**Exam 1 relied heavily on knowing biomechanics review.

Not every blue highlight meant that

it was a direct answer to a question, but could mean that you had to know the material to cross
it off as a possible answer choice**

MEMORIZE EVERYTHING

Biomechanics Review

 Gait cycle
o Composed of stance + swing phase
 Stance phase = 65% of entire gait cycle
o Contact period= 27% of stance or 20% gait
o Midstance= 40% stance or 25% of gait
o Propulsive period= 33% stance or 20% gait
 Swing phase= 35% of entire gait cycle **Know for exam/life** *Exam 1 tested*
 Double support= 0-12% & 50-62% of full gait
 Functions of muscles
o To accelerate
o To decelerate
o To stabilize
 Tibialis Anterior- Acceleration functions
o Assist DF at toe off
o DF of first ray in early swing
o Assist toe clearance at midswing
 Tibialis Anterior- Deceleration functions
o Prevent excessive pronation of the foot during swing phase
o Supination of the forefoot **Know for exam/exam 1 tested** about the
longitudinal MTJ axis prior to heel strike, in preparation for forefoot contact
o Resist PF of the foot at heel strike
o Allows for smooth loading of the forefoot from lateral to medial during contact
period
o Foot will slap if no deceleration
 Gait cycle- Contact Period
o Heel strike of WB side to toe off opposite limb
 Contact Period- Compensatory Motions
o Prior to heel strike, lower extremity is internally rotated and heel strikes the
ground 2-3 inverted
o Internally position lower extremity then causes STJ pronation due to the fact that
talus is locked in ankle mortise
 o Pronation produces DF, eversion, abduction of foot w/ calcaneus everting 4
degrees beyond STJ neutral
o STJ passes thru neutral for the 1st time
 STJ passes thru neutral 2x in normal gait cycle
 Contact Period- Phasic Muscle Activity
o Anterior muscles (TA, EDL, EHL) decelerate ankle PF to slowly lower foot to
ground to prevent foot slap
o PT decelerates pronation **know for exam/exam 1 tested**
o Gastroc/soleus decelerate internal tibial rotation (exam 1 had an incorrect
answer choice stating gastrocs/soleus were involved in supination)
 Gait Cycle- Midstance Period
o Toe-off opposite foot and continues to heel-off of WB foot
o Foot transitions from pronating mobile adaptor to supinated rigid lever in
preparation for propulsion
 Midstance Period- Compensatory Motions
o During transition of pronation to supination
o STJ passes thru neutral for second time at 50-60% of stance during gait cycle
**Know for exam**
o Final position before heel-lift is when STJ is supinated, MTJ is max. pronated and
locked, foot is DF on leg at 10o
 Midstance Period- Phasic Muscle Activity
o **IT WAS ESSENTIAL TO REMEMBER BASIC MUSCLE ACTIONS IN GAIT TO PICK
OUT QUESTIONS. NEEDED TO KNOW WHEN THEY KICKED IN AND IF IT WAS
ECCENTRIC/CONCENTRIC**
o PT and soleus start to supinate on STJ while PB slows the extent of supination
o PL stabilizes the first ray and assists in weight distribution from lateral to medial
forefoot **Know for exam/exam 1 tested**
o Gastrocs/soleus decelerate forward ankle displacement of tibia and PF the ankle
join for initial heel-off
 Gait Cycle- Propulsive Period
o Heel-off to toe-off of WB foot
o For foot to be an effective lever for propulsion, foot must have resupinated prior
to entering propulsive phase
 Propulsive Period- Compensatory Motions
o Body moves over leg, shifting weight to forefoot
o Weight goes from lateral to medial forefoot to prepare to propel off stable hallux
o W/ hallux planted, the first ray PF w/ 65% degrees of passive DF at 1st MTPJ to
allow body to pass over foot *Know for exam/exam 1 tested**
o Soleus/PT assist w/ heel lift
o PL stabilizes first ray
o FHL, FHB, AbH, AdH stabilize hallux
o EHL DF hallux
 Swing Phase
 o Toe-off to heel strike
o Swing phase comprises the final 35% of gait cycle
 Swing Phase- Compensatory Motions
o Leg externally rotates after toe-off
o Leg internally rotates for remainder of swing phase
o Foot pronates at STJ for 1st 1/2 of swing to aid in ground clearance at midswing
o During second ½ of swing, STJ supinates to prepare for heel strike

 Musculature Action- Hip Extensors (gray bc not testable)

o Active from initial contact to midstance
o Support BW
o Extends hip
 Hamstrings
o Assist glut max during 1st 10% gait cycle
 Hip Flexors
o Eccentric to decelerate hip extension
o Followed by concentric
 Hip flexion for swing
o Active thru 1st half swing
 Last 50% = limb momentum
 Abduction
o Terminal Swing
o Medius active- prep for initial contact
o Medius + minimus -> Trendelenburg’s gait CONTRALATERAL pathology **Know
for exam/exam 1 tested**
o Active 1st 40% of cycle
 Eccentric during single limb support
 Controls contralateral drop of pelvis
 Followed by concentric
 Elevates pelvis in prep for swing
 Knee Flexion
o Terminal Swing- eccentric hamstrings
o Loading- assist hip extension
o Pre-swing + swing – minimal hamstring activity
o Exam 1 had a test question w/ info about “Pt has to abnormally flex hip and knee
to clear ground, what gait? -> high steppage, common peroneal nerve
 Ankle/Foot Musculature- Tibialis Anterior
o Initial contact- Eccentric
 Decelerate passive PF caused by body weight
 Controls foot slap
o Swing- Concentric
 Clears toes from ground **Know for exam/exam 1 tested**
 Extensor Digitorum + EHL
 o Initial contact- Eccentric
 Decelerates ankle PF
o Swing- Concentric
 Assists ankle DF
 Ankle PF (Gastroc-Soleus)
o Active most of stance
o Eccentric- controls DF
o Concentric- just before heel-off
o Initial swing
 Low activity of gastric- assist knee flexion
 Tibialis Posterior
o Eccentric- decelerates pronation 5-35% of gait cycle
o Concentric- Supinates foot midstance to toe-off 35-55% cycle **Know for
exam/exam 1 tested**
 Peroneal Muscles
o 20-30% cycle to after heel off
o PF
o Counteract foot inversion
o Align + stabilize STJ
o Peroneus longus
 Stabilize 1st ray on ground
 Rigid lever for propulsion **Know for exam/exam 1 tested**
 Description of Motion
o Typically in cardinal planes, but true mechanical axes are not perpendicular to
these cardinal planes
o Uniplanar- the axis of motion must lie in two planes and be perpendicular to the
third (the plane of motion) (sagittal)
o Biplanar- motion that occurs in two planes simultaneously
 The further an axis lies from any plane, the more motion there will be in that plane
 The closer an axis to any one plane, the less motion there will be on that plane
 Triplane Motion
o Axis of motion is angulated to all three planes and does not lie in any given
plane
o Motion will be equal if axis lies in all 3 planes at 45o
o Which plane most dominant? *important for flat foot determination*
 Significance of Axes
o Provide mobility as well as stability
o Single plane motion- “pure” plane motion
 Ankle and MTPH get “close” to single plane
o Triplane motion
 Motion occurring about an axis that is not aligned perpendicular to
cardinal planes, but at some angle to all 3 body planes
 STJ, MTJ, 1st and 5th rays
 Triplanar Motion
o Inversion/eversion always associated w/ supination/pronation regardless of
open/closed chain
o Pronation- Dorsiflexion, Eversion, Abduction
o Supination- Plantarflexion, Inversion, Adduction
 In open chain, talus is moving independent of the foot
 Ankle Joint- Talocrural Joint
 Primary motion of Talocrural Joint
o Ankle DF
 Occurs with abduction due to longer lateral talus
o Ankle PF
 Occurs with adduction due to longer lateral talus
 Talocrural ROM
o Normal ROM
 20o DF
 45-50o PF
o Gait requirements
 10o DF
 20o PF
o Axis Orientation
 Horizontal plane- axis runs posterolateral to anteromedial
 10o inclination in frontal plane, 20-30o transverse plane
 STJ- Talocalcaneal Joint
 STJ ROM
o Typically described by frontal plane component
o NWB ROM from STJN
 20o INV
 10o EV **Know for exam/Exam 1 Tested**
o Calcaneal component of STJ motion (relative to lower leg)
 In gait, ROM 8-12o total calcaneal INV/EV (WB)
 STJ- Axis Orientation
o Transverse Plane – 42o from transverse
o Sagittal Plane- 16o **Know for exam**
 Exam had an incorrect answer choice stating “42 degrees sagittal and 16
degrees transverse”
o Orientation travels in a plantar lateral direction from neck of talus thru sinus
tarsi to lateral wall of calcaneus
 STJ Open Chain Mechanics
o Pronation
 Calcaneal eversion
 Foot DF and abduction
o Supination
 Calcaneal inversion
  Foot PF and adduction
 STJ Closed Chain Mechanics
o Pronation
 Calcaneal Eversion
 Talus is adduction secondary to tibial IR
 Talus PF w/ secondary knee extension
o Supination
 Calcaneal Inversion
 Talus abduction secondary to ER tibia
 Talus DF w/ secondary knee flexion **Know for exam/exam 1 tested**
 Exam had a question like “in closed chain kinetics, these actions
occur with abduction”
 MTJ (Chopart’s Joint) Talonavicular joint, Calcaneocuboid Joint

