01964011/87/0901-0003$02.

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THEJOURNAL OF ORTHOPAEDIC AND SPORTS PHYSICAL THERAPY
Copyright 0 1987 by The Orthopaedic and Sports Physical Therapy Sections of the
American Physical Therapy Association

Locomotor Biomechanics and

Pathomechanics: A Review
LARRY P. BROWN, MA, PT, ATC,* PATRICIA YAVORSKY, BS, P T t

This review is intended to provide a working knowledge of clinical anatomy and

arthrokinematics of the foot and ankle. Primary functions of the foot, the gait cycle,
and pathomechanics will also be discussed. Emphasis is placed on basic
biomechanical considerations which form the basis for both static and dynamic
evaluations. Also presented are some of the most commonly seen osseous
deformities contributing to pathomechanics.
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Locomotion is the process or ability by which
man moves himself from one geographic location
to another.'' Biomechanics defined at face value
is made up of two roots, bio and mechanic^.^'
Copyright © 1987 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
gruency of the ankle mortise is maintained by the
strong ligamentous system, the capsule, the in-
terosseous ligament, and the various tendons and
retinacula about the joint. Functioning primarily as

"Bio" indicates a relationship to life, living tissue,
or organisms.24"Mechanics" is a physical science
dealing with the state of bodies and the action of
forces.20Therefore, locomotor biomechanics per-
tains to the study of forces and the effects of
those forces on and within the human body while
moving from one position to another.
Familiarity with the biomechanics of walking is
a prerequisite for an appreciation of the biome-
Journal of Orthopaedic & Sports Physical Therapy®
a hinge joint, it allows for motion in 1'of freedom,
the sagittal plane. These movements are typically
referred to dorsiflexion and plantarflexion. How-
ever, the axis of rotation is described as passing
laterally through the talus and slightly inferopos-
teriorly on the transverse plane.'* Since this axis
is not exactly perpendicular to the sagittal plane,
slight motions of abduction and eversion accom-
pany dorsiflexion, and adduction and inversion

chanics of running since the same basic mechan-
ics are present in both gaits. To further appreciate
the various types of pathomechanics seen in the
runner, a good working knowledge of normal
locomotor biomechanics is necessary. This allows
the practitioner to identify abnormal biomechanics
present during running so that treatment can be
based on a firm scientific basis rather than on an
empirical one.14 To support this statement, this
article will include discussions on basic arthroki-
nematics of the foot and ankle, primary functions
of the foot, review of the gait cycles, and patho-
mechanics.
Arthrokinematics
Ankle
The ankle joint is composed of three joints: the
tibiotalar, fibulotalar, and tibiofibular. The con-
* Director. Palo Alto Physical Therapy and Sports Injury Center. 913
Emerson Street, Palo Alto. CA 94301.
t Director, La Jolla Sports Therapy
3
accompany plantarflexion. Most authors report
that functional range of motion for the ankle is on
the order of 10-20' of dorsiflexion and 20-30' of
plantarfle~ion.~-'~~'~ When these movements be-
come extreme, the subtalar joint and midtarsal
joints contribute to the range of motion of the
ankle joint.
Subtalar Joint
The subtalar joint is the articulation between
the inferior surface of the talus and the superior
surface of the calcaneus. This articulation occurs
at two separate articular facets, a posterior facet
where the inferior concave surface of the talus
rests on the superior convex surface of the cal-
caneus, and an anterior facet with a convex talar
facet fitting into the concave calcaneal surface.
These facet surfaces are united by powerful liga-
ments that withstand the stress of locomotion.
