Manns Surgery of the Foot and Ankle - 9th Edition

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MANN’S SURGERY OF THE FOOT AND ANKLE ISBN: 978-0-323-07242-7

Volume 1 Part Number: 9996074684
Volume 2 Part Number: 9996074749

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Library of Congress Cataloging-in-Publication Data
Mann’s surgery of the foot and ankle / [edited by] Michael J. Coughlin, Charles Saltzman, Robert B.
Anderson.—Ninth edition.
    p. ; cm.
Surgery of the foot and ankle
Preceded by Surgery of the foot and ankle / edited by Michael J. Coughlin, Roger A. Mann, Charles
L. Salzmann. 8th ed. c2007.
Includes bibliographical references and index.
ISBN 978-0-323-07242-7 (set : hardcover : alk. paper)
I. Coughlin, Michael J., editor of compilation. II. Saltzman, Charles L., editor of compila-
tion. III. Anderson, Robert B. (Robert Bentley), 1957- editor of compilation. IV. Title: Surgery of
the foot and ankle.
[DNLM: 1. Ankle—surgery. 2. Foot—surgery. 3. Ankle Injuries—surgery. 4. Foot Diseases—
surgery. WE 880]
RD563
617.5’85059—dc23
   2013017557

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 Preface

In 1959, Henri L. DuVries, MD, published the first edition believe that the principles initially espoused by Drs.
of Surgery of the Foot. This text summarized his 30-year Inman and DuVries and expanded on by Dr. Mann have
personal experience in diagnosing and treating disorders, given me a unique perspective.
deformities, and injuries of the foot and ankle. His book In 1993, Dr. Mann and I collaborated on the sixth
became a classic, but it was also significant because it was edition, which was expanded to a comprehensive two-
written by a physician who originally had obtained his volume text. In 1999, this was revised by us as the seventh
training as a podiatrist and then subsequently became a edition and, in 2005, it was published as a colorized
doctor of medicine. eighth edition, in which we were joined by, Dr. Charles
In 1965, Dr. DuVries expanded the book to include L. Saltzman, as a co-editor.
several other contributors, taking a form that is a model This is a living text and has continued to evolve from
even for the current textbook. Included in this second the initial work of Henri L. DuVries. Much of our ortho-
edition were Verne T. Inman, MD, chairman of the paedic careers have been devoted to working with this
Department of Orthopaedic Surgery at the University of text; Dr. Mann has contributed to or edited all but one
California, San Francisco, and Roger A. Mann, MD, a of the first eight editions, and I have contributed to or
senior resident in orthopaedic surgery. Eight years later, in edited half of the editions. However, change and growth
1973, Dr. Inman succeeded Dr. DuVries as the editor of are important! As of this edition, Dr. Mann has become
the third edition of Surgery of the Foot. Again, with this text, an editor emeritus but has continued to give us his
an expanded objective included discussion of the ankle input and valued advice. To recognize and honor his
joint as well as an in-depth analysis of the biomechanics invaluable contributions to the textbook, we have named
of the foot and ankle. Five years later, in 1978, Dr. Mann this ninth edition Mann’s Surgery of the Foot and Ankle.
became the editor of the fourth edition. Dr. Mann, having Most important, Robert B. Anderson, MD, a past fellow
been a resident under Dr. Inman and having served a fel- of John Gould, MD, joins Dr. Saltzman and me as an
lowship under Dr. DuVries, was presented with a unique editor of this text. Dr. Anderson brings a wealth of clini-
opportunity to blend the special interests of these two cal knowledge and a sports medicine background to
unique clinicians—Dr. Inman’s basic biomechanical this association. Just as Dr. DuVries complemented his
research and Dr. DuVries’ wealth of clinical knowledge. In text by adding Dr. Inman, and Dr. Inman introduced
1986, Dr. Mann edited a revised fifth edition. Dr. Mann, we feel strongly that Dr. Anderson’s addition
In 1978, as Dr. Mann’s first foot and ankle fellow, I will make this a stronger and more well-rounded work.
had the opportunity to be exposed to both his philosophy The ninth edition is also enhanced by the work of many
of patient care and the creativity with which he addressed of our excellent fellows and colleagues from around the
the evaluation and treatment of his patients. His meticu- world who have made substantial sacrifices to contribute
lous surgical technique and comprehensive postoperative to this textbook. In this edition, 25 authors continue
program were coupled with an introspective method of to contribute, but 42 new authors have been added.
assessing the results of specific procedures to delineate the These contributing authors are at the forefront of their
preferred treatment regimen. Dr. Mann’s 45 years in specific area of foot and ankle surgery. Each contributing
private practice, stimulated by more than 75 foot and author has covered a specific topic in a comprehensive
ankle fellows, have complemented my interaction with fashion, which we believe will leave the reader with a
him. In 1999, I initiated my own fellowship program and clear, concise appreciation of the subject. Although this
have learned a great deal from the 15 fellows who I have book is not meant to be encyclopedic in nature, our
trained. I also have frequently reviewed the surgical pro- goal has always been to provide the reader with a method
cedures used in my everyday practice, with the common of evaluating and treating a particular problem. More
goal of defining the strengths of individual procedures as than 40% of the ninth edition has been completely
well as their weaknesses. From the 34 years that I have rewritten by both new and returning contributors, and
been in private practice in Boise, Idaho, I have come to the remaining chapters have been updated.