 MTJ ROM
o Described about longitudinal and oblique axes
o ROM depends on WB or NWB position of foot and 1st ray stabilization
 Normal gait approx. 45 degrees
 More ROM needed for running, stair climb, squat
 MTJ – Axis Orientation
o Oblique axis
 54 degrees from trans. Plane
 57 degrees from sagittal plane
 Primary motion= abd/add
o Longitudinal axis
 5 degrees from trans plane
 9 degrees from sagittal plane
 Primary motion= in/ev
o Inversion about longitudinal axis and adduction about oblique =RAISE medial
arch
o Eversion about longitudinal axis and abduction about oblique= LOWER medial
arch
 MTJ and STJ Relationships
o In closed chain kinetics, STJ and MTJO move similarly, MTJL is opposite **Know
for exam**
 Exam 1 had an incorrect answer choice stating “MTJL moves similarly to
STJ”
o Amount of MTJ motion depends on STJ position
o Contact- STJ/MTJO pronate, MTJL supinates
o Propulsion- STJ/MTJO supinate, MTJL pronate
o STJ pronation= free motion at MTJ, axes are more parallel
o STJ supination= “locks” MTJ, axes are crossed, minimal STJ mobility

o Parallel-> unstabilize, flexible, hypermobile
o Perpendicular-> increased stability, propulsive gait (STJ supination)
 The First Ray
o Axis passes dorsomedially to plantarlaterally
o Motion of 1st ray is opposite to STJ
o DF/Inversion and PF/Eversion in a 1:1 ratio
 Maybe asked on this.. I think it said STJ 2:1 ratio, but know so you don’t
confuse
 First ray TROM influenced by the position of STJ
 Total relative motion of 1st ray will be increased w/ STJ pronation and decreased w/ STJ
supination
 Increase in 1st ray ROM w/ STJ pronation helps foot to become a mobile adaptor over
varied terrain during gait
 Decrease in 1st ray ROM w/ supination helps foot to become structurally more stable
(rigid lever) during propulsion
o Tricky question on the first ray….Question choices were essentially pick the right
answer “a) Increasing vertical plane will cause less motion in sagittal b) increase
in horizontal plane causes sagittal to increase c) increase in horizontal plane
causes transverse to increase”

 Pronation causes a more vertical orientation of 1st MTJ axis. This allows for greater 1st
MT adduction and loading on the lateral side of 1st MTPJ
o Door and hinge concept for pronation and vertical
 5th Ray- Similar Axis to STJ
o Not much focus on this, just know its similar to STJ, independent motion but
doesn’t play a huge part in foot function
 Root Theory
o Human foot functions ideally around the STJ neutral position, deviation ->
pathology
o Forefoot to RF frontal plane relationship ideally should be parallel
o Deviations from ideal positions are termed deformities
o Biomechanical treatments according to Root are intended to re-align the foot so
as to function around the neutral ST position and/or prevent frontal plane
compensation from a deformed foot

Rearfoot Varus

 Normal Foot
o From STJNP, foot can supinate twice as much as it pronates
o In STJNP, the foot should be neither pronated or supinated
o In STJNP, the MTP maximally pronated and locked
 Relationship w/ the FF to the RF should be perpendicular
 Met 1-5 should be perpendicular to a bisection to the posterior calcaneus
**Know for the exam**
 On exam, this was an incorrect choice for what foot type, I think
RF Valgum
 You must have 10 DF of the foot relative to the leg w/ the knee extended.
This measurement mimics the position that occurs at 50-40% of stance
phase, right before heel off
o There is no significant transverse or frontal plane influence on the foot from the
leg that would cause significant hyper-pronation
o Frontal plane development of the foot and leg determines the position of the
calcaneus at heel strike
o Normal foot strikes ground at 2-3 inverted because the STJ is supinated **Know
for exam**
o STJNP= (TROM/3) – eversion
 Example: 25 degrees inversion, 5 eversion: (30/3) – 5 = 5 degree inverted
**know for exam**
o Available Motion = TROM/3
 25 inversion, 5 eversion, STJNP 5 inverted, 5 tibial varum
 Foot is contacting ground at 10 inverted (STJNP + tibial)
 Total motion available= (TROM/3) = 10 (so this patient would be able to
fully compensate for their RF varus)
 Evaluating FF to RF Relationship
o Best w/ patient lying prone with feet off table **Know for exam**
o Place patient into STJNP (palpate TNJ congruency)
o MTJ maximally pronated and locked (pressure applied submet 4/5 **Know for
exam**
 Normal Foot
 Met 1-5 are in same plane and perpendicular to calcaneal
bisection
 Abnormal Foot
 Compensation refers to STJ
 RF Varus
o Any condition in frontal plane that will cause calcaneus to strike ground more
than 2-3 degrees inverted
 Coxa Valga (bow legged, isolated closure of medial epiphysis)
 Blouts
 Tibial varum
 Talar Varum
 Subtalar Varum
 Tibial Epiphyseal Varum
o RF Varus will only compensate to perpendicular-> will not go past to eversion
 Heel strike
o If foot is inverted too much, calcaneus must evert via STJ pronation to bring
medial column of the foot down to ground
o Calcaneus inverted 8 degrees at heel strike, STJ must pronate 8 degrees to fully
compensate
o Occurs only if motion available, if not, symptoms develop
 Types of RF Varus
o Defined by amount of compensation able to be achieved
o Each w/ own characteristic symptoms
o RF varus deformities will compensate to perpendicular **Know for exam**
 STJ pronates, partial unlocking of MTJ, abduction of FF on RF
 Uncompensated RF Varus
o No motion at STJ, calcaneus can’t evert **know for exam**
o Calcaneus is forced to function in an inverted position throughout the entire
stance of gait

