Hindfoot

The hindfoot includes the talus, calcaneus, and the subtalar joint (joint between the talus and calcaneus). Inclusion of the talus in both the ankle and the foot indicates the importance of the talus to the function of the foot, as well as the function of the leg. The talus is responsible for absorbing and transmitting rotatory forces that have come from the hip and/or knee but also transmits rotatory forces up to the knee and hip that originated in the foot. The interconnectedness of the leg to the foot by way of the talus has led many to consider alignment of the hindfoot key in understanding the mechanics of the foot. In assessing alignment of the hindfoot, one can begin by assessing standing calcaneal alignment. The calcaneal alignment is generally classified as valgus, varus, or neutral and generally rests in slight valgus (3.5 degrees).⁸ The standing alignment of the calcaneus is then compared to the position of the calcaneus in subtalar joint neutral.

Assessment of subtalar joint neutral is the only clinical method available to determine structural variation in the hindfoot. Subtalar joint neutral is difficult to determine and measure in a reliable manner. However, the neutral alignment is a useful tool in interpreting standing alignment and providing a general reference for understanding the function of the foot. The determination of subtalar joint neutral occurs in prone. The examiner grasps the head of the talus with the thumb and index finger of one hand and the fifth metatarsal head with the other hand (Figure 8-2). The examiner uses the grasp on the fifth metatarsal head to move the forefoot and hindfoot into abduction and adduction until the fingers on the head of the talus palpate an equal proportion of the head of the talus on the medial and lateral side (under the thumb and index finger). The foot is held in this position to assess alignment. The alignment of the vertical bisection of the calcaneus is compared to the bisection of the lower leg.

Figure 8-2 Subtalar joint neutral hand placement on skeleton: Outside hand at fifth metatarsal head and inside hand on head and neck of talus in standard position (A) and dorsal view (B).

The hindfoot is determined to be in varus alignment if the calcaneus is inverted relative to the lower leg, in valgus alignment if the calcaneus is everted relative to the lower leg, and neutral if the calcaneus is aligned with the lower leg (Figure 8-3, A). The forefoot alignment is determined to be in subtalar joint neutral by comparing the plane of the hindfoot to the plane of the forefoot. If the forefoot is inverted on the hindfoot, the forefoot is considered to have a varus alignment. If the forefoot is everted on the hindfoot, the forefoot has a valgus alignment, and if the hindfoot and forefoot planes are parallel, the forefoot has a neutral alignment (Figure 8-3, B).

Figure 8-3 A, Neutral hindfoot alignment with vertical bisection of lower leg in line with the vertical bisection of the calcaneus. B, Neutral forefoot to hindfoot alignment with the plane of the hindfoot parallel to the forefoot.

The alignment of the metatarsal heads can also be assessed at this time. The metatarsal heads should be aligned along the same plane. Often the first metatarsal head will be located in a more plantar position than the remaining metatarsal heads. This is called a plantarflexed (dropped) first ray, which is a forefoot compensation for structural variations of varus at the hindfoot or forefoot (Figure 8-4).

Figure 8-4 A, First metatarsal head is plantarflexed (dropped) below the plane of second to fourth metatarsal heads. B, Correction of the dropped first ray. The forefoot varus alignment relative to the hindfoot is now apparent.

The non–weight-bearing subtalar joint neutral alignment, providing insight into structure variability, is the backdrop for interpreting standing alignment and function. For example, suppose during prone subtalar joint assessment the neutral subtalar joint position was with the calcaneus inverted relative to the lower leg (hindfoot varus). During the standing alignment assessment, the calcaneus is vertical. The hindfoot is assessed as being able to compensate for the varus structural deviation (hindfoot alignment is termed compensated hindfoot varus); however, the standing calcaneal alignment is now understood as potentially harmful as the subtalar joint is being maintained near an end-range position.

Arches

Standing alignment assessment proceeds to the arches of the foot. There is truly only one arch in the foot that is continuous from anterior to posterior and medial to lateral, but the arch is usually described as three arches: the medial longitudinal arch, the lateral longitudinal arch, and the transverse arch. Much of the research on foot type, function, and injury has used the standing alignment of the medial longitudinal arch as the primary method of determining foot type.^9-11 The height of the arch is often a key element. Extremes of high arch and low arch are relatively easy to classify. The high arch, a supinated foot type, is often accompanied by calcaneal inversion and an adducted forefoot, and the head of the talus and navicular are more prominent on the dorsal surface of the foot. The low-arch foot, a pronated foot type, is often accompanied by calcaneal eversion and a splayed and abducted forefoot, and the head of the talus and the navicular are more prominent in the middle of the arch (medial bulge).

The lateral longitudinal arch has greater inherent bony stability than the medial longitudinal arch. The joint surfaces of the calcaneus and cuboid are concavoconvex, providing some restriction to movement.¹² The lateral longitudinal arch height is much lower, often appearing flat in visual assessment.

The transverse arch is formed in part by the wedge shape of the cuneiforms¹² (Figure 8-5). As the transverse arch is assessed more distally on the foot, the height of the arch decreases until all metatarsal heads are in a level plane and capable of bearing weight.

Figure 8-5 Non–weight-bearing computed tomography image of the foot in the frontal plane with the metatarsals and phalanges removed. Note the wedged shape of cuneiforms 1 to 3 contributing to the formation of the arch.

Forefoot

The forefoot includes the metatarsals and phalanges. The normal alignment of the forefoot includes metatarsal and phalanges all aligned straight on one another. The toes should be relatively flat on the ground.

The common alignment impairment at the first MTP joint is hallux valgus. This alignment presents as angulation of the first metatarsal into abduction and the phalanx into adduction. The toes will also present with alignment faults that usually include a component of metatarsal-phalangeal hyperextension with flexion at the all interphalangeal joints (claw toes) or flexion at the proximal interphalangeal joint and extension at the distal interphalangeal joint (hammer toes).

Proximal and Distal Tibiofibular Joints

The proximal tibiofibular joint has very little motion, and individual variability in the shape of the joint surfaces has resulted in a wide variety of associated fibular motions reported with dorsiflexion and plantarflexion.¹³ The fibula at the proximal tibiofibular joint has been reported to glide anterior, lateral, and superior with talocrural dorsiflexion and to glide posterior, medial, and inferior with talocrural plantarflexion.¹³ The distal tibiofibular joint consists of a convex fibula and a concave tibia.¹² During talocrural joint motion from neutral to dorsiflexion, the fibula at the distal tibiofibular joint has been found to have motions of internal rotation, lateral displacement (widens), and posterior and superior glide.¹⁴ During talocrural motion from dorsiflexion to plantarflexion, the fibula at the distal tibiofibular joint has been found to be medially displaced.¹⁵

Talocrural Joint

The axis of motion at the talocrural joint is not uniplanar but triplanar, crossing all three planes of motion. The motions about the axis are termed pronation and supination. Table 8-1 shows component motion description. The axis at the talocrural joint, although it crosses all three planes, lies primarily in the transverse plane in a medial-to-lateral direction. Thus plantarflexion and dorsiflexion are the primary motions.

