TRANSVERSE ROTATION OF THE SEGMENTS OF THE LOWER

EXTREMITY IN LOCOMOTION *

BY A. S. LEVENS, M.S., C.E., BERKELEY, VERNE T. INMAN, M.D., SAN FRANCISCO, AND

J. A. BLOSSER, M.D., BERKELEY, CALIFORNIA

Iro,,o the ‘nier,sity of California, College of Engineering, and Division of Orlhopaedic Surgery, ,lfedical Scho3l

A complete analysis of human locomotion is difficult. The fact that persons walk and
run with apparent ease, and without conscious effort, does not. imply that. the mechanisms
employed are simple or readily understood. A comprehensive study of locomotion includes
not only analysis of the movements of the various segments of the body, but also the con-
relation of these movements with force studies and muscle action. Consideration of a prob-
1cm of such complexity suggests that delimitations are necessary, and the present study
endeavors to present. but one component. in the displacement pattern of the low’er cx-
tremity.
Many investigators have reported their findings with regard to the movements of
the various segments of the body, as projected upon the parasagittal plane. Few’ have
described the motions projected onto the frontal plane. It is doubtful that any previous
observers have attempted to measure the transverse rotatory motions of the various seg-
ments of the low-er extremity, as projected upon a horizontal plane. It is conceivable that
little attention has been given to transverse rotatory motions, possibly because motion in
the parasagittal plane has usually been regarded as a more significant act-ion in human
propulsion.
Present indications are that transverse rotations of the various segments of the low’cr
extremity are an important factor in the ease and rhythm of walking of normal individuals.
In order to improve function, reduce fatigue, and prevent more or less continual abrasion
at critical points on the stump of the amputee, provision in the prosthesis for allow-ing
transverse rotations of the same order of magnitude as those in normal legs may be a major
contribution toward the improvement of artificial legs.
Transverse rotations, as discussed herein, refer to angular d!isplaccments of the
various bone segments of the leg about their longitudinal axes. Results are presented of a
study of these movements in twenty-six normal individuals, tw’elve of t’hom provided
completely satisfactory data.
The primary objectives in this study were:
1. To determine the magnitude of transverse rotations of the segments of the low’cn
extremity, and their relative transverse rotations with respect to each other.
2. To formulate ideas for design with regard to artificial limbs.

TECHNIQUES

Placenient of Pins

Stainless-steel threaded pins, 2.5 millimeters in diameter, were drilled firmly into the
contices of the various bony prominences adjacent to the hip and knee joints, sterile pre-
cautions and local anaesthesia being used. Targets, each consisting of a light w-ooden rod
w’it.h spheres attached! at tw-o points, w’ere fastened to the pins. Figure 1 shows pins No. 1,
No. &, and No. 3, placed in the iliac crest of the pelvis, in the adductor tuberele of the
femur, an(! in the upper portion of the tibia (tibial tubercle), respectively. The insertion
* In So’ptember 1945, a research project on prosthetic devices was undertako’n at. the Univo’rsity of
(‘alifornia, supervised by Professor H. D. Eberhart of the Civil Engineering Division. The work was initi-
ated by the National Research Council, at. the reQuest of the Surgeon General of tho’ Army. The national
program is directed by the Committee on Artificial Limbs of the National Research Council.

‘OI,. 30-A, NO. 4, OCTOBFR 194$ 85

S6() A. 5. LEVENS, V. T. INMAN, AND J. A. BLOSSER

of pin No. 2 into the medial sidle of tile femur ‘as dict-atco! by the fact that placement.
fm’om tile iat.eial aspect so restricted movement of the iliotihial tract. that motion at the
knee -as suppressed.