o Tarsal coalition **memorize all foot types caused by this **

 o STJ trauma
o Muscle spasticity (UMN problem)
o LMN or other disease state- not always ontogeny related
o Bowing of calcaneus (intrinsic deformity, structural w/i calcaneus, requires
osteotomy)
 Exam question needed to know if spastic equinus was upper or lower
motor neuron
 Charcot Marie Tooth (PMP22)
o LMN disorder (demyelinating polyneuropathy)**Know for exam**
o Peroneal muscle atrophy with anterior muscle compartment atrophying 1st
o Poor muscle definition, extreme cavo-varus, extensor substation hammer toes,
inverted champagne bottle legs
o Unopposed posterior compartment maintains PF, lesions submet 1/5, subject to
lateral ankle sprains
 RF cant compensate for varus but FF can
o 1st ray PF and everts on its axis thru action of peroneus longus*
o 1st ray axis motion: DF/Inv and PF/ev **Know for exam**
o Brings medial forefoot down to ground- TRIPOD EFFECT
 Calcaneus, 1 and 5 are points of contact
o *Test question needed to know action of peroneus longus
 Uncompensated RF Varus
o Once 1st ray is PF
 1-5 relationship to calcaneus is everted
 2-5 is perpendicular
o Compensation thru first ray motion in this instance will not lead to HAV or HL/HR
 No hypermobility, 1st ray is stabile on the ground **Know for exam**

 Needed to know this to answer questions but can’t remember specifics

 Uncompensated RF Varus

o FF has adducted/supinate relative to RF

o High arched (cavus) foot type
 Maintained inversion of heel, PF 1st ray
  Poor shock absorption, can present w/ heel pain syndrome (increased
pressure, displacement of medial fat pad)
o Digital Contractures
 Intrinsic muscles unable to stabilize proximal phalanx to ground, buckling
 Mechanical advantage to contracted position (extensor substitution)
 Exam needed to know which arch heights was associated with
that foot type, had to answer for what arch height flatfoot was
 Uncompensated RF Varus Symptoms
o Tibial sesamoiditis- secondary to PF and everted position of the MT **Know for
the exam**
o Increased bipartite sesamoids
o Predisposed to repeated lateral ankle sprains secondary to fixed supinated
position
 Injury to ATFL, CFL, PTFL, avulsion fracture, ankle fracture
 Exam question tried to confuse w/ fibula sesamoiditis as an option,
needed to know what foot types were prone to lateral ankle sprains
o Callus along lateral column of foot
o Lateral shoe wear (exacerbates lateral ankle sprains)
o Lower back pain, lateral knee pain
o Iselin’s Disease- apophysitis of 5th met base in children
 Uncompensated RF Varus- Lesion Pattern
o Submet 1 and 5 keratomas
 Supination creates increased pressure laterally
 1st ray is plantar flexed under tibial sesamoid (everted metarsal) **Know
for exam**
 Increased pressure during stance, especially propulsion
o May have pain w/ or w/o callus formation

o
 Uncompensated RF Varus- Treatment
o Orthotics- stabilize high arch and redistribute weight away from metheads
 Forefoot extension, deep heel cup to shift fat pad back ** know for
exam**
o Debride lesions (pallative)
o Lateral Dutchman heel on shoe to help block supinatory motion/prevent sprains
o Padding to offload tibial sesamoid
 Partially Compensated RF Varus
o Some STJ pronation available
 Calcaneus everts, but not enough to fully compensate
 Medial forefoot doesn’t come all the way down to ground
  May have proximal varum deformity which leads to an excessively
inverted position at contact which the STJ can’t fully compensate for
o Calcaneus still functions in an inverted position, lateral heel contact
o Sprains and lateral shoe wear seen less frequently than in uncompensated
**Know for exam**
 Compensation is only relevant to RF varus at the STJ
 Partially Compensated RF Varus -Symptoms
o Develop pump-bump – irritation on posterolateral calcaneus **know for exam**
 Retroachilles and/or retrocalcaneal bursa/irritation
 Englarged posterolateral surface of calcaneus
 NOT Haglund’s- cavus foot, increased calcaneal pitch w/ prominence of
posterosuperior calcaneus centrally
 A bunch of questions had Haglund’s as an option for answer (do
not remember selecting Haglund’s as an answer for any)
o Treatment
 Orthotics (decreases need for compensation)
 NSAIDS (anti-inflammatory)
 Injections- into bursa, avoid tendon (can rupture, breakdown)
 Memorize all foot types get pump bump for exam
o Tailor’s bunion -Hallmark of partially compensated RF varus **Know for exam**
 Bowing/splaying of 5th MT
 Eversion/pronatory motion trying to bring medial FF down to ground
 Hypermobility of 5th ray axis
 Prominent 5th met head, adductovarus 5th digit
o Heloma Molle (4th IS)
 Treatment- 5th metarsal osteomy/osectomy- depending on severity
 Digital derotational arthroplasty
 Partially Compensated RF Varus- 1st Ray Symptoms
o If hypermobility is present, may have HAV in conjuction w/ Tailor’s bunion
creating splay foot type
o If PF of 1st met, will be less severe than uncompensated and not as
symptomatic- may have callus or bipartite sesamoid
 Partially Compensated RF Varus- Lesion Pattern
o Submet 4/5 keratoma and medial hallux pinch callus
o Lateral foot contact first, then medial shift produces abductory motion on hallux

o
 Fully Compensated RF Varus
o Pronation available at STJ is equal to amount of varus at heel strike
 o Heel can function perpendicular to the ground in stance
o FF is fully on ground and bears weight
o Rapid contact phase pronators – heel everts to perpendicular
o FF abducts relative to RF
 Maintains arch despite the hyper-pronation **Know for exam**
 Calcaneus only compensates to perpendicular, so the talus cannot
diverge medially
 Helbing’s Sign- medial bowing of the Achilles
 Due to eversion motion and if fully compensating for tibial/genu

varum (not STJ varum alone)

 Fully Compensated RF Varus – 1st ray Hypermobility
o Sagittal plane issues **Know for exam**
o Unlocking STJ and MTJ via pronation unlocks the 1st ray as you are WB
o Ground force pushes up on MT which can cause jamming at the 1st MPJ leading
to HL/HR
o Will only develop HAV if FF is adducted on RF
o Test had a bunch of questions about what plane stuff was happening at 1st ray
 Fully Compensated RF Varus- Symptoms
o Do not develop lateral foot symptoms
o Pump-Bump (know all foot types that develop this)
o Leg cramps, postural symptoms
o Pain submet 2 – secondary to hypermobility of 1st ray
o Hammertoes secondary to fatigue of intrinsics
 Retracted position of toes produce anterior displacement of fat pad,
leading to increased submet pressure (metatarsalgia)
 Fully Compensated RF Varus- Lesion Patterns
o Submet 2- hypermobility of 1st ray transfer weight laterally **Know for exam**
o Plantar hallux IPJ- in HL/HR, limited ROM at 1st MPJ, so the IPJ compensates
 o There was definitely a question about what causes submet 2 lesions, I think
answer choice was “hypermobility of 1st ray”
 Fully Compensated RF Varus – Treatment
o Neutral position orthotics w/ medial RF post **Know for exam**
o Supports deformity, maintain RF in inverted position, controls frontal plane
motion, foot does not have to pronate to reach ground – eliminates need for
compensation and therefore symptoms
o Surgery to address symptoms will still need to control w/ orthotic post op
 Exam question asked if lateral or medial RF to control w/ same degree,
remember- bring ground to deformity
 RF Varus Lesion Pattern Review
o Uncompensated
 Submet 1 and 5 keratomas
 Supination creates increased pressure laterally
 1st ray is PF -under tibial sesamoid (everted MT)
 Increased pressure during stance, especially during propulsion
o Partially Compensated
 Submet 4/5 keratoma and medial hallux pinch callus, possible submet 1 if
PF
 Lateral foot contacts first, then medial shift produces abductory
motion on hallux
o Fully Compensated
 Submet 2 keratoma
o **COMPLETELY BE ABLE TO REGURGITATE THIS- MEMORIZE ALLLL IT**