TABLE 8-1 Motions at the Hindfoot Associated with Open- and Closed-Chain Pronation and Supination

Dorsiflexion

Adequate dorsiflexion motion at the talocrural joint is crucial in advancing the tibia over the foot in walking, running, jumping, squatting, and many other weight-bearing activities. A minimum of 10 degrees of dorsiflexion (with the knee extended) is needed for walking and 30 degrees for running.¹⁶ Dorsiflexion motion requires adequate length of the gastrocnemius muscle, soleus muscle, and calcaneal (Achilles) tendon, as well as ligaments and joint structures of the talocrural joint. Because the head of the talus is wider anteriorly than posteriorly, a small amount of motion is required at the tibiofibular joint to fully accept the dome of the talus.¹³ If dorsiflexion is found to be limited, the source of limited talocrural motion can be assessed by measuring talocrural dorsiflexion with the knee extended and flexed and assessing talocrural joint accessory motion. Additionally, dorsiflexion should be isolated to the talocrural joint, and compensations at the foot (e.g., eversion, midtarsal dorsiflexion, and pronation) should not be allowed during dorsiflexion. The following information is gleaned from this test:

• Gastrocnemius muscle/calcaneal (Achilles) tendon short if dorsiflexion is ≤10 degrees with the knee extended but ≥10 degrees with knee flexed.

• Soleus muscle short if dorsiflexion is ≤10 degrees regardless of knee position and accessory talocrural motion is normal.

• Talocrural joint limitation if dorsiflexion is ≤10 degrees regardless of knee position and accessory talocrural joint motion is limited (cannot rule out soleus muscle limitation in this case).

Without adequate motion at the talocrural joint, the body can employ a number of strategies for compensating. The patient can increase the foot progression angle, demonstrate an early heel rise, or use a forefoot strike pattern (only the forefoot is in contact with the ground) during walking and running to compensate for the lack of dorsiflexion. Additionally, the failure to dorsiflex at the talocrural joint during stance phase can be compensated for by hyperextending the knee and/or increasing the dorsiflexion that occurs at the more distal joints of the foot: talonavicular, naviculocuneiform, calcaneocuboid, and/or cuboid-metatarsal joints (Figure 8-6).

Figure 8-6 Dorsiflexion at the talocrural joint is limited. Compensation has occurred with dorsiflexion at the midtarsal joint.

Plantarflexion

Plantarflexion at the talocrural joint plays an important role in propelling the body during walking, running, and jumping. Normal plantarflexion motion during gait is approximately 30 degrees. Plantarflexion at the talocrural joint alone, however, is relatively ineffective in propelling the body forward. The foot (calcaneus to metatarsal heads) must become a rigid lever to transfer the plantarflexion force through the foot, raising the body over the toes. The foot becomes more rigid in a number of ways. First, the foot becomes rigid through maximizing bony alignment. The contraction of the plantarflexors has a supination component. Supination of the subtalar joint and transtarsal joint helps place the joints in their closed pack, which is a more stable position providing some stability to the foot.

The second way the foot becomes rigid is by the passive tensioning function of the plantar aponeurosis. The plantar aponeurosis is a thick fascial sheath originating at the calcaneal tubercle and inserting into multiple locations but primarily into the flexor tendons of the foot and the base of the fifth metatarsal. As the heel begins to rise at the end of the stance phase, the MTP joints dorsiflex and the plantar aponeurosis becomes taut. The joints of the foot are approximated, the arch rises, and the foot becomes more rigid (windlass mechanism). Third, the foot is rigid because of the muscular forces that directly impact joint stability. The posterior tibialis muscle/tendon is aligned to provide not only a force that produces plantarflexion with supination but also a force directed along the long axis of the foot. The posterior tibialis tendon inserts into all the tarsal bones, except the talus, as well as the bases of second to fourth metatarsals. The posteriorly directed force along the long axis of the foot is critical to the function of the foot. The force provides muscular “cinching” of the foot bones, increasing foot rigidity and the effectiveness of the ankle plantarflexor muscles.¹⁷ An extreme example of failure of the mechanisms that provide rigidity to the midfoot allowing plantar flexion at the midfoot is seen in Figure 8-7. (Contraction of the gastrocnemius in subject B of Figure 8-7 would result in isolated plantarflexion of the calcaneus without a forceful transfer of plantarflexion to propel the body.) The intrinsic muscles of the foot also function to support the arch of the foot and provide rigidity to the foot during plantarflexion.

Figure 8-7 A, An individual with diabetes and peripheral neuropathy. Note the normal upward inclination of the calcaneus. B, The foot of an individual with diabetes, peripheral neuropathy, and Charcot’s osteoarthropathy. This individual has lost the necessary rigidity of the foot and the pull of the gastrocnemius/soleus muscle through the calcaneal (Achilles) tendon resulted in calcaneal plantarflexion.

Subtalar Joint

The axis of motion at the subtalar joint is also triplanar. The axis, although it crosses all planes, lies primarily between the sagittal and transverse plane, allowing more inversion and eversion and abduction and adduction than plantarflexion and dorsiflexion.

Transverse Tarsal or Midtarsal Joints

The transverse tarsal joint is comprised of the talonavicular and calcaneocuboid joints. The axes of motion at the transverse tarsal joints are triplanar, allowing pronation and supination. In most feet, motion at the subtalar joint is intimately connected to the motions that occur at the talonavicular and calcaneocuboid joints. As the subtalar joint supinates, it draws the transverse tarsal joint into supination, a more stable joint position of the transverse tarsal joint (locked position), converting the midfoot into a more rigid lever. As the subtalar joint pronates the transverse tarsal joint pronates, which creates a more loose position of the joints and a more flexible midfoot.²²,²³

The transverse tarsal joints are the intermediate joints between the hindfoot and the forefoot. One of the functions of the transverse tarsal joint is to position the forefoot for ground contact during push-off. In performing this function, the transverse tarsal joint becomes a frequent site of compensation for structural variances and movement impairments of both the hindfoot and forefoot. The transverse tarsal joint can become hyperflexible, limiting the ability of the foot to transform into a rigid lever and decreasing the stability of the longitudinal arches, which contributes to flat-foot deformities.

In the high arched or more rigid foot type, the subtalar joint and the transverse tarsal joints are maintained in the closed pack or locked position. The lack of mobility is thought to contribute to injuries at the foot and lower extremity as a result the inability of the rigid foot to dissipate the high forces occurring during weight-bearing activities.

Tarsometatarsal Joints

The tarsometatarsal joints generally have very little motion and are critical in providing the structure for the transverse arch. Motion that occurs at the tarsometatarsal joints is generally with the focus of positioning the forefoot flat on the ground for push-off. If the motion that has proceeded from the hindfoot to the midfoot during gait has inadequately prepared the forefoot for weightbearing, the tarsometatarsal joints may assist. For example, insufficient pronation of the hindfoot and midfoot from heel strike through midstance might result in the medial side of the forefoot being up off the weight-bearing surface. If there is motion available at the tarsometatarsal joints, a pronatory twist will occur at the tarsometatarsal joints to bring the forefoot flat.²³ A supinatory twist will occur in the tarsometatarsal joints if too much pronation has occurred at the hindfoot and midfoot during early stance phase. The site of compensatory motion often becomes the source of symptoms.

Metatarsophalangeal Joints

The MTP joints’ primary direction of function is into dorsiflexion. Adequate MTP dorsiflexion allows the foot to roll over the toes as the plantarflexor muscles propel the body forward. Additionally, MTP dorsiflexion stretches the plantar aponeurosis, elevating the arch and assisting in making the foot rigid during push-off. First MTP joint dorsiflexion needed for walking is reported to be between 30 to 60 degrees.²⁴,²⁵ Lack of first toe extension prevents the normal pattern of roll-over, and weight is transferred either medial or lateral of the first toe. Medial weight transfer increases the abduction force on the proximal phalanx, predisposing the individual to hallux valgus deformity. Lateral transfer of weight increases the force borne by the second and third metatarsal heads, often resulting in pain at the MTP joints.