The reported axis of rotation is 41-45' from the
horizontal in the sagittal plane and 16-23' medi-
ally, when measured from a longitudinal axis pass-
 BROWN AND YAVORSKY
ing through the midcalcaneus in the transverse
plane.4~9~'0~'2~15This oblique single axis is oriented
from a posterior, lateral, inferior position, to an
anterior, medial, superior position.13 The oblique
orientation of the axis causes it to traverse the
three cardinal planes, thus movement about this
axis will occur in all three planes. The term used
to describe this type of movement is "triplanar
motion." Manter15describes the overall movement
of the subtalar joint as a combination of eversion,
abduction, and slight dorsiflexion of the foot. This
combined triplanar movement is simply termed
"pronation." The combined movements of inver-
sion, adduction, and slight plantarflexion are
termed "supination." The amount of subtalar joint
range of motion reported is controversial; how-
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ever, most authors agree that the amount of
inversion as a component of supination is signifi-
cantly greater than eversion as a component of
pronation when the foot is free.l4 The -normal
functional range of motion seen in walking is
between 6 and 10' of motion equally divided by
Copyright © 1987 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
a neutral position of the subtalar joint. The neutral
subtalar position as described by Root et aI.l7 is
that position from which the subtalar joint can be
maximally pronated and supinated, or when the
subtalar joint is neither pronated nor supinated.
Midtarsal Joint
The midtarsal joint or transverse tarsal joint
consists of the talonavicular joint medially and the
Journal of Orthopaedic & Sports Physical Therapy®
calcaneocuboid joint laterally. Two separate ro-
tational movements with distinct axes are de-
scribed by Manter.15 Both axes are positioned
obliquely to the cardinal planes; thus, they exhibit
triplanar motion. The longitudinal axis of the mid-
tarsal joint is directed anteriorly and superiorly
15' from the horizontal plane, and medially di-
rected 9 ' from the longitudinal plane. It allows
pivotal movements of the cuboid on the calca-
neus. The axis passes between the first and
second rays, and allows motion of inversionlad-
duction and eversion/abduction of the cuboid. The
oblique axis of the midtarsal joint is directed an-
teriorly and superiorly 52' from the horizontal
plane, and medially 57' from the longitudinal
plane. The major actions about this axis are dor-
siflexion/abduction, and plantarflexion/adduction
of the forefoot.
Though the description of the midtarsal joint
appears complex, the biomechanical function can
be greatly simplified by recognizing that motion
perpendicular to the two axes may be indepen-
JOSPT Vol. 9, No. 1
dent of each other, but both depend on the posi-
tion of the subtalar joint. When the calcaneus is
in an everted position, the subtalar joint is pron-
ated and the planes of the axes between the
talonavicular and calcaneocuboid joints become
parallel. This results in increased midtarsal joint
motion by "unlocking" the j ~ i n t . ' ~Conversely,
~*~
when the calcaneus is inverted, the axes are no
longer parallel, and there is decreased motion of
the midtarsal joint due to the convergence of the
axes. This convergence "locks" the bones of the
midtarsal joint creating a rigid forefoot. The mo-
bility created during rearfoot pronation and the
rigidity created during supination play a major role
in the primary functions of the foot.
Other Functional Joints
The first ray is a functional metatarsal unit con-
sisting of the first metatarsal and the first cunei-
form bones. The first metatarsallfirst cuneiform
joint, and the first cuneiform navicular joint move
together about a common axis of m ~ t i o nThe .~
axis passes anteriorly, laterally, and plantarly
through the foot at a 45' angle from the frontal
and sagittal planes. This axis produces the tri-
planar motions of dorsiflexion/inversion, and plan-
tarflexion/eversion.
The second, third, and fourth r&s are formed
by the articulations of the metatarsals with the
appropriate cuneiforms. Each of these rays ap-
pears to exhibit pure sagittal plane motion.
The fifth ray consists of the fifth metatarsal only.
The axis of motion lies at an angle of approxi-
mately 20' from the transverse plane and 35'
from the sagittal plane. Therefore, it has a triplanar
axis allowing movement in the directions of supi-
nation and pronation.
The first metatarsophalangealjoint consists of
the articular surface of the first metatarsal head
and the base of the proximal phalanx of the hallux.