( ‘OlleCt’iofl of Data

A photographic t’ccoro! o1 the movement. of tile targets w’as obtained by three syn-
(‘11 ronizc(l 35-millimeter motion-picture cameras, operating at forty -eight frames per
second, with a shutter speed of 1, ‘96 second!, orientc(l at- distances of twenty-five feet from
the siibjO’(’t. The cameras were so located as to refer the targets to three mutually penpen-
oli(’ular (‘o-o)r(!inate ncfcrcn(’c planes ( Fig. 2 ) Iti this
. mannel’ top, front , and side views of

Fmu. 2
Fig. 1: Subject with limls and targets attached.
Fig. 2: Arramigemiient for recording pin-study data. (Re-
produo’ed, liv J)crn)issiomi, fromu Populer Scien.ce Monthly,
Flo;. 1 page 82, July 1947.)

the sul)jcct ‘crc obtaine(l simultaneously. A clock mechanism made it possible to identify
related frames , \Vhi(’ll we ii’ studied from enlarged! proj ectcd images.

Reduction of I)ata
The first method employed in the reduction of data made use of computed space
co-ordinates of the targets. This -as felt necessary to correct for possible errors due to
perspective amid parallax. Later it was found that. in certain cases the values of the angles
between pins, ol)tamed from orthogonal projections, compared quite favorably with values
obtained from measurements taken directly from the photographs, showing the projections
UOI1 the horizontal plane only.
Further study show’ed that. if the pins is’ene set horizontally or within 10 degrees of
horizontal, the angle between the pins, read directly from the photographs show’ing hori-
zontal projections, yielded! results that were w’ithin 2 degrees of the true values for the
middle 60 per cent. of the stance phase; the maximum variation between values obtained
by the two methods was 5 to 6 degrees at the instant of toe-off. Phase relationships were
not affected by the results obtained from the tw-o methods. The differences between
computed values and those obtained directly from the motion-picture frames were
not significant, since the variations were less t.han the variations among the individuals
tested.

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 THE SEGMENTS OF THE LOWER EXTREMITY IN LOCOMOTION 861

TABLE I
DATA ON AlA, SUBJECTS* FROM PIN STUDIES

Subject Age Weight Height It’niarks

(Years) (Pounds) (Feet) (Inches)

24 185 6 4 Mo’chan;cal difficulties; 110 olata

2 27 150 6 2 One pin only; no data

3 40 180 5 9 Pins miot set properly; ono’ Pill bemit
4 21 168 5 112 Excessive pin vibration
19 160 6 0 Excessive pin vibration
6 26 150 5 10 Excessive pin vibration
7 20 160 .5 1132 Excessive pin vibration
8 25 162 6 1 Satisfactory data
9 21 165 5 11 Gait affected by pins; no data
10 21 175 6 l3 Pin loosened; 110 runs made
ii 27 152 5 11 Satisfactory data
12 24 165 5 10 Satisfactory (lata
13 23 175 6 Satisfactory data
14 23 170 5 9 Satisfactory data
15 Below-the-knee amputee; no piis
16 27 152 5 3 Satisfactory data
17 21 180 6 2 Bad limp; pain; mio data
18 Bilateral amputo’e; 110 pins
19 Above-the-knee amput-co’; 1101 pillS

20 23 145 5 932 Limping; one leg short

21 28 140 5 6 Removed pin No. 1; paimi
22 28 175 5 8 Tibial pimi No. 3 broken
23 23 200 6 7 Satisfactory data
24 26 145 5 83 Satisfactory data
25 23 180 6 0 Satisfactory data
26 25 182 6 1 Pin No. 2 worked looso’
27 19 160 5 11 Satisfactory data
28 27 135 5 10 No comriplo’to’ usable o’yo’io’
29 21 160 5 7 I)ata 110)1 reduce:1

*Tii.o,Iit.,_5ix mio)rnial sul)jects and three aliih)utc’es.

Test Results
Twenty-six normal subjects, varying in age from nineteen to forty, i’ere studied.
No data were obtained from the first seven subjects because of excessive pin vibration,
bending of pins, single pin settings, and mechanical difficulties. Of the remaining nineteen
subjects, the data from seven i’ere not used for the reasons shown in Table I. Tw’elve of
the subjects were considered satisfactory for study and analysis. The pin data obtained
from the photographs w-ere plotted on a rectangular co-ordinate system, in w’hich the
horizontal axis represented time in seconds and t.he vertical axis represented transverse
notation in degrees.
Complete analysis has been made only of the data dealing w’ith the top view, in
straight. and level walking. Data dealing with front and lateral views, in straight and level
walking, will be presented in subsequent publications.

