Dr.

Tag

Foot
Functions of the Foot:
1- Shock Absorption: Foot is structurally developed for weight bearing
function and Maintaining its structural shape is essential to avoid
mechanical failure, E.g.: Flat Foot.
2- Foot Rockers: 3 Rockers >>
1- Heel (HC) 2- Mid-Foot (Mst.) 3- Forefoot Rocker (Tst.)
Interaction between rockers during translation in respect to each other lead to
ambulation.
3- Balance:
Cog: It is a point that around it that is an equal distribution of mass in all
direction. As long as the vertical projection of COG is lying within the BOS,
The structure is considered stable.
BOS: IT is the borders of stability ( The area that its circumference
represents the outer border of the body).
So, Bipedal standing is more stable than Uni-pedal Stance
4- During Gait: It has 2 contradictive functions.
A: Rigid (last 1/3 of stance) >> At heel rise (PF of foot to provide push off),
to avoid Midtarsal break and provide a long lever arm for Tendo-achillis to
make PF easily.
B: Supple(First 1/3 of stance) >> At stance, For mainly shock absorption in
case irregular surfaces. (Foot is flat on the ground)
NB.: 1- Mid-Tarsal break: medial shift of center of pressure trajectory with dorsiflexion of mid-
tarsal joint; occurs during gait in an unstable foot, when body weight transfers from rear- to
forefoot. (happens when the rigid function of the foot is lost).
2- Shock absorption: For it to happen, structural deformation (Movement of a structure in
relation to the other) must happen, causing force dissipation (By using a part of the force
applied for the deformation itself), decrease the stress applied on the structure.
3- Subtalar Jt. is the house of the foot.

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Dr. Tag

Anatomy of subtalar (Talocalcaneal) joint:

*Why there are 2 bones in the heel?

-To provide Talocalcaneal Divergence (An angle formed by the anatomical
separation of Calcaneus and Talus in mid foot), Which has 2 functions:
1- Foot splaying (Increase the size of the foot), Which help in increasing the BOS
specially at Single limb stance. (Mainly seen from AP view)
2- Achieving Horizontal alignment of the calcaneus and talus at the point of
articulation with Cuboid and Navicular bones. (Mainly seen from Lateral view)

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Dr. Tag

Weight Transfer on foot.

All the weight is transferred on the talus, then is distributed on the calcaneus
posteriorly through the talus (About 50%), and the rest is transferred through the
neck of talus and navicular bone to the forefoot.
*This criteria of weight transfer needs the talus to be totally supported
anatomically.
Talar Support:
Posteriorly (The body): by the Posterior Facet (the biggest one)
Neck of Talus: By the middle facet + (Sustentaculum Tali)
Head of Talus (Apex of MLA): Anterior Facet (very small facet) + Planter
calcaneonavicular ligament (From the sustentaculum tali to the navicular bone),
also known as Spring Ligament

NB: Talo-navicular joint is a ball and socket joint.

*Axis of ankle (Talocrural) joint: it is the intermalleolar Axis, which lies more
with the coronal axis (Because the desired movement is in the sagittal plane.
It is directed from Inferior, posterior and laterally to upward, anterior and
medially.
The direction of this axis causes Internal and external rotation in the ankle
associated with the actual movement (Dorsiflexion and Plantarflexion).

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Dr. Tag

This movement is not a (Range) in the ankle joint, it happens due to the direction
of the analyzed forces and cannot happen as an isolated movement in the ankle.

Axis of Subtalar Joint:

The Axis is oriented just as the ankle, but its axis lies more near the direction of
the sagittal axis, because the movement needed is in the Coronal plane
(Supination and Pronation as a resultant composite movement seen from the
coronal view not an isolated range in the joint).
NB: Pronation = DF + Abd. +ER Supination = PF +Add. +IR

NB: Everything in the foot (Moves on the talus and with the Calcaneus). So
Calcaneus movement as the distal part, associated with movement in the rest of
the bones and the joints within the foot in the same direction.