First MTP joint dorsiflexion can be limited by the length of the flexor hallucis longus, plantar aponeurosis (fascia), or joint restrictions. Theoretically, the contribution of flexor hallucis longus muscle length to limited MTP joint dorsiflexion motion can be determined by comparing MTP dorsiflexion ROM with the talocrural joint dorsiflexed (flexor hallucis longus on stretch) to MTP dorsiflexion ROM with the talocrural joint plantarflexed (flexor hallucis longus on slack). First MTP dorsiflexion in full plantarflexion should measure ≥60 degrees. First MTP dorsiflexion in full talocrural dorsiflexion is rarely measured. Hopson et al²⁵ found on average 85 degrees of MTP dorsiflexion in 0 degrees of talocrural dorsiflexion. Nawoczenski et al²⁴ found 35 to 45 degrees of MTP dorsiflexion in a standing passive and active test. Clinically, MTP dorsiflexion measured in talocrural dorsiflexion is very limited, between 10 to 15 degrees (Figure 8-8). Decreased MTP dorsiflexion in full talocrural dorsiflexion can indicate flexor hallucis muscle length impairment. However, the plantar aponeurosis may also be limiting MTP motion in this position because the position of maximum MTP and ankle dorsiflexion has been found to place maximum stretch on the plantar aponeurosis.²⁶

Figure 8-8 First metatarsophalangeal extension. A, In talocrural joint dorsiflexion. B, In talocrural joint plantarflexion.

Functionally, there is rarely an occasion in which maximum MTP dorsiflexion is needed during maximum talocrural dorsiflexion. During gait, 30 to 60 degrees of first MTP dorsiflexion²⁴,²⁵ is needed during push-off when the talocrural joint is in approximately 10 to 25 degrees of talocrural plantarflexion.²¹,²³ Thus the most functional assessment of first MTP dorsiflexion would be to assess MTP dorsiflexion motion in approximately 20 degrees of talocrural plantarflexion. In summary, the following information can be gleaned from the test:

The contribution of MTP dorsiflexion to engage the windlass mechanism of the foot thus increasing foot rigidity during push-off is critical. Stretching into first MTP dorsiflexion should be approached with caution to avoid overlengthening of the foot structures critical for engaging the windlass mechanism of the foot.

Interphalangeal Joints

The interphalangeal joints have a critical role in increasing the area over which the weight-bearing force is distributed during push-off. To increase surface area during push-off, the toes must be flat on the ground. The intrinsic muscles of the foot are critical in stabilizing the MTP joints against excessive dorsiflexion (hyperextension) while extending the interphalangeal joints of the toes to provide a flat surface for force distribution. Without appropriate function of the intrinsic muscles of the foot, claw toe deformities develop as the extrinsic toe flexors and extensors act unopposed.

Posterior Compartments

The superficial and deep posterior compartments of the leg contain the primary plantarflexors of the ankle (the gastrocnemius, soleus, tibialis posterior, flexor hallucis longus, and flexor digitorum longus muscles), the posterior tibial artery and veins, tibial nerve, and fibular (peroneal) artery and veins. All posterior compartment muscles insert medial to the midline of the foot and therefore also assist in supination. Strong plantarflexion with supination is important in the muscular component that transforms the foot into the rigid lever for effective push off during gait. The posterior compartment also has a significant eccentric role during walking and running by controlling tibial progression over the foot and pronation of the foot from initial contact until the start of push-off.

The posterior tibialis, flexor hallucis longus, and flexor digitorum muscles and the posterior tibial artery and tibial nerve make a sharp turn around the medial malleolus and travel beneath the flexor retinaculum in the region posterior to the medial malleolus. The area in which this sharp turn occurs is a frequent site for tendon injury, as well as nerve compression.

Lateral Compartment

The lateral compartment contains the fibularis (peroneus) longus and brevis muscles and the superficial fibular (peroneal) nerve. The fibularis muscles are ankle evertors and weak ankle plantarflexors. Additionally, the fibularis longus muscle crosses the plantar surface of the foot and inserts on the base of the first metatarsal and medial cuneiform bone, providing a supportive sling for the foot and muscular control of the forefoot position. The fibularis brevis muscle inserts into the base of the fifth metatarsal, providing rigidity to the lateral column of the foot.

Anterior Compartment

The anterior compartment contains the tibialis anterior, extensor hallucis longus, and the extensor digitorum longus muscles; the anterior tibial artery and veins; and the deep fibular (peroneal) nerve. The muscles, the anterior tibial artery, and the deep fibular nerve pass under the superior and inferior extensor retinaculum. All muscles within the anterior compartment are ankle dorsiflexors. The insertions of the tibialis anterior and extensor hallucis longus are medial to the talocrural joint axis, inverting the foot during dorsiflexion. The insertion of the extensor digitorum longus is lateral to the talocrural joint axis and everts the foot during dorsiflexion. For balanced dorsiflexion that occurs primarily in the sagittal plane, the anterior tibialis and extensor hallucis longus inversion force must be countered by the eversion force produced by the extensor digitorum longus.

The anterior compartment muscles function concentrically during the swing phase of walking and running, dorsiflexing the foot, and clearing the toe. The anterior compartment muscles work eccentrically to control lowering of the foot from heel strike to foot flat in a heel-strike first pattern of walking and running.

Stress Fracture

Stress fractures are a common musculoskeletal source of undiagnosed foot and ankle symptoms that must be ruled out before completing a movement system examination and prescribing an intervention. Stress fracture pain generally is local and isolated to the bone, although symptom presentation can be diffuse and confusing. The six locations of stress fractures that are at high risk for serious sequelae if undertreated are anterior lateral tibial diaphysis, medial malleolus, talus, navicular, fifth metatarsal, and sesamoids.²⁷ Local or suspicious signs and symptoms in the high risk areas should be immediately referred to a physician because delayed treatment or undertreatment tends to result in progression to a complete fracture, a nonunion, the need for operative intervention, and/or recurrence or refracture.

Deep Vein Thromboses

Deep vein thromboses (DVT) can be the source of calf pain and edema. The strongest risk factors associated with development of a DVT include a fracture of the pelvis, femur, or tibia; hip or knee replacement; spinal cord injury; major general surgery; or major trauma. The Homans’ sign^28-30 (calf squeeze) has been commonly used to assess the presence of DVTs. Unfortunately, Homans’ sign has little diagnostic value.³¹ The Clinical Decision Rule developed by Wells et al assesses signs and symptoms, assigning a score and a probability of the presence of a DVT and has been found reliable and valid.³²,³³

Diabetes Mellitus

The lower extremity is at risk for devastating consequences of diabetes mellitus. Peripheral neuropathy and small vessel vascular disease can lead to unperceived injury, deformity, and nonhealing ulcers. Lower extremity amputation is often the outcome. An aggressive and complete screening for sensation and blood flow (see the “Peripheral Vascular Disease” section) should be completed on all patients who have suspicious histories. Sensation should be tested with Semmes-Weinstein monofilaments. For the foot and ankle, individuals are considered to lack protective sensation, which is sensation capable of detecting injury, if they are unable to feel the 5.07/10-gm filament on any location on the foot.