Discu-snion of Curves

Curves obtained from motion-picture records of twelve normal subjects performing

straight, level w’alking, as viewed from above, show-ed the same general pattern of action,
although the magnitudes of inward and outw’ard transverse rotation varied in individual
cases.
Detailed study and analysis of individual and composite curves of all subjects (Fig. 3)
had to he based on the action of both legs, since the significant. changes occurred with nela-

VOL. 30-A, NO. 4. OCTOBER 1948

862 A. S. LEVENS, V. T. INMAN, AND J. A. BLOSSEII

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864 A. 5. IJEVENS, ‘I. T. INMAN, AND J. A. BLOSSER

TABLE II

RANGE OF TRANSVERSE HTArmoN

Po’lvis-Pin No. 1 l’mniir-Pin No. 2 Tibia-Pili No, 3

Subject (Degrees) ( I)egrees) (I)egrees)

8 8.0 17.6 25.6

11 9.8 9.6 16.4
12 4.0 10.2 23.0
13 - 4.7 15.0 15.0
14 10.0 17.2 19.6
16 7.2 9.8 13.4
21 Notin 24.8 22.8
23 8.4 18.0 15.0
24 3.0 14.0 17.0
25 7.4 8.6 17.4
26 9.4 Loose 21.4
27 13.3 23.3 24.1

Maximum 13.3 24.8 25.6

Minimum 3.0 8.6 13.4
Average 7.7 15.3 19.2

tion to positions of each leg. The following leg positions proved to he of salient importance:
1. Toe (of extremity with pins) leaving the floor;
2. Foot. of sw’inging leg abreast of other foot;
3. Heel (of extremity with pins) striking the floor;
4. Foot fiat, other foot at toe-off;
5. Foot flat and abreast of other foot;
6. Heel (of extremity with pins) rising and heel of other foot- striking.
rrh time during ivhich the foot is in space is the swing phase, and the time d!uning
w-hich any part. of the foot is in contact with the floor is the stance phase. These two phases
comprise a w-alking cycle of one extremity.
From the time the foot of the pin-loaded extremity leaves the floor (toe-off), until the
moment it comes abreast of the other foot, the pelvis, femur, and tibia have start.e(l the
cycle of inw’ard rotation. At the time the feet. are abreast of each other, there is a definite
increase in the rate of rotation of the femur and the tibia. As the swinging leg continues to
move forward, there is considerable increase in inw’ard rotation until the heel strikes the
floor, and then a rapid increase until the other foot leaves the floor. At the peaks of the
curves, the pin-loaded extremity receives the full weight of the body. This period then,
from the time the foot leaves the floor until the full weight of the body is on the foot, is
characterized by inward notation of all segment-s (pelvis, femur, and tibia), the distal pants
rotating more than the proximal ones. Beyond this point, outward rotation of all segments
takes place until the foot of the pin-loaded extremity again leaves the floor; and is related
to the period of increased forward and upward acceleration of the body. Here again, the
distal segments rotate more than the proximal ones. In addition, the more significant
features of t.hese curves are related to weight-bearing, in that inward rotation starts with a
minimum of w-eight-bearing and terminates w’ith full weight-bearing, w’heneas outw’and
rotation starts i-ith full weight-bearing and ends w’ith minimal weight-bearing. Rotation
of the tibia is momentarily suppressed just as the heel-striking position is reached, while
the pelvis and femur continue inward rotation. Tibial rotation is again suppressed just
before the heel-rising position, while the pelvis and femur continue outward notation. This
is show-n in Figure 5-A for a single subject.
The magnitude and time of occurrence of the transverse rotation of the femur on the