It has two distinct axes of motion, a transverse
axis and a vertical axis. Pure plantarflexion and
dorsiflexion are provided by the transverse plane
and pure adduction/abduction are provided by the
vertical plane.'*
PRIMARY FUNCTIONS OF THE FOOT
DURING LOCOMOTION
The joints of the foot perform two primary func-
tions during the stance phase of gait; they allow
the foot to interface with the ground and they
provide a base over which the body can be pro-
 JOSPT July 1987 LOCOMOTOR BIOMECHANICS AND PATHOMECHANICS
pelled.' During ground interface at heel strike, the
foot becomes a mobile adapter. This allows ac-
commodation to terrain variances and postural
deviations of the trunk, and assists in providing
shock absorption. Shock absorption is a necessity
since impact stress at heel strike may exceed
body weight and may be increased to three times
body weight during running.14
Locking of the major joints of the foot trans-
forms the foot into a rigid lever. This is necessary
for normal propulsion during the late stance phase
of gait. These functions are accomplished by the
joints of the foot and ankle through the combined
actions and motions of the subtalar and midtarsal
joints during pronation and supination.
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GAIT CYCLE
The gait cycle is used as the basic reference in
the description of locomotion. This makes it pos-
sible to compare walking and running very easily.
One full gait cycle is the interval of time from heel
Copyright © 1987 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
strike of one foot to heel strike by the same foot
at the next Therefore, there are two
steps in each gait cycle. During the gait cycle,
motion occurs in both open and closed chains.
Open chain motion occurs when the distal com-
ponent is not,fixed and the muscle contraction is
concentric. Closed chain motion occurs when the
distal component is fixed and muscle contraction
is eccentric. The gait cycle is divided into two
Journal of Orthopaedic & Sports Physical Therapy®
phases, the stance phase and swing phase.
Closed chain motion occurs during the stance
phase and open chain motion occurs during the
swing phase. The stance phase is that period
which begins with heel contact and ends with toe-
off. The swing phase occurs between toe-off and
heel strike. In normal walking, the stance phase
consists of approximately 60% of the gait cycle,
and the swing phase approximately 40oO/ 14,17.18
Since one complete cycle takes approximately 1
sec to complete, and 60% of the cycle consists
of the stance phase, the foot is on the ground for
approximately 0.6 sec during ~ a l k i n g . ~
To facilitate clinical observations of the lower
extremity during locomotion, the stance phase of
gait is divided into three periods, contact, mid-
stance, and propulsion.
Contact
Contact begins with heel strike and ends as the
forefoot becomes fully weight borne with the en-
tire foot flat on the ground. Contact accounts for
5
27% of the total stance phase and is character-
ized by hip joint extension and internal rotation,
knee flexion, lower leg internal rotation, ankle
plantarflexion, and subtalar joint and forefoot pro-
nation. The lower leg and foot are viewed as
functional units, the talus and lower leg function
as one unit, the calcaneus and foot as another.
With closed chain motion, during the stance phase
of gait, the talus moves in the same direction as
the lower leg, and the foot follows the calcaneus.
At heel strike, the leg is externally rotated so the
subtalar joint and forefoot are supinated. The
initial supinated position results from the contrac-
tion of the dorsiflexors and inverters of the ankle
as they prepare to decelerate plantarflexion and
pronation during contact. Controlled pronation oc-
curs, helping with shock absorbancy. A normal
foot does not pronate beyond the contact period,
and reaches its maximally pronated position at
the end of contact (Fig. 1A). The calcaneus is
everted from neutral by approximately 4-6O at
this point.l4*l8
Midstance
Midstance follows contact and is characterized
by single limb support in normal walking. It con-
sists of the intermediate 40% of stance phase.
The primary event occurring during this period is
the conversion of the foot from a mobile adapter
to a rigid lever for p r o p ~ l s i o n . This
~ ~ ' is
~ ac-
~~~~~~
complished as the lower leg begins to externally
rotate, and closed chain supination occurs at the
subtalar joint. The talus abducts and dorsiflexes
on the calcaneus while the calcaneus inverts.