For individuals with diabetes mellitus, the hemoglobin A1c level (HbA1c) measures the percentage of hemoglobin in the blood that has glucose attached, indicating blood glucose control over a 3 month period of time. Normally, this value should be ≤6%. A higher HbA1c value indicates poor glucose control and is correlated with an increase risk of developing complications related to diabetes.³⁴

Peripheral Vascular Disease

Peripheral vascular disease can present as claudicating pain, which is pain in the lower leg that comes on with walking and decreases or resolves with rest. The clinician should look for loss of hair on the feet and legs, decreased capillary refill, nonpalpable pulses at the dorsalis pedis and/or posterior tibial arteries, and poor skin color. The patient may also report results from an ankle-arm index assessment that compares blood pressure in the arms to blood pressure in multiple sites in the lower extremity. Normal ankle-arm index values should be between 0.91 to 1.3.³⁵ There is and increased risk of a cardiovascular event with values <1.0 and ≥1.4.

Rheumatoid Arthritis

Although rare (16%), an initial presentation of rheumatoid arthritis (RA) occurs in the foot and ankle.³⁶ Specifically, individuals complain of forefoot pain. Hindfoot pain is often a later manifestation of RA.

Seronegative Spondyloarthropathies

Foot and ankle pain are also common complaints in ankylosing spondylitis, psoriatic arthritis, Reiter’s syndrome, and inflammatory bowel arthritides. Foot and ankle complaints are generally accompanied by additional signs and symptoms specific to the disease.

Gout

Gout can present in an acute or chronic manner. The pain, redness, and swelling is generally localized to the first MTP.³⁷

Plantar Aponeurosis (Fascia)

Involvement of the plantar aponeurosis is most often accompanied by patient complaints of heel pain that is worse with the first step out of bed in the morning and after a period of prolonged non–weight-bearing activities.

Posterior Tibialis Muscle and Tendon

The patient complains of pain localized to the muscle at distal one-third of the medial tibia or anywhere along the tendon as it follows its course around the medial malleolus to the primary insertion at the navicular bone. The symptoms are most apparent during the weight-bearing phase of activities as the muscle works eccentrically to control pronation and/or concentrically to supinate and plantarflex the foot and ankle.

Anterior Tibialis Muscle and Tendon

Pain is localized to the muscle at the proximal lateral tibia and/or the tendon as it inserts into the medial cuneiform and first metatarsal. The symptoms are often present at heel strike as the muscle works eccentrically to control plantarflexion. Anterior tibialis muscle pain is often called shin splints and particularly apparent after running or long distance walking.

Tibial Nerve

Pain, tingling, and/or numbness is located on the posterior medial ankle and/or the plantar surface of the foot. Determining whether the tibial nerve is involved is critical but also difficult. Tinel’s tapping test along the nerve pathway and if needed, Tinel’s tapping test in the provocative positions of full dorsiflexion, calcaneal eversion, and toe extension can assist the physical therapist is determining the source of symptoms.³⁸

Gastrocnemius/Soleus Muscles and Calcaneal (Achilles) Tendon

The patient complains of pain in the muscle belly or tendon, particularly during late stance, as the muscle is working eccentrically and the tendon is being placed on stretch to control the tibia’s progression over the foot and during the concentric contraction required during push-off.

Metatarsal Heads

For the movement impairment of pronation, metatarsal pain is localized to the head of the second and third metatarsals and increases during the late stance and the push-off phases of walking and running (Figure 8-11).

Figure 8-11 High pressure at second and third metatarsal heads in a subject with pronation during walking. Lateral midfoot pressure is related to cuboid subluxation.

Interdigital Nerves

The interdigital nerves can become irritated, producing complaints of pain, tingling, or numbness between the metatarsals and into the corresponding toes. The most common location is between the third and fourth toes. The interdigital nerve often receives branches from both the medial plantar nerve and the lateral plantar nerve, increasing the size of the nerve and the risk of impingement during weight-bearing activities.

Medial Column Joints

The patient complains of generalized midfoot pain, often in the joints of the medial column (talus, calcaneus, navicular, three cuneiforms, or first, second, or third metatarsals). The pain can progress to joint degeneration and involve the joints of the lateral column.

Walking and Running

During walking and running, the pronation movement impairments can include excessive calcaneal eversion during the early and midstance phases, excessive arch flattening in the midstance phase, and/or insufficient movement of the foot in the direction of supination in the late stance phase (Figure 8-15). Often, there is poor contraction of the gastrocnemius muscle with very little push-off noted. Medial rotation of the hip with an increase in medial foot loading can also be viewed.

Figure 8-15 Instances in stance in an individual with pronation syndrome. A, Heel strike. B, Midstance. C, Heel off. D, Toe off.

Plantar pressure scans taken during barefoot walking show an increase in force distributed through the medial side of the foot, as well as high pressure through second and third metatarsal heads (Figure 8-16).

Figure 8-16 High pressure at second and third metatarsal heads in a subject with pronation during walking. Lateral midfoot pressure is related to cuboid subluxation

During running, the pattern used by most people is to contact the ground first with the heel of the foot. A heel-strike pattern of running recruits the anterior compartment muscles to absorb shock and lower the foot down. The posterior compartment muscles are then recruited to control tibial advancement and assist with plantarflexion force. A running pattern that results in the midfoot or forefoot making the initial contact can contribute to pronation movement impairments. With a midfoot or forefoot initial contact, the force of body weight travels through the midtarsal joint and encourages dorsiflexion motion at the midtarsal joints. Additionally, the anterior compartment muscles are not recruited and the posterior compartment muscles remain active throughout stance, placing additional stress on the gastrocnemius and posterior tibialis muscles. The patient should be encouraged to run with a relatively frequent heel-strike–first pattern. In most cases, the patient does not need to make a complete shift to a heel-strike running pattern, but often a moderate decrease in the frequency or severity of the midfoot or forefoot strike pattern can result in a decrease in symptoms.

If symptoms are reproduced during walking and running and the pronation impairment is suspected, the secondary tests would be to provide cues to contract the gastrocnemius and posterior tibialis muscles, lifting from the heel and raising the medial longitudinal arch. If the patient is unable to control pronation during walking and running, external arch support (inserts, scaphoid pads, or arch taping) can be added, and movement and symptom reproduction is reassessed. If hip and knee medial rotation control appears to be an important factor, cues to contract the gluteal muscles and intrinsic hip lateral rotators can be used to assess the impact of the hip and knee movement impairment on foot function and symptom production.

Single-Leg Hopping

The patient is asked to repetitively hop on one leg. Individuals with the pronation syndrome demonstrate calcaneal eversion, dropping of the medial longitudinal arch, forefoot abduction, and/or knee and hip medial rotation. Poor contraction of the gastrocnemius is often very apparent during the single-leg hop test. The patient has a decreased jump height and compensates for the lack of plantarflexion strength with an increased swing of the upper extremities and increased reliance on the quadriceps and/or hip extensors to complete the jump. The contributing movement impairments of medial rotation at the hip and/or knee are also easily assessed during single-leg hop. If symptoms occur during single-leg hop, the secondary tests would be similar to those described for the walking and running test: Encourage gastrocnemius muscle contraction, add external arch support, and correct associated hip and knee movement impairments to assess movement and symptom production.

Step-Down and/or Small Knee Bend

The patient is asked to perform a step-down and/or a small knee bend. The physical therapist assesses the movement and symptom reproduction. Movement impairments consistent with pronation (calcaneal eversion, arch flattening, and weight transferred over the medial side of the foot and knee or hip medial rotation) and symptom reproduction support the movement system diagnosis of pronation. If symptoms are reproduced or the therapist suspects baseline symptoms could be reduced, the patient is cued to correct the movement impairment raising the arch, transferring weight slightly more lateral, and contracting the hip lateral rotators to control femoral medial rotation. A decrease in symptoms with the correction of the movement impairment supports the diagnosis of pronation syndrome.