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 THE SEGMENTS OF THE LOWER EXTREMITY IN LOCOMOTION 865

TABLE III

RELATIVE TRANSVERSE ROTATION AT Hm AND 1NEE JOINTS

DURING STANCE PHASE

Subject Fo’mmmr with Respect to Pelvis Tibia with Respect to Feniur

(Degrees) (Degrees)

8 7.4 8.2
11 6.3 12.0
12 8.6 11.1)
13 10.1 6.2
14 7.4 6.6
16 6.4 9.4
21 Pin No. 1 out 8.8
23 11.4 6.4
24 10.3 9.0
25 4.9 13.3
26 Pin No. 2 loose Pin No). 2 loose
27 11.1 4.1

Average 8.4 8.6

Stamidard deviation ±2.5 ±2.7

tibia are of particular interest to the clinician, for they are no doubt related to the locking
mechanism of the knee. When the knee is locked, inward notation of the femur occurs; and!,
in unlocking the knee, outw’ard notation takes place. Normally the knee locks and unlocks
twice in a-n average w’alking cycle, once during the last portion of the sw’ing phase and
again near the end of the stance phase. This action is’as cleanly show-n in high-speed motion
pictures of a number of normal subject-s. Cadence alt-ens the degree to w’hich the double-
locking action occurs, in that during slow’er rates of w’alking the knee tends to remain
ext-ended during the entire stance phase. The double locking is more apparent in the fast-er
cadences.
Ranges of transverse notation of the pelvis, femur, and tibia, as well as the maximum,
minimum, and average values in each case, are shown in Table II. These values were
obtained from the individual curves. While the magnitudes of transverse rotation vary
ill individual cases, it is of importance for the designer of mechanisms and for the clinician
tO) have a concept. of ranges of these motions and ie average values. Curves for a single
subject are show-n in Figure 5-A. The general pattern is similar to that of the curves shown
in Figure 3. As previously mentioned, however, the knee-locking effect is shown more dis-

TABLE IV
MAGNITUDES OF TRANSVERSE ROTATION OF THE PELVIS, FEMUR, AND TIBIA *

Transverse Rotation Relative Transverse Rotation

Member Range Average Members Rango’ Average

(Degrees) (Degrees) (Degrees) (Degrees)

Pelvis 3.0 to 13.3 7.7 Tibia with respect 4.1 to 13.3 8.7
to femur
Feniur 8.6 to 24.8 15.3
Femur with respect 4.9 to 11 .4 8.4
Tibia 13,4 to 25.6 19.3 to pelvis

* Complete data are shown in Tables II and III.

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866 A. 5. LE’ENS, V. T. INMAN, AND J. A. BLOSSE1(

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868 A. S. LEVENS, V. T. INMAN, AND J. A. BLOSSER

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Relation of rotation, in degrees, to percentile rank (during stance phase).