Rearfoot Valgus

 Rearfoot Valgus

o Frontal plane deformity
 Calcaneus is everted relative to the floor at heel strike
o Seen in early childhood development w/ subsequent development of equinus
due to valgus ankle **Know for exam**
  There was a question asking what foot type with equinus, don’t
remember wording
 Rearfoot Valgus
o Genu valgum
o Tibial valgum
o Ankle valgum
o STJ valgum
o Calcaneovalgus (triplanar, flexible flatfoot)
o Tarsal coalition (remember everything that is caused by tarsal coalition) **Know
for exam**
 Rearfoot Valgus
o Coxa vara genu valgum **Know for exam**

o Knock-kneed
o Etiology
 Development abnormalities
 Internal femoral torsion
 Elderly patients with arthritis
o Clinical Presentation
 Wide base of gait
 Significant lateral creasing of dorsal foot
 Flatfoot
 Rearfoot Valgus- Ankle Valgus
o Deformed fracture fibula
o Premature closure of fibular epiphysis
o Fibular hemimelia/agenesis
o Tibial pathology (fracture, premature closure of lateral distal tibial epiphysis)
o Fibula bears 20% of weight, acts as a lateral strut/support ankle joint
o If fibular pathology as above, the ankle will shift into valgus
o Ankle valgus will produce RF valgus (STJ)
 Rearfoot Valgus
o The calcaneus strikes everted w/ no mechanism to invert
 Leg is internally rotating
o Normal WB and internal rotation of leg leads to needed/normal pronation for
gait
 Striking everted leads to severe pronation and symptoms
 o STJ maximally pronates and unlocks MTJ- collapse of medial arch and flatfoot

**Know for exam**

o GFR pushes up on medial FF
 Significant inversion about longitudinal axis of MTJ
 Brings the lateral FF to the ground
o Results in a FF supinatus **Know for exam**
 Supinatus vs. FF Varus
o Supinatus is a triplane, soft tissue deformity
 Maintained by TA tendon, dramatic effect on 1st ray/medial column
 Results in as much as 20 degrees of FF inversion relative to the RF
(compensatory deformity)
o FF Varus is a fixed, osseous deformity of frontal plane
 FF is inverted relative to RF
 Otogenic/result of abnormal frontal plane development of the head/neck
of the talus relative to the body **know for exam**
o Clinicial presentation
 Medial bulge- talar head and navicular tuberosity protrude medially
 Due to TV plane dominance of oblique MTJ
 Entire foot abducts w/ added abduction of FF on RF
 Longitudinal arch drops
 Due to motion in sagittal plane around oblique MTJ
 Rotation of medial column at TNJ
 Due to frontal plane motion at longitudinal MTJ leading to
supinatus

o Hallux IPJ pinch callus due to rolling off mechanism **Know for exam**
o Adductovarus 5th digit w/ dorsolateral corn
o Medial heel wear
 o Calcaneal fat pad shifts laterally (medial heel pain, calcaneal apophysitis in kids)
o HAV due to excess pronation

 Know what foot types cause HAV

 Clinical Presentation of RF Valgus
o Postural symptoms due to instability
o Sinus tarsi symptoms secondary to lateral pinching
 Pain during attempted supination bc PB is tight (in spasm)
 AKA peroneal spastic flatfoot (PB, not PL)
 If present in children, think tarsal coalition
o Equinus- DF limited due to contracture of Achilles (due to pronation)- may lead
to HL/HR **Know for exam**
 Evaluation of RF Valgus
o Have patients perform single/double heel raise
 Mimics propulsion , calcaneus should invert **know for exam**
 If no inversion, indicative of PT rupture/disease or RF valgus
o Calcaneus remains everted and abducted, FF is inverted relative to RF due to
supinatus

 Treatment of RF Valgus
o General orthotic management
 Maintain STJ neutrality
 Allow for normal pronation/supination
 Provide stability in all 3 planes
 Allow for medial and lateral column function
 Allow for normal foot development (peds)
o Will NOT tolerate neutral position orthotics **know for exam**
 Since they can’t fully compensate, does not help to be in a rigid orthotic
that supports the deformity
 Need a soft orthotic to alleviate symptoms while allowing for some
pronation
  Orthotics for RF Valgus
o DSIS- Dynamic Stabilizing Innersole System
 Long medial and lateral phalange- prevents abduction of FF
 Deep heel cup to prevent fat pad migration
 Not completely rigid w/ central cut out to allow spreading of good
 Triplane control- calcaneus is held in 5 inversion, some sagittal TNJ
control
 If you can control RF, PL may be able to de-rotate the medial column and
reduce the supinatus **know for exam**
 Ankle Valgus
o Can’t be treated with an orthotic
o Consider wedge osteotomy of the tibia (medial base)
o Inverts the tibial plafond into a neutral position
o Epiphysiodesis – peds patients with open tibial growth plates
o Staple across distal medial tibial epiphysis to stop growth medially while allowing
the lateral aspect to grow
o Rebalance joint position
o MAFO – holds foot in alignment with leg
o Imparts STJ stability, but has potential to cause medial ulcerations

Forefoot Valgus + Varus

 RF Varus
o Any condition in the frontal plane that will cause the calcaneus to strike the ground
more than 2-3 degrees inverted
o Coxa Valga Genu Varum (Bow-legged, isolated closure of proximal medial epiphysis)
**Know for exam**
o Rickets (Children, Vitamin D deficiency)
o Blount’s
o Tibial Varum
o Talar Varum
o Subtalar Varum
o Tibial Epiphyseal Varum
 There was a question about knock-knee being what foot type
 Types of RF Varus
o Uncompensated
o medial foot can’t go to ground-> peroneous longus brings first ray to PF 1st ray
**Know for exam**

 Partially Compensated

 Fully Compensated
o STJ has enough motion to get to perpendicular to get medial column to ground
o

 RF Varus Lesion Pattern Review

o Uncompensated
 Submet 1 and 5 keratomas
 Supination creates increased pressure laterally
 1st ray is plantarflexed – under tibial sesamoid (everted metatarsal)
 Increased pressure during stance, especially propulsion
o Partially Compensated
 Submet 4/5 keratoma and medial hallux pinch callus, possible submet 1 if PF
 Lateral foot contacts first, then medial shift produces abductory
motion on hallux
o Fully Compensated
 Submet 2 keratoma **know for exam**
 RF Valgus
o Frontal plane deformity
 Calcaneus is everted relative to the floor at heel strike
o Etiologies
 Genu, Tibial, Ankle, STJ valgum
 Tarsal coalition
 Clinical Presentation of RF Valgus
o Medial bulge – talar head and navicular tuberosity protrude medially
 Due to TV plane dominance of the oblique MTJ

o Entire foot abducts w/ added abduction of FF on RF

o Longitudinal arch drops
 Due to motion in sagittal plane about oblique MTJ
o Rotation of Medial column at TNJ
 Due to frontal plane motion at longitudinal MTJ leading to supinatus
o TMT-> drop in arch height, needed to know WHY too many toes sign for exam
 Forefoot Valgus
o Single plane osseous deformity where FF is everted relative to calcaneus
o After heel strike, calcaneus must invert rapidly during the contact phase leading to
“supinatory rock” to bring lateral column down
o Produces a predominantly cavus foot type (high arch)
 Asked about what kind of foot type for FF valgus, need to remember cavus
o After heel strike, the tibial sesamoid is the first structure to contact the ground
**Know for exam**