Talocrural Dorsiflexion

See the previous “Dorsiflexion/Talocrural Joint” section.

Passive First Metatarsophalangeal Dorsiflexion

Adequate dorsiflexion motion of the first MTP joint is required as the tibia advances over the foot and the heel begins to rise from the floor. MTP dorsiflexion is measured in full plantarflexion and in 20 degrees of plantar flexion.

Subtalar Joint Eversion

In the presence of adequate eversion ROM, varus structural variations of the hindfoot and/or forefoot often result in pronation syndrome at the hindfoot (calcaneal eversion) in weight bearing.

Gastrocnemius/Posterior Tibialis Muscles

The gastrocnemius muscle is critical in producing powerful plantarflexion during walking and running. Along with the posterior tibialis, flexor digitorum longus, and flexor hallucis longus, the gastrocnemius muscle contributes to supination of the foot during the late stance phase. To assess function, observe the calcaneus during single-leg heel rise. Together, the ankle plantarflexors should contract and result in calcaneal inversion and elevation of the calcaneus through the full available motion. The ability to complete 25 single-leg heel raises is considered normal.³⁹ Dysfunction of the posterior tibialis tendon and muscle is evident during a single-heel rise since the calcaneus does not invert, the individual is unable to complete a full heel raise, and often dorsiflexion is seen at the midfoot (Figure 8-17). During walking and running, a visible and strong contraction of the gastrocnemius muscle is expected. Weakness or poor recruitment of the plantarflexor muscles contributes to pronation that occurs past midstance.

Figure 8-17 This patient has posterior tibialis dysfunction on the left. A, Note that on the left the calcaneus remains everted and the heel does not rise through full motion. B, Inversion of calcaneus during right heel raise.

Posterior Gluteus Medius, Gluteus Maximus, and Intrinsic Hip Lateral Rotation Muscles

Performance impairment of the hip lateral rotators results in excessive hip medial rotation. Hip medial rotation can cause pronation motion at the foot.

Intrinsic Muscles of the Foot

The intrinsic muscles of the foot are important in maintaining the arches of the foot during weight-bearing activities. The strength assessment is often indirect, observing the individual’s ability to complete a towel crunch with the toes, lifting the arch, and flexing the MTP joints.

Heel Counter

The heel counter is the posterior component of the shoe that wraps around the heel and is attached to the sole of the shoe. The purpose of the heel counter is to cup the heel and control hindfoot motion. The heel counter should fit the heel snugly and should be made of firm material. If the material is flexible or absent (e.g., an open-back sandal) there is no external assistance to control the calcaneal motion of eversion that can contribute to pronation syndrome.

Shoe Sole Components

The density (firmness) of the material used in the sole of the shoe impacts the shoe’s “resistance” to a particular motion. Shoes manufactured to control pronation often have a dual or multidensity sole. A material with increased firmness is added to the medial side of the shoe (a less dense or softer material remains lateral), discouraging motion in the direction of pronation (Figure 8-18).

Figure 8-18 Right Asics Gel Foundation 8. Firm density material at the medial heel with less dense material laterally. Gel material is also dual density with firm gel medial and soft gel lateral.

The location of the firm material as it relates to the patient’s specific movement impairment is very important. For a patient with a neutral calcaneus but increased pronation at the midfoot, the firm material should be located only at the medial midfoot (Figure 8-19). For this particular patient, inclusion of firm material at the hindfoot may encourage a new movement impairment of calcaneal inversion and potentially result in new symptoms. If the pronation impairment occurs at the hindfoot and midfoot, the firm material should run from the heel through the midfoot.

Figure 8-19 Right Asics GT-2150. Note multidensity arch material to increase support for the midfoot.

The general flexibility of the sole should be assessed. The sole of the shoe should bend easily only at the toe break. Where the shoe breaks is in part determined by the location of the grooves in the sole material. The removal of sole material to form the grooves encourages bending at the specific location. The groove on the shoe should match the patient’s MTP joint line from the first to the fifth toes (Figure 8-20). Footwear with little sole rigidity results in bending at the midfoot, which encourages dorsiflexion at the midtarsals and tarsometatarsal joints (Figure 8-21).

Figure 8-20 A, Left Air Pegasus+ 26. Note the white line of material at the metatarsal break is more distal lateral than medial. B, Left Asics Gel Nimbus 11. The white line of material is more proximal lateral than medial. The pattern of sole material removal at the forefoot should match the outline of the metatarsophalangeal joints where dorsiflexion occurs during walking and running.

Figure 8-21 A shoe that bends easily at the midportion of the sole.

Heel-to-Toe Height

Limited dorsiflexion contributes to pronation as discussed previously in this chapter. Limited dorsiflexion can be compensated for by lifting the heel slightly above the toe. This can be accomplished through footwear and is often unnoticed by the individual wearing the shoe (Figure 8-22). The onset of foot symptoms related to a change in footwear may be associated with a change in the heel to forefoot height (the amount of heel lift). Even a small reduction of heel height can increase the stress on the foot and result in injury.

Figure 8-22 Shoe has been cut in half. Note the difference in height of the heel of the shoe compared to the toe of the shoe.

Arch Support

The amount of direct arch support material in the insole of the shoe is generally small and often made of very soft (compressible) materials. The location is also fixed and may fail to support the arch in the appropriate location. External arch pads (scaphoid/navicular pads) can be easily added to most any footwear.

Last Shape

The last of a shoe is the mold used to shape the shoe. The shape of shoes is generally straight, semi-curved, or curved. To assess last shape, bisect the heel into equal amounts of sole material, medial and lateral. Continue the line that bisects the heel up to the forefoot of the shoe. A straight last will have equal amounts of forefoot sole material on the medial and lateral sides of the line that bisects the heel (Figure 8-23). Curved lasts will have more material on the medial side of the forefoot portion of the shoe compared to the lateral side. Individuals with pronation syndrome often have a straighter foot and would fit best into a straight or semi-curved last. The shape of the shoe should not be used to force a change in foot shape.

Figure 8-23 Left New Balance 883. Pronation control shoe with a straight last.

Walking and Running

The patient is instructed to work on the specific cues that assisted in symptom reduction during the examination or the cues that the physical therapist believes, with practice, may result in symptom reduction. The following cues are among the possibilities that may assist the patient:

Many of the changes being requested of the patient during walking and running are similar to a strengthening program. As such, encourage the patient to have focused practice time and gradual implementation to avoid injury.

Muscle Performance

Weakness of the supinators (gastrocnemius and posterior tibialis muscles) can be addressed with a progressive strengthening program, which includes elastic band resistance exercise into plantarflexion and plantarflexion/inversion, heel raises, and single-leg hopping. During the exercise, assess the contraction of the gastrocnemius muscle cueing the patient to raise the heel.

Intrinsic muscles of the foot can be strengthened by completing towel crunches using the toes to grab the towel and pull the towel under the foot. The movement must be accomplished by flexing at the MTP joints, raising the arch, and cupping the foot (Figure 8-24, A). The patient should not be allowed to complete the towel crunch with isolated motion of the flexor digitorum longus with flexion occurring only at the proximal and distal interphalangeal joints (Figure 8-24, B). Weight can be added to the towel to increase resistance.

Figure 8-24 A, Towel crunch with toes using intrinsic muscles to flex the metatarsophalangeal joints. B, Toe intrinsic exercise done incorrectly using flexor digitorum longus and flexor hallucis longus to curl toes without flexing the metatarsophalangeal joint and raising the arch.