xiii
 Preface

In 1990, Dr. Mann and I published the Video Textbook plantar plate tears and treatment of this complex
of Foot and Ankle Surgery, the second volume of which problem. The chapters on sesamoids, keratotic disorders,
appeared in 1995. This enabled foot and ankle surgeons and toenail abnormalities have all been updated as well.
to view a surgical procedure while simultaneously reading Part III, Nerve Disorders, and Part IV, Miscellaneous,
about the operative technique. Encouraged by the success have been completely updated to cover both acquired and
of this endeavor, the eighth edition of Surgery of the Foot static neurologic disorders; the material about heel pain
and Ankle incorporated, for the first time, 60 edited videos has been rewritten and updated by new authors.
on two DVDs. This unique addition has now become an Part V, Soft Tissue Disorders of the Foot and Ankle,
industry standard. To enhance the current edition, we includes revised chapters on infection, dermatology, and
have retained 45 classic videos narrated by Dr. Mann and soft tissue reconstruction and a completely new chapter
added 75 new videos contributed by us as well as many on tumors of the foot and ankle.
other colleagues. Furthermore, advances in Internet and Part VI, Arthritis, Postural Disorders, and Tendon Dis-
online learning have enhanced the electronic version of orders, has been completely revamped, updating our
the ninth edition textbook and video compilation to current knowledge and treatment of systemic inflamma-
allow viewing on smartphone and tablet devices before tory arthritis, traumatic arthritis, and osteoarthritis. The
performing surgical procedures, affecting both learning chapter on total ankle arthroplasty presents substantial
and improving patient care. changes because of the dramatic developments that have
This new edition has been divided into 10 sections that occurred over the past decade in ankle joint replacement.
have been subdivided into chapters. Specific surgical tech- Revisions of the chapters on pes planus and pes cavus are
niques within the chapters are described and illustrated included. The chapter on arthrodesis of the foot has been
in detail to afford the reader an understanding of the replaced by one on arthritis of the hindfoot and midfoot,
indications for each procedure and insight into the per- containing both assessment and surgical treatment of
formance of the technique. Although many different conditions in this region. The chapter on tendon abnor-
treatment regimens are presented, our goal is to recom- malities has been extensively rewritten to reflect signifi-
mend a specific treatment plan for each pathologic entity. cant technical advances in this area.
Furthermore, some topics are presented in more than one A separate section, Part VII, Diabetes, contains three
section, enabling the reader to appreciate the varying completely updated chapters on diabetes, amputations,
points of view presented by individual contributors. It is and prostheses of the foot and ankle.
our goal to provide the reader with an accurate assess- Part VIII, Sports Medicine, includes a comprehensive
ment of both the attributes and the deficiencies of specific chapter on athletic soft tissue injuries as well as specific
orthopaedic foot and ankle procedures, new and old. In chapters regarding stress fractures and arthroscopy; all
this edition, we present our most up-to-date thinking three chapters have been revised and updated to familiar-
regarding the diagnosis, treatment, and specific surgical ize the reader with this exciting and evolving area of
care of foot and ankle problems. orthopaedic technology.
In Part I, General Considerations, the biomechanics, Pediatrics is covered in Part IX with two chapters: a
examination, and conservative treatment of foot and general pediatric chapter and a separate chapter on con-
ankle problems are addressed. In large part, the initial genital and acquired neurologic disorders, where new
principles advocated by Dr. DuVries, Dr. Inman, and Dr. authors have added significant new information.
Mann, as presented in their early editions, are included Finally, Part X, Trauma, includes six chapters. These
in this portion of the text but have been updated. Anes- chapters, which have been updated and revised, include
thetic techniques have been completely rewritten and discussion of fractures of the distal tibia; ankle; disloca-
have been updated to include popliteal blocks and tions of the foot and ankle; and calcaneus talus, midfoot,
indwelling catheters. Discussions of imaging methods, and forefoot fractures, which are covered in a comprehen-
an integral part of the evaluation process for foot and sive fashion.
ankle disorders, have also been completely rewritten and As Roger Mann stated in the preface of the fifth edition,
include in-depth coverage of magnetic resonance imaging “As medicine continues to progress, the information of
and computed tomography. this textbook will again need to be upgraded. The prin-
In Part II, Forefoot, an extensive analysis of deformi- ciples presented, however, are basic in their approach and
ties of the great toe, along with complications associated will not change significantly over the years.” We believe
with individual hallux valgus procedures, has been com- that the ninth edition of Mann’s Surgery of the Foot and
pletely revised to make the reader aware of primary sur- Ankle will strongly enhance this dynamic and exciting
gical techniques as well as salvage techniques used for field of orthopaedics and will complement the learning
postsurgical complications. Inclusion of newer, popular experience of the resident and fellow-in-training as well
surgical techniques has been added. The chapter on lesser as the practicing surgeon.
toes has been completely rewritten and updated because Michael J. Coughlin, MD
of the vast number of advances made in the area of

xiv
We are proud to dedicate the ninth edition of Surgery of the Foot and Ankle to Roger A.
Mann, MD, and have changed the official name to Mann’s Surgery of the Foot and Ankle.
Dr. Mann served as a mentor and teacher at a time when there were few foot and ankle
fellowships or fellows. He guided the American Orthopaedic Foot and Ankle Society in its
early years and promoted education of residents and surgeons in active practice through
programs at the American Academy of Orthopedic Surgeons and the American Orthopaedic
Foot and Ankle Society meetings. Prolific in his studies and publications, he has introduced
more than 75 fellows to his methods of investigation and surgery, thus truly changing
surgery in America during his time. He took the rather small primer entitled Surgery of
the Foot and changed it to a two-volume color textbook—Surgery of the Foot and Ankle,
with a video supplement—that has become the definitive textbook for foot and ankle
surgery in the world.
His vision and action are proof that one man can truly make a difference, and he has
done that.

