsals,
with “rolling over” the metatarsals, preventing the greater
load in late toe-off from getting to the medial greater
metatarsals. Stress reactions and occasional fractures may
be seen.
Tight Heel Cord
An overly tight Achilles causes loading of the forefoot
earlier in the stance phase than normal, before the events
providing and maintaining rigidity of the mid- and
Figure 7 Lateral radiograph demonstrating pes cavus with
talometatarsal angle directed dorsally.
72 SEMINARS IN MUSCULOSKELETAL RADIOLOGY/VOLUME 7, NUMBER 1 2003
A B
C rigid lever arm.
forefoot are achieved.2,5,19 Characterized by “toe walk-
ing,” it is exacerbated by wearing high heels, which pre-
vent normal stretching of the gastrocnemeus and soleus
muscles and leads to abnormal forefoot load (Fig. 8).
Loading in plantarflexion allows greater than normal
valgus at the ankle joint and excessive direct loading of
the metatarsal heads and is thought to predispose to
Freiberg’s infraction or osteonecrosis of the metatarsal
heads.
Hypermobile First Ray
Metatarsum primum varus may be intrinsic or due to
weak flexion by the peroneus longus.2,5,7,13 It allows not
only varus but also dorsiflexion of the first metatarsal,
which in turn allows forefoot pronation during toe-off.
These contribute to the association with hallux valgus,
in which the great toe attains progressive valgus angula-
tion from medial loading during toe-off, with lateraliza-
tion of the sesamoids, medial eminence formation, and
arthrosis.
Dislocations
Virtually all dislocations of the foot result in dorsal po-
sitioning of the distal fragment, as the anterior joist of
the sagittal truss breaks down, allowing the posterior
structure to “plow” beneath the structure directly in front
of it.2,5,7,10,27,30 In the neuropathic foot, this leads to a
Figure 8 (A) Normal Achilles tendon and align-
ment. (B, C) A tight heel cord causes “toe walk-
ing” and eversion and loading prior to attaining a
lack of a competent lever arm as well as plantar bony
prominences, usually at the cuboid, termed the “rocker
bottom” deformity.
More troublesome is the “midfoot sprain” often
treated by brief immobilization. This often represents a
Lisfranc dislocation with spontaneous reduction.30,31 Al-
though no static deformity can be seen on non–weight-
bearing films in the acute setting, significant valgus defor-
mity with even modest loading is typical. Weight-bearing
or stress views (particularly after anesthetic injection)
often reveal the deformity, warranting rigid fixation and
prolonged immobilization to allow collagen maturation
sufficient to bear load (Fig. 9). CT examination in the
acute setting may show entheseal avulsions indicating lig-
ament injuries in individuals who cannot bear weight.
Failure to recognize this entity results in a planus midfoot
in which fitting shoes is very difficult and in which
arthrosis almost uniformly occurs.
CONCLUSION
The normal daily function we expect from our feet and
ankles requires a careful balancing of mobility and sta-
bility. Complex structures consisting of interconnected
articular surfaces, bones, and soft tissues, the foot and
ankle are critical to activities of daily living and quality
of life. By understanding the basic biomechanics of the
foot and ankle the radiologist can more fully appreciate
and understand the morphology and function presented

A B
Figure 9 AP foot radiographs demonstrating (A) normal alignment, (B) Lis Franc fracture dislocation, and (C) fracture dislocation
with stress view.
in imaging studies. Work is continuing to enhance the
information provided by imaging. In the near future we
expect functional (biomechanical) assessments to be a
routine part of our exams.
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