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 Dr. Tag

Plan of Supination Pronation

movement
Open Chain Closed Chain Open Chain Closed Chain
Coronal Calcaneal Calcaneal Adduction Calcaneal Calcaneal Abduction
Adduction associated with Abduction associated with
forefoot pronation forefoot supination
caused by Tarso- caused by Tarso-
metatarsal twist metatarsal twist
mechanism mechanism

Sagittal Calcaneal PF Talar DF (inside the Calcaneal Talar PF (inside the

ankle mortis) DF ankle mortis) (
(Providing The needed Providing The needed
PF range) DF range)
Axial Calcaneal IR Talar ER made by the Calcaneal Talar IR made by the
ER of the Tibia( Degree ER IR of the Tibia ( Degree
for Degree) for Degree)
*What is the importance of Tarso-metatarsal twist mechanism in CPP?
-To achieve plantigrade foot (Which means that the foot touches the ground in 3
points: Calcaneus, 1st metatarsal head, 5th metatarsal head)>> The whole planter
surface of the foot touches the ground, which provide more stability.
CPP movements in the forefoot is described by 2 Mechanisms:
1- Kinematic link: Obligatory movement in a segment due to a movement in
another segment. (E.g.: CP pronation causes IR of tibia and vice versa)

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Dr. Tag

2- Mitered Hinge1: Talus moves in the coronal plan as the tibiofibular part of
the ankle joint moves in the axial plan, because of the anatomical
properties of the hinged joint.

Movement of the head of talus and associated arch changes:

As the talus is supported by the calcaneus from below, any movement in
calcaneus will affect the position of the talus.
E.g.: 1- Pronation of the foot cause abduction of the calcaneus leads to an
increase in the talo-calcaneal divergence and lowering of the head of talus >>>
Foot Flat.
2- CP IR of Tibia causes the calcaneus pronate>> Increase the
Divergence>> Descended talar head>> Flat foot.

1
How the Kinematic Link and Mitered Hinge Help the foot?
-Foot contact>>IR of tibia (caused by the advanced position of the leg in relation to the rest of the body)>>IR of
talus>> ER of calcaneus (part of subtalar pronation composite movement)>>Unlocking of Mid-tarsal joint >>
Supple foot with the ability to conform uneven surface (without the need of any active muscle movement)
-(In Tst and Psw)>>ER of tibia>> ER of talus>> IR of the calcaneus (Part of subtalar Supination composite
movement)>>Rigid foot to prevent mid-tarsal break.

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Dr. Tag

SO… It is impossible to flat foot in a supinated foot, neither a high arch in

pronated foot.
NB: 1- For any joint to move, Both the Axes of joint components
must be parallel.
2- Normally the subtalar resting position is 7° of pronation
- Rigidity vs Suppleness of the foot:
*The Helicoid shape of any surface of a joint surface causes a translatory
movement (Either to or fro) on the other articulating surface.
So based on that, During Supination and pronation, the calcaneus translates on
the talus.
The importance of this movement is to change the axis of the calcaneocuboid
joint, resulting in 2 possible scenarios:
1- Make it parallel to the axis of talonavicular joint >>> Allowing mobility of
the foot >>> ( Supple foot )….. Happens with Pronation
2- Make it unparallel to the axis of talonavicular joint>>> hindering movement
in the joint >>> (Rigid Foot ) ….. Happens with Supination
P.s: Go back to Functions of the foot(Page one), to remmember the
importance of this function.
*Midtarsal joint or Chopart's joint is formed by the articulation of the
calcaneus with the cuboid (the calcaneocuboid joint), and the articulation of
the talus with the navicular (the talocalcaneonavicular joint).

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Dr. Tag

Lecture (2)
Foot Units:
1- Calcaneopedal Unit (CPU)
2- Tibiotalar Unit (TTU) (A- As a one unit, B- Divided as 2 movement components).