xvii
 Chapter 1
Biomechanics of the Foot
and Ankle
Andrew Haskell, Roger A. Mann

CHAPTER CONTENTS Hindfoot Alignment 29

Midfoot Alignment 30
GAIT CYCLE 4 Forefoot Principles 31
Walking Cycle 4 Tendon Transfers 31
First Interval 4 Ligaments of the Ankle Joint 31
Second Interval 5
Third Interval 6
Running Cycle 7 The human foot is an intricate mechanism that functions
KINEMATICS OF HUMAN LOCOMOTION 7 interdependently with other components of the locomo­
Vertical Body Displacements 8 tor system. Failure of the functioning of a single part,
Lateral Body Displacements 9 whether by disease, external forces, or surgical manipula­
Horizontal Limb Rotation 9 tion, will alter the functions of the remaining parts. To
KINETICS OF HUMAN LOCOMOTION 10 further complicate things, wide variations occur in the
Measuring Whole Body Kinetics and normal component parts of the foot and ankle, and these
Plantar Pressure 10 variations affect the degree of contribution of each part
Types of Studies 11 to the function of the entire foot. Depending on the
Data Representations 13 contributions of an individual component, the loss or
Measurement Variability 14 functional modification of that component by surgical
Kinetics of Walking 15 intervention may result in minor or major alterations in
Whole Body Kinetics 16 the function of adjacent components. This variation helps
Plantar Pressure Kinetics 17 to explain why the same procedure performed on the foot
Kinetics of Running 18 of one person produces a satisfactory result, whereas in
BIOMECHANICS OF THE COMPONENT OF THE another person the result is unsatisfactory.
LOCOMOTOR SYSTEM 19 Yet the surgeon is called on constantly to change the
Heel Strike to Foot Flat: Supple for anatomic and structural components of the foot. When
Impact Absorption 19 so doing, awareness of the consequences of these changes
Ankle Joint 19 is fundamental to achieving desired results. Put another
Subtalar Joint 20 way, an understanding of interrelationships between
Transverse Tarsal Joint Complex 22 foot and ankle components and how they interact with
Foot Flat to Toe-Off: Progression to the greater locomotor system is critical to achieving
a Rigid Platform 23 predictable outcomes when altering these components
Ankle Joint 24 surgically.
Subtalar Joint 25 Understanding the biomechanics of the foot and ankle
Transverse Tarsal Articulation 25 also contributes to sound surgical decision making and
Plantar Aponeurosis 25 adds to the success of postoperative treatment. Appre­
Metatarsophalangeal Break 26 ciating the mechanical behavior of the foot allows the
Talonavicular Joint 27 physician to differentiate foot disabilities that may be
Swing Phase 27 successfully treated by nonsurgical procedures rather than
Component Mechanics of Running 28 approached surgically. Furthermore, some operative pro­
SURGICAL IMPLICATIONS OF BIOMECHANICS cedures that fail to completely achieve the desired result
OF THE FOOT AND ANKLE 28 can be improved by minor alterations in the behavior of
Biomechanical Considerations in adjacent components through shoe modification or the
Ankle Arthrodesis 29 use of orthotic inserts or braces.