 Total FF Valgus
o Rigid deformity
o Can lead to lateral knee pain /postural symptoms
 o Instability in TJ compelx
o Frequent lateral ankle sprains, ATFL pathology
o Sinus Tarsi syndrome
o Pump bump (dude to supinatory rock) **know for exam**
o Heel pain to due poor shock absorption (fat pad shifts medially due to rapid heel
inversion)
o Cavus foot type w/ extensor substitution HT
o Submet 1/5 lesion (contact and rock)
 Flexible Forefoot Valgus
o Flexibility in the MTJ allows lateral column to reach ground
o Heel may still function perpendicular to ground
o Amount of compensation leads to unstable gait and excess pronation
o Appears as a cavus foot when NWB
o Flat when WB
o Can result from un- or partially-compensated RF Varus
 Forefoot Valgus – PF 1st Ray
o Valgus is caused by excessively plantarflexed 1st ray **know for exam**
o Mets 2-5 are perpendicular to heel bisector and parallel to ground

 Forefoot Varus
o Single plane osseous deformity
o Attributed to abnormal position of the head and neck relative to the body of the
talus **know for exam**
 Normal development – head and neck undergo valgus torsion
 Doesn’t occur fully in FF varus
o Medial column does not come down to the ground
 FF inverted relative to RF

 Important Distinction
o Rearfoot Varus
 Calcaneus hits inverted/forefoot is relative to ground
  Compensates to perpendicular and medial column is down, some arch
height maintained

o Forefoot Varus
 Calcaneus hits perpendicular, forefoot is inverted relative to ground
 Compensates by STJ eversion past perpendicular to get the medial column
down
 Lose arch height (STJ pronation, MTJ unlocked)

 Combined RF Varus and FF Varus

o Both STJ/calcaneal inversion and FF inversion
o Forefoot is structurally inverted, not positional as in RF Varus
o Final position of foot is dependent on amount of motion available at STJ

 Forefoot Varus vs Supinatus

o Supinatus – triplane, soft tissue deformity
 Maintained by TA tendon, dramatic effect on first ray/medial column
 Results in as much as 20 degrees of forefoot inversion relative to the
rearfoot (compensatory deformity)
o Forefoot Varus- fixed, osseous deformity of frontal plane **know for exam**
 Forefoot is inverted relative to the rearfoot
 Ontogenetic/result of abnormal frontal plane development of the head/neck
of the talus relative to the body
o Supinatus - up to 20 degrees inverted to RF
 o Varus - usually only 5-7 degrees inverted to RF
o If STJ is able to pronate to fully compensate for the FF Varus and still has more
pronation available (over-pronates), then may get a FF Supinatus superimposed on
FF Varus (to bring lateral column back down) **know all of this**
 Uncompensated FF Varus
o Not enough available motion at STJ to bring medial column down
o 1st Ray PF to balance foot
o 1-5 relationship is perpendicular to calcaneal bisector, 2-5 is varus
o Normal lateral shoe wear
o Submet 1 and 5 callus
o Tailor’s bunion **know for exam**
o Adductovarus 4/5 HT
 Fully Compensated FF Varus
o STJ pronates past perpendicular, unlocks
MTJ
o Pronates longer into gait cycle, less stable going into propulsion
 Fully Compensated FF Varus -Clinical Symptoms
o 1st Ray hypermobility leading to HAV
o Diastasis at 1st/2nd MCJs exacerbating hypermobility
o Hammertoes - EDL mechanical advantage over plantar interossei
o Submet 2 callus (hyperpronation/hypermobility)
o Hallux pinch callus (roll off during propulsion)
o Helbing’s Sign – medial bowing of Achilles due to calcaneal eversion
o No arch height
o Abducted FF on RF
o Prominent talar bulge medially
o Concavity inferior to lateral malleolus

 Fully Compensated FF Varus Radiographically

o DP
 Lateral deviation of calc/cuboid/navicular and medial deviation of talus
 Medial bulge may be from talar deviation, gorilliform navicular, os tibiale
externum
 Increased Kite’s angle
 Forefoot abduction, increased cuboid abduction, deviation of talar-1st met
angle
  These findings are a result of the STJ pronating to bring the medial column
down to the ground

o Laterally
 Decreased calcaneal inclination angle (equinus component)
 Obliterated sinus tarsi
 Anterior break in cyma line
 Increased talar declination angle, offset of Meary’s
 Midfoot fault
 Supinatus
 Superimposition of lesser mets in addition to above findings **know
for exam**

 Orthotic Management
o Medial forefoot post measuring the same number of degrees clinically
 Prevents the need for compensation (supports the deformity)
o NWB neutral position cast with forefoot fully loaded
 Cast is placed on flat surface, the movement of the cast mimics the
compensation (eversion to bring medial column down)
o Note: If Supinatus, you can’t post to the deformity because too extreme
 Control the hyperpronation so PL can derotate the supinatus – then place a
smaller forefoot post **know for exam**
o DSIS
 Advanced hyperpronation only
 Deep heel cup
 Medial and lateral phlange out to met necks (control TV plane motion,
prevent HAV/forefoot abduction)
 Hallux Abducto Valgus
o Etiology: Hypermobility of 1st ray secondary to compensation (hyperpronation of STJ
and unlocking of MTJ) **know for exam**
o Hyperpronation in frontal and TV planes---MTJO unlocks---adductor hallucis pull-
 o --hallux and sesamoid displacement---STJ pronation---hypermobility of 1st ray---
increased IMA---functional/structural elevatus---HL/HR
o Associated with Flexor Stabilization hammertoes
o Treatment: Conservative vs. Surgical
 Hammertoes
o Extensor substitution, flexor stabilization, flexor substitution
o Biomechanical etiology
 Hyperpronation
 Intrinsic fatigue of lumbricals and interossei resulting in extensor/flexor
muscle imbalance and anterior shift in fat pad – long flexors buckle the toes
and extensors DF at MPJ
 Intrinsic fatigue---loss of propulsive stability---contracture of extensors
leading to DF at MPJ--- flexor contracture leading to distal buckling---HAV---
intrinsic contracture---ST adaptation
o Cavus foot
 Digits are DF relative to the mets due to an increase in met declination
 Extensors and interossei gain mechanical advantage: extensors buckle and
interossei DF at MPJ