Movement of foot units:

As it was mentioned before that everything in the foot (moves on the talus and
with the Calcaneus), So Foot units can move on each other in certain
circumstances. Also its parts can move on each other.
A) Mid-foot and Fore-foot follows the movement of the calcaneus.
B) Calcaneopedal unit moves on the talotibial unit only in the axial plan (e.g.:
In CKC supination or pronation, the Calcaneopedal unit follow the rotation
of the Tibiotalar unit degree by degree)
C) Talus and calcaneus moves on the tibia in sagittal plan only (E.g.: Talar DF
movement on the tibia inside the ankle mortis to complete the PF
component of calcaneus in the sagittal plan to provide CKC supination)>>
So in this example the talus moves on both the Calcaneopedal unit and
the tibia as a separate unit to provide the movement.
Medial Longitudinal Arch (MLA)

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Dr. Tag

Formation: It is made up by the calcaneus, the talus, the navicular, the medial
cuneiform, and the first metatarsal. The highest point of the arch is the head
of talus.
Function: Maintaining the MLA in its normal position, help to maintain foot
kinematics and prevents disability
Stabilizers:
1- Static stabilizers:
(A) Bony: Normal talo-calcaneal divergence (20°): As it means that
the subtalar joint is in its normal position, without any changes in
the position of the head of talus.
(B) Plantar Fascia (PF): Arises from
the medial aspect of calcaneal
tuberosity to the base of the
proximal phalanx of the big toe. (
With an attachment in head of 1st
MT)
It has a limited degree of
elasticity, because its function is:
1- Truss function: PF ,as a fibrous
structure, holds the arch
components together, helping in
supporting the arch and preventing 3
its flattening. 1 2
2- Windlass Mechanism: During Gait
at heel rise, MTPJ2 undergoes
hyperextension (DF)>>PF will cause
dorsiflexion and IR of the calcaneus
(Because the PF is not elastic
enough to stretch and provide this range of motion)
Which will cause:

2
Has the highest Rom among all LL joints>> 55° of DF.

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Dr. Tag

I. Decrease TCD>> Upward movement of the head of

talus>>Arching of the foot and increase of the MLA.
II. Better ability of weight bearing: As the tension in plantar
fascia caused by DF of calcaneus and Hyperextension of
forefoot will make the 1st metatarsal bone implant in the
plantar fascia, which has a great role in the weight bearing
mechanism of the forefoot to the whole body weight during
this stage of gait.
III. Prevent the effect of shear forces on the metatarsals. >> MTs
makes normally a 30° angle with the ground (caused by the
normal arching of the foot). So with the 30° talar Pf at heel
rise, Plantar Fascia will make about 20° to 25° of PF to the MTs,
caused by the effect of windlass mechanism, which will make
the MTs. nearly perpendicular on the ground (85°),
transforming all the shear forces to compressive forces, that
is better for the bones to withstand.
P.S.: PF & IR of calcaneus are parts of subtalar supination of
the foot.
2- Dynamic Stabilizers (Dynamic Truss): The external muscles of foot support
the MLA, Especially Tibialis posterior muscles. These Muscles are (TA, TP,
EHL, PL and intrinsic plantar muscles).
NB: In case of TPTD, acquired flat foot happens…..

Foot Diseases
1- Symptomatic Flat Foot(SFF)
Flat Foot Definition: It is a disease that is characterized by collapsed MLA
associated with pronated foot.
Flat foot is considered only a pathology in case of it is symptomatic only, because
there are a lot of normal people that live with flat foot without any disturbing
symptoms specific to flat foot.

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Dr. Tag

Clinical Picture:
1- Cosmetic disfigurement: Caused by Sprouted, Splayed, Foot. It is caused by
the abnormal increase in Talocalcaneal divergence and out toeing of the
foot.
2- Flat foot gait: 1- Pseudo-stiff knee gait (walking with no knee flexion).
Why? >> Because for the knee to flex or extent
During gait, it has to be within the gait
Progression line. ( And it is not, because
of toeing out)
2- Walking with dynamic hip flexion and
internal rotation: Which will be associated
Squinting ( inward ) Patella.
Why? >> To restore the knee in the gait
Progression line, that was disrupted
by the toeing out.
NB: 1- Patella is considered as the tip tail of femoral rotation (It expose any
malalignment in the femur related to any abnormal rotation).
2- In case of toeing out, rockers function of the foot is lost
and the only function for the foot is only for providing
base of support during gait and for rolling to transfer
weight.
3- High incidence of hallux valgus: Out toeing >> Valgus stress on the big toe
during heel rise >>> Hallux Valgus.
4- Pain: (A) Calf Discomfort or soreness3: Caused by Calf muscles overwork,
which happens due decrease the moment arm of calf muscles, which was
the whole foot, due to mid-tarsal break >> That will increase the force
demands needed from the muscles and also the amount of shortening
needed (Because now it works on 2 joints >>Mid-foot and MTPJ) and will
decrease muscle excursion4 .