During the first part of midstance, the subtalar
joint is supinating as the rearfoot moves from a
maximally pronated position back toward a neu-
tral position just prior to heel lift. During the re-
maining midstance period, the subtalar joint con-
tinues to supinate and the rearfoot moves into a
supinated position. When the neutral subtalar joint
position is reached, the midtarsal joint locks up
against the rearfoot. A rigid forefoot is produced
in preparation for propulsion. This rigid state is
important to allow for the various tendons of the
leg to function around stable bony levers. During
this phase of gait, the trunk and lower leg move
forward, and the ankle is required to dorsiflex to
10'. The knee begins to extend as the hip con-
tinues its extension from the initial contact phase.
 6 BROWN AND YAVORSKY
Fig. 1 . Normal subtalar joint motion and the neutral foot. A, At heelstrike (HS) the subtalar joint is slightly supinated. Normal
pronation occurs through contact to foofflat (FF). At midstance, supination begins so that just prior to heel rise (HR), the subtalar
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joint is in neutral position. Supination continues through toe-off (TO). The neutral foot and lower leg is illustrated in this figure in
compliance with the criteria of normalcy.
Propulsion
The final 33% of the stance phase of gait is the
Copyright © 1987 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
propulsive portion which begins with heel lift and
ends with toe-off. The body weight is shifted from
the lateral side of the foot to the medial side and
to the great toe. This is accomplished by contin-
ued closed chain supination at the subtalar joint
as the leg continues to externally rotate. This
increases the skeletal efficiency of the foot as it
continues to function as a rigid lever. The ankle
moves from its terminally dorsiflexed position of
Journal of Orthopaedic & Sports Physical Therapy®
10° to its terminally plantarflexed position of 20°.
The knee rapidly flexes and the hip continues to
externally rotate and flex. The final phase of pro-
pulsion requires the first metatarsophalangeal
joint to be stabilized, enabling it to dorsiflex ap-
proximately 70° as the weight is being transferred
from the first ray to the great toe, and finally to
the opposite foot.
CHANGES WHICH OCCUR IN RUNNING
GAIT
Running gait differs from normal ambulation in
that there is an airborne float phase when neither
foot is in contact with the ground. This produces
two primary changes in the running gait: an in-
creased magnitude of the vertical ground reaction
forces and a progressive shortening of the stance
phase of gait.7914.17318321
As the speed of gait increases, the vertical
ground reaction forces increase from 70-80% of
body weight during walking to approximately
275-300% during running.14 This occurs as a
JOSPT Vol. 9, No. 1
Tibia# Fbi;
-- --
Talus
--- +- ---
I
I Calcaneous
I
0 0
result of Newton's third law: for every action there
is an equal and opposite reaction. Other ground
reaction forces such as fore and aft shear, medial
and lateral shear, and torque demonstrate essen-
tially the same patterns for walking and running
gait, but the magnitudes of these forces increase
somewhat with r ~ n n i n g . ~ , ' ~
As the speed of gait increases, there is a pro-
gressive decrease of total stance time from 0.6
sec during walking to 0.2 sec during running.
Therefore, all events which normally occur during
stance must occur approximately three times
faster in running than in walking. This marked
decrease in stance phase and the marked in-
crease in ground reaction forces are the primary
reasons given for injuries to runners.21
CRITERIA FOR NORMALCY
A normal lower leg and foot is one which, during
locomotion, places no undue stress upon itself or
the proximal joint^.^' The criteria for normalcy,
described below, represent the ideal physical re-
lationship of osseous segments of the foot and
leg which should be present for maximum effi-
ciency during loc~motion.'~ Seldom seen clini-
cally, these relationships represent a basis for
evaluation of the degree of deformity present.
Once the criteria for normalcy are evaluated, any
deviation from one criterion constitutes deformity
or abnormality.'