 Tested on the starred picture for a fill in the blank question

Equinus

 Less than 10 degrees DF at ankle

 Approximately 10 degrees of DF is needed to progress thru normal gait cycle **know for
exam**
o 10 degrees of DF w/ knee extended correlates to 50-50% of stance phase (end of
midstance)
o Thigh is fully extended relative to pelvis, knee is fully extended and foot is DF
relative to leg
 Anatomical Structures of Equinus
 o Gastroc-Soleus Is the largest posterior compartment structure and exerts the
most force at the ankle
 Gastroc crosses knee, ankle, STJ
 Soleus crosses ankle and STJ only
o Anything that passes posterior to the ankle joint axis can have an effect on DF/PF
at the ankle (not necessarily its primary function)- TP, FDL, FHL, Peroneals
 Etiology of Equinus
o Most patients have secondary equinus
 Primary is usually congenital
 Decreased flexibility with age
 ROM naturually diminishes as we age
 Kids have more ROM and can DF 15 degrees extended and 20-25
flexed
o Ex: an adult w/ 5 degree F does not necessarily have
primary equinus or symptoms bc they may have adapted
o Wearing heels over a long period of time
o Trauma
o Neurological conditions
o Growth- bone grows faster than muscle
o Arthritis at the ankle
o Tonic contracture/spasms of the posterior muscles
o Knee flexion contractures
o Cavus foot (osseous equinus)
o Pronation in forefoot varus (secondary equinus)
o Charcot- DM foot breakdown
o Clubfoot (talipes equino varus)
 Triplane deformity including equinus, adductus and varus position
 Equinus- How to assess
o Place STJ in neutral and MTJ max pronated and locked
 Thumb pressure under 4/5 and DF foot
o Can place into slight supination to help prevent distal compensatory mechanisms
that would falsely increase the measured DF
o Goniometer placement
 One arm in line with the fibula (fixed arm)
 Hinge over lateral heel
 Second arm in line with the lateral calcaneus at glabrous junction (mobile
arm)
 Equinus- How to assess
o Do not evaluate off 5th MT – measurement is based on the calc/rearfoot only
 The patient may be getting some DF thru MTJ
o Silfverskiold Test
 Evaluate w/ knee straight and flexed
 Greater DF should be achieved in flexion (15) vs extension (10)
  If patient is able to achieve full DF with knee flexed, but not w/ knee
straight, then gastric equinus is present **know for exam**
 If patient is not able to achieve full DF in flexion or extensions, then
gastro-soleal equinus is present
 Radiographically
o Negative calcaneal inclination angle
o Increased talar declination
o Anterior break in Cyma line
o Obliterated sinus tarsi
o TN/CN fault
o Forefoot supinatus with superimposition of mets
o Possible elevatus of 1st met
o Increased Kite’s angle
o Medial talar uncovering
o Lateral calc and forefoot abduction
o Increased cuboid abduction angle
o Kidner findings – os tibiale externum, gorilliform navicular
 Pseudoequinus
o Known as Anterior equinus/anterior cavus
o Relative PF of the FF relative to RF
o Apex at midfoot
o May involve purely the MT or include tarsal bones as well
o False ankle equinus may be measured if focusing on the relationships of the leg
to FF
o Not a limitation in ankle DF, rather than an increased demand for DF
 Osseous Equinus
o Associated w/ cavus foot type
o Calcaneal inclination angle is increased, talus sits high in the mortise
which reduces available DF
o May also be associated w/ a bony block or spurring off the anterior tibia
or dorsal talar head/neck
 Pt may have nerve symptoms, in addition to limited DF, as this
may impinge on anterior NV bundle
o Can check stress F lateral view to evaluate- will see abutment of the tibia
+ talus
o No indication for tendon lengthening- boney block is the issue and resected
 If evaluated intra-op following resection and superimposed ST
component, could consider tendon lengthening
 Spastic Equinus
o Upper motor neuron lesion **Know for exam**
o Babinski test
 Negative/down-going Babinski- normal, toes curl/PF
 Positive/up-going Babinski- UMN (less than 1 years old, normal)
 o May also quickly DF the ankle
 If clonus results, may indicate UMN pathology/spasticity- foot
beats/oscillates 8-10 cycles per second
 Clonus may present in young pts in the absence of UMN pathology
 Spastic Equinus – Treatment
o Soft tissue procedures will fail bc problem is hyperinnervation, so following the
lengthening, the tendon will shorten more
o Murphy Procedure
 Detach/reattach of Achilles to superior surface of calcaneus near the
ankle **know for exam**
 Anterior advancement shortens the moment arm and the tendon will
have less effect on ankle (door/hinge concept)
 Uncompensated Equinus
o Primary, congenital condition
o Patients walk on toes
o Inverted heel off ground w/ entire foot in equinovarus position
 Compensated Equinus
o Hyperpronation at STJ, MTJ unlocks – DF they can’t accomplish at the ankle is
now coming from oblique MTJ axis
o Leads to unstable foot during propulsion
o Collapse arch w/ abduction of FF
o May see a midfoot break or plantar convexity
o In gait, this appears as a peeling off the foot instead of lifting as one rigid beam
o FF supinatus develops to keep lateral foot on the ground and is maintained by TA
o Extensor substitution – EDL excessively DF the digits to try to help the foot clear
the ground during swing
o Flexion at the knee- helps decrease the equinus force of the gastric
o Abduct/externally rotate the lower extremity – increases angle of gait, reduces
amount of DF needed at ankle
o Shorter stride- decreases extension of thigh, which decreases the amount of DF
needed at ankle
o Early heel rise
o In stance, patient’s heel may appear to be off ground due to negative calcaneal
inclination angle; may also be seen in genu recurvatum
 Compensated Equinus – Symptoms
o Similar to severely pronated foot
o Heel pain- stretch of PF on medial tubercle
o Arch pain- due to collapse
o Early leg fatigue – child related growing pains or tired muscles in adults
o Bunion – JHAV occurs in primary equinus, hallux drifts laterally and digits retract
secondary to pronation
o Calf pain
o Hammertoes
o Plantar FF keratomas
 o Lower back pain
o Calcaneal apophysitis- children w/ open posterior growth center
 Traction and compression environment – compression from gorund,
traction from PF and Achilles – if Achilles is tight and PF stretches in
pronation it will cause irritation (self limiting, apophysis may appear
fragmented which is normal)
o Squeeze the heel to produce symptoms
 Compensated Equinus – Lesion Patterns
o Plantar forefoot calluses due to increased PF force
o May be seen in the submet 1-5 distribution if FF varus or pronatory foot type
 Compensated Equinus – Conservative Treatment
o Children w/ compensated Equinus
 DSIS – controls 3 planes, allows for normal motion and med/lat column
function, allows for normal growth, reduction of FF varus or supinatus,
deep heel cup, medial and lateral phalanges
o Stretching
o Heel lifts w/ gradual decrease
 Compensated Equinus – Surgical Treatment
o Tendoarchilles Lengthening vs Gastrocnemius Recession
o TAL if GS equinus- triple hemisection, Z-slide
o GR is gastro equinus only- various approaches
o Resection of boney block- if osseous equinus
o Fusion of ankle if intra-articular pathology
o For a pronatory foot
 TAL/GR
 PT tendon advancement (Kidner)
 PB lengthening
 Young’s tenosuspension
 Arthroeresis- children, props up the talus and blocks hypertension
 Murphy advancement (spastic equinus) **know for exam**
 Evans/Kouts/Cotton
 Triple- if rigid/arthritis
 Coalition resection