3
Like chronic compartment syndrome in the calves’ area.
4
The full range of extensibility and contractility of a muscle is called functional excursion or it's amplitude.

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Dr. Tag

(B) Mid plantar pain at the start of heel rise: Caused

by Mid tarsal break causing massive strain on
the spring ligament which is caused by the drop
of head of talus.
Why at the start of heel rise? >> Because of foot
over pronation, which will require more time
at heel rise to make subtalar supination, so
Mid tarsal break occur, putting stress on the
spring ligament.
(C) Heal pain that is caused by Planter fasciitis: It is an inflammation
in the planter fascia5.
It is characterized by burning sensation in the foot in the morning
(first steps), then it decreases with activities all over the day and
then return back at the end of the day (but not the same
intensity as the morning pain).
Why? >> Because during sleeping, planter fascia heels in
shortening(relaxing) position. So during the first step in the
morning, overstretch of the shortened plantar fascia6 happens,
causing a micro-injury in it, which will cause a burning and painful
sensation that resolves with time as the inflammation resolves
and the waste products are washed out >> Then with exertion,
inflammation and accumulation of inflammatory waste causes
returning of pain again at night.

5
the plantar fascia is the thick connective tissue (aponeurosis) which supports the arch on the bottom (plantar
side) of the foot. It runs from the medial aspect of tuberosity of the calcaneus (heel bone) forward to the heads of
the metatarsal bones and base of 1st phalanx. Its inflammation is also more common in females.
6
By the DF of calcaneus and DF of toes (bilateral overstretch).

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Dr. Tag

Why does it increase with flat foot?>> Because in flat foot there is
overstress on the plantar fascia caused by the externally rotated
calcaneus.

Imaging: For X-rays,

Observe:
1- TCD form AP and Lateral views: (A) Normal: (20°)

AP

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 Dr. Tag

(B) Abnormal:

AP L

AP view: In flat foot, TCD increases and the talus appears shorter.
Lateral View: Talar drop and calcaneal upward movement >> Increase in TCD.
2- Talo-1st metatarsal angle7 from AP and Lateral view: (A) Normal 0°, To
provide optimal weight transfer to the floor.

AP

(B) Abnormal: AP>>Lateral angulation (medial apex angulation) happens, caused

by the following of forefoot to the calcaneal lateral movement.

7
How to describe an angle? >> By two ways: 1- The direction of the distal part in relation to the proximal part of
the angle (angulation), 2- The direction of movement of angle apex, which is always in the opposite direction to
the angulation.

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 Dr. Tag

Lateral: Dorsal angulation (or apex plantar angulation)

AP L

3- Talo-navicular joint from AP and lateral view: (A) Normal

AP

(B) Abnormal: AP >> Lateral talo-navicular joint subluxation, caused by lateral

navicular deviation or angulation (or medial apex angulation) (following the
calcaneus).

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Dr. Tag

Lateral >> Dorsal talo-navicular subluxation.

AP
Diagnostic Tests:
1- Subtalar joint examination: SFF only happens in case of subtalar joint
pronation.
2- Rigid Vs Flexible flat foot: It can be discovered by doing some special test in
which we observe the movement of the heel and determine its ability to
supinate. In case of heel`s ability to supinate, it is an indicator for flexible
flat foot.
Special Tests for flat foot:
1- Tip Toeing Test: Ask the patient to do PF from standing and observe the
heel. In case of heel supination>> Flexible FF. If it was locked in valgus, it
is rigid.
2- Testing using windlass mechanism (Windlass test): Patient is standing or
sitting with his back is opposite to a mirror and the feet in a weight
bearing positon on the ground. The therapist will do full passive DF of
the big to and observe the heel. In case of heel supination>> Flexible FF.
3- A test that is used for uncooperative patients: Patient is standing on one
foot, and by holding the patient pelvis, do trunk rotation toward the
non-weight bearing foot, inducing calcaneus IR, and observe the heel. In
case of heel supination>> Flexible FF.
NB: SFF is more common in Females.