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 THE SEGMENTS OF THE LOWER EXTREMITY IN LOCOMOTION 869

tinctly in the tibia! curve. Note particularly the flattening of the curve near the heel-
striking an(! the heel-rising positions of the stance phase.
While it is important to know’ the ranges of transverse rotation of the p’lvis, femur,
and tibia, it is even more significant to learn of the magnitudes of relative notations of the
femur w’ith respect to the pelvis, and of the tibia w-ith respect to the femur, since such
values may have a bearing upon the design of artificial limbs, as w’ell as upon the functions
of the joints from a clinical point of view-.
Composite curves for all subjects, showing relative transverse notations of the tibia
w’ith respect to the femur (knee joint) and of the femur with respect to the pelvis (hip)
aie presented in Figure 4. In the former instance there is practically no relative rotation
during the period from the feet-abreast position to the locked-knee position of the swing
phase, and relative inward rotation of approximately 3.5 degrees occurs between the
locked-knee position and the full weight-bearing posit-ion. Beyond this point there is a
slight outward relative transverse rotation of approximately 1.5 degrees, during the in-
t-erval from the full weight-bearing position to the time flexing at- the knee occurs. This is
followed by a very slight mw-and rotation of about 0.5 degree, after which there is a marked
relative outward rotation of approximately 3.5 degrees as the foot reaches the toe-off
position.
The relative rotation of the femur with respect to the pelvis is also of considerable
interest. Throughout the period from minimal load to full weight-hearing, inward notation
of approximately 7 degrees occurs. From the fill! u-eight-bearing position to the toe-off
position, outward rotation of about 6.5 degrees takes place. It. should be reiterated that
this discussion of results deals only with transverse rotatory motions of the various seg-
ments low-en extremity,
of the as projected upon a horizontal plane, and only for the cases
covering straight and level w’alking.
In all subjects, the average relative notation of the tibia with respect to the floor w’hen
the foot is fixed on the floor-that is, during the major portion of the stance phase-may
be obtained from the tibia! pin curve. The magnitude of the relative rotation is approxi-
matelv 7 degrees mw-and, during the interval from 7 per cent. to 17 per cent. of the walking
cycle ; and it is approximately 8 degrees outward in the interval from 17 pen cent. to 43
per cent. of the w-alking cycle (Fig. 3).
Ranges of relative transverse rotation of the tibia with respect to the femur and of the
femur wit-h respect to the pelvis, as well as maximum, minimum, and average values for the
individual cases, are show-n in Table IV. Here again, variations exist in the magnitudes of
relative transverse rotations for the individual cases. A know’ledge of the possible ranges
and average values is of significance to both designer and clinician, since such information
w’ill he helpful both in developing mechanisms for the improvement of artificial limbs and
in a bet-ten understanding of locomotion.
Figure 5-B shows the relative transverse rotations at the knee and hip joints of one
subject. During the stance phase, in the interval from the heel-striking position to the
feet-abreast position, very little transverse rotation of the tibia with respect to the femur
takes place (about 1 to 1 .5 degrees) As the knee . locks, relative rotation increases inw-ardly
about 2.5 degrees, follow-ed by a rapid outward relative rotation of about 4 degrees as the
knee flexes to the toe-off position.
During the interval from the heel-striking position to the foot-flat position of the
stance phase, the relative transverse rotation of the femur with respect to the pelvis is
about 10 degrees inward, follow-ed by a shorter interval from the latter position to the
feet--abreast position, during which the relative out-w-ard.
rotation This is about 2 degrees
action is then followed by mw-and relative rotation of about 2 degrees, during the interval
from the feet--abreast position to the heel-rising position. From this point- on, fairly rapid
outw’and relative rotation of approximately 10 degrees occurs as the toe-off position is
reached.

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870 A. 5. LEVENS, V. T. INMAN, AND J. A. BLOSSER

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 THE SEGMENTS OF THE LOWER EXTREMITY IN LOCOMOTION 871

Arm klo’-m’otat ion mechanism oluring vitl king.

‘l’he relation to percentile i’ank of the relative rotations of the iemui’ with t’espect to
the pelvis, a.I1d of the tibia with iespect to the femur, is show’n in Figure 6. ( )m’olinate values
represent percentages of SuI)jects having magnitudes of Iotation less than the values shown
by the corresponding abscissae. The points for both cases-femur with respect. to pelvis
and tibia w’ith respect to femur lie -eny nearly on straight lines, indicating a normal
dist nil)iltiOIi pattern.
A sti’iking demonstration of relative transverse notation betw’een tile tibia and femur
at the knee joint is show’n in Figures 7-A and 7-B. The angular dhsplacement caused by the
change from the flexed position of the leg to the fully extended position is cleally seen in
the angular change between the targets.

SUMMARY AND CONCLUSIONS

TraIlSvel’se rotations of the pelvis, femur, and tibia occur in all normal individuals
(Table IV). Inward and! Outward! rotations of the segment-s are relate(l to weight-hearing.
Inward rotation takes place during the phase from minimal w’eight-i)eaning to full weight-
bearing, and outward rotation occurs (luring the phase from fill! weight-bearing to minimal
load.
The ro(ations of the low-er extremity appear to be absorbed in the articulations of the
foot and their related ligamentous structures.
Restrictions placed! upon the normal transverse notations will, to varying degrees,
modify the synchrony an(! rhythm of walking. The awkwardness an(l discomfort of a
patient., required to wear a leg brace w-hich does not provide for these rotations at the hip.
knee, and foot., are no doubt due, in pant., to the restriction of these motions.
At. the present time no prosthesis for t.he lower extremity has purposely incorporated
mechanisms to provide for transverse rotatory motions, except on an experimental basis.
Suppressing this rotation prevents the prosthesis from approaching t.he behavior of a
normal extremity, and thus requires alterations in the normal pattern of movement of the.