Lab 1 Material

 Palpation
 STJ Neutral
o Can be supine or prone
o Right Foot Evaluation
  Left thumb submet 4/5 to manipulate/load FF, achieve neutral ankle
positioning
 Right thumb and index finger placed on side side of TN joint
 Right thumb and index finger palpating for congruency of TNJ as left hand
moves FF
 Once TNJ congruity achieved, DF/load foot w/ left thumb submet 4/5 -
this is now neutral
 FF to RF Assessment
o Best observed in prone position
o Left Foot Evaluation
 Find STJ Neutral using left thumb submet 4/5 and right thumb/index
finger palpating TNJ
 Once in neutral, maintain 4/5 submet loading and examine position of
heel w/ ground (can draw a perpendicular bisector)
 Evaluating plane of FF and RF relative to plane of the ground and relative
to each other
 Evaluating if parallel planes or if one is inverted/everted relative to
other/ground
 1st Metatarsocuneiform Joint (1st tarsometarsal joint)
o Joint between 1st MT base and medical cuneiform
o Important in bunion and flatfoot evaluation, looking for hypermobility
o Have patient actively try to invert/DF foot- identify tibailis anterior tendon and
trace down to insertion- the tendon starts at 1st TMTJ
 Navicular Tuberosity
o Bony prominence at medial midfoot, insertion of posterior tibial tendon
o Readily palpable on most patients, larger in those accessory
navicular/gorillaform navicular
o Important when evaluating patients with flatfoot and PT tendon symptoms
 5th Metatarsal Base
o Bony prominence of lateral midfoot, insertion of peroneus brevis tendon
**know for exam**
o Readily palpable on most patients, flares out as palpating proximally along 5th
met shaft
o Important when evaluating patients w/ peroneal tendon symptoms
 Sustenaculum Tali
o Medial shelf of the calcaneus
o FHL courses underneath
o Not readily palpable, forms the medial floor of the STJ (anterior/middle facet)
o May be able to appreciate FHL motion if manipulating 1st MPJ
o Important when evaluating FHL pathology, calcaneal fracture, tarsal tunnel
symptoms
 Sinus Tarsi
 o Palpated laterally, thumb sized delve just proximally to EHB muscle belly and just
anterior to lateral malleolus
o Bifurcate and cervical ligaments overlie the area, access point to STJ if giving an
injection
o Important when evaluating patients with flatfoot and laterally based symptoms,
as the area becomes compressed and inflamed in this position
 Anterior Talofibular ligament (ATFL)
o Part of lateral ankle ligament, intra-capsular
o Anterior/inferior border of the lateral malleolus to talar neck
o Important for evaluating ankle injury, most commonly injured of all 3 ligaments
o Not palpable
o Best tested with anterior drawer test **know for exam**
 Calcaneofibular Ligament (CFL)
o Parts of lateral ankle ligament, extra-capsular
o Runs from inferior margin of lateral malleolus to lateral calcaneus
o Angle between ATFL and CFL is 105
o Not palpable
o 2nd most commonly injured
o Best tested with Talar Tilt Test **know for exam**
 Test question about external rotation, included CFL as a choice
 Posterior Talofibular Ligament (PTFL)
o Part of lateral ligament complex, intra-capsular, least commonly injured
o Runs from posterior/inferior margin of lateral malleolus to posterior talar body
o Not palpable
 Deltoid Ligament
o Medial ankle ligament complex, comprised of deep + superficial bands
o Runs from medial malleolus w/ slips to talus, calcaneus, navicular
o Not palpable
o Best tested w/ palpation, reverse talar tilt, and DF External Stress Rotation Stress
Test
 Test question on what was being tested during the ERT
 Syndesmotic Complex
o Comprised of Anterior Infertior Tibiofibular ligament (AITFL), interosseous
ligament, and posterior inferior tibiofibular (PITFL)
o Palpate anteriorly just above ankle joint line at tibo-fibular juncture
o Best assessed clinically with Tib-Fib Squeeze Test, and DF External Rotation
Stress Test **Know for Exam**
 Fibular Head
o Bony prominence laterally just distal to the knee, in line with tibial tuberosity
o Important in ankle injury evaluation, suspected fracture but no fracture line
visualized at lateral malleolus and with patients preseting with neurologic
symptoms to dorsal foot (common peroneal nerve courses around fibular neck)
 Hip Evaluation
o ASIS – Anterior prominence of Ilium
o PSIS – Posterior prominence of Ilium
o Iliac Crests – superior margins of Ilium/pelvis
o Greater Trochanter – palpable prominence at hip

 Goniometry- Special Tests

 Silfverskiold Test
o Think silver-FOLD test -> fold the knee
o Testing Equinus – Loading 4/5 met, measuring DF with knee extended (both
gastrocs and soleus in play)
o Bending the knee to knock out the gastrocs and remeasuring the DF
o If more DF when bent -> gastric equinus
o If no change -> both gastrosc and soleus equinus **know for exam**
 Needed to know this super in depth!
 Apparent vs True Limb Length
o Apparent: from the navel to the tip of a medial malleolus
o True limb length: inferior surface of ASIS to tip of medial malleolus
 Allis Test
o Femur leg length measurement **Know for exam**
o Legs bent at 45 degree angle
o Put ruler on tibial tuberosity and look for angling
o If one femur is longer -> that leg will be pushed forward, leading to a visible
angle
 Anterior Drawer
o Supine
o Grip leg above ankle and smoosh into table
o Take heel and pull upwards
o Testing ATFL (the weakest of all syndesmotic ligaments) **Know for exam**
 Talar Tilt
o Supine
o Grab ankle and smoosh into table
o Take heel and push it medially
o Tested CFL **Know for exam**
 Reverse Talar Tilt
o Supine
o Grab ankle, smoosh into table , take heel and pull it laterally
o Testing for deltoids (medial ligaments) **Know for exam**
 Thompson Test
o Prone
o Leg in the air squeezing the back of the calf, the foot appears to PF **Know for
exam**
 Mulder Click
o Supine
o Grasp the edges of the foot dorsally and squish them together, arching the the
other hand pinching above and below the 3rd/4th me
o Clicking for Morton’s Neuroma
 External Rotation Stress Test
o Supine
o One hand squishing the leg into the table, other hand cupped around the heel,
forcibly externally rotating
o Testes the deltoid ligaments and interosseous ligaments **Know for exam**
 Test question was on the interosseous ligaments
 Tib-Fib Squeeze Test
o Supine
o Place heels of hand on either side of calf and squish together
o Tests syndesmotic complex – ATFL (weakest), interosseous, PTFL (strongest)
**know for exam**
 Homan’s Sign
o Supine
o Squeezing calf while passively DF the ankle
o Testing for deep vein thrombosis
 Coleman Block Test
o Tells us if varus is flexible or rigid
o Place block under lateral FF
o Varus switches to valgus -> STJ is flexible
o Block allows the FF to pronate
o If foot remains varus after block -> STJ is NOT flexible and need to correct FF
pronation + hindfoot rigid varus **know for exam**
 Heel Raise/ Toe Raise
o Heel raise - Valgus hindfoot (with Too Many Toes), switches to varus w/ heel lift
o Another way of testing STJ flexibility
o Toe Raise – takes advtange of windlass, toe up, arch elevates bc of Windlass
effect (a flexible STJ allows this to happen)
 Lab 2

 STJNP, the foot can supinate twice as much as it pronates

 In STJNP, the foot should be neither pronated nor supinated
o STJNP= (TROM/3) – eversion
o TROM= inversion + eversion