The criteria for normalcy are as follows: the
distal one-third of the lower leg is vertical or in the
sagittal plane; the subtalar, ankle, and knee joints
lie in the transverse plane parallel to the ground;
 JOSPT July 1987 LOCOMOTOR BIOMECHANICS AND PATHOMECHANICS
the subtalar joint is in its neutral position, neither
pronated nor supinated; bisection of the posterior
surface of the calcaneus is vertical or inverted no
more than 3-4" from the vertical; the midtarsal
joint is locked in its maximum position of prona-
tion; the metatarsals and plantar surface of the
calcaneus lie parallel to each other in the trans-
verse plane; and last, there are no rotational or
torsional influences present in the lower leg. Fig-
ure 1B illustrates this ideal physical relationship.
During locomotion, all normal criteria should be
present just prior to heel lift. Deviations from
normalcy in the biomechanical system may cause
abnormal motion and stress to occur during the
stance phase of gait. This may, in turn, be mani-
fested in the form of a stress injury.'
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PATHOMECHANICS
As defined previously, locomotor biomechanics
is the application of mechanical laws to living
systems in motion. Pathomechanics can then be
Copyright © 1987 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
defined as the mechanics of living systems in
motion resulting in, or leading to, dysfunction or
injury. The remainder of this article is devoted to
the pathomechanics of the ankle and foot includ-
ing common intrinsic abnormalities, resultant
pathological states, and treatment options.
In order to understand the pathomechanics of
the ankle and foot, one must first understand the
concept of compensation. Compensation is de-
fined by Root et al.'' as a change of structure,
Journal of Orthopaedic & Sports Physical Therapy®
position, or function of one part of the body in an
attempt to adjust to a deviation of structure,
position, or function of another body part. More
basically stated, compensation is the counterbal-
ancing of any defect in structure or f~nction.~ from its'infantile position.'' In childhood, the cal-
There are two types of compensation, normal and
abnormal. Normal compensation maintains bal-
ance and produces no abnormality or pathology.
An example of normal compensation is the ad-
aptation of the foot to variations in surface terrain. at heel strike in order for the condyles of the
Abnormal compensation is an adjustment for ab-
normal structure or function of the body which,
upon repetitive demand, may lead to pathology.
In the foot, both types of compensation, normal
and abnormal, result from pronation and supina-
tion of the subtalar and midtarsal joints. When
bony or soft tissue deformities of the foot or lower
extremities are present, abnormal compensatory
pronation or supination may result. Each is dis-
cussed below.
Pronation is considered abnormal when it is in
excess of the amount required, or when it occurs
7
when supination should be occurring during lo-
comotion.18 Normal minimum pronation required
during walking locomotion has been shown to be
6", with maximum values averaging 9.4" and a
standard deviation of 3.5°.3,'8,21Excessive pro-
nation can then be defined as 13" or greater.
According to S~botnick,~'the most common
cause of foot pathology is abnormal compensa-
tory pronation because the foot is abnormally
unstable in a weightbearing situation. This leads
to hypermobility, subluxation, resultant micro-
trauma, and Causes of abnormal
compensatory pronation can be intrinsic or extrin-
sic to the foot. This paper focuses only on the
intrinsic causes. They include subtalar varus, fore-
foot varus, forefoot supinatus, forefoot valgus,
and ankle joint equinus.
Abnormal supination is excessive supination, or
supination that occurs when pronation should be
occurring during normal gait. Normal values for
supination have been shown to range from 6-
12°.'8,21 Compensation for a forefoot valgus,
plantarflexed first ray, or equinus deformity can
cause abnormal supination. Pathology may also
occur when motion is restricted or when it is
insufficient for normal locomotion. Disease,
trauma, contracture, or congenital coalition may
be some causes of these problems. The following
are descriptions of common intrinsic abnormalities
of the foot.
Subtalar Varus
Subtalar varus, as illustrated in Figure 2A, is an
inversion deformity of the calcaneus due to an
incomplete derotation of the posterior calcaneus
caneus derotates 3-4". If this derotation is incom-
plete or does not occur, subtalar varus re-
s u l t ~ . ~ .Compensation
~~'' for this deformity during
locomotion requires calcaneal eversion to vertical
calcaneus to reach the ground. The foot remains
partially pronated at heel lift not allowing the sub-
talar joint to supinate to neutral in early propulsion.