3
 Part I ■ General Considerations

With increased attention being given to athletics, the Heel Foot Heel Heel
Strike Flat Rise Toe-off Strike
physician must have a basic knowledge of the mechanics
that occur during running. Many of the same basic mech­
anisms that will be described for the biomechanics of the Opposite Opposite
foot and ankle are not significantly altered during running. Toe-off Heel Strike
The same stabilization mechanism within the foot occurs
Stance phase Swing phase
during running as during walking. The major differences
observed during running are that the gait cycle is altered
considerably, the amount of force generated (as measured Double Single Double
Limb Limb Limb
by force plate data) is markedly increased, the range of Support Support Support
motion of the joints of the lower extremities is increased,
and the phasic activity of the muscles of the lower extrem­
ities is altered. Differences between walking and running
will be highlighted in the following sections. 0 7 12 34 50 62 100
Starting this textbook with a chapter focused on foot Percent of gait cycle
and ankle biomechanics is meant to provide a foundation
Figure 1-1 Phases of the walking cycle. Stance phase
for the reader upon which the remaining chapters are
constitutes approximately 62%, and swing phase 38% of
built. It has been assumed that the orthopaedic surgeon cycle. During stance phase of walking, there are two periods
possesses an accurate knowledge of the anatomy of the of double limb support and one period of single limb
foot and ankle. If this knowledge is lacking, textbooks of support. Stance phase is further divided into three intervals:
anatomy are available that depict in detail the precise from heel strike to foot flat at approximately 7% of the gait
anatomic structures constituting this part of the human cycle, foot flat to heel rise at approximately 34% of the gait
body.46,49 In this chapter, the gait cycle is reviewed, kine­ cycle, and heel rise to toe-off at approximately 62% of the
gait cycle.
matic and kinetic aspects of gait are explored, and specific
anatomic interrelationships of the foot and ankle are
emphasized. Throughout this discussion, mechanics that 34% as the contralateral leg swings through and passes
differentiate running from walking are described. Finally, the stance foot. Finally, contralateral heel strike occurs at
clinical examples are explored, and methods for func­ 50% of the gait cycle.
tional evaluation of the foot are presented as practical In a patient with spasticity, the initial heel strike may
demonstrations of the concepts within. be toe contact, and foot flat may not occur by 7% of the
cycle. Heel rise may be premature if spasticity or an
equinus contracture is present or delayed in the case of
GAIT CYCLE weakness of the gastrocnemius–soleus muscle group.
Weakness of anterior compartment leg musculature
Walking Cycle
resulting in a footdrop may lead to accentuated hip and
Human gait is a rhythmic, cyclic forward progression knee flexion during swing-through and alteration in
involving motion of all body segments. A single cycle is attaining a foot-flat position.
often defined as the motion between the heel strike of The walking cycle being one of continuous motion is
one step and the heel strike of the same foot on the sub­ difficult to appreciate in its entirety because so many
sequent step. Gait parameters, such as stride length, veloc­ events occur simultaneously. To help appreciate the dif­
ity, and cadence, are easy to measure based on this ferent activities and functions of the components of the
definition. foot and ankle during gait, the stance phase can be
A single cycle can be divided further. The walking cycle divided into three intervals: the first interval, extending
for one limb is broken into a stance phase and a swing from initial heel strike to the foot laying flat on the floor;
phase. The stance phase typically constitutes 62% of the the second interval, occurring during the period of foot
cycle and the swing phase 38%. The stance phase is flat as the body passes over the foot; and the third inter­
further divided into a period of double limb support val, extending from the beginning of ankle joint plantar
(from 0% to 12%), in which both feet are on the ground, flexion as the heel rises from the floor to when the toes
followed by a period of single limb support (from 12% lift from the floor.
to 50%) and a second period of double limb support
(from 50% to 62%), after which the swing phase begins First Interval
(Fig. 1-1). The first interval occurs during approximately the first
The opposite leg also goes through a predictable 15% of the walking cycle and is defined from the moment
sequence during a gait cycle. The position and activities of initial heel strike to when the foot becomes flat on the
of this contralateral leg can be seen at predictable times. floor. Typically, the opposite heel has lifted from the floor,
For instance, contralateral toe-off is typically at 12% of but weight remains on the forefoot. During the first inter­
the gait cycle, occurring after the ipsilateral foot has val, the foot helps to absorb and dissipate the forces
reached a foot-flat position. Ipsilateral heel rise begins at generated by the foot striking the ground.

4
 Biomechanics of the Foot and Ankle ■ Chapter 1

appears to play a role in restricting this motion at initial

ground contact.
The subtalar joint links rotation of the hindfoot to
First interval rotation of the leg. During the first interval, eversion of
the calcaneus is translated by the subtalar joint into
inward rotation that is transmitted proximally across the
Body weight
ankle joint into the lower extremity (Fig. 1-2E). Distally,
125% this hindfoot eversion unlocks the transverse tarsal joint
Percentage 100%
of
(Fig. 1-2D), allowing the midfoot joints to become
50%
A body weight supple. This allows the flattening of the longitudinal arch
that contributes to energy dissipation during this phase.
20
˚ Ankle rotation At heel strike, the center of gravity of the body is decel­
erated by ground contact, then immediately accelerated
Dorsiflexion 10
˚ Neutral standing position
upward to carry it over the extending lower extremity. The
Plantar heel’s impact and body’s center of gravity shift accounts
B flexion
10
˚ for a vertical floor reaction that exceeds body weight by
20
˚ 15% to 25% (Fig. 1-2A).
EMG activity Eccentric contraction of the anterior compartment leg
Intrinsic muscles of foot muscles slows the rapid ankle plantar flexion during this
Posterior tibial muscles phase from heel strike until a foot-flat position is reached.
The posterior calf muscles all are electrically quiet, as are
Anterior tibial muscles
C the intrinsic muscles in the sole of the foot (Fig. 1-2C).
There is no muscular response in those muscles usually
20
˚ Subtalar rotation considered important in supporting the longitudinal arch
Supination 10
˚ Neutral standing position
of the foot. Weakness of the anterior compartment
muscles leads to a loss of this deceleration and a charac­
Pronation
teristic slap foot gait.
D
10
˚
20
˚
Horizontal rotation Second Interval
Internal
20
˚ of tibia The second interval extends from 15% to 40% of the
rotation 10
˚ walking cycle. During this interval, the body’s center of
Neutral standing position gravity passes from behind to in front of the weight-
External
E rotation
10
˚ bearing leg. It reaches a maximum height as it passes over
the leg at about 35% of the cycle, after which it com­
20
˚ 0% 15% mences to fall. During this interval, the foot transitions
Percentage of from a flexible, energy-absorbing structure to a more rigid
walking cycle
one, capable of bearing the body’s weight.
Figure 1-2 Composite of events of first interval of walking, The ankle joint undergoes progressive dorsiflexion
or period that extends from heel strike to foot flat. EMG,
during the second interval, reaching its peak at 40% of
electromyograph.
the walking cycle. This is when the force across the ankle
joint has reached a maximum of 4.5 times body weight.
Heel rise begins at 34% of the cycle as the contralateral
The ankle joint undergoes rapid plantar flexion from leg passes by the stance foot and precedes the onset of
heel strike until foot flat is achieved. At approximately 7% plantar flexion, which begins at 40% (Fig. 1-3B).
of the walking cycle, dorsiflexion begins (Fig. 1-2B). During the second interval, the subtalar joint progres­
As the foot is loaded with the weight of the body sively inverts. This starts at about 30% of the cycle in a
during the first interval, the calcaneus rapidly everts and normal foot and at about 15% of the cycle in a flatfoot
the longitudinal arch flattens. This flattening of the arch (Fig. 1-3D). Multiple factors contribute to this inversion,
originates in the subtalar joint and reaches a maximum but precisely which plays the greatest role is unclear.
during this interval (Fig. 1-2D). The hindfoot is often Above the subtalar joint, the swinging contralateral limb
mildly supinated at initial ground contact associated with externally rotates the stance limb. This external rotation
ankle dorsiflexion during swing-through. The hindfoot torque is translated by the subtalar joint into hindfoot
moving from supination to pronation during the first inversion. The oblique nature of the ankle joint axis, the
interval is a passive mechanism, and the amount of oblique setting of the metatarsal break, and the function
motion appears to depend entirely on the configuration of the plantar aponeurosis also contribute to hindfoot
of the articulating surfaces, their capsular attachments, inversion. Inversion of the subtalar joint is passed distally
and ligamentous support. No significant muscle function into the midfoot, increasing the stability of the transverse