Posterior hip muscle strengthening is described in detail in Chapter 7, “Corrective Exercises: Purposes and Special Considerations,” in Sahrmann.³ An appropriate strengthening progression activity includes sidelying hip lateral rotation progressing to lateral rotation with abduction and adding weight as appropriate.

Muscle strengthening occurs when the muscle is overloaded. The general recommendations are that the exercise should be completed at 70% of the patient’s maximum voluntary contraction for 10 repetitions, 3 sets, 3 to 5 times/week. In general, exercise or activity is permissible if pain remains ≤2/10 on a 0 to 10 scale.

Muscle Length and Joint Integrity

Decreased length of the gastrocnemius muscle and tendon can be addressed with a small lunge stretch at the wall, dropping the heel off a ledge, or long sitting dorsiflexion towel stretch; all stretches would be done with the knee extended. The soleus muscle and tendon can be stretched by bending the knee during the wall, heel hang, or towel stretch. Unique instructions for patients with pronation syndrome include preventing pronation during the stretch (this could include active patient correction of pronation and wearing good footwear during the stretch) and keeping the foot facing forward or in line with the femur and tibia. The heel should be kept on the ground during the stretch.

To address talocrural joint limitation, a posterior glide or a distraction technique of the talus on the ankle mortise is recommended in addition to the stretches described. Additionally, a prolonged stretch can be provided by a dorsiflexion splint. The splint is a non–weight-bearing brace and is generally recommended for night wear but could be used during the day if the individual could remain non–weight-bearing during splint use. Splint use in the foot and ankle is often reserved for patients whose symptoms do not respond to the traditional treatment plan to improve dorsiflexion. Splint wearing at night can be uncomfortable, disrupting sleep, which often results in poor patient compliance.

Limited talocrural dorsiflexion can be compensated for by adding a heel lift in the shoe. A heel lift used long term can contribute to loss of talocrural dorsiflexion and should be approached with caution.

Limited extensor digitorum longus muscle and tendon extensibility can be addressed by having the patient plantarflex the involved foot with the toes plantarflexed either in a sitting position or while on hands and knees and rocking back. Limited first MTP dorsiflexion related to decreased extensibility of the flexor hallucis longus can be addressed with a prolonged stretch into dorsiflexion with the ankle in dorsiflexion. To address limitations in first MTP joint dorsiflexion, an anterior glide of the proximal phalanx on the metatarsal can be performed.

Stretching should be held for 30 seconds, 2 to 3 repetitions, completed regularly throughout the day (5 to 8 times/day), and completed 5 to 7 days/week.

Activity Modification

Activity level should be modified to decrease forces on the foot. If the symptoms are severe, the therapist should consider the use of an assistive device or a period of immobilization to decrease tissue irritability.

As the tissue heals, a cautious and gradual increase in activity will assist in returning the patient to the previous level of activity. If appropriate for the patient’s goals, activity should progress to dynamic activities such as jumping, hopping, shuttle run, cutting, and so on. A guide for progressing from walking to running begins with a run/walk program. Generally, a 1 : 4 ratio (1 minute run with a 4 minute walk) is a reasonable place to begin. The physical therapist should closely monitor symptoms. The symptoms guidelines used in clinical practice are that symptoms should remain ≤2 out of 10, and symptoms that come on with activity should resolve within a very short time after activity (no longer than 1 hour). As the tissue tolerance to activity improves, the number of run/walk cycles is increased and then duration of running is increased while walking duration is decreased.

The progression to high level agility sport activity includes starting with straight plane jogging and jumping on a smooth flat surface. The most effective strategy is to work on increasing distance before increasing speed because an increase in speed increases the peak forces through the foot and is more likely to result in tissue injury or reinjury. As the patient’s tolerance of weight-bearing activities improves, the terrain should be varied, as well as the addition of hills, cutting, and progressing to unexpected turns. The equipment (balls, cleats, sticks, rackets, and so on) associated with the sport of interest should be introduced, as well as a plan to gradually introduce other players and to address the dynamics of the sport (player contact, single-leg balance activities, speed of the sport, or ball movement).

External Tissue Support

Orthoses

Orthoses are not recommended for all patients. Indications that orthoses may be appropriate include (1) the inability to correct the movement impairment through cueing, (2) significant structural variations, (3) the problem is recurrent, or (4) the foot alignment places the individual at risk for future problems. A temporary orthosis is a cheap and efficient method to assess the usefulness of an orthosis. Components can be easily added and removed to aid in determining what is most helpful for managing the patient’s symptoms. The component most often added is arch support (scaphoid/navicular pad). Medial hindfoot and forefoot posts are additional options that can assist with limiting motion that results in symptoms (Figure 8-25). The goal of the orthosis is not to achieve a subtalar joint neutral position but to prevent excessive or end-range motion so that the symptoms resolve. For local metatarsal pain, a common orthoses component is a metatarsal pad (Figure 8-26). The pad should be located just proximal (0.5 to 1 cm proximal) to the metatarsal head to unload the metatarsal heads and limit MTP hyperextension.⁴⁰

Figure 8-25 An off-the-shelf orthosis with a (A) scaphoid/navicular pad and (B) hindfoot medial post.

Figure 8-26 A, Total contact insert with local metatarsal relief. B, Global (all) metatarsal head relief.

An important orthoses modification for patients with tarsal tunnel nerve (tibial nerve) involvement is to avoid firm materials in the medial heel of the orthosis or sole of the shoe. Firm materials may contribute to nerve compression and irritation (Figure 8-27).

Figure 8-27 Example of a total contact orthosis with professional quality visco elastic polymer (Riecken’s, Evansville, Ind.) at the medial heel.

Taping

Taping to support the arch can assist in symptom management while additional treatment options are being implemented. There are a variety of techniques, but most have a common component of restraining longitudinal motion between the calcaneus and the metatarsal heads (Figure 8-28).

Figure 8-28 Arch taping to provide external arch support during weight-bearing activities.

Case Presentation

Pronation Syndrome

Symptoms and History

An internist referred a 42-year-old female for evaluation and treatment of right “heel pain.” Her heel pain began approximately 10 weeks ago when she returned to work full time as a floor salesperson at a local shopping center. The patient has had to decrease her working hours from 40 to 20 because she was unable to tolerate the heel pain. The patient’s pain is located on the plantar surface of the heel. She states the pain occurs only during weight bearing and is much worse in the morning when she first gets out of bed (7/10) than later in the afternoon (4/10). She states her pain is worse when walking barefoot or in her work shoes, which are dress flats. She reports increasing pain with walking more than 15 minutes and has difficulty completing daily activities like grocery shopping and playing games with her children. She is 5 foot 6 inches and weighs 190 lb. Her Foot and Ankle Ability Measure score is 49% (100% indicates normal function).

Alignment Analysis

In standing, the foot alignment shows a vertical calcaneus and a normal-to-low arch bilaterally. The alignment of the hip and knee includes medial rotation of the femur and slight lateral rotation of the tibia bilaterally. Symptoms in standing were 3/10. In prone the assessment of subtalar joint neutral reveals a small hindfoot varus and neutral forefoot alignment.

Movement Analysis

Walking/running

During walking, the calcaneus hits in inversion, moves into eversion by midstance, and remains in the everted position through late stance (right foot greater than left). Symptoms during barefoot walking increased to 5/10. Secondary tests, including cues to raise her heel earlier in stance and to contract her gastrocnemius, decreased the amount of eversion during midstance to late stance and decrease her symptoms minimally (4/10).

Single-leg hopping

The patient demonstrated decreased use of plantarflexors during single-leg hopping. Symptoms were generally less (3/10) when remaining on her toes and avoiding weight bearing through the heel.