The first ray is not adequately stabilized by the
peroneus longus muscle and hypermobility is
present. Increasedload and shear forces are pres-
ent beneath the second metatarsal headT8.Once
the heel is off the ground, the normal forefoot
supinates in an attempt to become a rigid lever.
Abnormal compensatory pronation occurs only
during the time the abnormal calcaneus is in
ground contact (Fig. 28).
 BROWN AND YAVORSKY JOSPT Vol. 9, No. 1

Fig. 2. Subtalar varus. A, Subtalar varus deformity is illustrated as seen when in the subtalar joint neutral position. It is an inversion
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osseous deformity of the calcaneus in the neutral position. 8,Abnormal compensatory pronation begins at heel-strike (HS) and
continues until heelrise (HR) when the abnormal calcaneus is no longer in contact with the ground. The foot supinates late after
heelrise (HR) in time for propulsion to be fairly normal. (Abnormal cycle shown in broken line.)

Abnormal compensatory pronation for a sub- ity. The first ray is hypermobile and the second
talar varus may result in pathology. Plantar kera- metatarsal takes most of the force during propul-
Copyright © 1987 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

toses beneath the second metatarsal head may sion.

develop due to increased shear, inflammation, and
hyperplasia. Soft tissue lesions may also develop
such as peroneus longus tendinitis due to insuffi-
cient first ray stabilization, posterior tibialis tendi-
nitis due to excessive deceleration of pronation,
or Achilles tendinitis due to excessive active su-
pination. Articular lesions may develop at the pa-
tellofemoral joint due to the antagonistic state of
Journal of Orthopaedic & Sports Physical Therapy®
Figure 3B illustrates how abnormal compensa-
tory pronation occurs throughout stance and pro-
pulsion in a compensated forefoot varus. This
results in more destructive pathologies in the soft
tissues and bony tissues mentioned previously
with subtalar varus. The pronated position of the
forefoot during propulsion can also lead to fore-
foot pathology.

maximum pronation and maximum knee flexion
not occurring sim~ltaneously.'~'~~~~
Forefoot Varus
Forefoot varus, as illustrated in Figure 3A, is a
fixed congenital osseous deformity of the forefoot
in which the plane of the lesser metatarsals is
inverted in relation to the calcaneus in subtalar
joint neutral position. Forefoot varus is caused by
a failure of the head and neck of the talus to fully
derotate from the infantile p o ~ i t i o n . ~It. ' ~is the
most common cause of abnormal compensatory
pr~nation.~~
The pathomechanics of compensated forefoot
varus are much more destructive than subtalar
varus. Once the condyles of the calcaneus are on
the ground, the subtalar joint must continue to
pronate in order for the first ray to reach the
ground. The calcaneus then everts past the neu-
tral position and at heel rise, the foot is in maxi-
mum pronation. The forefoot remains in pronation
throughout propulsion resulting in severe instabil-
Predisposing factors to the development of
forefoot pathology are the amount of first ray
hypermobility and the congenital angulation of the
longitudinal axis of the metatarsals to the rear-
foot." Hypermobility of the first ray during pro-
pulsion results from the inability of the peroneus
longus to stabilize sufficiently. Hypermobility can
lead to subluxation of the first metatarsophalan-
geal joint.