VOL. 30-A. NO. 4, OCTOBER 1948

872 A. 5. LEVENS, v. T. INMAN, AND J. A. BLOSSER

joints proximal to the amputation. Relative motion will take place where the resistance
to torque is the least. During weight-bearing in the stance phase, this motion will tend to
occur between the stump and the socket, producing a most uncomfortable force on the
stump. This is particularly true of the above-the-knee suction-socket limb. In the below-
the-knee amputee, in addition to the major rotations that occur between the trunk and
the fixed foot position, there is further restriction of rotatory motion at the knee, produced
by the side hinge bars connecting the thigh lacer and the shank. In the case of below-the-
knee amputees who have adequate stump length and shape, the use of suction sockets and
an ankle mechanism may make it possible not only to provide for transverse rotation, but
also to do aw’ay w’ith side hinge bars and lacers, w-hich tend to restrict the normal action
of the knee.
The incorporation of a simple mechanism w’hich provides for transverse rotation of
sufficient magnitude, together with a unit for the return of the foot to the normal position,
may well constitute a major contribution to both the comfort of the amputee and the
improvement of function and synchrony in walking. An experimental mechanism has been
used on this project. All amputees who have employed this mechanism have attested to
the very marked improvement in comfort. Figure 8 shows reproductions of frames, taken
from high-speed motion pictures, of an amputee using the experimental rotatory mecha-
nism. The frames selected for reproduction show the six salient positions of the foot during
the stance phase. Attention should be called to changes in the gap (A) between the stops;
the width of the gap shows the amount of rotation occurring betw-een the leg and the foot.
The ultimate incorporation of this device, or modifications of it, in a prosthesis may well
become standard practice, and may be advantageous in leg braces.

CWdPLETE DISLOCATION oF THE TALUS

BY WENDELL J. NEWCOMB, M.D., PENSACOLA, FLORIDA, AND

ERNEST A. BRAY, M.D., LOUISVILLE, KENTUCKY

This case is reported because of its rarity and because it demonstrates the need for
immediate reduction, the possibility of revasculanization, and the policy of preserving
the talus.

A man, forty-five years old, jumped from a moving vehicle and struck the occipital port-ion of his skull
against the ground. He suffered a mild cerebral concussion and, therefore, had no recollection of the mecha-
nism of his associated ankle injury. He arrived at the hospital about one hour after the injury, and treatment
wa-s rendered immediately.
Physical examination showed inversion of the right foot- with a marked prominence anterior to the
lateral malleolus. The skin was very tense over the prominence. The roentgenograms revealed rotation of the
talus 90 degrees about the horizontal and vertical axes. The position of this bone was transverse to the hori-
-zontal axis of the foot, and its posterior portion was lateral and anterior to the fibula. No fracture was noted
<Figs. 1 and 2).
The treatment, carried out with the patient under spinal anaesthesia, consisted of traction by means of a
Kirschner wire through the calcaneus, and countertraction on a Steinmann pin in the proximal portion of
the tibia. Considerable traction was necessary before pressure in a posteromedial direction, over the lateral
prominence, forced the displaced bone into the anteroposterior plane. Roentgenograms then revealed that
it had rotated 90 degrees about the vertical axis, while travelling the 90 degrees of displacement in the
horizontal plane.
The Kirschner wire and Steinmann pin were removed, and a toe-to-groin plaster was applied. This was
immediately split anteriorly. After one week the plaster was changed; at this time a small necrotic area was
THE JOURNAL OF BONE AND JOINT SURGERY