Small knee bend

An increase in calcaneal eversion and a lowering of the arch was noted (right greater than left) during a small knee bend. Symptoms remained at 3/10.

Muscle Length/Joint ROM Analysis

	Right	Left
Talocrural dorsiflexion (knee extended)	0 degrees	5 degrees
Talocrural dorsiflexion (knee flexed)	5 degrees	10 degrees
Calcaneal eversion	5 degrees	5 degrees
First MTP joint extension (30 degrees talocrural plantarflexion)	60 degrees*	60 degrees

* Increased symptoms at the calcaneal tubercle and into the arch.

Joint accessory motion assessment found no difference in mobility between the right and left talocrural joints during an anterior-to-posterior glide of the talus on the ankle mortise.

Muscle Performance Impairments

• Single-leg heel raise could be completed 10 times through full plantarflexion and inversion range with fatigue, resulting in a decreased height of the heel raise and incomplete inversion in subsequent repetitions.

• Sidelying gluteus medius strength was 3+/5 on the right and 4/5 on the left.

Towel crunch with toes: the toes flexed, the MTP joints extended. The patient was able to correct performance to lift arch and plantarflex the MTP joints, but the foot cramped after five toe crunches.

Footwear

Patient wore her work shoes, which were dress flats. The heel counter was flexible, and the sole was made of a flexible plastic.

Palpation

Symptoms were reproduced with palpation of the calcaneal tubercle on the right foot. Pain continued with palpation of the plantar aponeurosis into the arch of the foot.

Diagnosis

Pronation occurred past midstance with no motion in the direction of supination during late stance. The primary contributing factors to pronation syndrome were decreased talocrural dorsiflexion ROM from decreased length of the gastrocnemius and soleus muscles and weakness of the gluteus medius/hip lateral rotators and foot plantarflexors/supinators. There was also a slight structural variation (hindfoot varus in the presence of sufficient calcaneal eversion motion) that could contribute to pronation. Additionally, the footwear provided insufficient support and cushion for a job that requires prolonged standing. The stage for rehabilitation is 2. The pain rating was moderate to high, she was mobile but limited in her ability to complete activities that require longer weight bearing, and her Foot and Ankle Ability Measure indicates a moderate amount of disability. Source of the symptoms was the plantar aponeurosis. The patient was seen 1 time/week for 8 weeks to assess and modify the treatment plan.

Treatment and Outcomes

Table 8-4 includes pronation syndrome interventions and outcomes.

TABLE 8-4 Pronation Syndrome: Interventions and Outcomes

Activity education

• First-step pain

• Gentle dorsiflexion stretch before stepping onto the foot after a prolonged period of non–weight-bearing activity (e.g., sleeping).

• Step directly into her most supportive shoes as she gets out of bed and for as long in the morning as she is able to avoid the trauma associated with first-step pain and morning symptoms.

• Femoral medial rotation and pronation

• Patient instructed to squeeze the buttock, keep the knee over the toe (not medial), and lift the arch during weight-bearing activities.

• Gluteus medius strengthening.

Arch taping resulted in an immediate decrease in symptoms with weight bearing to a 2/10. First step morning pain decreased to a 4/10 within the first week after implementation of the suggested changes to her morning routine. The temporary addition of a heel lift and scaphoid pad to the shoe was needed to assist with initial symptom relief. The patient continued the home exercise program to strengthen the hip, ankle, and foot, increase talocrural dorsiflexion motion, and modify the medial femoral rotation and foot and ankle pronation for approximately 8 weeks before symptoms consistently remained at 0/10 with a full 40-hour week of work.

Plantar Aponeurosis (Fascia)

Involvement of the plantar aponeurosis is most often accompanied by patient complaints of heel pain that is worse with the first step out of bed in the morning and after a period of prolonged non–weight-bearing function.

Fibular (Peroneal) Muscles and Tendon

The patient complains of pain localized to the muscles (posterior to the fibula) or anywhere along the tendon as it follows its course around the lateral malleolus to the insertion at the base of the fifth metatarsal for the fibularis brevis or following the fibularis longus as it runs along the lateral border of the cuboid and to the plantar surface of the foot. The symptoms are most apparent during the weight-bearing phase of activities as the muscle works to eccentrically control supination and dorsiflexion and during push-off as the muscle acts concentrically to assist with plantarflexion.

Gastrocnemius/Soleus Muscles and Calcaneal (Achilles) Tendon

The patient complains of pain in the muscle belly or tendon, particularly during late stance, as the muscle is working eccentrically and the tendon is being placed on stretch to control the tibia’s progression over the foot and during the concentric contraction required during push-off.

Metatarsal Heads

The patient complains of metatarsal pain localized to the head of the first and fifth metatarsals that becomes worse during late stance and the push-off phase of walking and running.

Lateral Column Joints

The patient complains of generalized pain along the joints of the lateral column of the foot (talus, calcaneus, cuboid, and fourth and fifth metatarsals).

Walking and Running

During walking and running, the supination movement impairment usually includes calcaneal inversion at heel strike that remains through push-off. There is generally an absence of pronation during the initial portion of stance. The center of gravity during stance remains lateral on the weight-bearing surface of the foot (Figure 8-30). There is often a very late whip to the medial side of the foot during push-off. The foot is rigid, and there is very little shock absorption during walking and running, which can contribute to symptoms at the knee, hip, and back. The rigid foot can also produce varus motion at the knee that can contribute to knee symptoms.

Figure 8-30 Calcaneus stays vertical and arch is high from heel strike through push-off.

The barefoot plantar pressure assessment in Figure 8-31 is common in individuals with the supination movement impairment. There is no loading of the midfoot, which reduces the surface area for force distribution (increases localized pressure). The metatarsal head pressure is high, particularly under the first metatarsal. In this individual, there is also very high medial great toe pressure, evidence of the late transfer of weight medially over the first toe.

Figure 8-31 Barefoot pressure scan during walking of supinated individual. Note the lack of midfoot loading and the high forefoot pressure under the first metatarsal.

If symptoms are reproduced during walking and running and the movement impairments previously described are noted, the supination impairment is suspected. The secondary tests for supination impairment can be challenging to implement as the foot and the movement pattern are often fixed and unable to be volitionally corrected. Attempts can be made to control the offending motion (calcaneal inversion, late medial motion) with verbal cues to avoid extreme lateral loading through the foot, to soften the landing with knee flexion, and to roll medially sooner. Unfortunately, the rigidity of the foot often prevents the individual from changing the movement pattern. Attempts can be made to post the heel laterally to encourage eversion motion. Additionally, an arch support can be added to footwear to assess the effect of increasing the contact area over which the load is borne.

Single-Leg Hopping

The patient is asked to hop repetitively on one foot. The rigid foot associated with supination syndrome is an excellent lever for the plantarflexors, transferring the plantarflexor force easily and propelling the body up. Often, the patient with supination syndrome is able to jump fairly high and with what seems like little effort. The supination movement impairment at the foot is generally not apparent during the single-leg hop, since only the forefoot is striking the ground. Observation of the single-leg hop provides valuable information about plantarflexor muscle performance, as well as contributing movement impairments at the knee and hip. If symptoms occur during single-leg hop, the secondary test would be cues to address hip and knee movement impairments (lateral rotation or varus motions) and soften the landing with knee flexion. Weakness of the gastrocnemius/soleus complex should also be assessed further through single-leg heel rises. The addition of arch support may not affect the symptoms during the test because the heel and midfoot do not touch the ground during single-leg hopping.