Subluxation in the transverse plane can result
in hallux-abductovalgus (HAV) deformity,8918 Sub-
luxation in the sagittal plane can result in hallux
limitus deformity. The determining factor in the
development of HAV or hallux limitus is the con-
genital angulation of the forefoot to rearfoot. The
more adducted the forefoot, the more likely a HAV
is to develop. Conversely, a more rectus forefoot
would more likely lead to a hallux limitus.18
Forefoot supinatus is a reducible, acquired soft
tissue contracture at the midtarsal joint resulting
in supination of the forefoot.' Supination contrac-
ture may occur about either the oblique or longi-
 JOSPT July 1987 LOCOMOTOR BIOMECHANICS AND PATHOMECHANICS

A
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Fig. 3. Forefoot varus. A, Forefoot varus is an osseous deformity of the talus in which the forefoot is inverted relative to the
calcaneus in subtalar joint neutral position. 6, In order to get the inverted forefoot to the ground, abnormal compensatory pronation
occurs. Pronation is excessive and continues from foofflat (FF) throughout the stance phase of gait into propulsion. (Abnormal
cycle shown in broken line.)

tudinal axis of the midtarsal joint. Forefoot supi- Abnormal supination occurring during mid-
natus about the oblique axis results in forefoot stance can lead to pathologies related to lack of
Copyright © 1987 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

adduction, plantarflexion, and slight inversion.
Clawing of the toes may result from the transverse
plane instability caused by the relatively abducted
position of the phalanges to the metatarsals in
oblique axis forefoot supinatus. Supinatus about
the longitudinal axis is difficult to differentiatefrom
forefoot varus. However, it is attributed to con-
tracture or spasm of the anterior tibialis muscle
resulting in dorsiflexion of the first ray and forefoot
Journal of Orthopaedic & Sports Physical Therapy®
shock absorption in the upper leg, but also to
development of plantar lesions beneath the fifth
and first metatarsals. Abnormal pronation occur-
ring late in propulsion can lead to hallux subluxa-
tions previously discussed for forefoot v a r ~ s . ~ ~ ' ~
Equinus
Ankle equinus is a fixed limitation of dorsiflexion

supination rather than talar pathology seen in
forefoot varus. Abnormal compensatory pronation
is the result of either forefoot supinatus and re-
sultant pathologies including those previously
mentioned for subtalar and forefoot varus.18
Forefoot Valgus
Forefoot valgus, as illustrated in Figure 4A, is
an osseous deformity of the forefoot in which the
plane of the lesser metatarsals is everted relative
to the calcaneus in subtalar joint neutral position18
Heel strike is normal with forefoot valgus, but the
forefoot is prematurely loaded. The first ray is
stable, and abnormal compensatory supination
occurs at the subtalar joint resulting in absence
of normal pronation during midstance and late
pronation at heel-off to allow knee f l e ~ i o n . ~ , ' ~may occur independently or in combination. An
Forefoot valgus can take the form of a plantar-
flexed first ray or a total forefoot valgus. Figure
4 8 illustrates the absence of normal pronation
during stance with forefoot valgus as well as late
abnormal compensatory pronation.
at the ankle joint to less than 10' when in the
subtalar neutral position and with the knee ex-
tended.'' Compensation takes place at the sub-
talar and midtarsal joints in the form of abnormal
pronation allowing dorsiflexion of the forefoot on
the rearfoot. Abnormal pronation is present during
propulsion resulting in hypermobility of the first
ray. Resultant pathologies are those noted previ-
ously for abnormal pronation occurring through
propulsion including keratoses and hallux deform-
ities, but symptoms seem to occur earlier in life
and are resistant to conservative manage-
ment.10,22923
CONCLUSION
Ankle and foot biomechanical abnormalities
understanding of normal and abnormal locomotor
biomechanics is essential for effective patient
care. Once normal mechanics are understood,
pathomechanicscan be identified and the etiology
of patient complaints postulated. It is necessary
 BROWN AND YAVORSKY
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Fig. 4. Forefoot valgus. A, Forefoot valgus is an osseous deformity of the forefoot in which the forefoot is everted relative to the
calcaneus in subtalar joint neutral position. 6, Abnormal supination occurs as the forefoot is prematurely loaded after heelstrike
(HS). Pronation is insufficient, then occurs late in stance at heel-off (HO) to allow knee flexion. (Abnormal cycle shown in broken
line.)
Copyright © 1987 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
to treat not only the symptoms but also the cause
of the dysfunction.