5
 Part I ■ General Considerations

Second
interval

Third interval

125% Body weight

Percentage
of body 100%
weight 50% Body weight
125%
Percentage 100%
A of
Ankle rotation
20
˚ A body weight
50%
Dorsiflexion 10
˚
Plantar Neutral standing position
20
˚ Ankle rotation
flexion
10
˚ Dorsiflexion 10
˚
B 20
˚ EMG activity Neutral standing position
Intrinsic Plantar
muscles of foot B flexion
10
˚
Posterior
tibial muscles
20
˚
EMG activity
Anterior tibial
muscles Intrinsic muscles of foot
C
Posterior tibial muscles
20
˚ Subtalar rotation
Supination 10
˚ C
Anterior tibial muscles

Neutral standing position

Pronation 10
˚ 20
˚ Subtalar rotation
D 20
˚ Supination 10
˚
Internal
20
˚ Horizontal rotation of tibia

rotation
10
˚ Pronation
Neutral standing position

D
10
˚
External Neutral standing position
rotation
10
˚ 20
˚
E 20
˚15% 30% 40% Internal
20
˚
Horizontal rotation
of tibia
Percentage of walking cycle rotation 10
˚ Neutral standing position
Figure 1-3 Composite of events of second interval of
walking, or period of foot flat. EMG, electromyograph. External
E rotation
10
˚
20
˚ 40% 65%
tarsal articulation and transforming the flexible midfoot Percentage of
into a rigid structure. walking cycle
During this interval, full body weight is not borne on Figure 1-4 Composite of all events of third interval of
the foot, smoothing the transition to single limb support. walking, or period extending from foot flat to toe-off. EMG,
Force plate recordings show that the load on the foot electromyograph.
may be as low as 70% to 80% of actual body weight
(Fig. 1-3A).
During the second interval, important functional Third Interval
changes occur in both the foot and leg, which are the The third interval constitutes the last of the stance phase
result of muscular action. The posterior and lateral com­ and extends from 40% to 62% of the walking cycle.
partment leg muscles (triceps surae, peroneals, tibialis The ankle joint demonstrates rapid plantar flexion
posterior, long toe flexors) and intrinsic muscles in the during this interval as the foot essentially extends the
sole of the foot demonstrate electrical activity (Fig. 1-3C). stance, effective length. The subtalar joint continues to
Intrinsic muscle activity of the normal foot begins at 30% invert during this interval, reaching its maximum at
of the cycle, whereas in flatfoot, activity begins at 15% of toe-off (Fig. 1-4D). This completes the conversion of the
the cycle. The posterior calf musculature slows the forward forefoot from the flexible structure observed in the first
movement of the tibia over the fixed foot, which permits interval at the time of weight acceptance to a rigid struc­
the contralateral limb to increase its step length. Weak­ ture at the end of the third interval in preparation for
ness of the posterior compartment muscles may lead toe-off. The inversion is a continuation of the processes
to premature contralateral heel strike and shortened that began in the second interval. These include external
stride length. rotation of limb above the foot passing across the ankle