Step-Down and/or Small Knee Bend

During a step-down or small knee bend, the most common impairment noted is limited dorsiflexion. The compensation is often an early heel rise and the rigidity of the foot becomes apparent (no decrease in arch height during the motion). The lateral distribution of force through the foot can also be seen during the small knee bend. Symptom reproduction during low impact activities like step-downs or small knee bends is rare. However, if symptoms are reproduced or the therapist suspects baseline symptoms could be reduced, the patient is cued to correct the movement impairment keeping weight more central (away from the lateral aspect of the foot). A decrease in symptoms with the correction of the movement impairment supports the diagnosis of supination syndrome. Additionally, the physical therapist can assess the role of insufficient dorsiflexion in symptom reproduction by limiting dorsiflexion motion to avoid end-range or adding a small heel lift. If correction of the insufficient dorsiflexion results in symptom reduction, the therapist needs to consider insufficient dorsiflexion syndrome as a possible movement impairment diagnosis (see the following “Insufficient Dorsiflexion Syndrome” section).

Talocrural Dorsiflexion and Passive First Metatarsophalangeal Dorsiflexion

Limitation in motion at the talocrural joint and the first MTP joint are also associated with the supination movement impairment. Decreased talocrural dorsiflexion during late stance results in either an early heel rise or transfer of weight lateral for the tibia to advance over the foot. Limited first MTP motion results in a transfer of force medial at late stance (push-off) or keeps the force lateral. The tests to determine source of limitation are described in the “Metatarsophalangeal Joints” section.

Subtalar Joint Eversion

Subtalar joint eversion is often limited (<0 degrees) in patients with supination syndrome.

Heel Counter

In patients with supination syndrome the heel counter should have qualities similar to those recommended for pronation syndrome in that the counter should be made of firm material and hold the heel snugly. In the case of supination syndrome the heel counter will help to control inversion of the calcaneus.

Shoe Sole Components

The supinated foot has a decreased ability to absorb shock during early stance and may require additional attention to cushioning. Sole components, such as air and soft materials, are marketed to attenuate shock (Figure 8-32). Footwear manufacturers rarely add firm material components to the lateral side of the shoe to encourage pronation. However, the individual with supination syndrome should not wear a shoe designed for pronation syndrome because the shoe would have firm materials medially and would encourage the supination movement impairment.

Figure 8-32 Asics GEL-Nimbus 11. Manufactured primarily for cushion and flexibility with the inclusion of gel and sole materials that attenuate shock.

As with pronation syndrome, the sole of the shoe should bend easily only at the MTP joint line. The groove on the forefoot of the shoe should match the patient’s MTP joint line from the first to the fifth toes.

Heel-to-Toe Height

Limited dorsiflexion is also associated with supination syndrome and can be compensated for by lifting the heel slightly above the toe. A reduction in the heel-to-toe height ratio can contribute to symptom onset similar to that described with pronation syndrome.

Arch Support

The lack of contact area of the supinated foot during walking contributes to high pressure. Footwear should be assessed for the ability of the insoles to provide contact, support, and force distribution through the entire foot.

Last Shape

The most common shape of a supinated foot is forefoot adduction relative to the hindfoot. A curved last generally matches the shape of the supinated foot best (Figure 8-33). The shape of the shoe should not be used to force a change in the shape of the foot or to attempt to alter motion of the foot.

Figure 8-33 Left Nike Air Pegasus +26. Curved last with additional material on the medial forefoot compared to the lateral forefoot.

Walking and Running

The patient is instructed to work on the tasks that use specific cues that assisted in symptom reduction during the examination or the cues that the physical therapist believes with practice may result in symptom reduction. Often, the cues are related to softening the landing, hitting more centrally on the heel, and concentrating on trying to limit lateral loading through the foot.

Range of Motion

The treatment plan for limited motion is similar to that described for pronation syndrome.

Activity Modification

The general guidelines for activity restriction and progression described in the “Pronation Syndrome” section apply here as well. For supination syndrome, specific suggestions include use of softer surfaces when shock absorption is a concern.

External Tissue Support

Taping

Taping to support the arch can be helpful in supination syndrome as well. The indications for taping are that providing support for the arch and assisting with force distribution (arch supports were helpful) decreased symptoms during the examination. Calcaneal (Achilles) tendon irritation can be assisted with a taping technique that provides support to the tissue (Figure 8-34).

Figure 8-34 Calcaneal (Achilles) taping to reduce tensile forces at the calcaneal tendon.

Footwear

The last of the shoe should match the patient’s foot. Additionally, as with most individuals, a firm heel counter with a sole that bends at the metatarsal head break is generally appropriate. Shoe length and width and height of the toe box should accommodate the size of the foot and any deformities. An increase in the heel-to-toe ratio may be a reasonable compensation, particularly if the treatment to address talocrural dorsiflexion limitation is unsuccessful.

Orthoses

A heel lift may be indicated temporarily or permanently, depending on the ability of the stretching plan to improve talocrural dorsiflexion.

Case Presentation

Footwear

For patients with hypomobility syndrome, shoe size and shape are particularly important. The involved foot and ankle is often larger, and edema fluctuates with weight-bearing activity. A shoe that has extra depth with laces is helpful to accommodate size and edema fluctuation. An increase in the heel-to-toe ratio may be a reasonable compensation, particularly if the treatment to address talocrural dorsiflexion limitation is unsuccessful.

For patients with OA or RA, there are a number of shoe modifications that can be made to assist with foot and ankle symptoms during weight bearing. A steel shank in the sole of the shoe (making the sole of the shoe rigid) with a rocker at the toe break allows the patient to more easily roll over the foot without needing as much talocrural dorsiflexion or MTP dorsiflexion.

Orthoses

For individuals with OA or RA, a total contact insert made of accommodative material is often indicated. Deformities of the foot should be considered in the design and materials chosen for the orthosis. A heel lift may be necessary to manage the loss of dorsiflexion ROM. Temporary orthoses or additional arch support are often indicated to manage foot pain that is often related to the new onset of a pronation impairment that results from the limited foot and ankle mobility.

Case Presentation

Symptoms and History

The patient is a 40-year-old female referred by the orthopedist for physical therapy 6 weeks s/p right ankle bimalleolar fracture, ORIF. The patient reports that 6 weeks ago she missed the last step going down to her basement and fractured her right tibia and fibula. The patient reports non–weight-bearing activity in a cast for 2 weeks after surgery and progressed to partial weight bearing in a walking cast for 4 weeks. The physician started her on full weight-bearing activity 3 days ago in a boot. She reports she always has a bit of pain even when sitting or resting (3/10). Pain increases to 5/10 with attempts at full weight bearing activity. Her Foot and Ankle Ability Measure score was 10% (100% indicates normal function).

Alignment Analysis

Patient is obese with visible psoriatic patches noted on bilateral lower and upper extremities. The ankle, foot, and toes are moderately swollen with pitting edema of the right ankle and foot.

Girth measurements:

Scar: Incision closed, no redness, no warmth, no drainage. Scar is slightly adhered centrally with very mild hypersensitivity to touch.

Movement Analysis

Taping

Taping to immobilize or limit motion between the proximal tibia and fibula can help reduce symptoms (Figure 8-41). Caution should be taken to avoid compression of the common fibular nerve as it passes superficially around the fibular head. Taping of the fibula is a required precursor to hamstring and talocrural stretching exercises that assist in stabilizing the joint during the prescribed exercise. Taping of the fibula is also helpful after mobilization treatments correcting positional impairments.

Figure 8-41 Example of fibular taping, avoiding the fibular (peroneal) nerve while providing resistance to posterior motion of the fibular head.