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Dr. Tag

Treatment
Indications:
Only in case of symptomatic painful flat foot.
Types:
1- Calcaneal lengthening osteotomy: The surgeon breaks between the
anterior and middle facet of calcaneus (Part of LLA) and increase its length
then do fixation.
Purpose: Increase the length of the lateral longitudinal arch (LLA).
Why? >> MLA is a mobile arch, while LLA is rigid. So by increasing the
length of LLA>>it will increase the length of the foot>> Put tension on the
minimally relaxed plantar fascia>> Plantar fascia will cause supination (IR,
PF and adduction) of the calcaneus in resting position to relief the
tension>> Put the calcaneus under the talus>> Push the head of talus up>>
Increase the MLA.
Advantages: More biological and safer with more satisfaction from the patients
about the decreased pain level.
Disadvantages: Later recovery time than arthroereisis.

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Dr. Tag

2- Arthroereisis:
Purpose: By putting an irritant ( Bulky material or wedge), inside the sinus
tarsi8 >> Prevent the closure between the this space during pronation, causing
mechanical obstruction of pronation>> prevent flat foot.
Advantage: Earlier recovery and faster procedure.
Disadvantage: Postoperative severe pain in some patients, indicates failure of
the operation and the importance of the removal of the material.

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Tunnel (Depression) between the talus and the calcaneus that contains structures that contribute to the stability
of the ankle.

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Dr. Tag

3- Cavovarus foot deformity

(High arched foot with calcaneal varus)

Mainly happens as an associated complication to a serious neuromuscular disease

such as: Spastic CP, Spinal tumor, Poliomyelitis, Neuropathies, Mythenia Gravies
and Myopathies

Pathophysiology:
(A) Old Theory:
For Cavovarus diagnosis, you should have 2 major characteristics:
1- Muscles imbalance:
Over-powerful Peroneus Longus muscle, causing causes 1st metatarsal drop
(forefoot pronation) >> Hind-foot supination9 >> Both leading to higher MLA.
Weak Tibialis Anterior muscle >> Leads to more powerful Peroneus longus
and weak forefoot supination, causing more forefoot pronation >> Hind foot
compensatory supination>> Higher MLA

9
As a result of the metatarsal drop, a compensatory hind foot supination will occur aiming to restore the normal
weight bearing mechanism on 2 points, instead of one point, which will cause higher MLA >> Cavus

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Dr. Tag

2- Secondary contracture of the small intrinsic muscle of foot, as a result of

the high MLA changes to foot mechanics. It slacks first, then become
contracture happens.
(B) Current Theory: Weak Tibialis Anterior >> Loss of hind foot
pronation >> Hind Foot Supination associated with forefoot
pronation due to relatively powerful peroneus longus muscle >>
Causing 1st metatarsal drop and High MLA.
NB.: How to examine Tibialis Anterior Muscles?
Patient is sitting and ask him to do knee flexion while you resist it.
Normally foot and toes will do DF in relation to knee flexion. In case
of weak Tibialis anterior, DF of ankle will be done by the recruitment
of long toe extensors (EDL, EHL), Which will cause clawing of toes
(hyperextension of the MTP joint and hyper-flexed IP caused by
active insufficiency on the level of IPJs), allowing the muscle to do its
action on the ankle joint.

Clinical Picture:
1- Cosmetic Disfigurement: High arched and short feet with high pressure
point.
2- Frequent ankle sprain (Most common symptoms): No Hind foot pronation
caused by the fixed foot supination >> Lost of the supple function of the
foot in response to irregular surfaces >> Frequent Sprains (Supination
adduction type I>> Tension on the lateral collateral ligaments results in
rupture of the ligaments or avulsion of the lateral malleolus below the
syndesmosis.)
3- Patient shoe`s always wear out on the lateral side, caused by the
continuous lateral foot weight bearing.
4- Metatarsalgia: Extreme pain under the metatarsals caused by:
Hyperextension of MTPJs( Caused by muscle recruitment and hyperflexion
of IPs)>> leads to the loss of the metatarsal fat pad that aid in weight
bearing and shock absorption process >> Callosities formation and severe
pain during weight bearing.