6
 Biomechanics of the Foot and Ankle ■ Chapter 1

and subtalar joints as well as mechanisms in the foot such CYCLE TIME
as the obliquity of the ankle joint, the function of the
plantar aponeurosis, and obliquity of the metatarsal
break. Distally, the transverse tarsal joint is converted
from a flexible structure into a rigid one by the progressive Stance Float Swing Float
inversion of the calcaneus. The talonavicular joint also is Run 0.6
stabilized during this period by the pressure placed across
the joint by both body weight and the intrinsic force
created by the plantar aponeurosis. Jog 0.7
At the beginning of the third interval, force plate
recordings demonstrate an increase in the percentage of
body weight borne by the foot resulting from the center Walk
of gravity falling. The load on the foot exceeds body
weight by approximately 20%. Later in the interval, the
vertical floor reaction force falls to zero as the body’s
weight is transferred to the opposite foot (Fig. 1-4A).
Ankle plantar flexion during the third interval is caused 0.2 0.4 0.6 0.8 1.0
primarily by the concentric contraction of the posterior
Sec
calf musculature, in particular the triceps surae (Fig.
1-4B). The plantar flexion leads to relative elongation of Figure 1-5 Variations in gait cycle for running, jogging, and
the extremity. Although full plantar flexion at the ankle walking. Note that as the speed of gait increases, stance
phase decreases. In this illustration, subject is walking at 3.75
joint occurs during this interval, electrical activity is miles per hour, jogging at about 1 mile per 9 minutes, and
observed only until 50% of the cycle, after which there is running about 1 mile per 5 minutes.
no longer electrical activity in the extrinsic muscles (Fig.
1-4C). The remainder of ankle joint plantar flexion occurs
because of the transfer of weight from the stance leg to merely placing one foot in front the other. During walking,
the contralateral limb. The intrinsic muscles of the foot all major segments of the body are in motion. Displace­
are active until toe-off. Although the intrinsic muscles ments of the body segments occur in a well-preserved
help to stabilize the longitudinal arch, the main stabilizer fashion and can be accurately described. Kinematics is the
is the plantar aponeurosis, which is functioning maxi­ study of the motion of these body segments.
mally during this period as the toes are brought into Human locomotion is a learned process; it does not
dorsiflexion and the plantar aponeurosis is wrapped develop as the result of an inborn reflex.59 The first few
around the metatarsal heads, forcing them into plantar steps of an infant holding onto his or her parent’s hand
flexion and elevating the longitudinal arch. The anterior exemplify the learning process necessary to achieve ortho­
compartment muscles become active in the last 5% of this grade progression. The result of this learning process is
interval, probably to initiate dorsiflexion of the ankle the integration of the neuromusculoskeletal mechanisms,
joint immediately after toe-off. with their gross similarities and individual variations,
into an adequately functioning system of locomotion.
Once a person has learned to walk, the mechanisms of
Running Cycle
ambulation are adaptable and work whether the person
The changes that occur in the gait cycle during running is an amputee learning to use a prosthesis, a long-distance
relative to walking are illustrated in Figure 1-5. During runner, or a high-heeled shoe wearer.
walking, one foot is always in contact with the ground; A smoothly performing locomotor system results from
as the speed of gait increases, a transition occurs wherein the harmonious integration of many components.
a float phase is incorporated, during which time both feet Because human locomotion involves all major segments
are off the ground. Rather than a period of double limb of the body, certain suprapedal movements demand spe­
support as occurs during walking, there is a period of no cific functions from the foot, and the manner in which
limb support. As the speed of gait continues to increase, the foot functions or fails to function may be reflected in
the time the foot spends on the ground, both in real time patterns of movement in the other segments of the body.
and in percentage of cycle, decreases considerably. The Similarly, alterations in movements above, such as a stiff
speed at which one transitions from walking to running knee or hip from arthritis or knee hyperextension from
is greater than the speed at which one transitions back postpolio quadriceps weakness, may be reflected below
from running to walking. by changes in the behavior of the foot.
Although bipedal locomotion imposes gross similari­
ties in the manner in which all of us walk, each of us
KINEMATICS OF HUMAN LOCOMOTION
exhibits minor individual differences that allow us to be
Humans use a unique and characteristic orthograde recognized by a friend or acquaintance, even from a dis­
bipedal mode of locomotion. But walking is more than tance. The causes of these individual characteristics of

7
 Part I ■ General Considerations

Figure 1-6 Displacement of center of gravity of body in smooth sinusoidal path. (From Saunders JB, Inman VT, Eberhart HD:
The major determinants in normal and pathological gait. J Bone Joint Surg Am 35A:543-558, 1953.)

locomotion are many. Each of us differs somewhat in the particularly noticeable when someone is out of step in a
length and distribution of mass of the various segments parade. These displacements in the vertical plane are a
of the body, segments that must be moved by muscles of necessary concomitant of bipedal locomotion. When the
varying fiber length. Furthermore, individual differences legs are separated, as during transmission of the body
occur in the position of axes of movement of the joints, weight from one leg to the other (double weight bearing),
with concomitant variations in effective lever arms. These the distance between the trunk and the floor must be less
and many more such factors combine to establish in each than when it passes over a relatively extended leg, as
of us a final idiosyncratic manner of locomotion. during midstance.
Just as no two people walk exactly alike, gait kinemat­ Smoothing and minimizing vertical oscillations of the
ics will not always be identical even within the same body’s center of gravity minimizes energy expenditure.
individual. The contribution of a single component varies Physics principles tell us that much more energy is needed
under different circumstances. Type of shoe, amount of to lift the body against gravity and slow its descent (verti­
fatigue, weight of load carried, and other such variables cal displacement) than to move perpendicular to gravity’s
can cause diminished functioning of some components, pull (fore–aft or lateral displacement). Because the nature
with compensatory increased functioning of others. An of bipedal locomotion demands such vertical oscillations
enormous number of variations in the behavior of indi­ of the body, they should occur in a smooth manner. The
vidual components are possible; however, the diversely center of gravity of the body does displace in a smooth
functioning components, when integrated, are comple­ sinusoidal path; the amplitude of displacement is approx­
mentary and will produce smooth forward progression. imately 4 to 5 cm (Fig. 1-6).65,66 The body’s center of
Average values of single anthropometric observations gravity reaches its maximum elevation immediately after
of gait kinematic parameters are alone of little value. The passage over the weight-bearing leg and then begins to
surgeon should be alert to the anthropometric variations fall. This fall is stopped at the termination of the swing
that occur within the population, but it is more important phase of the opposite leg as the heel strikes the ground.
to understand the functional interrelationships among Much of the coordination of motion between the dif­
the various components. This is particularly true in the ferent segments of the lower limbs results in minimizing
case of the foot, where anatomic variations are extensive. the vertical displacement of the body’s center of gravity.
If average values are the only bases of comparison, it Although movements of the pelvis and hip modify the
becomes difficult to explain why some feet function amplitude of the sinusoidal pathway, the knee, ankle, and
adequately and asymptomatically, although their mea­ foot are particularly involved in converting what would
surements deviate from the average, whereas others be a series of intersecting arcs into a smooth, sinusoidal
function symptomatically, even though their measure­ curve.66 This conversion requires both simultaneous and
ments approximate the average. Therefore, in this chapter, precise sequential motions in the knee, ankle, and foot.
emphasis is placed on functional interrelationships and In a well-functioning system, the body’s falling center
not on lists of kinematic measurements. of gravity is smoothly decelerated, because relative short­
ening of the leg occurs at the time of impact against a
gradually increasing resistance. The knee flexes against a
Vertical Body Displacements
graded contraction of the quadriceps muscle; the ankle
The rhythmic upward and downward displacement of the plantar flexes against the resisting anterior tibial muscle.
body during walking is familiar to everyone, and is After the foot-flat position is reached, further shortening