 Calculating STJNP= (TROM/3) – eversion

o Ex: 25 degrees inversion, 5 degrees eversion: (30/3) – 5 = 5 degrees
inverted**know for exam**
 Available Motion= (TROM/3)
o Ex: 25 inversion, 5 eversion, STJNP 5 inverted, 5 tibial varum
o Foot contacting ground at 10 degrees inverted (STJNP + tibial)
o Total motion available- (TROM/3) = 10 (so patient can fully compensate for RF
varus
 Example problem:
o 10 degrees inversion
o 2 eversion
o 5 tibial varum
o STJNP = (10+2)/3= 2
o (12/3) = 4 degrees inverted PLUS 5 degrees in from varus = 7 inverted
o AM= 12/3 = 4 degrees of motion available, CANNOT FULLY COMPENSATE
 Example problem:
o 5 degrees inversion
o 4 eversion
o 2 tibial valgum
o STJNP= (5+4)/3 -4
o (9/3) -4 = -1 (1 degree everted) PLUS 2 valgum = 3 degrees everted
o AM= 9/3 = 3 degrees available, CAN FULLY COMPENSATE
 Evaluating FF to RF Relationship
o Best identified with patient lying PRONE w/ feet off the table
o Normal foot has met 1-5 in same plane and perpendicular to calcaneal bisector
 RF Varus
o Both RF varus and valgus are frontal plane deformities
o RF varus causes calcaneus to strike ground more than 2-3 degrees inverted
 Remember- foot normally strikes internally rotated 2-3 degrees,
supinated at contact
o A patient presents w/ high arch foot w/ extreme cavoadductovarus deformity.
They have weakness in anterior + lateral compartments. What is the likely
underlying etiology
 CMT PMP22
 What are some other etiology?
 Coxa varus, genu varus (double check)
 Uncompensated RF Varus
o No available motion at STJ, calcaneus can’t evert
o Calcaneus forced to function in inverted position throughout the entire stance

phase of gait
 Uncompensated RF Varus
o RF can’t compensate for varus, but forefoot can
o Because foot is pointing in, must get FF pointing out
o Pronation to bring medial column down
o Peroneus longus wraps all the way around the foot to base of 1st met to pull

 Uncompensated RF Varus
o High-arch (cavus) foot type
o Digital contractures
 o Tibial sesamoiditis
o Predisposed to repeated lateral ankle sprains secondary to fixed supinated
position
o Callus along lateral column of foot
o Lateral shoe wear
o Lowerback pain and lateral knee pain
o Iselin’s Disease- Apophysitis of 5th met base in children
 Partially Compensated RF Varus
o Some STJ pronation available
 Calcaneus everts, but not to fully compensate
 Medial FF doesn’t come all the way down to ground
o Symptoms
 Pump-bump- irritation on posterolateral calcaneus
 Tailor’s bunion**

 Fully Compensated RF Varus

o Pronation available at STJ is equal to the amount of varus at heel strike
o Heel can function perpendicular to the ground in stance
o FF is fully on the ground and bears weight
o Rapid contact phase pronators- heel everts to perpendicular
 Fully Compensated RF Varus- Symptoms
o Do not develop lateral foot symptoms
o Pump-bump
o Leg cramps, postural symptoms
o Pain submet 2- secondary to hypermobility of 1st ray
o Hammertoes secondary to fatigue of intrinsics
o Possible HL/HR

 Fully Compensated RF Varus - Treatments

o Neutral position orthotics w/ medial RF post
 Supports deformity, maintains RF in inverted position, controls frontal
plane motion, foot does not have to pronate to reach ground- eliminates
need for compensation and therefore symptoms
 o Surgery to address will still need an orthotic post-op
 Coleman Block Test
o Testing to see if varus is flexible or not
o If varus switches to valgus-> STJ is flexible
o Block allows foot to pronate
o If foot remains in varus after block, STJ is not flexible and will need to correct FF
pronation + RF varus **know for exam**
RF Valgus


o Frontal plane deformity
 Calcaneus is everted relative to floor at heel strike
o Coxa Vara Genu Valgum
o Knock-kneed
o Wide base of gait
o Significant lateral creasing of dorsal foot
o Flatfoot
o Ankle Valgus
 Fibula 20% of weight, acts as a lateral strut/support ankle joint
 Ankle valgus will produce RF valgus (STJ)
 Supinatus vs Forefoot Varus
o Supinatus-> triplane, soft tissue deformity
 Maintained by TA tendon, dramatic effect on first ray, medial column
 Results in 20 degrees of FF inversion relative to RF (compensatory
deformity)
o Compensation for RF valgus to get lateral column to ground
 TA from tibia and inserts onto medial cuneiform and 1st met base
o FF varus
 Fixed, osseous deformity of frontal plane
 FF is inverted relative to RF
 Ontogenetic result of abnormal frontal plane development of the
head/neck of the talus relative to the body **know for exam**
 Clinical Presentation
o Medial bulge from TNJ
o Entire foot abducts with added abduction of FF on RF
 o Hallux IPJ pinch callus due to rolling off mechanism
o Adductovarus 5th digit w/ dorsolateral corn
o Medial heel wear
o Calcaneal fat pad shifts laterally (medial heel pain, calcaneal apophysitis in kids)
o HAV development due to excess pronation
 Remember HAV w/ fully compensated RF varus + RF valgus
o Sinus tarsi syndrome
o Equinus
 Orthotics for RF Valgus
o Will not tolerate neutral position orthotics
o DSIS
 Not completely rigid- has central cut out to allow spreading of foot and
independent function of medial/lateral columns
 Triplane control- calcaneus held in 5 inversion, some sagittal TNJ control
 If you can control the RF, PL may be able to de-rotate the medial column
and reduce the supinatus

o Lesion pattern: deep keratoma submet 1 and 5

o Lesion pattern: Submet 5 Callus/Keratoma: Submet 1 and 4 Callus

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o Lesion pattern: submet 2 callus; pinch callus medial hallux

FF Valgus + Varus

 Forefoot Valgus
 Single plane osseous deformity where FF is everted relative to calcaneus

 Total Forefoot Valgus

o Rigid deformity
o Can lead to lateral knee pain/postural symptoms
o Lateral ankle sprains, ATFL pathology
o Sinus tarsi syndrome
o Pump bump and heel pain
 Flexible FF Valgus
o Flexibility at MTJ allows lateral column to reach ground
 o Heel may function perpendicular to ground
o Compensation leads to unstable gait and excess pronation
o Can result from un- or partially compensated RF varus

o
 Forefoot Valgus
o Single plane osseous deformity
o Medial column does not come to ground
 FF inverted relative to RG
 
 Important Distinction
o RF Varus
 Calcaneus hits inverted/FF is inverted relative to ground
 Compensates to perpendicular and medial column is down, some arch
height is maintained
o FF Varus
 Calcaneus hits perpendicular, FF is inverted relative to ground
 Compensates by STJ eversion past perpendicular, FF is inverted relative
to ground
 Lose arch height (STJ pronation, MTJ unlocked)


 Combined RF and FF Varus
o Both STJ/calcaneal inversion AND Forefoot inversion
o Forefoot is structurally inverted, not positional as in RF Varus
o Final position of foot is dependent on amount of motion available at STJ
 FF Varus vs Supinatus
o If STJ is able to pronate to fully compensate for the FF Varus and still has more
pronation available (over-pronates), then may get a FF Supinatus superimposed
on FF Varus (to bring lateral column back down)
o RF pronates -> MTJ unlocked, flat foot arch collapse
 Uncompensated FF Varus
 Not enough available motion at STJ
• 1st Ray PF to balance foot
• 1-5 is perpendicular to calcaneal bisector, 2-5 is varus
 Fully Compensated FF Varus
o STJ pronates past perpendicular, unlocks MTJ
o Pronates longer into gait cycle, less stable

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