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Dr. Tag

Radiological Examination (X-ray):

1- Talocalcaneal divergence:
(A) AP: Decreased TCD caused by calcaneal supination and more tapered
foot.
(B) Lateral: Decreased TCD, caused by PF and internal rotation of the
calcaneus.

2- Talo- 1st metatarsal angle:

(A) AP: Medial angulation and lateral apex angulation.
(B) Lateral: Plantar angulation with dorsal apex angulation.

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Dr. Tag

3- Talonavicular Joint:

(A) AP: Medial talonavicular subluxation.

(B) Lateral: Plantar talonavicular subluxation

Treatment:
1- Identify the cause first>> Because it is mainly due to a very serious illness.
2- Wearing comfortable shoe is a must (wide and soft heel).
Surgical correction:
(A) Muscle rebalancing: Modified John’s Procedure: Detachment of the
tendon of the extensor hallucis longus close to its insertion and transfer to
the neck of the first metatarsal.
Advantages:
1- Provide good ankle DF, So no need for muscle
recruitment.
2- Prevent 1st metatarsal drop and Forefoot pronation
an also acts as Subtalar pronation, which will
prevent high arching in MLA.

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Dr. Tag

(B) Soft tissue release: Release for the plantar fascia and reattachment of
all the muscles attached to the medial and plantar aspects of calcaneus
more distally (Steindler stripping).
(C) Dorsal closing wedge osteotomy of the base of 1st metatarsal bone.
(D) Calcaneal corrective osteotomy: To correct the fixed varus deformity

Talipes Equinovarus (TECV)

(clubfoot)

DEF.: Foot is presented to the floor with the talus, Talar PF, Hind foot supination
and forefoot pronation.
Club Foot >>> because the shape of the foot caused by the deformity is like a club
glove.
NB.: Deformity: It is the complete absence of passive range in the opposite
direction.

Pathology:
1- Talocalcaneal parallelism: No talocalcaneal divergence due to supination
subluxation of the calcaneus.
2- Tendo-Achilles contracture: Caused by PF of calcaneus leading to Tendo-
Achilles slackening then adaptive contracture.
3- Varus Deformity: caused by medial translation of the calcaneus in relation to
the talus, that force the patient to walk on the lateral edge of the talus.
4- Club foot: TC parallelism causes a loss in normal alignment of foot with the
floor and it became vertical on the floor, which in association with the varus
deformity give the shape of the club.

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Dr. Tag

Presentation:
Referred mainly to a pediatric orthopedic by a pediatrician.
Types:
1- Idiopathic: Only club foot without any associated abnormalities.
2- Syndromatic: Associated with other problems, most commonly skeletal
anomalies.
The most common associated anomalies are:
(A) Paralytic Talipes: Myelomeningocele associated with club foot. So the
therapist should observe the back.
(B) Arthrogrypotic club foot: Arthrogryposis causing club foot as a result of
the pathology of arthrogryposis. Therapist should also observe the wrist to
confirm, because it is the most common joint affected in arthrogryposis.

Radiological examination (X-ray):

1- TCD: TC parallelism in both AP and Lateral views.

2- Talo-1st metatarsal angle >> Same as Cavovarus

3- Talonavicular joint >> Same as Cavovarus, but the subluxation is more
prominent.

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Dr. Tag

Irrelevant NB: 1- Spring ligament is stretched in flat foot and

contracted in Cavovarus and club foot.
Dorsal tendons: Stretched in Cavovarus and club foot and
contractured in flat foot.
Management:
- Old methods have resulted in Corrected but painful foot for the rest
of patient`s life, due to excessive scaring.
- Ponseti method: Using serial casting aiming to do external rotation
of the forefoot to about 70° of foot thigh angle (increasing the foot
thigh angle from 15° to 70°), which in response will be associated
with dorsiflexion and abduction of the calcaneus, correcting all the
deformities. After the end of correction, it will return to be normal
again.
- It is followed by tenotomy of Achilles tendon.
- Before applying the method, restore the normal hind foot/ fore foot
alignment by pushing the 1st metatarsal upward >>>upward
movement of navicular, restoring the normal talonavicular join>>>
increase the supination of forefoot till it become in the same
alignement.
- Casting period is 3 weeks, followed by Dennis brown splint till the
child`s 4th year of life to maintain the correction and prevent the
recurrence.

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