8
 Biomechanics of the Foot and Ankle ■ Chapter 1

is achieved by pronation of the foot to a degree permitted approximately over the weight-bearing foot. Watching
by the ligamentous structures within. someone walk from behind highlights this subtle side-to-
So, to reemphasize, hindfoot pronation constitutes an side shift of their center of gravity toward the stance limb.
important additional factor to that of knee flexion and When walking side by side with a companion, if one gets
ankle plantar flexion needed to smoothly decelerate and out of step with the other, their bodies may bump from
finally to stop the downward path of the body. If one were this side-to-side sway.
forced to walk stiff-kneed or without a mobile foot and The body is shifted slightly over the weight-bearing leg,
ankle, the downward deceleration of the center of gravity with each step creating a sinusoidal lateral displacement
at heel strike would be instantaneous. The body would of the center of gravity of approximately 4 to 5 cm with
be subjected to a severe jarring force, and the locomotor each complete stride. This lateral displacement can be
system would lose kinetic energy. increased by walking with the feet more widely separated
After reaching its nadir, the center of gravity moves and decreased by keeping the feet close to the plan of
upward to propel it over the stance leg. The leg function­ progression (Fig. 1-7). Normally, the slight valgus of the
ally elongates by transitory extension of the knee, further tibiofemoral angle (physiologic genu valgum) permits the
plantar flexion of the ankle as the heel elevates, and supi­ tibia to remain essentially vertical and the feet close
nation of the foot. Elevation of the heel is the major together while the femurs diverge to articulate with the
component contributing to upward acceleration of the pelvis, minimizing the lateral displacement.
center of gravity at this time.
Horizontal Limb Rotation
Lateral Body Displacements
In addition to vertical and lateral displacements of the
When a person is walking, the body does not remain body, a series of axial rotatory movements occur that can
precisely in the plane of progression but oscillates be measured in the horizontal (transverse) plane. Rota­
slightly from side to side to keep the center of gravity tions of the pelvis and the shoulder girdle are easy to see

A B
Figure 1-7 A, Slight lateral displacement of body occurring during walking with feet close together. B, Increased lateral
displacement of body occurring during walking with feet wide apart. (From Saunders JB, Inman VT, Eberhart HD: The major
determinants in normal and pathological gait. J Bone Joint Surg Am 35A:543-558, 1953.)