A comprehensive treatment regimen must in-
clude a thorough biomechanical evaluation, ap-
propriate for pain and
therapeutic exercise to restore normal length/
strength/function of musculature, and exercises
enhance P ~ ~ Or-P
thotic devices to correct biomechanical abnor-
Journal of Orthopaedic & Sports Physical Therapy®
malities may be indicated to help decrease ab-
normal compensation. Early identification of
biomechanical dysfunction and proper interven-
for and decreased
likelihood for recurrence of injury in the future.
REFERENCES
1. Bates BT, Ostemig LR, Mason JR, James SL: Functionalvariability
of the lower extremity during the support phase of running. Med
Sci Sports Exerc 11:328-331,1979
2. Calliet R: Foot and Ankle Pain. Philadelphia: FA Davis Co, 1968
3. ClarkeTE, Frederick EC, Hamill C: The study of rearfoot movement
in running, In: Frederick EC (&), Sports Shoes and Playing Sur-
faces, Ch 10, pp 116-189. Champaign, IL: Human Kinetics Pub
lishers Inc. 1984
4. Close JR, lnrnan VT. Poor PM, Todd BA: The function of the
subtalar joint. Clin Orthop 50:159-179. 1967
5. Dorland's Illustrated Medical Dictionary, ED 25, p 345. Philadelphia:
WB Saunders Co, 1974
6. Ebisui JM: The first ray axis and the joint. J Am Podiatry Assoc
58:160-168,1968
7. Gray G: When The Feet Hit the Ground, Everything Changes.
Toledo: American Physical RehabilitationNetwork, 1984
JOSPT Vol. 9, No. 1
8. Hlavac H: compensated forefoot varus. J Am Podiatry Assoc
60:229-233.1970
9. lnrnan VT: The human foot. Manitoba Med Rev 46:513-515,1966
lo. Inman vr, Mann RA: Biomechanicsof the foot and ankle. In: Mann
RA (ed), DeVries Surgery of the Foot, c h 1, pp 3-21. s t Louis: cv
Mosby Co, 1978
11. Inman, , Ralston HJ, Todd F: Human Walking. Baltimore: Wil-
liams 8 Wilkins, 1981
12. Isman RE, lnrnan VT: Anthropometric studies of the human foot
and ankle. Bull Prosthet Res 97:76, 1969
13. Kapandji~ JA: The Physiology
~ of the Joints,~ Val 2. New Yo*: ~ ~
churchill-~ivingstone,1970
14. Mann RA: Biomechanics of running. In: Mock RP (ed), Symposium
on the Foot and Leg in Running Sports, pp 1-29, St Louis: CV
Mosby Co, 1982
15. Manter JT: Movements of the subtalar and transversetarsal joints.
Anat Rec 80:397,1941
16. Mumy MP, Drought AB. Kory RC: Walking patterns of nonnal
men. J Bone Joint Surg (Am) 46:335-344,1964
17. Root ML, Orien WP, Weed JH: Biomechanical Examination of the
Foot. LOS Angeles: Clinical Biomechanics Corporation, 1971
18. Root ML, Orien WP, Weed JH: Normal and Abnormal Function of
the Foot. Los Angeles: Clinical Biomechanics Corporation, 1971
19. Sammarco GJ, Burstein AH, Frankel VH: Biomechanics of the
ankle: a kinematic study. Orthop Clin North Am 4:75-83, 1973
20. Smidt GL: Biomechanics and physical therapy: a Perspective. Phys
Ther 64:1807-1808,1984
21. Subotnick SI: Biomechanics of the subtalar and midtarsaljoints. J
Am Podiatry Assoc 65:756-764, 1975
22. Subotnick SI: The biomechanics of running: implications for the
preventionof foot injuries. Sports Med 2:144-153, 1985
23. Subotnick, SI: The flat foot. Phys Sports Med 9:85-91, 1981
24. Taber CW: Taber's Cyclopedic Medical Dictionary, Ed 14, pp 179.
Philadelphia: FA Davis Co, 1977