9
 Part I ■ General Considerations

when watching someone walk. Similar horizontal rota­

KINETICS OF HUMAN LOCOMOTION
tions occur in the femoral and tibial segments of the
extremities. The tibias rotate about their long axes, inter­ To begin a review of gait kinetics, one must recognize that
nally during swing phase and into the first interval of the ambulating human is both a physical machine and a
stance phase and externally during the latter phases of biologic organism subject to physical laws and beholden
stance. The degree of these rotations is subject to marked to muscular action. Gait kinematics and lower-extremity
individual variations. In a series of 12 male subjects, the anatomic interrelationships strive to achieve a system that
recorded average horizontal rotation of the tibia was 19 takes us from one spot to another with the least expendi­
degrees during a gait cycle but varied between 13 and 25 ture of energy.60 Said another way, human locomotion is
degrees.48 a blending of physical and biologic forces that combine
At heel strike, progressive inward rotation occurs in the to achieve maximum efficiency at minimum cost. Kinetics
lower extremity, which consists of the pelvis, femur, and is the study of these energy expenditures.
tibia, and this inward rotation reaches a maximum at the All characteristics of muscular behavior are exploited
time of foot flat. The internal rotation at heel strike is in locomotion. Muscle groups may accelerate or deceler­
initiated by the collapse of the subtalar joint into valgus, ate body segments at different points in the gait cycle.
and its magnitude is determined by the flexibility of the They may contract concentrically (as they shorten) or
foot and its ligamentous support. After contralateral toe- eccentrically (as they lengthen). Part of energy conserva­
off, at about 12% of the cycle, progressive outward rota­ tion during the gait cycle involves having muscles work
tion occurs, which reaches a maximum at the time of near their peak efficiency, which tends to be at or longer
toe-off, when inward rotation resumes (Fig. 1-8). Once than their resting length.14,17,65 When motion in the skel­
the foot is on the ground, progressive external rotation is etal segments is decelerated or when external forces work
probably initiated by the contralateral swinging limb, on the body, activated muscles become efficient. Activated
which rotates the pelvis forward, imparting a certain muscles, in fact, are approximately six times as efficient
degree of external rotation to the stance limb. This exter­ when resisting elongation (eccentric contraction) as when
nal rotation subsequently is passed from the pelvis dis­ shortening to perform external work.1,5,6 In addition, non­
tally to the femur and tibia, across the ankle joint, and is contractile elements in muscles and specific connective
translated by the subtalar joint into inversion, which tissue structures assist muscular action by providing an
reaches its maximum at toe-off. The external rotation is elastic component that stores and later releases kinetic
enhanced by the external rotation of the ankle joint axis, energy.
the oblique metatarsal break, and the plantar aponeurosis Assessment of the forces and torques imparted by the
after heel rise begins. ground on the lower extremity has illuminated the bio­
mechanical processes at work during gait. Investigation
of the pressures experienced by the various regions of the
plantar foot has provided insight into the pathogenesis
PELVIC ROTATION and treatment of many foot and ankle disorders. A
Heel strike Toe-off Heel strike number of tools have evolved to study gait kinetics. These
10
in are described in detail in the next section, followed by an
0 analysis of kinetics during gait.
out
10
FEMORAL ROTATION Measuring Whole Body Kinetics
10
and Plantar Pressure
Degrees

in
0 Studying the foot’s interaction with the ground has a long
out history, ranging from examining footprints in soil to real-
10
TIBIAL ROTATION time mapping of plantar pressure under natural condi­
10 tions. Plantar pressure and ground reaction force
in measurements are well established in the research realm
0
and have been instrumental in refining our understand­
out
10
ing of foot and ankle biomechanics. In conjunction with
other technology, including high-speed cameras, video
motion-sensing equipment, electrogoniometers, and
0 10 20 30 40 50 60 70 80 90 100 electromyograph (EMG) devices, the study of the ground–
Percent of walk cycle foot interaction has aided the understanding of gait kinet­
ics and kinematics.
Figure 1-8 Transverse rotation occurring in the lower
extremity during walking. Internal rotation occurs until
Despite improvements in available measurement
approximately 15% of cycle, at which time progressive methods, however, practical collection of clinically novel
external rotation occurs until toe-off, when internal rotation information remains difficult. The wide variability of
begins again. normal measures makes clinical comparisons difficult.

10
 Biomechanics of the Foot and Ankle ■ Chapter 1

The large number of measurement systems and equally plantar pressures and to isolate particular areas under
large number of data analysis techniques make it difficult the foot.
to generalize results. The earliest direct measurement methods relied on
Although confirmation of areas of excess pressure and physical properties of a material to capture the interac­
monitoring the effects of treatment may prove useful, tion of the foot with the ground. Casts of the foot
there is little specificity between plantar pressure patterns in clay, plaster, or soil were used with the assumption
and clinical syndromes. that areas of deeper penetration represented areas of
highest pressure.10,21 Rubber mats incorporating longitu­
Types of Studies dinal ridges,54 pyramidal projections,21 or a multilevel
A variety of measurement techniques have been used to grid (such as the Harris-Beath mat),67,78 use the elastic
study the interaction of the foot with the ground. Indirect property of rubber which, when stood or walked on,
techniques rely on correlating other measurable gait distorts in proportion to the pressure applied (Fig. 1-9).
parameters to plantar characteristics and offer the advan­ Although fast, inexpensive, and portable, these methods
tage of not relying on expensive and often bulky equip­ have low measurement resolution and lack temporal
ment. For example, an estimation of ground reaction discrimination.67
force can be made based on a simple-to-measure tempo­ Optically based systems rely on visualizing the plantar
ral variable, foot–ground contact time.13 aspect of the foot during stance or gait. The simplest
Direct measurement techniques rely on physical prop­ allows observation or photographic recording of the
erties or electronic transducers to translate the interaction plantar foot through a clear platform (Fig. 1-10). This
between the foot and the ground into a measurable provides an accurate, dynamic, qualitative representation
quantity. Multiple direct measurement systems are avail­ of foot morphology. Addition of a physical transduction
able that use a variety of strategies to record plantar device between the foot and glass plate allows quantifica­
pressure or ground reaction force. Unfortunately, results tion of regionalized plantar pressures and adds the tem­
obtained with different systems under similar conditions poral component missed using a physical transduction
are not always similar, and even qualitative comparisons system alone.21 The pedobarograph places a thin plastic
may not be appropriate.38 Spatial resolution and sample sheet over the clear plate.4 The sheet is illuminated at the
rate affect the ability of a system to record true peak edges, and pressure on the plastic distorts the light in

Figure 1-9 Pressure distribution on plantar aspect of foot as demonstrated by use of barograph. As dots get larger and
denser, pressure distribution is greater. (From Elftman H: A cinematic study of the distribution of pressure in the human foot.
Anat Rec 59:481-491, 1934.)

11